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).
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).
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).
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).
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).
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).
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).
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).
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.
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.
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.
1. Singer A, Exuzides A, Spangler L, et al. Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States. Mayo Clin Proc. 2015;90:53–62.
2. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573–1579.
3. Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152:380–390.
4. Lee LA, Caplan RA, Stephens LS, et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology. 2015;122:659–665.
5. Guay J. The benefits of adding epidural analgesia to general anesthesia: a metaanalysis. J Anesth. 2006;20:335–340.
6. Saunders KW, Dunn KM, Merrill JO, et al. Relationship of opioid use and dosage levels to fractures in older chronic pain patients. J Gen Intern Med. 2010;25:310–315.
7. Haslam L, Lansdown A, Lee J, van der Vyver M. Survey of current practices: peripheral nerve block utilization by ED physicians for treatment of pain in the hip fracture patient population. Can Geriatr J. 2013;16:16–21.
8. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560.
9. Pace NL. Research methods for meta-analyses. Best Pract Res Clin Anaesthesiol. 2011;25:523–533.
10. Schünemann HJ, Oxman AD, Vist GE, et al. Higgins JPT, Green S. Interpreting results and drawing conclusions. In: Cochrane Handbook for Systematic Reviews of Interventions. 2011. London, UK: The Cochrane Collaboration; Available at: http://training.cochrane.org/handbook
11. Pogue J, Yusuf S. Overcoming the limitations of current meta-analysis of randomised controlled trials. Lancet. 1998;351:47–52.
12. Berde CB, Strichartz GR. Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL. Local anesthetics. In: Miller’s Anesthesia. 2009:7th ed. San Francisco, CA: Churchill Livingstone; Chapter 30.
13. Guyatt GH, Oxman AD, Vist GE, et al.; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–926.
14. Diakomi M, Papaioannou M, Mela A, Kouskouni E, Makris A. Preoperative fascia iliaca compartment block for positioning patients with hip fractures for central nervous blockade: a randomized trial. Reg Anesth Pain Med. 2014;39:394–398.
15. Domac A, Kelsaka E, Sarihasan B. The effect of preoperative fascia iliaca compartment block on postoperative analgesic use in patients with femoral fracture [Femur kiriti olan hastalarda preoperatif uygulanan fasia iliaka kompartman blotunun postoperatif analjezik tuketimine etkisi]. Anestezi Dergisi. 2015;23:144–151.
16. Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology. 2007;106:773–778.
17. Gille J, Gille M, Gahr R, Wiedemann B. Acute pain management in proximal femoral fractures. Femoral nerve block (catheter technique) vs systemic pain therapy using a clinic internal organisation model [Akutschmerztherapie bei patienten mit huftgelenknahen frakturen. N.-femoralis-katheter-analgesie vs systemische schmerztherapie unter anwendung eines klinikinternen organisationsmodells]. Der Anaesthesist. 2006;55:414–422.
18. Iamaroon A, Raksakietisak M, Halilamien P, Hongsawad J, Boonsararuxsapong K. Femoral nerve block versus fentanyl: analgesia for positioning patients with fractured femur. Local Reg Anesth. 2010;3:21–26.
19. Murgue D, Ehret B, Massacrier-Imbert S, et al. Equimolar nitrous oxide/oxygen combined with femoral nerve block for emergency analgesia of femoral neck fractures. [French] [Utilisation du mélange équimolaire de protoxyde d’azote/oxygène et du bloc fémoral pour la prise en charge antalgique des fractures du col du fémur dans un service d’urgences]. Journal Européen Des Urgences (Jeur). 2006;19:9–14.
20. Szucs S, Iohom G, O’Donnell B, et al. Analgesic efficacy of continuous femoral nerve block commenced prior to operative fixation of fractured neck of femur. Perioper Med (Lond). 2012;1:4.
21. Yun MJ, Kim YH, Han MK, Kim JH, Hwang JW, Do SH. Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block. Acta Anaesthesiol Scand. 2009;53:1282–1287.
22. Cuvillon P, Nouvellon E, Ripart J, et al. A comparison of the pharmacodynamics and pharmacokinetics of bupivacaine, ropivacaine (with epinephrine) and their equal volume mixtures with lidocaine used for femoral and sciatic nerve blocks: a double-blind randomized study. Anesth Analg. 2009;108:641–649.
23. Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. Ultrasound guidance for upper and lower limb blocks. Cochrane Database Syst Rev. 2015;9:CD006459.
24. Cuvillon P, Ripart J, Debureaux S, et al. Analgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study [Analgésie postopératoire par cathéter fémoral après fracture du col du fémur chez la personne agée: étude prospective randomisée]. Ann Fr Anesth Réanim. 2007;26:2–9.
25. Godoy Monzón D, Vazquez J, Jauregui JR, Iserson KV. Pain treatment in post-traumatic hip fracture in the elderly: regional block vs systemic non-steroidal analgesics. Int J Emerg Med. 2010;3:321–325.
26. Graham CA, Baird K, McGuffie AC. A pilot randomised clinical trial of 3-in-1 femoral nerve block and intravenous morphine as primary analgesia for patients presenting to the emergency department with fractured hip. Hong Kong J Emerg Med. 2008;15:205–211.
27. Kullenberg B, Ysberg B, Heilman M, Resch S. Femoral nerve block as pain relief in hip fracture. A good alternative in perioperative treatment proved by a prospective study [Femoralnervsblockad som smärtlindring vid höftfraktur. Bra alternativ i perioperativ behandlingsarsenal visar prospektiv studie] [in Swedish]. Lakartidningen. 2004;101:2104–2107.
28. Mouzopoulos G, Vasiliadis G, Lasanianos N, Nikolaras G, Morakis E, Kaminaris M. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthop Traumatol. 2009;10:127–133.
29. Nie H, Yang YX, Wang Y, Liu Y, Zhao B, Luan B. Effects of continuous fascia iliaca compartment blocks for postoperative analgesia in patients with hip fracture. Pain Res Manag. 2015;20:210–212.
30. White IW, Chappell WA. Anaesthesia for surgical correction of fractured femoral neck. A comparison of three techniques. Anaesthesia. 1980;35:1107–1110.
31. Altermatt RF, De la Fuente RF, Echevarría GC, et al. Evaluation of the effect of perioperative continuous lumbar plexus block upon the incidence of ischaemic cardiovascular events in elderly patients with hip fracture. Reg Anesth Pain Med. 2013;38:E182.
32. Luger TJ, Kammerlander C, Benz M, Luger MF, Garoscio I. Peridural anesthesia or ultrasound- guided continuous 3-in-1 block: which is indicated for analgesia in very elderly patients with hip fracture in the emergency department? Geriatr Orthop Surg Rehabil. 2012;3:121–128.
33. Fletcher AK, Rigby AS, Heyes FL. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2003;41:227–233.
34. Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone Joint Surg Br. 1995;77:922–923.
35. Cordero J, Maldonado A, Iborra S. Surgical delay as a risk factor for wound infection after a hip fracture. Injury. 2016;47suppl 3S56–S60.
36. De La Tabla Gonzalez SRO, Angel Martinez ND, Mercedes Echevarra MS. Influence of perioperative pain treatment in postoperative morbidity in femur fractured patients over sixty-five years old: a randomised study. Reg Anesth Pain Med. 2010;35:469.
37. Hood G, Edbrooke DL, Gerrish SP. Postoperative analgesia after triple nerve block for fractured neck of femur. Anaesthesia. 1991;46:138–140.
38. Jones SF, White A. Analgesia following femoral neck surgery. Lateral cutaneous nerve block as an alternative to narcotics in the elderly. Anaesthesia. 1985;40:682–685.
39. Segado Jiménez MI, Bayón Gago M, Arias Delgado J, et al. [Efficacy of obturator and femoral cutaneous nerve blocks for postoperative analgesia in hip surgery]. Rev Esp Anestesiol Reanim. 2009;56:590–597.
40. Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013;20:584–591.
41. McRae PJ, Bendall JC, Madigan V, Middleton PM. Paramedic-performed fascia iliaca compartment block for femoral fractures: a controlled trial. J Emerg Med. 2015;48:581–589.
42. Marhofer P, Schrögendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg. 1997;85:854–857.
43. Chudinov A, Berkenstadt H, Salai M, Cahana A, Perel A. Continuous psoas compartment block for anesthesia and perioperative analgesia in patients with hip fractures. Reg Anesth Pain Med. 1999;24:563–568.
44. Johnston DF, Stafford M, McKinney M, Deyermond R, Dane K. Peripheral nerve blocks with sedation using propofol and alfentanil target-controlled infusion for hip fracture surgery: a review of 6 years in use. J Clin Anesth. 2016;29:33–39.
45. Guay J, Parker MJ, Griffiths R, Kopp S. Peripheral nerve blocks for hip fractures. Cochrane Database Syst Rev. 2017;5:CD001159.
46. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016;16:157.
47. Johnson RL, Kopp SL, Hebl JR, Erwin PJ, Mantilla CB. Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis. Br J Anaesth. 2013;110:518–528.
48. Memtsoudis SG, Danninger T, Rasul R, et al. Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology. 2014;120:551–563.
49. Johnson RL, Duncan CM, Ahn KS, Schroeder DR, Horlocker TT, Kopp SL. Fall-prevention strategies and patient characteristics that impact fall rates after total knee arthroplasty. Anesth Analg. 2014;119:1113–1118.
50. Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc. 1994;42:809–815.
51. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: the SOS Regional Anesthesia Hotline Service. Anesthesiology. 2002;97:1274–1280.
52. Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007;104:965–974.
53. Sites BD, Taenzer AH, Herrick MD, et al. Incidence of local anesthetic systemic toxicity and postoperative neurologic symptoms associated with 12,668 ultrasound-guided nerve blocks: an analysis from a prospective clinical registry. Reg Anesth Pain Med. 2012;37:478–482.
54. Njathi CW, Johnson RL, Laughlin RS, Schroeder DR, Jacob AK, Kopp SL. Complications after continuous posterior lumbar plexus blockade for total hip arthroplasty: a retrospective cohort study. Reg Anesth Pain Med. 2017;42:446–450.
55. Parkinson SK, Mueller JB, Little WL, Bailey SL. Extent of blockade with various approaches to the lumbar plexus. Anesth Analg. 1989;68:243–248.
Supplemental Digital Content
Copyright © 2017 International Anesthesia Research Society