Femoral Nerve Block Intervention in Neck of Femur Fracture (FINOF): a randomised controlled trial

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.

Peripheral regional anaesthesia and outcomes: a narrative review of the literature from 2013 to 2023

The use of peripheral regional anaesthesia continues to increase, yet the evidence supporting its use and impact on relevant outcomes often lacks scientific rigour, especially when considering the use of specific blocks for a particular surgical indication. In this narrative review, we consider the relevant literature in a 10-yr period from 2013. We performed a literature search (MEDLINE and EMBASE) for articles reporting randomised controlled trials and other comparative trials of peripheral regional anaesthetic blocks vs systemic analgesia in adult patients undergoing surgery. We evaluated measures of effective treatment and complications. A total of 128 studies met our inclusion criteria. There remains variability in the technical conduct of blocks and the outcomes used to evaluate them. There is a considerable body of evidence to support the use of interscalene blocks for shoulder surgery. Saphenous nerve (motor-sparing) blocks provide satisfactory analgesia after knee surgery and are preferred to femoral nerve blocks which are associated with falls when patients are mobilised early as part of enhanced recovery programmes. There are additional surgical indications where the efficacy of cervical plexus, intercostal nerve, and ilioinguinal/iliohypogastric nerve blocks have been demonstrated. In the past 10 yr, there has been a consolidation of the evidence indicating benefit of peripheral nerve blocks for specific indications. There remains great scope for rigorous, multicentre, randomised controlled trials of many peripheral nerve blocks. These would benefit from an agreed set of patient-centred outcomes.

Bilateral pericapsular end nerve blocks for steroid-induced avascular necrosis following COVID-19 infection requiring bilateral total hip replacement

BACKGROUND

Osteonecrosis or avascular necrosis (AVN) of the hip was one of the dreaded complications of coronavirus disease 2019 (COVID-19), which emerged in patients who received steroid therapy. Corticosteroids have been a mainstay in the treatment protocol of COVID-19 patients. Popular corticosteroid drugs used in patients suffering from COVID-19 were intravenous (IV) or oral dexamethasone, methylprednisolone or hydrocortisone. The use of such high doses of corticosteroids has shown very positive results and has been lifesaving in many cases. Still, long-term consequences were drug-induced diabetes, osteoporosis, Cushing syndrome, muscle wasting, peripheral fat mobilization, AVN, hirsutism, sleep disturbances and poor wound healing. A significant number of young patients were admitted for bilateral total hip replacements (THR) secondary to AVN following steroid use for COVID-19 treatment.

AIM

To assess the efficacy of bilateral pericapsular end nerve group (PENG) blocks in patients posted for bilateral THR post-steroid therapy after COVID-19 infection and assess the time taken to first ambulate after surgery.

METHODS

This prospective observational study was conducted between January 2023 and August 2023 at Care Hospitals, Hyderabad, India. Twenty young patients 30-35 years of age who underwent bilateral THR were studied after due consent over 8 months. All the patients received spinal anaesthesia for surgery and bilateral PENG blocks for postoperative analgesia.

RESULTS

The duration of surgery was 2.5 h on average. Seventeen out of twenty patients (85%) had a Visual Analog Score (VAS) of less than 2 and did not require any supplementation. One patient was removed from the study, as he required re-exploration. The remaining two patients had a VAS of more than 8 and received IV morphine post-operatively as a rescue analgesic drug. Fifteen out of seventeen patients (88.2%) could be mobilized 12 h after the procedure.

CONCLUSION

Osteonecrosis or AVN of the hip was one of the dreaded complications of COVID-19, which surfaced in patients who received steroid therapy requiring surgical intervention. Bilateral PENG block is an effective technique to provide post-operative analgesia resulting in early mobilization and enhanced recovery after surgery.

What factors affect early mobilisation following hip fracture surgery: a scoping review

OBJECTIVES

Identify and evaluate factors affecting early mobilisation on the day following hip fracture surgery.

DESIGN

Mixed methods, scoping review.

DATA SOURCES

MEDLINE, AMED, CINAHL, APA PsycINFO, APA PsycArticles, ISRCTN, Clinical Trials registry and grey literature accessed in November 2022 with publication dates between 2001 and November 2022.

ELIGIBILITY CRITERIA

English language publications that:1. Include patient populations who sustain a fragility hip fracture managed surgically2. Include patient populations who are mobilised out of bed on the day following their hip fracture surgery3. Report factors which influence the ability to undergo early mobility postsurgery DATA EXTRACTION AND SYNTHESIS: One reviewer screened all titles and abstracts for inclusion. Two reviewers performed data extraction and quality assessments using the relevant Critical Appraisal Skills Programme tools and the Mixed Methods Appraisal Tool.

RESULTS

3337 papers were identified, of which 23 studies were eligible for review, representing 210 811 patients. The heterogeneity in the types of study included, the definition of early mobilisation and the outcome measures used precluded meta-analysis. 13 factors were identified as having an effect on whether people were mobilised on day 1 post-hip fracture surgery, grouped into 5 principal themes: (1) healthcare setting or worker-related factors, (2) patient psychological factors, (3) acute patient health factors, (4) non-acute patient health factors and (5) surgical factors.

CONCLUSIONS

There was a paucity of robust research investigating day 1 mobilisation post-hip fracture surgery.Each of the five factors identified is potentially modifiable through service improvement change and innovation strategies. There is an opportunity to explore how service provision change could be implemented to improve outcomes for all patients following hip fracture surgery demonstrating the clinical and cost benefits of these changes against the cost of delivering the change.

Role of supplemental regional blocks on postoperative neurocognitive dysfunction after major non-cardiac surgeries: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND/IMPORTANCE

Postoperative neurocognitive dysfunction (PNCD) is a frequent and preventable complication after surgery. The large high-quality evidence for the efficacy of supplemental regional analgesia blocks (RAB) for preventing PNCD is still elusive.

OBJECTIVE

The objective of this meta-analysis was to evaluate the effect of RAB versus standard anesthesia care on the incidence of PNCD in adult patients undergoing major non-cardiac surgery.

EVIDENCE REVIEW

PubMed, EMBASE, Scopus, and the Cochrane Central Registers of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) from 2017 until June 2022. The primary outcome was the incidence of PNCD within 1 month of surgery. A random-effects model with an inverse variance method was used to pool results, and OR and mean differences were calculated for dichotomous and continuous outcomes. Various exploratory subgroup analyses were performed to explore the possibility of the association between the various patient, technique, and surgery-related factors. Grading of Recommendation, Assessment, Development, and Evaluation guidelines were used to determine the certainty of evidence.

FINDINGS

Twenty-six RCTs comprizing 4414 patients were included. The RAB group was associated with a significant reduction in the incidence of PNCD with an OR of 0.46 (95% CI 0.35 to 0.59; p<0.00001; I2=28%) compared with the control group (moderate certainty). Subgroup analysis exhibited that the prophylactic efficacy of RAB persisted for both delirium and delayed neurocognitive recovery.

CONCLUSIONS

Current evidence suggests that supplemental RAB are beneficial in preventing PNCD in patients after major non-cardiac surgery.

PROSPERO REGISTRATION NUMBER

CRD42022338820.

Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis

BACKGROUND

Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery.

OBJECTIVE

Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture.

METHODS

Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65 years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis.

RESULTS

Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80 years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01-0.39, I2 = 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I2 = 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24-1.05, I2 = 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements.

CONCLUSIONS

Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.

Effects of posterior lumbar plexus block on anesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric comminuted fractures

To study the effect of posterior lumbar plexus nerve block on anaesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures. The research subjects selected 48 patients with postmenopausal osteoporotic subtrochanteric comminuted fractures who were hospitalized between January 2020 and January 2022, and were allocated to clusters according to the random number TBL approach. The controlling cluster (24 situations) underwent dura mater Under external anesthesia, the test cluster (24 situations) underwent posterior lumbar plexus block, and the block effect, anesthesia effect, sedation effect, hemodynamics, vital signs and reactions of adverse nature were contrasted involving the two clusters. In comparison to the control group, the test group had a longer duration of anesthesia and motor block, higher oxygenation indices but lower ITBVI, GEDVI, and ScrO2 values, lower MAP levels, and lower BIS contraction values at 5, 15, and 30 minutes following anesthesia (P < 0.05). The test group had shorter induction time and block onset time compared to the control group (P < 0.05), and a lower incidence of adverse reactions (16.67% vs. 29.17% in the control group), but the variation was not noTBL (P < 0.05). Posterior lumbar plexus nerve block in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures has a better sedative effect, shortens the induction time of anaesthesia and the onset of block, promotes sTBL haemodynamic indexes and has fewer adverse effects to ensure safety.

The Effect of Peripheral Nerve Block on Postoperative Delirium in Older Adults Undergoing Hip Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This meta-analysis aimed to determine whether peripheral nerve blocks (PNB) reduce postoperative delirium (POD) in elderly patients undergoing hip surgery. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022328320). The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for randomized controlled trials (RCTs) on 26 April 2022. A total of 19 RCTs with 1977 participants were included. Perioperative PNB lowered the POD incidence on the third postoperative day (OR: 0.59, 95% CI [0.40 to 0.87], p = 0.007, I² = 35%), in patients without underlying cognitive impairment (OR: 0.47, 95% CI [0.30 to 0.74], p = 0.001, I² = 30%), and when a fascia iliaca compartment block (OR: 0.58, 95% CI [0.37 to 0.91], p = 0.02, I² = 0%) or a femoral nerve block (OR: 0.33, 95% CI [0.11 to 0.99], p = 0.05, I² = 66%) were performed. The pain score was also reduced (SMD: -0.83, 95% CI [-1.36 to -0.30], p = 0.002, I² = 95%) after PNB. Perioperative PNB can lower the POD incidence and pain scores up to the third postoperative day. However, considering the wide variety of PNBs performed, more trials are needed to identify the effects of each PNB on POD.

Measurement of Mobility and Physical Function in Patients Hospitalized With Hip Fracture: A Systematic Review of Instruments and Their Measurement Properties

OBJECTIVE

Hip fractures are common and significantly impact mobility and physical function. Measurement of patient progress post hip fracture in the acute hospital setting is important to monitor early recovery and outcomes. The objective of this systematic review was to assess the measurement properties (reliability, validity, responsiveness), interpretability, and clinical utility of instruments used to measure mobility and physical function in patients with hip fracture in the acute hospital setting.

METHODS

Three databases (MEDLINE, Embase, and CINAHL) were searched. Studies reporting direct clinician assessment instruments to measure mobility or physical function in patients with hip fracture were included. Data were extracted by 2 reviewers, and the quality of each study was determined using the COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist.

RESULTS

Sixty-eight studies were included with 19 measurement instruments identified. The most frequently used instruments were the Timed "Up & Go" Test (TUG) (19 studies), Barthel Index (BI) (18 studies), Cumulated Ambulation Score (CAS) (18 studies), and Functional Independence Measure (FIM) (14 studies). All 4 of these instruments demonstrated good predictive validity (clinical outcomes and mortality) and responsiveness over time (effect sizes 0.63-2.79). The BI and CAS also had good reliability (intraclass correlation coefficient [ICC] >0.70). Floor effects were demonstrated for the TUG, CAS, and FIM (16%-60% of patients). The TUG, CAS, and BI all had good clinical utility.

CONCLUSION

Depending on the context (use by treating clinicians, research, benchmarking), 1 or a combination of the BI, CAS, and TUG provide robust measurement of mobility and physical function for patients with hip fracture in the acute hospital setting.

IMPACT

This study identified 3 instruments suitable for measuring mobility and physical function in hospitalized patients following hip fracture. This provides clinicians with tools to measure patient progress and benchmark across sites to improve patient outcomes.

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.

Intelligent Three-Dimensional Reconstruction Algorithm-Based Ultrasound-Guided Nerve Block in Intraoperative Anesthesia and Postoperative Analgesia of Orthopedic Surgery

This research was aimed at analyzing the role of ultrasound-guided nerve block based on intelligent three-dimensional (3D) reconstruction algorithm in intraoperative anesthesia and postoperative analgesia of orthopedic surgery. 68 elderly patients were undergoing orthopedic surgery on the lower extremities, and they were randomly rolled into two groups with 34 patients in each group. The patients in control group received sciatic nerve block anesthesia (SNBA), and the patients in the experimental group received ultrasound-guided SNBA (UG-SNBA) under 3D reconstruction algorithm to analyze and compare the anesthesia effect and the postoperative analgesia effect. The results showed that compared with other algorithms, the evaluation index of ultrasound images processed by the 3D reconstruction algorithm was better. In terms of anesthesia effect, there was no significant difference in systolic blood pressure, diastolic blood pressure, and heart rate between the two groups before surgery ( $P>0.05$ ). Intraoperative and postoperative indicators of the experimental group were significantly better than those of the control group; the drug dosage (61 mg) was less than that of the control group (78 mg). In addition, the onset time of anesthesia, the time of pain blockade, and the postoperative awake time (5 minutes, 8 minutes, and 8 minutes, respectively) were shorter than those in the control group (13 minutes, 15 minutes, and 15 minutes, respectively). The visual analogue scale (VAS) scores of the experimental group were better than those of the control group on the day after surgery, one day after surgery, two days after surgery, and three days after surgery, with significant differences ( $P<0.05$ ). In summary, 3D reconstruction algorithm-based ultrasound image effect was clearer, the effect of UG-SNBA was more stable, and the postoperative analgesic effect was better. This work provided a higher reference for the selection of safe and effective anesthesia options in orthopedic surgery.

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.

The effect of regional nerve block on perioperative delirium in hip fracture surgery for the elderly: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

With minimal systemic toxicity, an analgesic effect of regional nerve block (RNB) has been proved in hip fracture cases. Analgesia was expected to reduce delirium by controlling pain, a known predisposing factor for delirium. We performed a meta-analysis to investigate the effect of RNB on delirium after hip fracture surgery in elderly patients. We aimed to answer the question: Can regional nerve block reduce postoperative delirium in hip fracture patients?

HYPOTHESIS

Our hypothesis was that RNB could reduce postoperative delirium after hip fracture surgery in elderly patients.

PATIENTS AND METHODS

MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before September 9, 2020, investigating the effect of RNB on perioperative delirium after hip fracture in elderly patients. We performed synthetic analyses for overall RNB compared to a control group both in 1) overall elderly patients, including the cognitively impaired, and 2) for patients without cognitive impairment (CoI). Also, we performed subgroup analyses for each of the block techniques, such as fascia-iliac block (FIB) and femoral nerve block (FNB).

RESULTS

Eight randomized controlled trials compared the incidence of perioperative delirium between the RNB and control groups. A pooled analysis showed no differences in delirium incidence between the RNB and control groups (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.36-1.22; p=0.18; I²=58%) in overall elderly patients. However, there was a significant reduction of delirium in the RNB group in patients without CoI (OR: 0.44; 95% CI: 0.21-0.94; p=0.03; I²=51%). In the subgroup analyses, we were unable to discern any differences in delirium incidence between the groups for FIB (OR, 0.89; 95% CI: 0.19-4.19; p=0.88; I²=78%) and FNB (OR 0.61; 95% CI: 0.31-1.20, p=0.15, I²=47%).

CONCLUSIONS

In cases of hip fracture in elderly, RNB demonstrated a preventive effect on perioperative delirium for patients without preoperative CoI. No significant reduction in perioperative delirium was observed when cognitively impaired patients were included.

Early recovery of basic mobility under femoral nerve block after hip fracture surgery - A propensity score matched pilot study

BACKGROUND

Previous studies have shown better pain reduction utilizing femoral nerve block (FNB) in patients who underwent hip fracture surgery. However, few studies have focused on the recovery of physical function after FNB, and most studies excluded patients with dementia. We investigated the association between FNB performed in the operating room and the recovery of physical function after hip fracture surgery, including patients with dementia.

METHODS

A total of 103 patients with a mean age of 87.4 years who underwent hip fracture surgery under spinal anesthesia between July 2015 and December 2017 (46 patients receiving a single injection of FNB and 57 standard care) were enrolled. Patients with FNB versus standard care were matched by a propensity score to adjust for patient characteristics. An anesthesiologist performed FNB with 20ml of 0.2% ropivacaine, and the standard care group received intravenous 1000 mg acetaminophen or 50mg flurbiprofen once after surgery. After matching, 78 patients were analyzed. Our primary outcome was 3-day cumulated ambulation score (CAS, 0-18 points) and secondary outcomes were 1-day CAS on postoperative day 1-3 and length of hospital stay. We also stratified patient groups based on the presence of dementia and fracture type.

RESULTS

Patients undergoing FNB had significantly better 3-day CAS compared to standard care (mean [SD], 8.72 [3.42] vs 7.33 [2.62]; mean difference, 1.38 [95%CI; 0.03 - 2.74]; p = 0.048) and 1-day CAS on postoperative day two (mean [SD], 3.10 [1.39] vs 2.56 [0.94]; mean difference, 0.54 [0.01 - 1.07]; p = 0.049). Length of hospital stay did not significantly differ among the two groups (p = 0.65). Larger positive effect was likely to be seen for patients with a femoral neck fractures and for those without dementia.

CONCLUSIONS

Patients who underwent surgery with spinal anesthesia plus FNB had better ambulatory status early after hip fracture surgery compared to patients not offered FNB. The beneficial association between FNB and ambulatory status was likely to be observed especially in patients with femoral neck fracture and without dementia.

Psoas compartment block efficacy and safety for perioperative analgesia in the elderly with proximal femur fractures: a randomized controlled study

Background

Proximal femur fractures are most common fractures in the elderly and associated with significant mortality and morbidity, with high economic and social impact. Perioperative pain management influence outcomes and mortality after surgery with early mobilization being possible. The goal of the study was to compare the efficacy and safety of the psoas compartment block (PCB) with spinal and general anesthesia.

Methods

We included 90 patients in this randomized controlled study and divided them into three groups. For patients in group 1 ultrasound-guided PCB with bupivacaine 0.125% 6–8 ml / h was performed. Intraoperative anesthesia was provided with PCB and a sciatic nerve block. Postoperative analgesia include prolonged CPB with bupivacaine 0.125% 6–8 ml / h. In group 2 intraoperative spinal anaesthesia were performed. Group 3 patients underwent general sevoflurane inhalation anaesthesia with fentanyl infusion for analgesia. All patients received paracetamol 3 g/day and dexketoprofen 75 mg/day during hospitalization. On-demand, nalbuphine 5 mg SC was used for analgesia. Efficacy outcomes were the ICU length of stay and the total duration of hospitalization, number of patients who had severe pain after surgery, incidence of on-demand analgesia, sleep quality, postoperative mobilization time. Safety outcomes include complication incidence.

Results

There were no differences in the duration of ICU stay - gr.1 72 [70–75], gr.2 74 [72–76], gr.3 72 [70–75] hours respectively (p = 0.29), and the total duration of hospitalization - gr.1144 [170–184], gr.2170 [148–188], gr.3178 [144–200] hours respectively. Patients in gr.1 had significantly lower nalbuphine consumption in the first 24 h after surgery and total during hospitalization (0 [0–5] mg versus 15 [10–20] and 20 [15–25] mg in the first 24 h in groups 2 and 3, respectively (p < 0.001). Gr. 1 had lower number of patients with severe pain (10% vs. 47 and 60% in groups 2 and 3, respectively, p < 0.05), lower number of on demand analgesia (0 [0–1] vs. 3 [2–4] and 4 [3, 4] in groups 2 and 3, respectively), better sleep quality (8 [7–9] vs. 6 [5–7] and 4 [3, 4] in groups 2 and 3, respectively, p < 0.001), significantly faster mobilization after surgery – sitting in bed and getting to his feet. MINS was diagnosed significantly more often in gr. 2 and 3 compared with gr. 1 (OR 9 95 CI 1,01–77, p = 0,048 for gr. 2 and OR 11 95 CI 1,2–91, p = 0, 03 for gr. 3). However, none of the patients had symptoms of myocardial ischemia and was not diagnosed with myocardial infarction. There were no difference in the incidence of nosocomial pneumonia and delirium.

Conclusion

Perioperative PCB in elderly patients with a proximal femur fracture could be an effective analgesia technique, as it decrease the number of patients with severe pain, need for on demand analgesia and opioid consumption. PCB also decrease the incidence of opioid-associated nausea and vomiting, comparing to general anesthesia, and increase the number of patients, who was mobilized in the 1st day (sitting) and 2nd day (getting up) after surgery. PCB may reduce the incidence of MINS, although to assess this outcome more studies are needed.

Trial registration

Clinicaltrials.gov: NCT04648332, first registration date 1/12/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01473-9.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

OBJECTIVE

The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries.

METHODS

Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method.

RESULTS

A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost.

CONCLUSION

This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

The impact of loco-regional anaesthesia on postoperative opioid use in elderly hip fracture patients: an observational study

Purpose

Hip fractures are a common health problem among the elderly with an increasing incidence. They are associated with high mortality and morbidity. Optimal pain management remains challenging and inadequate pain control is known for negatively affecting outcomes. Loco-regional anaesthetics (LRA) have been proven to benefit pain management and to lower the risks of opioid use and -related side effects. We aimed to evaluate the use and efficacy of different LRA in elderly hip fracture patients.

Methods

Single-center cohort study of elderly hip fracture patients, who were treated in central Switzerland. We compared patients who received LRA in the form of a femoral nerve block (FNB) or a continuous femoral nerve catheter (CFNC) with patients who did not receive LRA. Primary outcomes were pain—as measured in perioperative morphine use—hospital length of stay (HLOS), postoperative complications, postoperative falls and mortality.

Results

407 patients were included for analysis. Mean age was 85.2 (SD6.3). There was a significant difference in intraoperative morphine use between the groups (p = 0.007). Postoperative morphine use differed significantly and was lowest in patients with FNB and highest in patients without LRA (p < 0.001). The use of LRA was a significant predictor for postoperative morphine use for postoperative morphine use at the recovery room and for postoperative morphine use 48 h after surgery. No significant differences were found in postoperative complications, a significant difference was found in 1-year mortality.

Conclusions

This article shows that LRA in the form of FNB and CFNC causes a significant decrease in postoperative opioid consumption. Differences between single-shot FNB or CFNC were minimal. There were no significant differences in clinical outcomes such as HLOS, delirium, 30-day and 90-day mortality and postoperative falls. We suggest that use of LRA should be incorporated in the perioperative treatment of elderly patients with a hip fracture. For future research, we recommend evaluating the number of postoperative complications and mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01674-4.

Invasive placebos in research on peripheral nerve blocks: a follow-up study

INTRODUCTION

The Serious Harm and Morbidity "SHAM" grading system has previously been proposed to categorize the risks associated with the use of invasive placebos in peripheral nerve block research. SHAM grades range from 0 (no potential complications, eg, using standard analgesia techniques as a comparator) through to 4 (risk of major complications, eg, performing a sub-Tenon's block and injecting normal saline). A study in 2011 found that 52% of studies of peripheral nerve blocks had SHAM grades of 3 or more.

METHODS

We repeated the original study by allocating SHAM grades to randomized controlled studies of peripheral nerve blocks published in English over a 22-month period. Documentation was made of the number of study participants, age, number of controls, body region, adverse events due to invasive placebos and any discussion regarding the ethics of using invasive placebos. We compared the proportion of studies with SHAM grades of 3 or more with the original study.

RESULTS

In this current study, 114 studies fulfilled the inclusion criteria, 5 pediatric and 109 adult. The SHAM grade was ≥3 in 38 studies (33.3%), with 1494 patients in these control groups collectively. Several studies discussed their reasons for choosing a non-invasive placebo. No pediatric studies had a SHAM grade of ≥3.

CONCLUSIONS

The use of invasive placebos that may be associated with serious risks in peripheral nerve block research has decreased in contemporary peripheral nerve block research.

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.

Ultrasound image guided lateral cervical approach to stellate ganglion block for cervical headache

OBJECTIVE

To explore the feasibility and safety of real-time ultrasound-guided transcervical lateral stellate ganglion block.

METHODS

From September 2017 to December 2018, 80 cases of cervical headache were diagnosed by high-frequency ultrasound on the lateral cervical region, and evaluated at the level of the transverse process of cervical vertebrae 6 and 7. Risk factors for the ganglia. Choose a safe path and guide puncture and drug injection in real time.

RESULTS

The lateral approach of horizontal C6 and C7 transverse processes in 80 cases was explored. There are risk factors on the 32-sided puncture path, in which the inferior thyroid artery accounts for 34.4 % (11/32), the jugular vein accounts for 31.2 % (10/32), and the vertebral arteriovenous accounts for 12.5 % (4/32) The other arteries accounted for 21.9 % (7/32). The puncture was completed in 79 cases, and one patient gave up the puncture because of risk factors in the horizontal puncture path of C6 and C7. Horner syndrome occurred in 79 cases within 10 min after puncture. There were 4 cases (5.1 %) of minor side effects, including hoarseness in 2 cases, numbness in upper limbs and dizziness in 1 case, all of which resolved on their own. The VAS score of 79 cases before block (8.9 ± 0.9) points and 0.5h VAS score (5.7 ± 2.1) points after block were significantly lower than those before block (t = 13.154, P = 0.003); 1dVAS score (5.3 ± 2.5) after block was significantly lower than that before block (t = 12.626, P = 0.002).

CONCLUSION

High-frequency ultrasound guided stellate ganglion block in lateral cervical approach in real time has a high success rate and the method is safe.

Iatrogenic Peroneal Nerve Palsy Rates Secondary to Open Reduction Internal Fixation for Tibial Plateau Fractures Using an Intraoperative Distractor

OBJECTIVE

To report the rate of peroneal nerve palsy after routine use of intraoperative distraction during open reduction internal fixation (ORIF) for lateral unicondylar and bicondylar tibial plateau fracture (TPF) repairs.

DESIGN

Retrospective chart review.

SETTING

Level I trauma center.

PATIENTS

Patients with traumatic TPF treated with ORIF between 2007 and 2017.

INTERVENTION

ORIF for lateral unicondylar and bicondylar TPF.

MAIN OUTCOME MEASUREMENT

Presence and resolution of neurovascular injury.

RESULTS

There were a total of 21 lateral unicondylar and 40 bicondylar TPFs repaired through ORIF in 60 patients identified during the study period with 1-year follow-up and complete records for review. Thirty-six patients had staged external fixation before ORIF while 24 were treated with ORIF initially. Of the staged patients, 9 of 36 (25%) developed nerve palsy while those undergoing initial ORIF (not staged) developed palsy in only one case (1 of 24, or 4%). Of the patients who developed nerve palsy, 9 of 10 (90%) were staged with an initial external fixator before ORIF. The incidence of iatrogenic peroneal nerve palsy secondary to intraoperative distraction was 16.4% (10 of 61). Only 60% (6 of 10) of peroneal nerve palsies recovered clinically with a mean recovery time of approximately 14 weeks. Comparison of demographics in patients with peroneal nerve palsy versus those without yielded no significant difference by sex (P = 0.08), age (P = 0.27), fracture type (P = 0.29), tobacco use (P = 0.44), or alcohol use (P = 0.78).

CONCLUSIONS

Peroneal nerve palsy is a common sequela of ORIF for TPFs involving the lateral compartment using an intraoperative distractor. Staged external fixation followed by definitive ORIF using intraoperative distraction was associated with significant risk for developing nerve palsy (9/10). Many patients (40%) who develop peroneal nerve palsies do not recover, leading to permanent loss of motor and/or sensory function for 7% of patients studied. None of the epidemiologic variables evaluated yielded predictive value for development of peroneal nerve palsy or subsequent resolution. Caution should be exercised in avoiding overdistraction when using intraoperative distraction, especially in those cases that had staged fixation, most notably bicondylar injuries.

LEVEL OF EVIDENCE

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

Management of Pain Associated with Fractures

PURPOSE OF REVIEW

The purpose is to review current literature on pain management strategies from initial presentation to postoperative care on common fracture types.

RECENT FINDINGS

- Hip fractures benefit from use of multimodal pain control for early mobility and decreased narcotic requirement. - Distal radius fracture pain during reduction can be managed with hematoma block. Postoperatively, a soft dressing is adequate, and use of a compression glove may improve pain control and edema. - Ankle fractures can be reduced with hematoma block, though use of procedural sedation may reduce reduction attempts for fracture dislocations. - Long bone fracture pain management is trending toward multimodal pain control. Though there is no high-quality evidence, concern that regional anesthesia may mask compartment syndrome has limited its use in high-risk fractures. - The effect of NSAIDs on bone healing has not been conclusively demonstrated. The literature is still inconclusive regarding superiority of either spinal or general anesthesia during operative treatment. Fracture pain control is complex and multifactorial, requiring nuanced clinical judgment in the face of mixed clinical findings.

Comparison of preoperative ultrasound guided fascia iliaca block versus femoral nerve block for proximal femur fractures before positioning for spinal anesthesia: an observational study

Background

Severe pain associated with proximal femur fractures makes the positioning for regional anesthesia a challenge. Systemic administration of analgesics can have adverse effects. Individually, both the fascia iliaca block (FIB) and femoral nerve blocks (FNB) have been studied. However, there is little evidence comparing the two. The aim of this study was to compare the overall efficacy of the two blocks in patients with proximal femur fracture before positioning for spinal anesthesia.

Methods

ASA (American Society of Anesthesiologists) class I, II, and III patients scheduled for elective and emergency surgery with the diagnosis of proximal femur fracture between October 2018 and June 2019 were included in the study. The patients were assigned to two groups by convenience nonprobability sampling of 35 each.

Results

Our study showed a reduction in visual analogue scale scores at 3, 4, and 5 minutes after administration of the FIB being 5.1 ± 1.1, 4.1 ± 1.3, and 2.8 ± 0.8, and those after the FNB as 4.4 ± 1.1, 3.3 ± 1.1, and 2.1 ± 1.4 with P < 0.05, which was statistically significant. The mean first rescue analgesia time for the FIB was 7.1 ± 2.1 hours, while for the FNB it was 5.2 ± 0.7 hours. The P value was less than 0.001, which was significant.

Conclusions

Both ultrasound guided FNB and FIB techniques provide sufficient analgesia for patient's positioning before spinal anesthesia. However, the duration of postoperative analgesia provided by FIB was greater than that of the FNB.