Efficacy of supplemental peripheral nerve blockade for hip fracture surgery: multiple treatment comparison

Abstract

This study was designed to determine the most effective peripheral nerve block supplement to standard anesthesia management for hip fracture patients. We systematically reviewed randomized controlled trials (RCTs) published from 1990 to 2010 and conducted multiple treatment comparisons using direct and indirect evidence for two outcomes, i.e., acute pain intensity and delirium. We combined trials by type of injection (regardless of time of insertion during the perioperative phase, use of nerve block catheter, local anesthetic type, additives, or duration of treatment). Twenty-one RCTs comprising 1,422 participants were included. In most cases, the trials were conducted in Europe; they excluded patients with cognitive impairment, and they were unclear or at high risk of bias. The combination of obturator and lateral femoral cutaneous nerve blockade had the highest probability of being the most effective against acute postoperative pain. Fascia iliaca blockade had the highest probability of being the most effective against delirium. There was no difference in outcomes among other nerve blocks. Not all nerve blocks are equally effective in improving outcomes after hip fracture. Multiple treatment comparison, a tool to compare the effectiveness of multiple treatments simultaneously, provides useful guidance to anesthesia providers seeking effective treatment when faced with a body of RCTs wherein each investigates one treatment. More RCTs comparing multiple nerve blocks in hip fracture are needed.