Fascia Iliaca Block Decreases Hip Fracture Postoperative Opioid Consumption: A Prospective Randomized Controlled Trial

Preoperative Fascia Iliaca Blocks Associated With Decreased Opioid Consumption in Femoral Shaft and Distal Femur Fractures

OBJECTIVES

To examine the impact of fascia iliaca (FI) blocks performed in the emergency department on femoral shaft and distal femur fracture patients on opioid consumption, length of stay (LOS), and readmission rate.

METHODS

DESIGN

Prospective cohort study.

SETTING

Community-based Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients with isolated low-energy femoral shaft or distal femur fractures (OTA/AO 32 and 33) presenting from January 1, 2020, to May 31, 2022, were included.

OUTCOME MEASURES AND COMPARISONS

Opioid consumption, LOS, discharge disposition, and 30-day readmission rate were compared between patients undergoing FI compartment block and not receiving the block.

RESULTS

One hundred thirty-six patients were included. Twenty-four received FI block. Both cohorts were primarily female gender (66.7% and 66.9%, respectively, for the FI block and the no FI block cohort). Most of the FI block cohort had femoral shaft fractures (62.5%), whereas the no FI block cohort had mostly distal femur fractures (56.2%). The mean body mass index, fracture type, and surgical procedure were similar between patients undergoing FI block and not receiving FI block. The FI block group had significantly lower opioid consumption preoperatively [36.1 vs. 55.3 morphine milliequivalents (MMEs), P = 0.030], postoperatively (71.7 vs. 130.6 MMEs, P = 0.041), and over total hospital stay (107.9 vs. 185.9 MMEs) including the mean opioid consumption per day of hospital stay (25.9 vs. 48.4 MMEs, P = 0.003). There was no significant difference in LOS (4.9 vs. 5.0 days, P = 0.900), discharge disposition destination ( P = 0.200), or 30-day readmissions (12.5% vs. 4.5%, P = 0.148) between groups.

CONCLUSIONS

Undergoing FI block in the emergency department was associated with decreased opioid consumption in patients with femoral shaft or distal femur fractures. There was no associated difference in LOS, discharge disposition, or 30-day readmissions.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis

STUDY OBJECTIVE

We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip fractures.

METHODS

We searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged more than 16 years with hip fractures who received peripheral nerve blocks or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 hours after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA).

RESULTS

We included 63 randomized controlled studies (4,778 participants), of which only a few had a low risk of bias. The femoral nerve block, 3-in-1 block, fascia iliaca compartment block, and pericapsular nerve group block yielded significantly lowered pain scores at 2 hours after block placement compared with those with no block (standardized mean differences [SMD]: -1.1; 95% credible interval [CrI]: -1.7 to -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0 to -0.55, [low]; SMD: -1.4; 95% CrI: -2.0 to -0.72, [low]; SMD: -2.3; 95% CrI: -3.2 to -1.4, [moderate], respectively). The pericapsular nerve group block, 3-in-1 block, fascia iliaca compartment block, and femoral nerve block resulted in lower pain scores than the no-block group. Additionally, the pericapsular nerve group block yielded a lower pain score than femoral nerve block or fascia iliaca compartment block (SMD: -1.21; 95% CrI: -2.18 to -0.23, [very low]: SMD: -0.92; 95% CrI: -1.70 to -0.16, [low]). However, both the fascia iliaca compartment block and femoral nerve block did not show a reduction in morphine consumption compared with no block. To our knowledge, no studies have compared the pericapsular nerve group block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay.

CONCLUSIONS

Compared with no block, preoperative peripheral nerve blocks for hip fractures appear to reduce pain 2 hours after block placement. Comparing different blocks, pericapsular nerve group block might be superior to fascia iliaca compartment block and femoral nerve block for pain relief, though the confidence evidence was low in most comparisons because of the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Anesthetic Methods for Hip Fracture

PURPOSE OF REVIEW

To review the benefits, risks, and contraindications of traditional and new anesthesia approaches for hip fracture surgery and describe what is known about the impact of these approaches on postoperative outcomes.

RECENT FINDINGS

This review describes general and spinal anesthesia, peripheral nerve block techniques used for pain management, and novel, local anesthesia approaches which may provide significant benefit compared with traditional approaches by minimizing high-risk induction time and decreasing respiratory suppression and short- and long-term cognitive effects. Hip fracture surgery places a large physiologic stress on an already frail patient, and anesthesia choice plays an important role in managing risk of perioperative morbidity. New local anesthesia techniques may decrease morbidity and mortality, particularly in higher-risk patients.

Supra-inguinal fascia iliaca block in older-old patients for hip fractures: a retrospective study

BACKGROUND

Pain management in hip fracture patients is of great importance for reducing postoperative morbidity and mortality. Multimodal techniques, including peripheral nerve blocks, are preferred for postoperative analgesia. Older-old hip fracture patients with high ASA scores are highly sensitive to the side effects of NSAIDs and opioids. Our aim was to investigate the effectiveness of the recently popularized Supra-Inguinal Fascia Iliaca Block (SIFIB) in this population.

METHODS

Forty-one ASA III...IV patients who underwent SIFIB...+...PCA (G-SIFIB) or PCA alone (Group Control: GC) after general anesthesia were evaluated retrospectively. In addition to 24-hour opioid consumption, Visual Analog Scale (VAS) scores, opioid-related side effects, block-related complications, and length of hospital stay were compared.

RESULTS

Twenty-two patients in G-SIFIB and 19 patients in GC were evaluated. The postoperative 24-hour opioid consumption was lower in G-SIFIB than in GC (p...<...0.001). There was a statistically significant reduction in VAS scores at the postoperative 1st, 3rd, and 6th hours at rest (p...<...0.001) and during movement (p...<...0.001 for the 1st and 3rd hours, and p...=...0.02 for the 6th hour) in G-SIFIB compared to GC. There was no difference in pain scores at the 12th and 24th hours postoperatively. While there was no difference between the groups in terms of other side effects, respiratory depression was significantly higher in GC than in G-SIFIB (p...=...0.01).

CONCLUSION

The SIFIB technique has a significant opioid-sparing effect and thus reduces opioid-related side effects in the first 24 hours after hip fracture surgery in older-old patients.

Total intravenous anesthesia for geriatric hip fracture with severe systemic disease

PURPOSE

Our study aimed to determine the impact of a novel technique of anesthesia administration on the clinical outcomes and complications in geriatric patients with severe systemic disease undergoing hip surgery.

METHODS

We retrospectively identified patients aged > 65 years with severe systemic disease that was a constant of life [American Society of Anesthesiologists (ASA) IV] who underwent surgery for hip fracture between January 2018 and January 2020. The patients were divided into two groups: Group I [fascia iliaca compartment block plus propofol-based total intravenous anesthesia (FICB + TIVA)] and Group II [general anesthesia (GA)]. The primary outcomes were 30-day and 1-year mortality. The secondary outcomes included length of hospital stay, length of intensive care unit (ICU) stay, postoperative morbidity, Visual Analog Scale score, and consumption of analgesics.

RESULTS

There was no significant difference in the 30-day mortality (5 vs. 3.8%, p = 0.85) and 1-year mortality (15 vs. 12%, p = 0.73) between the groups. Group I had significantly lower ICU requirements (p = 0.01) and shorter lengths of ICU stay (p < 0.001) and hospital stay (p < 0.001). Moreover, a smaller proportion of patients in Group I required postoperative morphine or oral opiates.

CONCLUSION

Geriatric patients who underwent hip surgery under FICB + TIVA required fewer ICU admissions, shorter lengths of ICU and hospital stay, and had lesser postoperative opioid consumption than those who were under GA. Hence, we recommend the novel FICB + TIVA technique for hip fracture surgery in geriatric patients with poor general health status and high surgical risks (ASA IV).

Current Strategies in Medical Management of the Geriatric Hip Fracture Patient

Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know.

An integrative comparative study between ultrasound-guided regional anesthesia versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: A systematic review and meta-analysis

Background

Emergency physicians play a major role in managing patients with hip fractures. The most commonly used pain management option is parenteral opioids. However, parenteral opioids are subjected to several adverse effects. New pain management techniques such as regional anesthesia are used as alternatives to parenteral opioids. Anatomical landmarks were used to administer regional anesthesia; however, ultrasound guidance has shown promising results with regional anesthesia.

Objective

of the Review: The present study compares the efficacy of ultrasound-guided regional anesthesia (USGRA) to parenteral opioids in analgesia of hip fractures patients.

Methods

A literature search for original and relevant articles carried out through six electronic databases, yielded 710 articles which were then assessed using the eligibility criteria resulting in 8 studies eligible for inclusion.

Results

A Meta-analysis of the seven studies showed that ultrasound-guided femoral nerve block was more effective than parenteral opioids in relieving pain. Similarly, meta-analysis of data from two studies shows that US-guided FICB significantly reduced pain scores than parenteral opioids. A subgroup analysis of adverse events showed no significant difference in nausea/vomiting and respiratory complications. However, a subgroup analysis on hypotension showed that the incidence of hypotension was significantly lower in USGRA than parenteral opioids. The present study also revealed that patients in the USGRA group required less frequent rescue analgesia than the patients in the parenteral opioids group.

Conclusion

Results of the present study show that USGRA is superior to parenteral opioids in reducing pain and the need for rescue analgesia in patients with hip fractures.

The Impact of the Fascia Iliaca Block Beyond Perioperative Pain Control in Hip Fractures: A Retrospective Review

Background

Geriatric hip fractures are common injuries that are associated with high morbidity and mortality. Adequate pain control remains a challenge as the altered physiology in elderly patients makes use of traditional analgesics challenging. The use of regional anesthetics, specifically the fascia iliaca compartment block (FICB), in the perioperative period has been shown to decrease opioid use in this population. This study aimed to investigate the effect the FICB had on pain control, length of stay, readmissions, and complications in a 30-day postoperative period.

Methods

This was a retrospective cohort study comparing patients who sustained hip fractures; one cohort (110 patients) received a preoperative fascia iliaca block with continuous infusion (FICB), whereas the other cohort (110 patients) did not receive a block (NO-FICB). Both cohorts were from level II trauma centers. Data were collected between 2016 and 2019. Descriptive statistics was performed to describe and summarize the data. Bivariate analysis was performed using chi-square test, with 2 tailed P-values ≤ .05 were considered statistically significant.

Results

The FICB group had a lower length of stay (3.9 days vs 4.8 days; P < .001), and lower pain scores on post-operative days 2 and 3 (P = .019). There was no difference in time from admission to surgery (P = .112) or narcotic use between cohorts (P = .304). However, the FICB group was more likely to discharge to a skilled nursing facility (P=.002), and more likely to be readmitted within 30 days (P = .047). There were no differences in medical complications or mortality between the 2 groups.

Conclusions

The primary study endpoint, length of stay, was found to be significantly shorter in the patients who underwent the FICB vs the group who did not undergo the FICB. Pain scores on POD2 and POD3 were lower in patients who received a FICB. This study adds to the body of evidence that the FICB is an effective addition to a multimodal pain pathway.

Level of Evidence

Level III Evidence – Retrospective Cohort Study

Comparison of Femoral Nerve Block and Fascia Iliaca Block for Proximal Femoral Fracture in the Elderly Patient: A Meta-analysis

Introduction

Pain management modalities after proximal femoral fracture are variable and have been studied extensively. Regional anesthesia, specifically femoral nerve (FNB) and fascia iliaca compartment blocks (FICB), can be used to provide analgesia preoperatively.

Methods

Systematic searches of all related literature were conducted in the Medline, Embase, and Cochrane Central Register of Controlled Trials databases. Randomized controlled trials (RCTs) of proximal femoral fractures were included. The pain scores at different time points, opioid requirement in 24 h, mean arterial pressure, time for spinal anesthesia, patient satisfaction, and incidence of side effects between the 2 groups were extracted throughout the study.

Results

Fifteen RCTs including 1240 patients met the inclusion criteria. The present meta-analysis indicated that compared with FNB, FICB could decrease the visual analog scale (VAS) scores at 4 h after surgery (P < .05). The incidence of side effects (nausea, vomiting, and sedation) was lower in the FNB group (P < .05). Compared to the FICB, no significant difference was found at any other observed time point. Additionally, no difference was found in opioid requirement at 24 h, mean arterial pressure, time for spinal anesthesia, or patient satisfaction (P > .05).

Conclusions

FICB demonstrates a reduction in VAS score at 4 while FNB decreases the risk of several adverse events. More high-quality RCTs are necessary for proper comparison of the efficacy and safety of FNB and FICB.

Ultrasound-guided peripheral nerve blocks for preoperative pain management in hip fractures: a systematic review

Systematic reviews associate peripheral nerve blocks based on anatomic landmarks or nerve stimulation with reduced pain and need for systemic analgesia in hip fracture patients. We aimed to investigate the effect of ultrasound-guided nerve blocks compared to conventional analgesia for preoperative pain management in hip fractures. Five databases were searched until June 2021 to identify randomised controlled trials. Two independent authors extracted data and assessed risk of bias. Data was pooled for meta-analysis and quality of evidence was evaluated using Grades of Recommendation Assessment, Development and Evaluation (GRADE). We included 12 trials (976 participants) comparing ultrasound-guided nerve blocks to conventional systemic analgesia. In favour of ultrasound, pain measured closest to two hours after block placement decreased with a mean difference of -2.26 (VAS 0 to 10); (p < 0.001) 95% CI [–2.97 to –1.55]. In favour of ultrasound, preoperative analgesic usage of iv. morphine equivalents in milligram decreased with a mean difference of –5.34 (p=0.003) 95% CI [–8.11 to –2.58]. Time from admission until surgery ranged from six hours to more than three days. Further, ultrasound-guided nerve blocks may be associated with a lower frequency of delirium: risk ratio 0.6 (p = 0.03) 95% CI [0.38 to 0.94], fewer serious adverse events: risk ratio 0.33 (p = 0.006) 95% CI [0.15 to 0.73] and higher patient satisfaction: mean difference 25.9 (VAS 0 to 100) (p < 0.001) 95% CI [19.74 to 32.07]. However, the quality of evidence was judged low or very low. In conclusion, despite low quality of evidence, ultrasound-guided blocks were associated with benefits compared to conventional systemic analgesia.

Interventional therapies for management of hip fracture pain peri-operatively: A review article

Background

Hip fracture is a common reason for elderly admission to hospital and majority of patients will require a hip fixation surgery. Pain originating from a hip fracture is usually severe and the need to improve comfort is paramount, especially before the hip fixation surgery because severe pain results in unnecessary stress response such as catecholamines release, tachycardia and hypertension. This worsens outcomes, increases risk of complications such as myocardial ischaemia, strokes, pulmonary embolus or deep vein thrombosis. Multimodal systemic analgesia has been shown to be effective in reducing pain in hip fractures but the associated side effects and contraindications have accelerated the adoption of nerve blocks in the peri-operative management of hip fracture patients. 1 As a result, this has been increasingly recognised as a important component of the hip fracture pathway (as part of a multimodal approach for analgesia) and many hospitals have protocols to perform various interventional therapies (various nerve blocks) for newly admitted patients with hip fracture to alleviate pain immediately and potentially provide intra and post-operative analgesia.

Objective

The aim of this review is to elucidate the various interventional therapies currently available (including pericapsular nerve group (PENG) block which was first described in 2018), their evidence and the pros and cons.

Methods

We reviewed the latest evidence for femoral nerve block (FNB), 3-in-1 block, lumbar plexus block (LPB), fascia iliaca block (FIB), erector spinae plane block (ESPB) and pericapsular nerve group (PENG) block.

Results and conclusion

Each block has its pros and cons, as discussed in this review article. The procedurist should deliberate these considerations before deciding which block is most appropriate.

Is Femoral Nerve Block Superior to Fascia Iliac Block in Hip Surgery? Meta-Analysis of Randomized Controlled Trials

Background. Femoral nerve block (FNB) and fascia iliac compartment block (FICB) are alternative methods of pain relief during hip surgery. Nevertheless, the effectiveness and safety of FNB compared with FICB are yet to be fully determined. Methods. Electronic databases were systematically searched. Only randomized controlled trials (RCTs) on hip surgery were included. Postoperatively, the pain scores at different time points, narcotic requirements in 24 h, mean arterial pressure, spinal anesthesia (SA) time, patient satisfaction, and adverse effect rates between the two groups were extracted throughout the study. Results. Fourteen RCTs including 1179 patients were included. Compared to the FICB, FNB decreased the VAS scores postoperatively at 24 h at rest ( $P<0.05$ ) and the incidence rate of some side effects (nausea, vomiting, and sedation) ( $P<0.05$ ). However, compared to the FICB, no significant difference was found in the FNB regarding the VAS scores postoperatively at any of the other time points (2 min, 20 min, 2 h, 24 h at movement, 48 h at rest, and 48 h at movement). Patients in both groups had similar narcotic needs after 24 h, mean arterial pressure, SA time, and patient satisfaction ( $P>0.05$ ). Conclusions. FNB has more advantages in reducing VAS scores postoperatively at 24 h at rest and the odds of some adverse effects. A better quality RCT is needed to properly compare FNB with FICB.

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.

Fascia Iliaca Blocks Performed in the Emergency Department Decrease Opioid Consumption and Length of Stay in Patients with Hip Fracture

OBJECTIVES

To examine the impact of fascia iliaca (FI) blocks performed in the emergency department on patients with hip fracture on opioid consumption, length of stay, and readmission rate.

DESIGN

Prospective cohort study.

SETTING

Community-based Level 1 trauma center.

PATIENTS/PARTICIPANTS

Ninety-eight patients with isolated femoral neck, intertrochanteric, and subtrochanteric femur fractures (OTA/AO 31-A and 31-B) presenting from January 1, 2020, to June 30, 2020.

INTERVENTION

Ultrasound-guided FI compartment block using 40 mL of 0.25% bupivacaine.

MAIN OUTCOME MEASUREMENTS

Opioid consumption, length of stay, discharge disposition, and 30-day readmission rate.

RESULTS

Thirty-three patients had contraindication to FI block. Thirty-nine of 65 patients (60%) without contraindications to undergoing FIB received FI block. Mean age, body mass index, fracture type, and surgical procedure were similar between patients undergoing FIB and not receiving FIB. The FIB group had significantly lower opioid consumption preoperatively [17.4 vs. 32.0 morphine milliequivalents (MMEs)], postoperatively (37.1 vs. 85.5 MMEs), over total hospital stay (54.5 vs. 117.5 MMEs), and mean opioid consumption per day of hospital stay (13.3 vs. 24.0 MMEs). Patients in the FIB group had shorter length of stay compared with the control group (4.3 vs. 5.2 days). There was no significant difference in discharge disposition destination between groups. No patients reported complications of FI block.

CONCLUSIONS

Undergoing FI block in the emergency department was associated with decreased opioid consumption, decreased length of stay, and decreased hospital readmission within 30 days of hip fracture.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Fascia Iliaca Compartment Blockade on Mortality in Patients With Hip Fractures: Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The purpose of this meta-analysis was to determine whether perioperative fascia iliaca compartment blockade (FICB) decreases mortality in patients with hip fracture.

METHODS

MEDLINE (PubMed and Ovid platforms), Web of Science, EMBASE, and Cochrane Database of Systemic Reviews were screened for "fascia iliaca compartment block, hip fracture" articles in English, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from January 1, 2005, to March 1, 2020. All relevant randomized controlled trials and cohort and case-control studies were included for analysis. Relevant article titles were identified, and their corresponding abstracts were independently reviewed by two authors for inclusion. The full-text articles were then obtained for all relevant identified abstracts and assessed for inclusion in the meta-analysis. Conflicts in quality assessment between the two independent reviewers were resolved by a consensus vote of all authors.

RESULTS

Study quality was assessed objectively using the Jadad and Newcastle-Ottawa Scale. This meta-analysis was done in accordance with the PRISMA (http://links.lww.com/JAAOS/A731) and QUORUM guidelines. Quantitative synthesis analysis was done using Cochrane Reviews Review Manager (version 5.3). All analyses were completed using random-effects models and comparing the individual effect sizes within each study.

DISCUSSION

Management of hip fracture pain with FICB does not markedly decrease short-term mortality. Our findings support the continued use of FICB for the management of hip fractures in geriatric patients and suggest the need for future prospective randomized controlled trials to further determine FICB's effect on short-term and long-term mortality and functional status.

LEVEL OF EVIDENCE

Therapeutic level I.

Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use

Introduction

Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures.

Materials and Methods

This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups.

Results

Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging.

Discussion

Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ.

Conclusion

Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.

Monitored Anesthesia Care and Soft-Tissue Infiltration With Local Anesthesia: An Anesthetic Option for High-Risk Patients With Hip Fractures

OBJECTIVES

To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails.

DESIGN

Retrospective cohort study.

SETTING

The study setting involved an urban, academic Level 1 trauma center, a tertiary care academic medical center, and an orthopaedic specialty hospital.

PATIENTS/PARTICIPANTS

Twenty recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients were included in the study.

INTERVENTION

All patients with an OTA/AO 31.A1-3 intertrochanteric hip fracture presenting from October 1, 2019 to March 31, 2020 treated with a short cephalomedullary nail underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA).

MAIN OUTCOME MEASUREMENTS

Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost.

RESULTS

A total of 60 patients (20 each: MAC, general, and spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 beats per minute). For the first 3 hours postoperatively, MAC-STILA patients reported consistently lower pain scores (visual analog scale <1) than spinal or general patients (visual analog scale > 1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately 5 times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or postoperative ambulatory distance. There was no difference in inpatient cost among cohorts.

CONCLUSIONS

This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA/AO 13.A1-3 intertrochanteric fractures with a short cephalomedullary nail and may be the preferred method for patients with severe medical comorbidities or relative contraindications to general and/or spinal anesthesia.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Regional Nerve Block Decreases the Incidence of Postoperative Delirium in Elderly Hip Fracture

Postoperative delirium is common in elderly patients with hip fracture. Pain is a major risk factor for delirium, and regional nerve blocks (RNBs) effectively control pain in hip fractures. This study aimed to evaluate the effect of RNB on delirium after hip surgery in elderly patients. This retrospective comparative study was performed in a single institution, and the data were collected from medical records between March 2018 and April 2021. Patients aged ≥60 years who underwent proximal femoral fracture surgery were included, while those with previous psychiatric illness and cognitive impairment were excluded. Two hundred and fifty-two patients were enrolled and divided into an RNB or a control group according to RNB use. Delirium was assessed as the primary outcome and postoperative pain score, pain medication consumption, and rehabilitation assessment as the secondary outcomes. Between the RNB (n = 129) and control groups (n = 123), there was no significant difference in the baseline characteristics. The overall incidence of delirium was 21%; the rate was lower in the RNB group than in the control group (15 vs. 27%, respectively, p = 0.027). The average pain score at 6 h postoperatively was lower in the RNB group than in the control group (2.8 ± 1.5 vs. 3.3 ± 1.6, respectively, p = 0.030). There was no significant difference in the pain score at 12, 24, and 48 h postoperatively, amount of opioids consumed for 2 postoperative days, and time from injury to wheelchair ambulation. We recommend RNB as a standard procedure for elderly patients with hip fracture due to lower delirium incidence and more effective analgesia in the early postoperative period.

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.

Peripheral nerve blocks for hip fractures in adults

BACKGROUND

This review was published originally in 1999 and was updated in 2001, 2002, 2009, 2017, and 2020. Updating was deemed necessary due to the high incidence of hip fractures, the large number of official societies providing recommendations on this condition, the possibility that perioperative peripheral nerve blocks (PNBs) may improve patient outcomes, and the major role that PNBs may play in reducing preoperative and postoperative opioid use for analgesia.

OBJECTIVES

To compare PNBs used as preoperative analgesia, as postoperative analgesia, or as a supplement to general anaesthesia versus no nerve block (or sham block) for adults with hip fracture. Outcomes were pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction, chest infection, death, time to first mobilization, and costs of an analgesic regimen for single-injection blocks. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.

SEARCH METHODS

For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), in the Cochrane Library; MEDLINE (Ovid SP, 1966 to November 2019); Embase (Ovid SP, 1974 to November 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to November 2019), as well as trial registers and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing use of PNBs compared with no nerve block (or sham block) as part of the care provided for adults 16 years of age and older with hip fracture.  DATA COLLECTION AND ANALYSIS: Two review authors independently screened new trials for inclusion, assessed trial quality using the Cochrane Risk of Bias-2 tool, and extracted data. When appropriate, we pooled results of outcome measures. We rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 49 trials (3061 participants; 1553 randomized to PNBs and 1508 to no nerve block (or sham block)). For this update, we added 18 new trials. Trials were published from 1981 to 2020. Trialists followed participants for periods ranging from 5 minutes to 12 months. The average age of participants ranged from 59 to 89 years. People with dementia were often excluded from the included trials. Additional analgesia was available for all participants. Results of 11 trials with 503 participants show that PNBs reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.05, 95% confidence interval (CI) -1.25 to -0.86; equivalent to -2.5 on a scale from 0 to 10; high-certainty evidence). Effect size was proportionate to the concentration of local anaesthetic used (P = 0.0003). Based on 13 trials with 1072 participants, PNBs reduce the risk of acute confusional state (risk ratio (RR) 0.67, 95% CI 0.50 to 0.90; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 7 to 47; high-certainty evidence). For myocardial infarction, there were no events in one trial with 31 participants (RR not estimable; low-certainty evidence). From three trials with 131 participants, PNBs probably reduce the risk for chest infection (RR 0.41, 95% CI 0.19 to 0.89; NNTB 7, 95% CI 5 to 72; moderate-certainty evidence). Based on 11 trials with 617 participants, the effects of PNBs on mortality within six months are uncertain due to very serious imprecision (RR 0.87, 95% CI 0.47 to 1.60; low-certainty evidence). From three trials with 208 participants, PNBs likely reduce time to first mobilization (mean difference (MD) -10.80 hours, 95% CI -12.83 to -8.77 hours; moderate-certainty evidence). One trial with 75 participants indicated there may be a small reduction in the cost of analgesic drugs with a single-injection PNB (MD -4.40 euros, 95% CI -4.84 to -3.96 euros; low-certainty evidence). We identified 29 ongoing trials, of which 15 were first posted or at least were last updated after 1 January 2018.  AUTHORS' CONCLUSIONS: PNBs reduce pain on movement within 30 minutes after block placement, risk of acute confusional state, and probably also reduce the risk of chest infection and time to first mobilization. There may be a small reduction in the cost of analgesic drugs for single-injection PNB. We did not find a difference for myocardial infarction and mortality, but the numbers of participants included for these two outcomes were insufficient. Although randomized clinical trials may not be the best way to establish risks associated with an intervention, our review confirms low risks of permanent injury associated with PNBs, as found by others. Some trials are ongoing, but it is unclear whether any further RCTs should be registered, given the benefits found. Good-quality non-randomized trials with appropriate sample size may help to clarify the potential effects of PNBs on myocardial infarction and mortality.

Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials

Background

With continuous increase of the aging population, the number of geriatric patients with fragility hip fractures is rising sharply, and timely surgery remains the mainstay of treatment. However, adequate and effective pain control is the precondition of satisfactory efficacy. This systematic review aimed to summarize the use of fascia iliaca compartment block (FICB) as an analgesic strategy for perioperative pain management in geriatric patients with hip fractures.

Methods

PubMed and Embase databases were searched for English published randomized controlled trials (RCTs) reporting application of FICB for pain control of the older adults with hip fractures between January 1^st, 2000, and May 31^st, 2020. The modified Jadad scale was used to evaluate quality of the RCTs included. Primary outcomes of the eligible RCTs were presented and discussed.

Results

A total of 27 RCTs with 2478 cases were included finally. The present outcomes suggested, after admission or in the emergency department (ED), FICB can provide patients with equal or even better pain relief compared with the conventional analgesia methods, which can also reduce additional analgesic consumptions. While, before positioning for spinal anesthesia (SA), FICB is able to offer superior pain control, facilitating SA performance, after surgery FICB can effectively alleviate pain with decreased use of additional analgesics, promoting earlier mobilization and preventing complications.

Conclusions

FICB is a safe, reliable, and easy-to-conduct technique, which is able to provide adequate pain relief during perioperative management of geriatric patients with hip fractures.

Impact of the Fascia Iliaca Block on Pain, Opioid Consumption, and Ambulation for Patients With Hip Fractures: A Prospective, Randomized Study

OBJECTIVES

To determine the effect of the fascia iliaca block (FIB) on patients undergoing surgery for hip fractures.

DESIGN

Prospective, randomized controlled trial.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Patients (N = 97) undergoing surgery for hip fractures were prospectively randomized to receive either a perioperative FIB (FIB group) or no block (control group) from February 2018 to April 2019.

MAIN OUTCOME MEASURES

Visual analog scale (VAS) score, morphine milligram equivalents, and postoperative ambulatory distance.

RESULTS

Fifty-seven patients were randomized to the FIB group, and 40 patients were randomized to the control group. Eighteen patients crossed over from the FIB to the control group, and 12 patients crossed over from the control to the FIB group. In the intent-to-treat analysis, demographic data, mechanism of injury, radiographic fracture classification, and surgical procedure were similar between the 2 groups. The FIB group consumed fewer morphine milligram equivalents before surgery (13 vs. 17, P = 0.04), had a trend toward an improved visual analog scale score on postoperative day 2 (0 vs. 2 P = 0.06), and walked a farther distance on postoperative day 2 (25' vs. 2', P = 0.09). A greater proportion of the FIB group were discharged home (50.9% vs. 32.5%, P = 0.05). There were no differences in opioid-related, block-related, or medical complications between groups. In the as-treated and per-protocol analyses, there were no significant differences.

CONCLUSIONS

A single perioperative FIB for patients with hip fractures undergoing surgery may decrease opioid consumption and increase the likelihood that a patient is discharged home.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.