[Femoral nerve block as pain relief in hip fracture. A good alternative in perioperative treatment proved by a prospective study]. [Analgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study]. Non-invasive interactive neurostimulation in the post-operative recovery of patients with a trochanteric fracture of the femur. A randomised, controlled trial. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Ultrasound guidance improves the success of sciatic nerve block at the popliteal fossa. Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study. Methodological challenges of multiple-component intervention: lessons learned from a randomized controlled trial of functional recovery after hip fracture.
Almost 25% of all patients with hip fracture experience temporary confusion pre- and directly postoperatively due to trauma, advanced age, transport between units, and the use of analgesics, 35-50% of the patients suffer temporary or chronic decubitus. Analgesics often lead to nausea. A femoral nerve block can interrupt sensory impulses from the hip joint and provide complete pain relief without affecting the CNS, thus making preoperative care easier and postoperative rehabilitation can be started earlier. 80 consecutive patients with hip fracture were randomized to femoral nerve block or pharmacological treatment only. Paracetamol and tramadol were the standard analgesics used. All patients were followed up with regard to pain, duration of the block, number of analgesics doses, temporary confusion and time for postoperative mobilization. Pain was estimated by the patients using the visual analogue scale (VAS). A nerve block was performed to block the femoral nerve, the lateral femoral cutaneous nerve and the obturator nerve with 30 ml of ropivacaine 7.5 mg/ml. Mental status was evaluated with Pfeiffer-test. All patients experienced relatively intense pain on admission with an average VAS of 6. After nerve block the VAS was 2. Pain relief was the same in the control group. Pain relief was sustained for 15 hours. The time for mobilization after surgery was significantly lower, 23 hours compared to 36 for the control group. There was a lower number of patients temporarily confused in the block group compared to the control group, however no significant differences were seen. Femoral nerve block provides adequate pain relief, equivalent to pharmacological treatment in most patients. The time for postoperative mobilization was shorter and less temporary confusion was seen. There were no complications in this group, making nerve block a good alternative to traditional pharmacological preoperative treatment for patients with hip fractures. The usefulness of peripheral femoral nerve block for pain management after hip fracture has been established. This prospective and randomised study compared the analgesia effect of a continuous femoral nerve block (CF) versus two conventional analgesia procedures after hip fracture.
                Patients. (n=62) scheduled for surgery under spinal anaesthesia were prospectively included. After surgery, analgesia (48 hours) was randomised: group FC (femoral catheter, anterior paravascular approach, initial bolus followed by continuous infusion of ropivacaine 0.2%), group P (iv 2 g propacetamol/6 hours), group M (sc morphine, 0.05 mg/kg per 4 hour). Intravenous morphine titration was performed, followed by subcutaneous (sc) morphine every 4 hours according to the VAS score. The primary end-point was the morphine requirements. Secondary end-points were VAS score, side effects, and mortality.
                Demographic data and surgical procedures were similar between groups. After morphine titration, the VAS pain score did not differ between groups. All patients in-group M received additional morphine. Morphine mean consumption was increased in CF group: 26 mg (5-42) versus P: 8 mg (3-12) (p=0.0001) or M: 19 mg (8-33) (p<0.006) while constipation was decreased in P group vs CF. Percentage of patients requiring no morphine was similar between P (n=6; 28%) and CF (n=6; 28%) and greater than M (n=0; 0%). Hospital discharge, cardiovascular or pulmonary complications and mortality after 6 months showed no statistical difference.
                Continuous femoral nerve block provided limited pain relief after hip fracture did not reduced side effects and induced an expensive cost. We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were randomised after stabilisation of the fracture into two equal groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device. All other aspects of their rehabilitation were the same. The treatment was continued for ten days after operation. Outcome measurements included the use of a visual analogue scale for pain, the brief pain inventory and Ketorolac for post-operative control of pain, and an overall assessment of outcome by the surgeon. There were significantly better results for the patients receiving treatment by active electrical stimulation (repeated measures analysis of variance, p < 0.001). The findings of this pilot trial justify a larger study to determine if these results are more generally applicable. The use of ultrasound reduces the onset time, improves the quality of sensory block, and minimizes the risks associated with the supraclavicular approach for brachial plexus and stellate ganglion blockade. The present study was designed to evaluate whether ultrasound also facilitates the approach for 3-in-1 blocks. Forty patients (ASA physical status II or III) undergoing hip surgery after trauma were randomly assigned to two groups. In the ultrasound (US) group, 20 mL bupivacaine 0.5% was administered under US guidance, whereas in the control group, the same amount and concentration of local anesthetic was administered with the assistance of a nerve stimulator (NS). After US- or NS-based identification of the femoral nerve, the local anesthetic solution was administered, and the distribution of the local anesthetic solution was visualized and recorded on videotape in the US group. The quality and the onset of the sensory block was assessed by using the pinprick test in the central sensory region of each of the three nerves and compared with the same stimulation on the contralateral leg every 10 min for 60 min. The rating was performed using a scale from 100% (uncompromised sensibility) to 0% (no sensory sensation). Heart rate, noninvasive blood pressure, and oxygen saturation were measured at short intervals for 60 min. The onset of sensory blockade was significantly shorter in Group US compared with Group NS (US 16 +/- 14 min, NS 27 +/- 16 min, P < 0.05). The quality of the sensory block after injection of the local anesthetic was also significantly better in Group US compared with Group NS (US 15% +/- 10% of initial value, NS 27% +/- 14% of initial value, P < 0.05). A good analgesic effect was achieved in 95% of the patients in the US group and in 85% of the patients in the NS group. In the US group, visualization of the cannula tip, the femoral nerve, the major vessels, and the local anesthetic spread was possible in 85% of patients. Incidental arterial puncture (n = 3) was observed only in the NS group. We conclude that an US-guided approach for 3-in-1 block reduces the onset time, improves the quality of the sensory block and minimizes the risks associated with this regional anesthetic technique. Implications: The onset time and the quality of a regional anesthetic technique for the lower extremity is improved by ultrasonographic nerve identification compared with older techniques. Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery.
                Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 mug/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy.
                Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups.
                Postoperative epidural analgesia after hip fracture surgery provides superior analgesia attenuating pain as a restricting factor during rehabilitation without motor dysfunction. However, superior analgesia did not translate into enhanced rehabilitation. Future studies with multimodal rehabilitation are required to establish whether superior analgesia can be translated into enhanced rehabilitation and reduced morbidity in hip fracture patients. Recently it has been demonstrated that the use of ultrasound (US) improves the onset time and the quality of sensory block for 3-in-1 blocks compared with conventional nerve stimulator (NS) techniques. The present study was designed to evaluate if US guidance for 3-in-1 blocks reduces the amount of local anesthetic compared to NS guidance.
                After institutional approval and informed consent, 60 patients undergoing hip surgery following trauma were randomly assigned to three groups of 20 patients each. In group A, the 3-in-1 block was performed using US guidance with 20 mL 0.5% bupivacaine. Group B received 20 mL 0.5% bupivacaine, and group C received 30 mL 0.5% bupivacaine during NS guidance. The quality and the onset time was assessed by pinprick test in the central sensory region of each of the three targeted nerves and compared with the contralateral leg every 10 minutes for 1 hour by a blinded observer. The rating was undertaken using a scale from 100% (uncompromised sensibility) to 0% (no sensation).
                Overall success for the 3-in-1 block in group A was 95% and in groups B and C 80%. Onset time was significantly shorter in the US-guided group compared with both NS-guided groups (group A 13+/-6 minutes; group B 27+/-12 minutes; and group C 26+/-13 minutes; P < .01 to groups B and C). Quality of sensory block was significantly better in group A (4%+/-5% of initial value) compared with groups B and C (group B 21%+/-11% of initial value, P < .01 to group A; group C 22%+/-19%, P < .01 to group A).
                The amount of local anesthetic for 3-in-1 blocks can be reduced by using US guidance compared with the conventional NS-guided technique. Real time ultrasound guidance is a recent development in the area of peripheral nerve blockade. There are limited data from prospective randomized trials comparing its efficacy to that of traditional nerve localization techniques. In the present study, we tested the hypothesis that ultrasound guidance improves the success rate of sciatic nerve block at the popliteal fossa when compared with a nerve stimulator-guided technique.
                After Institutional Research Ethics Board approval and informed consent, 74 patients undergoing elective major foot or ankle surgery were randomly assigned to receive a sciatic nerve block at the popliteal fossa guided by either ultrasonography (group US, transverse view, needle in plane approach above the sciatic nerve bifurcation), or nerve stimulation (group NS, single injection, 10 cm proximal to the knee crease). A standardized local anesthetic admixture (15 mL of 2% lidocaine with 1:200,000 epinephrine and 15 mL of 0.5% bupivacaine) was used. Sensory and motor function was assessed by a blinded observer at predetermined intervals for up to 1 hour. Block success was defined as a loss of sensation to pinprick within 30 minutes in the distribution of both tibial and common peroneal nerves.
                Group US had a significantly higher block success rate than group NS (89.2% vs. 60.6%, P = .005), while the procedure time was similar.
                Ultrasound guidance enhances the quality of popliteal sciatic nerve block compared with single injection, nerve stimulator-guided block using either a tibial or peroneal endpoint. Ultrasound guidance resulted in higher success, faster onset, and progression of sensorimotor block, without an increase in block procedure time, or complications. To compare the analgesic benefit of preoperative skin traction with the placement of a pillow under the injured extremity in patients with hip fractures.
                Prospective, randomized clinical study.
                University-affiliated teaching institution.
                One hundred consecutive patients with hip fractures admitted to the authors' institution who met inclusion criteria were enrolled. Fifty-five patients had femoral neck fractures, and forty-five patients had intertrochanteric fractures. The average patient age was seventy-eight years.
                All patients were preoperatively randomized into two intervention groups. One group underwent placement of five pounds of skin traction on the injured extremity, whereas the second underwent placement of a pillow under the injured extremity. Fifty patients were enrolled in each intervention group.
                With respect to immediate postintervention pain levels, patients treated with a pillow showed a trend toward better pain relief, as compared with patients treated with skin traction; however, this was not statistically significant. On the morning after admission, patients treated with a pillow had a statistically significant greater reduction in pain (p = 0.04). These patients also requested a statistically significant lower amount of pain medication (p < 0.01).
                The authors think that preoperative skin traction in patients with hip fractures does not provide significant pain relief, as compared with pillow placement under the injured extremity, and thus should not be routinely performed in this patient population for analgesia. We conducted a randomized controlled trial to assess the efficacy and safety of a multiple-component intervention designed to improve functional recovery after hip fracture. One hundred seventy-six patients who underwent surgery for a primary unilateral hip fracture were assigned randomly to receive usual care (control arm, n = 86) or a brief motivational videotape, supportive peer counseling, and high-intensity muscle-strength training (intervention arm, n = 90). Between-group differences on the physical functioning, role-physical, and social functioning domains of the SF-36 were assessed postoperatively at 6 months. At the end of the trial, 32 intervention and 27 control patients (34%) completed the 6-month outcome assessment. Although patient compliance with all three components of the intervention was uneven, over 90% of intervention patients were exposed to the motivational videotape. Intervention patients experienced a significant (P = 0.03) improvement in the role-physical domain (mean change, -11 +/- 33) compared to control patients (mean change, -37 +/- 41). Change in general health (P = 0.2) and mental health (P = 0.1) domain scores was also directionally consistent with the study hypothesis. Although our findings are consistent with previous reports of comprehensive rehabilitation efforts for hip fracture patients, the trial was undermined by high attrition and the possibility of self-selection bias at 6-month follow-up. We discuss the methodological challenges and lessons learned in conducting a randomized controlled trial that sought to implement and assess the impact of a complex intervention in a population that proved difficult to follow up once they had returned to the community.
Because of the small number of participants included in this review, limitations in the measurement and reporting of outcomes and the differing types of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant clinical benefit when compared with other analgesic methods as part of the treatment of a hip fracture. They do, however, reduce the degree of pain experienced by the patient from the hip fracture and subsequent surgery. Further randomised trials with larger numbers of participants and full reporting of clinical outcomes would be justified.