Efficacy of ultrasound-guided fascia iliaca compartment block after hip hemiarthroplasty: A prospective, randomized trial

Comparison of the Effect of Pericapsular Nerve Group Block Combined with Lateral Femoral Cutaneous Nerve Block and Fascia Iliaca Compartment Block in Patients Undergoing Hip Arthroscopy Under General Anesthesia: A Randomized, Double-Blind Trial

Purpose

Patients undergoing arthroscopic hip surgery (AHS) require good analgesia and early rehabilitation after surgery, and there is no consensus on the optimal nerve block. We aimed to compare the efficacy of the pericapsular nerve group (PENG) block with lateral femoral cutaneous nerve (LFCN) block compared to fascia iliaca compartment block (FICB) in patients with AHS.

Patients and Methods

A total of 80 patients receiving AHS under general anesthesia were randomized to receive either FICB (group F) or PENG block in combination with LFCN block (group P). The primary outcomes were the rate of quadriceps weakness after block on the afflicted side, as well as muscle strength grading and pain score after block, and the quality of recovery on the second postoperative day.

Results

Compared with group F, group P had a lower incidence of quadriceps weakness 48 h after block (76.9% vs 28.2%, P < 0.001), and had less impact on muscle strength grade and lower static pain score at 6, 12, 18, 24, 36, and 48 h after block (P < 0.001), and a lower dynamic pain score at 6 and 12 h after block in group P (p < 0.05). The quality of recovery on the second postoperative day improved (p < 0.05).

Conclusion

In comparison to FICB, PENG block in combination with LFCN block can affect less quadriceps muscle strength and reduce the use of postoperative analgesics, which is beneficial for the postoperative recovery of AHS patients.

Implementation of a Fascia Iliaca Compartment Block Program in Geriatric Hip Fractures: The Experience at a Level I Academic Trauma Center

OBJECTIVES

Determine adherence to a newly implemented protocol of fascia iliaca compartment block (FICB) in geriatric hip fractures.

METHODS

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Patients with a hip fracture treated with cephalomedullary nailing or hemiarthroplasty (CPT codes 27245 or 27236).

OUTCOME MEASURES AND COMPARISONS

Adherence to a protocol for FICB, time intervals between emergency department arrival, FICB, and surgery stratified by time of admission.

RESULTS

Three hundred eighty patients were studied (average age 78 years, 70% female). Approximately 53.2% of patients received an FICB, which was less than a predefined acceptable adherence rate of 75% ( P < 0.001). Approximately 5.0% received an FICB within 4 hours and 17.3% within 6 hours from admission. Admission during daylight hours (7 am -7p m ) when compared with evening hours (7 pm -7 am ) was associated with improved timeliness ([8.3% vs. 0% within 4 hours, P < 0.001] [27.5% vs. 2.4% within 6 hours, P < 0.001]). Improved adherence to the protocol was observed over time (odds ratio: 1.0013, 95% confidence interval, 1.0001-1.0025, P = 0.0388).

CONCLUSIONS

FICB implementation was poor but gradually improved over time. Few patients received an FICB promptly, especially during night hours. Overall, this study demonstrates that implementation of an FICB program at a Level I academic trauma center can be difficult; however, many hurdles can be overcome with institutional support and dedication of resources such as staff, space, and additional training.

Hip Fracture Surgery: Regional Anesthesia and Opioid Demand

BACKGROUND

Hip fracture surgery is painful, and regional anesthesia (RA) has been used in an attempt to reduce pain and opioid consumption after surgery. Despite potential analgesic benefits, the effect of RA on inpatient and outpatient opioid demand is not well known. We hypothesized that RA would be associated with decreased inpatient opioid demand and has little effect on outpatient opioid demand in hip fracture surgery.

METHODS

This study retrospectively evaluated all patients of 18 years and older undergoing hip fracture surgery from July 2013 to July 2018 at a single, level I trauma center (n = 1,659). Inpatient opioid consumption in 24-hour increments up to 72-hour postoperative and outpatient opioid prescribing up to 90-day postoperative were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models evaluated the effect of RA on opioid demand after adjusting for other baseline and treatment variables.

RESULTS

After adjusting for baseline and treatment variables, there were small increases in inpatient opioid consumption in patients with RA (2.6 estimated OE's without RA versus three OE's with RA from 0 to 24 hours postoperatively, 2.1 versus 2.4 from 24 to 48 hours postoperatively, and 1.6 versus 2.2 from 48 to 72 hours postoperatively, all P values for RA <0.001). However, there were no notable differences in outpatient opioid demand.

DISCUSSION

RA did not decrease inpatient or outpatient opioid demand in patients undergoing hip fracture surgery in this pragmatic study. In fact, there were slight increases in inpatient opioid consumption, although these differences are likely clinically insignificant. These results temper enthusiasm for RA in hip fracture surgery.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

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.

Fascia Iliaca Pain Block Results in Lower Overall Opioid Usage and Shorter Hospital Stays than Epidural Anesthesia After Hip Reconstruction in Children With Cerebral Palsy

INTRODUCTION AND OBJECTIVE

Epidural anesthesia (EA) is often used for pain control in children with cerebral palsy (CP) who undergo hip reconstructions. The purpose of this study is to determine if preoperative fascia iliaca (FI) pain blocks would improve pain scores, decrease opioid use, and result in shorter hospital stays in comparison to the use of EA.

METHODS

This is a nonrandomized retrospective cohort study examining 60 consecutive patients with CP who underwent hip reconstruction utilizing either a fascia iliac compartment nerve block (FICNB) (N=37) or continuous lumbar epidural (N=22) from January 2017 to March 2019. Age at surgery was 8.5±4.6 years. We recorded age, weight, operating room (OR) time, FLACC (Face, Legs, Activity, Cry, Consolability scale) scores on postoperative days (PODs) 0, 1, 2, and 3, opioid doses, overall opioid (mg) used, and length of stay. We compared pain scores, opioid usage, OR time, and lengths of stay between our 2 patient groups.

RESULTS

Pain scores were similar between groups on POD #0, 2, and 3 but were statistically improved on POD #1 (1.8±1.3 vs. 3.1±1.4, P<0.001). Total number of opiod doses (7.9±4.4 vs. 10.7±2.3, P=0.004), total milligram given (18.3±11.8 vs. 24.7±12.3, P<0.05), and milligram per kilogram given (0.77±0.42 vs. 1.11 mg/kg±0.36 mg/kg, P=0.001) were less for the FI group versus the epidural group. The OR time (which includes time for blocks/epidurals) was lower in the FI group (4.6±1.2 vs. 5.7±1.1 h, P=0.0002). Overall hospital stays were lower in the FI group (3.4±1.5 vs. 4.1±1.0 d, P<0.05).

CONCLUSIONS

This study demonstrates that in the setting of hip reconstruction, patients that received preoperative FI blocks used a lower amount of opioids, required fewer rescue doses and ultimately had a shorter hospital length of stay than those undergoing EA.

The effect of fascia iliaca block on postoperative pain and analgesic consumption for patients undergoing primary total hip arthroplasty: a meta-analysis of randomized controlled trials

Background

The primary aim of this systematic review and meta-analysis was to compare postoperative pain, analgesic consumption, and complications after fascia iliaca block (FIB) versus control for patients undergoing primary total hip arthroplasty (THA). Second, we compared the outcomes of FIB versus placebo. Finally, we sought to evaluate pain and analgesic consumption after preoperative and postoperative FIB.

Methods

We performed a systematic literature search in MEDLINE, Embase, Scopus, Web of Science, Google Scholar, ClinicalTrials.gov, and CENTRAL through February 2021 to identify randomized controlled trials (RCTs) that evaluated the efficacy of FIB versus control for patients undergoing primary THA. All analyses were conducted on intent-to-treat data with a random-effects model.

Results

Twelve RCTs with a total of 815 patients were included. There was no difference in postoperative pain (P = 0.64), analgesic consumption (P = 0.14), or complication rate (P = 0.99) between FIB and control groups. Moreover, no difference in postoperative pain (P = 0.26), analgesic consumption (P = 0.06), or complication rate (P = 0.71) was found between FIB and placebo. Moreover, sensitivity analysis suggested that no significant difference in postoperative pain, analgesic consumption, or complication rate was present between FIB and control in studies that used preoperative and postoperative FIB.

Conclusion

FIB was not found to be superior to placebo or various anesthetic techniques for patients undergoing primary THA, as measured by postoperative pain, analgesic consumption, and complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02585-1.

A comparison of analgesic techniques for total knee arthroplasty: A network meta-analysis

STUDY OBJECTIVE

There is no established analgesic method for postoperative total knee arthroplasty. We comprehensively compared the analgesic methods for postoperative total knee arthroplasty.

DESIGN

A network meta-analysis of randomised controlled trials was used to compare 18 interventions, which were ranked by six outcome indices, to select the best modality.

SETTING

Postoperative recovery room and inpatient ward.

PATIENTS

98 randomised controlled trials involving 7452 patients (ASA I-III) were included in the final analysis.

INTERVENTIONS

Studies that included the use of at least one of the following 12 nerve block(fascia iliaca compartment block (FIB), FNB, cFNB, single femoral nerve block (sFNB), adductor canal block (ACB), sciatic nerve block (SNB), obturator nerve block (ONB), continuous posterior lumbar plexus block (PSOAS), FNB + SNB, ACB + LIA, FNB + LIA, PCA + FNB).

MEASUREMENTS

Pain intensity was compared using Visual Analogue Scale (VAS). Also, postoperative complications, function score, hospital length of stay, morphine consumption and patient satisfaction were measured.

MAIN RESULTS

For visual analogue scale scores, continuous femoral nerve block (FNB) and FNB + sciatic nerve block (SNB) were the the most effective interventions. For reducing postoperative complications, fascia iliaca compartment block, FNB, SNB, and obturator nerve block showed the best results. For reducing postoperative morphine consumption, adductor canal block (ACB) + local infiltration analgesia (LIA) and FNB + SNB were preferred. For function scores (range of motion, Timed-Up-and-Go test), ACB and LIA were optimal choices. For reducing hospital length of stay and patient satisfaction, ACB + LIA and FNB + LIA were best, respectively.

CONCLUSIONS

Peripheral nerve block, especially FNB and ACB, is a better option than other analgesic methods, and its combination with other methods can be beneficial. Peripheral nerve block is a safe and effective postoperative analgesia method. However, our findings can only provide objective evidence. Clinicians should choose the treatment course based on the individual patient's condition and clinical situation.

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.

Comparison of the Effectiveness of Suprainguinal Fascia Iliaca Compartment Block and Patient-Controlled Analgesia for Major Hip Surgeries in Elderly Patients

OBJECTIVE

Fascia iliaca compartment block is an alternative analgesic technique for hip surgeries. In the new suprainguinal technique, the 'bowtie' sign is detected with an ultrasound probe, and local anaesthetic is injected into the fascial plane with in-plane approach. In this retrospective study, we compared the postoperative analgesic efficacy of suprainguinal fascia iliaca compartment block (S-FICB) and patient-controlled analgesia (PCA) after major hip surgery in elderly patients.

METHODS

We retrospectively recorded visual analogue scale (VAS) scores, morphine consumptions and opioid side effects who underwent either a S-FICB (n=67) or PCA (n=61). In the S-FICB group, 25-40 mL of 0.25% bupivacaine was administered with a single-shot S-FICB technique after induction of anaesthesia. VAS scores during resting (VAS-S) and movement (VAS-D); morphine consumption at 0, 6, 12, 24 and 48 hours; total morphine consumption; and opioid-related complications were recorded.

RESULTS

Morphine consumptions in each measurement period and in total were significantly lower in the S-FICB group (694.03±2,007.47 μg vs. 13,368.85±4,834.68 μg; p<0.05). The total number of opioid-related complications were also significantly lower in the S-FICB group (17/67 vs. 48/62; p<0.05). More than half of the patients (38/67, 56%) did not need morphine administration in the S-FICB group. VAS-S during the first 6 hours and VAS-D up to 24 hours postoperatively were significantly lower in the S-FICB group (p<0.05).

CONCLUSION

In our study, S-FICB provided better analgesia than the PCA technique after hip surgery in elderly patients. Moreover, S-FICB reduced opioid consumption and opioid-related complications in the first 24 hours postoperatively.

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.

Pain Control After Total Hip Arthroplasty: A Randomized Controlled Trial Determining Efficacy of Fascia Iliaca Compartment Blocks in the Immediate Postoperative Period

BACKGROUND

The purpose of this randomized controlled trial is to identify if a fascia iliaca block reduces postoperative pain and narcotic consumption and improves early functional outcomes in primary total hip arthroplasty (THA) performed through the mini-posterior approach.

METHODS

Patients were recruited from September 2017 to September 2019. Eligible patients received a primary THA using a mini-posterior approach with epidural anesthesia. Postoperatively, patients were randomized to receive a fascia iliaca compartment block or a placebo block. Numeric Rating Scale pain scores, narcotic consumption, and functional outcomes were recorded at regular intervals postoperatively.

RESULTS

Upon study completion, 122 patients were available for final analysis. There was no difference in the average pain scores at any time interval between the placebo and block groups during the first 24 hours (P = .21-.99). There was no difference in the morphine equivalents consumed between the groups during any time interval postoperatively (P = .06-.95). Functional testing showed no difference in regards to distance walked during the first therapy session (67.1 vs 68.3 ft., P = .92) and timed-up-and-go testing (63.7 vs 66.3 seconds, P = .86). There was an increased incidence of quadriceps weakness in the block group (22% vs 0%, P = .004) requiring alterations in therapy protocols.

CONCLUSION

This randomized trial shows that a fascia iliaca compartment block does not improve functional performance and does not decrease pain levels or narcotic usage after mini-posterior THA, but does increase the risk of quadriceps weakness postoperatively. Based on these results we do not recommend routine fascia iliaca compartment blocks after THA performed with the mini-posterior approach.

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

OBJECTIVES

To determine the efficacy of a preoperative fascia iliaca compartment block in decreasing postoperative pain and improving functional recovery after hip fracture surgery.

DESIGN

Randomized prospective Level 1 therapeutic.

SETTING

Academic Level 1 trauma center.

PATIENTS

Geriatric patients with fractures of the proximal femur (neck, intertrochanteric, or subtrochanteric regions) were prospectively randomized into an experimental (A) or control (B) groups. Forty-seven patients met inclusion criteria, 23 randomized to the experimental group and 24 to the control group.

INTERVENTION

Patients randomized to the experimental group received an ultrasound-guided fascia iliaca compartment block administered by a board-certified anesthesiologist immediately before the initiation of anesthesia.

MAIN OUTCOME MEASUREMENTS

Primary outcome measure was postoperative pain medication consumption until postoperative day 3. Secondary outcomes included functional recovery and a study-specific patient-reported satisfaction survey assessed on postoperative day 3.

RESULTS

There was no significant difference in consumption of acetaminophen for mild pain, tramadol for moderate pain, or functional recovery between the 2 groups. There was a statistically significant decrease in morphine consumption (0.4 mg vs. 19.4 mg, P = 0.05) and increase in patient-reported satisfaction (31%, P = 0.01).

CONCLUSIONS

Preoperative fascia iliaca compartment block significantly decreases postoperative opioid consumption while improving patient satisfaction. We recommend the integration of this safe and efficacious modality into institutional geriatric hip fracture protocols as an adjunctive pain control strategy.

LEVEL OF EVIDENCE

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

Comparison of the postoperative analgesic efficacies of intravenous acetaminophen and fascia iliaca compartment block in hip fracture surgery: A randomised controlled trial

BACKGROUND

Managing pain during movement after hip fracture surgery is important for achieving earlier hip mobilisation and for preventing postoperative complications. In the present study, we tested the hypothesis that the fascia iliaca compartment block (FICB) would improve postoperative pain on movement compared with intravenous acetaminophen.

METHODS

In this prospective, randomised, controlled, parallel trial, patients were assigned to either the intravenous acetaminophen or the ultrasound-guided FICB group. Visual analog scale (VAS) pain scores were evaluated at 6, 9, 12, 18, 24 h, 2 days, and 7 days postoperatively. The primary outcome was VAS scores on movement at 24 h after surgery. The secondary outcomes were VAS scores on movement at the other time points, VAS scores at rest, the total number of rescue analgesics required and incidence of delirium during the first 24 h postoperatively, potential drug or block-related complications, and the time to first standing.

RESULTS

VAS scores on movement at 24 h after surgery were significantly lower in the FICB group than in the intravenous acetaminophen group [median (the 25th to 75th percentiles), 20 (10-30) vs 40 (30-53); P < 0.01]. The VAS scores on movement at any other time point and the scores at rest at 12 h after surgery were also significantly lower in the FICB group than in the intravenous acetaminophen group. The two groups did not differ in terms of the total number of rescue analgesics required or the incidence of delirium during the first 24 h postoperatively; complications; or the time to first standing.

CONCLUSIONS

FICB improved postoperative pain on movement compared with intravenous acetaminophen without increasing the complication rate. However, the total number of rescue analgesics required and the time to first standing were not significantly different between the two groups.

Ultrasound-guided fascia iliaca compartment block combined with general anesthesia for amputation in an acute myocardial infarction patient after percutaneous coronary intervention: A case report

BACKGROUND

Fascia iliaca compartment block is a technique that blocks three nerves, similar to a 3-in-1 nerve block. This block provides analgesia for patients undergoing lower limb surgery, and is a simple technique that is easy to implement. Here, we report a case of fascia iliaca compartment block in a patient with myocardial infarction who underwent emergency middle thigh amputation.

CASE SUMMARY

A 78-year-old female patient weighing 38 kg with gangrene and occlusive peripheral atherosclerosis of the right leg underwent an emergency middle thigh amputation. The patient had a history of hypertension, coronary heart disease, cerebral infarction, anterior wall myocardial infarction, and had recently undergone percutaneous coronary intervention consisting of coronary angiography and right coronary artery stent implantation. Considering the patient's condition, an ultrasound-guided fascia iliaca compartment block combined with general anesthesia was implemented for amputation. The fascia iliaca compartment block provided analgesia for the operation, and reduced the dosage of general anesthetics. It also alleviated adverse cardiovascular effects caused by pain stress, and ensured the safety of the patient during the perioperative period. This block also provided postoperative analgesia. The patient had a good prognosis, and was subsequently discharged from hospital.

CONCLUSION

Fascia iliaca compartment block provides surgical analgesia. It also alleviates adverse cardiovascular effects, and ensures patient safety during the perioperative period.

Postoperative analgesia with ropivacaine and dexmedetomidine for ultrasound-guided fascia iliaca compartment block after arthroscopic knee surgery

Objective

The objective of this study is to evaluate the postoperative analgesic effect of a combination of ropivacaine and dexmedetomidine for ultrasound-guided fascia iliaca compartment block (FICB) after knee arthroscopy.

Materials and Methods

Forty patients scheduled for knee arthroscopy were randomized to receive either 30 ml of 0.25% ropivacaine alone (Group A, n = 20) or combined with dexmedetomidine 1 μg/kg (Group B, n = 20). Pain intensity was evaluated using the visual analogue scale (VAS), at rest and during activity at 4, 6, 8, 12, and 24 h after surgery. Level of consciousness was evaluated using the Ramsay sedation score. Time to first analgesic request after surgery, the dose of analgesic used in the first 24 h after surgery, variation of heart rate, and adverse reactions were also recorded.

Results

VAS scores at 6 and 12 h after surgery were significantly lower in Group B compared to Group A (P < 0.05). No significant difference was observed in the Ramsay sedation score or time to first analgesic request after surgery (P > 0.05). The total dose of analgesic used in the first 24 h after surgery was higher in Group A than in Group B. The incidence of bradycardia was higher in Group B compared to Group A. No adverse reactions were observed in either group.

Conclusion

FICB with a combination of ropivacaine and dexmedetomidine resulted in significant reduction of VAS scores with lower postoperative analgesic requirement after arthroscopic knee surgery. No adverse reactions or complications were noted except for lower heart rate in Group B patients.

A safe percutaneous technique for the reduction of irreducible femoral neck fractures using ultrasound localization of the femoral vascular and nervous structures at the hip

We present a safe percutaneous technique for the placement of Kirschner wires into the femoral head to assist in the reduction of irreducible femoral neck fractures using ultrasound to identify the vascular and nervous structures about the hip.From January 2011 to June 2014, a total of 36 patients (25 males and 11 females) were enrolled in this study. Patients were placed on a fracture reduction table for limb traction. After 3 unsuccessful reductions with limb traction, ultrasound-guided localization of the patient's femoral artery, vein, and nerve at the hip was performed. These structures were marked on the overlying skin and then Kirschner wires were inserted into the femoral head avoiding these marked structures. After the surgery, the Kirschner wire insertions were routinely reviewed by ultrasound, the hip fracture reduction and the femoral nerve sensorimotor function were routinely examined as well.All 36 patients with an irreducible variant of a femoral neck fracture showed anatomic reduction under C-arm fluoroscopy using ultrasound to avoid K wire injury to the femoral vascular structures and nerve. No major vascular injury during operation. In post-surgical ultrasound examination, local hematoma formation was not evident. There was normal function of the femoral nerve. On follow-up, there were no infections, wound problems, recurrence of fracture displacement, laxity, or implant breakage.Preoperative ultrasonic localization of the femoral artery, vein, and femoral nerve safely allowed. Kirschner wire placement under C-arm fluoroscopy into the femoral head to assist in fracture reduction. This assisted reduction method for irreducible femoral neck fractures had a number of advantages, including closed anatomic reduction with minimal attempts, used simple equipment, and avoided further destruction of the blood supply to the femoral head.

Ultrasound-guided suprainguinal fascia iliaca compartment block versus periarticular infiltration for pain management after total hip arthroplasty: a randomized controlled trial

Background and objectives

Fascia iliaca compartment block (FICB) has been shown to provide excellent pain relief in patients undergoing total hip arthroplasty (THA). However, the analgesic efficacy of FICB, in comparison with periarticular infiltration (PAI) for THA, has not been evaluated. This randomized, controlled, observer-blinded study was designed to compare suprainguinal FICB (SFICB) with PAI in patients undergoing THA via posterior approach.

Methods

After institutional review board approval, 60 consenting patients scheduled for elective THA were randomized to one of two groups: ultrasound-guided SFICB block or PAI. The local anesthetic solution for both the groups included 60 mL ropivacaine 300 mg and epinephrine 150 µg. The remaining aspects of perioperative care, including general anesthetic and non-opioid multimodal analgesic techniques, were standardized. An investigator blinded to group allocation documented pain scores at rest and with movement and supplemental opioid requirements at various time points. Patients were evaluated for sensory changes and quadriceps weakness in the operated extremity.

Results

There were no differences between the groups with respect to demographics, intraoperative opioid use, duration of surgery, recovery room stay, nausea scores, need for rescue antiemetics, time to ambulation and time to discharge readiness as well as 48 hours postoperative opioid requirements. The pain scores at rest and with movement also were similar at all time points. Significantly more patients in the SFICB group experienced muscle weakness at 6 hours after surgery.

Conclusions

Under the circumstances of our study, in patients undergoing THA, SFICB provided the similar pain relief compared with PAI, but was associated with muscle weakness at 6 hours postoperatively.

Trial registration number

NCT02658240.

The efficacy of fascia iliaca compartment block for pain control after total hip arthroplasty: a meta-analysis

Purpose

Fascia iliaca compartment block (FICB) provides an analgesic option for total hip arthroplasty (THA) patients. The evidence supporting FICB is still not well established. The purpose of this meta-analysis was to assess FICB for pain control in THA patients.

Methods

PubMed, Embase, Cochrane Library, and Chinese Wanfang database were interrogated from their inceptions to December 15, 2018. We included randomized controlled studies reported as full text, those published as abstracts only, and unpublished data, if available. Data were independently extracted by two reviewers and synthesized using a random-effects model or fixed-effects model according to the heterogeneity.

Results

A total of eight RCTs were finally included for meta-analysis. Compared with placebo, FICB could significantly reduce VAS pain scores at 1–8 h (WMD = − 0.78, 95% CI [− 1.01, − 0.56], P = 0.000), 12 h (WMD = − 0.69, 95% CI [− 1.22, − 0.16], P = 0.011), and 24 h (WMD = − 0.46, 95% CI [− 0.89, − 0.02], P = 0.039). Compared with the control group, FICB could significantly decrease the occurrence of nausea and length of hospital stay (P < 0.05). There was no significant difference between the VAS pain score at 48 h and risk of fall between the FICB and the control groups (P > 0.05).

Conclusions

FICB could be used to effectively reduce pain intensity up to 24 h, total morphine consumption, and length of hospital stay in THA patients. Optimal strategies of FICB need to be studied in the future.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1053-1) contains supplementary material, which is available to authorized users.

Fascia iliaca compartment block versus no block for pain control after lower limb surgery: a meta-analysis

Background

The analgesic effect of fascia iliaca compartment block (FICB) versus no block (NB) after lower limb surgery (LLS) is still controversial, so we performed this meta-analysis.

Materials and methods

By searching the PubMed, Embase and the Cochrane Library (last update by July 20, 2017), randomized controlled trials comparing the analgesic effect of FICB versus NB in patients receiving LLS were identified. The primary outcome was the pain scores at 4, 12, and 24 h after LLS. The dosage of morphine at 24 h was also collected. The side effect of anesthesia was assessed according to the occurrence rate of postoperative nausea and vomiting.

Results

Data from 7 clinical trials that included 508 patients were summarized. The results showed that patients receiving FICB had lower pain scores at 4 h (mean difference [MD]=−1.17; 95% CI=−2.30 to −0.05; P=0.041), 12 h (MD=−0.41; 95% CI=−0.76 to −0.05; P=0.026) and 24 h (MD=−0.96; 95% CI=−1.77 to −0.15; P=0.020) after LLS. Besides, FICB could reduce the dosage of morphine at 24 h (MD=−2.06; 95% CI=−3.82 to −0.30; P=0.022) and the incidence of postoperative nausea and vomiting (relative risk rate=0.44, 95% CI=0.24–0.80, P=0.008).

Conclusion

Compared with NB, FICB is an effective and safe method for alleviating the pain after LLS. More high-quality randomized controlled trials are needed to confirm this finding.

Nerve blocks or no nerve blocks for pain control after elective hip replacement (arthroplasty) surgery in adults

BACKGROUND

It is estimated that over 300,000 total hip replacements are performed each year in the USA. For European countries, the number of hip replacement procedures per 100,000 people performed in 2007 varied from less than 50 to over 250. To facilitate postoperative rehabilitation, pain must be adequately treated. Peripheral nerve blocks and neuraxial blocks have been proposed to replace or supplement systemic analgesia.

OBJECTIVES

We aimed to compare the relative effects (benefits and harms) of the different nerve blocks that may be used to relieve pain after elective hip replacement in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2016), MEDLINE (Ovid SP) (1946 to December Week 49, 2016), Embase (Ovid SP) (1980 to December week 49, 2016), CINAHL (EBSCO host) (1982 to 6 December 2016), ISI Web of Science (1973 to 6 December 2016), Scopus (from inception to December 2016), trials registers, and relevant web sites.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) performed in adults undergoing elective primary hip replacement and comparing peripheral nerve blocks to any other pain treatment modality. We applied no language or publication status restrictions.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors. We contacted study authors.

MAIN RESULTS

We included 51 RCTs with 2793 participants; of these 45 RCTs (2491 participants: peripheral nerve block = 1288; comparators = 1203) were included in meta-analyses. There are 11 ongoing studies and three awaiting classification.Compared to systemic analgesia alone, peripheral nerve blocks reduced: pain at rest on arrival in the postoperative care unit (SMD -1.12, 95% CI -1.67 to -0.56; 9 trials, 429 participants; equivalent to 3.2 on 0 to 10 scale; moderate-quality evidence); risk of acute confusional status: risk ratio (RR) 0.10 95% CI 0.02 to 0.54; 1 trial, 225 participants; number needed to treat for additional benefit (NNTB) 12, 95% CI 11 to 22; very low-quality evidence); pruritus (RR 0.16, 95% CI 0.04 to 0.70; 2 trials, 259 participants for continuous peripheral nerve blocks; NNTB 4 (95% CI 4 to 8); very low-quality evidence); hospital length of stay (SMD -0.75, 95% CI -1.02 to -0.48; very low-quality evidence; 2 trials, 249 participants; equivalent to 0.75 day). Participant satisfaction increased (SMD 0.67, 95% CI 0.45 to 0.89; low-quality evidence; 5 trials, 363 participants; equivalent to 2.4 on 0 to 10 scale). We did not find a difference for the number of participants walking on postoperative day one (very low-quality evidence). Two nerve block-related complications were reported: one local haematoma and one delayed persistent paresis.Compared to neuraxial blocks, peripheral nerve blocks reduced the risk of pruritus (RR 0.33, 95% CI 0.19 to 0.58; 6 trials, 299 participants; moderate-quality evidence; NNTB 6 (95% CI 5 to 9). We did not find a difference for pain at rest on arrival in the postoperative care unit (moderate-quality evidence); number of nerve block-related complications (low-quality evidence); acute confusional status (very low-quality evidence); hospital length of stay (low quality-evidence); time to first walk (low-quality evidence); or participant satisfaction (high-quality evidence).We found that peripheral nerve blocks provide better pain control compared to systemic analgesia with no major differences between peripheral nerve blocks and neuraxial blocks. We also found that peripheral nerve blocks may be associated with reduced risk of postoperative acute confusional state and a modest reduction in hospital length of stay that could be meaningful in terms of cost reduction considering the increasing numbers of procedures performed annually.

AUTHORS' CONCLUSIONS

Compared to systemic analgesia alone, there is moderate-quality evidence that peripheral nerve blocks reduce postoperative pain, low-quality evidence that patient satisfaction is increased and very low-quality evidence for reductions in acute confusional status, pruritus and hospital length of stay .We found moderate-quality evidence that peripheral nerve blocks reduce pruritus compared with neuraxial blocks.The 11 ongoing studies, once completed, and the three studies awaiting classification may alter the conclusions of the review once assessed.

Nerve Blocks in the Geriatric Patient With Hip Fracture: A Review of the Current Literature and Relevant Neuroanatomy

Introduction

Hip fracture is a common occurrence in the elderly population with high morbidity and mortality due to postoperative pain and opioid use. The goal of this article is to review the current literature on the neuroanatomy of the hip and the use of localized nerve block in controlling hip fracture pain.

Methods

A thorough search of MEDLINE/PubMed, Embase, and the Cochrane Database of Systematic Reviews was conducted using the search terms "hip fracture" and "fascia iliaca block (FICB)." An additional search was conducted utilizing multiple search terms including "hip fracture," "greater trochanter," "femur," "hip," "anatomy," "neuroanatomical," and "anatomic." Each search result was investigated for cadaveric studies on the innervation of the trochanteric region.

Results

Twenty-five clinical studies examining the use of FICBs in hip fracture patients were identified. These studies show that FICB is safe and effective in controlling perioperative pain. Additionally, FICB has been shown to decrease opioid requirement and opioid-related side effects. Neuroanatomical studies show that the hip capsule is innervated by contributions from the femoral, obturator, sciatic, and superior gluteal nerves. Imaging studies suggest that FICB anesthetizes these branches through localized spread along the fascia iliaca plane. Cadaveric evidence suggests that the greater trochanter region is directly innervated by a single branch from the femoral nerve.

Discussion

The proven efficacy of nerve blocks and their anatomic basis is encouraging to both the anesthesiologist and orthopedic surgeon. Their routine use in the hip fracture setting may improve patient outcomes, given the unacceptably high morbidity and mortality associated with opioid use.

Conclusions

Localized nerve blocks, specifically FICB, have been shown to be safe and effective in managing acute hip fracture pain in geriatric patients, leading to decreased opioid use. Knowledge of the hip neuroanatomy may help guide future development of hip fracture pain blockade.

Comprehensive geriatric care reduces acute perioperative delirium in elderly patients with hip fractures: A meta-analysis

BACKGROUND

The aim of the current meta-analysis was to assess the treatment effect of comprehensive geriatric care in reducing acute perioperative delirium in older patients with hip fractures, compared with the effect of a routine orthopedic treatment protocol.

METHODS

We conducted a search of multiple databases to identify randomized controlled trials (RCTs) and quasi-RCTs comparing comprehensive geriatric care and routine orthopedic treatment regarding the following outcomes: incidence of delirium, assessment of cognitive status, and duration of delirium. Odds ratios (ORs) and mean differences (MDs) were pooled using either a fixed-effects or a random-effects model, depending on the heterogeneity of the trials included in the analysis.

RESULTS

Six RCTs and 1 quasi-RCT provided data from 1840 patients. These data revealed that comprehensive geriatric care may reduce the incidence of perioperative delirium (OR = 0.71; 95% confidence interval [CI], 0.57-0.89; P = .003) and that it was associated with higher cognitive status during hospitalization or at 1 month postoperatively (MD = 1.03; 95% CI, 0.93-1.13; P ≤ .00001). There was no significant difference in duration of perioperative delirium between the 2 treatment groups (MD = -2.48; 95% CI, -7.36 to 2.40; P = .32).

CONCLUSION

Based on the quality of evidence provided, comprehensive geriatric care may reduce the incidence of perioperative delirium. To obtain evidence regarding the merits of comprehensive geriatric care in reducing severity of delirium and shortening the duration of delirium, there is a need for multicenter RCTs with high methodological quality.