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Блокада периферических нервов при переломах бедра

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Referencias

References to studies included in this review

Altermatt 2013 {published and unpublished data}

Altermatt 2015 [pers comm]. Additional information for our trial. Email to J Guay 26 May 2015. CENTRAL
Altermatt RF, De la Fuente RF, Echevarría GC, Baeza R, Ferrada M, De la Fuente N, 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. Regional Anesthesia and Pain Medicine. 2013; Vol. 38, issue 5 (Suppl 1):E182. CENTRAL

Antonopoulou 2006 {published data only}

Antonopoulo E, Papaloannou K, Konstantinou G, Papadopoulos D, Karamoulas B, Molas TH. Continous femoral block in elderly patients with hip fractures. Regional Anesthesia and Pain Medicine. 2006; Vol. 31, issue 5 Suppl 1:92. CENTRAL

Beaudoin 2013 {published data only}

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. Academic Emergency Medicine 2013;20(6):584‐91. [PUBMED: 23758305]CENTRAL

Chudinov 1999 {published data only}

Chudinov A, Berkenstadt H, Salai M, Cahana A, Perel A. Continuous psoas compartment block for anaesthesia and perioperative analgesia in patients with hip fractures. Regional Anesthesia and Pain Medicine 1999;24(6):563‐8. [PUBMED: 10588563]CENTRAL
Chudinov A, Berkenstadt H, Salai M, Cahana A, Perel A. Continuous psoas compartment block for anesthesia and perioperative analgesia in patients with hip fractures [abstract]. British Journal or Anaesthesia. 1999; Vol. 82, issue Supplement 1:111. CENTRAL

Coad 1991 {published data only}

Coad NR. Post‐operative analgesia following femoral‐neck surgery ‐ a comparison between 3 in 1 femoral nerve block and lateral cutaneous nerve block. European Journal of Anaesthesiology 1991;8(4):287‐90. [PUBMED: 1874226]CENTRAL

Cuvillon 2007 {published data only}

Cuvillon P, Ripart J, Debureaux S, Boisson C, Veyrat E, Mahamat A, et al. Analgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study [Analgesie postoperatoire par catheter femoral apres fracture du col du femur chez la personne agee: etude prospective randomisee]. Annales Francaises d' Anesthesie et de Reanimation 2007;26(1):2‐9. [PUBMED: 17142005]CENTRAL

De La Tabla 2010 {published and unpublished data}

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. Regional Anesthesia and Pain Medicine. 2010; Vol. 35, issue 5:469. CENTRAL
Ortiz de la Tabla González 2015 [pers comm]. Additional information for our trial. Email to J Guay 5 July 2015. CENTRAL

Diakomi 2014 {published data only}

Diakomi M, Gkliatis E, Papaioannou M, Polymenopoulou E, Papadopoulos P, Makris A. Fascia iliaca compartment block for positioning hip fracture patients for spinal anaesthesia: a randomised trial. Regional Anesthesia and Pain Medicine. 2014; Vol. 39, issue 5 (Suppl):ESRA1‐0229. CENTRAL
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 randomised trial. Regional Anesthesia and Pain Medicine 2014;39(5):394‐8. [PUBMED: 25068412]CENTRAL

Domac 2015 {published data only}

Domac A, Kelsaka, 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(3):144‐51. [EMBASE: AN: 2015379598 ]CENTRAL

Fletcher 2003 {published data only}

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. Annals of Emergency Medicine 2003;41(2):227‐33. [PUBMED: 12548273]CENTRAL

Foss 2007 {published data only}

Foss NB, Kristensen BB, Bundgaard M, Bak M, Heiring C, Virkelyst C, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo‐controlled trial. Anesthesiology 2007;106(4):773‐8. [PUBMED: 17413915]CENTRAL

Gille 2006 {published and unpublished data}

Gille 2006 [pers comm]. Additional information for our trial. Email to M Parker2006. CENTRAL
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(4):414‐22. [PUBMED: 16320011]CENTRAL

Godoy 2010 {published data only}

Godoy Monzon D, Vazquez J, Jauregui JR, Iserson KV. Pain treatment in post‐traumatic hip fracture in the elderly: regional block vs. systemic non‐steroidal analgesics. International Journal of Emergency Medicine 2010;3(4):321‐5. [PUBMED: 21373300]CENTRAL

Graham 2008 {published data only}

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 Journal of Emergency Medicine 2008;15(4):205‐11. CENTRAL

Haddad 1995 {published data only}

Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. Journal of Bone and Joint Surgery ‐ British Volume 1995;77(6):922‐3. [PUBMED: 7593107]CENTRAL

Hood 1991 {published data only}

Hood G, Edbrooke DL, Gerrish SP. Postoperative analgesia after triple nerve block for fractured neck of femur. Anaesthesia 1991;46(2):138‐40. [PUBMED: 1872429]CENTRAL

Iamaroon 2010 {published data only}

Iamaroon A, Raksakietisak M, Halilamien P, Hongsawad J, Boonsararuxsapong K. Femoral nerve block versus fentanyl: analgesia for positioning patients with fractured femur. Local and Regional Anesthesia 2010;3:21‐6. [PUBMED: 22915864]CENTRAL

Jadon 2014 {published and unpublished data}

Jadon 2015 [pers comm]. Additional information for our trial. Email to J Guay 22 March 2016. CENTRAL
Jadon A, Kedia SK, Dixit S, Chakraborty S. Comparative evaluation of femoral nerve block and intravenous fentanyl for positioning during spinal anaesthesia in surgery of femur fracture. Indian Journal of Anaesthesia 2014;58(6):705‐8. [PUBMED: 25624533]CENTRAL

Jones 1985 {published data only}

Jones SF, White A. Analgesia following femoral neck surgery. Lateral cutaneous nerve block as an alternative to narcotics in the elderly. Anaesthesia 1985;40(7):682‐5. [PUBMED: 3896019]CENTRAL

Kullenberg 2004 {published data only}

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. [Swedish]]. Lakartidningen 2004;101(24):2104‐7. [PUBMED: 15282985]CENTRAL

Luger 2012 {published data only}

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?. Geriatric Orthopaedic Surgery & Rehabilitation 2012;3(3):121‐8. [PUBMED: 23569705]CENTRAL

Mossafa 2005 {published data only}

Mosaffa F, Esmaelijah A, Khoshnevis H. Analgesia before performing a spinal block in the lateral decubitus position in patients with a femoral neck fracture: a comparison between fascia iliaca block and IV fentanyl. Regional Anesthesia and Pain Medicine. 2005; Vol. 30, issue Suppl 1:61. CENTRAL

Mouzopoulos 2009 {published data only}

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. Journal of Orthopaedics and Traumatology 2009;10(3):127‐33. [PUBMED: 19690943]CENTRAL

Murgue 2006 {published data only}

Murgue D, Ehret B, Massacrier‐Imbert S, Durand O, Gibaud F, Maakel A, et al. Equimolar nitrous oxide/oxygen combined with femoral nerve block for emergency analgesia of femoral neck fractures. [French] [Utilisation du melange equimolaire de protoxyde d'azote/oxygene et du bloc femoral pour la prise en charge antalgique des fractures du col du femur dans un service d'urgences]. Journal Europeen Des Urgences (Jeur) 2006;19(1):9‐14. CENTRAL

Nie 2015 {published data only}

Nie H. Information on our trial [personal communication]. Email to: J Guay 5 September 2016. CENTRAL
Nie H, Yang YX, Wang Y, Liu Y, Zhao B, Luan B. Effects of continuous fascia iliaca compartment blocks for postoperative analgesia in hip fracture patients. Pain Research & Management 2015;20(4):210‐2. [PUBMED: 26125194]CENTRAL

Segado Jimenez 2009 {published data only}

Segado Jimenez MI, Bayon Gago M, Arias Delgado J, Casas Garcia ML, Dominguez Hervella F, Lopez Perez A, et al. [Efficacy of obturator and femoral cutaneous nerve blocks for postoperative analgesia in hip surgery] [Eficacia del bloqueo de los nervios obturador y femorocutaneo para analgesia postoperatoria en cirugia de cadera]. Revista Espanola de Anestesiologia y Reanimacion 2009;56(10):590‐7. [PUBMED: 20151520]CENTRAL

Spansberg 1996 {published data only}

Spansberg NL, Anker‐Moller E, Dahl JB, Schultz P, Christensen EF. The value of continuous blockade of the lumbar plexus as an adjunct to acetylsalicyclic acid for pain relief after surgery for femoral neck fractures. European Journal of Anaesthesiology 1996;13(4):410‐2. [PUBMED: 8842667]CENTRAL

Szucs 2012 {published data only}

Szucs S, Iohom G. Functional recovery following operative fixation of fractured neck of femur in the elderly. Regional Anesthesia and Pain Medicine. 2010; Vol. 35, issue 5:Abstract 534. CENTRAL
Szucs S, Iohom G, O'Donnell B, Sajgalik P, Ahmad I, Salah N, et al. Analgesic efficacy of continuous femoral nerve block commenced prior to operative fixation of fractured neck of femur. Perioperative Medicine (London, England) 2012;1:4. [PUBMED: 24764520]CENTRAL

Tuncer 2003 {published data only}

Tuncer S, Sert OA, Yosunkaya A, Mutlu M, Celik J, Okesli S. Patient‐controlled femoral nerve analgesia versus patient‐controlled intravenous analgesia for postoperative analgesia after trochanteric fracture repair. Acute Pain 2003;4(3‐4):105‐8. CENTRAL

White 1980 {published data only}

White IWC, Chappell WA. Anaesthesia for surgical correction of fractured femoral neck. A comparison of three techniques. Anaesthesia 1980;35(11):1107‐10. [PUBMED: 7446914]CENTRAL

Yun 2009 {published data only}

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 Anaesthesiologica Scandinavica 2009;53(10):1282‐7. [PUBMED: 19650803]CENTRAL

References to studies excluded from this review

Bech 2011 {published data only}

Bech RD, Lauritsen J, Ovesen O, Emmeluth C, Lindholm P, Overgaard S. Local anaesthetic wound infiltration after internal fixation of femoral neck fractures: a randomized, double‐blind clinical trial in 33 patients. Hip International : the Journal of Clinical and Experimental Research on Hip Pathology and Therapy 2011;21(2):251‐9. [PUBMED: 21484739]CENTRAL

Bölükbasi 2013 {published and unpublished data}

Bolukbasi GE, Turhan CK, Can SO, Ozcelik M, Okten F. Comparison of the effects of ultrasound‐guided fascia iliaca compartment block and remifentanil infusion on positional pain in patients undergoing hip fracture surgery under spinal anaesthesia. Regional Anesthesia and Pain Medicine 2013;38(5 Suppl 1):E182. [CENTRAL: 01061852]CENTRAL
Turhan 2015 [pers comm]. Additional information for our trial. Email to J Guay 25 May 2015. CENTRAL

Durrani 2013 {published data only}

Durrani HD, Butt KJ, Khosa AH, Umer A, Pervaiz M. Pain relief during positioning for spinal anaesthesia in patients with femoral fracture: a comparison between femoral nerve block and intravenous nalbuphine. Pakistan Journal of Medical and Health Sciences 2013;7(4):928‐32. [CENTRAL: 00977951]CENTRAL

Foss 2005 {published data only}

Foss NB, Kristensen MT, Kristensen BB, Jensen PS, Kehlet H. Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double‐blind, placebo‐controlled trial. Anesthesiology 2005;102(6):1197‐204. [PUBMED: 15915033]CENTRAL

Fujihara 2013 {published data only}

Fujihara Y, Fukunishi S, Nishio S, Miura J, Koyanagi S, Yoshiya S. Fascia iliaca compartment block: its efficacy in pain control for patients with proximal femoral fracture. Journal of Orthopaedic Science 2013;18(5):793‐7. [PUBMED: 23744530]CENTRAL

Ghimire 2015 {published data only}

Ghimire A, Bhattarai B, Koirala S, Subedi A. Analgesia before performing subarachnoid block in the sitting position in patients with proximal femoral fracture: a comparison between fascia iliaca block and femoral nerve block. Kathmandu University Medical Journal (KUMJ) 2015;13(50):152‐5. [PUBMED: 26643833]CENTRAL

Gorodetskyi 2007 {published data only}

Gorodetskyi IG, Gorodnichenko AI, Tursin PS, Reshetnyak VK, Uskov ON. Non‐invasive interactive neurostimulation in the post‐operative recovery of patients with a trochanteric fracture of the femur. a randomised, controlled trial. Journal of Bone and Joint Surgery ‐ British Volume 2007;89(11):1488‐94. [PUBMED: 17998187]CENTRAL

Hussain 2014 {published data only}

Hussain R, Nazeer T, Asim A. Unilateral fascia iliaca block (FIB) for post‐operative analgesia in fracture neck of femur surgery; comparison with standard post‐operative analgesia. Pakistan Journal of Medical and Health Sciences 2014;8(4):818‐20. CENTRAL

Hwang 2015 {published data only}

Dickman E, Pushkar I, Likourezos A, Todd K, Hwang U, Akhter S, Morrison S. Ultrasound‐guided nerve blocks for intracapsular and extracapsular hip fractures. Academic Emergency Medicine. 2015; Vol. 22 5 Suppl 1:S133. [CENTRAL: CN‐01080180]CENTRAL
Dickman E, Pushkar I, Likourezos A, Todd K, Hwang U, Akhter S, Morrison S. Ultrasound‐guided nerve blocks for intracapsular and extracapsular hip fractures. The American Journal of Emergency Medicine 2016;34(3):586‐9. [PUBMED: 26809928]CENTRAL
Henderson K, Akhtar S, Sandoval M, Siddiqui S, Todd K, Wirtner A. Femoral nerve block for pain management of hip fractures in the emergency department: preliminary results of a randomised,controlled trial. Annals of Emergency Medicine 2008;52(4):S164. CENTRAL
Hwang U, Todd K, Dickman E, Akhtar S, Morrison S. Emergency department femoral nerve blocks for acute hip fracture pain: a randomised controlled trial. Journal of the American Geriatrics Society 2015;63(Suppl S1):S103. CENTRAL
Todd K, Dickman E, Hwang U, Akhtar S, Morrison R. Emergency department femoral nerve blocks for acute hip fracture pain: a randomised controlled trial. The Journal of Pain 2015;16(4):S68. CENTRAL

Irwin 2012 {published data only}

Irwin M, Mahalingam S, Mills G, Krahe L. Acute pain management for neck of femur fractures: a comparison of the fascia iliaca block versus traditional opiates. British Journal of Anaesthesia 2012;108(Suppl 2):ii422. CENTRAL

Kang 2013 {published data only}

Kang H, Ha YC, Kim JY, Woo YC, Lee JS, Jang EC. Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: a randomized, controlled study. The Journal of Bone and Joint Surgery ‐ American volume 2013;95(4):291‐6. [PUBMED: 23302898]CENTRAL

Kumie 2015 {published data only}

Kumie FT, Gebremedhn EG, Tawuye HY. Efficacy of fascia iliaca compartment nerve block as part of multimodal analgesia after surgery for femoral bone fracture. World Journal of Emergency Medicine 2015;6(2):142‐6. [PUBMED: 26056546]CENTRAL

Mannion 2005 {published data only}

Mannion S, Hayes I, Loughnane F, Murphy DB, Shorten GD. Intravenous but not perineural clonidine prolongs postoperative analgesia after psoas compartment block with 0.5% levobupivacaine for hip fracture surgery. Anesthesia and Analgesia 2005;100(3):873‐8. [PUBMED: 15728081]CENTRAL

Manohara 2015 {published data only}

Manohara S, Lim YC. A randomized, controlled trial comparing analgesic effects of ultrasound‐guided supra‐inguinal fascia iliaca block with femoral nerve block for surgical fixation of hip fractures. Regional Anesthesia and Pain Medicine. 2015; Vol. 40 (5 Suppl 1):e93‐4. [EMBASE: AN: 72027148 ]CENTRAL

Marhofer 1998 {published data only}

Marhofer P, Schrogendorfer K, Wallner T, Koinig H, Mayer N, Kapral S. Ultrasonographic guidance reduces the amount of local anesthetic for 3‐in‐1 blocks. Regional Anesthesia and Pain Medicine 1998;23(6):584‐8. [PUBMED: 9840855 ]CENTRAL

Matot 2003 {published data only}

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]CENTRAL

McRae 2015 {published data only}

McRae P, Bendall JC, Madigan V, Middleton P. Paramedic performed fascia iliaca compartment block (FICB) for femoral fractures: a randomised controlled trial. Australasian Journal of Prehospital Care 2013;10(3):14‐5. CENTRAL
McRae PJ, Bendall JC, Madigan V, Middleton PM. Paramedic‐performed fascia iliaca compartment block for femoral fractures: a controlled trial. The Journal of Emergency Medicine 2015;48(5):581‐9. [PUBMED: 25661312]CENTRAL

Mutty 2007 {published data only}

Mutty CE, Jensen EJ, Manka MA, Anders MJ, Bone LB. Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department. Journal of Bone and Joint Surgery ‐ American Volume 2007;89(12):2599‐603. [PUBMED: 18056490]CENTRAL

Piangatelli 2004 {published data only}

Piangatelli C, De 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]CENTRAL

Reavley 2015 {published data only}

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]CENTRAL

Scheinin 2000 {published and unpublished data}

Scheinin 2015 [pers comm]. Additional information for our trial. Email to: J Guay 25 May 2015. CENTRAL
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]CENTRAL

Schiferer 2007 {published data only}

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]CENTRAL

Segado Jimenez 2010 {published data only}

Segado Jimenez I. Information on our trial [personal communication]. Email to: J Guay 24 April 2016. CENTRAL
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. CENTRAL

Sia 2004 {published data only}

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]CENTRAL

Turker 2003 {published data only}

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]CENTRAL

Van Leeuwen 2000 {published data only}

Van 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]CENTRAL

ACTRN12609000526279 {published data only}

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}

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}

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}

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}

Analgesic effect of a supplemental nerve block in patients with hip fracture. Ongoing study 17/03/2015.

ISRCTN07083722 {published data only}

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}

Femoral nerve blockade in hip fracture patients. Ongoing study 30/03/2009.

ISRCTN75659782 {published data only}

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}

Sahota O, Rowlands M, Bradley J, Van de 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]CENTRAL

NCT00749489 {published data only}

Improving pain and function in hip fracture. Ongoing studyNovember 2008.

NCT01052974 {published data only}

Perioperative analgesia by femoral perineural catheter for femoral neck fracture ‐ Study KTcol. Ongoing studyMarch 2009.

NCT01219088 {published data only}

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 studySeptember 2010.

NCT01547468 {published data only}

Does femoral nerve catheterization reduce the incidence of post‐operative delirium in patients presenting for hip fracture repair?. Ongoing studyMarch 2012.

NCT01593319 {published data only}

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 studyJanuary 2012.

NCT01638845 {published data only}

Hip fracture and perineural catheter. Ongoing studyJune 2012.

NCT01904071 {published data only}

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 studyOctober 2008.

NCT02381717 {published data only}

Comparison of ultrasound guided femoral nerve blockade and standard parenteral opioid pain management alone in patients with hip fracture in the emergency department. Ongoing studyFebruary 2015.

NCT02406300 {published data only}

Contribution of anaesthesia technique for post‐operative mortality reduction after proximal femur fractures surgical treatment ‐ a randomized clinical trial. Ongoing studyApril 2015.

NCT02433548 {published data only}

Fascia iliaca block in the emergency department for analgesia after femoral neck fracture. Ongoing studyOctober 2014.

Auroy 2002

Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier FJ, et al. Major complications of regional anesthesia in France: the SOS Regional Anesthesia Hotline Service. Anesthesiology 2002;97(5):1274‐80. [PUBMED: 12411815]

Berde 2009

Berde CB, Strichartz GR. Local anesthetics (Chapter 30). In: Miller RD, Eriksson LI, Fleisher LA, Wiener‐Kronish JP, Young WL editor(s). Miller's Anesthesia. 7th Edition. London, UK: Churchill Livingstone, 2009.

Brauer 2009

Brauer CA, Coca‐Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA 2009;302(14):1573‐9. [PUBMED: 19826027]

Brull 2007

Brull R, McCartney CJ, Chan VW, El‐Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesthesia and Analgesia 2007;104(4):965‐74. [PUBMED: 17377115]

Cates 2002

Cates CJ. Simpson's paradox and calculation of number needed to treat from meta‐analysis. BMC Medical Research Methodology 2002;2:1. [PUBMED: 11860604]

Cordero 2016

Cordero J, Maldonado A, Iborra S. Surgical delay as a risk factor for wound infection after a hip fracture. Injury 2016;47 Suppl 3:S56‐60. [PUBMED: 27692108]

Cuvillon 2009

Cuvillon P, Nouvellon E, Ripart J, Boyer JC, Dehour L, Mahamat A, 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. Anesthesia and Analgesia 2009;108(2):641‐9. [PUBMED: 19151302]

Deeks 2002

Deeks JJ. Issues in the selection of a summary statistic for meta‐analysis of clinical trials with binary outcomes. Statistics in Medicine 2002;21(11):1575‐600. [PUBMED: 12111921]

Dochez 2014

Dochez E, van Geffen GJ, Bruhn J, Hoogerwerf N, van de Pas H, Scheffer G. Prehospital administered fascia iliaca compartment block by emergency medical service nurses, a feasibility study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014;22:38. [PUBMED: 24957807]

Gozlan 2005

Gozlan C, Minville V, Asehnoune K, Raynal P, Zetlaoui P, Benhamou D. [Fascia iliaca block for femoral bone fractures in prehospital medicine] [Bloc iliofascial en medecine prehospitaliere pour les fractures du femur.]. Annales francaises d'anesthesie et de reanimation 2005;24(6):617‐20. [PUBMED: 15885976]

Guay 2006

Guay J. The benefits of adding epidural analgesia to general anaesthesia: a meta‐analysis. Journal of Anaesthesia 2006;20(4):335‐40. [PUBMED: 17072704]

Guay 2016

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References to other published versions of this review

Parker 2002

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]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Altermatt 2013

Methods

RCT

Approved by the ethics committee and informed consents obtained

Setting: Chile

Funding: unspecified

NCT01961895

Participants

31 older than 60 years, ASA II‐III with risk factors for known coronary artery disease (≥ 2 risk factors for coronary heart disease as defined by Wallace 1987) and hip fracture within 48 hours of fracture

Exclusion criteria: receiving orthopaedic treatment, coagulopathy (clinic or laboratory), sepsis or infection of the catheter insertion site of the lumbar plexus, neurological diseases evolving

Also, disoriented, dementia, chronic renal failure stage IV National Kidney Foundation, glomerular filtration rate between 15 and 29 mL/min/1.73 m2, unable to assess pain, non‐sinus rhythm or conduction abnormalities (right bundle branch block or left atrioventricular block) on admission EKG, with pacemaker, acute coronary syndrome or decompensated cardiovascular disease at entry, allergy to any drugs of the protocol and inability to understand or sign informed consent unaided

Interventions

Treatment group: continuous lumbar plexus started preoperatively and continued for 72 hours after surgery (n = 17)

Control group: IV PCA with morphine (n = 14)

Outcomes

Ischaemic events per participant (extracted as P value): continuous EKG monitoring and serial cardiac enzymes

Notes

Conference abstract. Email sent on 25 May 2015. Study authors responded that the manuscript had not been submitted for publication yet and confirmed the registration number.

They noted no major cardiac events during the entire period of observation

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomized", no details

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Double=blind (participant, caregiver, investigator)

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Double‐blind (participant, caregiver, investigator)

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

No details on participants enrolled

Antonopoulou 2006

Methods

RCT

Setting: Greece

Funding; unspecified

Participants

84 participants (63 female and 21 male) with hip fracture

Interventions

Treatment group: continuous femoral nerve block with 0.125% levobupivacaine at 3‐4 mL/h, started after surgery (n = 49)

Control group: IM pethidine (n = 35)

Spinal anaesthesia and paracetamol after surgery for all participants

Outcomes

Pain scores during 24 hours (not included in analysis)

Notes

No complications such as motor blockade, local haematoma or infection, inadvertent arterial puncture, direct nerve damage and cardiovascular or neurological toxicity

Conference abstract

Email sent on 25 May 2015: no reply

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

"randomized", no details. Unequal groups: 48 and 35

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

No failed block

Five accidental catheter dislodgements ‐ 4 during procedure of securing the catheter, 1 on the ward

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

No details for each group separately

Beaudoin 2013

Methods

RCT

Approved by the ethics committee and written informed consents obtained

Setting: United States of America

Funding: charity

Registered at ClinicalTrials.gov (Identifier NCT01701414)

Participants

36 participants

Eligible: aged ≥ 55 years, radiographically proven femoral neck or intertrochanteric fracture, normal lower extremity neurovascular examination, able to consent and actively participate in the study, moderate to severe pain (numerical pain rating score 5) at time of enrolment

Excluded: known international normalized ratio > 3.0, prior femoral artery vascular surgery on the same side as the fracture, other significant trauma, hypoxia (pulse oximetry < 92%), hypotension (systolic blood pressure < 100 mm Hg), known hypersensitivity to local anaesthetics or morphine

Interventions

Treatment group: ultrasound‐guided femoral nerve block plus subcutaneous morphine (n = 18)

Control group: sham‐injection (3 mL of saline under ultrasound probe over 5 minutes) plus subcutaneous morphine (n = 18)

Outcomes

Pain scores at 15 minutes after the block

Opioids during 4 hours after the block

Notes

One participant in the SC group had an episode of rapid atrial fibrillation requiring diltiazem, but this participant had a history of chronic atrial fibrillation. No other adverse events (respiratory depression, hypotension, nausea or vomiting) were noted during the study period, and no other adverse events were reported to study investigators

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

After consent, participants were randomized by sequentially numbered cards in sealed envelopes

Internet‐based programme with a 1:1 allocation ratio performed by the research department
co‐ordinator, who was not involved in enrolment or data collection

Allocation concealment (selection bias)

Low risk

After consent, participants were randomized by sequentially numbered cards in sealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

"Blinded" with sham injection

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"Blinded" with sham injection

Incomplete outcome data (attrition bias)
All outcomes

Low risk

One participant withdrawn from each group (38 randomized and 36 analysed)

Two patients enrolled (1 in each arm) dropped out after randomization but before the study procedure. No reason provided

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Chudinov 1999

Methods

RCT

Approved by the ethics committee

Setting: Israel

Funding: unspecified

Participants

40 participants (30 female and 10 male) with a hip fracture undergoing surgery

Excluded: patients with severe cardiac, pulmonary, renal or liver dysfunction; systemic infection; decubitus ulcer; dementia; aspirin or anticoagulant treatment; allergy to local anaesthetics
Mean age: 80 years (range 67‐96)

Percentage female: 75%

Lost to follow‐up: none

No details on surgical technique provided

Interventions

Treatment group: psoas compartment block. Chayen's technique with loss of resistance to air (operated side up), using 2 mg/kg/body weight of 0.25% bupivacaine with adrenaline (0.8 mL/kg) and supplementary doses as required via a catheter inserted 2‐3 cm cephalad past the tip of the needle. Blocks were performed before surgery (16‐48 hours), within 6 hours of admission (n = 20). According to assessment, a sciatic nerve block (n = 5), general anaesthesia (n = 1) or spinal anaesthesia (n = 11) was added for surgery. Catheters were kept for 72 hours after surgery

Control group: IM meperidine and diclofenac as required for pain relief (n = 20). Neuraxial block (spinal or epidural n = 19) or general anaesthesia (n =1) for surgery

Outcomes

Pain relief as assessed by VAS at 30 minutes after block placement and at 8, 24, 48 and 72 hours after surgery

Complications of the block: 3 participants showed inflammation at the site of insertion; 1 had epidural spread. Local anaesthetic toxicity: none. No major complications associated with the block

Notes

Length of follow‐up: 72 hours after surgery

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Randomized trial: method not stated

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No failed block. None lost to follow‐up

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

Groups well balanced. No details on surgical technique provided

Coad 1991

Methods

RCT

Approved by the ethics committee and consents obtained

Setting: United Kingdom

Funding: unspecified

Participants

50 participants with a hip fracture undergoing surgery with a pin and plate or a sliding hip screw
Mean age: 77 years (range 64‐89)
Percentage female: 84%
Lost to follow‐up: none

Excluded: receiving analgesic drugs, diagnosis of dementia, regional anaesthesia considered contraindicated

Interventions

Treatment group 1: lateral cutaneous nerve of thigh block with 15 mL 0.5% bupivacaine; Eriksson's technique (n = 17)

Treatment group 2: femoral (3‐in‐1) nerve block with 15 mL 0.5% bupivacaine; Winnie's technique (n = 17)

Control group : IM meperidine (n = 16)

All participants had general anaesthesia consisting of fentanyl, etomidate, vecuronium, nitrous oxide and enflurane
Blocks performed at completion of the operation

Outcomes

No complications related to the blocks

Notes

Length of follow‐up: 24 hours

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Randomized trial: method not stated

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Unclear for participants; nurses administering supplemental analgesia were blinded to the treatment group

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Nurses administering supplemental analgesia were blinded to treatment

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Cuvillon 2007

Methods

RCT

Approved by the ethics committee and written informed consents obtained

Setting: France

Funding: charity

Participants

62 participants with a hip fracture undergoing surgery.
Mean age: 82 years (range not stated).
Percentage female: 86%.

Arthroplasty: 58%
Lost to follow‐up: not stated

Excluded: more than 72 between fracture and surgery, weight < 40 kg, ASA physical status > IV, neurological disease (alcoholic or diabetic), allergy or contraindication to regional anaesthesia, severe hepatic or renal dysfunction, Mini Mental score < 15/30

Interventions

Treatment group: continuous femoral nerve block. Nerve stimulator, 0.3 to 0.5 mA, catheter introduced 10 to 15 cm past needle tip and loaded with 30 mL of lidocaine 1.5% plus epinephrine. Infusion of 0.2% ropivacaine at 10 mL/h for 48 hours (n = 21)

Control groups: intravenous propacetamol 2 G 6‐hourly (n = 21) or subcutaneous morphine 0.05 mg/kg 4‐hourly (n = 20)

Propacetamol and morphine before surgery, spinal anaesthesia for surgery for all participants. Treatment group and propacetamol group participants could also receive morphine after surgery if needed

Outcomes

Pain scores at 8, 24 and 48 hours after surgery

Number of participants who required additional opioids during first 48 hours after surgery

Confusion/somnolence

Transfused

Pressure sores

Mortality at 6 months

Cost of analgesic regimens

Notes

Length of follow‐up: 6 months

Study authors contacted 22 May 2015; no reply

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomized trial: use of numbered envelopes

Allocation concealment (selection bias)

Low risk

Randomized trial: use of numbered envelopes

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

Failed blocked excluded, but no immediate failed block. Four catheter dislodgements; these participants were kept in the analysis (intention‐to‐treat)

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

Groups well balanced except for delay between admission and surgery (median 40 hours in femoral catheter group and 21 and 23,5 hours in the 2 control groups)

De La Tabla 2010

Methods

RCT

Setting: Spain

Funding: unspecified

Participants

49 participants older than 65 years with a neck fracture scheduled for surgical treatment

Interventions

Treatment group: double guidance (ultrasound and nerve stimulator) femoral nerve block with 15 mL of 0.2% ropivacaine followed by infusion of 0.2% ropivacaine at 5 mL/h plus 10 mL every 30 minutes (n = 11)

Control group: intravenous metamizole 2 G every 6 hours (n = 38)

Rescue analgesia with 100 mg tramadol and ondansetron 4 mg

Outcomes

Pain scores at rest and on movement at 24 and 48 hours after surgery

Death at 6 months

Notes

Conference abstract

Additional information on pain scores received from study authors

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

No details and very unequal groups

Allocation concealment (selection bias)

Unclear risk

No details

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No loss to follow‐up mentioned

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Diakomi 2014

Methods

RCT

Approved by the ethics committee and informed consents obtained

Setting: Greece

Funding: unspecified

NCT02037633

Participants

41 ASA I‐III participants, aged 38 to 94 years, scheduled for hip fracture repair

Excluded: contraindications for central nervous blockade, impaired cognition or dementia, multiple fractures, any previous analgesic administration in last 12 hours before surgery

Interventions

Treatment group: fascia iliaca block, modified Dalen's technique with 40 mL ropivacaine 0.5% injected while caudal pressure maintained, then turned lateral (fracture side up) for spinal 20 minutes later (n = 21)

Control group: IV fentanyl 1.5 mcg/kg, then turned lateral (fracture side up) for spinal 5 minutes later (n = 20)

Spinal anaesthesia for surgery. IV PCA with morphine after surgery

Outcomes

Pain at rest and on movement at 20 minutes after the block (or 5 minutes after fentanyl administration; movement = positioning for spinal anaesthesia)

Opioid requirement during first 24 hours after surgery

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Patients were randomly assigned, using a sealed envelope method"

Allocation concealment (selection bias)

Low risk

"Patients were randomly assigned, using a sealed envelope method"

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Pain scores were assessed by a blind observer who entered the operating room only after the analgesic intervention (IV fentanyl administration or fascia iliaca block performance) had taken place. Landmarks were drawn on all participants, and gauze was applied to the “puncture” site for all participants. Each participant was aware of his/her group allocation because we considered a placebo injection in the inguinal area not acceptable. The observer who recorded participant satisfaction was unaware of group allocation and was not involved in any other step of the study

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Pain scores were assessed by a blind observer who entered the operating room only after the analgesic intervention (IV fentanyl administration or fascia iliaca block performance) had taken place. Landmarks were drawn on all participants, and gauze was applied to the “puncture” site for all participants. Each participant was aware of his/her group allocation because we considered a placebo injection in the inguinal area not acceptable. The observer who recorded participant satisfaction was unaware of group allocation and was not involved in any other step of the study

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up. One participant withdrew consent

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Domac 2015

Methods

RCT

Approved by the ethics committee and informed consents obtained

Setting: Turkey

Funding: departmental

Participants

40 ASA I‐III participants aged 65 to 80 years undergoing femoral fracture repair under spinal anaesthesia

Excluded: patients < 65 years of age or > 80 years of age, with peripheral neurological disease, mental

disorders, allergy to amide local anaesthetics, coagulation/haemostasis diseases, moderate or severe liver or kidney failure, contraindication to or refusing fascia iliaca block

Interventions

Treatment group: fascia iliaca block with 15 mL of 0.5% bupivacaine and 15 mL of 2% lidocaine (n = 20)

Control group: no block (n = 20)

Spinal anaesthesia for surgery and IV patient‐controlled analgesia with morphine for postoperative analgesia for all participants

Outcomes

Pain at rest and on movement (positioning for spinal) and after surgery

Opioids requirements for the first 4 and 48 hours

Participant satisfaction

Notes

SD of 0.00 entered as 0.001

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"divided into two equal groups for this prospective double‐blind study", no details

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Participants in control group received no block

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Study is said to be double‐blinded. No sham block reported. Unclear who was the outcome assessor for pain scores

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No drop‐out

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Fletcher 2003

Methods

RCT

Approved by the ethics committee and informed consents obtained

Seeting: United Kingdom

Funding: unspecified

Participants

50 participants with a hip fracture
Mean age: 78 years (range not stated)
Percentage female: 70%
Lost to follow‐up: none

Excluded: confused (and therefore unable to give informed consent), bleeding diathesis or taking warfarin, local or systemic infection, previous hypersensitivity to local anaesthetics

Interventions

Treatment group: femoral (3‐in‐1) nerve block inserted at the time of admission with 20 mL 0.5% bupivacaine, Winnie's technique and 5 minutes distal compression (n = 24)

Control group: intravenous morphine alone (n = 26)

Blocks performed by trained emergency physicians

Outcomes

Pneumonia from chart review at 6 months

Mortality at 6 months

Opioids during first 24 hours after block placement (before surgery)

Notes

Extra information supplied by trialists to confirm secure randomization and that no participants were lost to follow‐up

Length of follow‐up: 6 months.

Study authors re‐contacted 22 May 2015: no reply

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomized trial: use of sealed opaque numbered envelopes with randomization generated by a random number generator

Allocation concealment (selection bias)

Low risk

Randomized trial: use of sealed opaque numbered envelopes with randomization generated by a random number generator

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Participants were not blinded to group allocation because our research ethics committee
considered placebo injection unacceptable. Admitting orthopaedic senior house officer was also unaware of study intervention; therefore, analgesic prescription (although standard at Rotherham) was not influenced by participant allocation. These assessments (pain scores) were made by ward nursing staff blinded to the intervention and were included in regular nursing observations undertaken at these times according to the hospital’s fractured neck of femur protocol

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"blinded assessors"; "the same blinded observer (AKF) abstracted all data"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Foss 2007

Methods

RCT

Approved by the ethics committee and written informed consents obtained

Setting: Denmark

Funding: charity

NCT00162630

Participants

Orthopaedic hospital in Copenhagen, Denmark
48 participants with a hip fracture
Mean age: 80 years (range 69‐88)
Percentage female: 73%
Lost to follow‐up: none

Excluded: refusal to participate in the study, previous surgery in the affected hip, regular prefracture opioid or glucocorticoid therapy, alcohol or substance abuse, infection at the injection site, morphine intolerance, any previous opioid administration for acute pain and non‐confirmation of hip fracture suspicion on x‐ray

Interventions

Treatment group: fascia iliaca compartment blockade with 40 mL 1% mepivacaine and epinephrine based on landmarks to fractured limb with saline injection into the contralateral gluteal region (n = 24)

Control group: saline injection into fractured side at the site of the fascia iliac block and injection of morphine (0.1 mg/kg) into the contralateral gluteal region (n = 24)

After 3 hours, all participants received epidural analgesia

Outcomes

Pain scores at rest and on movement (15‐degree leg raise) 30 minutes after block

Use of supplementary opiates during first 3 hours after block placement

Notes

Length of follow‐up: till 3 hours after the block

No side effects attributable to the fascia iliac block were noted in any participants during their hospital stay

Before block placement, pain at rest was significantly less (P = 0.05) in participants with intracapsular fractures (median 2, (interquartile range (IQR) 0–5)) vs those who had trochanteric (median 4, (IQR 2–5)) or subtrochanteric fractures (median 5, IQR 4–7), but no significant difference in movement‐associated pain between fracture types, which was median 8 (IQR 6.5–10), 9 (IQR 8–10) and 10 (IQR 8–10) for intracapsular, trochanteric and subtrochanteric fractures, respectively

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomized trial: method stated as via a computer‐generated list using treatments prepared by a nurse not involved in collection of participant data

Allocation concealment (selection bias)

Low risk

"the medicine used for each individual patient was prepared by a nurse not otherwise involved with the collection of patient data"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Study was double‐blind

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Study was double‐blind

Incomplete outcome data (attrition bias)
All outcomes

Low risk

One participant did not have a fracture but only a severe contusion and was excluded after x‐ray; an extra participant was therefore included on a new number

Two participants (1 from each group) had protocol violations because they received sufentanil as supplementation instead of morphine; both of these supplementations occurred in the post‐anaesthesia care unit more than 60 minutes after block placement

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

High risk

Groups well balanced except for higher proportion of male participants in the block group. Participants in the block group had higher pain scores on admission (P = 0.04)

Gille 2006

Methods

RCT

Approved by the ethics committee and informed consents obtained

Setting: Germany

Funding: corresponding study author had no relationship with any mentioned product nor competitors, classified as departmental resources

Participants

Orthopaedic hospital in Leipzig, Germany
100 participants with a hip fracture
Mean age: 80 years (range 35‐103)
Percentage female: 77%
Lost to follow‐up: none

Excluded: < 18 years old, uncooperative, contraindications to regional anaesthesia or drugs used in the protocol, long‐term use of opioids and/or opioid dependence, history of ulcers, multiple trauma, absence of consent, anaesthetist inexperienced (fewer than 5) with the technique

Interventions

Treatment group: femoral nerve block with catheter inserted at the time of admission (stitched in place) using 40 mL 1% prilocaine, then 30 mL 0.2% ropivacaine 6‐hourly (n = 50)

Control group: no injection (n = 50)

Operated 14 hours after admission. All participants had ibuprofen every 8 hours after surgery

Outcomes

Pain score on a scale of 1 to 5 (least pain level 1) at rest and passive movement (30 degrees anteflexion) 30 minutes after insertion of the block and at 24, 48 and 72 hours after surgery

No severe complications related to analgesia: more specifically, no infection at insertion points of the catheters. 10 catheters were dislodged. No significant respiratory depression due to opioids, no allergic reactions

Notes

Length of follow‐up: until discharge from orthopaedic ward

Extra information regarding method of randomization and length of follow‐up supplied by trialists

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomized by anaesthesiologists called to the emergency room: "Sealed envelopes: information from the authors to previous reviewers"

Allocation concealment (selection bias)

Low risk

Sealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

20% rate of catheter dislodgement, resulting in the need for systemic analgesia

Unclear whether participants with dislodged catheters were included in pain scores in their treatment group

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced, including similar admission pain scores (2.50 and 2.46 at rest and 4.30 and 4.34 on movement)

Godoy 2010

Methods

RCT

Approved by the ethics committee and signed informed consents obtained

Setting: Argentina

Funding: unspecified

Participants

154 adult participants > 65 years old who presented to the emergency department because of a previously
undiagnosed and untreated hip fracture
Excluded: anatomical abnormalities in the inguinal area different from fracture, known coagulation disorders, history of allergy to any of the active ingredients used during the study, refusal to participate

Interventions

Treatment group: fascia iliaca compartment block with 0.3 mL/kg 0.25% bupivacaine and 5 mL 5% dextrose (n = 92)

Control group: normal saline in the fascia iliaca compartment and IV non‐steroidal anti‐inflammatory drugs (diclofenac or ketorolac) (n = 62)

Outcomes

Pain scores at rest at 15 minutes after block placement

Confusion

Notes

Protocol included observing participants for 8 hours

The only complications were local bruises at the site of injection

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants randomized into 2 groups (A and B) with numbers generated by the EPI‐INFO™ (Atlanta, GA: Centers for Disease Control and Prevention) programme

Allocation concealment (selection bias)

Low risk

Randomization list was kept by one of the study authors who did not interact with participants. He gave instructions to participants’ ED nurse about which treatment should be administered

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Nurse prepared the medication according to physician’s instructions and assigned a letter to the protocol (from a set of 10 letters: 5 for group A and 5 for group B) that designated whether the participant was receiving active medications in the fascia‐iliaca block. The physician administering medications and obtaining VAS scores did not know which medications the participant was
receiving. The treating nurse was aware of the randomization group

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

The physician administering the medications and obtaining the VAS scores did not know which medications the participant was receiving

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

In all, 175 participants were randomized upon presentation to the ED. A total of 21 were excluded from participation (1) because they or their legal decision‐maker declined to participate, (2) owing to systemic or laboratory abnormalities that interfered with their participation or (3) because they were subsequently found to have missing data (pain scores not recorded or incomplete vital signs on scheduled measurements)

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Graham 2008

Methods

RCT

Approved by the ethics committee and informed consents obtained

Setting: China

Funding: unspecified

Participants

40 adult participants (> 16 years of age) with adequate Mini Mental tests and hip fracture confirmed by x‐ray

Excluded: known allergy or contraindication to morphine or bupivacaine, Mini Mental test score < 9

Interventions

Treatment group: femoral (3‐in‐1) nerve block with 30 mL 0.5% bupivacaine (not exceeding 3 mg/kg) (n = 18; 15 analysed)

Control group : IV morphine 0.1 mg/kg (n = 22; 18 analysed)

Intravenous morphine 0.1 mg/kg bolus as required 2‐ to 4‐hourly, oral dihydrocodeine 30‐60 mg 4‐hourly as required (maximum 240 mg per 24 hours), rectal diclofenac 50 mg 8‐hourly as required (maximum 150 mg per 24 hours), oral paracetamol 1 G 4‐ to 6‐hourly (maximum 4 G per 24 hours)

Outcomes

Pain scores at 30 minutes after block placement

Confusion 24 hours after block placement or to surgery (whichever came first)

Opioids used in 24 hours or to surgery (whichever came first)

Notes

No immediate complications in either group, defined as inadvertent vascular puncture, anaphylaxis or collapse, severe pain or inability to tolerate the procedure for the femoral block group and anaphylaxis or collapse, respiratory depression or requirement for naloxone use within 1 hour of IV morphine administration for the systemic analgesia group

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Patients were then randomized using numbered, sequential, sealed opaque envelopes"

Allocation concealment (selection bias)

Low risk

"Patients were then randomized using numbered, sequential, sealed opaque envelopes"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Open‐label trial

Blinding of outcome assessment (detection bias)
All outcomes

High risk

Open‐label trial

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Seven participants had incomplete data

One participant in the morphine group was unable to complete the study owing to development of an acute confusional state. Full data were unavailable for 3 other participants in the IV morphine group owing to incomplete data collection post intervention. Within the '3‐in‐1' nerve block group, 1 participant was found to have an impalpable femoral artery on the side of the hip fracture after randomization and was unable to receive a nerve block owing to lack of anatomical landmarks. Full data were unavailable for 2 other participants owing to incomplete data collection post intervention. Full results were available for 33 participants: 18 in the morphine group and 15 in the femoral nerve block group

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

Groups well balanced

Data were not analysed in intention‐to‐treat

Haddad 1995

Methods

RCT

Setting: United Kingdom

Funding: unspecified

Participants

Orthopaedic hospital in Stevenage, UK
50 participants with an extracapsular hip fracture
Mean age: 77 years (range 68‐89)
Percentage male: 30%
Lost to follow‐up: none

Excluded: dementia, unable to rate their pain

Interventions

Treatment group: femoral nerve block inserted at the time of admission using 0.3 mL/kg 0.25% bupivacaine (n = 25)

Control group: no injection (n = 25)

Outcomes

Pneumonia

Mortality

Wound infection

Pressure sores

No local or systemic complications of femoral nerve blocks

Notes

Length of follow‐up: 24 hours for analgesia, unclear for other outcomes ("short term"; taken as in hospital)

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Sealed envelopes

Allocation concealment (selection bias)

Low risk

Sealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No placebo injections used

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Admitting house surgeons and nursing staff who administered analgesia were unaware to which group participants had been allocated

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

One failed block; data included

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Hood 1991

Methods

RCT

Approved by the ethics committee and written informed consents obtained

Setting: United Kingdom

Funding: unspecified

Participants

Orthopaedic hospital in Sheffield, UK
50 participants with a hip fracture surgically treated with a pin and plate or a compression screw
Mean age: 81 years (range 62‐94)
Percentage female: 88%
Lost to follow‐up: 1 (2%)

Excluded: absolute contraindication to a regional technique, allergy to local anaesthetic agents, systemic disease that indicated an alternative method of anaesthesia

Interventions

Treatment group: femoral (triple nerve block) nerve block with 35 mL 0.75% prilocaine and infiltration above the iliac crest with 8 mL 0.75% prilocaine inserted before induction of anaesthesia (n = 25)
Control group: no blocks (control) (n = 25)
All participants had general anaesthesia using alfentanil, etomidate, nitrous oxide, isoflurane

Outcomes

Death

Notes

Length of follow‐up: 24 hours

No untoward sequelae were associated with nerve blocks. Venous blood for plasma prilocaine levels in the first 12 participants in group 2 was taken from an indwelling cannula at 0, 5, 10, 15, 20, 25, 30, 45 and 60 minutes after completion of the prilocaine injection. Concentrations were measured using gas chromatography. Cmax occurred no later than 25 minutes. Methemoglobin levels were not mentioned

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Use of 'unmarked envelopes'

Allocation concealment (selection bias)

Low risk

Use of 'unmarked envelopes'

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

All participants were prescribed intramuscular papaveretum 0.2 rng/kg; administration was done at the discretion of the nursing staff, who were unaware of participant groups. All participants had their skin prepared and an elastoplast placed over the possible injection site to minimize bias. Unclear for participants: blocks performed before induction of general anaesthesia

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

All participants were prescribed intramuscular papaveretum 0.2 rng/kg; administration was done at the discretion of the nursing staff, who were unaware of participant groups. All participants had their skin prepared and an elastoplast placed over the possible injection site to minimize bias

The operating theatre recovery sister and ward staff, who were blind to participant groups, were asked to assess the quality of analgesia after the operation

Incomplete outcome data (attrition bias)
All outcomes

Low risk

One participant lost to follow‐up

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Iamaroon 2010

Methods

RCT

Approved by the ethics committee and written informed consents obtained

Setting: Thailand

Funding: unspecified

Participants

64 ASA I–III participants aged 18–80 years undergoing surgery for femur fracture with body weight > 50 kg and scheduled for surgery under spinal block

Excluded: multiple fractures, peripheral neuropathy, bleeding disorders, mental disorders, communication failure, allergy to local anaesthetics, use of analgesics for premedication

Interventions

Treatment group: femoral nerve block with a nerve stimulator and 20 mL bupivacaine 0.5% and 10 mL saline 15 minutes before positioning for the spinal (n = 32)

Control group: 2 doses of IV fentanyl 0.5 mcg/kg (n = 32)

During positioning for the spinal (lateral position with the fracture site up), fentanyl in 0.5 mcg/kg increments was given every 5 minutes until pain scores were < or = 4

Outcomes

Pain scores at rest and on movement (positioning for the spinal) 15 minutes after block placement

No adverse systemic toxicity of bupivacaine, such as seizure, arrhythmia or cardiovascular collapse, was noted in the femoral nerve block group. Neither vascular puncture nor paraesthesia occurred. No complications, such as haematoma, infection or persistent paraesthesia, were observed within 24 hours after the operation. No participant in either group had hypoventilation (ventilatory rate < 10/min) or oxygen saturation < 95%

Notes

Although the vast majority of participants had a proximal fracture, 10 participants had a shaft (6 participants for the femoral nerve block and 1 for the control) or a distal (3 participants in the control group) fracture. The only outcomes retained in the analysis were pain scores. Pain scores at rest and on movement after block placement were finally excluded because we thought that measurement was done before the block could be effective (please see Results)

An email was sent on 17 March 2016, to obtain data separately for participants with a proximal fracture. No reply

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were allocated by computer‐generated random numbers into 2 groups of 32 participants each

Allocation concealment (selection bias)

Low risk

The random allocation sequence was concealed in opaque, sealed envelopes until a group was assigned

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Not blinded: "All patients were aware of their treatment group allocation"

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Blinded: "Assessors of pain were blinded to the patients’ allocated treatment group"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

No failed block reported

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

Groups well balanced except that time from trauma to surgery was significantly longer in the fentanyl group than in the FNB group (P = 0.03) and most participants in the FNB had femoral neck fractures, whereas most of those in the fentanyl group had intertrochanteric fractures (P = 0.04)

Jadon 2014

Methods

RCT

Insitutional approval and informed consents obtained

Participants

Included: patients of both sexes, 18–70 years, weight > 50 kg, American Society of Anesthesiologists physical status I‐III, scheduled for fracture femur operation under central neuraxial block but unable to sit because of pain

Excluded: could sit comfortably, any contraindication to spinal anaesthesia, FNB or local anaesthetic

Interventions

Treatment group: femoral nerve block with 20 mL lidocaine 1.5% (15 mL lidocaine 2% and 5 mL distilled water) with epinephrine 5 mcg/mL, nerve stimulator, quadriceps response at 0.3‐0.5 mA, insulated 50 mm 22 G needle (n = 23)

Control group: fentanyl 1.0 mcg/kg IV (n = 21)

Positioning for spinal 5 minutes after block placement or IV fentanyl. Additional fentanyl 0.5 mcg/kg every 5 minutes in both groups allowed if VAS scores ≥ 4 until VAS scores < 4 or a maximal dose of 3 mcg/kg (whichever came first). No participant required an additional dose of fentanyl

Outcomes

Pain scores on movement (positioning for the spinal) 5 minutes after block placement (scale 0‐10)

Notes

Study also includes participants with shaft fracture. We obtained results for pain scores on movement for participants with proximal fracture only from the study authors. However, we did not keep results in the analysis (see Effects of interventions) owing to the short delay between the block and the evaluation

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Patients were distributed in two groups through computer generated random numbers table"

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up. For 2 participants from each group, surgery was postponed owing to infection at the surgical site and a change in the surgical plan. One participant from each group was excluded owing to refusal for spinal anaesthesia on the table after initial consent. Therefore, 6 participants were subsequently excluded, leaving 60 participants for final analysis

All participants for whom a pain score could be obtained during spinal positioning had their score analysed within their assigned group

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

"Demographic data and type of surgery were comparable in both the groups"

Jones 1985

Methods

RCT

Informed consents obtained

Setting: United Kingdom

Funding: unspecified

Participants

Orthopaedic hospital in London, UK
19 participants with an extracapsular hip fracture treated with a pin and plate or a sliding hip screw
Mean age: 82 years (range 67‐93)
Percentage female: 95%
Lost to follow‐up: none

Excluded: other painful lesions, signs of moderate or severe dementia, < 65 years of age, systemic disease indicating an alternative method of anaesthesia (e.g. spinal)

Interventions

Tretament group: lateral cutaneous nerve of thigh block with 15 mL 0.5% bupivacaine and adrenaline (n = 10)
Control group: no block (control) (n = 9)

All participants had general anaesthesia with fentanyl, thiopentone, suxamethonium, nitrous oxide, halothane. Blocks performed at completion of surgery

Outcomes

Death (24 hours)

Notes

One participant died within 24 hours of surgery, and results for this participant were not given

Length of follow‐up: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

'Random envelopes'

Allocation concealment (selection bias)

Low risk

'Random envelopes' opened at completion of surgery

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Postoperative analgesia was prescribed before allocation to respective groups, with administration performed at the discretion of the nursing staff, who were unaware of whether a block had been performed. The dose of pethidine was 25 or 50 mg intramuscularly, depending on the participant's estimated weight ‐ not on general condition

Incomplete outcome data (attrition bias)
All outcomes

Low risk

One lost to follow‐up

Results for 1 participant who died are not included: "One patient in Group 2 who died within the 24‐hour period is not included in analysis of the results: there are thus nine patients in each group"

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Kullenberg 2004

Methods

RCT

Setting: Sweden

Funding: no conflict of interest declared, classified as departmental resources

Participants

Orthopaedic hospital in Sweden
80 participants with a hip fracture
Mean age: 82 years (range not stated)
Percentage female: 64%
Lost to follow‐up: not stated

Excluded: inability to rate their pain

Interventions

Treatment group: femoral nerve block inserted at the time of admission with 30 mL ropivacaine (7.5 mg/mL) (n = 40). Mean bock duration 15.8 ± 5.6 hours. Four participants had their block during transportation to the hospital. The block was repeated for 3 participants owing to a long delay before surgery (23.9 hours, 26.3 hours and 30.9 hours)

Control group: no injection (n = 40)

Outcomes

Confusion (Pfeiffer test, graded according to a 4‐degree scale (0‐3: no, light, moderate and pronounced confusion) at 48 hours

Time to first mobilization

Pressure sores

Opioids used per 24 hours

Notes

Length of follow‐up: length of acute hospital stay (mean 11 days)

No complication related to the nerve block

All participants indicated that they would consider a new future blockade if this would be necessary

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Use of sealed envelopes

Allocation concealment (selection bias)

Low risk

Use of sealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

Five failed blocks; participants kept in their treatment groups

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

Groups well balanced except for a longer delay in arrival to surgery for the block group (15.5 hours vs 5.8 hours)

Luger 2012

Methods

RCT

Approved by the ethics committee and written informed consents obtained

Setting: Austria

Funding: departmental resources

Participants

Included: 37 very elderly participants (> 80 years) with hip fractures (of whom 3 with dementia had to be excluded) scheduled for surgery under spinal anaesthesia

Excluded: score < 18 on the Mini‐Mental State Examination, surgery did not take place within 36 hours, known intolerance or allergies to drugs, planned or required general anaesthesia, refusal of consent, participation in a different study, administration of midazolam as premedication, chronic pain, contraindications and spinal anaesthesia failure, incomplete data records

Interventions

Treatment groups: ultrasound‐guided continuous femoral (3‐in‐1) nerve block with bupivacaine (n = 10)

Control group: systemic analgesia with IV/SC piritramide and IV paracetamol (n = 10)

Outcomes

Pain scores at rest and on movement at 24 hours after surgery

Opioids at 24 hours after surgery

Number of participants with postoperative myocardial ischaemia

Notes

Study also includes a group with epidural analgesia ‐ not retained in this review

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"The patients were randomized according to a computer‐generated randomization list"

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No drop‐out for the 2 included subgroups

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups comparable

Mossafa 2005

Methods

RCT

Setting: Iran

Funding: unspecified

Participants

40 participants with femoral neck fracture

Interventions

Treatment group: fascia iliaca block with 20 mL 1.5% lidocaine (n = 20)

Control group: IV fentanyl 1.5 mcg/kg (n = 20)

Lateral decubitus position for spinal anaesthesia

Outcomes

Pain on movement 5 minutes after block placement (positioning for spinal)

Participant satisfaction

Notes

Conference abstract

Email sent on 26 May 2015; no reply

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"Randomized", no details

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

No details

Mouzopoulos 2009

Methods

RCT

Approved by the ethics committee and signed informed consents obtained

Setting: Greece

Funding: unspecified

Participants

207 participants aged 70 years or older at intermediate or high risk of delirium scheduled for hip fracture repair

Risk classification was based on the presence of 4 predictive risk factors (severity of illness, measured by acute physiology age and chronic health examination; cognitive impairment, measured by the mini‐mental state examination score; index of dehydration, measured by the ratio of blood urea nitrogen to creatinine; and visual impairment, measured by the standardized Snellen test) as described by Inouye. Intermediate risk for postoperative delirium was defined as the presence of 1 or 2 risk factors; high risk was defined as the presence of ≥ 3 risk factors

Excluded: delirium at admission, metastatic hip cancer, history of bupivacaine allergy, use of cholinesterase inhibitors, severe coagulopathy, parkinsonism, epilepsy, levodopa treatment, delayed surgery more than 72 hours after admission, inability to participate in interviews (profound dementia, respiratory isolation, intubation, aphasia, coma or terminal illness)

Interventions

Treatment group: fascia iliaca block with bupivacaine 0.3 mL/kg (0.25%?) repeated daily until delirium or surgery and at 24 hours after surgery, and daily until delirium or discharge (n = 108 randomized; n = 102 analysed)

Control group: placebo medication (water for injection) identical in appearance to the active drug and administered at the same site and in the same way (n = 111 randomized; n = 105 analysed)

Intravenous and intramuscular analgesics were administered as needed in both groups

Outcomes

Confusion (Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM‐IV) and Confusion Assessment Method criteria)

No complications of fascia iliaca block administration report, except 3 local haematomas developed at the injection site, which resolved spontaneously. Exact number of blocks performed was not specified

Notes

Reduction was seen only in participants at intermediate risk of developing delirium ‐ not among those at high risk

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"sequentially randomly assigned" "according to a computer‐generated randomization code"

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

"All participants were blinded to the treatment group." "Placebo medication (water for injection) was identical in appearance to the active drug and was administered at the same site and in the same way as the fascia iliaca block was injected." However, no clear mention of blinding of personal taking care of participants

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not really clear

Incomplete outcome data (attrition bias)
All outcomes

Low risk

A total of 12 participants were further excluded from both groups for different reasons: 6 lost to follow‐up, 3 refused further participation and 3 died (2 pulmonary embolism and 1 stroke) between second and fourth days of admission

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

Groups well balanced

Not in intention‐to‐treat

Murgue 2006

Methods

RCT

Informed consents obtained

Setting: France

Funding: unspecified

Participants

Orthopaedic hospital in Feurs, France
30 participants with a hip fracture
Mean age: 86 years (range 70‐96)
Percentage female: 82%
Lost to follow‐up: none

Excluded: inability to rate their pain (Mini Mental score < 24), contraindication to nitrous oxide, regional anaesthesia, allergy to study drugs, renal dysfunction or prefracture opioid treatment

Interventions

Treatment group: femoral nerve block inserted at the time of admission with 20 mL mepivacaine (n = 16)

Control groups: no injection. IV morphine (n = 14) or IV paracetamol and ketoprofen (n = 15). We retained only the IV morphine group as the control group

All participants received nitrous oxide for withdrawal of clothing on arrival

Outcomes

Pain score on VAS at movement (x‐ray): 20 minutes after block placement

Notes

Length of follow‐up: duration of time in emergency department

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Hat drawing

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

Failed block (defined as pain scores > 4/10 at skin traction installation) 18.7%. Results included in treatment group

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Nie 2015

Methods

RCT

Approved by the ethics committee and written informed obtained

Setting: China

Funding: governmental

Open reduction and internal fixation surgery with the antirotation proximal femoral nail technique

Participants

104 participants scheduled for open reduction of hip fracture

Excluded: neuropathy involving lower extremities, bladder dysfunction, coagulopathies, known allergy to amide local anaesthetic drugs or opioids, inability to co‐operate, psychological disorders or linguistic difficulties that could interfere with pain assessment

Interventions

Treatment group: fascia iliaca block (n = 51)

Control treatment: intravenous patient‐controlled analgesia (n = 53)

General anaesthesia with fentanyl, remifentanil, propofol and atracurium for surgery and flurbiprofen 40 mg at completion of surgery, plus acetaminophen and dihydrocodeine or morphine on request as rescue analgesia for all participants

Outcomes

Pain at 2, 4, 6, 12, 24 and 48 hours after surgery (taken as at rest)

Acute confusional state (time point unspecified, participants screened daily; length of hospital stay 23 and 21 days for fascia iliaca and IV groups, respectively)

Opioid consumption up to 48 hours

Participant satisfaction (92.5% of participants receiving a fascia iliaca block were satisfied vs 94.3% of participants receiving IV analgesia)

Notes

Additional information received from study authors

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Randomly assigned according to a computer‐generated random number table"

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

High risk

"Blinding could not be conducted due to differences in the analgesia procedures and
infusion pumps used"

Blinding of outcome assessment (detection bias)
All outcomes

High risk

"Blinding could not be conducted due to differences in the analgesia procedures and
infusion pumps used"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

"Patients who underwent the full protocol were included in the analysis"

2 participants withdrawn from fascia iliaca group owing to catheter failure

Selective reporting (reporting bias)

Unclear risk

All results mentioned in methods section given in results section, except preoperative and postoperative mini‐mental state examination. We contacted study authors who informed us that Mini Mental tests were not "collected"

Other bias

Unclear risk

Groups well balanced. Prophylaxis against nausea and vomiting given to IV group only

Not in intention‐to‐treat

Segado Jimenez 2009

Methods

RCT

Approved by the ethics committee and informed consents obtained

Setting: Spain

Funding: unspecified

Participants

75 participants undergoing hip fracture repair under spinal anaesthesia

Excluded: general anaesthesia or intravenous administration of analgesics intraoperatively, pretreatment for chronic pain, or for ischaemic heart rhythm disorders, neurodegenerative and psychiatric diseases, lack of collaboration and/or understanding of the participant, allergy to local anaesthetics and contraindications for regional anaesthesia

Interventions

Treatment group: femoral cutaneous and obturator nerve block (n = 25) or obturator nerve block only (n = 25). Blocks were performed after the spinal had worn off

Control group: intravenous analgesia (n = 25)

For all groups, investigators administered additional intravenous analgesia according to participants' demands (if VAS scores ≥ 3): metamizole 2 G or dexketoprofen trometamol 50 mg IV up to every 8 hours (depending on allergies). If pain persisted, tramadol 100 mg and metoclopramide 10 mg IIV every 8 hours was added.
In addition, if needed, 0.5 mg/kg morphine chloride was used as a rescue

Outcomes

Drug expenses

Time to first mobilization (sitting)

Participant satisfaction (score from 1 to 5; 1 = bad, 2 = regular, 3 = good, 4 = very good and 5 = excellent)

Opioids during first 48 hours after surgery

Participant satisfaction (score from 1 to 5; 1 = bad, 2 = regular, 3 = good, 4 = very good and 5 = excellent)

"We did not observe any complication in the realization of locoregional techniques during or subsequent to the locoregional technical"

Notes

Email sent on 26 May 2015; no reply

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomly distributed", no details

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Triple blinded

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Triple blinded

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing results

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section are given in results section

Other bias

Low risk

Groups well balanced

Spansberg 1996

Methods

RCT

Approved by the ethics committee and informed consents obtained

Setting: Denmark

Funding: unspecified

Participants

20 participants with a hip fracture surgically treated
Mean age: 81 years (range 58‐91)
Percentage female: unclear
Lost to follow‐up: none

Interventions

All participants had spinal anaesthesia with 3.5 mL 0.5% bupivacaine
Postoperatively, participants received:
Treatment group: femoral nerve block with 0.4 mL/kg bolus of 0.5% bupivacaine, then infusion of 0.14 mL/kg/h 0.25% bupivacaine for 16 hours (n = 10)

Control group: saline infusion for 16 hours of same volume of fluid (control) (n = 10)

Regular aspirin administration and IM morphine on demand

Outcomes

Opioids used during first 18 hours after surgery

No haematomas at the site of femoral catheters. Length of follow‐up unspecified

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomized by a computer after surgery

Allocation concealment (selection bias)

Low risk

Adequate

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Placebo‐controlled study: participants, recovery staff and observers were blind to the solution used

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Placebo‐controlled study: participants, recovery staff and observers were blind to the solution used

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

Nine of 10 participants receiving bupivacaine were analgesic to pin prick in the distribution of all 3 nerves. The other participant was analgesic only in the distribution of the lateral femoral cutaneous nerve of the thigh

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

Szucs 2012

Methods

RCT

Approved by the ethics committee and written informed consents obtained

Setting: Ireland

Funding: unspecified

Participants

24 participants presenting with fractured neck of femur, ASA I‐III and aged > 50 years
Excluded: participant refusal, presence of more than 1 fracture; Mini‐Mental Score < 22; coagulation disorders; head injury; loss of consciousness; 10 mg or more morphine administration pre‐hospital; acute intercurrent heart disease; allergy to bupivacaine, morphine or paracetamol; skin lesions/infection at block site; renal dysfunction, evidence of systemic infection (clinically defined or elevated C‐reactive protein levels, leucocytosis or body temperature > 37.8°C)

Interventions

Treatment group : continuous femoral nerve block with bupivacaine 0.25% for 72 hours (n = 12)

Control group: IM morphine (n = 12)

All participants received paracetamol regularly and parenteral morphine up to 0.1 mg/kg IM 4‐hourly as required

Outcomes

Pain at rest and on passive movement (30 degrees flexion) at 30 minutes after block placement

Participant satisfaction

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"random number sequence and sealed envelopes"

Allocation concealment (selection bias)

Low risk

"random number sequence and sealed envelopes"

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Three participants were excluded for the following reasons: (1) elastomeric pump failure resulting in local anaesthetic administered over less than 54 hours instead of 72 hours, (2) participant confusion with subsequent pump disconnection after 12 hours, (3) late diagnosis of a complicating acetabular fracture

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

Groups well balanced

Not in intention‐to‐treat

Tuncer 2003

Methods

RCT

Approved by the ethics committee and informed consents obtained

Setting: Turkey

Funding: unspecified

Participants

Orthopaedic hospital in Konya, Turkey
40 participants with a hip fracture undergoing surgery for a trochanteric hip fracture
Mean age: 59 years (range not stated)
Percentage male: not stated
Lost to follow‐up: none

Excluded: coagulation abnormality, age < 18 or > 80 years, weight < 50 or > 100 kg, known allergy to bupivacaine or opioids, previous analgesic treatment with opioids, inability to understand pain scales or use a patient‐controlled analgesia device

Interventions

All participants had general anaesthesia with fentanyl, propofol atracurium, nitrous oxide, isoflurane. At completion of the operation, participants had:

Treatment group: femoral (3‐in‐1) nerve block with 30 mL 2% lidocaine with 2% epinephrine 1:200,000, followed by continuous infusion with 0.125% bupivacaine for 48 hours (n = 20)

Control group: patient‐controlled analgesia with morphine (control) (n = 20)

Outcomes

Participant satisfaction (rated as excellent, good, moderate or poor; we attributed scores from 1 to 4 to compare the data)

Notes

Length of follow‐up: 48 hours

Email sent to study authors on 24 May 2015, to ask for additional information; no reply

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Randomized at completion of surgery, method unspecified

Allocation concealment (selection bias)

Low risk

Randomized after inclusion

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Two missing results for participant satisfaction

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

White 1980

Methods

RCT

Consents obtained

Setting: South Africa

Funding: unspecified

Participants

Orthopaedic hospital in Cape Town, South Africa
40 participants with a hip fracture undergoing surgery
Mean age: 79 years (range not stated).
Percentage female: 81%
Lost to follow‐up: none

Excluded: fracture sustained more than 8 days before admission; < 60 years old; absolute contraindication to a regional technique, such as localized sepsis, suspicion of bacteraemic process or patients receiving anticoagulant therapy; overt or suspected endocrine disorder other than diabetes mellitus

Interventions

Treatment groups: psoas block (n = 16) or spinal (n = 20) plus 'light" general anaesthesia using althesin, nitrous oxide

Control group: general anaesthesia with fentanyl, thiopentone, suxamethonium, nitrous oxide, halothane (n = 20)

Outcomes

Confusion

Pneumonia

Mortality

Notes

Length of follow‐up: 4 weeks

Four of 20 participants allocated to receive psoas nerve block failed to achieve a satisfactory block; outcome for these participants was not given (other than for mortality)

No participant showed evidence of toxicity to the local anaesthetic

Trial also includes a group with spinal (n = 20) added to light general anaesthesia

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomly allocated", no details

Allocation concealment (selection bias)

Unclear risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Four failed psoas compartment blocks, no other losses to follow‐up

Selective reporting (reporting bias)

Low risk

All measurements mentioned in methods section given in results section

Other bias

Unclear risk

Groups well balanced, except for preoperative pneumonia: 1 in the psoas compartment block and 4 in the group general anaesthesia alone

Not in intention‐to‐treat

Yun 2009

Methods

RCT

Approved by the ethics committee and written informed consents obtained

Setting: Korea

Funding: unspecified

Participants

40 ASA physical status I–III participants aged 62–88 years with isolated femoral neck fracture

Excluded: known allergy to amide local anaesthetics, haemorrhagic diathesis, peripheral
neuropathy, mental disorders

Interventions

Treatment group: fascia iliaca with 30 mL 0.375% ropivacaine (n = 20)

Control group: IV alfentanil 10 mcg/kg followed by 0.25 mcg/kg/min starting 2 minutes before spinal (n = 20)

Participants were moved to the operating suite for the spinal 20 minutes after block placement. Spinals were performed in lateral decubitus position on the side best tolerated by the participant. When a participant reported a VAS 4 during this positioning, the procedure was stopped, and 100 mg of IV alfentanil was administered in both groups

Outcomes

Pain scores on movement at 30 minutes after block placement (positioning for spinal anaesthesia) and at rest at 6 and 24 hours after surgery

Participant satisfaction (yes/no: 1 = good (if necessary, I would repeat the procedure) and 2 = bad (I would never repeat the procedure again))

Opioids at 24 hours

No adverse systemic toxicity of ropivacaine was noted, and neither vascular puncture nor paraesthesia was elicited in the fascia iliaca block group. No complications, such as haematoma or persistent paraesthesia, were observed in participants with a fascia iliaca block within 24 hours after the operation

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Randomly assigned, using an allocation sequence (which was generated by Y. H. Kim using a computer)"

Allocation concealment (selection bias)

Low risk

"The random allocation sequence was concealed until group was assigned (by J. W. Hwang)"

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

None lost to follow‐up

No failed block mentioned. 40% (8 of 20) of participants had a complete block (3 nerves) and 60% (12 of 20) had blockade of 2 nerves (lateral femoral cutaneous and femoral)

Selective reporting (reporting bias)

Low risk

All results mentioned in methods section given in results section

Other bias

Low risk

Groups well balanced

ASA: American Society of Anesthesiologists physical status

DSM: Diagnostic and Statistical Manual of Mental Disorders

ECG or EKG: electrocardiogram

ED: emergency department

FNB: femoral nerve block

G: gram

h: hour

IM: intramuscular

IV: intravenous

IQR: interquartile range

mcg: microgram

mg: milligram

mL: millilitre

n: number

PCA: patient‐controlled analgesia

RCT: randomized controlled trial

SC: subcutaneous

VAS or VRS: = visual or verbal analogue/response scale

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Bech 2011

Different intervention: local anaesthetic infiltration

Bölükbasi 2013

No outcome of interest. Conference abstract. Not enough details on possible outcomes of interest in the abstract. Study authors contacted on 25 May 2015. Confirmed that they were the authors of the abstracts but did not provide requested information

Durrani 2013

Different population. 47 proximal fractures, 28 shaft fractures and 9 distal fractures. Mean age 42 years. Email sent 17 March 2016, to request separate data for participants with a proximal fracture. No reply

Foss 2005

Different intervention: epidural analgesia

Fujihara 2013

Not randomized: "The included patients were assigned to one of two groups in alternating order"

Ghimire 2015

Different intervention. Comparison between fascia iliaca block and femoral nerve block for positioning for spinal anaesthesia

Gorodetskyi 2007

Different intervention. This was a randomized study of 60 participants with a trochanteric hip fracture fixed with a sliding hip screw or a trochanteric external fixator. After surgery, participants were randomized to an active non‐invasive interactive neurostimulation device or to a sham device. The active device generated biphasic electrical impulses. Participants allocated to the active group had a reduced level of pain, a reduced analgesic requirement and a greater range of flexion of the injured limb. We excluded the study as it was not a study of nerve blocks

Hussain 2014

Different intervention. The amount of local anaesthetic used (bupivacaine 12.5 mg/kg of body weight) exceeds recommendations

Hwang 2015

No outcome of interest at our selected time points (a study may be legitimately excluded if outcomes of interest were not measured; Higgins 2011 Section 5.4.1). Here, pain intensity was measured at 2 and 3 hours after block placement only from the results of 2 conference abstracts for this study, and at 1, 4 and 24 hours after block placement in the third abstract. The third abstract also reported absence of a difference in opioid consumption "during the course of the study (no specific time point mentioned for this outcome) on preliminary results:12.0 mg of morphine equivalent (6 participants) versus 12.9 mg for the control group (8 participants); P value 0.88." This result was not retained in the analysis. Adding it would not change the conclusions for opioid consumption standardized mean difference ‐0.71 (95% confidence interval ‐0.94 to ‐0.48); I2 statistic = 44%, with this result vs standardized mean difference ‐0.77 (95% confidence interval ‐0.98 to ‐0.56); I2 statistic = 30% without. No complications were recorded in either group

Irwin 2012

Retrospective study

Kang 2013

Different intervention: local anaesthetic infiltration

Kumie 2015

Not a RCT. Single‐institution case control study

Mannion 2005

Different intervention. This was a randomized trial of 36 participants who were having hip fracture surgery. All participants had a psoas block and general anaesthesia. Participants were randomized into 3 groups. A control group received a psoas block and IV saline, another group received psoas block and IV clonidine 1 mg/kg and a third group received a psoas block and peripheral clonidine. The interval from time of completion of block to first supplementary analgesic administration was longer in the IV clonidine group. Results show no significant differences among groups regarding postoperative adverse effects. We excluded the study as investigators included no 'control' group that received no block

Manohara 2015

Different intervention. Comparison between ultrasound‐guided supra‐inguinal fascia iliaca block and femoral nerve block

Marhofer 1998

Different intervention. This was a randomized trial of 60 participants. 20 received a 3‐in‐1 block with ultrasound guidance with 20 mL 0.5% bupivacaine, 20 received 20 mL of 0.5% bupivacaine and 20 received 30 mL of 0.5% bupivacaine with nerve stimulator guidance. We excluded the study as investigators included no comparison with a group without nerve block

Matot 2003

Different intervention: epidural analgesia

McRae 2015

Different population: 6 participants with shaft fracture. Letter sent 17 March 2016, to request separate data for participants with a proximal fracture. No reply

Mutty 2007

Different population. This was a randomized trial comparing femoral nerve block vs no block for 54 participants with a femoral shaft or distal femoral fracture. We excluded the study as it included no proximal femoral fractures

Piangatelli 2004

Different intervention. This was a randomized study of 80 participants undergoing lower extremity surgery that compared 4 different methods. A lumbar plexus block with 30 mL 0.5% levobupivacaine or a lumbar plexus block with 30 mL 0.75% ropivacaine or a sciatic nerve block with 10 mL 0.75% ropivacaine or a sciatic nerve block with 10 mL 0.5% levobupivacaine. We excluded the study from this review, as investigators included no 'control' group without nerve block

Reavley 2015

Different intervention. Comparison between fascia iliaca block and femoral (3‐in‐1) block for preoperative analgesia in the emergency department

Scheinin 2000

Different intervention: epidural analgesia

Schiferer 2007

Different population. This was a randomized trial of 62 participants with femoral trauma who were randomized to receive at the site of the accident a femoral nerve block or intravenous metamizole for pain. Studiy provided a variety of causes for the femoral trauma, including 20 cases of hip fracture. The nerve block was shown to reduce the degree of pain as assessed by the visual analogue scale and to reduce anxiety and heart rate. We excluded the study as it included participants with other conditions. Trialists were unable to provide separate results for hip fracture participants

Segado Jimenez 2010

Study authors informed us that the trial included participants with hip fracture and participants without hip fracture undergoing elective hip arthroplasty. They could not give us data separately for participants with and without hip fracture: "I did not registered which patients were hip fractures, just the type of surgery"

Sia 2004

Different population. Femoral shaft fractures

Turker 2003

Different intervention. This was a randomized study of 30 participants who underwent partial hip replacement surgery. 15 received general anaesthesia plus epidural block with 15 mL of 0.5% bupivacaine, and 15 received general anaesthesia plus psoas compartment block with 30 mL of 0.5% bupivacaine. Both groups had similar pain scores, but the epidural group showed greater drops in mean arterial blood pressure from baseline and more complications. We excluded the study from this review because it did not include a control group that did not receive nerve block

Van Leeuwen 2000

Different intervention. This was a randomized study of 3 different combinations of doses of local anaesthetics given to produce a 'three in one' femoral nerve block. We excluded this study from the review because it did not include a 'control' group that did not receive nerve block

Characteristics of ongoing studies [ordered by study ID]

ACTRN12609000526279

Trial name or title

Ultrasound‐guided femoral nerve block using 1% ropivacaine as a method of pain control in patients who present to emergency with a fractured hip

Methods

Parallel RCT

Open label

Approved by the ethics committee

Participants

Inclusion criteria: 18 years or older with radiological proof of fractured neck of femur

Exclusion criteria: women lactating, pregnant or of childbearing potential who are not willing to avoid becoming pregnant during the study, < 18 years old, allergy to ropivacaine, allergy to paracetamol and morphine, anticoagulated patients and those with significant coagulation abnormalities that increase their risk of bleeding. localized injection site infection. neurological deficits in the distribution of the femoral nerve noted, consent denied, documented severe hepatic disease, unable to give consent themselves, history of heart block or on amiodarone, acute cardiac event in the last 3 months

Interventions

Treatment group: An ultrasound‐guided femoral nerve block will be placed with 1% ropivacaine. An ultrasound vascular probe is placed to locate structures anatomically: The main structures were the femoral nerve itself, the femoral artery and vein and the fascia iliaca. Then under real‐time ultrasound guidance via an out‐of‐plane approach, 15 mL of 1% ropivacaine is injected around the femoral nerve as visualized. A 2‐person technique is employed with the needle attached to the syringe of ropivacaine via a 90 cm minimum volume extension set. The probe and needle operator is present along with an assistant who injects the anaesthetic. Digital pressure is then placed for 30 seconds just distal to the injection site. The entire procedure takes about 15 to 20 minutes. Objective measure of the nerve block is assessed at 30 minutes by testing sensation over the anterolateral aspect of the thigh

Control group: Both study and control groups will receive regular oral tablet paracetamol 1 G every 4 to 6 hours to a maximum dose of 4 G in 24 hours and parenteral (intravenous) morphine as required for pain control

Outcomes

Primary outcome: morphine use in patients for both groups at 24 hours

Secondary outcomes: pain scores and subsequent pain scores to be looked at in each group and compared over the first 12 hours. Scores will range from 0 to 10, with 10 indicating the worst pain. Pain scores in both groups will be assessed at enrolment into the study, 30 minutes after enrolment or after nerve block has been given, then at 4 then 8 then 12 hours after enrolment

Starting date

04/04/2009

Contact information

Dr Edmond Park, Emergency Department, St Vincents Hospital, Victoria Street, Darlinghurst 2010 New South Wales

+61 2 8382 2040, [email protected]

Notes

Recruiting

EUCTR2006‐004001‐26‐GB

Trial name or title

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

Methods

RCT

Open label

Participants

Inclusion criteria: suspected isolated hip fracture (clinical suspicion of hip fracture defined as the presence of painful, unilateral shortening and external rotation of the lower limb, preventing weight‐bearing), alert and oriented, willing to be randomized for pain relief as described, > 18 years of age

Exclusion criteria: other significant injury, clinical suspicion of fracture other than to the hip, sensitivity to any study preparation, local infection at the injection site, symptoms/Injury > 8 hours, prehospital parenteral analgesia, unable to give informed consent as a result of current or pre‐existing physical or mental condition, known coagulopathy, taking warfarin or clopidogrel within 2 weeks, body mass index > 40

Interventions

Treatment group: fascia iliaca compartment block with bupivacaine 0.25%

Control group: morphine

Outcomes

Primary outcome measure: comparison between experimental and control groups of the difference in maximum tolerable passive hip flexion from supine (verbal pain score ≤ 3), expressed in degrees measured with a goniometer at baseline (on arrival after recruitment but before randomization) vs 45 minutes post intervention

Secondary objective: investigation of duration of effect, ease of use, failure rates and morphine‐sparing effect of using fascia iliaca block in this participant group

Starting date

Contact information

Nottingham University Hospitals NHS Trust

Notes

EUCTR2008‐004303‐59‐SE

Trial name or title

Blocking the femoral nerve in patients with suspected hip fracture ‐ does it work in clinical practice?

Methods

Parallel RCT

Double‐blind

Participants

Inclusion criteria: 132 participants with suspected hip fracture, ≥ 65 years old

Exclusion criteria: more fractures incurred in the context of an accident, at home for more than 12 hours after the accident, hypersensitivity to local analgesics, infection, neurovascular problems, blockade not available within a specific period, patients for whom the attending physician considers that blockade could be harmful (e.g. atrioventricular block type II or III, elderly, severe liver disease, greatly reduced renal function)

Interventions

Treatment group: femoral nerve block with ropivacaine

Control group: placebo, subcutaneous injection

Outcomes

Primary objective: pain scores

Secondary outcomes: complications (decubitus ulcers), rehabilitation time, analgesic use

Starting date

24/10/2008

Contact information

Notes

EUCTR2010‐023871‐25‐GB

Trial name or title

The FINOF (Femoral Nerve‐Block Intervention in Neck Of Femur Fracture) study ‐ FINOF

Methods

RCT

Single‐blind

Participants

Inclusion criteria: ≥ 70 years of age, resident in own home or in warden‐aided flat, cognitively intact (as defined by a score ≥ 7 on the Abbreviated 10 point Mental Test Score (AMTS), prior fracture New Mobility Score ≥ 3, indicating independent indoor ambulation)

Exclusion criteria: pre‐fracture hospitalization, contraindications to femoral nerve block analgesia, regular pre‐fracture opioid or glucocorticoid therapy, alcohol or substance abuse, morphine intolerance, postoperative surgical restrictions for ambulation

Interventions

Treatment group: femoral nerve block with ropivacaine 0.2%

Control group: standard care

Outcomes

Primary endpoint(s): from day 1 to day 3 postoperatively: cumulative ambulation score, cumulative dynamic pain score postoperatively

Secondary objective: to estimate the cost‐effectiveness of femoral nerve blockade vs usual care, to examine issues of compliance, acceptability to staff and participants

Starting date

20/04/2011

Contact information

Nottingham University Hospitals NHS Trust, United Kingdom; no contact provided

Notes

EUCTR2015‐000078‐36‐DK

Trial name or title

Analgesic effect of a supplemental nerve block in patients with hip fracture

Methods

Parallel RCT

Double‐blind

Participants

Inclusion criteria: clinical suspicion of hip fracture, successful sensory effect of femoral nerve block, mentally capable of comprehending and using verbal pain score and distinguishing between pain from fractured hip and pain from other location, arrival in the emergency department at times when one of the doctors who do the nerve blocks for this investigation are on call, possible visualization of necessary structures with ultrasound, verbal pain score (0‐10) > 3 at rest or > 5 with passive leg raise 30 minutes after femoral nerve block, informed consent, ≥ 18 years of age

Exclusion criteria: hip fracture not confirmed by x‐ray, weight < 45 kg, previously included in this trial If participant wishes to be excluded, allergy to local anaesthetics or adrenocortical hormone, visible infection in the area of the point of needle injection

Interventions

Treatment group: femoral nerve block with bupivacaine 0.25%

Control group: placebo

Outcomes

Primary outcome: frequency of sufficient analgesia 20 minutes after a supplemental obturator nerve block vs placebo

Secondary outcomes: success rate, time to perform the block, onset time

Starting date

17/03/2015

Contact information

Department of Anaesthesia and Intensive Care, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, Denmark

+4528782877

[email protected]

Notes

ISRCTN07083722

Trial name or title

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

Methods

RCT

Double‐blind

Approved by the ethics committee: Health and Social Care Research Ethics Committee (HSC REC 1) (Northern Ireland) approved on 18th of April 2008 (ref: 08/NIR01/20)

Funding: governmental: Belfast Health and Social Care Trust (UK) (ref: RGHT 000559)

Participants

Target number of participants

100 participants ‐ 40 in first part of study and 60 in second part of study

Inclusion criteria: ASA physical status class I‐IV, able to give written informed consent, requiring operative repair of fractured neck of femur, aged 18 years and over, either sex

Exclusion criteria: history of dementia or difficulty in obtaining consent, history of allergy to any of the medications used in the study

Interventions

Treatment group: fascia iliaca block for positioning before spinal anaesthesia and continuous infusion after surgery

Part 1: Participants randomized to receive fascia iliaca compartment block with 2 mg/kg 1% lignocaine or conventional sedation with 0.2 mg/kg IV ketamine and 0.025 mg/kg IV midazolam. At completion of surgery, a fascia iliaca block with 1 mg/kg 0.25% levobupivacaine will be performed in all participants

Part 2: participants randomized to receive a preoperative fascia iliaca block with 1 mg/kg of 0.25% levobupivacaine or 2 mg/kg of 1% lignocaine. After administration of fascia iliaca block, a catheter will be inserted below the fascia iliaca and secured in place. Participants will be reviewed in the postoperative period and bolus doses of 0.125% levobupivacaine will be administered through the fascia iliaca block catheter if visual analogue scale is greater than 4. The catheter will be removed no longer than 24 hours after surgery

Control group: no block

Outcomes

Primary outcome measures:

‐ Part 1: comparison of pain score at rest and positioning for spinal anaesthesia in participants who have received a fascia iliaca compartment block or conventional sedation
Part 2: comparison between postoperative pain scores among participants receiving fascia iliaca blockade with lignocaine or levobupivacaine, and effects of bolus top‐up doses of low‐dose levobupivacaine on pain scores

Secondary outcome measures: length of time to first request of additional analgesia, level of assistance required for transfer from sitting to standing position, incidence and severity of motor blockade, time to mobilization with walking aid, measurement of oxygen saturations without supplemental oxygen in both groups, incidence of all complications associated with analgesic techniques in both groups, incidence of nausea and/or vomiting within first 48 hours after surgery in both groups, use of blood products in all groups

Starting date

01/07/2009

Contact information

Ms Rosemary Hogg

Department of Anaesthetics & Intensive Care Medicine, Queen's University Belfast, 2nd Floor, Mulhouse Building, Grosvenor Road
Belfast, BT12 6BJ, United Kingdom

Notes

Completed

Protocol/serial number: RGHT000559

http://www.belfasttrust.hscni.net

ISRCTN46653818

Trial name or title

Femoral nerve blockade in hip fracture patients

Methods

RCT

Approved by the ethics committee

Funding: governmental: Umeå University (Sweden)

Participants

Target number of participants: 250

Inclusion criteria: both males and females, aged 70 years and above, all hip fracture patients admitted to the orthopaedic department

Exclusion criteria: local infection, allergy to local anaesthesia, dying patients, pathologic hip fractures

Interventions

Treatment group: Participants in the intervention group will receive a femoral nerve blockade as soon as they arrive. Participants with pain scores > 4 will be given morphine IV according to the standard protocol (morphine 10 mg/mL, 1 to 5 mg when necessary)

Control group: regular use of opioids

Both groups will receive 1 G of paracetamol 4 times/d. Postoperative pain treatment will be given according to the standard protocol in both arms of the study. Total follow‐up for both arms will end at the time of discharge

Outcomes

Primary outcome measures: postoperative delirium, assessed 3 times a day; postoperative complications, such as decubital ulcers, infections, thrombosis, heart failure and pain. A cognitive test will be assessed in the ambulance pre‐hospital arrival and at 24 +/‐ 6 hours postoperatively. At days three to five, a more thorough assessment will be done including delirium, depression, cognitive status, quality of life and more

Secondary outcome measures: mortality, orthopaedic recovery recorded at the time of discharge from the hospital, EQ‐5D, economics

Starting date

30/03/2009

Contact information

Prof Ola Winso

Operationscentrum
Norrlands universitetssjukhus
Umea
SE‐901 85
Sweden

Notes

Completed

http://www.umu.se/umu/index_eng.html

ISRCTN75659782

Trial name or title

Intra‐ and post‐operative analgesia for patients undergoing surgery for hip fracture ‐ role of fascia iliaca compartment block

Methods

RCT

Double‐blind (participants and caregivers)

Funding: governmental: Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NL, United Kingdom
+44 (0)20 7307 2622; [email protected], http://www.dh.gov.uk/Home/fs/en

Participants

40 adult participants of ASA I‐III admitted to Selly Oak Hospital with hip fracture and scheduled for fixation will be recruited after consent is obtained

inclusion criteria: scheduled for hip fracture surgery

Exclusion criteria: dementia/confusion, preoperative chest infection and/or poor respiratory function, temperature ≥ 38°C, white cell count > 11,000 mm3, respiratory rate > 25 per minute, auscultation and/or chest x‐ray evidence, SpO2 < 90% on air, congestive cardiac failure, bed‐bound or use of ≥ 2 aids for mobilization pre‐fracture, malignancy, coagulopathy, known or suspected allergy to ropivacaine and/or morphine, local infection at site where the block is to be performed, refusal of permission to approach general practitioner

Interventions

Treatment group: fascia iliaca compartment block (n = 20)

Control group: morphine (n = 20)

Each participant will have a standard preoperative assessment, standard monitoring and recovery care and will be given assessments at 1, 3, 6 and 24 hours postop. Thereafter, data will be collected on a daily basis until 30 days postop/discharge/death, whichever is earlier. Our hospital already has a framework for data collection (Integrated Care Pathway). For our study, we will be using the same data

Outcomes

Primary outcome measures: total dose of morphine required during first 24 hours post‐op

Secondary outcome measures: time to first dose of morphine postop, pain scores in recovery room and at 13, 16 and 24 hours after surgery, time to first appropriate response to verbal commands, time to discharge from recovery room, occurrence of nausea and vomiting in recovery and number of episodes during the first 24 hours postop, total dose of cyclizine required in the first 24 hours, need for granisetron during the first 24 hours, sedation scores at 1, 3, 6 and 24 hours, mental test scores at 1, 3, 6 and 24 hours, complications, rehabilitation outcomes, mortality

Starting date

04/04/2006

Contact information

Dr FA Levins, Anaesthetics, Selly Oak Hospital, Birmingham, B29 6JD, United Kingdom

Notes

DOI 10.1186

Protocol/serial number: N0265178818

Completed

ISRCTN92946117

Trial name or title

The FINOF ‐ Femoral nerve‐block Intervention in Neck Of Femur fracture study

Approved by Nottingham Research Ethics Committee 2, 28th January 2011, ref: 10/H0408/113

Funding: governmental; Funder name: National Institute of Health Research (NIHR) (UK) ‐ Research for Patient Benefit (RfPB)

Methods

RCT

Participants

150 elderly patients admitted with an acute hip fracture

Inclusion criteria: aged ≥ 70 years, resident in their own home or warden‐aided flat, cognitively intact (as defined by a score ≥ 7 on the Abbreviated 10 point Mental Test Score (AMTS), and prior fracture New Mobility Score ≥ 3 (indicating independent indoor ambulation)

Exclusion criteria: prefracture hospitalization, contraindications to femoral nerve block analgesia, regular pre‐fracture opioid or glucocorticoid therapy, alcohol or substance abuse, morphine intolerance, postoperative surgical restrictions for ambulation

Interventions

Treatment group: femoral nerve block followed by continuous infusion

Control group: standard analgesic care

Outcomes

Drug‐related adverse events, earlier recovery, shorter length of stay in hospital and overall, improved quality of life for patients suffering with an acute hip fracture

Primary outcome measures: cumulative dynamic pain score, cumulative ambulation score measured from day 1 to day 3 postoperatively

Secondary outcome measures: cumulative dynamic pain score preoperatively (at 30 minutes, 60 minutes, 12 hours after initial femoral nerve block), cumulative side effects (nausea, vomiting, constipation, delirium) (from admission to day 3 postoperatively),
cumulative calorific and protein intake (from admission to day 3 postoperatively), health‐related quality of life measured on the EUROQOL EQ‐5D, informing a cost‐effectiveness analysis, hospital length of stay, rehabilitation outcome measured by New Mobility Score, participant and staff experience (qualitative study)

Starting date

02/01/2012

Contact information

Dr Opinder Sahota, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, United Kingdom; [email protected]

Notes

Completed: DOI 10.1186/ISRCTN92946117

EudraCT number: 2010‐023871‐25

http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=10929

http://www.nuh.nhs.uk/

http://www.ncbi.nlm.nih.gov/pubmed/24885267

  1. Protocol: Sahota O, Rowlands M, Bradley J, Van de Walt G, Bedforth N, Armstrong S, Moppett I, Femoral nerve block Intervention in Neck of Femur fracture (FINOF): study protocol for a randomized controlled trial. Trials 2014, 15, 189, doi: 10.1186/1745‐6215‐15‐189. PubMed AbstractPublisher Full Text

NCT00749489

Trial name or title

Improving pain and function in hip fracture

Methods

RCT

Single‐blind (outcome assessor)

Participants

Inclusion criteria: adults (≥ 60 years) presenting to the MSMC ED from 8:00 to 20:00 with a radiographically confirmed hip fracture (femoral neck, intertrochanteric or pericapsular)

Exclusion criteria: history of advanced dementia, presence of multiple trauma, pathological fractures, bilateral hip fractures, previous fracture or surgery at the currently fractured site, transferred from another hospital, cirrhosis or liver failure, able to self‐report pain intensity

Other exclusion criterion: < age 60 because our focus is on treatment of pain in older adults

Interventions

Treatment group: femoral nerve block

Control group: no intervention

Outcomes

Primary outcome measures: pain (11‐point numerical evaluated 3 times daily for the duration of hospital stay (average stay is 4 days))

Secondary outcome measures: delirium (confusion assessment method) evaluated 3 times daily for duration of hospital stay

Starting date

November 2008

Contact information

R. Sean Morrison, MD, and Knox Todd, MD, Beth Israel, New York, USA 10003

Notes

This study has been completed

NCT01052974

Trial name or title

Perioperative analgesia by femoral perineural catheter for femoral neck fracture ‐ Study KTcol

Methods

Parallel RCT

Double‐blind (participants, investigator)

Participants

Inclusion criteria: adults (≥ 18 years) with femoral neck fracture

Exclusion criterion: contraindication with analgesia

Interventions

Treatment group: analgesic treatment with a femoral perineural catheter (inserted from hospital admission) with continuous infusion of ropivacaine

Control group: placebo

Outcomes

Primary outcome measures: evaluation, in patients admitted in emergencies for suspicion of femoral neck fracture, the perioperative efficiency of an analgesic treatment provided with a femoral perineural catheter from hospital admission to 24 hours after surgical operation

Starting date

March 2009

Contact information

Guillaume Bouhours UHAngers, Angers, France

Notes

NCT01219088

Trial name or title

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

Methods

Parallel RCT

Single‐blind (outcome assessor)

Participants

Inclusion criteria: 18‐90 years old, good consciousness, well co‐operated, can use patient‐controlled analgesia machine, ASA physical status I‐III, no contraindication for spinal anaesthesia, accept spinal anaesthesia, body weight > 30 kg, body mass index 20‐35 kg/m2, no history of research drug allergy

Exclusion criteria: previous history of hip surgery (the same side), pathological fracture, severe infection or bone cancer

Interventions

Treatment group 1: femoral nerve block, spinal anaesthesia plus femoral nerve block with 20 mL of 0.25% bupivacaine

Treatment group 2: periarticular bupivacaine infiltration, spinal anaesthesia plus periarticular infiltration with 20 mL of 0.25% bupivacaine

Control group 1: spinal anaesthesia with 0.5% bupivacaine alone

Control group 2: spinal anaesthesia plus 0.1 mg of intrathecal morphine

Outcomes

Primary outcome measures: amount of morphine consumed during first 24 hours after surgery
Secondary outcome measures: efficacy of pain control, patient satisfaction, incidences of adverse events (nausea, vomiting, pruritus)

Starting date

September 2010

Contact information

Thitima Chinachoti, MD (Madihol University), Faculty of Medicine Siniraj Hospital, Bangok, Thailand, 10700

Notes

NCT01547468

Trial name or title

Does femoral nerve catheterization reduce the incidence of post‐operative delirium in patients presenting for hip fracture repair?

Methods

Parallel RCT

Open label

Participants

270 adults (≥ 50 years) presenting to Oschner Main Campus with a hip fracture

Exclusion criteria: head trauma as reported in the medical record and/or participant response, high‐impact fracture as reported in the medical record, aphasia as reported in the medical record and/or participant response, deafness, blindness as reported in the medical record and/or participant response, true allergy (not sensitivity or side effects) to local anaesthetics or opiates, pregnant, inability to complete study activities preoperatively

Interventions

Treatment group: femoral nerve catheterization

Control group: intravenous opioids

Outcomes

Primary outcome measure: number of participants developing delirium postoperatively during first 3 days after surgery

Secondary outcome measures: hospital length of stay, pain score, consumption of pain medication for breakthrough pain relief

Starting date

March 2012

Contact information

Leslie Thomas, MD, Oschner Clinic Foundation, New Orleans, Louisianna, USA 70121

Notes

Recruiting

NCT01593319

Trial name or title

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

Methods

Parallel RCT

Double‐blind (participants, caregivers, investigator, outcomes assessors)

Participants

Inclusion criteria: adults (≥ 65 years) with a hip fracture

Exclusion criteria: multiple fractures, delay (> 12 hours) from the time of injury until admission to the hospital, local infection, hypersensitivity to local analgesics, cognitive impairment

Interventions

Treatment group: local injection (fascia iliaca block) of 150 mg ropivacaine

Control group: saline injection

Outcomes

Primary outcome measure: pain during first 3 hours after surgery

Secondary outcome measures: medical complications (number of participants who develop pressure ulcers, number of participants who develop pneumonia): under hospitalization (expected average of 10 days)

Starting date

January 2012

Contact information

Landstinget i Värmland, Othopedikinken, Centralsjukhuset I Karlsad, Karlsad, Vamiand, Sweden, S‐65185

Notes

Terminated

NCT01638845

Trial name or title

Hip fracture and perineural catheter

Methods

Parallel RCT

Open label

Participants

Inclusion criteria: age ≥ 60 years, written informed consent obtained, ASA physical status I‐III, undergoing surgery for hip fracture, time < 24 hours after hip fracture

Exclusion criteria: contraindication to regional anaesthesia (constitutional or acquired disorder of coagulation, sepsis, local infection of puncture area, history of vascular surgery, prosthetic femoral neuropathy scalable, allergy to local anaesthetics), weight < 40 kg, receiving anticoagulant drugs or antiplatelet therapy (other than aspirin and clopidogrel), contraindication for standardized anaesthetic technique in this study, contraindication for analgesics used postoperatively (respiratory failure, severe liver failure, brain injury associated with intracranial hypertension, uncontrolled epilepsy, simultaneous treatment with monoamine oxidase inhibitors, hypersensitivity to opioids), unable to give informed consent, adults under guardianship or curator, persons not affiliated with a health insurance plan, deprived of liberty

Interventions

Treatment group: continuous perineural catheter

Control group: no intervention

Outcomes

Primary outcome measure: number of participants with cardiovascular events during the preoperative period: 3 days

Starting date

June 2012

Contact information

Vincent Compere, University Hospital, Rouen, France

Notes

Recruiting

NCT01904071

Trial name or title

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

Methods

Parallel RCT

Open label

Participants

Inclusion criteria: English‐speaking patients; ≥ 18 years of age; radiographic evidence of hip fracture; awake, alert and oriented to time, place and person; pain score ≥ 5 on 10‐point scale

Exclusion criteria: cognitive deficits, allergy to amide‐type local anaesthetic or morphine, more injuries than just hip fracture

Interventions

Treatment group 1 : ultrasound‐guided 3‐in‐1 femoral nerve block

Treatment group 2: ultrasound‐guided fascia iliaca compartment block

Control group: IV morphine

Outcomes

Primary outcome measure: pain score at 30 minutes

Secondary outcome measures: pain score at 60, 120, 240 and 480 minutes

Starting date

October 2008

Contact information

Eitan Dickman, MD, Maiminides Medical Center, Brooklyn, New York, USA 11219

Notes

Has results

NCT02381717

Trial name or title

Comparison of ultrasound guided femoral nerve blockade and standard parenteral opioid pain management alone in patients with hip fracture in the emergency department

Methods

Parallel RCT

Open label

Participants

Inclusion criteria: > 18 years of age presenting with radiologically established intracapsular, extracapsular hip fracture, able to consent and participate in the study, moderate to severe pain (numerical pain score ≥ 3) at time of enrolment

Exclusion criteria: previous history of hypersensitivity to local anaesthetics, signs of local infection at the site of planned needle placement

Interventions

Treatment group: ultrasound‐guided femoral nerve block with 0.5% bupivacaine (2 mg/kg)

Control group: IV morphine

Outcomes

Primary outcome measure: pain intensity reduction at 4 hours after initiation of study procedure

Starting date

February 2015

Contact information

Elena Skomorovsky, MD, Beth Israel Deaconess Medical Center

Notes

This study is not yet open for participant recruitment

NCT02406300

Trial name or title

Contribution of anaesthesia technique for post‐operative mortality reduction after proximal femur fractures surgical treatment ‐ a randomized clinical trial

Methods

Parallel RCT

Double‐blind (investigator, outcome assessor)

Participants

Inclusion criteria: adults (≥ 60 years) admitted with a diagnosis of proximal femur fracture (ICD‐9 codes 820.0 to 820.9) and submitted to surgical internal fixation of femur or hip prosthesis (ICD‐9 codes 7935, 8151 and 8152)

Exclusion criteria: multiple fractures; polytrauma, active malignancy, ASA physical status V, antiplatelet drugs (other than aspirin) in previous 5 days, known allergies to local anaesthetics, contraindication to general or regional anaesthesia

Interventions

Treatment group: femoral, lateral cutaneous nerve of the thigh and anterior obturator nerve blocks with ropivacaine and inhalational general anaesthesia with sevoflurane or desflurane

Control group: spinal anaesthesia with bupivacaine

Outcomes

Primary outcome measures: survival rate up to 1 year after surgery

Secondary outcome measures: incidence of postoperative delirium (up to 1 week postoperatively and measured with the 3D‐CAM Questionnaire (Confusion Assessment Method)), quality of life recovery (measured by quality of life assessment tools (SF12v2; EQ‐5D (EuroQol) at 30 days and 1 year after surgery)

Starting date

April 2015

Contact information

Raul Carvalho, MD, MSc, Centro Hospitalar do Porto

Notes

Enrolling

NCT02433548

Trial name or title

Fascia iliaca block in the emergency department for analgesia after femoral neck fracture

Methods

Parallel RCT

Double‐blind (caregiver, investigator, outcome assessor)

Participants

Inclusion criteria: adults (≥ 18 years) with femoral neck fracture in the emergency department

Exclusion criteria: presence of dementia, body weight < 40 kg, presence of cancer or receiving chemotherapy, allergy to local anaesthetics

Interventions

Treatment group: fascia iliaca block (injection of 30 mL of bupivacaine 0.5% with epinephrine 5 mcg/mL below the fascia iliaca, Carbostesin®)

Control group: sham injection = subcutaneous injection of 5 mL of normal saline

Outcomes

Primary outcome measures: pain scores at rest: 45 minutes after injection

Secondary outcome measures: pain scores at rest at 60 minutes, 4 hours, 8 hours, 12 hours and 24 hours after injection; pain scores on movement:at 60 minutes, 4 hours, 8 hours, 12 hours and 24 hours after injection; morphine consumption at 60 minutes, 4 hours, 8 hours, 12 hours and 24 hours after injection and length of stay

Starting date

October 2014

Contact information

Eric Albrecht, Program Director, Regional Aanaesthesia, CHU Vaudois, Switzerland

Notes

Recruiting

AMTS: Abbreviated 10‐point Mental Test Score

ASA: American Society of Anaesthesiologists physical status

C: Celsius

CAM Questionnaire: Confusion Assessment Method

EQ‐5D or EUROQOL: score for measurement of health‐related quality of life

G: gram

ICD‐9: list of codes for International Statistical Classification of Diseases and Related Health Problems

IV: intravenous

kg: kilogram

kg/m2: kilogram per square metre

mm: millimetre

MSMC ED: Maimonides Medical Center emergency department

n: number

NHS: Nottingham University Hospitals

OMC: orientation‐memory‐concentration

RCT: randomized controlled trial

RfPB: Research for Patient Benefit

Data and analyses

Open in table viewer
Comparison 1. Nerve block versus other modes of analgesia

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain on movement within 30 minutes of block placement Show forest plot

8

373

Std. Mean Difference (Random, 95% CI)

‐1.41 [‐2.14, ‐0.67]

Analysis 1.1

Comparison 1 Nerve block versus other modes of analgesia, Outcome 1 Pain on movement within 30 minutes of block placement.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 1 Pain on movement within 30 minutes of block placement.

2 Pain at rest within 30 minutes after block placement Show forest plot

7

322

Std. Mean Difference (Random, 95% CI)

‐0.80 [‐1.25, ‐0.35]

Analysis 1.2

Comparison 1 Nerve block versus other modes of analgesia, Outcome 2 Pain at rest within 30 minutes after block placement.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 2 Pain at rest within 30 minutes after block placement.

3 Pain at rest at 6 to 8 hours after surgery Show forest plot

5

286

Mean Difference (IV, Random, 95% CI)

‐0.38 [‐0.70, ‐0.06]

Analysis 1.3

Comparison 1 Nerve block versus other modes of analgesia, Outcome 3 Pain at rest at 6 to 8 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 3 Pain at rest at 6 to 8 hours after surgery.

4 Pain on movement at 24 hours after surgery Show forest plot

4

195

Mean Difference (IV, Random, 95% CI)

‐0.39 [‐1.08, 0.30]

Analysis 1.4

Comparison 1 Nerve block versus other modes of analgesia, Outcome 4 Pain on movement at 24 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 4 Pain on movement at 24 hours after surgery.

4.1 Surgical technique unspecified

3

169

Mean Difference (IV, Random, 95% CI)

0.09 [‐0.10, 0.29]

4.2 Arthroplasty for 38.4% of participants

1

26

Mean Difference (IV, Random, 95% CI)

‐1.94 [‐2.75, ‐1.13]

5 Pain at rest at 24 hours after surgery Show forest plot

8

435

Mean Difference (IV, Random, 95% CI)

‐0.68 [‐1.23, ‐0.13]

Analysis 1.5

Comparison 1 Nerve block versus other modes of analgesia, Outcome 5 Pain at rest at 24 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 5 Pain at rest at 24 hours after surgery.

5.1 Single shot blocks

2

80

Mean Difference (IV, Random, 95% CI)

‐0.5 [‐0.90, ‐0.10]

5.2 Continuous blocks

6

355

Mean Difference (IV, Random, 95% CI)

‐0.78 [‐1.58, 0.03]

6 Pain on movement at 48 hours Show forest plot

2

129

Mean Difference (IV, Fixed, 95% CI)

0.09 [‐0.23, 0.40]

Analysis 1.6

Comparison 1 Nerve block versus other modes of analgesia, Outcome 6 Pain on movement at 48 hours.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 6 Pain on movement at 48 hours.

7 Pain at rest at 48 hours after surgery Show forest plot

5

335

Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.87, 0.13]

Analysis 1.7

Comparison 1 Nerve block versus other modes of analgesia, Outcome 7 Pain at rest at 48 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 7 Pain at rest at 48 hours after surgery.

7.1 Psoas compartment block

1

40

Mean Difference (IV, Random, 95% CI)

‐1.10 [‐2.26, 0.06]

7.2 Femoral nerve block

3

191

Mean Difference (IV, Random, 95% CI)

0.06 [‐0.16, 0.28]

7.3 Fascia iliaca block

1

104

Mean Difference (IV, Random, 95% CI)

‐0.92 [‐1.47, ‐0.36]

8 Pain at rest at 72 hours after surgery Show forest plot

2

140

Mean Difference (IV, Random, 95% CI)

‐0.48 [‐1.83, 0.87]

Analysis 1.8

Comparison 1 Nerve block versus other modes of analgesia, Outcome 8 Pain at rest at 72 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 8 Pain at rest at 72 hours after surgery.

8.1 Psoas compartment block

1

40

Mean Difference (IV, Random, 95% CI)

‐1.20 [‐1.77, ‐0.63]

8.2 Femoral nerve block

1

100

Mean Difference (IV, Random, 95% CI)

0.18 [0.03, 0.33]

9 Acute confusional state Show forest plot

7

676

Risk Ratio (M‐H, Random, 95% CI)

0.69 [0.38, 1.27]

Analysis 1.9

Comparison 1 Nerve block versus other modes of analgesia, Outcome 9 Acute confusional state.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 9 Acute confusional state.

9.1 Peripheral nerve block based on landmarks

4

501

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.23, 2.93]

9.2 Peripheral nerve block based on nerve stimulator

3

175

Risk Ratio (M‐H, Random, 95% CI)

0.56 [0.32, 0.98]

10 Pneumonia Show forest plot

3

131

Risk Ratio (M‐H, Fixed, 95% CI)

0.41 [0.19, 0.89]

Analysis 1.10

Comparison 1 Nerve block versus other modes of analgesia, Outcome 10 Pneumonia.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 10 Pneumonia.

11 Mortality Show forest plot

7

316

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.34, 1.52]

Analysis 1.11

Comparison 1 Nerve block versus other modes of analgesia, Outcome 11 Mortality.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 11 Mortality.

12 Time to first mobilization Show forest plot

2

155

Mean Difference (IV, Random, 95% CI)

‐11.25 [‐14.34, ‐8.15]

Analysis 1.12

Comparison 1 Nerve block versus other modes of analgesia, Outcome 12 Time to first mobilization.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 12 Time to first mobilization.

13 Costs of analgesic regimens Show forest plot

2

Std. Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.13

Comparison 1 Nerve block versus other modes of analgesia, Outcome 13 Costs of analgesic regimens.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 13 Costs of analgesic regimens.

13.1 Single shot blocks

1

75

Std. Mean Difference (Random, 95% CI)

‐3.48 [‐4.23, ‐2.74]

13.2 Continuous blocks

1

62

Std. Mean Difference (Random, 95% CI)

0.93 [0.37, 1.48]

14 Pressure sores Show forest plot

3

187

Risk Ratio (M‐H, Random, 95% CI)

0.47 [0.09, 2.53]

Analysis 1.14

Comparison 1 Nerve block versus other modes of analgesia, Outcome 14 Pressure sores.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 14 Pressure sores.

14.1 Single shot femoral nerve block (on admission)

2

125

Risk Ratio (M‐H, Random, 95% CI)

0.18 [0.02, 1.38]

14.2 Continous femoral nerve block (after surgery)

1

62

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.19, 4.90]

15 Opioid requirement Show forest plot

7

285

Std. Mean Difference (Random, 95% CI)

‐0.70 [‐0.96, ‐0.44]

Analysis 1.15

Comparison 1 Nerve block versus other modes of analgesia, Outcome 15 Opioid requirement.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 15 Opioid requirement.

15.1 Single shot blocks

5

245

Std. Mean Difference (Random, 95% CI)

‐0.73 [‐1.01, ‐0.44]

15.2 Continuous blocks

2

40

Std. Mean Difference (Random, 95% CI)

‐0.55 [‐1.18, 0.08]

16 Participant satisfaction Show forest plot

5

237

Std. Mean Difference (Random, 95% CI)

0.91 [0.62, 1.20]

Analysis 1.16

Comparison 1 Nerve block versus other modes of analgesia, Outcome 16 Participant satisfaction.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 16 Participant satisfaction.

Flow diagram for this update.n: number.
Figuras y tablas -
Figure 1

Flow diagram for this update.

n: number.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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).
Figuras y tablas -
Figure 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).

Comparison 1 Nerve block versus other modes of analgesia, Outcome 1 Pain on movement within 30 minutes of block placement.
Figuras y tablas -
Analysis 1.1

Comparison 1 Nerve block versus other modes of analgesia, Outcome 1 Pain on movement within 30 minutes of block placement.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 2 Pain at rest within 30 minutes after block placement.
Figuras y tablas -
Analysis 1.2

Comparison 1 Nerve block versus other modes of analgesia, Outcome 2 Pain at rest within 30 minutes after block placement.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 3 Pain at rest at 6 to 8 hours after surgery.
Figuras y tablas -
Analysis 1.3

Comparison 1 Nerve block versus other modes of analgesia, Outcome 3 Pain at rest at 6 to 8 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 4 Pain on movement at 24 hours after surgery.
Figuras y tablas -
Analysis 1.4

Comparison 1 Nerve block versus other modes of analgesia, Outcome 4 Pain on movement at 24 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 5 Pain at rest at 24 hours after surgery.
Figuras y tablas -
Analysis 1.5

Comparison 1 Nerve block versus other modes of analgesia, Outcome 5 Pain at rest at 24 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 6 Pain on movement at 48 hours.
Figuras y tablas -
Analysis 1.6

Comparison 1 Nerve block versus other modes of analgesia, Outcome 6 Pain on movement at 48 hours.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 7 Pain at rest at 48 hours after surgery.
Figuras y tablas -
Analysis 1.7

Comparison 1 Nerve block versus other modes of analgesia, Outcome 7 Pain at rest at 48 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 8 Pain at rest at 72 hours after surgery.
Figuras y tablas -
Analysis 1.8

Comparison 1 Nerve block versus other modes of analgesia, Outcome 8 Pain at rest at 72 hours after surgery.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 9 Acute confusional state.
Figuras y tablas -
Analysis 1.9

Comparison 1 Nerve block versus other modes of analgesia, Outcome 9 Acute confusional state.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 10 Pneumonia.
Figuras y tablas -
Analysis 1.10

Comparison 1 Nerve block versus other modes of analgesia, Outcome 10 Pneumonia.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 11 Mortality.
Figuras y tablas -
Analysis 1.11

Comparison 1 Nerve block versus other modes of analgesia, Outcome 11 Mortality.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 12 Time to first mobilization.
Figuras y tablas -
Analysis 1.12

Comparison 1 Nerve block versus other modes of analgesia, Outcome 12 Time to first mobilization.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 13 Costs of analgesic regimens.
Figuras y tablas -
Analysis 1.13

Comparison 1 Nerve block versus other modes of analgesia, Outcome 13 Costs of analgesic regimens.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 14 Pressure sores.
Figuras y tablas -
Analysis 1.14

Comparison 1 Nerve block versus other modes of analgesia, Outcome 14 Pressure sores.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 15 Opioid requirement.
Figuras y tablas -
Analysis 1.15

Comparison 1 Nerve block versus other modes of analgesia, Outcome 15 Opioid requirement.

Comparison 1 Nerve block versus other modes of analgesia, Outcome 16 Participant satisfaction.
Figuras y tablas -
Analysis 1.16

Comparison 1 Nerve block versus other modes of analgesia, Outcome 16 Participant satisfaction.

Summary of findings for the main comparison. Peripheral nerve blocks for hip fracture

Peripheral nerve blocks for hip fracture

Patient or population: patients with hip fracture
Settings: trials performed in Argentina (n = 1), Austria (n = 1), Chile (n = 1), China (n = 2), Denmark (n = 2), France (n = 2), Geece (n = 3), Germany (n = 1), India (n = 1), Iran (n = 1), Ireland (n = 1), Israel (n = 1), Korea (n = 1), South Africa (n = 1), Spain (n = 2), Sweden (n = 1), Thailand (n = 1), Turkey (n = 2), United Kingdom (n = 5) and United States of America (n = 1)
Intervention: peripheral nerve blocks
Comparison: systemic analgesia

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Systemic analgesia

Peripheral nerve blocks

Pain on movement at 30 minutes after block placement
Follow‐up: 20‐30 minutes

Mean pain on movement at 30 minutes after block placement in the intervention groups was
1.41 standard deviations lower
(2.14 to 0.67 lower)

373
(8 studies)

⊕⊕⊕⊕
higha,b,c,d,e,f,g,h,i

Equivalent to
‐ 3.4 on a
scale from
0 to 10

Acute confusional state

Study population

RR 0.69
(0.38 to 1.27)

676
(7 studies)

⊕⊝⊝⊝
very lowc,f,h,j,k,l,m,n

198 per 1000

136 per 1000
(75 to 251)

Low

150 per 1000

104 per 1000
(57 to 190)

High

250 per 1000

172 per 1000
(95 to 317)

Myocardial ischaemia

Study population

RR 0.2
(0.03 to 1.42)

20
(1 study)

⊕⊝⊝⊝
very lowb,c,j,m,n,o,p,q

500 per 1000

100 per 1000
(15 to 710)

Low

100 per 1000

20 per 1000
(3 to 142)

High

500 per 1000

100 per 1000
(15 to 710)

Pneumonia

Study population

RR 0.41
(0.19 to 0.89)

131
(3 studies)

⊕⊕⊕⊝
moderatec,f,h,k,l,n,r,s,t

269 per 1000

110 per 1000
(51 to 239)

Low

50 per 1000

20 per 1000
(9 to 44)

High

200 per 1000

82 per 1000
(38 to 178)

Death
Follow‐up: 0‐6 months

Study population

RR 0.72
(0.34 to 1.52)

316
(7 studies)

⊕⊕⊝⊝
lowc,f,m,n,o,q,s,u

98 per 1000

70 per 1000
(33 to 149)

Low

25 per 1000

18 per 1000
(9 to 38)

High

150 per 1000

108 per 1000
(51 to 228)

Time to first mobilisation

Mean time to first mobilisation in intervention groups was
11.25 hours lower
(14.34 to 8.15 lower)

155
(2 studies)

⊕⊕⊕⊝
moderatea,c,d,e,h,k,n,p,s,v,w

Cost of analgesic regimens for single shot blocks

Mean cost of analgesic regimens for single shot blocks in intervention groups was
3.48 standard deviations lower
(4.23 to 2.74 lower)

75
(1 study)

⊕⊕⊕⊝
moderatea,c,l,n,p,q,s,v

The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

a50% or more of studies were rated as having unclear or high risk for allocation concealment or blinding of outcome assessor
bWe did not downgrade the evidence on inconsistency because we found a reasonable explanation for heterogeneity
cDirect comparisons in studies performed on the population of interest and the outcome measured is not a surrogate marker
dOptimal information size achieved
eWide confidence interval around effect size
fNo evidence of publication bias, or applying a correction for the possibility of one would not modify the conclusion
gLarge effect size (SMD > 0.8)
hNo study used ultrasound guidance, which could have increased success rate of blocks
iEffect size was proportional to the concentration of local anaesthetic used in lidocaine equivalent
j75% of studies or more were judged at unclear or high risk of bias for allocation concealment or blinding of outcome assessor
kModerate amount of heterogeneity or clinical heterogeneity
lOptimal information size not achieved
mNo evidence of a large effect
nNo evidence of a dose response
oEstimate included both absence of effect and important benefit
pCould not be assessed
qNo evidence of confounding factors that would justify upgrading
rGroups heterogenous for preoperative characteristics
sNo heterogeneity or ≤ 25%
tWe upgraded the level of evidence by one owing to a large effect size (RR < 0.5)
uWe did not downgrade for risk of bias
vWe upgraded the level of evidence on the basis of a large effect size (equivalent to SMD > 0.8)
wWe upgraded the level of evidence on the basis of a large effect size (equivalent to SMD of ‐1.87)

Figuras y tablas -
Summary of findings for the main comparison. Peripheral nerve blocks for hip fracture
Table 1. Anaesthetic techniques

Study

Purpose of blockade

Surgical anaesthesia

Block technique

Comparison

Altermatt 2013

Preoperative and postoperative analgesia

Unspecified

Continuous lumbar plexus with 0.1% bupivacaine in a patient‐controlled analgesia mode

IV morphine

Antonopoulou 2006

Postoperative analgesia

Spinal anaesthesia

Continuous femoral nerve block, nerve stimulator, loaded with 18 mL of 0.25% bupivacaine followed by an infusion of 0.125% levobupivacaine at 3‐4 mL/h

IM pethidine

Beaudoin 2013

Preoperative analgesia

Unspecified

Ultrasound‐guided femoral nerve block performed by an experienced operator with a 7.5 MHz linear probe, participant in Trendelenburg position, cross‐sectional view, 22 G Whitacre needle in‐plane and 25 mL of bupivacaine 0.5% and distal manual pressure for 5 minutes

IM morphine

Chudinov 1999

Preoperative and postoperative analgesia

Surgery for some participants

Treatment group: psoas block alone (3/20) with a sciatic block (5/20), a spinal (11/20) or general anaesthesia (1/20)

Control group: neuraxial block (19/20) or general anaesthesia (1/20).

Psoas, loss of resistance, Chayen's technique 0.8 mL/kg of bupivacaine 0.25%, operated side up (1 epidural spread)

IM meperidine and diclofenac

Coad 1991

Postoperative analgesia

General anaesthesia for all participants with etomidate, nitrous oxide, enflurane, fentanyl and vecuronium

Lateral cutaneous: 15 mL of 0.5% bupivacaine with epinephrine, Eriksson's technique

Femoral (3‐in‐1): 15 mL of 0.5% bupivacaine with epinephrine, Winnie's technique

IM meperidine

Cuvillon 2007

Postoperative analgesia

Spinal anaesthesia for all participants

Continuous femoral nerve block. Nerve stimulator 0.3 to 0.5 mA. Non‐stimulating catheter passed 10‐15 cm past the needle tip loaded with 30 mL of 1.5% lidocaine followed by ropivacaine 0.2% at 10 mL/h for 48 hours

SC morphine

De La Tabla 2010

Preoperative analgesia

Unspecified

Femoral nerve block under dual guidance (ultrasound and nerve stimulator), catheter loaded with 15 mL of ropivacaine 0.2% followed by an infusion of the same solution at 5 mL/h and 10 mL every 30 minutes

IV metamizole and tramadol

Diakomi 2014

Preoperative analgesia (spinal positioning)

Spinal anaesthesia

Fascia iliaca block, Dalen's technique, landmarks, 40 mL of 0.5% ropivacaine

IV fentanyl

Domac 2015

Preoperative analgesia (spinal positioning) plus postoperative analgesia

Spinal anaesthesia

Fascia iliaca block with 15 mL of 0.5% bupivacaine and 15 mL of 2% lidocaine; 2‐3 cm below inguinal ligament at the junction of lateral 1/3 and medial 2/3 of a line from pubis tubercle to anterior iliac spine; 2 pops

IV morphine

Fletcher 2003

Preoperative analgesia

Unspecified

Fermoral (3‐in‐1 nerve block, Wiinie's technique with 20 mL of 0.5% bupivacaine and 5 minutes distal compression)

IV morphine

Foss 2007

Preoperative analgesia

Unspecified

Fascia iliaca block based on Dalen's landmarks with a 24 G blunted needle and 40 mL of 1% mepivacaine with epinephrine

IM morphine

Gille 2006

Preoperative and postoperative analgesia

Treatment group: spinal anaesthesia for 37/50 and general anaesthesia for 13/50

Control group: spinal anaesthesia for 38/50 and general anaesthesia for 12/50

Femoral non‐stimulating catheter: needle 18 G, catheter 20 G (Brown‐Perifix‐Plexus Anaesthesia); 0.5 mA and 0.1 msec. Catheters were advanced about 10 cm past the needle tip and fixed. Loading dose was 40 mL of prilocaine 1% followed 2 hours later by ropivacaine 0.2% 30 mL, repeated every 6 hours. Amount (up to 40 mL; n = 5) and intervals (up to every 4 hours; n = 8) or both (n = 6) adjusted on pain scores

IV metamizole plus oral tilidine and naloxone

Godoy 2010

Preoperative analgesia

Unspecified

Fascia iliaca compartment block, 21G long bevel needle, Dalen's technique with 0.3 mL/kg of 0.25% bupivacaine

IV non‐steroidal anti‐inflammatory drugs

Graham 2008

Preoperative analgesia

Unspecified

Femoral (3‐in‐1) nerve block, Winnie's technique, nerve stimulator and 30 mL of bupivacaine 0.5% (not exceeding 3 mg/kg)

IV morphine

Haddad 1995

Preoperative analgesia

Unspecified

Femoral nerve block with 0.3 mL/kg of bupivacaine 0,25%. Paraesthesia technique with a short bevel needle

IM pethidine, oral co‐dydramol and IM voltarol

Hood 1991

Postoperative analgesia

General anaesthesia for all participants with etomidate, nitrous oxide, isoflurane and alfentanil

Femoral nerve block (triple nerve block) with nerve stimulator < 1.0 mA and 35 mL of prilocaine 0.75% and distal digital pressure plus infiltration above the iliac crest with 8 mL of the same solution

IM papaveratum

Iamaroon 2010

Preoperative analgesia

Spinal anaesthesia

Femoral nerve block with nerve stimulator (0.2 to 0.4 mA) and 20 mL of bupivacaine 0.5% plus 10 mL of saline

IV fentanyl

Jadon 2014

Preoperative analgesia

Spinal anaesthesia

Femoral nerve block with nerve stimulator (0.3 to 0.5 mA) and 15 mL of lidocaine 2% plus 5 mL of distilled water

IV fentanyl

Jones 1985

Postoperative analgesia

General anaesthesia for all participants with thiopental, nitrous oxide, halothane, fentanyl and alcuronium

Lateral cutaneous nerve block with 15 mL of 0.5% bupivacaine, Eriksson's technique

IM pethidine

Kullenberg 2004

Preoperative analgesia

Unspecified

Femoral nerve block with 30 mL of 0.75% ropivacaine. Winnie's approach and nerve stimulator

IM ketobemidon plus tramadol and paracetamol

Luger 2012

Preoperative and postoperative analgesia

Spinal anaesthesia

Ultrasound‐guided femoral (3‐in‐1) nerve block (13‐6 MHz linear probe), catheter inserted ≥ 12‐15 cm past the needle tip) loaded with 30 mL of 0.25% bupivacaine followed by an infusion of 0.125% bupivacaine at 6 mL/h (motor blockade not evaluated)

or

Lumbar epidural analgesia with 0.125% bupivacaine at 8 mL/h

IV/SC piritramide or IV paracetamol

Mossafa 2005

Preoperative analgesia

Spinal anaesthesia

Fascia iliaca block with 20 mL of 1.5% lidocaine

IV fentanyl

Mouzopoulos 2009

Preoperative and postoperative analgesia

Epidural anaesthesia

Fascia iliaca block daily, Dalen's technique with 0.3 mL/kg of bupivacaine (0.25%?)

IV and analgesics

Murgue 2006

Preoperative analgesia

Unspecified

Femoral nerve block with nerve stimulator and 20 mL of mepivacaine

IV morphine or

IV paracetamol and ketoprofen

Nie 2015

Postoperative analgesia

General anaesthesia with propofol, remifentanil and atracurium

Fascia iliaca block with landmarks (2‐3 cm below the inguinal ligament); catheter inserted at least 10 cm cranially and loaded with 20 to 30 mL (weight basis) of 0.5% ropivacaine followed by 0.25% bupivacaine at 0.1 mL/kg/h for 48 hours

IV patient‐controlled analgesia with fentanyl and tropisetron

Segado Jimenez 2009

Postoperative analgesia

Spinal anaesthesia

Landmarks. Obturator nerve with 15 mL of bupivacaine with a vasoconstrictive agent, proximal to the obturator orifice. Femoral lateral cutaneous (Brown) with 10 mL of the same solution

IV morphine

Spansberg 1996

Postoperative analgesia

Spinal anaesthesia

Femoral nerve block with nerve stimulator, non‐stimulating catheter advanced 8‐15 cm past needle tip. Inserted just before surgery. Loaded with 0.4 L/kg of bupivacaine 0.5%; continuous infusion with 0.14 mL/kg/h of bupivacaine 0.25% for 16 hours after surgery

IM morphine

Szucs 2012

Preoperative and postoperative analgesia

Spinal anaesthesia

Non‐stimulating catheter for femoral nerve block, inserted in the emergency department with a nerve stimulator, 0.4 mA and 0.1 msec, space dilated before catheter insertion with 10 mL of 2% lidocaine, catheter advanced 3 cm past the needle tip and 10 mL of 0.5% bupivacaine through the catheter followed by 0.25% bupivacaine infused at
4 mL per hour for 72 hours

IM morphine

Tuncer 2003

Postoperative analgesia

General anaesthesia for all participants with propofol, nitrous oxide, isoflurane, fentanyl, morphine and atracurium

Femoral (3‐in‐1) nerve block, nerve stimulator 0.1 mA, non‐stimulating catheter advanced 4‐5 cm past the needle tip. Loaded with 30 mL of 2% lidocaine with epinephrine followed by an infusion with bupivacaine 0.125% at 4 mL/h for 48 hours

IV morphine

White 1980

Intraoperative analgesia

General anaesthesia with thiopental, nitrous oxide, halothane and fentanyl or nitrous oxide and alfaxolone/alfadolone

Psoas block with 30 mL of 2% mepivacaine, side to be blocked uppermost, Chayen's technique

or

Spinal: 0.6 to 0.8 mL of hyperbaric cinchocaine

Conventional general anaesthesia

Yun 2009

Preoperative analgesia

Spinal anaesthesia

Fascia iliaca block, Dalen's technique with 30 mL of 0.375% ropivacaine

IV alfentanil

G: gram

h: hour

IM: intramuscular

mA: milliAmpere

mcg/mL: microgram/millilitre

mg/kg: milligram/kilogram

MHz: megahertz

mL: millilitre

msec: millisecond

n: number

SC: subcutaneous

Figuras y tablas -
Table 1. Anaesthetic techniques
Table 2. Outcome definitions for acute confusional state

Study

Study authors' definition

Cuvillon 2007

Clinical evaluation "somnolence‐confusion"

Godoy 2010

"episodes of delirium"

Graham 2008

"acute confusional state"

Kullenberg 2004

"transient confusion"

Mouzopoulos 2009

"The primary outcome was perioperative delirium.
Diagnosis of the syndrome was defined using the Diagnostic
and Statistical Manual of Mental Disorders, 4th
edition (DSM‐IV), and Confusion Assessment Method
(CAM) criteria"

"Daily patient assessments using the MMSE, DRS‐R‐
98, and Digit Span test [assessment of attention, range 0
(no attention) to 42 (good attention)] were used to enable
the DSM‐IV and CAM diagnoses and assess delirium
severity"

Nie 2015

"Presurgery cognitive status was estimated using the
mini‐mental state examination before and after surgery. The Confusion
Assessment Method was used to diagnose delirium pre‐ and postsurgery"

White 1980

"confused"

Figuras y tablas -
Table 2. Outcome definitions for acute confusional state
Table 3. Complications of blocks and/or analgesic technique

Study

Complications related to regional anaesthesia

Complications related to analgesic technique

Altermatt 2013

Not reported

Not reported

Antonopoulou 2006

No complications such as motor block. local
haematoma or infection, inadvertent arterial puncture, direct nerve
damage and cardiovascular or neurological toxicity were observed

Five participants had accidental removal or the catheter: 4 during the procedure or while the catheter was secured and 1 while in the ward

Not reported

Beaudoin 2013

No other adverse events were noted during the study period, and no other adverse events were reported to study investigators

Four‐hour oxygen saturation (%) 96 (93–99) vs (%) 98 (95–99) for regional blockade

Adverse events:
Hypotension, number (%) 3 (17) vs number (%) 0 (0) for regional blockade
Respiratory depression, number (%) 9 (50) vs number (%) 4 (22) for regional blockade
Nausea/vomiting, number (%) 5 (28) vs number (%) 5 (28) for regional blockade

One participant had an episode of rapid atrial fibrillation requiring diltiazem, but the participant had a history of chronic atrial fibrillation

Chudinov 1999

No major complications were described in group regional blockade. Three participants developed local erythema at the catheter insertion site at the end of the study period

No signs of local anaesthetic toxicity were documented

One participant developed bilateral blockade (L1‐L3 on the opposite side)

Not reported

Coad 1991

No complications related to nerve blocks and no case of prolonged motor blockade

Not reported

Cuvillon 2007

Four catheters were prematurely removed: 1 by a confused participant, 2 by nurses (unexplained fever) and 1 by a surgeon (unconfirmed suspicion of local anaesthetic toxicity (ropivacaine blood level < 2 ng/mL))

More constipation (47% vs 19% for regional blockade)

De La Tabla 2010

Not reported

Not reported

Diakomi 2014

Complications such as local anaesthetic toxicity recorded as well (none reported in results section)

Nor did complication rates vary between groups

Complications such as hypoventilation (breathing rate < 8 breaths/min) were recorded as well

Moreover, the 2 groups did not differ in these parameters at any time point until study completion at 24 hours after surgery. Nor did complication rates vary between groups

Domac 2015

Not reported

Not reported

Fletcher 2003

Among study participants, none experienced adverse effects as a result of nerve block administration

No clinically important differences between groups with respect to pulse rate, oxygen saturation or respiratory rate at any time interval. Oxygen saturation 94.87%

Foss 2007

No side effects attributable to femoral nerve block were noted in any participants during their hospital stay

More participants (P = 0.05) were sedated in the morphine group at 180 minutes after block placement

No difference was noted between groups in nausea and vomiting, with 3 participants in each group having these side effects

Tendency toward lower saturation was noted in the opioid group at 60 and 180 minutes after the block despite oxygen supplementation (P = 0.08)

Gille 2006

One inadvertent arterial puncture and blood aspiration positive for 3 participants

Two transient paraesthesias

No catheter site infection

Ten catheters accidentally removed

No respiratory depression from systemic analgesia and no allergic reactions

All complications were reversible

Godoy 2010

The only complications were local bruises at the site of injection

Two participants with nausea, and 2 with nausea and vomiting

Graham 2008

No immediate complications occurred in either group

No immediate complications were noted in either group

Haddad 1995

No local or systemic complications of femoral nerve blocks were noted

Not reported

Hood 1991

No untoward sequelae were associated with nerve blocks

All plasma prilocaine concentrations (maximum 3 pg/mL) were below the suggested threshold for toxicity for prilocaine of 6 pg/mL

Not reported

Iamaroon 2010

No adverse systemic toxicity of bupivacaine, such as seizure, arrhythmia or cardiovascular collapse was noted in the femoral nerve block group

Neither vascular puncture nor paraesthesia occurred

No complications, such as haematoma, infection or persistent paraesthesia, were observed within 24 hours after the operation

No participant in either group had hypoventilation (ventilatory rate < 10/min) or oxygen saturation < 95%

Jadon 2014

Not reported

In participants of fentanyl group, drowsiness was observed that required the presence of more persons for holding the participant during positioning

SpO2 was significantly lower in the fentanyl group (P = 0.001). However, no participant in either group had SpO2 < 90% during the procedure

Mean arterial blood pressure was significantly lower in the fentanyl group (P = 0.0019)

Jones 1985

No untoward sequelae associated with the nerve block were seen

Not reported

Kullenberg 2004

No complications related to the nerve blockade were noted in this study

Not reported

Luger 2012

Not reported

Not reported

Mossafa 2005

Not reported

Not reported

Mouzopoulos 2009

No complications of femoral nerve block administrations occurred, except 3 local haematomas developed at the injection site, which resolved spontaneously

Not reported

Murgue 2006

Not reported

Not reported

Nie 2015

No adverse effects, such as pain at the insertion site or paraesthesia, were observed

No positive cultures were observed with the fascia iliaca block catheter tip, nor were any signs of infection noted in the current study

Not reported

Segado Jimenez 2009

We did not observe any complications in the realization of regional anaesthetic techniques during or subsequent to the regional anaesthetic techniques

The incidence of side effects (sleepiness, hypotension, constipation, pruritus) was greater in the group with no block than in groups with blocks (P < 0.01)

Spansberg 1996

No haematomas at the site of femoral catheters

Two participants in each group experienced nausea and vomiting

Szucs 2012

For 1 participant, the elastomeric pump failed, resulting in local anaesthetic administered over less than 54 hours instead of 72 hours, and another participant, suffering from acute confusional state, disconnected his pump after 12 hours

The incidence of nausea/vomiting, pruritus or excessive sedation was similar in the 2 groups

Tuncer 2003

Not reported

Side effects (vomiting and pruritus) were observed significantly more frequently with intravenous analgesia

White 1980

No participants showed any evidence of local anaesthetic toxicity

Not reported

Yun 2009

No adverse systemic toxicity of ropivacaine was noted, and neither vascular puncture nor paraesthesia was elicited

No complications, such as haematoma or persistent paraesthesia, were observed in participants with a femoral nerve block within 24 hours after the operation

Hypoventilation (ventilatory rate 6–8/min) or pulse oximetric desaturation (oxygen saturation 88% or 89%) was encountered in 4 participants (20%) in the intravenous analgesia group. This was reverted with assisted manual mask ventilation

All participants in the intravenous group experienced mild dizziness, and mild drowsiness was present in 12/20 of them

%: percentage

L: litre

mg: milligram

min: minute

ng/mL: nanogram/millilitre

pg/mL: picogram/millilitre

Figuras y tablas -
Table 3. Complications of blocks and/or analgesic technique
Comparison 1. Nerve block versus other modes of analgesia

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain on movement within 30 minutes of block placement Show forest plot

8

373

Std. Mean Difference (Random, 95% CI)

‐1.41 [‐2.14, ‐0.67]

2 Pain at rest within 30 minutes after block placement Show forest plot

7

322

Std. Mean Difference (Random, 95% CI)

‐0.80 [‐1.25, ‐0.35]

3 Pain at rest at 6 to 8 hours after surgery Show forest plot

5

286

Mean Difference (IV, Random, 95% CI)

‐0.38 [‐0.70, ‐0.06]

4 Pain on movement at 24 hours after surgery Show forest plot

4

195

Mean Difference (IV, Random, 95% CI)

‐0.39 [‐1.08, 0.30]

4.1 Surgical technique unspecified

3

169

Mean Difference (IV, Random, 95% CI)

0.09 [‐0.10, 0.29]

4.2 Arthroplasty for 38.4% of participants

1

26

Mean Difference (IV, Random, 95% CI)

‐1.94 [‐2.75, ‐1.13]

5 Pain at rest at 24 hours after surgery Show forest plot

8

435

Mean Difference (IV, Random, 95% CI)

‐0.68 [‐1.23, ‐0.13]

5.1 Single shot blocks

2

80

Mean Difference (IV, Random, 95% CI)

‐0.5 [‐0.90, ‐0.10]

5.2 Continuous blocks

6

355

Mean Difference (IV, Random, 95% CI)

‐0.78 [‐1.58, 0.03]

6 Pain on movement at 48 hours Show forest plot

2

129

Mean Difference (IV, Fixed, 95% CI)

0.09 [‐0.23, 0.40]

7 Pain at rest at 48 hours after surgery Show forest plot

5

335

Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.87, 0.13]

7.1 Psoas compartment block

1

40

Mean Difference (IV, Random, 95% CI)

‐1.10 [‐2.26, 0.06]

7.2 Femoral nerve block

3

191

Mean Difference (IV, Random, 95% CI)

0.06 [‐0.16, 0.28]

7.3 Fascia iliaca block

1

104

Mean Difference (IV, Random, 95% CI)

‐0.92 [‐1.47, ‐0.36]

8 Pain at rest at 72 hours after surgery Show forest plot

2

140

Mean Difference (IV, Random, 95% CI)

‐0.48 [‐1.83, 0.87]

8.1 Psoas compartment block

1

40

Mean Difference (IV, Random, 95% CI)

‐1.20 [‐1.77, ‐0.63]

8.2 Femoral nerve block

1

100

Mean Difference (IV, Random, 95% CI)

0.18 [0.03, 0.33]

9 Acute confusional state Show forest plot

7

676

Risk Ratio (M‐H, Random, 95% CI)

0.69 [0.38, 1.27]

9.1 Peripheral nerve block based on landmarks

4

501

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.23, 2.93]

9.2 Peripheral nerve block based on nerve stimulator

3

175

Risk Ratio (M‐H, Random, 95% CI)

0.56 [0.32, 0.98]

10 Pneumonia Show forest plot

3

131

Risk Ratio (M‐H, Fixed, 95% CI)

0.41 [0.19, 0.89]

11 Mortality Show forest plot

7

316

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.34, 1.52]

12 Time to first mobilization Show forest plot

2

155

Mean Difference (IV, Random, 95% CI)

‐11.25 [‐14.34, ‐8.15]

13 Costs of analgesic regimens Show forest plot

2

Std. Mean Difference (Random, 95% CI)

Subtotals only

13.1 Single shot blocks

1

75

Std. Mean Difference (Random, 95% CI)

‐3.48 [‐4.23, ‐2.74]

13.2 Continuous blocks

1

62

Std. Mean Difference (Random, 95% CI)

0.93 [0.37, 1.48]

14 Pressure sores Show forest plot

3

187

Risk Ratio (M‐H, Random, 95% CI)

0.47 [0.09, 2.53]

14.1 Single shot femoral nerve block (on admission)

2

125

Risk Ratio (M‐H, Random, 95% CI)

0.18 [0.02, 1.38]

14.2 Continous femoral nerve block (after surgery)

1

62

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.19, 4.90]

15 Opioid requirement Show forest plot

7

285

Std. Mean Difference (Random, 95% CI)

‐0.70 [‐0.96, ‐0.44]

15.1 Single shot blocks

5

245

Std. Mean Difference (Random, 95% CI)

‐0.73 [‐1.01, ‐0.44]

15.2 Continuous blocks

2

40

Std. Mean Difference (Random, 95% CI)

‐0.55 [‐1.18, 0.08]

16 Participant satisfaction Show forest plot

5

237

Std. Mean Difference (Random, 95% CI)

0.91 [0.62, 1.20]

Figuras y tablas -
Comparison 1. Nerve block versus other modes of analgesia