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Fig. 1 Femoral neck fracture treated with bipolar hemiarthroplasty
Courtesy of Nassau University Medical Center

AAOS Now

Published 3/24/2021
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Terry Stanton

Fascia Iliaca Block in Hip Fracture Surgery Reduces Opioid Consumption, Yields Other Benefits

A study that sought to determine the efficacy of a preoperative fascia iliaca compartment block (FICB) in geriatric patients undergoing surgery for hip fracture found that preoperative FICB significantly decreased postoperative opioid consumption while improving patient satisfaction.

The study was presented at the 2020 Annual Meeting of the Orthopaedic Trauma Association by Jeffrey Thompson, DO, a fifth-year resident at Nassau University Medical Center in East Meadow, N.Y., who received the Memorial Award for Resident/Fellow Research.

Fig. 1 Femoral neck fracture treated with bipolar hemiarthroplasty
Courtesy of Nassau University Medical Center
Fig. 2 Intertrochanteric femur fracture treated with long cephalomedullary nail
Courtesy of Nassau University Medical Center
Table 1 Average pain medication consumption from postoperative day one to three VAS, visual analog scale
Courtesy of Jeffrey Thompson, DO
Jeffrey Thompson, DO

Dr. Thompson explained that he and his colleagues were prompted to undertake the study because, “We found that some hip fracture patients were having issues with postoperative pain control. Some would report inadequate pain control, which limited their ability to mobilize, while others experienced profound somnolence, which also prevents appropriate postoperative rehabilitation.”

In the study, 341 hip fractures between February 2017 and February 2019 were assessed for eligibility to be included. Of those, 217 were excluded, primarily due to dementia, and 77 patients declined to participate, largely due to family concerns regarding clinical research. The remaining 47 patients were randomized into two groups: 23 patients in the experimental (A) group and 24 patients in the control (B) group. There were no significant differences in age, sex, fracture pattern, surgical procedure, or anesthesia technique between the two groups.

The researchers measured total pain medication consumption from the perioperative period to postoperative day (POD) three (Table 1). There was no statistically significant difference in the consumption of acetaminophen for mild pain; group A consumed 3,779.4 mg and group B consumed 4,546.9 mg, a difference of 17 percent (P = 0.14). Tramadol consumption for moderate pain recorded a 43 percent reduction in group A compared to group B (97.8 mg versus 170.4 mg; P = 0.08). For severe pain, group A consumed 0.4 mg of morphine, whereas group B consumed 19.4 mg; this 98 percent reduction in opioid consumption was statistically significant (P = 0.05). “Only two patients in group A had pain severe enough to require opioid dosing, in contrast to 13 patients in group B,” the authors wrote.

The researchers also analyzed the number of feet ambulated with physical therapy on POD three, as well as results of a patient satisfaction questionnaire administered on POD three. Group A displayed a 50 percent increase in average distance ambulated (20.2 versus 13.5 feet; P = 0.23). The patient satisfaction survey demonstrated a statistically significant 31 percent higher score in group A compared to group B (23.6 versus 17.9; P = 0.01).

Dr. Thompson said the study’s finding that FICB patients mobilized better postoperatively came as a bit of a surprise: “We were glad to see that the block did not produce any clinically significant motor weakness, which would limit functional recovery.”

Of the 23 patients in group A, no intervention-related complications or adverse events were recorded. None of the patients receiving a block reported residual injection site pain, sensory or motor deficits, intravascular injections, cardiopulmonary events, or other adverse events.

The authors noted that studies have demonstrated that geriatric hip fracture patients who have prolonged hospital stays and delayed early functional recovery are less likely to regain preoperative walking ability or ability to perform physical and instrumental activities of daily living. Most recovery usually occurs during the first six months postoperatively. One study, by Morrison et al. further described the importance of adequate pain control, “as patients with higher pain scores after hip fracture surgery were more likely to miss physical therapy sessions, less likely to be ambulating at POD three, and had significantly lower locomotion scores at six months.” Increasingly, there has been acknowledgment that heavy opioid use is linked to increased risk of delirium and decreased functional recovery. “Finding the perfect balance of pain management is further complicated by patient-driven factors, including hesitance to complain of pain and physician fear of masking or exacerbating medical decompensation with opiates,” Dr. Thompson and colleagues wrote.

Physiologically, the authors wrote, “A preoperative FICB was able to successfully desensitize sensory nerves before they were stimulated by operative insults, and the long-acting effects of the block limited early postoperative pain. We found that patients became less reliant on systemic medications for analgesia and were more tolerant of early mobilization, demonstrating that a preoperative FICB is a valuable adjunct to the institutional hip fracture protocol for decreasing postoperative opioid consumption. The FICB decreased postoperative pain and enhanced functional recovery regardless of the anesthesia technique used, which is likely due to the long-acting duration of the regional block exceeding the effects of both general and spinal anesthesia.” None of the patients who received the FICB experienced rebound pain, which, the authors noted, “may be the result of the timing of administration (before operative stimulus) or the long-acting nature of this large-volume compartment block.”

The primary limitation of the study was the small sample size. The authors noted, “The power was sufficient to detect statistically significant differences in opioid consumption and patient satisfaction; however, a larger sample size may be able to detect a significant difference in other outcome measures, such as tramadol consumption.”

Dr. Thompson said the findings have led to a change at his institution that may serve as a clinical takeaway for all surgeons who manage geriatric hip fractures. “We have added a preoperative FICB to our institution’s hip fracture protocol, which continues to be a potent adjunct to geriatric pain control,” he said. The result: “We have seen hip fracture patients using fewer opioids and mobilizing more rapidly postoperatively since instituting the FICB to our regimen.”

The study’s authors concluded, “We recommend the integration of FICB into institutional geriatric hip fracture protocols as an adjunctive pain control strategy.”

Dr. Thompson’s coauthors of “Fascia Iliaca Block Decreases Hip Fracture Postoperative Opioid Consumption: A Prospective Randomized Controlled Trial” are David Galos, MD; Mitchell Long, DO; Charles J. Ruotolo, MD; and Rhyne Champ Dengenis, DO.

Terry Stanton is the senior medical writer for AAOS Now. He can be reached at tstanton@aaos.org.

References 

  1. Morrison RS, Magaziner J, Gilbert M, et al: Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Bio Sci Med Sci. 2003;58:76-81.
  2. Morrison RS, Magaziner J, McLaughlin MA, et al: The impact of post-operative pain on outcomes following hip fracture. Pain 2003;103:303-11