A Systematic Review of the Effects of Fascia Iliaca Assignment Answer

See Appendix 1.

The effectiveness of Fascia Illiaca Block (FIB) in preoperative Neck of femur (NOF) adult patients: An integrative review

Introduction

Neck of femur (NOF) fractures represent a significant clinical challenge in orthopedic surgery, especially among the elderly. These fractures are associated with substantial morbidity and mortality, significantly impacting patients' quality of life (Verma et al. 2022). Timely and effective pain management is crucial to alleviate suffering and facilitate optimal surgical outcomes and early mobilisation. One promising approach that has gained attention in recent years is the Fascia Iliaca Block (FIB) (Marenghi et al. 2021). This integrative review aims to examine the effectiveness of the FIB as a preoperative analgesic technique in adult NOF fracture patients. This integrative review addresses this by systematically examining and synthesising the literature on FIB in adult NOF fracture patients. By following a critical discussion of the literature, this review aims to provide clinicians and researchers with a comprehensive understanding of its potential as a preoperative analgesic technique in this specific patient population.

Background

Hip fractures are a frequent injury, particularly in the elderly, when addressed in emergency rooms. Young patients participating in high-energy trauma or athletic competition may also experience it. Threatening joint issues must be diagnosed and treated immediately (Kazley and Bagchi 2023). Annually, approximately 200,000 Australians with NOF fractures are hospitalised at a cost of more than AUD445 million. Moreover, Over 6 per cent of patients with NOF fractures pass away within 30 days after the injury, which results in a significant mortality rate (Moore et al. 2021). Women account for 70% of all hip fractures. Age-related hip fracture risk rises exponentially, and white females are likelier to experience it (Kazley and Bagchi 2023).

Intracapsular fractures within the hip joint capsule are closely associated with osteoporosis, a condition characterised by decreased bone density and strength. Osteoporosis weakens the bone structure, making it more susceptible to fractures, especially in the femoral neck, which is already vulnerable due to its relatively narrow diameter (Kazley and Bagchi 2023). Advanced age is a significant risk factor for NOF fractures, primarily because aging is associated with bone density loss and changes in bone quality. As individuals age, their bones become less resilient, increasing the likelihood of fractures. Trauma, typically a fall or direct impact on the hip, is a common trigger for intracapsular fractures (Emmerson et al. 2023). The force applied to the hip during a fall can lead to a fracture in the weakened femoral neck. Additionally, the vascular supply to the femoral head, critical for maintaining bone health, traverses the neck of the femur. Consequently, a fracture in this region can disrupt blood flow to the femoral head, potentially leading to avascular necrosis, where bone tissue dies due to a lack of blood supply. This complication can result in significant joint dysfunction and long-term disability (Barney et al. 2023).

On the other hand, extracapsular NOF fractures occur outside the hip joint capsule, often in the intertrochanteric or subtrochanteric regions of the femur. These fractures result from higher-energy trauma and are more common in younger individuals with stronger bones (Emmerson et al. 2023). Mechanical stress plays a pivotal role in extracapsular fractures, with the femur breaking due to the sheer force applied during traumatic events. While osteoporosis is less frequently associated with extracapsular fractures, compromised bone quality or certain medications can still weaken bone structure (Piccirilli et al. 2022). NOF fractures have serious repercussions. In addition to the tremendous agony patients feel right once, these fractures frequently leave patients immobile and increase their risk of complications. Long-term bed rest can lead to pressure sores, decreased mobility, shallow breathing can lead to pneumonia, and diminished circulation can raise the risk of deep vein thrombosis. These problems may result in lengthy hospital stays or even death in extreme circumstances (O’Connor 2019).

Traditionally, opioids and systemic analgesics have been the primary approaches to pain management in patients with neck of femur (NOF) fractures, including hip fractures (Wennberg et al. 2018). However, mounting evidence underscores these pharmacological interventions' considerable drawbacks and risks, particularly in elderly populations more susceptible to adverse effects and complications (Aragaki and Brophy 2021). For instance, a study revealed that among older adults with hip fractures, opioid use was significantly linked to a heightened risk of adverse events, encompassing gastrointestinal complications and urinary retention. These adverse effects inflict discomfort upon patients and complicate their overall medical management (Dumic et al. 2019). Moreover, in the context of the opioid crisis, the potential for opioid-related complications, such as dependence, addiction, and overdose, has garnered significant attention. A randomised control trial found that opioid utilisation in hip fracture patients correlated with an increased risk of complications and extended hospital stays, emphasising the urgent need for strategies to curtail opioid consumption in this demographic (Unneby et al. 2020).

In response to these challenges, regional analgesic techniques like the Fascia Iliaca Block (FIB) have become a compelling alternative for pain management in NOF fractures. The research landscape unequivocally supports FIB's efficacy and multifaceted benefits (Kim et al. 2022). FIB has been administered in various clinical settings, including the emergency department, pre-hospital care, and operating rooms. For instance, a systematic review by Wan et al. 2020, demonstrated that FIB effectively provides pain relief in hip fracture patients. This study encompassed several studies that consistently showcased reductions in pain scores and diminished opioid requirements following FIB administration.

Another study by Scurrah et al. 2018, found that FIB provided rapid pain relief, with most patients experiencing significant pain reduction within 15 minutes of administration. The study also highlighted that FIB had a localised effect on pain relief, reducing the risk of systemic side effects associated with opioids. Furthermore, an integrative review conducted by Guinocor 2021 corroborated and reinforced these compelling findings, underscoring a significant reduction in opioid consumption among patients recovering from hip fractures who received Fascia Iliaca Compartment Block (FIB) compared to their counterparts who did not receive this intervention. This decrease in opioid utilisation is paramount as it is pivotal in mitigating the inherent risks and complications associated with prolonged opioid therapy, including dependency and adverse side effects (Guinocor 2021).

METHODOLOGY

To identify pertinent studies for inclusion in this research, a comprehensive search was conducted across three reputable databases: CINAHL, MEDLINE, and PubMed. The search strategy incorporated various combinations of keywords and phrases, including (Fascia Iliaca Block) AND (Neck of femur) OR (hip fracture) AND (elderly) along with corresponding MeSH terms as appropriate in PubMed. The search was limited to studies published in English from 2016 to the present, focusing on the adult population to ensure the most current and relevant evidence. Following the initial search, a rigorous screening encompassed duplicate checks, title assessments, and abstract reviews. Articles deemed potentially relevant based on these criteria were then subjected to a comprehensive evaluation of their entire content.

Employing the Equator critical appraisal tools, it was determined whether the identified papers had received informed consent and ethical approval (Buccheri and Sharifi 2017). As shown in Appendix 3, the outcomes and conclusions from these studies were collated to extract critical information about nutritional therapies and wound healing outcomes. A total of 15 papers, representing a range of evidence levels, met the inclusion criteria. These publications included a range of research approaches, including systematic reviews, randomised controlled trials, retrospective and prospective investigations, and cohort studies. This multifaceted strategy to gathering and assessing the evidence ensured a thorough comprehension of the subject and provided insightful information for the research.

DISCUSSION

Pain Management

The majority of the research examined in this review have shown how well FICB works to relieve hip fracture patients' pain. A retrospective cohort analysis (n=110) on patients with hip fractures was carried out by Houserman et al. in 2022. They discovered that FICB was linked to a shorter duration in the hospital, with an average of 3.9 days, contrasted to the non-FICB group, which had an average of 4.8 days (P .001), lower pain scores on postoperative days 2 and 3 (P =.019), and no significant difference between cohorts in the time from admission to surgery (P =.112) or the use of narcotics (P =.304). When compared to the non-FICB group, the FICB group had a greater chance of being readmitted within 30 days (P =.047). These results suggest that FICB could accelerate up healing and aid in pain management following surgery.

In a retrospective observational trial (n=192) on patients with different forms of fragility hip fractures, Li et al. (2019) further confirm the pain-relieving capabilities of FICB. They reported statistically significant pain score reductions (P=0.006) and a notable decrease in the need for opioid analgesia after FICB. This reduction in opioid consumption is particularly relevant in the ongoing opioid crisis, highlighting FICB's potential role in mitigating this issue.

Schulte et al. (2020) conducted a prospective randomised controlled trial (n=97) that further corroborated the effectiveness of FICB in decreasing opioid consumption. The study demonstrated a significant decrease in morphine consumption (13 vs. 17, P = 0.04) and increased patient-reported satisfaction in the FICB group ((25' vs. 2', P = 0.09). The proportion of people discharged home was also considerably more significant in the FIB group (50.9% vs. 32.5%, P = 0.05). The authors recommend integrating FICB into institutional geriatric hip fracture protocols as an adjunctive pain control strategy.

Moreover, Hao et al. (2022) explored the effects of FICB on postoperative pain and hip function in elderly patients with hip fractures. Their prospective, observational, and randomised trial (n=120) revealed that the FICB group had significantly lower pain scores (P < .05) at rest and with movement and a more rapid recovery of hip function after surgery. Moreover, the Harris hip scores (HHS) of the FICB and RA groups were (53.41±8.63) and (40.02±9.61). The incidence of postoperative complications and adverse events did not differ significantly between the FICB and control groups (P = .13).

Castillón et al. (2017) conducted a prospective cohort study focusing on the effects of FICB on pain management. According to their findings (95%CI: 2.45-3.53%), there were statistically significant variations between the VAS pain scores prior to and following FICB administration. The study also showed that 26% of patients needed morphine as a last resort, underscoring the value of FICB and other efficient pain relief methods.

The researchers found a significant reduction in morphine usage among patients who received preoperative FICB in Thompson et al.'s randomised prospective study (n=47) in 2020 (P = 0.05). The study also noted an improvement in patient-reported satisfaction. As evidenced by the reduced demand for morphine and greater patient satisfaction levels (31%, P = 0.01), the findings showed that FICB successfully reduced pain. The fact that there were no appreciable variations in the use of acetaminophen or tramadol for mild or moderate pain suggests that FICB mainly affected the need for stronger opioids like morphine.

FICB and its effect on pain alleviation were the subject of a systematic review by Wan et al. in 2020. They found that FICB could offer pain relief that was on par with or better than that offered by traditional analgesics. As a result, fewer extra analgesics were needed, which is good for controlling postoperative pain. Additionally, the study emphasized how FICB aided in earlier mobilization and helped to avoid problems. These results emphasize the possible advantages of integrating FICB into alleviating pain techniques.

A prospective, randomised, controlled trial (n=88) was carried out by Ma et al. in 2018 to examine the effects of FICB on pain management in very elderly persons with hip fractures. Patients who got FICB had considerably lower VAS pain levels than those who did not (P=0.023), showing that this method effectively lessened pain intensity. Additionally, the FICB group's participants reported higher levels of satisfaction with their general analgesic regimen (P 0.001). This shows that FICB not only enhanced pain management but also enhanced patient satisfaction with their pain reduction.

The preoperative and postoperative pain in patients undergoing FICB was evaluated by Hao et al. 2019 in their double-blind, randomised clinical trial (n=90). Their findings suggested that preoperative pain was reduced in the experimental group (p>0.05), suggesting that FICB was successful in treating pain before surgery. Although there were differences in preoperative pain scores that were statistically significant (13.9% versus 35.7%, p=0.018), there may not have been as much of a difference in postoperative pain scores.

Complications and Side Effects

Assessing the safety and potential side effects of FICB is critical in determining its overall utility. Zhou et al. (2019) compared the analgesia of femoral obturator nerve block (FONB) and FICB in elderly patients (65 years old) with hip fractures. The prospective, double-blind, controlled study (n=154) reported that the FONB group required significantly fewer postoperative analgesic drugs and experienced less nausea and vertigo than the FICB group(P=0.031 and P=0.034, respectively). In addition, significantly higher postoperative function quality was seen in the FONB group of patients (p=0.029). These findings suggest that while FICB may be effective, alternative techniques like FONB may provide better pain management with fewer side effects in some cases.

Furthermore, in their retrospective matched case control study (n=40), Rasappan et al. (2021) investigated the continuous infusion fascia iliaca compartment block (CFICB) in geriatric hip fracture patients. The study demonstrated that post-operative pain scores and total opioid consumption during the first three days were significantly lower in the CFICB group than in the control group (p < 0.0001). However, the CFICB group had slower rehabilitation in the short term but no significant difference in function and mobility at one year post-surgery. These findings suggest that CFICB provides safe and effective post-operative pain relief without adversely affecting long-term outcomes.

Block Techniques

Aprato et al. (2018) contributed to the review through their blind randomised control trial (n=120) by comparing FICB with intra-articular hip injection (IAHI) for pain management in patients with intracapsular hip fractures among patients more than 65 years of age. The results of this prospective study were intriguing as they found that IAHI provided better preoperative pain management and significantly reduced pain in the post-anesthesia care unit (p < 0.05). However, FICB offered superior analgesia on most patients' first and second postoperative days (72.9%). This finding indicated that the block technique may influence pain relief and should be tailored to the patient's condition and the type of hip fracture.

Stephan et al. (2020), on the other hand, provided a unique perspective by comparing single-shot FICB with continuous catheter FICB in their prospective, observational cohort study (n=107). Their prospective, randomised, controlled trial found no significant differences in pain management, postoperative analgesia requirements, or functional outcomes between these two techniques (p=0.067). The findings implied that single-shot FICB and continuous catheter FICB may be viable options for pain relief, giving healthcare providers some flexibility.

Cognitive function and delirium

In the double-blind, randomised controlled trial (n=127) by Wennberg et al. 2019, the researchers found that prehospital pain medicine was administered 50% more frequently in patients with mild to moderate cognitive impairment than those with severe cognitive impairment. This highlighted the importance of tailoring pain management strategies to the specific needs of patients with cognitive issues.

Hao et al. 2019 in their double-blind, randomised clinical trial (n=90), also investigated the incidence of postoperative delirium in patients who received FICB. Their study found a lower occurrence of postoperative delirium in the experimental group that received FICB (13.9% versus 35.7%, p=0.018). These findings suggested that pre-emptive analgesia with continuous FICB positively impacts postoperative delirium by providing more effective pain relief and mitigating the risk of delirium.

Lastly, Pasquier et al. (2019) conducted a double-blind, randomised, controlled trial (n=30) to investigate the impact of FICB on cognitive function in hip fracture patients who were over 70 years old. The results showed that FICB did not affect cognitive status in the study group (difference = - 0.9, 95%CI [- 2.4, 0.5]) and on movement (difference = - 0.9, 95%CI [- 2.7; 0.9]). Moreover, there was no significant difference in the pain score profiles for both groups at rest and movement (p=0.53 and p=0.45, respectively). However, the study only assessed long-term outcomes within three months, leaving the impact of FICB on sustained cognitive function unexplored.

CONCLUSION

The studies on Fascia Iliaca Compartment Block (FICB) in hip fracture patient management reveal its significant effectiveness. The findings have consistently demonstrated that pre-operatively, FICB reduces pain, lowers opioid use, and enhances patient satisfaction. Moreover, FICB promotes faster recovery, shorter hospital stays and early mobilisation, improving post-operative outcomes. However, alternative techniques such as femoral obturator nerve block (FONB) may benefit some patients. Moreover, continuous infusion fascia iliaca compartment block (CFICB) effectively controls pain but may cause short-term rehabilitation delays. These studies also emphasise the importance of personalised pain management, particularly for patients with cognitive impairment. FICB may help reduce the risk of postoperative delirium, but further research is needed regarding its long-term cognitive effects.

REFERENCES

Aprato, A., Audisio, A., Santoro, A., Grosso, E., Devivo, S., Berardino, M. and Masse, A., 2018. Fascia-iliaca compartment block vs intra-articular hip injection for preoperative pain management in intracapsular hip fractures: A blind, randomized, controlled trial. Injury, 49 (12), pp.2203-2208. 

Aragaki, D. and Brophy, C., 2021. Geriatric pain management. In Pain Care Essentials and Innovations (pp. 137-150). Elsevier. 

Barney, J., Piuzzi, S.N. and Akhondi, H., 2023. Femoral head avascular necrosis. In Stat Pearls

Buccheri, R.K. and Sharifi, C., 2017. Critical appraisal tools and reporting guidelines for evidence‐based practice. Worldviews on Evidence‐Based Nursing, 14 (6), pp.463-472. 

Castillón, P., Veloso, M., Gómez, O., Salvador, J., Bartra, A. and Anglés, F., 2017. Fascia iliaca block for pain control in hip fracture patients. Revista Española de Cirugía Ortopédica y Traumatología (English Edition), 61 (6), pp.383-389. 

Dumic, I., Nordin, T., Jecmenica, M., Stojkovic Lalosevic, M., Milosavljevic, T. and Milovanovic, T., 2019. Gastrointestinal tract disorders in older age. Canadian Journal of Gastroenterology and Hepatology , 2019 . 

Emmerson, B.R., Varacallo, M. and Inman, D., 2023. Hip fracture overview. In Stat Pearls . 

Guinocor, M., 2021. Identifying and Evaluating Pain Management in Hospitalized Older Adults with Hip Fractures: An Integrative Review. 

Hao, C., Li, C., Cao, R., Dai, Y., Xu, C., Ma, L., Guo, A. and Yu, H., 2022. Effects of Perioperative Fascia Iliaca Compartment Block on Postoperative Pain and Hip Function in Elderly Patients With Hip Fracture. Geriatric Orthopaedic Surgery & Rehabilitation, 13 , p.21514593221092883. 

Hao, J., Dong, B., Zhang, J. and Luo, Z., 2019. Pre-emptive analgesia with continuous fascia iliaca compartment block reduces postoperative delirium in elderly patients with hip fracture: A randomized controlled trial. Saudi Medical Journal, 40 (9), p.901. 

Houserman, D.J., Raszewski, J.A., Palmer, B., Chavan, B., Sferrella, A., Campbell, M. and Santanello, S., 2022. The impact of the fascia iliaca block beyond perioperative pain control in hip fractures: A retrospective review. Geriatric Orthopaedic Surgery & Rehabilitation, 13 , p.21514593221099107.

Kazley, J. and Bagchi K., 2023. Femoral neck fractures. In Stat Pearls . 

Kim, C.H., Yang, J.Y., Min, C.H., Shon, H.C., Kim, J.W. and Lim, E.J., 2022. The effect of regional nerve block on perioperative delirium in hip fracture surgery for the elderly: A systematic review and meta-analysis of randomized controlled trials. Orthopaedics & Traumatology: Surgery & Research , 108 (1), p.103151. 

Li, J., Dai, F., Chang, D., Harmon, E., Ibe, I., Sukumar, N., Halaszynski, T.M., Rubin, L.E. and O'Connor, M.I., 2019. A practical analgesia approach to fragility hip fracture: A single-center, retrospective, cohort study on femoral nerve block. Journal of Orthopaedic Trauma, 33 (4), pp.175-179. 

Ma, Y., Wu, J., Xue, J., Lan, F. and Wang, T., 2018. Ultrasound‑guided continuous fascia iliaca compartment block for pre‑operative pain control in very elderly patients with hip fracture: A randomized controlled trial. Experimental and Therapeutic Medicine, 16 (3), pp.1944-1952. 

Marenghi, N.M., Pilson, H.T.P. and Halvorson, J.J., 2021. Advances in Geriatric Hip Fractures: Pre-Operative Considerations and Tips to Optimize Outcome. Journal of Orthopaedic Trauma , 35 , pp.S32-S37. 

Moore, E., Obst, S., Heales, L., Clift, K. and Stanton, R., 2021. Pre-Hospital Immobilisation for Neck of Femur Fractures in Australia-a Break in the Evidence. Australasian Journal of Paramedicine , 18 , pp.1-4.

O'Connor, R., 2019. Prehospital care in isolated neck of femur fracture: A literature review. Journal of Paramedic Practice , 11 (1), pp.21-27. 

Pasquier, M., Taffé, P., Hugli, O., Borens, O., Kirkham, K.R. and Albrecht, E., 2019. Fascia iliaca block in the emergency department for hip fracture: A randomized, controlled, double-blind trial. BMC Geriatrics, 19 , pp.1-8.

Piccirilli, E., Cariati, I., Primavera, M., Triolo, R., Gasbarra, E. and Tarantino, U., 2022. Augmentation in fragility fractures, bone of contention: A systematic review. BMC Musculoskeletal Disorders , 23 (1), p.1046.

Rasappan, K., Chua, I.T.H., Tey, J.B.L. and Ho, S.W.L., 2021. The continuous infusion fascia iliaca compartment block: A safe and effective analgesic modality in geriatric hip fracture patients. Archives of Orthopaedic and Trauma Surgery, 141 , pp.29-37. 

Schulte, S.S., Fernandez, I., Van Tienderen, R., Reich, M.S., Adler, A. and Nguyen, M.P., 2020. Impact of the fascia iliaca block on pain, opioid consumption, and ambulation for patients with hip fractures: A prospective, randomized study. Journal of Orthopaedic Trauma, 34 (10), pp.533-538.

Scurrah, A., Shiner, C.T., Stevens, J.A. and Faux, S.G., 2018. Regional nerve blockade for early analgesic management of elderly patients with hip fracture–A narrative review. Anaesthesia , 73 (6), pp.769-783. 

Stephan, S.R., Garlich, J.M., Debbi, E.M., Johnson, C.R., Polakof, L.S., Noorzad, A.S., Moak, Z.B., Yalamanchili, D.R., Stephenson, S.K., Anand, K.K. and Lin, C.A., 2020. A comparison in outcomes of preoperative single-shot versus continuous catheter fascia Iliaca regional anesthesia in geriatric hip fracture patients. Injury, 51 (6), pp.1337-1342. 

Thompson, J., Long, M., Rogers, E., Pesso, R., Galos, D., Dengenis, R.C. and Ruotolo, C., 2020. Fascia iliaca block decreases hip fracture postoperative opioid consumption: A prospective randomized controlled trial. Journal of Orthopaedic Trauma, 34 (1), pp.49-54. 

Unneby, A., Svensson, O., Gustafson, Y., Lindgren, B.M., Bergström, U. and Olofsson, B., 2020. Complications with focus on delirium during hospital stay related to femoral nerve block compared to conventional pain management among patients with hip fracture–A randomised controlled trial. Injury , 51 (7), pp.1634-1641.

Verma, U.K., Dhamnaskar, N., Kulkarni, R.V., Archik, S., Kataria, J., Khatri, A., Dsouza, S.C. and Tiwari, A., 2022. Prospective Evaluation of Quality of Life and Function after Surgical Management of Femoral Neck Fractures in Elderly Patients. In Aging Clinical and Experimental Research, 34 (1), S391-S391. 

Wan, H.Y., Li, S.Y., Ji, W., Yu, B. and Jiang, N., 2020. Fascia iliaca compartment block for perioperative pain management of geriatric patients with hip fractures: A systematic review of randomized controlled trials. Pain Research and Management , 2020 . 

Wennberg, P., Andersson, H. and Sundström, B.W., 2018. Patients with suspected hip fracture in the chain of emergency care: An integrative review of the literature. International Journal of Orthopaedic and Trauma Nursing , 29 , pp.16-31. 

Wennberg, P., Möller, M., Herlitz, J. and Kenne Sarenmalm, E., 2019. Fascia iliaca compartment block as a preoperative analgesic in elderly patients with hip fractures–effects on cognition. BMC Geriatrics , 19 (1), pp.1-8. 

Zhou, Y., Zhang, W.C., Chong, H., Xi, Y., Zheng, S.Q., Wang, G. and Wu, X.B., 2019. A prospective study to compare analgesia from femoral obturator nerve block with fascia iliaca compartment block for acute preoperative pain in elderly patients with hip fracture. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 25 , p.8562. 

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