It is axiomatic that adequate analgesia after total hip arthroplasty has both subjective and objective benefits. Patient satisfaction is improved when postoperative pain is controlled. Less discomfort leads to earlier ambulation and an enhanced level of participation in physical therapy. Yet, achieving sufficient pain control can be challenging, especially in elderly patients for whom the choice of analgesia, at least to some degree, is based on associated medical comorbidities. In this regard, regional analgesia may be favored over parenteral narcotics in order to mitigate potential narcotic-related side effects, improve patient satisfaction, and promote rapid rehabilitation and earlier hospital discharge. However, although peripheral nerves are relatively resistant to damage from intraneural injection, mechanical compression may occur. The prevalence of prolonged paresthesia may be as high as 8% to 10%. Because of this concern, spinal and epidural analgesia may be advantageous. But even these modalities do have potential and serious disadvantages, including systemic hypotension, urinary retention, and an unpredictable onset.

Epidural analgesia may be administered by a physician-directed bolus, continuous infusion, patient-controlled epidural analgesia (PCEA), or a combination of any of the above. The study by Jules-Elysee et al. compared PCEA with a multimodal pain management program including periarticular injection (PAI). This Level-I investigation found that patients in the PAI group had more pain with ambulation and physical therapy and greater opioid consumption than the patients in the PCEA group. The ability to determine the precise efficacy of the PAI alone was limited, however, due to the concomitant use of oxycodone and a clonidine patch. In contradistinction, opioid-related symptoms, including nausea, vomiting, pruritus, dizziness, and headache, were higher in the PCEA group. Patient function and satisfaction were similar between the two groups.

Common side effects of epidural analgesia may also include urinary retention, orthostatic hypotension, and prolonged motor blockade including motor blockade of the nonoperative limb. More serious complications also include epidural abscess, back pain, and neck or back stiffness. It is very important to note that these problems were not specifically evaluated in this study. Furthermore, epidural analgesia limits the use of anticoagulation and has a much more unpredictable onset and regression.