Ultrasound-Guided Quadro-Iliac Plane Block for Pain Management After Total Hip Arthroplasty

Total hip arthroplasty is associated with significant postoperative pain. The Quadro-Iliac Plane (QIP) block is a recently described fascial plane block targeting the area where the quadratus lumborum muscle attaches to the iliac crest and may provide more comprehensive analgesia. This study is designed as a prospective, randomized, double-blind clinical trial including patients aged 18-80 years with ASA physical status I-III undergoing elective primary total hip arthroplasty.

Patients will be randomized into two groups. The QIP group will receive an ultrasound-guided QIP block with 40 mL of 0.25% local anesthetic solution containing epinephrine, and the control group will receive a sham block with 40 mL of 0.9% NaCl using the same technique. The primary outcome is postoperative 24-hour opioid consumption. Secondary outcomes include motor block, and dermatomal sensory assessment, pain scores, quality of recovery (QoR-15), rescue analgesic requirement and opioid-related side effects

Participants in this arm will receive the standard analgesia protocol used for patients undergoing total hip arthroplasty. In addition to this standard regimen, an ultrasound-guided Quadro-Iliac Plane (QIP) block will be performed in the preoperative period with the patient in the lateral decubitus position. The technique aims to provide postoperative analgesia by achieving sensory blockade in the relevant dermatomal areas.

Procedure: Quadro-Iliac Plane (QIP) Block

Participants in this arm will receive the standard analgesia protocol used for patients undergoing total hip arthroplasty. In addition to this standard regimen, a sham block will be performed using the same ultrasound-guided technique and patient positioning to mimic the block procedure without providing active regional anesthesia.

Procedure: Sham Block

An ultrasound-guided Quadro-Iliac Plane block performed in the preoperative period. At the level of the iliac crest, 40 mL of a solution containing 0.25% levobupivacaine and 5 µg/mL epinephrine is injected into the fascial plane between the erector spinae muscle and the quadratus lumborum muscle under aseptic conditions.

A sham block performed using the same ultrasound-guided technique in the preoperative period. At the level of the iliac crest, 40 mL of 0.9% NaCl is injected into the fascial plane between the erector spinae muscle and the quadratus lumborum muscle under aseptic conditions.

Time frame: Postoperative 24 hours

Total amount of morphine delivered by the patient-controlled analgesia (PCA) device during the first 24 hours after surgery, recorded in milligrams (mg).

Time frame: 2, 6, 12, 24, and 48 hours postoperatively

Postoperative pain will be assessed using the Numeric Rating Scale (NRS), where 0 indicates no pain and 10 indicates the worst pain imaginable.

Time frame: QoR-15 Recovery Score will be evaluated at the postoperative 48th hour

The investigators will use the Turkish version of Quality of Recovery (QoR) / QoR-15 questionnaire.

PART A How have you been feeling in the last 24 hours? (0 to 10, where: 0 = none of the time \[poor\] and 10 = all of the time \[excellent\])

Able to breathe easily Been able to enjoy food Feeling rested Have had a good sleep Able to look after personal toilet and hygiene unaided Able to communicate Getting support from hospital doctors and nurses Able to return to work or usual home activities Feeling comfortable and in control Having a feeling of general well-being

PART B Have you had any of the following in the last 24 hours? (10 to 0, where: 10 = none of the time \[excellent\] and 0 = all of the time \[poor\])

Moderate pain Severe pain Nausea or vomiting Feeling worried or anxious Feeling sad or depressed

\[Total score range: 0-150 points\]

Time frame: Postoperative 6th and 12th hours

Postoperative lower extremity muscle strength will be assessed at the 6th postoperative hour using a 0-5 grading scale, where 0 indicates no muscle contraction and 5 indicates normal strength.

The scale is defined as follows:

0 = no muscle contraction

1. = muscle contraction present without joint movement
2. = movement without overcoming gravity
3. = movement against gravity without resistance
4. = movement against partial resistance
5. = movement against full resistance (normal strength)

Time frame: Postoperative 0-48 hours

Number of patients requiring rescue analgesia (IV meperidine 0.5 mg/kg) and total dose administered when NRS ≥ 4.

Time frame: Postoperative 0-48 hours

Opioid-related side effects will be assessed postoperatively

Other opioid-related side effects, including pruritus, constipation, and somnolence, will be recorded as present or absent.

Effectiveness of Ultrasound-Guided Quadro-Iliac Plane Block for Pain Management After Total Hip Arthroplasty: A Prospective Randomized Study