The Role of Nerve Blocks in Hip Arthroscopy

The goal of this study is to determine whether QL blocks reduce opioid consumption following arthroscopic hip surgery by decreasing postoperative pain. Considering the current opioid epidemic, the responsibility of physicians to help prevent addiction, and the increasing prevalence of arthroscopic hip surgeries, this study holds a tremendous potential benefit for future patients.

Study Overview

• Status: Withdrawn
• Conditions: Femoroacetabular Impingement
• Intervention / Treatment: Drug: Saline Solution for Injection; Drug: Ropivacaine injection

Detailed Description

The popularity of arthroscopic hip surgery has increased greatly over the last 10 years, particularly for correcting Femoroacetabular Impingement (FAI). FAI is a structural abnormality of the proximal femur, the acetabulum, or both. It is a leading cause of labral tears in the hip joint and can cause cartilage damage, which may increase subsequent risk of developing osteoarthritis. Though far less invasive than open hip surgery such as for a total hip replacement, hip arthroscopy can cause significant postoperative pain for the patient. Given how relatively new the procedure still is, methods of pain control are highly variable. Peripheral nerve blocks, mainly femoral nerve and lumbar plexus blocks, have been used by some surgeons to control postoperative pain. However, in addition to their sensory effects, these blocks cause motor impairment that has been associated with a significantly higher risk of falling.

In managing pain after any operation, opioid consumption is, of course, a significant concern. Ideally, hip arthroscopy patients could receive a peripheral nerve block that decreases pain and the need for opioids, but without the muscular weakness and increased fall risk observed with femoral nerve and lumbar plexus blocks. This may be achievable with the newer Quadratus Lumborum (QL) block.

The ultrasound-guided QL block is currently most commonly used for abdominal surgery.

However, several case studies of a single-injection QL block in hip replacement surgeries have been successful in minimizing pain and opioid use while sparing motor function and avoiding the muscle weakness that can lead to falls. In the approach utilized in these cases, local anesthetic was injected at the anterolateral border of the QL muscle to achieve analgesia ranging from the T6-T10 through L3 dermatomes. One group has anecdotally reported great success in using these QL blocks for alleviating postoperative pain with hip arthroscopy, but no studies to date have evaluated the effectiveness of QL blocks for arthroscopic hip surgery.

This study is a randomized, controlled, double-blind trial. Patients undergoing hip arthroscopy who agree to participate will be randomly selected to receive an ultrasound-guided QL block with either local anesthetic (QL block group) or normal saline (control group) preoperatively.

After surgery and during the first postoperative week, patients will record their numerical pain score, the location of their pain, and their opioid consumption using our attached study instrument. On this form, they will record their pain score at 0.5, 1, 1.5, 2, 4, 6, 12, 24, and 48 hours and 7 days after surgery. The form specifies that if patients are unable to record their pain score at any of these time points, particularly because they are sleeping/recovering, they can simply skip that time point. For pain location, patients are instructed to draw X's on a standard cartoon at the site of their pain. For opioid consumption, patients simply record when and how many pills they take. This form will be collected from patients at their 10-14 day postoperative visit. Data will also be collected from the medical chart on time to discharge and any complications in the perioperative period. Questionnaires will be used to assess pain, physical and social health, such as Patient-Reported Outcomes Measurement Information System (PROMIS).

• Study Type: Interventional
• Phase: Phase 4

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients scheduled to receive unilateral arthroscopy hip surgery at Columbia University Medical Center with Dr. Lynch.

Exclusion Criteria:

• Patients scheduled to receive bilaterally or staged hip arthroscopy.
• Patients unwilling to participate in the research.
• History of chronic opioid use.
• Contraindication or allergy to study medications, such as QL block.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: Control; Subjects will be randomized to receive a single-injection QL block with normal saline (Saline Solution for Injection).	Drug: Saline Solution for Injection; 20 cc of saline will be injected in the form of a QL block as a placebo.; Other Names: Normal Saline
Experimental: QL Block; Subjects will be randomized to receive a single-injection QL block with either local anesthetic (0.25% Ropivacaine injection).	Drug: Ropivacaine injection; Naropin (Ropivacaine HCl) 0.25%; Dose: 20 cc; Other Names: Naropin

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	0.5 hour
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	1 hour
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	1.5 hours
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	2 hours
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	4 hours
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	6 hours
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	12 hours
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	24 hours
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	48 hours
Pain Score	Patients will record their numerical pain score on a scale of 0 to 10 (0 = no pain, 10 = worst pain imaginable)	7 days
Oral Morphine Equivalents	Opioid consumption following surgery as self reported by patients, measured in mg	24 hours after surgery
Oral Morphine Equivalents	Opioid consumption following surgery as self reported by patients, measured in mg	48 hours after surgery
Oral Morphine Equivalents	Opioid consumption following surgery as self reported by patients, measured in mg	7 days after surgery
Patient Satisfaction Score	Patients will record their satisfaction following surgery on a scale of 0-10 (0 being not satisfied, 10 being fully satisfied)	24 hours after surgery
Patient Satisfaction Score	Patients will record their satisfaction following surgery on a scale of 0-10 (0 being not satisfied, 10 being fully satisfied)	48 hours after surgery
Patient Satisfaction Score	Patients will record their satisfaction following surgery on a scale of 0-10 (0 being not satisfied, 10 being fully satisfied)	7 days after surgery
Percentage of Patients Reporting Nausea and/or Vomiting	Patients will self report any instances of nausea and/or vomiting	24 hours after surgery
Percentage of Patients Reporting Nausea and/or Vomiting	Patients will self report any instances of nausea and/or vomiting	48 hours after surgery
Percentage of Patients Reporting Nausea and/or Vomiting	Patients will self report any instances of nausea and/or vomiting	7 days after surgery

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
HOS-ADL Questionnaire Score	Hip Outcome Survey (HOS) is a self-administered questionnaire with a scoring system composed of 2 sub-scales - a rating tool to assess a patient's level of ability. Activities of Daily Living (ADL) sub-scale made of 19 items. Scales are scored from 0 to 4, with 0 being 'unable to do' and 4, 'no difficulty'. The average of the total scores of the patients in each arm will be provided.	Baseline preoperative
HOS-ADL Questionnaire Score	Hip Outcome Survey (HOS) is a self-administered questionnaire with a scoring system composed of 2 sub-scales - a rating tool to assess a patient's level of ability. Activities of Daily Living (ADL) sub-scale made of 19 items. Scales are scored from 0 to 4, with 0 being 'unable to do' and 4, 'no difficulty'. The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
mHHS Questionnaire Score	Modified Harris Hip Score (mHHS) is made up of 8 questions - a rating tool to assess how you are doing before and after surgery. The score is reported as 90-100 for excellent results, 80-89 being good, 70-79 fair, 60-69 poor, and below 60 a failed result.The average of the total scores of the patients in each arm will be provided.	Baseline preoperative
mHHS Questionnaire Score	Modified Harris Hip Score (mHHS) is made up of 8 questions - a rating tool to assess how you are doing before and after surgery. The score is reported as 90-100 for excellent results, 80-89 being good, 70-79 fair, 60-69 poor, and below 60 a failed result.The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
HOOS - Symptoms and Stiffness Questionnaire Score	A 40 item questionnaire (hip disability and osteoarthritis outcome score, HOOS) to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included. The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
HOOS - Symptoms and Stiffness Questionnaire Score	A 40 item questionnaire (hip disability and osteoarthritis outcome score, HOOS) to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included. The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
HOOS - ADL Questionnaire Score	A 40 item questionnaire (hip disability and osteoarthritis outcome score, HOOS) to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included.This subscale: Activities of Daily Living. The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
HOOS - ADL Questionnaire Score	A 40 item questionnaire (hip disability and osteoarthritis outcome score, HOOS) to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included.This subscale: Activities of Daily Living. The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
HOOS - Sports Questionnaire Score	HOOS will be used to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included. This subscale: Sport and Recreation Function (SP) (four items). The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
HOOS - Sports Questionnaire Score	HOOS will be used to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included. This subscale: Sport and Recreation Function (SP) (four items). The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
HOOS - Quality of Life Questionnaire Score	HOOS will be used to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included. This subscale: Hip Related Quality of Life (Q) (four items). The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
HOOS - Quality of Life Questionnaire Score	HOOS will be used to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included. This subscale: Hip Related Quality of Life (Q) (four items). The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
UCLA Activity Score Questionnaire Score	University of California, Los Angeles (UCLA) activity scale is a simple scale ranging from 1 to 10. The patient indicates her or his most appropriate activity level, with 1 defined as "no physical activity, dependent on others" and 10 defined as "regular participation in impact sports." The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
UCLA Activity Score Questionnaire Score	University of California, Los Angeles (UCLA) activity scale is a simple scale ranging from 1 to 10. The patient indicates her or his most appropriate activity level, with 1 defined as "no physical activity, dependent on others" and 10 defined as "regular participation in impact sports." The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
VR-12 Mental Health Questionnaire Score	Veterans Rand 12 Item Health Survey (VR-12) is a brief, generic, multi-use, self-administered health survey comprised of 12 items. The instrument is primarily used to measure health-related quality of life, to estimate disease burden and to evaluate disease-specific benchmarks with other populations. The 12 items are summarized into two scores, one for mental health and one for physical health. The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
VR-12 Mental Health Questionnaire Score	Veterans Rand 12 Item Health Survey (VR-12) is a brief, generic, multi-use, self-administered health survey comprised of 12 items. The instrument is primarily used to measure health-related quality of life, to estimate disease burden and to evaluate disease-specific benchmarks with other populations. The 12 items are summarized into two scores, one for mental health and one for physical health. The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
VR-12 Physical Health Questionnaire Score	VR-12 will be used to measure health-related quality of life, to estimate disease burden and to evaluate disease-specific benchmarks with other populations. The 12 items are summarized into two scores, one for mental health and one for physical health.The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
VR-12 Physical Health Questionnaire Score	VR-12 will be used to measure health-related quality of life, to estimate disease burden and to evaluate disease-specific benchmarks with other populations. The 12 items are summarized into two scores, one for mental health and one for physical health.The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
HOOS - Short Form Total Score Questionnaire Score	HOOS will be used to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included. The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
HOOS - Short Form Total Score Questionnaire Score	HOOS will be used to assess patient-relevant outcomes in five separate subscales. To answer each question, five Likert-boxes were used (no, mild, moderate, severe, extreme). All items were scored from zero to four, and each of the five subscales was calculated as the sum of the items included. The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
iHOT-12 Questionnaire Score	A Short Version of the International Hip Outcome Tool (iHOT-12) self administered outcome measure based on a Visual Analogue Scale response format designed for young and active population with hip pathology. The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
iHOT-12 Questionnaire Score	A Short Version of the International Hip Outcome Tool (iHOT-12) self administered outcome measure based on a Visual Analogue Scale response format designed for young and active population with hip pathology. The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
PROMIS v1.1 Pain Interference Questionnaire Score	PROMIS is a set of person-centered measures that evaluates and monitors physical, mental, and social health. The Pain Interference Questionnaire is comprised of 56 items, total score will be calculated. PROMIS is a computer adaptive test with branching logic. To answer each question, five Likert-boxes were used. The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
PROMIS v1.1 Pain Interference Questionnaire Score	PROMIS is a set of person-centered measures that evaluates and monitors physical, mental, and social health. The Pain Interference Questionnaire is comprised of 56 items, total score will be calculated. PROMIS is a computer adaptive test with branching logic. To answer each question, five Likert-boxes were used. The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
PROMIS v1.0 Pain Intensity 3a Questionnaire Score	PROMIS is a computer adaptive test with branching logic. The Pain Intensity Questionnaire is comprised of 3 items, total score will be calculated. To answer each question, five Likert-boxes were used (no pain, mild, moderate, severe, very severe). The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
PROMIS v1.0 Pain Intensity 3a Questionnaire Score	PROMIS is a computer adaptive test with branching logic. The Pain Intensity Questionnaire is comprised of 3 items, total score will be calculated. To answer each question, five Likert-boxes were used (no pain, mild, moderate, severe, very severe). The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
PROMIS v1.2 Physical Function Questionnaire Score	PROMIS is a computer adaptive test with branching logic. The Physical Function Questionnaire is comprised of 170 items, total score will be calculated. To answer each question, five Likert-boxes were used (without any difficulty, with a little difficulty, with some difficulty, with much difficulty, unable to do). The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
PROMIS v1.2 Physical Function Questionnaire Score	PROMIS is a computer adaptive test with branching logic. The Physical Function Questionnaire is comprised of 170 items, total score will be calculated. To answer each question, five Likert-boxes were used (without any difficulty, with a little difficulty, with some difficulty, with much difficulty, unable to do). The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
PROMIS v2.0 Ability to Participate Socially Questionnaire Score	PROMIS is a computer adaptive test with branching logic. The Ability to Participate Socially Questionnaire is comprised of 35 items, total score will be calculated. To answer each question, five Likert-boxes were used (never, rarely, sometimes, usually, always). The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
PROMIS v2.0 Ability to Participate Socially Questionnaire Score	PROMIS is a computer adaptive test with branching logic. The Ability to Participate Socially Questionnaire is comprised of 35 items, total score will be calculated. To answer each question, five Likert-boxes were used (never, rarely, sometimes, usually, always). The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery
PROMIS v2.0 Satisfaction with Roles and Activities Questionnaire Score	PROMIS is a computer adaptive test with branching logic. The Ability to Participate Socially Questionnaire is comprised of 44 items, total score will be calculated. To answer each question, five Likert-boxes were used (not at all, a little bit, somewhat, quite a bit, very much). The average of the total scores of the patients in each arm will be provided.	Baseline preoperatively
PROMIS v2.0 Satisfaction with Roles and Activities Questionnaire Score	PROMIS is a computer adaptive test with branching logic. The Ability to Participate Socially Questionnaire is comprised of 44 items, total score will be calculated. To answer each question, five Likert-boxes were used (not at all, a little bit, somewhat, quite a bit, very much). The average of the total scores of the patients in each arm will be provided.	2 weeks after surgery

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to Discharge	The average time for the experimental patients to be discharged (in minutes)	Up to 1 day (day of surgery)
Percentage of patients reporting falls in the first 24 hours after surgery	Falls will be self reported by patients	24 hours after surgery

Collaborators and Investigators

• Sponsor: Columbia University
• Investigators: Principal Investigator: Thomas S Lynch, M.D., Columbia University Department of Orthopedics

Publications and helpful links

General Publications

• La Colla L, Ben-David B, Merman R. Quadratus Lumborum Block as an Alternative to Lumbar Plexus Block for Hip Surgery: A Report of 2 Cases. A A Case Rep. 2017 Jan 1;8(1):4-6. doi: 10.1213/XAA.0000000000000406.
• La Colla L, Uskova A, Ben-David B. Single-shot Quadratus Lumborum Block for Postoperative Analgesia After Minimally Invasive Hip Arthroplasty: A New Alternative to Continuous Lumbar Plexus Block? Reg Anesth Pain Med. 2017 Jan/Feb;42(1):125-126. doi: 10.1097/AAP.0000000000000523. No abstract available.
• Ben-David B, La Colla L. Extravasated Fluid in Hip Arthroscopy and Pain: Is Quadratus Lumborum Block the Answer? Anesth Analg. 2017 Jul;125(1):364. doi: 10.1213/ANE.0000000000002198. No abstract available.

Study record dates

Study Major Dates

• Study Start (Anticipated): January 1, 2019
• Primary Completion (Actual): February 7, 2020
• Study Completion (Actual): February 7, 2020

Study Registration Dates

• First Submitted: April 13, 2018
• First Submitted That Met QC Criteria: April 23, 2018
• First Posted (Actual): April 24, 2018

Study Record Updates

• Last Update Posted (Actual): May 20, 2020
• Last Update Submitted That Met QC Criteria: May 18, 2020
• Last Verified: May 1, 2020

More Information

Terms related to this study

• Keywords: femoroacetabular impingement; hip arthroscopy; QL nerve block
• Additional Relevant MeSH Terms: Pathologic Processes; Joint Diseases; Musculoskeletal Diseases; Femoracetabular Impingement; Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Sensory System Agents; Anesthetics; Anesthetics, Local; Ropivacaine
• Other Study ID Numbers: AAAR7247

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No