Abstract
Background
Pertrochanteric femoral fractures in the elderly are associated with high morbidity and delayed recovery. The type of anesthesia used during surgical fixation may significantly impact postoperative outcomes. The erector spinae plane (ESP) block has recently emerged as a promising alternative to traditional techniques.
Methods
This retrospective study evaluated 64 patients who underwent proximal femoral nailing (PFN) and received either general anesthesia (GA), spinal anesthesia (SA), or ESP block. Pain (VAS), function (Harris and Oxford Hip Scores), quality of life (EQ-5D), complication rates, mobilization time, and hospital stay were compared.
Results
All groups showed improvement, but the ESP block group had significantly lower pain scores (p < 0.001), better functional outcomes, earlier mobilization, and shorter hospital stays. Complications such as urinary retention and delirium were more frequent in the GA group.
Conclusion
ESP block provided superior pain control, enhanced functional recovery, and fewer complications in patients undergoing PFN. It represents a safe and effective alternative in the anesthetic management of elderly patients with fragility fractures.
Keywords: Anesthesia, Erector spinae plane block, Fragility fracture, Geriatrics, Proximal femoral nailing
Introduction
Pertrochanteric femoral fractures are a common and significant health concern, particularly among the elderly population. These fractures typically result from low-energy trauma in individuals with osteoporotic bone structures and are associated with high rates of morbidity and functional decline. Due to the increasing life expectancy and the global rise in the elderly population, the incidence of these fractures is expected to increase substantially, with estimates suggesting over 6 million annual cases by the year 2050 [1–3].
Surgical stabilization is currently regarded as the gold standard in the treatment of these fractures, with the use of modern intramedullary devices such as proximal femoral nails (PFN) providing improved biomechanical stability, reduced hospital stays, and earlier mobilization [4, 5]. However, postoperative outcomes are influenced by multiple factors beyond the choice of implant, including fracture type, patient age, comorbidities, surgical timing, and the type of anesthesia administered [6].
The anesthesia method used during surgery plays a critical role in both intraoperative management and postoperative recovery. Commonly utilized techniques—including general anesthesia (GA), spinal anesthesia (SA), and the more recently adopted erector spinae plane (ESP) block—each offer specific advantages and limitations. General anesthesia provides optimal surgical conditions and is widely used in orthopedic trauma surgery; however, it has been associated with higher rates of certain postoperative complications in elderly and frail patients. In contrast, spinal anesthesia has been shown to facilitate early ambulation and may reduce the incidence of complications such as delirium or urinary retention. Nonetheless, high-quality randomized trials and systematic reviews, including a Cochrane meta-analysis [7], have reported no consistent difference in major outcomes between GA and SA. This highlights the need for further exploration of alternative regional techniques such as ESP block, which may offer additional benefits in selected patient populations [8–10]. Spinal anesthesia has been shown to enhance postoperative analgesia, facilitate early ambulation, and reduce complication rates [11]. Meanwhile, the ESP block, an emerging regional technique, has demonstrated efficacy in postoperative pain management and may significantly reduce opioid requirements [12, 13].
Despite these findings, there is no consensus in the literature regarding the superiority of one anesthesia method over another in the context of pertrochanteric fracture surgery. This lack of uniformity suggests that anesthesia selection often varies by clinical setting and should be guided by patient-specific considerations such as age, fracture stability, and systemic health status.
The aim of this study is to compare the effects of different anesthesia methods—general anesthesia, spinal anesthesia, and ESP block—on postoperative clinical and functional outcomes in patients undergoing proximal femoral nailing (PFN) for pertrochanteric femoral fractures. By providing data-driven insights, this study seeks to support a more individualized, evidence-based approach to anesthesia selection and contribute to optimizing treatment protocols in orthopedic trauma surgery.
Materials and methods
Study design and ethical approval
This retrospective descriptive study was conducted at the Department of Orthopedics and Traumatology, Düzce University Faculty of Medicine, and included patients who underwent proximal femoral nailing (PFN) for pertrochanteric femoral fractures between January 1, 2020, and January 1, 2023. All eligible patients meeting the inclusion and exclusion criteria were consecutively included in the study to minimize selection bias.
The study was carried out in accordance with the ethical standards outlined in the 1964 Declaration of Helsinki and its 2000 revision. Ethical approval was obtained from the Clinical Research Ethics Committee of Düzce University, Türkiye (Date: 06.05.2024; Decision No: 2024/89). Informed consent was obtained from all patients during the course of their treatment. This manuscript was prepared in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for observational studies, ensuring clarity, transparency, and methodological rigor in reporting.
Patient selection and inclusion criteria
A total of 64 patients who presented to the emergency department or were referred via the 112 ambulance system due to pertrochanteric femoral fractures and subsequently underwent PFN surgery were included. The inclusion criteria were: age ≥ 60 years, radiologically confirmed pertrochanteric fracture based on AO/OTA classification, treatment with PFN, and availability of complete postoperative clinical data. Exclusion criteria were: subtrochanteric or pathological fractures, polytrauma, history of previous hip surgery, and severe systemic or neurological conditions that could interfere with anesthesia.
Anesthesia groups
Patients were classified into three groups based on the type of anesthesia administered: General Anesthesia (GA), Spinal Anesthesia (SA), and Erector Spinae Plane Block (ESP). The choice of anesthesia was based on the patient’s general health condition, comorbidities, anesthesiologist’s evaluation, and surgical team preference. In the GA group, induction was performed with intravenous propofol, fentanyl, and rocuronium, followed by endotracheal intubation and maintenance with inhalational agents. In the SA group, 10–12 mg of 0.5% hyperbaric bupivacaine was administered intrathecally via a 25G spinal needle at the L3–L4 or L4–L5 interspace.
In the ESP group, the block was performed under aseptic conditions with the patient in the sitting position. A high-frequency linear ultrasound probe was placed longitudinally over the T8–T10 transverse process. A 22G echogenic needle was advanced in-plane to the fascial plane deep to the erector spinae muscle. After negative aspiration, 20–30 mL of 0.25% bupivacaine was administered incrementally. Light sedation with midazolam (1–2 mg) or fentanyl (25–50 mcg) was provided as needed for patient comfort. No case required conversion to general anesthesia. The ESP block was used either as a standalone method or in combination with sedation [14, 15].
The expected dermatomal distribution of the sensory block was approximately from T8 to L2, covering the surgical area of the hip and proximal femur. The duration of the block was observed to be between 6 and 8 h. Postoperative analgesia was maintained with intravenous paracetamol (1 g every 8 h) and additional NSAIDs (e.g., diclofenac sodium 75 mg IM) as needed. Opioid rescue analgesia was not routinely required in the ESP group.
All anesthesia procedures were performed by experienced anesthesiologists according to standardized clinical protocols, with continuous monitoring of intraoperative vital parameters.
Surgical technique
All patients underwent closed reduction and internal fixation using a standardized PFN technique based on AO/ASIF guidelines. Under general, spinal, or ESP block anesthesia, patients were positioned supine on a traction table. The affected limb was secured, and closed reduction was achieved using fluoroscopy.
A 5–6 cm longitudinal skin incision was made over the lateral proximal femur. After entry into the intramedullary canal, an appropriately sized PFN was inserted, followed by proximal dynamic and distal static locking screws. Implant position was verified using fluoroscopic imaging. Wounds were closed in layers, and sterile dressing was applied.
Postoperatively, patients were mobilized within 24 to 48 h under the guidance of a structured physiotherapy and rehabilitation protocol [16].
Clinical and functional evaluation
Postoperative assessments included the Harris Hip Score and Oxford Hip Score to evaluate functional outcomes, the EQ-5D-3 L questionnaire for health-related quality of life, and the Visual Analog Scale (VAS) for pain intensity. Time to mobilization, length of hospital stay, and occurrence of postoperative complications were also recorded.
Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics version 25.0. Continuous variables were expressed as mean ± standard deviation or median with interquartile ranges, and categorical variables as frequencies and percentages. The normality of data distribution was assessed with the Kolmogorov–Smirnov test. For comparisons between two groups, independent samples t-test or Mann–Whitney U test was used. ANOVA or Kruskal–Wallis test was applied for multiple group comparisons. Categorical data were analyzed using Chi-square or Fisher’s exact test. A p-value < 0.05 was considered statistically significant.
A priori power analysis was conducted using G*Power software (version 3.1.9.7). Based on previous studies and expected effect sizes, it was determined that a minimum of 17 patients per group would be required to achieve 80% power at a significance level of 0.05 for detecting differences among the three anesthesia techniques [17].
Results
The baseline characteristics of the study cohort were analyzed to evaluate the homogeneity between the groups and to describe the patient profile. As seen in Table 1, the mean age was 75.89 ± 9.63 years and the mean BMI was 26.32 ± 3.37 kg/m². The majority of the patients were female (64.1%) and the most common trauma mechanism was low-energy trauma due to simple falls (89.1%). Distribution among anesthesia types was relatively even. Chronic disease prevalence was high (85.9%), consistent with the advanced age of the population and the fragility associated with such fractures.
Table 1.
Baseline demographic and clinical characteristics
| Parameter | Value | %/Range |
|---|---|---|
| Age (years, mean ± SD) | 75.89 ± 9.63 | 60–95 |
| BMI (kg/m², mean ± SD) | 26.32 ± 3.37 | 18.67–36.58 |
| Gender | ||
| Female | 41 | 64.1% |
| Male | 23 | 35.9% |
| Trauma Mechanism | ||
| Non-vehicle trauma | 1 | 1.6% |
| Simple fall | 57 | 89.1% |
| Fall from height | 6 | 9.4% |
| Anti-rotation | ||
| Present | 33 | 51.6% |
| Absent | 31 | 48.4% |
| Type of Anesthesia | ||
| General | 22 | 34.4% |
| Spinal | 23 | 35.9% |
| ESP Block | 19 | 29.7% |
| Chronic Disease Presence | ||
| Present | 55 | 85.9% |
| Absent | 9 | 14.1% |
Postoperative pain outcomes were assessed using the Visual Analog Scale (VAS) at four time points. As demonstrated in Table 2, all three anesthesia groups experienced statistically significant reductions in pain scores from baseline through the 6th month (p < 0.001 for each group). The ESP block group consistently reported the lowest VAS scores at all follow-up points, indicating superior postoperative analgesia. In contrast, the spinal anesthesia group had higher early postoperative pain, though pain levels decreased over time.
Table 2.
Preoperative and postoperative VAS pain scores
| Anesthesia Type | Pre-op VAS (Mean ± SD) | 1 st Month (± SD) | 3rd Month (± SD) | 6th Month (± SD) | p-value |
|---|---|---|---|---|---|
| General | 23.35 ± 4.50 | 13.43 ± 3.67 | 5.25 ± 2.63 | 0.25 ± 0.87 | < 0.001 |
| Spinal | 25.32 ± 3.59 | 17.41 ± 2.97 | 5.64 ± 2.50 | 0.91 ± 1.58 | < 0.001 |
| ESP Block | 24.88 ± 4.22 | 12.35 ± 2.64 | 3.42 ± 2.19 | 0.13 ± 0.49 | < 0.001 |
Functional outcomes were evaluated using Harris Hip Score, Oxford Hip Score, and EQ-5D index at 1 st, 3rd, and 6th months. As seen in Table 3, all groups showed progressive improvements in function and quality of life over time. However, the ESP group exhibited statistically higher functional scores, especially in the 6th month, suggesting enhanced rehabilitation potential with this anesthesia technique.
Table 3.
Functional outcomes (Harris, Oxford, EQ-5D Scores)
| Anesthesia Type | Harris (1st Mo) | Harris (3rd Mo) | Harris (6th Mo) | Oxford (6th Mo) | EQ-5D (6th Mo) |
|---|---|---|---|---|---|
| General | 77.67 ± 3.31 | 79.58 ± 3.09 | 81.33 ± 3.34 | 39.1 ± 4.2 | 0.82 ± 0.05 |
| Spinal | 75.82 ± 3.66 | 77.73 ± 4.10 | 79.45 ± 4.03 | 37.5 ± 4.8 | 0.78 ± 0.06 |
| ESP Block | 78.35 ± 2.85 | 80.88 ± 2.71 | 83.25 ± 3.01 | 41.3 ± 3.9 | 0.86 ± 0.04 |
As illustrated in Table 4, operative and postoperative course metrics, including operation duration, blood loss, mobilization timing, and hospital stay, were evaluated. Although operation time and blood loss were comparable between groups, patients in the ESP group achieved earlier mobilization and were discharged sooner, indicating a potential advantage in terms of efficiency and recovery speed.
Table 4.
Operative and postoperative course metrics
| Anesthesia Type | Surgery Time (min) | Blood Loss (ml) | Mobilization Time (hrs) | Length of Stay (days) |
|---|---|---|---|---|
| General | 57.2 ± 10.1 | 250 ± 40 | 30.5 ± 6.8 | 5.6 ± 1.7 |
| Spinal | 59.4 ± 11.5 | 240 ± 38 | 29.8 ± 7.2 | 5.2 ± 1.6 |
| ESP Block | 54.6 ± 9.8 | 220 ± 35 | 26.3 ± 5.9 | 4.1 ± 1.2 |
Postoperative adverse outcomes were also recorded and compared. As shown in Table 5, urinary retention and delirium were more commonly observed in the general anesthesia group. While the reoperation and mortality rates were not statistically different between groups, all observed deaths occurred in high-risk patients from the general anesthesia cohort, underlining the importance of individualized perioperative risk assessment.
Table 5.
Postoperative complications and mortality
| Outcome | General | Spinal | ESP Block | Total | p-value |
|---|---|---|---|---|---|
| Urinary Retention | 5 | 3 | 1 | 9 | 0.041 |
| Delirium | 3 | 2 | 0 | 5 | 0.037 |
| Reoperation | 2 | 1 | 0 | 3 | 0.128 |
| Readmission (30 days) | 1 | 1 | 0 | 2 | 0.422 |
| 30-day Mortality | 2 | 0 | 0 | 2 | 0.091 |
Discussion
In this study, we aimed to investigate the effects of different anesthesia techniques—general anesthesia (GA), spinal anesthesia (SA), and erector spinae plane (ESP) block—on postoperative pain control, functional recovery, and complication profiles in elderly patients undergoing proximal femoral nailing (PFN) for pertrochanteric femoral fractures. Our results revealed that while all techniques led to significant postoperative improvements, patients in the ESP block group consistently achieved superior outcomes in terms of pain reduction, early mobilization, hospital stay duration, and functional recovery.
The ESP block group demonstrated significantly lower pain scores at all follow-up points, including the early postoperative period and up to six months. These findings are consistent with previous research highlighting the analgesic efficacy of ESP blocks in both thoracic and abdominal surgeries, and increasingly in orthopedic interventions [18, 19]. The sustained pain control observed in the ESP group may be attributed to its ability to deliver regional analgesia without motor blockade, thereby supporting faster rehabilitation and reduced opioid consumption [20, 21].
Functionally, the ESP group outperformed the other groups in both Harris Hip and Oxford Hip Scores at six months. Improved early pain control likely contributed to increased participation in physiotherapy and accelerated return to mobility. Moreover, higher EQ-5D scores in the ESP group indicate a broader benefit of regional anesthesia techniques on overall health-related quality of life, beyond mere analgesia [22, 23].
From a perioperative standpoint, operation duration and blood loss were comparable across all groups, but the ESP group showed earlier mobilization and shorter hospital stays—factors known to enhance postoperative outcomes and reduce healthcare costs [9, 24]. These findings further support the integration of ESP block into the anesthetic management of frail orthopedic patients. Although the anesthesia method is primarily a perioperative factor, superior pain control in the ESP block group during the early postoperative period may have facilitated more active participation in physiotherapy and mobilization. This early advantage could translate into better long-term functional recovery, as reflected in the 6-month follow-up scores.
The complication analysis revealed a higher incidence of urinary retention and postoperative delirium in the GA group, both of which are common in elderly patients and associated with longer recovery times and increased morbidity [25, 26]. The ESP group exhibited the lowest complication rates, possibly due to better hemodynamic stability and minimal systemic drug exposure. This supports the use of ESP block as a safer alternative for elderly patients with multiple comorbidities.
In the current literature, the use of ESP block as the primary anesthetic technique for hip or proximal femoral surgeries is still relatively rare. However, promising findings have been reported in limited case series. For example, Ahiskalioglu et al. evaluated 15 high-risk elderly patients who underwent hip surgery under ESP block combined with intravenous sedation and reported favorable outcomes regarding analgesia and perioperative stability [27]. Our study adds to this evolving body of evidence by systematically comparing ESP block to standard techniques in a larger retrospective cohort. These findings support the feasibility and potential benefits of ESP block as a primary anesthetic option in selected patients, although further prospective trials are warranted.
Limitations
This study has several limitations that must be acknowledged. First, the retrospective and non-randomized design introduces potential selection bias, as anesthesia modality was determined based on clinical discretion rather than random allocation. To minimize this, all patients meeting the inclusion criteria within the study period were consecutively included. Second, although the sample size was sufficient for statistical analysis, the overall number of patients—especially when divided into three groups—remains relatively small, limiting the statistical power and generalizability of the findings. Third, the study was conducted at a single center, which may limit external validity. Fourth, while ESP blocks were administered under standardized conditions by experienced anesthesiologists, inter-operator variability and availability of ultrasound guidance in different institutions may affect reproducibility. Fifth, the follow-up period was limited to six months; hence, long-term outcomes such as chronic pain, delayed complications, or sustained functional independence could not be assessed. Lastly, the study did not include metrics such as opioid consumption, cognitive recovery, or patient satisfaction, which could provide a more comprehensive assessment of anesthesia impact on overall recovery.
Conclusion
The findings of this study suggest that the erector spinae plane block is an effective and reliable anesthetic technique in the perioperative management of pertrochanteric femoral fractures treated with PFN in elderly patients. Compared to general and spinal anesthesia, ESP block demonstrated superior performance in terms of postoperative analgesia, functional outcomes, quality of life, and safety profile. These advantages, coupled with reduced hospital stay and lower complication rates, highlight the clinical value of ESP block in enhancing recovery pathways. However, further large-scale, multicenter, randomized controlled trials are warranted to confirm these results and to establish standardized protocols for the use of ESP block in orthopedic trauma surgery.
Acknowledgements
Not available.
Authors’ contributions
SS, MOY and IC contributed to the analysis and interpretation of the data and to the writing and revision of the manuscript. SS, MOY and IC performed the surgical operations. SS, MOY and IC contributed to data analysis, interpretation and writing. SS and IC contributed to data collection, analysis and methodology. SS, MOY and IC contributed to experimental design, data collection and data revision.
Funding
The authors received no financial support for the research and/or authorship of this article.
Data availability
All data and materials can be requested from Dr. Sönmez Saglam when needed. ([sonmezsaglam@duzce.edu.tr](mailto: sonmezsaglam@duzce.edu.tr))
Declarations
Ethics approval and consent to participate
The study design was approved by the Düzce University Clinical Research Ethics Committee (Düzce, Türkiye) (Date: 06.05.2024; Decision No: 2024/89). The study was conducted in accordance with the principles of the Declaration of Helsinki.
Informed consent was obtained from all individual participants included in the study.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data and materials can be requested from Dr. Sönmez Saglam when needed. ([sonmezsaglam@duzce.edu.tr](mailto: sonmezsaglam@duzce.edu.tr))