Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis

Abstract

ObjectiveWe conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block (PNB) types for preoperative pain management of hip fractures. MethodsWe searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged > 16 years with hip fractures who received PNBs or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 h after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). ResultsWe included 63 randomized controlled studies (4778 participants) were included, of which only a few had a low risk of bias. The femoral nerve block (FNB), 3-in-1 block, fascia iliaca compartment block (FICB), and pericapsular nerve group block (PENG block) yielded significantly lower pain scores at 2h after block placement than those of no block (standardized mean differences (SMD): -1.1; 95% credible interval (CrI): -1.7, -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0, -0.55, [low]; SMD: -1.4; 95% CrI: -2.0, -0.72, [low]; SMD: -2.3; 95% CrI: -3.2, -1.4, [moderate], respectively). The PENG block, 3-in-1 block, FICB, and FNB resulted in lower pain scores than the no-block group. Additionally, the PENG block yielded a lower pain score than FNB, or FICB (SMD: -1.21, 95% CrI: -2.18, -0.23, [very low]; SMD: -0.92; 95% CrI: -1.70, -0.16, [low]). However, both the FICB and FNB did not show a reduction in morphine consumption compared to no block. No studies have compared the PENG block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay. ConclusionsCompared with no block, preoperative PNBs for hip fractures appear to reduce pain 2 hours after block placement. When comparing different blocks, PENG block might be superior to FICB and FNB for pain relief, though the confidence evidence was low in most comparisons due to the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.