Minimizing Opioid Use after Total Hip Arthroplasty: Comparing Periarticular Injection versus Patient Controlled Epidural Analgesia versus a Combination Protocol

BACKGROUND:Effective management of postoperative pain after total hip arthroplasty (THA) may be challenging. We sought to develop an opioid-sparing pain management pathway by comparing the relative effectiveness of 3 different protocols: (1) Local anesthetic administered patient-controlled epidural analgesia (PCEA) without intrathecal opioids; (2) Periarticular injection (PAI); and (3) PCEA + PAI. METHODS:In this double-blinded randomized controlled trial, 180 patients undergoing THA were randomized to receive either (1) PCEA with 0.06% bupivacaine, (2) PAI, or (3) a PAI + PCEA with 0.06% bupivacaine. All patients received the same postoperative multimodal analgesic regimen. The primary outcome was opioid consumption, measured in oral morphine equivalents, at 24, 48, and 72 hours after anesthesia stop time. Secondary measures included pain at rest and with movement, opioid side effects, patient satisfaction, and quality of recovery, as assessed via standardized self-reporting scales and surveys. RESULTS:Opioid consumption was significantly higher in the PAI group in the first 24 hours postoperatively compared to the PAI + PCEA group (30 versus 15, P = .012). No differences were detected among groups for length of stay, pain scores, patient satisfaction, or duration of surgery. More patients in the PAI + PCEA group were opiate-free in the first 24 hours compared to PAI (23.7 versus 8.5%, P = .043). CONCLUSION:Use of PAI + PCEA regimen was opioid-sparing in the first 24 hours after surgery, favoring this group when opioid reduction is desired. Increased drowsiness was noted in the subsequent 24 to 48 hours once the epidural catheter was removed and opioid consumption also increased.