To determine the optimum choice of implant for a patient with a the different types of trochanteric hip fracture.
1000 patients with a trochanteric hip fracture were randomised to internal fixation ...of the fracture with either a Sliding Hip Screw or an intramedullary nail. Fractures were subdivided into two part fractures, comminuted fractures and fractures at the level of the lesser trochanter (reversed/oblique and transverse). Functional assessment for up to one year from injury was undertaken by a research nurse blinded to the treatment allocation.
The mean age of patients was 82years and 77% were female. There was a significantly improved regain of mobility for those treated with the intramedullary nail. No statistically significant differences between the two types of fixation methods was observed for mortality, fracture healing complications, re-operations, hospital stay, length of surgery, blood transfusion requirements, medical complications, degree of residual pain or regain of independence. These finding were valid for all fracture types.
This study is the first adequately powered randomised trial on this topic and demonstrates that there are no notable differences in either process or functional outcomes between these two treatment methods, other than a tendency to better regain of mobility for those fractures fixed with an intramedullary nail.
Peripheral nerve blocks for hip fractures Guay, Joanne; Parker, Martyn J; Griffiths, Richard ...
Cochrane database of systematic reviews,
05/2017, Letnik:
5
Journal Article
Recenzirano
Odprti dostop
Various nerve blocks with local anaesthetic agents have been used to reduce pain after hip fracture and subsequent surgery. This review was published originally in 1999 and was updated in 2001, 2002, ...2009 and 2017.
This review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anaesthesia for hip fracture surgery. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.
For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), MEDLINE (Ovid SP, 1966 to August week 1 2016), Embase (Ovid SP, 1988 to 2016 August week 1) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to August week 1 2016), as well as trial registers and reference lists of relevant articles.
We included randomized controlled trials (RCTs) involving use of nerve blocks as part of the care provided for adults aged 16 years and older with hip fracture.
Two review authors independently assessed new trials for inclusion, determined trial quality using the Cochrane tool and extracted data. When appropriate, we pooled results of outcome measures. We rated the quality of evidence according to the GRADE Working Group approach.
We included 31 trials (1760 participants; 897 randomized to peripheral nerve blocks and 863 to no regional blockade). Results of eight trials with 373 participants show that peripheral nerve blocks reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I
= 90%; high quality of evidence). Effect size was proportionate to the concentration of local anaesthetic used (P < 0.00001). Based on seven trials with 676 participants, we did not find a difference in the risk of acute confusional state (risk ratio (RR) 0.69, 95% CI 0.38 to 1.27; I
= 48%; very low quality of evidence). Three trials with 131 participants reported decreased risk for pneumonia (RR 0.41, 95% CI 0.19 to 0.89; I
= 3%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 72; moderate quality of evidence). We did not find a difference in risk of myocardial ischaemia or death within six months, but the number of participants included was well below the optimal information size for these two outcomes. Two trials with 155 participants reported that peripheral nerve blocks also reduced time to first mobilization after surgery (mean difference -11.25 hours, 95% CI -14.34 to -8.15 hours; I
= 52%; moderate quality of evidence). One trial with 75 participants indicated that the cost of analgesic drugs was lower when they were given as a single shot block (SMD -3.48, 95% CI -4.23 to -2.74; moderate quality of evidence).
High-quality evidence shows that regional blockade reduces pain on movement within 30 minutes after block placement. Moderate-quality evidence shows reduced risk for pneumonia, decreased time to first mobilization and cost reduction of the analgesic regimen (single shot blocks).
Anaesthesia for hip fracture surgery in adults Guay, Joanne; Parker, Martyn J; Gajendragadkar, Pushpaj R ...
Cochrane database of systematic reviews,
02/2016, Letnik:
2
Journal Article
Recenzirano
Odprti dostop
The majority of people with hip fracture are treated surgically, requiring anaesthesia.
The main focus of this review is the comparison of regional versus general anaesthesia for hip (proximal ...femoral) fracture repair in adults. We did not consider supplementary regional blocks in this review as they have been studied in another review.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2014, Issue 3), MEDLINE (Ovid SP, 2003 to March 2014) and EMBASE (Ovid SP, 2003 to March 2014).
We included randomized trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The main outcomes were mortality, pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, deep vein thrombosis and return of patient to their own home.
Two reviewers independently assessed trial quality and extracted data. We analysed data with fixed-effect (I(2) < 25%) or random-effects models. We assessed the quality of the evidence according to the criteria developed by the GRADE working group.
In total, we included 31 studies (with 3231 participants) in our review. Of those 31 studies, 28 (2976 participants) provided data for the meta-analyses. For the 28 studies, 24 were used for the comparison of neuraxial block versus general anaesthesia. Based on 11 studies that included 2152 participants, we did not find a difference between the two anaesthetic techniques for mortality at one month: risk ratio (RR) 0.78, 95% confidence interval (CI) 0.57 to 1.06; I(2) = 24% (fixed-effect model). Based on six studies that included 761 participants, we did not find a difference in the risk of pneumonia: RR 0.77, 95% CI 0.45 to 1.31; I(2) = 0%. Based on four studies that included 559 participants, we did not find a difference in the risk of myocardial infarction: RR 0.89, 95% CI 0.22 to 3.65; I(2) = 0%. Based on six studies that included 729 participants, we did not find a difference in the risk of cerebrovascular accident: RR 1.48, 95% CI 0.46 to 4.83; I(2) = 0%. Based on six studies that included 624 participants, we did not find a difference in the risk of acute confusional state: RR 0.85, 95% CI 0.51 to 1.40; I(2) = 49%. Based on laboratory tests, the risk of deep vein thrombosis was decreased when no specific precautions or just early mobilization was used: RR 0.57, 95% CI 0.41 to 0.78; I(2) = 0%; (number needed to treat for an additional beneficial outcome (NNTB) = 3, 95% CI 2 to 7, based on a basal risk of 76%) but not when low molecular weight heparin was administered: RR 0.98, 95% CI 0.52 to 1.84; I(2) for heterogeneity between the two subgroups = 58%. For neuraxial blocks compared to general anaesthesia, we rated the quality of evidence as very low for mortality (at 0 to 30 days), pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, decreased rate of deep venous thrombosis in the absence of potent thromboprophylaxis, and return of patient to their own home. The number of studies comparing other anaesthetic techniques was limited.
We did not find a difference between the two techniques, except for deep venous thrombosis in the absence of potent thromboprophylaxis. The studies included a wide variety of clinical practices. The number of participants included in the review is insufficient to eliminate a difference between the two techniques in the majority of outcomes studied. Therefore, large randomized trials reflecting actual clinical practice are required before drawing final conclusions.
Numerous types of arthroplasties may be used in the surgical treatment of a hip fracture (proximal femoral fracture). The main differences between the implants are in the design of the stems, whether ...the stem is cemented or uncemented, whether a second articulating joint is included within the prosthesis (bipolar prosthesis), or whether a partial (hemiarthroplasty) or total whole hip replacement is used.
To review all randomised controlled trials comparing different arthroplasties for the treatment of hip fractures in adults.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2009), CENTRAL (The Cochrane Library 2009, Issue 3), MEDLINE, EMBASE and trial registers (all to September 2009), and reference lists of articles.
All randomised and quasi-randomised controlled trials comparing different arthroplasties and their insertion with or without cement, for the treatment of hip fractures.
Two review authors independently assessed trial quality, by use of a 10-item checklist, and extracted data.
Twenty-three trials involving 2861 older and mainly female patients with proximal femoral fractures are included. Cemented prostheses, when compared with uncemented prostheses (6 trials, 899 participants) were associated with a less pain at a year or later and improved mobility. No significant difference in surgical complications was found. One trial of 220 participants compared a hydroxyapatite coated hemiarthroplasty with a cemented prosthesis and reported no notable differences between the two prosthesis. Comparison of unipolar hemiarthroplasty with bipolar hemiarthroplasty (7 trials, 857 participants, 863 fractures) showed no significant differences between the two types of implant. Seven trials involving 734 participants compared hemiarthroplasty with a total hip replacement (THR). Most studies involved cemented implants. Dislocation of the prosthesis was more common with the THR but there was a general trend within these studies to better functional outcome scores for those treated with the THR.
There is good evidence that cementing the prostheses in place will reduce post-operative pain and lead to better mobility. From the trials to date there is no evidence of any difference in outcome between bipolar and unipolar prosthesis. There is some evidence that a total hip replacement leads to better functional outcome than a hemiarthroplasty. Further well-conducted randomised trials are required.
Debate continues about whether it is better to use a cemented or uncemented hemiarthroplasty to treat a displaced intracapsular fracture of the hip. The aim of this study was to attempt to resolve ...this issue for contemporary prostheses.
A total of 400 patients with a displaced intracapsular fracture of the hip were randomized to receive either a cemented polished tapered stem hemiarthroplasty or an uncemented Furlong hydroxyapatite-coated hemiarthroplasty. Follow-up was conducted by a nurse blinded to the implant at set intervals for up to one year from surgery.
A total of 115 patients died in the year after surgery. There was a tendency towards a slightly higher mortality in those treated with the uncemented prosthesis after one year (64 vs 51; p = 0.18). For the survivors, there was no significant difference in pain score at any of the time intervals. Patients treated using the cemented hemiarthroplasty recovered mobility better than those treated with the uncemented hemiarthroplasty (mean decrease in mobility score at one year: 1.7 vs 1.1, SD 1.9; p = 0.008). There was a tendency to more periprosthetic fractures in the uncemented group (five vs two cases; p = 0.45), but overall the need for further surgery was similar in both groups (nine vs seven cases). There were four perioperative deaths in the cemented group.
These results indicate that a contemporary cemented hemiarthroplasty gives better results than an uncemented hemiarthroplasty for patients with a displaced intracapsular fracture of the hip. When the condition of the patient permits, a cemented hemiarthroplasty should be used. Cite this article:
2020;102-B(1):11-16.
•Displaced intracapsular fractures in the ‘fitter’ elderly patient may be treated with either a hemiarthroplasty or total hip replacement, but the optimum choice of implant remains ...controversial.•This randomised trial of 104 participants found no major difference between treatment methods after a five year follow up period.•We advise caution over the recent promotion of THR for intracapsular hip fractures.
104 patients with a displaced intracapsular fracture were randomised to surgical treatment with either a cemented hemiarthroplasty or a cemented total hip arthroplasty. All surviving patients were followed up for five years from injury by a blinded observer. No differences in outcome between groups was seen for the degree of residual pain or regain of function or independence. There was a tendency to more complications and re-operations for those treated with the total hip arthroplasty.
We continue to recommend that caution should be exercised regarding the increased promotion of THR for intracapsular hip fractures until further studies with long term follow up are completed.
This review focuses on the use of peripheral nerve blocks as preoperative analgesia, as postoperative analgesia, or as a supplement to general anesthesia for hip fracture surgery and tries to ...determine if they offer any benefit in terms of pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction/ischemia, pneumonia, mortality, time to first mobilization, and cost of analgesic.
Trials were identified by computerized searches of Cochrane Central Register of Controlled Trials (2016, Issue 8), MEDLINE (Ovid SP, 1966 to 2016 August week 1), Embase (Ovid SP, 1988 to 2016 August week 1), and the Cumulative Index to Nursing and Allied Health Literature (EBSCO, 1982 to 2016 August week 1), trials registers, and reference lists of relevant articles. Randomized controlled trials involving the use of nerve blocks as part of the care for hip fractures in adults aged 16 years and older were included. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted the data. The quality of evidence was judged according to the Grading of Recommendations, Assessment, Development, and Evaluations Working Group scale.
Based on 8 trials with 373 participants, peripheral nerve blocks reduced pain on movement within 30 minutes of block placement: standardized mean difference, -1.41 (95% confidence interval CI, -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I statistic = 90%; high quality of evidence). The effect size was proportional to the concentration of local anesthetic used (P < .00001). Based on 7 trials with 676 participants, no difference was found in the risk of acute confusional state: risk ratio, 0.69 (95% CI, 0.38-1.27; I statistic = 48%; very low quality of evidence). Based on 3 trials with 131 participants, the risk for pneumonia was decreased: risk ratio, 0.41 (95% CI, 0.19-0.89; I statistic = 3%; number needed-to-treat for additional beneficial outcome, 7 95% CI, 5-72; moderate quality of evidence). No difference was found for the risk of myocardial ischemia or death within 6 months but the number of participants included was well below the optimum information size for these 2 outcomes. Based on 2 trials with 155 participants, peripheral nerve blocks also reduced the time to first mobilization after surgery: mean difference, -11.25 hours (95% CI, -14.34 to -8.15 hours; I statistic = 52%; moderate quality of evidence). From 1 trial with 75 participants, the cost of analgesic drugs when used as a single-shot block was lower: standardized mean difference, -3.48 (95% CI, -4.23 to -2.74; moderate quality of evidence).
There is high-quality evidence that regional blockade reduces pain on movement within 30 minutes after block placement. There is moderate quality of evidence for a decreased risk of pneumonia, reduced time to first mobilization, and reduced cost of analgesic regimen (single-shot blocks).
A review of the literature was undertaken to determine which amenable factors could be identified that would potentially improve the morbidity or mortality after hip fracture. Only four factors were ...identified that have been clearly reported to be associated with a reduction in mortality or morbidity, these were early surgery, cemented arthroplasty and experience of the surgeon and peri-operative antibiotics. Five interventions were identified that may reduce mortality or morbidity: nerve blocks, nutritional support, pharmacological thromboembolic prophylaxis, mechanical intermittent pneumatic compression and nail fixation of extracapsular fractures. Several other factors were identified for which it remains uncertain if they will reduce mortality or morbidity: preoperative assessment, β-blockers, blood transfusion, anti-embolism stockings, choice of surgical implant, cardiac output monitoring during surgery, choice of anaesthesia, prevention of intraoperative hypotension, anabolic steroids, multidisciplinary care, and rehabilitation. Continuing research is required to define which interventions are clearly effective and to further identify any adverse effects.
Abstract Continued debate exists about the merits of the different surgical approaches for arthroplasty of the hip. For hemiarthroplasty to the hip the two most commonly used approaches are lateral ...and posterior. 216 patients with an intracapsular hip fracture being treated with a cemented hemiarthroplasty were randomised to surgery using either a lateral or posterior approach. Surviving patients were followed up for one year with pain and functional outcomes assessed by an assessor blinded to the treatment allocation. No statistically significant differences were observed for any of the outcome measures including mortality, degree of residual pain and regain of walking ability. A subjective assessment of the ease of surgery favoured the lateral approach. In conclusion both surgical approaches appear to produce comparable function outcomes.
Abstract Background Debate exists as to what should be the transfusion threshold for patients with anaemia after hip fracture surgery. Methods A total of 200 patients aged 60 years and above with a ...haemoglobin level of between 8.0 and 9.5 g dl−1 after hip fracture surgery were randomised to receive a transfusion to raise the haemoglobin to at least 10.0 g dl−1 or not to have a transfusion unless definite symptoms of anaemia became apparent. Patients were followed up for 1 year. Results There was no statistically significant difference in the outcomes of mortality, hospital stay, regain of mobility or complications between the two groups. Conclusions This study confirms other recent research studies which found that reducing the transfusion threshold to 8.0 g dl−1 appears to be a safe practice for this group of patients.
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