Skip the Nerve Block for Hip Fractures

Peripheral nerve blocks delayed mobilization and hospital discharge in a large, single-center series

What’s the Claim?

In a large, single-center, retrospective-comparative case series, peripheral nerve blocks delayed time to ambulation and hospital discharge after hip fracture surgery in patients over the age of 65. Alternatives, including general anesthesia and, in particular, epidural anesthesia, fared better. Interestingly, spinal anesthetics were not used in this series. The effect sizes were large enough to care about — for ambulation, the difference was about 37% (a hazard ratio of 0.63, 95% CI 0.53 to 0.74) after controlling for relevant confounding variables.

How’s It Stack Up?

Although seemingly straightforward, review of the available evidence on this topic is confusing. The best comparator here probably is a recently updated Cochrane review of randomized trials. It favored peripheral nerve blocks, though it included a heterogeneous group of indications for these blocks, including some studies that evaluated them for pain management before surgery. The strongest finding (from the pooling of 13 trials) was that blocks reduced pain as well as the risk of delirium (confusion) after surgery when compared with systemic opioids alone. Weaker findings (from three studies each) were that these blocks facilitated early mobilization — in contrast to the current study — and concomitantly reduced the risk of pneumonia. Many of the RCTs in the Cochrane analysis excluded patients with dementia; the current study included those patients, which makes it perhaps a bit more real-world relevant. Still, it’s confusing.

What’s Our Take?