Pain management practice patterns after hip arthroscopy: an international survey

Abstract Several post-operative pain control methods have been described for hip arthroscopy including systemic medications, intra-articular or peri-portal injection of local anesthetics and peripheral nerve blocks. The diversity of modalities used may reflect a lack of consensus regarding an optimal approach. The purpose of this investigation was to conduct an international survey to assess pain management patterns after hip arthroscopy. It was hypothesized that a lack of agreement would be present in the majority of the surgeons’ responses. A 25-question multiple-choice survey was designed and distributed to members of multiple orthopedic professional organizations related to sports medicine and hip arthroscopy. Clinical agreement was defined as > 80% of respondents selecting a single answer choice, while general agreement was defined as >60% of a given answer choice. Two hundred and fifteen surgeons completed the survey. Clinical agreement was only evident in the use of oral non-steroidal anti-inflammatory drugs (NSAIDs) for pain management after hip arthroscopy. A significant number of respondents (15.8%) had to readmit a patient to the hospital for pain control in the first 30 days after hip arthroscopy in the past year. There is significant variability in pain management practice after hip arthroscopy. The use of oral NSAIDs in the post-operative period was the only practice that reached a clinical agreement. As the field of hip preservation surgery continues to evolve and expand rapidly, further research on pain management after hip arthroscopy is clearly needed to establish evidence-based guidelines and improve clinical practice.

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Pain Management After Hip Arthroscopy: Systematic Review of Randomized Controlled Trials and Cohort Studies

The American Journal of Sports Medicine ◽

10.1177/0363546517734518 ◽

2017 ◽

Vol 46 (13) ◽

pp. 3288-3298 ◽

Cited By ~ 18

Author(s):

Jason J. Shin ◽

Chris L. McCrum ◽

Craig S. Mauro ◽

Dharmesh Vyas

Keyword(s):

Systematic Review ◽

Pain Management ◽

Postoperative Pain ◽

Hip Arthroscopy ◽

Pain Control ◽

Femoral Nerve ◽

Lumbar Plexus ◽

Nerve Blocks ◽

Fascia Iliaca Block ◽

Plexus Block

Background: Hip arthroscopy is often associated with significant postoperative pain and opioid-associated side effects. Effective pain management after hip arthroscopy improves patient recovery and satisfaction and decreases opioid-related complications. Purpose: To collect, examine, and provide a comprehensive review of the available evidence from randomized controlled trials and comparative studies on pain control after hip arthroscopy. Study Design: Systematic review. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature for postoperative pain control after hip arthroscopy was performed using electronic databases. Only comparative clinical studies with level 1 to 3 evidence comparing a method of postoperative pain control with other modalities or placebo were included in this review. Case series and studies without a comparative cohort were excluded. Results: Several methods of pain management have been described for hip arthroscopy. A total of 14 studies met our inclusion criteria: 3 on femoral nerve block, 3 on lumbar plexus block, 3 on fascia iliaca block, 4 on intra-articular injections, 2 on soft tissue surrounding surgical site injection, and 2 on celecoxib (4 studies compared 2 or more methods of analgesia). The heterogeneity of the studies did not allow for pooling of data. Single-injection femoral nerve blocks and lumbar plexus blocks provided improved analgesia, but increased fall rates were observed. Fascia iliaca blocks do not provide adequate pain relief when compared with surgical site infiltration with local anesthetic and are associated with increased risk of cutaneous nerve deficits. Patients receiving lumbar plexus block experienced significantly decreased pain compared with fascia iliaca block. Portal site and periacetabular injections provide superior analgesia compared with intra-articular injections alone. Preoperative oral celecoxib, compared with placebo, resulted in earlier time to discharge and provided significant pain relief up to 24 hours. Conclusion: Perioperative nerve blocks provide effective pain management after hip arthroscopy but must be used with caution to decrease risk of falls. Intra-articular and portal site injections with local anesthetics and preoperative celecoxib can decrease opioid consumption. There is a lack of high-quality evidence on this topic, and further research is needed to determine the best approach to manage postoperative pain and optimize patient satisfaction.

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Peri-operative pain management in hip arthroscopy: a systematic review of the literature

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnz050 ◽

2019 ◽

Vol 6 (4) ◽

pp. 353-363

Author(s):

Jensen G Kolaczko ◽

Derrick M Knapik ◽

Michael J Salata

Keyword(s):

Systematic Review ◽

Pain Management ◽

Hip Arthroscopy ◽

Pain Control ◽

Review Of The Literature ◽

Discharge Time ◽

Nerve Blocks ◽

Vas Score ◽

Significant Difference ◽

Control Protocols

Abstract The purpose of this article was to review current literature on peri-operative pain management in hip arthroscopy. A systematic review of the literature on pain control in hip arthroscopy published January 2008 to December 2018 was performed. Inclusion criteria consisted of English language or articles with English translations, subjects undergoing hip arthroscopy with documented peri-operative pain control protocols in studies reporting Level I to IV evidence. Exclusion criteria were non-English articles, animal studies, prior systematic review or meta-analyses, studies not reporting peri-operative pain control protocols, studies documenting only pediatric (<18 years of age) patients, studies with Level V evidence and studies including less than five subjects. Statistical analysis was performed to assess pain protocols on narcotic consumption in PACU, VAS score on discharge, time to discharge from PACU and incidence of complications. Seventeen studies were included, comprising 1674 patients. Nerve blocks were administered in 50% of patients (n = 838 of 1674), of which 88% (n = 740 of 838) received a pre-operative block while 12% (n = 98 of 838) post-operative block. Sixty-eight complications were recorded: falls (54%, n = 37), peripheral neuritis (41%, n = 28), seizure (1.5%, n = 1), oxygen desaturation and nausea (1.5%, n = 1) and epidural spread resulting in urinary retention (1.5%, n = 1). No significant differences in narcotic consumption, VAS score at discharge, time until discharge or incidence of complication was found based on pain control modality utilized. No statistically significant difference in PACU narcotic utilization, VAS pain scores at discharge, time to discharge or incidence of complications was found between peri-operative pain regimens in hip arthroscopy.

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International survey: real-world pain management strategies

European Journal of Public Health ◽

10.1093/eurpub/ckaa166.1183 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

M Hagen ◽

A Georgescu

Keyword(s):

Pain Management ◽

Real World ◽

Pain Control ◽

Online Survey ◽

Management Strategies ◽

Pain Medication ◽

International Survey ◽

Nationally Representative ◽

Online Panels ◽

Control Pain

Abstract Background Pain is a nearly universal experience, but little is known about how people treat pain. This international survey assessed real-world pain management strategies. Methods From 13-31 January, 2020, an online survey funded by GSK Consumer Healthcare was conducted in local languages in Australia, Brazil, Canada, China, Colombia, France, Germany, India, Italy, Japan, Saudi Arabia, Malaysia, Mexico, Poland, Russia, Spain, Sweden, UK, and USA. Adults were recruited from online panels of people who agreed to participate in surveys. Quotas ensured nationally representative online populations based on age, gender, and region. Results Of 19,000 people (1000/country) who completed the survey, 18,602 (98%) had ever experienced physical pain; 76% said they would like to control their pain better. Presented with 17 pain-management strategies and asked to select the ones they use in the order of use, respondents chose an average of 4 strategies each. The most commonly selected strategies were pain medication (65%), rest/sleep (54%), consult a doctor (31%), physical therapy (31%), and nonpharmacologic action (eg, heat/cold application; 29%). Of those who use pain medication, 56% take some other action first. Only 36% of those who treat pain do so immediately; 56% first wait to see if it will resolve spontaneously. Top reasons for waiting include a desire to avoid medication (37%); willingness to tolerate less severe pain (33%); concerns about side effects (21%) or dependency (21%); and wanting to avoid a doctor's visit unless pain is severe or persistent (21%). Nearly half (42%) of those who take action to control pain have visited ≥1 healthcare professional (doctor 31%; pharmacist 18%; other 17%) about pain. Conclusions This large global survey shows that people employ a range of strategies to manage pain but still wish for better pain control. Although pain medication is the most commonly used strategy, many people postpone or avoid its use. Key messages More than three-quarters (76%) of respondents across countries seek better pain control. Pain medication and rest/sleep consultation are the most common pain management strategies. More than half of respondents (56%) wait to see if pain will resolve spontaneously before taking any action, and 56% of those who use pain medication try some other approach first.

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Procedural Sedation and Pain Management

Pediatric Emergencies ◽

10.1093/med/9780190073879.003.0048 ◽

2020 ◽

pp. 588-602

Author(s):

Rosalia Holzman ◽

Jennifer Mitzman

Keyword(s):

Pain Management ◽

Pain Control ◽

Procedural Sedation ◽

Nerve Blocks ◽

Administration Routes ◽

Wide Range ◽

Age Appropriate ◽

Control Pain ◽

And Control ◽

Pharmacologic Agents

There are many conditions in the emergency department that require pain management or procedural sedation due to significant pain or complexity. There are also a number of procedures and conditions that will require pain control or anxiolysis in children due to developmental and behavioral factors. Pain control and procedural sedation in pediatric patients can be challenging. A variety of pharmacologic agents can be utilized to minimize anxiety and control pain. These have a wide range of administration routes, including topical, oral, intravenous, intramuscular, intranasal, and regional pain control via nerve blocks. In addition, many non-pharmacologic adjuncts can be coupled with age-appropriate interaction tips to decrease the medications required. This chapter discusses pharmacologic intervention, including narcotic and non-narcotic medications, non-pharmacologic interventions, procedural sedation, and nerve blocks.

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Pain Management after Outpatient Foot and Ankle Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000350 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0003

Author(s):

Austin Sanders ◽

Akash Gupta ◽

Mackenzie Jones ◽

Matthew Roberts ◽

David Levine ◽

...

Keyword(s):

Pain Management ◽

Peripheral Nerve ◽

Pain Control ◽

Outpatient Surgery ◽

The United States ◽

Prescribing Patterns ◽

Foot And Ankle ◽

Nerve Blocks ◽

Ankle Surgery ◽

Long Acting

Category: Pain Management, Anesthetic Advances Introduction/Purpose: The number of opioid prescriptions in the United States has significantly increased over the past 20 years, including those given after low-risk surgery. Unintentional opioid overdoses have also dramatically risen. Excess pills are widely acknowledged as a source of diversion, which accounts for up to 40% of opioid-related overdoses. In the foot and ankle literature, there are no studies looking at the quantity of pain medications that should be prescribed following outpatient surgery. Furthermore, with the increasing use of peripheral nerve blocks, their effect on quantities of narcotics needed after these surgeries have not been explored. This study aims to determine prescribing patterns for common outpatient foot and ankle surgery and whether patients are over or under-prescribed opioids and if so, by how much. Methods: 57 patients undergoing outpatient foot and ankle surgeries were prospectively enrolled. Patients received a spinal neuraxial block and a long-acting popliteal peripheral nerve block, and did not receive ketorolac perioperatively. Patients were excluded if they had a history of chronic pain, or were currently using opioids or muscle relaxers. Enrolled patients received a standard post-operative prescription regimen of 60 tablets of narcotics, 3 days of scheduled ibuprofen, aspirin 81 mg twice a day (or alternate based on risk factors) for DVT prophylaxis, and ondansetron taken as needed. Patients used a pain diary to record when their block wore off and the quantity of narcotic taken. They received surveys at post-operative day (POD) 3, 7, and 14 detailing how many days they took the medication and how many pills were consumed, how their actual pain compared to their expected level of pain, and if they were satisfied with their pain control. Results: At POD 3, compared to their expected level of pain 36 patients had less pain, 15 had the same pain, and 3 had more pain than expected. The mean pain score was 4. Patients first started feeling the block wear off at 0.9 days. Patients averaged 10.3 pills of narcotics in the first 3 days and rated their overall satisfaction with pain control at 8.5. Between days 4-7, patients took an average of 7 pills, and on POD 7, 22 patients were still taking narcotics. At POD 14, patients experienced 74.4% relief of pain compared to their expected pain, and rated their overall satisfaction at 8.2. Patients had an average of 33.5 remaining pills on POD 14 and 13 patients (22.8%) were still taking narcotics. Conclusion: Patients receiving spinal and long-acting popliteal blocks, followed by the prescription regimen described above had excellent pain control after outpatient foot and ankle surgeries. Patients had a high level of satisfaction with their pain control, with many patients describing better pain relief than expected. However, 60 tablets of narcotics were excessive in most cases. We suggest that in patients receiving spinal and long-acting popliteal blocks, 30 tablets of a narcotic would cover the pain needs of most patients. This would provide a small excess in case of need, but would help minimize the risk of narcotic related complications and diversion.

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Paper 44: Femoral Nerve Blocks are Effective for Post-Operative Pain Control after Hip Arthroscopy

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2012.04.050 ◽

2012 ◽

Vol 28 (6) ◽

pp. e69

Author(s):

Thomas Youm ◽

James Ward ◽

David Albert ◽

Robert Altman ◽

Andrew Rosenberg ◽

...

Keyword(s):

Hip Arthroscopy ◽

Pain Control ◽

Femoral Nerve ◽

Nerve Blocks ◽

Post Operative Pain

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Are Femoral Nerve Blocks Effective for Early Postoperative Pain Management After Hip Arthroscopy?

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2012.01.003 ◽

2012 ◽

Vol 28 (8) ◽

pp. 1064-1069 ◽

Cited By ~ 45

Author(s):

James P. Ward ◽

David B. Albert ◽

Robert Altman ◽

Rachel Y. Goldstein ◽

Germaine Cuff ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Hip Arthroscopy ◽

Femoral Nerve ◽

Postoperative Pain Management ◽

Nerve Blocks

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A Novel Technique to Reduce Reliance on Opioids for Analgesia from Acute Appendicitis: The Ultrasound-guided Erector Spinae Plane Block

Clinical Practice and Cases in Emergency Medicine ◽

10.5811/cpcem.2019.4.42117 ◽

2019 ◽

Vol 3 (3) ◽

pp. 248-251 ◽

Cited By ~ 2

Author(s):

Daniel Mantuani ◽

Josh Luftig ◽

Andrew Herring ◽

Andrea Dreyfuss ◽

Arun Nagdev

Keyword(s):

Pain Management ◽

Acute Appendicitis ◽

Pain Control ◽

Single Injection ◽

Femoral Nerve ◽

Injured Patient ◽

Erector Spinae ◽

Ultrasound Guided ◽

Nerve Blocks ◽

Hospital System

Single injection, ultrasound-guided nerve blocks have drastically changed the multimodal approach to pain management of the acutely injured patient in the emergency department (ED). Ultrasound-guided femoral nerve blocks in the ED have become standard aspects of multiple, hospital system pain management protocols, with early evidence demonstrating improved patient outcomes. Developing a multimodal pain management strategy can improve analgesia while reducing reliance on opioids in this era of opioid addiction.1 The single injection, ultrasound-guided erector spinae plane (ESP) block is a technique safely used for pain control for rib fractures that can be easily performed at the bedside and integrated into optimal emergency care. A more inferiorly located ultrasound-guided ESP block has been recently described in the anesthesia literature for perioperative pain control for various abdominal surgeries but has not yet been described for patients with acute appendicitis. Here we describe a single injection, lower ESP block performed by emergency physicians that successfully alleviated pain from acute appendicitis in an ED patient awaiting definitive surgical treatment. Along with allowing clinicians to actively manage pain without reliance on opioids, this novel ED technique may improve patient care outcomes.

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