Perioperative pain management in orthopaedic surgery continues to be an area ripe for study. Peripheral nerve blocks have frequently been utilized to help provide pain control, but in hip surgery, there has been some question as to whether certain blocks are preferred to a local multimodal injection.
Li et al. present valuable insights into pain management techniques in a well-performed prospective randomized controlled trial. Their study is in the October 7, 2026 issue of The Journal:
This was a single-center randomized controlled trial conducted at Yale New Haven Hospital. The authors compared 2 regional analgesic strategies for primary total hip arthroplasty (THA): preoperative anterior quadratus lumborum block, a fascial plane block, combined with a lateral femoral cutaneous nerve block (aQLB+LFCNB) versus surgeon-administered periarticular and local infiltration analgesia (PALIA).
To isolate the effect of delivery route, both arms received an identical mixture of 60 mL of 0.2% ropivacaine with dual glucocorticoids: 10 mg of hydrophilic dexamethasone sodium phosphate and 80 mg of lipophilic methylprednisolone acetate, intended to prolong analgesia to 48 to 72 hours.
Study Highlights
- A total of 192 patients undergoing elective unilateral THA for osteoarthritis were randomized, and 188 were analyzed (93 aQLB+LFCNB, 95 PALIA). All received spinal anesthesia and a standardized multimodal regimen.
- The primary outcome was opioid consumption on postoperative day (POD) 1; secondary outcomes included POD-2 opioid use, Brief Pain Inventory scores, AMPAC mobility scores, length of stay, fasting glucose, white blood-cell count, and PROMIS scores through 1 year.
- Opioid use on POD 1 did not differ between groups (median 29.8 vs. 30.5 oral morphine milligram equivalents; p = 0.57), nor did pain (POD1 and 2 weeks), early function (PODs 1 to 3), length of stay, or 1-year patient-reported outcomes. The only significant difference in secondary outcomes was lower fasting glucose on POD 1 in the aQLB+LFCNB group (141.5 vs. 153.0 mg/dL; p = 0.003). No block-related complications, wound dehiscence, or infections occurred. Patients used a median of 10 oxycodone 5-mg tablets after discharge, which prompted the institution to cut its standard prescription from 50 to 15 tablets.
The authors concluded that PALIA, being less labor-intensive and less costly, is a reasonable first choice, while noting the null result may reflect the difficulty of detecting differences under robust multimodal analgesia.
Limitations include unblinded proceduralists and patients, supratherapeutic steroid dosing, a baseline imbalance in anxiety (with the PALIA group having a higher proportion of patients with baseline anxiety), and no direct quadriceps strength measurement.
After years of being told that orthopaedic patients need to have peripheral nerve blocks for pain control, there are multiple studies now calling that into question. I would have liked to have seen some cost analysis included in this study, as there are inherent additional costs for a peripheral nerve block performed by an anesthesiologist versus a local injection performed by the operating surgeon. Nonetheless, the data in this study suggest that PALIA seems to work just as well as an aQLB+LFCNB in patients undergoing THA.
Kudos to the authors for a well-performed RCT and for adding to our understanding of more efficient approaches to pain management for patients undergoing THA.
You can find the full study and a related visual abstract at JBJS.org: Glucocorticoid-Enhanced Fascial Plane and Peripheral Nerve Blocks Versus Periarticular and Local Infiltration Analgesia in Total Hip Arthroplasty. A Prospective Randomized Controlled Trial
Additional perspective on this study:
Commentary by J.L. Marsh, MD: Good News: The Easier, More Efficient Technique for Pain Management Is Equivalent
Matthew R. Schmitz, MD
JBJS Senior Editor for Pediatrics and Social Media