Orthopaedic surgeons' perspectives on peripheral nerve blocks for surgical fixation of hip fractures in older adults

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Abstract

Objectives:

This study aimed to identify factors influencing orthopaedic surgeons' decision to request peripheral nerve blocks (PNBs) for older adults undergoing hip fracture surgery and to assess the need for further research.

Design:

A cross-sectional survey.

Setting:

Academic and private practice.

Participants:

One hundred twenty-nine orthopaedic surgeons.

Intervention:

A 24-question survey assessed PNB usage, perceived advantages and disadvantages.

Main Outcome Measures:

Survey responses describing factors influencing orthopaedic surgeons' decision to request PNBs for older adults undergoing hip fracture surgery.

Results:

Seventy-one percent of orthopaedic surgeons reported they believed there were benefits to using PNBs for older adults undergoing surgical fixation of hip fractures. The main perceived advantages were reduced pain and opioid use within 72 hours postoperatively. Primary concerns about PNB use were the negative impact on clinical care efficiency and delayed mobilization. Most surgeons (85%) agreed that higher-level evidence investigating benefits beyond acute postoperative pain control would aid decision-making.

Conclusion:

Surgeons believe PNBs provide acute postoperative analgesic benefits; however, concerns about delaying clinical care have likely limited widespread implementation. If future research demonstrates the effectiveness of PNBs beyond acute pain relief, it may further motivate healthcare systems to solve workflow challenges and increase the use of PNBs for hip fracture surgery.

Level of Evidence:

III, Cross-Sectional Study.

1. Introduction

Hip fractures in older adults are severe injuries that pose a significant global healthcare challenge.^1–3 Despite advances in perioperative care, older patients undergoing hip fracture surgery continue to experience high rates of complications and mortality postoperatively.^3,4 The reasons for these poor outcomes are not fully understood but may stem from a combination of fracture-related trauma and pre-existing comorbidities.^5,6

Debate continues regarding the most effective anesthesia and analgesia for hip fracture surgery.⁷ Several professional guidelines recommend peripheral nerve blocks (PNBs) as a primary method for managing perioperative pain in geriatric hip fractures.^8–12 PNBs are a regional anesthesia technique that provides targeted peripheral neural blockade to reduce the pain signal and stress response associated with the fracture. However, despite suggested guidelines and recognized benefits for acute pain management, the use of PNBs varies widely in surgical practice.^13,14 Recent population-based data from Ontario shows that only 18.5% of patients with hip fracture receive a PNB within 1 day of surgery, with similar low utilization reported in the United States (<5%).¹⁵ By contrast, PNB utilization rates exceed 50% in the United Kingdom.¹⁵ This variability may be due to conflicting evidence in current literature regarding the overall benefits of PNBs for older adults undergoing surgical fixation of hip fractures.^14,15

Given the inconsistent literature and variable clinical implementation, the study's primary aim was to identify factors influencing orthopaedic surgeons' decision to request PNBs for older adults undergoing hip fracture surgery. In addition, the study sought to assess surgeons' interest in participating in a clinical trial designed to evaluate the effectiveness of PNBs beyond acute pain control in this patient population.

2. Material and Methods

2.1. Study Design

This cross-sectional study used an anonymous online survey to gather perspectives from orthopaedic surgeons across multiple countries, including the United States, Canada, and Europe. After obtaining Institutional Review Board exemption, the study survey was conducted from April 2024 to June 2024.

2.2. Questionnaire Development

A questionnaire was developed to assess orthopaedic surgeons' preferences and practices regarding PNBs for older adults with hip fractures. The questionnaire was based on a review of existing literature and input from key informants in the field. A team consisting of 2 orthopaedic surgeons, 1 epidemiologist, and 1 anesthesiologist contributed to the questionnaire's development. This group also evaluated the questions for comprehension and clarity to ensure the survey would effectively capture the intended information.

2.3. Pretesting and Validity Assessment

The questionnaire was pretested with an independent group of 5 orthopaedic surgeons to evaluate its validity. This process assessed face validity (whether the questionnaire as a whole adequately addressed current clinical practices in using PNBs for hip fractures in older adults) and content validity (whether individual questions adequately addressed the study's objectives). These surgeons provided feedback on the questionnaire's clarity, length, clinical indications, and comprehensiveness. To further validate the questionnaire, a larger convenience sample of 10 orthopaedic surgeons completed the survey. Based on recommendations from both groups, we revised the questionnaire. We then retested the revised version with 5 surgeons from the original group, repeating this process until no additional issues or concerns were identified.¹⁶

2.4. Survey Description

The final survey consisted of 24 questions, using a variety of question formats, including Likert-scale questions, checkboxes, constant sum, and brief open-ended questions (Appendix, http://links.lww.com/OTAI/A116). To enhance the validity of results, we used clear and widely recognized terminology throughout. The survey length was minimized to maximize response rates and limit respondent fatigue. The survey content included respondents' demographics: practice location, fellowship training, years in practice, and annual number of hip fracture patients treated. We queried the use of PNBs in clinical decision-making for hip fractures and perceptions of PNBs' effects on clinical outcomes. In addition, we asked about the perceived advantages and disadvantages of PNBs and the importance of future research on PNB use in managing hip fractures in older adults. The survey layout was designed to fit an average screen, with related questions grouped together for ease of completion.

2.5. Survey Administration

We distributed the survey via email to academic and private practice orthopaedic surgeons who had previously collaborated with the investigators and their colleagues. The email contained a link to the online survey, information about its purpose, data storage, and usage details, estimated completion time, and the investigators' contact information. To boost response rates, we sent follow-up emails at 3 and 6 weeks after the initial request. Survey completion was considered implicit and informed consent. We used Qualtrics (Provo, UT), a cloud-based online survey platform, for survey administration. This software provides tools for data analysis, sample selection, bias elimination, and data representation. No monetary incentives or prenotification calls were used for this survey. Participation was voluntary, and individual responses were kept confidential through data deidentification and password-protected accounts.

2.6. Sample Size

To determine the required number of respondents for a sufficiently powered analysis, we assumed an equal distribution of PNB use among surgeons (50% requesting PNBs and 50% not requesting PNBs) for hip fractures in older patients. We calculated the appropriate sample size using the formula for estimating a proportion: N = (Zα/w)² p(1 − p). In this formula, Z is the z-value for a 95% confidence interval (1.96), w is the desired precision of the estimate (0.1, giving a ±10% margin of error), and p is the hypothesized proportion of PNB requested (0.50). Based on these calculations, we determined that approximately 97 completed questionnaires would be necessary to achieve the precision targets in the results.

2.7. Statistical Analysis

For this study, we analyzed only submitted questionnaires. Categorical and dichotomous variables were summarized using frequencies and percentages, while continuous data were described using medians and interquartile ranges (IQRs). All statistical analyses were conducted using a combination of QualtricsXM (Qualtrics) for initial data processing and the R version 4.2.2 (R Foundation for Statistical Computing, Vienna, Austria).

3. Results

3.1. Characteristics of the Respondents

The survey was distributed via email to a convenience sample of 260 prior collaborators and their colleagues. This combined distribution method yielded a response rate of 50%, resulting in 129 completed surveys. Respondents were geographically diverse, with the majority practicing in the United States (73%), followed by Europe (16%), Canada (10%), and Australia or New Zealand (1%) (Table 1). Most of the respondents (85%) had completed an orthopaedic trauma fellowship, while 14% had completed a fellowship in lower extremity arthroplasty. Experience levels varied, with 57% having more than 10 years of experience treating geriatric hip fractures, 25% having 5–10 years, and 18% having less than 5 years. More than three-quarters reported treating more than 30 hip fractures annually; there was no significant relationship between case volume and reported PNB utilization patterns.

Table 1.

Respondent characteristics.

Characteristic	N (%)
Location of practice
United States	94 (73%)
Europe	21 (16%)
Canada	13 (10%)
Australia or New Zealand	1 (1%)
Fellowship training
Orthopaedic trauma	107 (85%)
Lower extremity arthroplasty	18 (14%)
Number of years spent treating older adults with hip fractures
<5 y	23 (18%)
5–10 y	32 (25%)
>10 y	72 (57%)
Total number of fragility hip fractures treated yearly
<15	11 (9%)
15–30	24 (19%)
>30	92 (72%)

3.2. Use of Peripheral Nerve Blocks and Peripheral Nerve Catheters

When asked about the perceived benefits of PNBs, 71% (88/124) of orthopaedic surgeons indicated they believed that there were clinical advantages to using PNBs for older adults with hip fractures versus other approaches to analgesia. Nearly all respondents believed that PNBs would benefit all types of hip fracture fixation (Table 2). Greater than two-thirds of surgeons reported requesting a PNB from the anesthesiologist more than half the time for surgical fixation of hip fractures. By contrast, only 35% of surgeons believed peripheral nerve catheters benefited older adults with hip fractures, and over two-thirds reported never or rarely requesting a peripheral nerve catheter (Table 2).

Table 2.

Peripheral nerve block use among orthopaedic surgeons for surgical management of hip fractures in older adults.

	N (%)
Proportion of orthopaedic surgeons reported there were perceived benefits from peripheral nerve blocks for their older adults undergoing surgical fixation of hip fracture
Yes	88 (71%)
No	8 (7%)
Unsure	28 (23%)
Proportion of orthopaedic surgeons reported there were perceived disadvantages from peripheral nerve catheters for their older adults undergoing surgical fixation of hip fracture
Yes	43 (35%)
No	28 (23%)
Unsure	53 (43%)
The main promoter for peripheral nerve block use
Anesthesiologist	51 (41%)
Surgeon	38 (31%)
Institutional culture/practice	19 (15%)
Institutional policy/protocol	16 (13%)
Frequency orthopaedic surgeons request peripheral nerve block
Never	10 (8%)
Rarely	25 (20%)
Occasionally	14 (11%)
Half of the time	6 (5%)
Frequently	12 (10%)
Very frequently	30 (24%)
Always	27 (22%)
Frequency orthopaedic surgeons request peripheral nerve catheter
Never	61 (49%)
Rarely	41 (33%)
Occasionally	8 (7%)
Half of the time	2 (2%)
Frequently	4 (3%)
Very frequently	3 (2%)
Always	5 (4%)
Types of surgical procedures that orthopaedic surgeons report would benefit from a peripheral nerve block*
Short cephalomedullary nail	92%
Long cephalomedullary nail	91%
Hemiarthroplasty	90%
Sliding hip screw	89%
Total hip arthroplasty	85%
Closed reduction percutaneous pinning femoral neck fracture	85%
None	6%

^*N = 123.

3.3. Factors Influencing the Utilization of Peripheral Nerve Blocks for Hip Fractures

Surgeons were asked to identify factors influencing the use of PNBs for their older adults with hip fractures. The 2 primary drivers were anesthesiologist recommendation (41%, 51/124) and surgeon request (31%, 38/124). Institutional factors played a smaller role. Institutional culture prompted PNB use in 15% (19/124) of cases, while institutional policy or protocol influenced only 13% (16/124) of decisions (Table 2).

Next, surgeons were asked to identify the top 5 concerns or difficulties of PNB use. Desire to avoid a delay of case (54% reported as a major or moderate barrier) and lack of anesthesiology availability (46% reported as a major or moderate barrier) were commonly reported concerns. Lack of postprocedural care from the anesthesiologist was considered a major or moderate barrier to requesting a peripheral nerve block or peripheral nerve catheter in 25% of responses. These factors, combined with general workflow concerns, suggest that both anesthesia resources and system efficiency are key barriers to regular PNB use. Other clinical concerns, such as surgical site infection (1%) and hematoma formation (2%), were rarely reported as reasons not to request a PNB (Fig. 1).

Figure 1.

Orthopaedic surgeon considerations for not using a peripheral nerve block (PNB).

3.4. Surgeon Perceived Advantages and Disadvantages of Peripheral Nerve Block Use

Surgeons ranked their perceived advantages and disadvantages of PNBs on a scale from 0 (least important) to 100 (most important), with the total summing to 100. The primary perceived benefits were reduced pain (median 32.5; IQR: 20.0–45.0) and opioid use (median 20; IQR: 10.0–30.0) within 72 hours postoperatively and reduced delirium postoperatively (median 15; IQR: 4.3–21). However, surgeons reported no significant advantages in reducing intraoperative opioid use or long-term pain or opioid use at 3 months. Surgeons also perceived no significant impact on postoperative cardiac or pulmonary complications or mortality rates. The main perceived disadvantages of requesting PNB were negative impacts on operating room efficiency (median 20.5; IQR: 0.0–50.0), delayed mobilization (median 8.5; IQR: 0.0–27.0), and postoperative rebound pain (median 6; IQR: 0.0–20.8). Potential for peripheral nerve injury, neuritis, surgical site infection, hematoma formation, and increased length of stay were not considered significant drawbacks (Fig. 2).

Figure 2.

Orthopaedic surgeons perceived advantages and disadvantages of peripheral nerve blocks (PNBs) for older adults with hip fractures.

3.5. The Need for Future Research

Surgeons demonstrated a strong interest in further research on PNBs for older adults undergoing hip fracture surgery. A substantial majority of respondents (85%) agreed or strongly agreed there is a need for high-quality, rigorously designed studies to definitively assess the efficacy and broader impacts of PNBs in hip fracture surgery for older adults. In addition, 92% were willing to participate in a randomized controlled trial comparing the use of PNBs with no PNBs in this patient population.

4. Discussion

The key findings of this cross-sectional study reveal that surgeons believe PNBs are effective for managing acute postoperative pain and reducing immediate opioid use. However, the wide variability in PNB reported use suggests delaying surgical workflow may be a major barrier to routine implementation.

Orthopaedic surgeons' perceptions of implementation barriers to PNB use align with previous observations in the literature. In a large review article, Scala et al⁸ highlighted, that despite the development of numerous protocols by different specialties for timely and consistent placement of PNB for older adults with hip fractures, their use remains inconsistent. Guidelines from the American Academy of Orthopaedic Surgeons and the Association of Anaesthetists have emphasized the importance of timely PNB placement to address this variability.^9,12,15 However, studies continue to show that PNBs are not regularly used for orthogeriatric hip fractures.⁸ More recent guidelines by the Association of Anaesthetists and Fragility Fracture Network in the United Kingdom have also attempted to address these inconsistencies with updated best practice guidelines and closer monitoring.⁹

The results of this study also confirm that while surgeons believe in the acute pain management benefits of PNBs, they do not readily endorse other potential benefits. Previous authors have suggested that PNBs may offer benefits beyond pain relief in hip fracture cases, such as reduced cardiac stress and lower mortality.^11,17 The proposed mechanism for these additional potential benefits involves minimizing the body's stress response to surgery, including neuroendocrine changes and autonomic nervous system imbalances.¹⁸ This stress reduction could potentially decrease myocardial oxygen demand and improve hemodynamic stability, which is particularly important for patients with pre-existing comorbidities.¹⁹ By attenuating the body's physiological response to surgical stress, PNBs may offer broader benefits beyond acute pain control^14,19; however, there are limited clinical data to strongly support this assertion.

The results of this survey must be interpreted in the context of the study design. The convenience sample, consisting primarily of academic orthopaedic traumatologists and arthroplasty surgeons involved in previous research studies, may be biased toward practice patterns at larger referral hospitals that do not represent all orthopaedic surgeons who care for older adults with hip fractures. Furthermore, there is potential for response bias, as individuals with strong opinions about PNBs may have been more motivated to participate, potentially skewing the results. These potential limitations are mitigated by the survey's rigorous development and thorough pilot testing. Another limitation was that we did not query orthopaedic surgeons for their perspectives on specific peripheral nerve blocks or their perspectives on complications. The uneven geographical distribution of respondents, with 73% from the United States, also limited our ability to analyze geographical variations in practice patterns. In addition, the study was strengthened by the multicenter distribution, international surgeon sample, and inclusion of open-ended questions to capture surgeons' perspectives without restricting responses to predefined categories.

5. Conclusion

In conclusion, this study reports orthopaedic surgeons' perspectives on peripheral nerve blocks for older adults undergoing hip fracture surgery. While surgeons acknowledge peripheral nerve blocks’ immediate postoperative analgesic benefits, they also recognize potential negative impacts on overall patient care efficiency. If broader implementation of peripheral nerve block use is desired, further research should assess both short-term benefits and long-term outcomes, as well as implementation strategies to overcome local barriers that impact system-wide health care delivery.

Appendix 1. The Survey Respondents Contributors

Héctor J. Aguado, MD, PhD, Jamal Alasiri, MBBS, FRCSC, FACS, Daniel Axelrod, MD, MSC, FRCSC, Mariano Balaguer-Castro, MD, MSc, PhD, Brent Bauer, MD, Michael J. Beltran, MD, Patrick F. Bergin, MD, Marissa Bonyun, MD, Christina Boulton, MD, Henry Broekhuyse, MD, Juan Ramón Cano, PhD, Anna Carreras-Castaner, PhD, Gerard Chang, MD, Natalie R. Danna, MD, Malcolm R. DeBaun, MD, Niloofar Dehghan, MD, Graham DeKeyser, MD, Gregory J. Della Rocca, MD, PhD, MBA, FACS, Hannah Elsevier, MD, Mark J. Gage, MD, Virginia García-Virto, MD, Joshua L. Gary, MD, Greg Gaski, MD, John Gentile, DO, Ida Leah Gitajn, MD, J.C. Goslings, MD, PhD, Enrique Guerado, BSc, MD, PhD, MS, Ernesto Guerra-Farfan, MD, Pierre Guy, MD, MBA, FRCSC, Justin T. Fowler, MD, Darin Friess, MD, Frede Frihagen, MD, PhD, Marilyn Heng, MD, MPH, Thomas F. Higgins, MD, Wayne Hoskins, PhD, FRACS, MBBS (Hons), Robert A. Hymes, MD, Izuchukwu Ibe, MD, Ruurd L. Jaarsma, MD, PhD, FRACS, Kyle Jeray, MD, Aaron J. Johnson, MD, Pierce Johnson, MD, Clifford B. Jones, MD, FACS, Patrick J. Kellam, MD, D.H.R. Kempen, MD, PhD, Conor Kleweno, MD, William Lack, MD, Kelly A. Lefaivre, MD, MSc, FRCSC, Ashley E. Levack, MD, MAS, Carol A. Lin, MD, MA, Francesc Marcano-Fernández, MD, PhD, Geoffrey S. Marecek, MD, Meir T. Marmor, MD, Amir Matityahu, MD, Todd O. McKinley, MD, Samir Mehta, MD, Sean J. Meredith, MD, Peter Mittwede, MD, PhD, Gudrun Mirick Mueller, MD, Sumon Nandi, MD, MBA, Jason Nascone, MD, Roman M. Natoli, MD, PhD, William M. Naylor, DO, William Obremskey, MD, MPH, Steve Papp, MD, Sarah N. Pierrie, MD, Andrew N. Pollak, MD, Rudolf W. Poolman, MD, PhD, JM De María Prieto, MD, Rachel M. Reilly, MD, Christopher Renninger, MD, Matthew D. Riedel, MD, Edward K. Rodriguez, MD, PhD, Nicholas M. Romeo, DO, Augustine Mark Saiz, MD, Emil H. Schemitsch, MD, Jeff E. Schulman, MD, John A. Scolaro, MD, Alesha N. Scott, DO, FAAOS, Aresh Sepehri, MD, Steven F. Shannon, MD, Anthony Sorkin, MD, David J. Stockton, MD, MASc, FRCSC, Eric Swart, MD, Guillermo Triana, MD, Aswinkumar Vasireddy, FRCS, Darius Viskontas, MD, FRCSC, Richard Vlasak, MD, Arvind von Keudell, MD, MPH, Emily A. Wagstrom, MD, Zachary M. Working, MD, Taylor M. Yong, MD, MS, Robert D. Zura, MD.