Fascia Iliaca Block Decreases Hip Fracture Postoperative Opioid Consumption: A Prospective Randomized Controlled Trial
Authors: Raymond Pesso
Charles Ruotolo
Jeffrey Thompson
Mitchell Long
Eloise Rogers
David Galos
Rhyne Champ Dengenis
Journal: Journal of Orthopaedic Trauma (2020)
Discipline: CLINICAL MEDICINE
Keywords: preoperative fascia iliaca compartment block; postoperative pain; functional recovery; hip fracture surgery; geriatric patients
Affiliations: Departments of Orthopedics., Anesthesia, Nassau University Medical Center, East Meadow, NY.

Abstract:  Objectives: To determine the efficacy of a preoperative fascia iliaca compartment block in decreasing postoperative pain and improving functional recovery after hip fracture surgery. Design: Randomized prospective Level 1 therapeutic. Setting: Academic Level 1 trauma center. Patients: Geriatric patients with fractures of the proximal femur (neck, intertrochanteric, or subtrochanteric regions) were prospectively randomized into an experimental (A) or control (B) groups. Forty-seven patients met inclusion criteria, 23 randomized to the experimental group and 24 to the control group. Intervention: Patients randomized to the experimental group received an ultrasound-guided fascia iliaca compartment block administered by a board-certified anesthesiologist immediately before the initiation of anesthesia. Main outcome measurements: Primary outcome measure was postoperative pain medication consumption until postoperative day 3. Secondary outcomes included functional recovery and a study-specific patient-reported satisfaction survey assessed on postoperative day 3. Results: There was no significant difference in consumption of acetaminophen for mild pain, tramadol for moderate pain, or functional recovery between the 2 groups. There was a statistically significant decrease in morphine consumption (0.4 mg vs. 19.4 mg, P = 0.05) and increase in patient-reported satisfaction (31%, P = 0.01). Conclusions: Preoperative fascia iliaca compartment block significantly decreases postoperative opioid consumption while improving patient satisfaction. We recommend the integration of this safe and efficacious modality into institutional geriatric hip fracture protocols as an adjunctive pain control strategy. Level of evidence: Therapeutic Level II See Instructions for Authors for a complete description of levels of evidence. 

Retracted: No

PubPeer comments:
 We read the article by Thompson et al. [1] with great interest, and appreciate the authorsu2019 efforts to investigate the postoperative efficacy of fascia iliaca compartment block in decreasing pain and improving functional recovery following surgery for hip fracture. However, we would like to raise three concerns. The primary outcome measure was postoperative pain medication consumption, assessed using a visual analog scale (VAS), from the perioperative period to postoperative day three. If the postoperative pain intensity is being evaluated, the primary outcome is usually pain intensity measurement using a VAS or numerical rating scale, as reported in previous studies [2, 3]. Postoperative pain medication consumption could be the secondary outcome. However, in this study by Thompson et al. [1] the pain intensity was unfortunately not reported, which could have been of interest to the Journal of Orthopaedic Trauma readership as it pertains to a clinical setting. Moreover, readers might find it helpful to know the total pain medication consumption per 24 hours over 3 days, not the total pain medication consumption until postoperative day three. In a study on postoperative pain, general or spinal anesthesia and the methods of intraoperative anesthesia should follow standardized study protocols. There is a serious concern that clinicians who are not familiar with studies on pain management may misinterpret the results, especially those of the first 24 hours postoperatively. In such a study on the postoperative functional recovery of elderly patients, the walking status and medical condition prior to hip fracture, according to the American Society of Anesthesiologistsu2019 physical status, are required in the included criteria to assess baseline characteristics. Hence, we are concerned about the misinterpretation of the reported outcomes based on the study design. References 1. Thompson J, Long M, Rogers E, et al. Fascia iliaca block decreases hip fracture postoperative opioid consumption: a prospective randomized controlled trial. J Orthop Trauma. 2019; doi: 10.1097 BOT.0000000000001634. [Epub ahead of print] 2. Amin NH, West JA, Farmer T, et al. Nerve blocks in the geriatric patient with hip fracture: a review of the current literature and relevant neuroanatomy. Geriatr Orthop Surg Rehabil. 2017;8:268-275.u3000 3. Yamamoto N, Sakura S, Noda T, et al. Comparison of the postoperative analgesic efficacies of intravenous acetaminophen and fascia iliaca compartment block in hip fracture surgery: A randomised controlled trial. Injury. 2019;50(10):1689u20101693. ,