New: Hip Fracture Repair Surgery

Summary of recommendations and key evidence for pain management in patients undergoing hip fracture repair surgery

Systemic analgesia

• No procedure-specific studies were identified for paracetamol. Nevertheless, paracetamol is recommended as part of basic multimodal analgesia because it contributes to pain relief, particularly when combined with NSAIDs or COX-2-selective inhibitors (Joshi 2019).
• No procedure-specific studies were identified for NSAIDs/COX-2-selective inhibitors. However, NSAIDs/COX-2-selective inhibitors are recommended as part of basic multimodal analgesia, when not contra-indicated. Of note, gastro-intestinal, cardiac and renal complications of NSAIDs should be taken into account particularly in older patients (Wongrakpanich 2018).

Regional analgesic strategies

• Procedure-specific evidence shows that both the FNB and the FICB reduced pain scores and opioid consumption in the majority of trials.
• Our findings confirm previous systematic reviews and meta-analyses, which concluded that either FNB or FICB is safe and effective to provide good perioperative analgesia and to reduce opioid consumption (Guay 2018; Skjold 2020; Rashiq 2013; Ritcey 2016; Riddell 2016; Fadhlillah 2019; Hong 2019; Steenberg and Møller 2018; Wan 2020).
• Of note, FICB is a heterogeneous group of blocks, the distal and the proximal supra-inguinal blocks, and some may consider them as different technqiues. Since the supra-inguinal approach covers a broader area than the infra-inguinal approach, the supra-inguinal approach is preferred.

Choice of nerve block should be based on local expertise

• Both the FICB and the FNB are easy to perform, with a favourable safety profile; there is no evidence to favour one technique over the other. Therefore, the choice between FNB or FICB should be based on clinician experience and/or institutional preferences.
• Although, in theory, FICB should provide better pain relief than FNB, as it blocks the lateral femoral cutaneous nerve along with the femoral nerve, several investigations have shown them to be equally effective (Shukla 2018).
• Also, FICB might provide better outcomes in terms of chronic postsurgical pain and might be preferable because of its relative simplicity and reduced invasiveness, but also because it requires less expensive equipment and less time to perform the FICB placement (Shukla 2018, Diakomi 2020; Newman 2013).

No catheter should be used except in specific circumstances

• The analgesic benefits of continuous infusion techniques are not sufficient to justify the placement of catheters on a routine basis, but may be considered if there is an expected delay for surgery.
• Motor blockade can occur depending on the local anaesthetic dilution. However, this should not preclude the use of peripheral nerve blocks because patients typically do not ambulate for about 24 h. Nevertheless, depending on the timing of surgery, single shot nerve blocks are recommended as continuous catheter techniques might delay ambulation. Also, peripheral blocks could be repeated if necessary.
• There is a need for further research assessing the balance of risks and complexity versus analgesic benefits of continuous techniques in the presence of optimal basic analgesic administration.

Anaesthesia techniques

• Spinal anaesthesia may provide superior pain relief in the immediate postoperative phase (Haghighi 2017; Heidari 2011; Luger 2010). However, the choice of spinal or general anaesthesia depends on factors other than pain (e.g. patient-, surgeon- and institution- related factors).
• Future trials are necessary to assess differences in outcome between different anaesthetic techniques in hip fracture patients.

Intervention

Reason for not recommending