The continuous infusion fascia iliaca compartment block: a safe and effective analgesic modality in geriatric hip fracture patients

Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients

BACKGROUND

Surgical management of geriatric hip fractures yields improved functional outcomes with decreased morbidity and mortality. Cohort studies have suggested that the older patients within the geriatric age group have worse outcomes with surgery, However, these studies inherently report inflated risks due to poor handling of confounders and have inadequately age-stratified their geriatric population.

AIM

This study aims to investigate the effect of age alone on the 1-year mortality and functional status of geriatric patients after hip fracture surgery.

METHODS

This is a retrospective single institution cohort study based on the prospectively-maintained registry of hip fracture patients. 2603 patients aged 60 years and above were treated surgically under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Patients were split into two age groups: ultra-old (≥ 85 years) vs old (< 85 years). Baseline demographics and the ASA (American Society of Anaesthesiologists) status and the Modified Barthel's Index (MBI) were obtained at admission and 1 year after the fracture. Adverse outcomes from the fracture and surgery were recorded during a follow-up period of minimally 2 years. A 2:1 matching process based on the gender, fracture type, ASA status, CCI and MBI categories was conducted.

RESULTS

There were 1009 and 515 patients in the old and ultra-old age groups, respectively. 1-year mortality was similar for both age groups (4.0% ultra-old vs 3.6% old, p = 0.703). 30-day morbidity was similar except for higher rates of postoperative pneumonia in the ultra-old (14.0 vs 6.3%, p < 0.001). MBI scores at 1-year were lower in the ultra-old (severe dependence: 16.4 vs 10.0%; p = 0.001). Ultra-old patients were less likely to be community ambulant at 12 months (21.2 vs 36.0%) with the deterioration in ambulatory status significant after correction for baseline status (p < 0.001).

CONCLUSION

The 1-year mortality of surgically-managed geriatric hip fracture patients older than 85 years of age is not determined by age alone. Patients aged 85 years and above are at higher risk for pneumonia postoperatively. Ultra-old hip fracture patients with an intertrochanteric fracture are more likely to have poorer function at 1 year after hip fracture surgery.

Effects of Continuous Fascia Iliaca Compartment Block on Early Quality of Recovery After Total Hip Arthroplasty in Elderly Patients: A Randomized Controlled Trial

Purpose

In recent years, patient-centered postoperative quality of recovery has gained attention. This study aimed to assess the influence of ultrasound-guided continuous fascia iliaca compartment block (CFICB) on early quality of recovery in elderly patients after total hip arthroplasty (THA) using the QoR-15 score.

Patients and Methods

In this single-center, randomized, prospective study, 60 patients scheduled for unilateral THA were randomized to the CFICB or patient-controlled intravenous analgesia (PCIA) group. The primary outcome was the QoR-15 score. The secondary outcomes were pain score, number of patients requiring rescue analgesics, time of first postoperative ambulation, incidence of postoperative complications, Bromage score, and length of hospital stay.

Results

The QoR-15 score was significantly higher in the CFICB group than in the PCIA group at 24 h (P < 0.001) after surgery. However, the QoR-15 score was not significantly different at 48 h (P = 0.074) between the two groups. Pain scores at rest and during movement were lower in the CFICB group than in the PCIA group at 12, 24, and 48 h postoperatively (P < 0.05). There was no difference in the number of patients requiring rescue analgesics, time of first postoperative ambulation, incidence of postoperative complications apart from dizziness, or length of hospital stay between the two groups. In addition, Bromage score of 1 point was reported by four patients in the CFICB group at 24 h (P = 0.048) after THA.

Conclusion

In elderly patients following THA, CFICB improved the quality of recovery at 24 h and reduced pain scores compared with PCIA. The time of first postoperative ambulation and length of hospital stay were not significantly affected.

Effects of Perioperative Fascia Iliaca Compartment Block on Postoperative Pain and Hip Function in Elderly Patients With Hip Fracture

Purpose

Pain management is a challenging issue in elderly patients with hip fracture. Despite the accepted clinical outcomes following hip surgery, pain and prolonged recovery time are the most difficult consequences associated with the rehabilitation process. The purpose of this study was to evaluate pain relief and functional improvement associated with the Fascia Iliaca Compartment Block (FICB) during the perioperative period of elderly patients with hip fracture.

Patients and methods

This study included 120 elderly patients with hip fracture, who were admitted to our institution between January 2019 and December 2020. The participants were subsequently randomly divided into the routine analgesia (RA) and fascia iliaca compartment block (FICB) groups. Inter-group differences were compared via VAS scores at rest and during movement, Harris hip scores (HHS), presence of complications, adverse events after surgery, and length of hospital stay.

Results

The FICB group VAS scores at rest at 6 hour, 1 and 3 days, and 1 week after surgery were significantly lower than the RA group (P < .05). Moreover, the FICB group VAS scores with movement were markedly lower at 6 hour, 1 and 3 days, as well as 1 and 2 weeks after surgery (P < .05). The HHS of the FICB and RA groups were (53.41±8.63) and (40.02±9.61), respectively, on the seventh day after surgery, and the difference was statistically significant (P < .05). The incidence of postoperative complications and adverse events in the FICB group were not statistically different from the RA group. The average hospital stay of the FICB group was 2.12 days shorter than the RA group, but the difference did not reach statistical significance (P = .13).

Conclusion

FICB provides superior analgesic effect both at rest and with movement, along with rapid short-term recovery of hip function following surgery in elderly patients with hip fracture, without increasing postoperative complications or adverse events.

From emergency department to operating room: interventional analgesia techniques for hip fractures

PURPOSE OF REVIEW

To provide an update on pain management options with regional anesthesia for patients with hip fractures at the emergency department (ED).

RECENT FINDINGS

Patients who sustain a hip fracture are typically admitted and diagnosed in the ED before being transferred to the operating room for surgery. Studies have clearly demonstrated the ability of the fascia iliaca compartment blocks (FICBs) and femoral nerve blocks (FNBs) to reduce pain and the risk of an acute confusional state. Their administration at an early stage of the patient's trajectory in the ED is beneficial. Recent anatomical studies contributed new knowledge of nociception in the hip joint, which allowed the development of more specific infiltration analgesia techniques without muscle weakness (e.g., pericapsular hip blocks). Further research on the timing of nerve blocks and an evaluation of new motor sparing techniques is indicated.

SUMMARY

FICB and FNB are established and recommended techniques in pain management for hip fracture patients. Their use early on in the ED may improve patient comfort and outcome. Pericapsular nerve hip blocks could provide a relevant alternative in future pain management in this group of patients.

The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery

PURPOSE OF REVIEW

Over 300,000 patients are hospitalized annually following hip fractures in the USA. Many patients experienced inadequate analgesia. We will review the perioperative effects of the fascia iliaca compartment block (FICB) in hip fracture patients.

RECENT FINDINGS

FICB by injecting local anesthetics beneath the fascia iliaca results in significant pain relief in hip fractures. Neuropathies and vascular injuries are almost unlikely. Single-shot FICB is faster to place, yet providing about 8 h of analgesia when bupivacaine is used. Continuous FICB provides prolonged titratable analgesia, improved patient satisfaction, and leads to faster hospital discharge. FICB reduces opioid consumption, decreases morbidity and mortality, reduces hospital stay, reduces delirium, and improves satisfaction. FICB should form part of a multimodal analgesic regime, in the context of a multidisciplinary approach to the management of hip fracture patients. More clinical investigations are needed to validate the long-term outcome benefits of FICB in hip fracture patients.