|Year : 2014 | Volume
| Issue : 3 | Page : 129-133
Comparative study of fascia iliaca compartment block and three in one block for postoperative analgesia in patients undergoing lower limb orthopedic surgeries
Malti Pandya, Savita Jhanwar
Department of Anaesthesiology, Surat Municipal Institute of Medical Education and Research, Veer Narmad South Gujarat University, Surat, Gujarat, India
|Date of Web Publication||11-Aug-2014|
602, Neel Ganga Aptt. Opp. St. Xaviers High School, Near "Tanishq", Ghod, Dod Road, Surat - 395 007, Gujarat
Source of Support: None, Conflict of Interest: None
Background: The fascia iliaca compartment block and three in one block (two single injections, anterior approach procedures) was compared simultaneously to block the femoral, obturator, genitofemoral and lateral femoral cutaneous (LFC) nerves in patients undergoing lower limb orthopedic surgeries. Study Design: Prospective randomized single-blinded study. Materials and Methods: Sixty patients of ASA I, II and III scheduled for hip and femur shaft surgery under spinal anesthesia were included in the study. On completion of the surgery, patients were randomly divided into two groups, Group I and Group II each consisting of 30 patients. Group I received fascia iliaca compartment block and Group II received three in one block. Patients of both the groups received 35-40 ml of 0.25% bupivacaine. Sensory blockade of femoral nerve, obturator nerve, LFC nerve and genitofemoral nerve, and motor blockade of femoral and obturator nerves were observed by weakness in knee extension and thigh adduction. Duration of analgesia, number of doses of rescue analgesics required in 24 hours, visual analog scale (VAS) scores at rest and during physiotherapy were also noted. Results: Sensory blockade of femoral, obturator and genitofemoral nerves, and motor blockade of femoral and obturator nerves did not differ between the two groups; however, sensory blockade of LFC nerve was significantly higher in Group I. VAS at 12 hours after surgery during movement of 3.43 ± 2.36 in Group I and 4.57 ± 0.15 in Group II were statistically significant (P value = 0.03) but the duration of analgesia between Group I and Group II was not statistically significant (P > 0.05). Conclusion: Fascia iliaca compartment block may represent an attractive alternative to three in one block for treatment of pain at rest and during physiotherapy.
Keywords: Fascia iliaca compartment block, lower limb orthopaedic surgery, postoperative analgesia, regional anaesthesia, three in one block
|How to cite this article:|
Pandya M, Jhanwar S. Comparative study of fascia iliaca compartment block and three in one block for postoperative analgesia in patients undergoing lower limb orthopedic surgeries. Indian J Pain 2014;28:129-33
|How to cite this URL:|
Pandya M, Jhanwar S. Comparative study of fascia iliaca compartment block and three in one block for postoperative analgesia in patients undergoing lower limb orthopedic surgeries. Indian J Pain [serial online] 2014 [cited 2020 Apr 10];28:129-33. Available from: http://www.indianjpain.org/text.asp?2014/28/3/129/138435
| Introduction|| |
Major lower limb surgery is often painful and requires aggressive management. Poorly treated pain can have a negative impact on recovery, especially owing to disruption in physiotherapy, resulting in stiffness of joints and slow progress in mobility. ,
Postoperative pain relief can be achieved by a variety of techniques, including parenteral NSAIDs, neuraxial local analgesics and narcotics, epidural analgesia, peripheral nerve block, wound infiltration and patient-controlled IV analgesia with opioids. , One of the most common peripheral nerve blocks to facilitate postoperative analgesia for lower limb surgery is three in one nerve block, which uses a single injection to block the femoral, lateral femoral cutaneous and obturator nerves simultaneously. These three nerves provides major sensation to the lower extremity, and the ability to inhibit the individual distribution allows for successful analgesia and anesthesia for lower limb surgeries.  Providing three in one block to the patients can be difficult and it often requires assistance of peripheral nerve stimulation, necessitating the development of special skill. This block can also result in anesthesia sparing to the obturator nerve and lateral femoral cutaneous nerve, thereby leading to increased dissatisfaction among patients.  An alternative to three in one block called fascia iliaca compartment block (FICB) was originally described for use in pediatric patients. FICB is placed more laterally than three in one block, thereby decreasing potential for an intravascular or intraneural injection. This block reported consistent capture of the three major nerves innervating the lower extremity, combined with the anatomical safety profile and the ease in placing the block, has made the FICB a viable alternative to three in one block. 
The present study was conducted to compare the analgesic efficacy of FICB and three in one block and effect on facilitating early physiotherapy in a patient with lower limb fracture operated under spinal anesthesia.
| Materials and Methods|| |
After approval from institutional ethics committee, 60 patients of 18-65 years of age belonging to ASA Class I, II and III, of either sex posted for hip and femur shaft surgery from Jan'13 to Dec'13 were included in the study. Patients were randomly divided into two groups, each group consisting of 30 patients. Those who had history of allergy to amide local anesthetics, with hepatic or renal failure, and contraindication to regional anesthesia were excluded from study. Informed written consent was obtained from all patients. In preoperative room, pulse rate, blood pressure, respiratory rate and visual analog scale (VAS) for pain at rest and at movement were noted. Patients were premedicated with either inj. Atropine 10 μg/kg or inj. Glycopyrrolate 5 μg/kg and inj. Midazolam 50 μg/kg I.M. half an hour before operation. In the operation theater, spinal anesthesia was given under aseptic precautions using 25-gauge Quinke's spinal needle with 2.5-3.0 ml of Bupivacaine Heavy 0.5% at L2-L3 or L3-L4 intervertebral space. On completion of surgery, patients of Group I received FICB and patients of Group II received three in one block. In patients of Group I, FICB was given in supine position as per the technique described by Range C et al. In this technique, a line is drawn on the skin connecting the anterior superior iliac spine to pubic tubercle; at the level of inguinal ligament this line was divided into three equal parts, at the junction of the lateral and medial two-thirds; a second line is drawn perpendicular to and intersecting the line joining anterior superior iliac spine and pubic tubercle, one cm below this line is the insertion point. A Tuhoy's needle is inserted perpendicular to the skin at this point, as soon as two "pop up" sensations are felt, first, as the needle passes through the fascia lata and the second when a loss of resistance is felt, as it passes through the fascia iliaca, after this, angle is reduced to 30 degrees and the needle is advanced 1-2mm further, anesthetic solution containing 35-40 ml of 0.25% bupivacaine is injected after negative aspiration for blood. A distal compression is applied immediately caudal to needle puncture site for 10 minutes to favor the proximal spread of local anesthetic drug.  In patients of Group II, the three in one block was given in supine position by the technique described by Winnie et al. In this technique, the femoral artery is palpated below the inguinal ligament. A 3.5 cm, short bevel 23-gauge needle is advanced lateral to the artery in the cephalad direction till a 'double pop' is felt after piercing fascia iliaca and pectineal fascia, and 35-40 ml of 0.25% bupivacaine is injected after negative aspiration for blood. Distal pressure is applied with the thumb, to the femoral sheath for 10 minutes, to facilitate proximal spread. , The time was noted when the block was performed initially, 3 hours after spinal anesthesia, when the effect of spinal anesthesia had been worn off. Sensory blockade of operated limb on the territories of femoral nerve (anterior aspect of thigh), obturator nerve (medial aspect of thigh), LFC nerve (lateral aspect of thigh) and genitofemoral nerve (skin over scarpa's triangle) was evaluated using a pin prick test. Motor blockade  was assessed by weakness in knee extension against resistance (femoral nerve) and weakness in thigh adduction against resistance (obturator nerve). The results of these sensory and motor blockade were reported as either "yes" (complete motor and sensory blockade) or "no" (partial or absent motor and sensory blockade) of a given nerve territory.
The patients were also assessed for pain using a 10-point VAS at 30 minutes, 1, 2, 4, 6, 12 and 24 hours after performing block. In the postoperative period, inj. diclofenac sodium 1.5 mg/kg IV was given as rescue analgesic when VAS ≥ 4. The time at the first analgesic supplementation (duration of analgesia) and total doses of analgesic requirement during 24 hours were also noted. Patients were also asked to rate their satisfaction to postoperative analgesia (excellent, good and poor). Side effects like intravascular injection, hematoma at injection site, local anesthetic toxicity and block failure were noted.
Statistical analysis 
Results were statistically analyzed by SPSS-15 software. Student's t-test and Mann-Whitney U test were used for quantitative data and χ2 test for qualitative data. We considered 5% level of significance. P value <0.05 was considered significant.
| Results|| |
The two groups were similar in terms of age, sex, weight, type of surgery, duration of surgery and preoperative VAS both at rest and during movement [Table 1].
The block was considered successful, only if, there was a documented loss of sensation to ice in the femoral, obturator, LFC and genitofemoral nerve distribution. The sensory blockade of femoral, obturator, and genitofemoral nerve were comparable in both groups but blockade of LFC nerve was significantly higher (P value = 0.005) in Group I as compared to Group II [Figure 1].
|Figure 1: Sensory blockade of Femoral, Obturator, LFC, Genitofemoral nerves in patients of Group I and Group II|
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However, motor blockade of both femoral and obturator nerves was higher in patients of Group II as compared to Group I, but the difference was statistically not significant (P > 0.05) [Figure 2].
|Figure 2: Motor blockade of femoral and obturator nerves in Group I and Group II|
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Postoperatively pain was assessed by VAS at 30 minutes, 1, 2, 4, 6, 12 and 24 hours both at rest and during physiotherapy. None of the patients had pain up to 6 hours postoperatively except in only 4 patients in both groups who had experienced mild pain during movement.
There was no significant difference noted in both groups in terms of VAS up to 24 hours postoperatively except at 12 hours after surgery during movement there was significant difference (P value = 0.036) with mean VAS of 3.43 ± 2.36 in Group I and 4.57 ± 0.15 in Group II [Table 2].
Thus, early physiotherapy and passive movement at knee joint was possible without pain in most of the patients.
The mean time for first demand of rescue analgesic was (duration of analgesia) 12.97 ± 3.06 hours in FICB group and 11.93 ± 3.02 hours in three in one group [Table 3].
Mean requirement of number of rescue analgesic was 1.50 ± 0.63 in Group I and 1.67 ± 0.71 in Group II, which was statistically insignificant P > 0.05 [Figure 3].
At the end of the study, patients were asked about the quality of postoperative analgesia (excellent, good, poor). In Group I, quality of analgesia was rated as excellent by 76.67%, good by 16.66% and poor by 6.67% of the patients.
In Group II, quality of analgesia was excellent in 56.67%, good in 36.66% patients and poor in 6.67% patients. Thus, both the block provides effective analgesia postoperatively [Figure 4].
No incidence of side effects like hematoma, accidental intra vascular injection, block failure, or local anesthetic toxicity was seen during the study in any patients of both the groups.
| Discussion|| |
In this study, both FICB and three in one block provided good quality of postoperative analgesia and patient satisfaction after hip surgery as evidenced by low VAS and low postoperative rescue analgesic requirements. We observed that both techniques provided equal sensory blockage of femoral nerve, obturator nerve and genitofemoral nerve, but sensory blockage of LFC nerve was demonstrated in 93.33% patients in FICB and 63.33%patient in three in one block, which was significantly higher (P value = 0.005). This sensory blockage of LFC nerve is important because the sparing of LFC nerve may at least, be responsible for pain in incisional area after hip surgery.  This is in agreement with the study done by Dalen et al.  and Capdevila et al.  and the difference noted in sensory blockage of LFC nerve is probably the result of FICB, which involves a shorter subfascial distance, allowing more local anesthetic to reach the nerve. , Motor blockade of both femoral and obturator nerves were comparable between the two groups. Higher degree of motor blockade of femoral nerve in three in one block was noted by Wallace and colleagues whereas, Capdevila et al.  found higher degree of motor blockade of obturator nerve in three in one group as compared to FICB; this might be because their use of high concentration of bupivacaine (0.5%). Mean VAS at 12 hours after surgery during movement was 3.43 ± 2.36 in FICB group and 4.57 ± 0.15 in three in one group (P value = 0.036). Thus, FICB is more useful when early physiotherapy is started postoperatively as it improves analgesia during activity. Total duration of analgesia was 12.97 ± 3.06 hours in fascia iliaca group and 11.93 ± 3.0 hours in three in one group. The results obtained by previous study regarding duration of postoperative analgesia, requirement of supplemental analgesics and patient satisfaction were similar to our study. ,
We had one limitation that we were not able to compare the onset of sensory and motor blockade of nerves of lumbar plexus, as both blocks were given under the effect of spinal anesthesia.
| Conclusion|| |
The FICB provides a high degree of sensory blockade of LFC nerve and improves analgesia when continuous passive motion is initiated in early postoperative period; also, it is easy to perform, reliable and does not threaten any vital organ. Thus, FICB can be recommended as an alternative to three in one block for the treatment of pain after hip and femur shaft surgery.
| References|| |
|1.||Srivastava U, Kumar A, Saxena S, Naz A, Goyal V, Mehrotra R. Lumbar plexus block for postoperative analgesia following hip surgery: A comparison of '3 in 1' block and psoas compartment block. Indian J Anaesth 2007;51:127-30. |
|2.||Singelyn JF, Deyaert M, Jorist D, Pendevillet E, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998;87: 88-92. |
|3.||Ganapathy S, Wasserman RA, Watson JT, Bennett J, Armstrong KP, Stockall CA, et al. Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty. Anesth Analg 1999;89:1197-202. |
|4.||SusanS: Gray's Anatomy Anatomical basis of clinical practice: Elsevier; 39 th edition, section 8- pelvic girdle and lower limb 2005;2:1395-96 |
|5.||Wallace JB, Andrade JA, Christensen JP, Osborne LA, Pellegrini JE. Comparison of fascia iliaca compartment block and 3-in-1 block in adults undergoing knee arthroscopy and meniscal repair. AANA J. 2012;80:37-44. |
|6.||Range C, Egele C. Fascia iliaca compartment block: Landmark and ultrasound approach. Anaesthesia tutorial of the week: World federation society of anaesthesiologits 2010;193. |
|7.||Mc Ewen A. Femoral nerve block: Landmark approach anaesthesia tutorial of the week: World federation society of anaesthesiologits 2012;249:1. |
|8.||Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technique of lumbar plexus anaesthesia: The '3 in 1' block. Anesth Analg 1973;52:989-96. |
|9.||de Lima E Souza R, Correa CH, Henriques MD, de Oliveira CB, Nunes TA, Gomez RS. Single-injection femoral nerve block with 0.25% ropivacaine or 0.25% bupivacaine for postoperative analgesia after total knee replacement or anterior cruciate ligament reconstruction. J Clin Anesth 2008;20:521-7. |
|10.||Mahajan BK. Methods in biostatistics. In: Significance of difference in means. 7 th ed. Ch. 9. Jaypee. p. 117-41. |
|11.||Möller T, Benthaus S, Maria Huber, Ingrid Bentrup, Markus Schofer. A randomized and observer blinded comparison of continuous femoral block and fascia iliaca compartment block in hip replacement surgery. J Anaesth Clin Res 2011;4: 277-83. |
|12.||Dalen B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 1989;69:705-13. |
|13.||Capdevila X, Biboulet P, Bouregba M, Barthelet Y, Rubenovitch J, d'Athis F. Comparison of the three-in-one and fascia lliaca compartment blocks in adults: Clinical and radiographic analysis. Anesth Analg 1998;86:1039-44. |
|14.||Cauhepe C, Olivier M, Colombani R, Railhac N. The "3-in-1" block: Myth or reality? Ann Fr Anesth Reanim 1989;8: 376-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]