Original Article Clinics in Orthopedic Surgery 2015;7:164-170 • http://dx.doi.org/10.4055/cios.2015.7.2.

164

Comparison of Continuous Epidural Analgesia,

Patient-Controlled Analgesia with Morphine,
and Continuous Three-in-One Femoral Nerve
Block on Postoperative Outcomes
after Total Hip Arthroplasty
Tomonori Tetsunaga, MD, Toru Sato, MD, Naofumi Shiota, MD, Tomoko Tetsunaga, MD*,
Masahiro Yoshida, MD, Yoshiki Okazaki, MD, Kazuki Yamada, MD
Department of Orthopaedic Surgery, Okayama Medical Center, Okayama,
*Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan

Background: Postoperative pain relief can be achieved with various modalities. However, there are only few reports that have
analyzed postoperative analgesic techniques in total hip arthroplasty patients. The aim of this retrospective study was to compare
the postoperative outcomes of three different analgesic techniques after total hip arthroplasty.
Methods: We retrospectively reviewed the influence of three analgesic techniques on postoperative rehabilitation after total hip
arthroplasty in 90 patients divided into three groups (n = 30 patients per group). Postoperative analgesia consisted of continuous
epidural analgesia (Epi group), patient-controlled analgesia with morphine (PCA group), or a continuous femoral nerve block (CFNB
group). We measured the following parameters relating to postoperative outcome: visual analog scale scores, the use of supple-
mental analgesia, side effects, length of the hospital stay, plasma D-dimer levels, and the Harris hip score.
Results: Each group had low pain scores with no significant differences between the groups. The PCA group had a lower fre-
quency of supplemental analgesia use compared to the Epi and CFNB groups. Side effects (nausea/vomiting, inappetence) and day
7 D-dimer levels were significantly lower in the CFNB group (p < 0.05). There were no significant differences between the groups
in terms of the length of the hospital stay or the Harris hip score.
Conclusions: Although there were no clinically significant differences in outcomes between the three groups, the CFNB provided
good pain relief which was equal to that of the other analgesics with fewer side effects and lower D-dimer levels in hospitalized
patients following total hip arthroplasty.
Keywords: Nerve block, Epidural anesthesia, Morphine, Total hip arthroplasty

Total hip arthroplasty (THA) is the primary orthopaedic early physical therapy following THA can be hindered by
surgical procedure used to alleviate hip pain due to de- postoperative pain. Postoperative pain relief after joint
generative diseases and improve quality of life. However, surgery can be achieved with various modalities such as
patient-controlled analgesia (PCA) with morphine, epi-
dural analgesia (Epi), and lumbar plexus and/or sciatic
Received October 3, 2014; Accepted February 15, 2015
blocks.1-5) Each of these analgesic options has advantages
Correspondence to: Tomonori Tetsunaga, MD
and disadvantages. The advantages of PCA are fewer
Department of Orthopaedic Surgery, Okayama Medical Center, 1711-1
Tamasu, Kitaku, Okayama 701-1192, Japan
technical problems, and uniform and sustained analgesia
Tel: +81-86-294-9911, Fax: +81-86-294-9255 with autonomy.6,7) The advantages of Epi are based on the
E-mail: [email protected] associated improved postoperative analgesia, and a reduc-
Copyright © 2015 by The Korean Orthopaedic Association
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Clinics in Orthopedic Surgery • pISSN 2005-291X eISSN 2005-4408
 165
Tetsunaga et al. Pain Management after Total Hip Arthroplasty
Clinics in Orthopedic Surgery • Vol. 7, No. 2, 2015 • www.ecios.org

tion in blood loss during surgery.1) Although both PCA tinuous Epi group (n = 30), PCA with morphine (PCA
and continuous Epi provide sufficient pain relief, they are group, n = 30), or a CFNB group (n = 30) (Table 1). On
associated with multiple side effects, including arterial hy- postoperative day 1, all patients in the PCA and CFNB
potension, respiratory depression, nausea/vomiting, and groups started fondaparinux (2.5 mg/day), which was con-
enuresis.5) Continuous femoral nerve block (CFNB) after tinued for 14 days. In the Epi group, the first fondaparinux
total knee arthroplasty (TKA) is one of the more popular injection was administered 2 hours after removal of the
types of analgesia with fewer side effects associated with epidural catheter on postoperative day 2. On postopera-
the use of morphine or fentanyl.1,5) On the other hand, tive day 1, all patients began a regimen of movement and
there are a few studies reporting on good outcomes using strengthening exercises; they were encouraged to complete
CFNB after THA.2,5,8) The effects of CFNB on immediate full weight-bearing exercises on postoperative day 2. On
postoperative outcome in patients undergoing THA have postoperative day 7, all patients underwent contrast-en-
not been fully evaluated. hanced computed tomography (CT) to rule out DVT and/
Deep venous thrombosis (DVT) is a common post- or pulmonary embolism (PE).
operative complication that can cause significant morbidi- In the Epi group, Epi was administered before gen-
ty and mortality after orthopaedic surgery, especially THA eral anesthesia at the level of L2–3 or L3–4. An 18-gauge
and TKA.9,10) D-dimer is a degradation product of cross- (G) catheter (Perifix, B-Brown, Tokyo, Japan) was thread-
linked fibrin; plasma levels increase after the cleavage of ed 4 to 5 cm into the epidural space. After a negative test,
thrombi by activated plasmin and have been suggested to a dose of 0.2% ropivacaine (2 mg/mL) with 0.5 mg of fen-
be a useful marker for the diagnosis of DVT.11,12) There are tanyl (4.5 × 10-­3 mg/mL) was injected at a rate of 2–4 mL/
few reports comparing the influence of different postoper- hr postoperatively; epidural fentanyl was continued for 48
ative analgesia techniques on patient outcomes, including hours, and the epidural catheter was removed on postop-
D-dimer levels, after THA. erative day 2.
The aim of the present study was to compare pain In the PCA group, each patient was educated about
relief with continuous Epi, PCA with morphine, and con- the use of PCA. All patients were provided with PCA de-
tinuous three-in-one femoral nerve block on postoperative vices supplying 1.0 mg/hr of morphine at a demand dose
outcomes, including D-dimer levels, after THA. of 1.0 mg and a lockout interval of 20 minutes. The pa-

METHODS Table 1 . Patient Background

We retrospectively reviewed and analyzed the clinical
Epi PCA CFNB
outcomes of three postoperative analgesia techniques after Variable p-value
(n = 30) (n = 30) (n = 30)
THA. We initially included110 patients (14 males and 96
Age (yr) 64 ± 10.4 66.6 ± 12.7 68 ± 11.0 0.53
females) who were admitted to Okayama Medical Center
with hip pain and scheduled for THA under general an- Female 23 26 26 0.63
esthesia. Patients with any of the following criteria were 2
Body mass index (kg/m ) 23.4 ± 3.8 24.4 ± 4.1 23.4 ± 4.2 0.68
excluded: local infection, cemented THA, revision THA,
Disease
preoperative DVT, renal failure, bleeding tendency due
to anticoagulant therapy, or allergy to local anesthetics or Osteoarthritis 25 27 25
opioids. We obtained informed consent from patient be- Rheumatoid arthritis 1 1 1
fore surgery and ethical approval was obtained from the
ANFH 3 1 3
Institutional Review Board. Ninety patients (14 males and
76 females; mean age, 68 years; range, 31 to 86 years) were Femoral neck fracture 1 1 1
included in this study. Preoperative comorbidity was ana- Comorbidity index (point) 2.7 ± 1.7 3.0 ± 2.2 3.1 ± 1.0 0.64
lyzed according to the comorbidity index.13)
All patients in this study had been operated on by Harris hip score (point) 36.7 ± 13.3 37.8 ± 13.2 35 ± 19.0 0.37
the three experienced hip surgeons. The direct-lateral Operation time (min) 87.1 ± 22.0 87.8 ± 20.6 81.8 ± 18.6 0.53
(modified Hardinge) approach was used in all patients. Bleeding (mL) 262 ± 147 233 ± 153 207 ± 127 0.42
In this study, we used the cementless implants for THA
(Summit, DePuy, Warsaw, IN, USA). Anesthesiologists Values are presented as mean ± standard deviation.
Epi: epidural analgesia, PCA: patient-controlled analgesia, CFNB: continuous
instituted one of the following analgesic modalities: con- femoral nerve block, ANFH: avascular necrosis of the femoral head.
 166
Tetsunaga et al. Pain Management after Total Hip Arthroplasty
Clinics in Orthopedic Surgery • Vol. 7, No. 2, 2015 • www.ecios.org

tients were encouraged to take a bolus as often as needed. effects, and the length of the hospital stay were recorded
In the CFNB group, a continuous 3-in-1 block was for each group. Peripheral blood samples were obtained
administered following the induction of general anesthesia from all patients preoperatively and on days 1, 3, and 7. All
according to the method described by Winnie et al.14) The samples were analyzed within 1 hour of being obtained.
femoral artery was located below the inguinal ligament, The D-dimer level was determined at each time-point and
and an 18-G needle (1.3 × 50 mm, Contiplex, B-Braun) used to assess coagulation and fibrinolytic factors.
connected to a nerve stimulator (Stimuplex HNS12, B-
Braun) was inserted just lateral to the artery via echogra- Statistical Analysis
phy (MICROMAXX, SonoSite). The femoral nerve was All data were normally distributed and are expressed
accurately identified by eliciting contractions of the quad- as means with standard deviation. Differences between
riceps with minimal stimulator settings (frequency, 2 Hz; groups were compared using a one-way analysis of vari-
current, 0.5 mA).15) Using the Seldinger technique, a20- ance (ANOVA) with the Bonferroni post hoc test. Fischer's
G catheter (0.85 × 1,000 mm, Contiplex, B-Braun) was exact test was used to compare differences in the gender
placed 10–15 cm into the psoas compartment, secured in ratio and the side effects between the three groups. All
place with Steri-strips (3M Health Care, Tokyo, Japan), differences were considered statistically significant at a p-
and covered with a transparent dressing (Tegaderm, 3M value < 0.05.
Health Care). After a negative aspiration test for blood, A pilot study was carried out on ten patients in each
0.2% ropivacaine (2 mg/mL) was injected at a rate of 4 group. As a result of the pilot study, the mean D-dimer
mL/hr postoperatively. levels (by postoperative day 7) were 6.5 g/mL in the Epi
Patients with intolerable pain were given loxoprofen group, 6.6 g/mL in the PCA group, and 4.4 μg/mL in the
sodium (60 mg) by mouth up to every 6 hours. If the pain CFNB group, with a standard deviation of 3. Based on the
persisted after 30 minutes, a diclofenac sodium supposi- effect size in this pilot study, a power calculation for a trial
tory (25 mg) was administered. The patient’s pain inten- (effect size, 0.34; α, 0.05; power, 0.8) suggest that 29 pa-
sity at rest was self-assessed using a visual analog scale tients would be needed in each group.
(VAS) at 24 hours postoperatively. The VAS for pain self-
assessment is a widely used, valid, and reliable tool to mea-
sure pain intensity.16) A 100-mm VAS was employed, and
RESULTS
patients could rate pain intensity from no pain (0 mm) No significant differences were identified in the popula-
to unbearable pain (100 mm). Metoclopramide hydro- tion data (race, age, gender ratio, body mass index, disease,
chloride was used to treat nausea and vomiting. Clinical and comorbidity index), preoperative HHS, operation
severity was assessed using the Harris hip score (HHS) on time, or bleeding between the three groups (Table 1). The
postoperative day 10.17) VAS score on postoperative day 1 did not significantly dif-
Food intake, use of supplemental analgesia, side fer between the groups (p = 0.72) (Fig. 1A). The amount

A B
100 6 *
90
5
80
70
VAS score (mm)

4
No. of times

60
50 3
40
2
30
20
1
10
0 0
Epi PCA CFNB Epi PCA CFNB

Fig. 1. (A) VAS for each group at 24 hours postoperatively. The VAS scores were not significantly different among the three groups. (B) Additional
analgesic treatment was given to each of the three groups for two days after surgery. Values are presented as mean ± standard deviation. VAS: visual
analog scale, Epi: epidural analgesia, PCA: patient-controlled analgesia, CFNB: continuous femoral nerve block. *p < 0.05.
 167
Tetsunaga et al. Pain Management after Total Hip Arthroplasty
Clinics in Orthopedic Surgery • Vol. 7, No. 2, 2015 • www.ecios.org

of loxoprofen sodium hydrate and diclofenac sodium contrast-enhanced CT to rule out DVT and/or PE. DVT
suppositories used by the CFNB group were significantly was identified by contrast-enhanced CT in two of 30 pa-
greater than that used by the PCA group (p < 0.05) (Fig. tients (6.7%) in both the Epi and PCA groups. No patients
1B). with DVT were identified in the CFNB group. There was
Seven patients in the Epi group, eight in the PCA not a significant difference in the incidence of DVT and/or
group, and one in the CFNB group developed nausea and/ PE as detected by contrast-enhanced CT (p = 0.54). There
or vomiting after THA (p < 0.05). Patients with nausea was no significant difference in the HHS on postoperative
were unable to begin movement and strengthening ex- day 10 between the groups (p = 0.10).
ercises on postoperative day 1. An ANOVA test showed
that there were significant differences in the mean amount
of food intake on postoperative day 1 between the three
DISCUSSION
groups (p < 0.05). The amount of food intake on postop- Postoperative pain control after THA enables patients to
erative day 1 was significantly greater in the CFNB group achieve earlier hip mobilization and restoration of func-
(70% ± 32%) relative to the Epi (50% ± 41%, p < 0.05) and tion. Compared with PCA and continual Epi, CFNB
PCA groups (37% ± 34%, p < 0.01). Food consumption provides good pain relief and is associated with fewer side
during breakfast and lunch was significantly greater in the effects such as nausea/vomiting, hematomas, arterial hy-
CFNB group relative to the Epi group (p < 0.05), whereas potension, and drowsiness.2,8) In our study, a significant
food consumption during all meals (breakfast, lunch, and number of patients in the Epi and PCA groups developed
dinner) was significantly greater in the CFNB group rela- nausea and/or vomiting, which resulted in poor appetites
tive to the PCA group (p < 0.01) (Fig. 2). The mean hos- and prevented these patients from starting postoperative
pital stay, including postoperative rehabilitation, was 25.3 rehabilitation on the day after surgery. We injected 0.2%
± 5.1, 23.3 ± 4.6, and 23 ± 3.1 days for the Epi, PCA, and ropivacaine (2 mg/mL) with 0.5 mg of fentanyl (4.5 × 10-3
CFNB groups, respectively; there was no significant dif- mg/mL) in the Epi group. A high incidence of nausea/
ference in the length of the hospital stay between the three vomiting in the Epi and PCA groups might be influenced
groups (p = 0.17). by the use of fentanyl or morphine. Different results might
There were no significant differences in D-dimer be obtained if studied without fentanyl in the Epi group.
levels between the three groups, except for on day 7, when However, because a pure local anesthetic may provide
the mean D-dimer level was significantly lower in the dense sensory and motor blockade, a combination of an
CFNB group (4.5 ± 1.5 μg/mL) compared with the Epi (6.7 opioid and a local anesthetic is recommended.6)
± 4.0 μg/mL) and PCA (6.4 ± 4.0 μg/mL) groups (p < 0.05) Postoperative analgesics promote early recovery
(Fig. 3). On postoperative day 7, all patients underwent with a lower incidence of DVT/PE.18) Although no signifi-
cant difference was found in the rate of DVT/PE between

Epi PCA CFNB

* * Epi PCA CFNB *
12
** ** ** *
100
90 10
80
D-dimer (mg/mL)

8
70
Percentage

60 6
50
40 4
30
2
20
10 0
0 0 1 3 7
Breakfast Lunch Dinner Day

Fig. 2. Food intake of the three groups on postoperative day 1. Values are Fig. 3. D-dimer levels preoperatively (day 0) and on postoperative days
presented as mean ± standard deviation. Epi: epidural analgesia, PCA: 1, 3, and 7. Values are presented as mean ± standard deviation. Epi:
patient-controlled analgesia, CFNB: continuous femoral nerve block. *p < epidural analgesia, PCA: patient-controlled analgesia, CFNB: continuous
0.05. **p < 0.01. femoral nerve block. *p < 0.05.
 168
Tetsunaga et al. Pain Management after Total Hip Arthroplasty
Clinics in Orthopedic Surgery • Vol. 7, No. 2, 2015 • www.ecios.org

the three groups in this study, D-dimer levels were signifi- hr to be appropriate in minimizing the risk of falling after
cantly higher in both the Epi and PCA groups compared THA. A variety of techniques, including continuous Epi,
with the CFNB group on postoperative day 7D-dimer is PCA, and CFNB have been used and compared in terms
a protein fragment formed following the degradation of of their efficacy and postoperative rehabilitation outcomes
a fibrin clot; it is a useful indicator of several conditions, in TKA patients.5,25) However, only a few reports have ana-
including venous thromboembolism, disseminated intra- lyzed these three analgesic techniques in THA patients.2,8)
vascular coagulation, and cardiovascular disease.19) The In this study, we integrated the use of ultrasound-guided
higher D-dimer levels in the Epi and PCA groups in our CFNB and compared it with the postoperative outcomes
study might have been affected by inadequate fluid and of these techniques after THA. There was no significant
dietary intake due to postoperative nausea and vomiting. difference in the VAS score between the groups, and each
Delayed rehabilitation, including active exercise and walk- group had good pain relief, which is in accordance with
ing, may have also contributed to the increase in D-dimer a previous report.5) Although the amount of loxoprofen
levels in these groups. Accordingly, the lower D-dimer sodium hydrate administered in the PCA group was
levels in the CFNB group might have been influenced by significantly lower than that administered in the CFNB
early mobilization, rehabilitation, and a lower incidence of group (p < 0.05), this difference might be due to the ability
side effects. of the PCA group to self-administer additional boluses of
However, it might not be valid to compare D-dimer morphine. However, when large amounts of loxoprofen
levels of the Epi group with those of the PCA and CFNB sodium hydrate are given, side effects may develop. Addi-
groups, since patients in the Epi group did not receive tionally, the frequent dosing of loxoprofen sodium hydrate
chemical anticoagulation for 2 days in order to reduce the increases the duties of the floor nurse.
risk of bleeding. In patients receiving Epi, the risk of clini- Although CFNB enables selective anesthesia at the
cally significant bleeding increases in response to preven- surgical site, the peripheral nerves have a complicated
tive measures against DVT/PE. According to the regional distribution and ectopia can make it more challenging.
anesthesia and anticoagulation guidelines formulated by Although permanent neurological injury after regional
the American Society of Regional Anesthesia and Pain anesthesia is rare in contemporary anesthetic practice, the
Medicine,20) it is important to prevent epidural hemato- rate of neurological complications after CFNB is higher
mas,21) which is a potential disadvantage of this modal- than epidural anesthesia.26) The use of supplemental de-
ity. To minimize the risk of hematomas, we cannot use vices enabled us to place the local nerve block with more
fondaparinux or other anticoagulants in a patient under precision in this study. We utilized echography, which is
Epi. If it is necessary to remove an epidural catheter ear- widely used owing to its portability and functionality. In
lier than desired in order to use an antithrombotic agent, the current study, there was no neurological injury after
the use of nonsteroidal anti-inflammatory drugs can be CFNB. The resulting enhanced echographic image quality
increased. In general, CFNB may be a more advantageous and concurrent use of an electrostimulator enabled us to
technique in patients receiving anticoagulants. accurately identify the nerve and its innervation zone.
A potential disadvantage of CFNB is a higher risk of This study has some limitations and weakness.
falling. Because patients have an increased risk of falling as Firstly, the present study’s retrospective nature is a weak-
a consequence of persistent quadriceps muscle weakness ness. A prospective, randomized, controlled study should
after receiving high doses of this type of analgesia, both the be conducted to eliminate selection bias and obtain more
density and flow of a CFNB should be controlled in accor- consolidated results. Secondly, the sample size is relatively
dance with its effect.22) Although we did not use any knee small, which makes explaining the effect of three differ-
immobilizers in this study, no patients in the CFNB group ent postoperative analgesia techniques difficult. To vali-
complained of postoperative quadriceps muscle weakness. date our findings, future studies with large sample sizes
In past studies, among patients receiving ropivacaine 0.2% and a prospective design are needed to further define
at 8 mL/hr, 42% to 43% experienced quadriceps femo- the efficacy of CFNB. Thirdly, we performed THA under
ris weakness,23) which may have resulted in an increase general anesthesia in this study. However, some clinical
number of falls. Ilfeld et al.24) recommended that if pa- studies support a transition to spinal conduction blockade
tients receiving ropivacaine 0.2% at 6 mL/hr experienced for intraoperative anesthetic management of orthopedic
quadriceps femoris weakness, the basal administration surgery. This technique has lower complications rate,27)
rate should be reduced by half (to 3 mL/hr). Based on our including reduced blood loss28) and decreased incidence of
experience, we consider a ropivacaine (0.2%) rate of 4 mL/ DVT.29) It is possible that we might have obtained different
 169
Tetsunaga et al. Pain Management after Total Hip Arthroplasty
Clinics in Orthopedic Surgery • Vol. 7, No. 2, 2015 • www.ecios.org

outcomes if we had used intraoperative spinal anesthesia the skin incision adjacent to CFNB. Additionally, if stud-
in this study. Moreover, in previous studies, the length of ied in the patients undergoing THA via the posterolateral
the hospital stay was shorter in patients who underwent approach, dividing short rotators and quadratus femoris, a
TKA under spinal anesthesia compared with general anes- different outcome might be obtained.
thesia,27) making spinal anesthesia more cost-effective.30) In Although there were no significant differences in
our study, there was no significant difference between the postoperative HHS between the three groups in our study,
length of the hospital stay or the costs between the three postoperative CFNB use achieved good pain relief—equal
groups because Japan’s universal health insurance system to that of other analgesics—with fewer side effects in hos-
keeps medical expenses relatively low for all patients, and pitalized patients following THA.
patients tend to stay in the hospital until they complete
their postoperative rehabilitation. Finally, all THAs in this
study were performed through the Hardinge approach.
CONFLICT OF INTEREST
It is not possible to perform CFNB using the anterior ap- No potential conflict of interest relevant to this article was
proach, including the direct anterior approach because of reported.

REFERENCES

1. Chelly JE, Greger J, Gebhard R, et al. Continuous femoral a prospective evaluation by our acute pain service in more
blocks improve recovery and outcome of patients undergo- than 1,300 patients. J Clin Anesth. 1999;11(7):550-4.
ing total knee arthroplasty. J Arthroplasty. 2001;16(4):436-
9. Niimi R, Hasegawa M, Shi DQ, Sudo A. The influence of
45.
fondaparinux on the diagnosis of postoperative deep vein
2. Singelyn FJ, Ferrant T, Malisse MF, Joris D. Effects of intra- thrombosis by soluble fibrin and D-dimer. Thromb Res.
venous patient-controlled analgesia with morphine, con- 2012;130(5):759-64.
tinuous epidural analgesia, and continuous femoral nerve
10. Piovella F, Wang CJ, Lu H, et al. Deep-vein thrombosis rates
sheath block on rehabilitation after unilateral total-hip ar-
after major orthopedic surgery in Asia: an epidemiologi-
throplasty. Reg Anesth Pain Med. 2005;30(5):452-7.
cal study based on postoperative screening with centrally
3. Buckenmaier CC 3rd, Xenos JS, Nilsen SM. Lumbar plexus adjudicated bilateral venography. J Thromb Haemost. 2005;
block with perineural catheter and sciatic nerve block for 3(12):2664-70.
total hip arthroplasty. J Arthroplasty. 2002;17(4):499-502.
11. Yukizawa Y, Inaba Y, Watanabe S, et al. Association between
4. Chelly JE, Schilling D. Thromboprophylaxis and peripheral venous thromboembolism and plasma levels of both soluble
nerve blocks in patients undergoing joint arthroplasty. J Ar- fibrin and plasminogen-activator inhibitor 1 in 170 patients
throplasty. 2008;23(3):350-4. undergoing total hip arthroplasty. Acta Orthop. 2012;83(1):
14-21.
5. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur
JM. Effects of intravenous patient-controlled analgesia with 12. Shiota N, Sato T, Nishida K, et al. Changes in LPIA D-dimer
morphine, continuous epidural analgesia, and continuous levels after total hip or knee arthroplasty relevant to deep-
three-in-one block on postoperative pain and knee rehabili- vein thrombosis diagnosed by bilateral ascending venogra-
tation after unilateral total knee arthroplasty. Anesth Analg. phy. J Orthop Sci. 2002;7(4):444-50.
1998;87(1):88-92.
13. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new
6. Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat method of classifying prognostic comorbidity in longitu-
CS. Multimodal pain management after total hip and knee dinal studies: development and validation. J Chronic Dis.
arthroplasty at the Ranawat Orthopaedic Center. Clin Or- 1987;40(5):373-83.
thop Relat Res. 2009;467(6):1418-23.
14. Winnie AP, Ramamurthy S, Durrani Z. The inguinal para-
7. Sinatra RS, Torres J, Bustos AM. Pain management after vascular technic of lumbar plexus anesthesia: the "3-in-1
major orthopaedic surgery: current strategies and new con- block". Anesth Analg. 1973;52(6):989-96.
cepts. J Am Acad Orthop Surg. 2002;10(2):117-29.
15. Hunt KJ, Bourne MH, Mariani EM. Single-injection femo-
8. Singelyn FJ, Gouverneur JM. Postoperative analgesia after ral and sciatic nerve blocks for pain control after total knee
total hip arthroplasty: i.v. PCA with morphine, patient- arthroplasty. J Arthroplasty. 2009;24(4):533-8.
controlled epidural analgesia, or continuous "3-in-1" block?:
 170
Tetsunaga et al. Pain Management after Total Hip Arthroplasty
Clinics in Orthopedic Surgery • Vol. 7, No. 2, 2015 • www.ecios.org

16. Bellamy N, Kirwan J, Boers M, et al. Recommendations for ous posterior lumbar plexus nerve blocks after hip arthro-
a core set of outcome measures for future phase III clinical plasty: a dual-center, randomized, triple-masked, placebo-
trials in knee, hip, and hand osteoarthritis: consensus de- controlled trial. Anesthesiology. 2008;109(3):491-501.
velopment at OMERACT III. J Rheumatol. 1997;24(4):799-
24. Ilfeld BM, Mariano ER, Madison SJ, et al. Continuous femo-
802.
ral versus posterior lumbar plexus nerve blocks for analge-
17. Harris WH. Traumatic arthritis of the hip after dislocation sia after hip arthroplasty: a randomized, controlled study.
and acetabular fractures: treatment by mold arthroplasty. Anesth Analg. 2011;113(4):897-903.
An end-result study using a new method of result evalua-
25. Baker MW, Tullos HS, Bryan WJ, Oxspring H. The use of
tion. J Bone Joint Surg Am. 1969;51(4):737-55.
epidural morphine in patients undergoing total knee arthro-
18. Grass JA. The role of epidural anesthesia and analgesia in plasty. J Arthroplasty. 1989;4(2):157-61.
postoperative outcome. Anesthesiol Clin North America.
26. Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurologi-
2000;18(2):407-28.
cal complications after regional anesthesia: contemporary
19. Lippi G, Franchini M, Targher G, Favaloro EJ. Help me, estimates of risk. Anesth Analg. 2007;104(4):965-74.
Doctor! My D-dimer is raised. Ann Med. 2008;40(8):594-
27. Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Callaghan
605.
JJ. Differences in short-term complications between spinal
20. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional an- and general anesthesia for primary total knee arthroplasty. J
esthesia in the patient receiving antithrombotic or thrombo- Bone Joint Surg Am. 2013;95(3):193-9.
lytic therapy: American Society of Regional Anesthesia and
28. Modig J. Regional anaesthesia and blood loss. Acta Anaes-
Pain Medicine Evidence-Based Guidelines (Third Edition).
thesiol Scand Suppl. 1988;89:44-8.
Reg Anesth Pain Med. 2010;35(1):64-101.
29. Modig J, Malmberg P, Karlstrom G. Effect of epidural versus
21. Christie IW, McCabe S. Major complications of epidural
general anaesthesia on calf blood flow. Acta Anaesthesiol
analgesia after surgery: results of a six-year survey. Anaes-
Scand. 1980;24(4):305-9.
thesia. 2007;62(4):335-41.
30. Gonano C, Leitgeb U, Sitzwohl C, Ihra G, Weinstabl C,
22. Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott
Kettner SC. Spinal versus general anesthesia for orthopedic
NB. Femoral nerve block for total knee replacement: a word
surgery: anesthesia drug and supply costs. Anesth Analg.
of caution. Knee. 2009;16(2):98-100.
2006;102(2):524-9.
23. Ilfeld BM, Ball ST, Gearen PF, et al. Ambulatory continu-