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Meta-Analysis
. 2017 May 11;5(5):CD001159.
doi: 10.1002/14651858.CD001159.pub2.

Peripheral nerve blocks for hip fractures

Joanne Guay  1 , Martyn J Parker  2 , Richard Griffiths  3 , Sandra Kopp  4
Affiliations
Meta-Analysis

Peripheral nerve blocks for hip fractures

Joanne Guay et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Various nerve blocks with local anaesthetic agents have been used to reduce pain after hip fracture and subsequent surgery. This review was published originally in 1999 and was updated in 2001, 2002, 2009 and 2017.

Objectives: This review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anaesthesia for hip fracture surgery. 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; 2016, Issue 8), MEDLINE (Ovid SP, 1966 to August week 1 2016), Embase (Ovid SP, 1988 to 2016 August week 1) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to August week 1 2016), as well as trial registers and reference lists of relevant articles.

Selection criteria: We included randomized controlled trials (RCTs) involving use of nerve blocks as part of the care provided for adults aged 16 years and older with hip fracture.

Data collection and analysis: Two review authors independently assessed new trials for inclusion, determined trial quality using the Cochrane tool and extracted data. When appropriate, we pooled results of outcome measures. We rated the quality of evidence according to the GRADE Working Group approach.

Main results: We included 31 trials (1760 participants; 897 randomized to peripheral nerve blocks and 863 to no regional blockade). Results of eight trials with 373 participants show that peripheral nerve blocks reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I2 = 90%; high quality of evidence). Effect size was proportionate to the concentration of local anaesthetic used (P < 0.00001). Based on seven trials with 676 participants, we did not find a difference in the risk of acute confusional state (risk ratio (RR) 0.69, 95% CI 0.38 to 1.27; I2 = 48%; very low quality of evidence). Three trials with 131 participants reported decreased risk for pneumonia (RR 0.41, 95% CI 0.19 to 0.89; I2 = 3%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 72; moderate quality of evidence). We did not find a difference in risk of myocardial ischaemia or death within six months, but the number of participants included was well below the optimal information size for these two outcomes. Two trials with 155 participants reported that peripheral nerve blocks also reduced time to first mobilization after surgery (mean difference -11.25 hours, 95% CI -14.34 to -8.15 hours; I2 = 52%; moderate quality of evidence). One trial with 75 participants indicated that the cost of analgesic drugs was lower when they were given as a single shot block (SMD -3.48, 95% CI -4.23 to -2.74; moderate quality of evidence).

Authors' conclusions: High-quality evidence shows that regional blockade reduces pain on movement within 30 minutes after block placement. Moderate-quality evidence shows reduced risk for pneumonia, decreased time to first mobilization and cost reduction of the analgesic regimen (single shot blocks).

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Conflict of interest statement

Joanne Guay: has no direct relationship with any pharmaceutical company or equipment manufacturer in the past five years. Has not acted as a witness expert in the past five years. Not an author of any of the included or excluded studies. Does not hold any stock other than mutual funds. Editor of a multi‐author textbook on anaesthesia (including notions on general and regional anaesthesia). Receives fees as associate professor for a course on airway management from University of Quebec in Abitibi‐Temiscamingue.

Martyn Parker: has received expenses and honorarium from several commercial companies and organizations for giving lectures on different aspects of hip fracture treatment. Has received royalties from BBrawn Ltd related to design and development of an implant used for internal fixation of intracapsular hip fractures.

Richard Griffiths: chaired Association of Anaesthetists of Great Britain & Ireland guidelines on proximal femoral fracture. Member of National Institute of Health and Care Excellence 124. Chaired Association of Anaesthetists of Great Britain & Ireland guidelines on surgery in the elderly. Founder of NHS Hip Fracture Perioperative Network.

Sandra Kopp: has no conflicts of interest.

Figures

1
1
Flow diagram for this update. n: number.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Pain on movement in participants with hip fracture between 20 and 30 minutes after block placement. The effect size is proportionate to the concentration of local anaesthetic (mg/mL) used in lidocaine equivalent (P < 0.00001). Local anaesthetic 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).
1.1
1.1. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 1 Pain on movement within 30 minutes of block placement.
1.2
1.2. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 2 Pain at rest within 30 minutes after block placement.
1.3
1.3. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 3 Pain at rest at 6 to 8 hours after surgery.
1.4
1.4. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 4 Pain on movement at 24 hours after surgery.
1.5
1.5. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 5 Pain at rest at 24 hours after surgery.
1.6
1.6. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 6 Pain on movement at 48 hours.
1.7
1.7. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 7 Pain at rest at 48 hours after surgery.
1.8
1.8. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 8 Pain at rest at 72 hours after surgery.
1.9
1.9. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 9 Acute confusional state.
1.10
1.10. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 10 Pneumonia.
1.11
1.11. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 11 Mortality.
1.12
1.12. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 12 Time to first mobilization.
1.13
1.13. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 13 Costs of analgesic regimens.
1.14
1.14. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 14 Pressure sores.
1.15
1.15. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 15 Opioid requirement.
1.16
1.16. Analysis
Comparison 1 Nerve block versus other modes of analgesia, Outcome 16 Participant satisfaction.
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References

References to studies included in this review

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Mossafa 2005 {published data only}
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References to studies excluded from this review

Bech 2011 {published data only}
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Marhofer 1998 {published data only}
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Matot 2003 {published data only}
    1. Matot I, Oppenheim‐Eden A, Ratrot R, Baranova J, Davidson E, Eylon S, et al. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology 2003;98(1):156‐63. [PUBMED: 12502992] - PubMed
McRae 2015 {published data only}
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Mutty 2007 {published data only}
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Piangatelli 2004 {published data only}
    1. Piangatelli C, Angelis C, Pecora L, Recanatini F, Testasecca D. Levobupivacaine versus ropivacaine in psoas compartment block and sciatic nerve block in orthopedic surgery of the lower extremity. Minerva Anestesiologica 2004;70(12):801‐7. [PUBMED: 15702061] - PubMed
Reavley 2015 {published data only}
    1. Reavley P, Montgomery AA, Smith JE, Binks S, Edwards J, Elder G, et al. Randomised trial of the fascia iliaca block versus the '3‐in‐1' block for femoral neck fractures in the emergency department. Emergency Medicine Journal 2015;32(9):685‐9. [PUBMED: 25430915] - PubMed
Scheinin 2000 {published and unpublished data}
    1. Scheinin 2015 [pers comm]. Additional information for our trial. Email to: J Guay 25 May 2015.
    1. Scheinin H, Virtanen T, Kentala E, Uotila P, Laitio T, Hartiala J, et al. Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture ‐ a randomized controlled trial. Acta Anaesthesiologica Scandinavica 2000;44(9):1061‐70. [PUBMED: 11028724] - PubMed
Schiferer 2007 {published data only}
    1. Schiferer A, Gore C, Gorove L, Lang T, Steinlechner B, Zimpfer M, et al. A randomized controlled trial of femoral nerve blockade administered preclinically for pain relief in femoral trauma. Anesthesia and Analgesia 2007;105(6):1852‐4. [PUBMED: 18042893] - PubMed
Segado Jimenez 2010 {published data only}
    1. Segado Jimenez I. Information on our trial [personal communication]. Email to: J Guay 24 April 2016.
    1. Segado Jimenez MI, Arias Delgado J, Casas Garcıa ML, Domınguez Hervella F, Lopez Perez A, Bayon Gago M, et al. Post‐surgical analgesia in hip surgery: a comparison of three techniques [Abordaje de la analgesia postoperatoria en cirugıa de cadera: comparativa de 3 tecnicas]. Revista Sociedad Espanola del Dolor 2010;17(6):259‐67.
Sia 2004 {published data only}
    1. Sia S, Pelusio F, Barbagli R, Rivituso C. Analgesia before performing a spinal block in the sitting position in patients with femoral shaft fracture: a comparison between femoral nerve block and intravenous fentanyl. Anesthesia and Analgesia 2004;99(4):1221‐4, table of contents. [PUBMED: 15385380] - PubMed
Turker 2003 {published data only}
    1. Turker G, Uckunkaya N, Yavascaoglu B, Yilmazlar A, Ozcelik S. Comparison of the catheter‐technique psoas compartment block and the epidural block for analgesia in partial hip replacement surgery. Acta Anaesthesiologica Scandinavica 2003;47(1):30‐6. [PUBMED: 12492794] - PubMed
Van Leeuwen 2000 {published data only}
    1. Leeuwen FL, Bronselaer K, Gilles M, Sabbe MB, Delooz HH. The 'three in one' block as locoregional analgesia in an emergency department. European Journal of Emergency Medicine 2000;7(1):35‐8. [PUBMED: 10839377] - PubMed

References to ongoing studies

ACTRN12609000526279 {published data only}
    1. Ultrasound‐guided femoral nerve block using 1% ropivacaine as a method of pain control in patients who present to emergency with a fractured hip. Ongoing study 04/04/2009.
EUCTR2006‐004001‐26‐GB {published data only}
    1. A randomized controlled trial of fascia iliaca compartment block versus morphine for pain in fractured neck of femur in the emergency department: a pilot study ‐ fascia Iliaca compartment block versus parenteral morphine sulphate. Ongoing study Starting date of trial not provided. Contact author for more information.
EUCTR2008‐004303‐59‐SE {published data only}
    1. Blocking the femoral nerve in patients with suspected hip fracture ‐ does it work in clinical practice?. Ongoing study 24/10/2008.
EUCTR2010‐023871‐25‐GB {published data only}
    1. The FINOF (Femoral Nerve‐Block Intervention in Neck Of Femur Fracture) study ‐ FINOF. Ongoing study 20/04/2011.
EUCTR2015‐000078‐36‐DK {published data only}
    1. Analgesic effect of a supplemental nerve block in patients with hip fracture. Ongoing study 17/03/2015.
ISRCTN07083722 {published data only}
    1. The effect of the use of fascia iliaca nerve blockade on patient positioning for spinal anaesthesia and the effect of continuous nerve blockade on postoperative pain and mobility outcomes in patients with hip fractures. Ongoing study 01/07/2009.
ISRCTN46653818 {published data only}
    1. Femoral nerve blockade in hip fracture patients. Ongoing study 30/03/2009.
ISRCTN75659782 {published data only}
    1. Intra‐ and post‐operative analgesia for patients undergoing surgery for hip fracture ‐ role of fascia iliaca compartment block. Ongoing study 04/04/2006.
ISRCTN92946117 {published data only}
    1. Sahota O, Rowlands M, Bradley J, Walt G, Bedforth N, Armstrong S, et al. Femoral nerve block Intervention in Neck of Femur fracture (FINOF): study protocol for a randomized controlled trial. Trials 2014;15(May 24):189. [PUBMED: 24885267] - PMC - PubMed
NCT00749489 {published data only}
    1. Improving pain and function in hip fracture. Ongoing study November 2008.
NCT01052974 {published data only}
    1. Perioperative analgesia by femoral perineural catheter for femoral neck fracture ‐ Study KTcol. Ongoing study March 2009.
NCT01219088 {published data only}
    1. Postoperative pain control among intrathecal 0.1 mg morphine, femoral nerve block or periarticular infiltration of 20 mL of 0.25% bupivacaine in patients post intramedullary hip screw. Ongoing study September 2010.
NCT01547468 {published data only}
    1. Does femoral nerve catheterization reduce the incidence of post‐operative delirium in patients presenting for hip fracture repair?. Ongoing study March 2012.
NCT01593319 {published data only}
    1. Is regional anaesthesia of the hip preferable over traditional analgesia in the acute stage of the management of patients with a fracture of the hip. Ongoing study January 2012.
NCT01638845 {published data only}
    1. Hip fracture and perineural catheter. Ongoing study June 2012.
NCT01904071 {published data only}
    1. Ultrasound‐guided femoral (three‐in‐one) nerve block versus ultrasound guided fascia iliacus compartment block versus standard treatment for pain control in patients with hip fractures in the emergency department. Ongoing study October 2008.
NCT02381717 {published data only}
    1. Comparison of ultrasound guided femoral nerve blockade and standard parenteral opioid pain management alone in patients with hip fracture in the emergency department. Ongoing study February 2015.
NCT02406300 {published data only}
    1. Contribution of anaesthesia technique for post‐operative mortality reduction after proximal femur fractures surgical treatment ‐ a randomized clinical trial. Ongoing study April 2015.
NCT02433548 {published data only}
    1. Fascia iliaca block in the emergency department for analgesia after femoral neck fracture. Ongoing study October 2014.

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References to other published versions of this review

Parker 2002
    1. Parker MJ, Griffiths R, Appadu BN. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database of Systematic Reviews 2002, Issue 2. [DOI: 10.1002/14651858.CD001159] - DOI - PubMed

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