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Peripheral Nerve Blocks for Hip Fractures: A Cochrane Review

Guay, Joanne MD*,†; Parker, Martyn J. MD; Griffiths, Richard MD§; Kopp, Sandra L. MD

doi: 10.1213/ANE.0000000000002489
Regional Anesthesia and Acute Pain Medicine
Free
SDC

BACKGROUND: This review focuses on the use of peripheral nerve blocks as preoperative analgesia, as postoperative analgesia, or as a supplement to general anesthesia for hip fracture surgery and tries to determine if they offer any benefit in terms of pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction/ischemia, pneumonia, mortality, time to first mobilization, and cost of analgesic.

METHODS: Trials were identified by computerized searches of Cochrane Central Register of Controlled Trials (2016, Issue 8), MEDLINE (Ovid SP, 1966 to 2016 August week 1), Embase (Ovid SP, 1988 to 2016 August week 1), and the Cumulative Index to Nursing and Allied Health Literature (EBSCO, 1982 to 2016 August week 1), trials registers, and reference lists of relevant articles. Randomized controlled trials involving the use of nerve blocks as part of the care for hip fractures in adults aged 16 years and older were included. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted the data. The quality of evidence was judged according to the Grading of Recommendations, Assessment, Development, and Evaluations Working Group scale.

RESULTS: Based on 8 trials with 373 participants, peripheral nerve blocks reduced pain on movement within 30 minutes of block placement: standardized mean difference, −1.41 (95% confidence interval [CI], −2.14 to −0.67; equivalent to −3.4 on a scale from 0 to 10; I2 statistic = 90%; high quality of evidence). The effect size was proportional to the concentration of local anesthetic used (P < .00001). Based on 7 trials with 676 participants, no difference was found in the risk of acute confusional state: risk ratio, 0.69 (95% CI, 0.38–1.27; I2 statistic = 48%; very low quality of evidence). Based on 3 trials with 131 participants, the risk for pneumonia was decreased: risk ratio, 0.41 (95% CI, 0.19–0.89; I2 statistic = 3%; number needed-to-treat for additional beneficial outcome, 7 [95% CI, 5–72]; moderate quality of evidence). No difference was found for the risk of myocardial ischemia or death within 6 months but the number of participants included was well below the optimum information size for these 2 outcomes. Based on 2 trials with 155 participants, peripheral nerve blocks also reduced the time to first mobilization after surgery: mean difference, −11.25 hours (95% CI, −14.34 to −8.15 hours; I2 statistic = 52%; moderate quality of evidence). From 1 trial with 75 participants, the cost of analgesic drugs when used as a single-shot block was lower: standardized mean difference, −3.48 (95% CI, −4.23 to −2.74; moderate quality of evidence).

CONCLUSIONS: There is high-quality evidence that regional blockade reduces pain on movement within 30 minutes after block placement. There is moderate quality of evidence for a decreased risk of pneumonia, reduced time to first mobilization, and reduced cost of analgesic regimen (single-shot blocks).

From the *Department of Anesthesiology, University of Sherbrooke, Sherbrooke, Quebec, Canada

Teaching and Research Unit, Health Sciences, University of Quebec in Abitibi-Temiscamingue, Rouyn-Noranda, Quebec, Canada

Department of Orthopaedics, Peterborough and Stamford Hospitals, NHS Foundation Trust, Peterborough, UK

§Department of Anaesthesia, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

Published ahead of print October 4, 2017.

Accepted for publication August 7, 2017.

Funding: University of Sherbrooke and University of Quebec in Abiti-Temiscamingue granted access to electronic databases and to major medical journals. Cochrane Anaesthesia Review Group, Denmark (Karen Hovhannisyan) designed the search strategy.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Joanne Guay, MD, Faculté de médecine et des sciences de la santé, 3001, 12e Avenue Nord, Sherbrooke (Québec) J1H 5N4. Address e-mail to joanneguay@bell.net.

In women aged 55 years or older, the Nationwide Inpatient Sample report for 2000 to 2010 found 4.9 million hospitalizations for osteoporotic fractures (2.6 million for hip fractures), 2.9 million for myocardial infarction, 3.0 million for stroke, and 0.7 million for breast cancer in the United States.1 Osteoporotic fractures accounted for more than 40% of the hospitalizations in these 4 outcomes, with an age-adjusted rate of 1124 admissions per 100,000 person-years. The annual total population facility-related hospital cost was highest for hospitalizations due to osteoporotic fractures (USD 5.1 billion), followed by myocardial infarction (USD 4.3 billion), stroke (USD 3.0 billion), and breast cancer (USD 0.5 billion).1 Care costs of hip fractures are high and, when both acute care and the care needed to provide for subsequent dependency are included, now exceed GBP 2 billion a year for the United Kingdom as a whole for 2012. The overall rate of return home by 30 days was 44.6% in the United Kingdom in 2012 (http://www.nhfd.co.uk/20/hipfractureR.nsf/) and 5.3% (95% confidence interval [CI], 5.2%–5.4%) in 2003 to 2005 in the United States, 52.8% of patients with hip fracture (95% CI, 52.5%–53.2%) in the United States being discharged to a skilled nursing facility.2 Hip fractures reduce life expectancies when they occur in patients older than 50 years of age. Pooled data of cohort studies revealed that relative hazard for all-cause mortality in the first 3 months after hip fracture was 5.75 (95% CI, 4.94–6.67) in women and 7.95 (95% CI, 6.13–10.30) in men.3 The term hip fracture refers to a fracture of the proximal femur down to about 5 cm below the lower border of the lesser trochanter.

The majority of hip fractures occur in an elderly population, and more than 30% of the patients are 85 years or older.2 Opioid-related respiratory depression may result in severe brain damage or death.4 By reducing the amount of opioids used before, during, and after the surgery,5 regional blockade may improve the mobility of persons suffering from hip fracture6 and hence potentially facilitate a person’s participation to rehabilitation. Despite their claim advantages, peripheral nerve blocks are still not widely used for people with hip fracture.7 Therefore, this study aims to evaluate through meta-analyses the beneficial/harmful effects of peripheral nerve blocks for hip fracture. This review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia, or as a supplement to general anesthesia for hip fracture surgery and tries to determine if they offer any benefit in terms of pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction/ischemia, pneumonia, mortality, time to first mobilization, and cost of analgesic.

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METHODS

All randomized controlled trials comparing peripheral nerve blocks inserted preoperatively, operatively, or postoperatively with no regional blockade (control group) were included. There was no language or publication status restriction. Those randomized controlled trials included adult (≥16 years old accepted) participants scheduled for proximal femoral fracture (hip fracture) repair. Differences between the treatment group and the control group were evaluated on the following outcomes:

Primary outcomes

  1. Pain on movement 30 minutes after block placement
  2. Acute confusional state
  3. Myocardial infarction

Secondary outcomes

  • 4. Pneumonia
  • 5. Mortality
  • 6. Time to first mobilization after surgery
  • 7. Costs of analgesic regimens

A search was done in the Cochrane Central Register of Controlled Trials (2016, Issue 8), MEDLINE (Ovid SP, 1966 to 2016 August week 1), Embase (Ovid SP, 1988 to 2016 August week 1), and CINAHL (EBSCO, 1982 to 2016 August week 1) (Supplemental Digital Content 1, Appendix 1, http://links.lww.com/AA/C15). Two review authors (J.G. and S.K.) independently assessed potentially eligible trials for inclusion, assessed included trials with the Cochrane Collaboration tool, and extracted data. Disagreements were resolved by discussion.

Events and total numbers of participants were extracted in each group for dichotomous data when available. Mean, standard deviation, and number of participants in each group were extracted for continuous data when available. If results were unavailable in these formats or provided on different scales, data were extracted as P values and number of participants for each group. Sites and dates of data collection (for exclusion of duplicate publication) and factors required for heterogeneity exploration (see assessment of heterogeneity) were also extracted. Authors were contacted for additional information when there was not enough information from the published articles to extract the data. No imputation was made. Clinical heterogeneity was considered before pooling results, and statistical heterogeneity was examined before carrying out any meta-analysis. Statistical heterogeneity was quantified using the I2 statistic. The amount was qualified as low (<25%), moderate (50%), or high (≥75%) depending on the value obtained for the I2 statistic.8 Publication bias was assessed with a funnel plot followed by Duval and Tweedie’s trim-and-fill technique. Data were analyzed with RevMan (http://ims.cochrane.org/revman/about-revman-5) and Comprehensive Meta Analysis Version 2.2.044 (www.Meta-Analysis.com) with fixed (I2 < 25%) or random-effects models (I2 > 25%). For standardized mean differences (SMDs), 0.8 was considered as the cutoff limit for a large effect.9 For clinical equivalents, the SMD was multiplied by the standard deviation of a study at low risk of bias and where a typical standard deviation on a clinical scale was provided.10 For results where the intervention produced an effect, the number needed-to-treat for additional beneficial outcome (NNTB) or the number needed-to-treat for additional harm was calculated based on the odds ratio. When results were negative, the optimum information size was also calculated to make sure that there were enough participants included in the retained studies to justify a conclusion on the absence of effect.11 Any amount of heterogeneity >25% was explored with Egger’s regression intercept (to eliminate a small-study effect), sensitivity analysis, subgrouping, or meta-regression as appropriate. A priori factors for heterogeneity were the type of block (psoas compartment, fascia iliaca, femoral nerve [3-in-1 or triple nerve block were considered as femoral nerve blocks], femoral lateral cutaneous, obturator, etc), single-shot versus continuous block (and duration of use), technique of localization (landmark, nerve stimulator, or ultrasound), local anesthetic concentration in lidocaine equivalent (calculated as follows: lidocaine = 1, bupivacaine = 4, chloroprocaine = 1.5, dibucaine = 4, etidocaine = 4, levobupivacaine = 3.9, mepivacaine = 0.8, prilocaine = 0.9, procaine = 0.5, ropivacaine = 3, and tetracaine = 4),12 time when the block was performed in relation to surgery, age of participants included, American Society of Anesthesiologists physical status of participants, year when the study was published, delay fracture (or hospital admission) to surgery, percentage of female in participants, percentage of arthroplasty in participants, and route of analgesia in the control group. A sensitivity analysis was performed based on the risk of bias of the study or when a study was a clear outlier as long as a reason differentiating this study from the other studies could be found. The quality of the body of evidence was judged according to the system developed by the Grading of Recommendations, Assessment, Development, and Evaluations Working Group13 and presented in a “Summary of Findings” table.

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RESULTS

The flow chart of the study selection is in Supplemental Digital Content 2, Appendix 2, http://links.lww.com/AA/C16. The risk of bias of the included studies is in Figure 1. Trials included studied a femoral (or 3-in-1 or triple-nerve block; n = 15), a femoral nerve block with an infiltration above the iliac crest (n = 1), a fascia iliaca compartment block (n = 8), a lateral cutaneous nerve block (n = 2), a lateral cutaneous nerve block plus an obturator nerve block (n = 1), an obturator nerve block (n = 1), or a psoas compartment block (n = 3).

Figure 1.

Figure 1.

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Pain on Movement Within 30 Minutes After Block Placement

Eight trials14–21 including 373 participants evaluating pain on movement within 30 minutes after block placement were retained: at 15 minutes (femoral nerve block with bupivacaine and nerve stimulator, pain during positioning for spinal anesthesia18), at 20 minutes (fascia iliaca with landmarks and ropivacaine, pain during positioning for spinal anesthesia14; fascia iliaca block with landmarks and ropivacaine, pain during positioning for spinal anesthesia21; femoral nerve block with a nerve stimulator and mepivacaine, pain during transfer on the radiological table for the X-ray19), or at 30 minutes (fascia iliaca with landmarks and mixture of lidocaine and bupivacaine for pain during positioning for spinal15; fascia iliaca block with landmarks and mepivacaine for pain during passive elevation of the leg at 15°16; nonstimulating femoral nerve catheter with prilocaine inserted with a nerve stimulator for pain with passive anteflexion of the hip at 30°17; nonstimulating femoral nerve catheter with bupivacaine inserted with a nerve stimulator for pain with passive anteflexion of the hip at 30°20). Pain scores were lower with regional blockade: SMD, −1.41 (95% CI, −2.14 to −0.67; I2 statistic = 90%) (Figure 2). Using the standard deviation (SD) in the control group of a study at low risk of bias14 (SD = 2.4), this was equivalent to −3.4 on a scale from 0 to 10. Egger’s regression intercept showed the possibility of a small-study effect (P = .02). Duval and Tweedie’s trim-and-fill analysis showed no evidence of publication bias. For 1 study, there is a possibility that the evaluation was performed before the effect of the local anesthetic took place in the majority of the participants (15 minutes18). When a femoral nerve block using a nerve stimulator is performed with bupivacaine, the median onset time for a complete sensory and motor block would be 30 minutes (5–95 percentiles, 15–45 minutes).22 Excluding this study18 and 1 study for which the exact concentration of the local anesthetic injected was not provided,19 the effect size was correlated to the concentration of local anesthetic used in lidocaine equivalent (P < .00001; Figure 3). Based on Diakomi et al14 (mean and SD of the control group 7.5 and 2.4), 182 participants (91 per group) would be required in a simple trial to eliminate a difference of 1 on a 0 to 10 scale (α, .05; β, .2; 2-sided test).

Figure 2.

Figure 2.

Figure 3.

Figure 3.

For level of evidence, the level of evidence was downgraded by 1 because 5 of the 8 included studies were rated as having unclear risk for blinding of outcome assessment. The level of evidence was not downgraded on the basis of inconsistency because a reasonable explanation was found for heterogeneity. The analysis included only direct comparisons with studies performed on the population of interest, and this is not a surrogate marker. The optimum information size was achieved, but the level was downgraded for imprecision owing to a wide CI around the effect size. There was no evidence of publication bias. The level of evidence was upgraded by 1 level on the basis of a large effect size (SMD > 0.8) and by 1 level on the basis of confounding factors due to the fact that no study used ultrasound guidance, an approach that could have increased block success.23 The evidence was also upgraded by 1 level on the basis of a dose–response relationship (effect size was proportionate to the concentration of local anesthetic used). The level of evidence was rated as high (Table).

Table.

Table.

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Acute Confusional State

Based on 7 trials24–30 with 676 participants (femoral nerve block = 3; fascia iliaca compartment block = 3; psoas compartment block = 1), no difference was found in the incidence of acute confusional state: risk ratio (RR), 0.69 (95% CI, 0.38–1.27): I2 statistic = 48%. Egger’s regression intercept showed no statistically significant small-study effect (2-sided test). Duval and Tweedie’s trim-and-fill analysis calculated that 1 trial might be missing to right of mean for an adjusted point of estimate RR 0.77 (95% CI, 0.40–1.45). Based on a rate of 19%, the number of participants required to eliminate a 25% decrease would be 1518 (759 per group) (α, .05; β, .2; 1-sided test).

For level of evidence, the level of evidence was downgraded by 2 for risk of bias because 75% or more of the studies were rated as having unclear or high risk of bias for blinding of outcome assessors. The level was downgraded by 1 for a moderate amount of heterogeneity. The analysis included only direct comparisons performed on the population of interest, and this is not a surrogate marker. The level was downgraded by 1 for imprecision because the optimum information size was not achieved. The level of evidence was not modified on the basis of the possibility of publication bias because applying a correction for the possibility of one would not change the conclusion. There was no evidence of a large effect. The level of evidence was upgraded by 1 level for confounding factors because no study used ultrasound guidance, an approach that could have increased block success.23 The level of evidence was rated as very low (Table).

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Myocardial Infarction/Ischemia

Two trials31,32 gave results for myocardial ischemia. With 31 participants and evaluating the effects of a continuous psoas compartment block started preoperatively and maintained until postoperative day 3, Altermatt et al31 reported a number of ischemic events (electrocardiographic segment analysis) recorded by the subject during the observation period of 6 per participant with regional blockade (n = 17) versus 3 per participant with IV patient-controlled analgesia (n = 14) (P = .618). Luger et al32 reported that 1 of 10 participants with an ultrasound-guided continuous femoral nerve block had myocardial ischemia (serum T troponin levels increase) versus 5 of 10 for participants without a peripheral nerve block (RR, 0.20; 95% CI, 0.03–1.42). Based on an incidence of 30%, 850 participants (425 per group) would be required in a simple trial to eliminate a 25% reduced rate in the number of patients experiencing cardiac enzyme elevation (α, .05; β, .2; 1-sided test).

For level of evidence, the level of evidence was downgraded by 2 for risk of bias because the included study32 was rated as having unclear risk for allocation concealment and blinding of outcome assessors. Heterogeneity could not be assessed. The trial performed a direct comparison. The level of evidence was downgraded by 2 for imprecision owing to inclusion of very few participants/trials in the analysis. No evidence was found for a large effect or confounding factors that would justify upgrading. No evidence was found for a dose–response effect. The quality was rated as very low (Table).

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Pneumonia

Based on 3 trials30,3334 with 131 participants (femoral or 3-in-1 = 2; psoas compartment block = 1), peripheral nerve blocks reduce the risk of pneumonia: RR, 0.41 (95% CI, 0.19–0.89); I2 statistic = 3% (Figure 4). Egger’s regression intercept showed no significant evidence of a small-study effect. Duval and Tweedie’s trim-and-fill analysis showed no evidence of a publication bias. Two trials evaluated a femoral (or 3-in-1) nerve block33,34 and 1 trial30 evaluated a psoas compartment block. The definitions and time points used were lower respiratory tract infection within 6 months from hospital notes,33 short-term respiratory infection,34 and pneumonia during hospitalization (mean duration, 20 days, with a SD of 11.5 days).30 Although all 3 trials showed a trend toward a reduced incidence of lower respiratory tract infection when a peripheral nerve block was added to the postoperative analgesia regimen, the highest reduction came from Haddad and Williams.34 The complication rate observed in Haddad and Williams34 was extremely high compared with the actual rate.35 Based on a basal rate of 27%, the NNTB would be 7 (95% CI, 5–72) and the number of participants required to eliminate a 25% decrease would be 978 (489 per group) (α, .05; β, .2; 1-sided test).

Figure 4.

Figure 4.

For level of evidence, the level was downgraded by 1 level for risk of bias. Statistical heterogeneity was less than 25% (I2 = 3%). The level of evidence was downgraded by 1 level for clinical heterogeneity owing to the excessive rate of complications observed in Haddad and Williams.34 The analysis included direct comparisons only with studies performed on the population of interest, and this is not a surrogate marker. The optimum information size was not achieved. No evidence of publication bias was found. The level of evidence was upgraded by 1 owing to a large effect size (RR, 0.41). The level was upgraded on the basis of confounding factors for technology because no study used ultrasound guidance23 or a nerve stimulator. There was no evidence of a dose–response effect. The quality of evidence was rated as moderate (Table).

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Mortality

Based on 7 trials2430333436–38 including 316 participants (femoral nerve block or 3-in-1 block = 4; femoral nerve block plus infiltration above the iliac crest = 1; psoas compartment block = 1; lateral cutaneous nerve = 1), no difference was found in short-term (within 6 months) mortality: RR, 0.72 (95% CI, 0.34–1.52); I2 statistic = 0% (Figure 5). Egger’s regression intercept showed no significant evidence of a small-study effect. Duval and Tweedie’s trim-and-fill analysis showed no evidence of a publication bias. Based on an incidence of 9.8%, 3228 participants (1614 per group) would have been required to eliminate a 25% reduction (α, .05; β, .2; 1-sided test).

Figure 5.

Figure 5.

For level of evidence, the level was not modified for risk of bias and there was no heterogeneity. The analysis included direct comparisons only with studies performed on the population of interest, and this is not a surrogate marker. The level of evidence was downgraded by 2 for imprecision because the CI included both absence of effect and important benefit. There was no evidence of publication bias nor of a large effect or dose–response effect, and no confounding factors justified upgrading an absence of effect. The level of evidence was rated as low (Table).

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Time to First Mobilization

Based on 2 trials27,39 with 155 participants (femoral nerve block = 1; obturator nerve block with or without a lateral cutaneous nerve block = 1), peripheral nerve blocks reduce time to first mobilization: mean difference, −11.25 hours (95% CI, −14.34 to −8.15 hours); I2 statistic = 52%. Based on Kullenberg et al27 (mean and SD 33.1 and 7.9 hours, respectively), 30 participants (15 per group) would be required to eliminate a 25% difference (α, .05; β, .2; 2-sided test) in a simple trial.

For level of evidence, the level of evidence was downgraded by 1 for risk of bias because 1 study was rated as having unclear risk for allocation concealment and the other as having unclear risk for blinding of outcome assessors. The quality of evidence was also downgraded by 1 level for a moderate amount of heterogeneity. The analysis included direct comparisons only with studies performed on the population of interest, and this is not a surrogate marker. The optimum information size was achieved, but the level was downgraded by 1 level for imprecision owing to a wide CI around the effect size. Publication bias could not be assessed. The level of evidence was upgraded by 1 on the basis of a large effect size (equivalent to an SMD of −1.87) and by another level on the basis of confounding factors due to the fact that no study used ultrasound guidance, an approach that could have increased block success.23 There was no evidence of a dose–response effect. The quality of evidence was rated as moderate (Table).

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Costs of Analgesic Regimens

Based on 2 trials24,39 (femoral nerve block = 1; obturator nerve block with or without a lateral cutaneous nerve block = 1) with 137 participants, costs related to analgesia were reduced when regional blockade was used as a single-shot block: SMD, −3.48 (95% CI, −4.23 to −2.74) but higher when regional blockade was used as a continuous infusion: SMD, 0.93 (95% CI, 0.37–1.48); I2 statistic for heterogeneity between the 2 subgroups = 99%.

For level of evidence for single-shot blocks, the level was downgraded by 1 for risk of bias because the included study was rated as having unclear risk for allocation concealment. The comparison was a direct one. The evidence was downgraded by 1 level for the small number of trials included. Publication bias could not be assessed. The level of evidence was upgraded by 1 level on the basis of a large effect size (SMD > 0.8). No confounding factors that would justify upgrading or dose–response effect were found. The quality of evidence for reduced cost of drugs for single-shot block compared to systemic analgesia was rated as moderate.

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DISCUSSION

Some advantages of peripheral nerve blocks compared to systemic analgesia for pain treatment of patients with hip fractures were found. Even at rest, pain after hip fracture is relatively high, particularly in patients with subtrochanteric fractures (median 5 of 10).16 Movement in these patients immediately after the injury is unavoidable: transport from the scene of injury to the hospital, unclothing for medical examination, transport for X-ray diagnostic confirmation, transfer on the operating room table, positioning for spinal anesthesia, and so on. Movement-associated median pain varies from 8 to 10 out of 10 depending on the type of fracture (intracapsular = 8; trochanteric = 9; subtrochanteric = 10).16 As many of these patients are elderly (30% older than 85 years of age2), doses of systemic opioids administered are often limited by the fear of inducing serious adverse events such as respiratory depression in a patient with a full stomach. Compared to systemic analgesia, pain on movement within 30 minutes after block placement will be lower by approximately 3.4 of 10 (Figure 2 and Table; high quality of evidence). Single-shot blocks have been successfully performed by emergency physicians40 or even trained paramedics on the scene of injury41 without an excessive rate of serious complications. Although continuous blocks require more expertise and are more expensive than single-shot blocks, they may be more suitable than single-shot blocks from the emergency department and thereafter. Due to a possible increased rate of morbidity induced by a longer delay between injury and surgery, authorities usually recommend proceeding to surgical repair of hip fractures as soon as feasible. However, the delay between hospital arrival and surgery (from 24 to 240 hours in the present review) often exceeds the duration of a single-shot block (median between 12 and 22 hours depending on the drug[s] used22), thus leading to the need of a repeated block27 or reverting to systemic analgesia. Continuous nerve blocks inserted at the emergency department would have the advantage of covering both preoperative and postoperative analgesia. The choice in exact type of regional block used may include practitioner’s personnel preference/training. However, some authors found it particularly difficult to insert epidural analgesia in the emergency room department.32 Compared to epidural analgesia or psoas compartment blocks, femoral nerve or fascia iliaca blocks may offer several advantages. First, they can be performed with the patient lying in the dorsal decubitus position, and second, because they are usually considered as superficial/compressible sites, patients will be suitable to receive any mode of thromboprophylaxis deemed required by their practitioner to suit their medical and surgical condition. When available, ultrasound guidance may be advantageous, in terms of decreasing onset time of block effect42 and increasing success rate (more blocks being assessed as sufficient for surgery after sensory or motor testing and fewer blocks requiring supplementation or conversion to general anesthetic23). The concentration of local anesthetic used for catheter loading or to perform a single-shot block at the site of injury or in the emergency department should be relatively high. At this phase, a motor block probably poses no clear disadvantage provided that adequate traction/immobilization is ensured, and the effect on pain with movement will be proportional to the concentration of local anesthetic used (Figure 4). Because of the high incidence of acute confusional state seen in these patients, appropriate fixation of these catheters is crucial24 and all connections between the pump and the catheter must be secured.20 If a femoral nerve or a fascia iliaca block is chosen, then additional regional blockade will be required for surgery.43,44 For postoperative analgesia, the difference between peripheral nerve blocks and systemic analgesia was less consistent and may be influenced by the surgical technique (fixation versus arthroplasty45) and/or the type of block used.

When regional blockade is used for postoperative analgesia, the time to first mobilization (Table) will be reduced. Hence, some complications secondary to immobilization such as pneumonia will also be reduced (Figure 4 and Table; moderate quality of evidence). If regional blockade is used for perioperative analgesia, the risk of pneumonia may be reduced by half (NNTB, 7; 95% CI, 5–72).

Our review included trials with participants aged from 59 to 88 years. Recently, frailty has been recognized as a good predictor for postoperative mortality, complications, and prolonged length of stay in older-old and oldest-old surgical patients.46 Details on presence/absence of frailty were not provided in the included studies of the present meta-analysis. We therefore cannot say if the beneficial effects would be increased, decreased, or identical in frail versus nonfrail patients.

Our review contained data for time to first mobilization with single-shot blocks only. Concerns on the risks of inpatient falls have been raised with the use of continuous lower limb peripheral nerve blocks for postoperative analgesia. Detailed analysis, however, revealed that attributable risk for patients who had a continuous peripheral nerve block was not outside the expected probability of postoperative falls after orthopedic surgery.47 One large retrospective trial found that risk for inpatient falls was higher in older patients, those with higher comorbidity burden and with more major complications but that the use of peripheral nerve blocks was not significantly associated with inpatient falls.48 Inpatient falls occur mainly while patients are within their own rooms (while in the bathroom, while going to and from the bathroom, or while using a bedside commode).49 Therefore, with or without peripheral nerve block, fall-prevention strategies should continue to provide education to all patients (especially elderly patients) and reinforce practices that will monitor patients within their hospital rooms.49

Acute confusional state is quite common after hip fracture and may delay rehabilitation and increase hospital length of stay, nursing home placement, and even mortality.50 It was not possible to demonstrate a decreased risk of acute confusional state with the use of peripheral nerve blocks; however, the number of participants included in the present meta-analysis is insufficient to eliminate a clinically relevant risk reduction (RR, 0.69; 95% CI, 0.38–1.27; very low quality of evidence; Table). The pathophysiology of acute confusional state in these patients may be multifactorial and may include side effects of medications used, hypoxemia, immobilization, infection, as well as systemic inflammation.28 Peripheral nerve blocks (or local anesthetics) may have an influence on any of these factors. Peripheral nerve blocks are associated with a clear reduction in opioids consumption (SMD, −0.70; 95% CI, −0.96 to −0.44; I2 = 0%45).

It was not possible to demonstrate a reduction in the incidence of myocardial ischemia (Table; very low quality of evidence) but the number of participants included in our review was clearly insufficient to draw definitive conclusions on this. Likewise, no reduction in short-term (up to 6 months) mortality rate (Figure 5 and Table; quality of evidence low) was found, but here again, the number of participants included was too low to allow us to draw definitive conclusions on this.

Patients’ satisfaction was also higher when peripheral nerve blocks were used as a modality of pain treatment (SMD, 0.91; 95% CI, 0.62–1.20; I2 = 0%; equivalent to a difference of 1.0 on a scale from 1 to 1045).

There was no major complication reported in any of the trials. This is consistent with information derived from large prospective studies indicating that the incidence of nerve injury lasting longer than 6 months associated with femoral nerve blocks would be fortunately relatively low: 0 to 1.2 per 1000 procedures51–53 and that major complications can be avoided even with the most difficult blocks when they are performed by well-trained operators.54

Although most included trials examined the benefits of a femoral (or 3-in-1 block) nerve block or a fascia iliaca block (24 of 31), our systematic review included a wide variety of blocks. Some differences have been clearly described between the distribution of these 2 blocks or between them and a psoas compartment block (3 of 31).55 At some point, however, 3 nerves are targeted with various degrees of success: femoral, obturator, and lateral femoral cutaneous nerves. Comparing the efficacy of 1 block to another was outside the scope of the present meta-analysis. We are therefore unable to determine if any of those blocks would be more or less effective in terms of our selected outcomes.

In conclusion, there is high-quality evidence that peripheral nerve blocks reduce pain on movement within 30 minutes after block placement. A high quality of evidence implies that further research is very unlikely to change our confidence in the estimate of effect. There is moderate quality of evidence that peripheral nerve blocks reduce pneumonia, time to first mobilization, and cost of analgesic drugs (this applies to single-shot blocks only). A moderate quality of evidence implies that further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

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DISCLOSURES

Name: Joanne Guay, MD.

Contribution: This author helped coordinate the review, screen search results, screen retrieved studies against inclusion criteria, appraise quality of studies, abstract, analyze and interpret data, and write the review and attest having approved the final manuscript.

Conflicts of Interest: None.

Name: Martyn J. Parker, MD.

Contribution: This author helped interpret the data and write the review and attest having approved the final manuscript.

Conflicts of Interest: M. J. Parker has received expenses and honorarium from a number of commercial companies and organizations for giving lectures on different aspects of hip fracture treatment. In addition, he has received royalties from B Brawn, Ltd related to the design and development of an implant used for the internal fixation of intracapsular hip fractures.

Name: Richard Griffiths, MD.

Contribution: This author helped interpret the data and write the review and attests to having approved the final manuscript.

Conflicts of Interest: R. Griffiths chaired the Association of Anaesthetists of Great Britain & Ireland guideline on proximal femoral fracture. Member National Institute of Health and Care Excellence. Chaired Association of Anaesthetists of Great Britain & Ireland guidelines on surgery in the elderly. Founder NHS Hip Fracture Perioperative Network.

Name: Sandra L. Kopp, MD.

Contribution: This author helped screen retrieved studies against inclusion criteria, appraise quality of studies, abstract and interpret data, write the review and attests to having approved the final manuscript.

Conflicts of Interest: None.

This manuscript was handled by: Richard Brull, MD, FRCPC.

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