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.

Peripheral nerve blocks for hip fractures in adults

Background Hip fracture is a common clinical problem which causes severe pain in geriatric patients. However, severe pain following fracture may bring on mental disorders and delirium. A neuroinflammatory response with IL-6 and IL-8 has been shown to be associated with the pathophysiology of delirium. In this study, our primary hypothesis is that preoperative femoral nerve block (FNB) intervention in geriatric patients will more effectively attenuate pain following trochanteric femur fracture than the preoperative paracetamol application. Our secondary hypothesis is that interleukin levels (IL-6, IL-8) in cerebrospinal fluid (CSF) will be lower in the femoral nerve block group than the paracetamol group. Our tertiary hypothesis is that the incidence of postoperative delirium will be lower in the femoral nerve block group. Methods The patients over 65 years of age with ASA status II-IV and admitted to the Emergency Service for femur fracture were included in this study. Recommendations of the 'delirium prevention table' were applied to all of the patients at arrival. In the first group, 15 mg/kg paracetamol was administered intravenously every eight hours. In the second group, femoral nerve blockage was performed, and a catheter was placed. Then, 0.5 mL/kg bupivacaine 0.25% was applied every eight hours. In both groups, pain scores four hours after interventions were recorded. All patients were operated within 48 hours under spinal anesthesia. During spinal anesthesia, 2 mL of CSF samples were taken from all patients for analysis of IL-6 and IL-8 cytokines, and pain scores during positioning were recorded. Results VAS scores four hours after the first preoperative pain treatment and during the positioning for regional anesthesia were significantly lower in the femoral nerve block group. IL-8 levels are significantly lower in the femoral nerve block group but not in IL-6 levels. The incidence of delirium was less in the femoral nerve block group, but the difference was not statistically significant. Conclusion The femoral nerve block was more effective in preoperative pain management of trochanteric femur fracture and preventing pain during regional anesthesia application. The mean IL-8 level was lower in the femoral nerve block group when compared to the paracetamol group. There is no difference in the postoperative delirium incidence between groups.

The effects of early femoral nerve block intervention on preoperative pain management and incidence of postoperative delirium geriatric patients undergoing trochanteric femur fracture surgery: A randomized controlled trial

Background Conversion arthroplasty for failed primary fixation of intertrochanteric fractures can be achieved using various methods, including cemented total hip arthroplasty, uncemented total hip arthroplasty, hybrid total hip arthroplasty, and hemiarthroplasty. Complication rates vary between each conversion method. The purpose of this paper is to examine the effect of conversion method on total conversion complication rates. Methods We performed a meta-analysis of five studies with sufficient data for analysis. We created a null hypothesis stating that the expected distribution of complications across conversion methods would reflect the distribution of conversion method used for failed primary fixation. Using a z test, we compared proportions of the expected distribution of complications to the observed distribution of complications. Results A total of 138 cases of conversion arthroplasty with 49 complications were available for analysis. The mean age was 73 (range, 32–96) years. 19 males and 48 females were included, with one study not including patient gender. The mean time from primary fixation failure to conversion was 11 months, and the mean duration of conversion surgery was 132 min. Expected and observed complication rate distributions were as follows: cemented total hip arthroplasty, 6.5% versus 4.1% ( p  = 0.79); uncemented total hip arthroplasty, 77.5% versus 81.6% ( p  = 0.69); hybrid total hip arthroplasty, 2.9% versus 2.0% ( p  = 1); and hemiarthroplasty, 13% versus 12.2% ( p  = 1). Conclusions Our findings suggest that the method of conversion arthroplasty following failed primary intertrochanteric femur fracture fixation does not influence complication rate.

A systematic review and meta-analysis of complications in conversion arthroplasty methods for failed intertrochanteric fracture fixation.

Introduction Excellent results have been published in the treatment of the trochanteric fractures in the elderly with cephalomedullary nails or compression hip screws but not free of complications. The perforation of the lag screw through the superior cortex of femoral neck or head followed by rotation and varus collapse of the head-neck fragment, also known as cut-out, is one of them. Probably total hip arthroplasty is the most common solution, but there is no systematic technique for treatment. The objective of this study is to evaluate the results obtained in the treatment of this complication using a variable angle femoral plate. Material and methods This retrospective study concerns patients over 65 years with peritrochanteric fractures treated with cephalomedullary nail with cut-out failure solved by re-osteosyntesis with variable angle femoral plate between 1st January 2000 and 31 st December 2017. The series includes 29 patients, 26 women and 3 men with average age 87,3. Patients were followed up clinically and radiologically at regular intervals until fracture consolidation at least 9 months. Results No patients died at the first 9 months after surgery. Fracture mean consolidation has occurred in all patients in 14th weeks (6-20). Operative time was 93,2 minutes (62-129) including removal of nail. No intraoperative complications were observed. Five patients experienced medical complications and two had a superficial wound infection. The mean tip-apex distance (TAD) was 5mm (2-7mm). The neck-shaft angle was 127 degrees. The mean valgization achieved was 32 degrees (15-40). Only one patient needed a second revision surgery due to aseptic hip joint subluxation after 8 weeks of the surgery solved with total hip arthroplasty. Conclusions The use of variable angle femoral plate in the cut-out treatment is an attractive option which allows the valgization of the fracture to virtually physiological limits and the placement of the cephalic screw in the most sutiable position with good outcomes and few complications.

Salvage of cephalomedullary nail cutout with the variable angle proximal femoral plate.

Author(s): St. Louis, Daniel; Iserson, Kenneth V.; Forget, Nicolas | Abstract: Introduction: Although the fascia iliaca compartment block (FICB) seems to be an ideal technique for femoral neck and shaft fractures occurring in resource-poor settings, it has been unclear how effective it is when used by emergency physicians (EP) with little training in the technique, using equipment, medications and methods that differ from those commonly available in developed countries. This series was designed to demonstrate that EPs in a resource-poor setting can provide effective analgesia for femur fractures with anatomic landmark-guided FICBs, clinician-compounded lidocaine-epinephrine (1:100,000), and a standard injection needle.Methods: Over a three-month period, patients ≥12 years old presenting to the emergency department with hip or femur fractures and a Likert visual analogue scale g4 had an EP-administered FICB. EPs used a standard intramuscular needle and a lidocaine-epinephrine solution they compounded at the bedside and located the injection site using only anatomic landmarks. EPs evaluated the patient’s pain level at 30 minutes and at two hours post-FICB. We also reviewed articles since 2016 that describe the FICB.Results: We enrolled a non-consecutive sample of 10 patients in the case series. Five had femoral neck (hip) fractures and five had femoral shaft fractures. All patients had a reduction in their pain levels after the FICB. On average, the block took effect about three minutes after injection. At 30 minutes all patients reported clinically meaningful pain reduction. The analgesic effect of the compounded agent lasted approximately 200 minutes. No adverse effects were reported. No published journal articles about FICB since 2016 were from resource-poor settings, and only one was from a developing country.Conclusion: This series suggests that the FICB is effective even when performed with the minimal materials that are usually available in resource-poor settings. Methods such as this, which use simplified clinical tests and techniques applicable in resource-poor settings, can assist global emergency medicine (EM). We can assist global EM by similarly finding methods to simplify useful clinical tests and techniques that can be used in resource-poor settings.

/pdf/fascia-iliaca-compartment-block-efficacy-in-resource-poor-4k1ktu9xpn.pdf

Fascia Iliaca Compartment Block Efficacy in Resource-poor Emergency Departments.

Fascia iliaca block for pain control in hip fracture patients.

Artroplastia de cadera con vástago convencional en fracasos de osteosíntesis de fracturas del fémur proximal

Hip arthroplasty with conventional stem as rescue treatment after failed treatment of intertrochanteric hip fractures

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Fascia iliaca block for pain control in hip fracture patients.

Artroplastia de cadera con vástago convencional en fracasos de osteosíntesis de fracturas del fémur proximal

Hip arthroplasty with conventional stem as rescue treatment after failed treatment of intertrochanteric hip fractures