Peripheral nerve blocks for hip fractures

Joanne Guay; Martyn J Parker; Richard Griffiths; Sandra Kopp

doi:10.1002/14651858.CD001159.pub2

. 2017 May 11;2017(5):CD001159. doi: 10.1002/14651858.CD001159.pub2

Peripheral nerve blocks for hip fractures

Joanne Guay ^1,^✉, Martyn J Parker ², Richard Griffiths ³, Sandra Kopp ⁴

Editor: Cochrane Anaesthesia Group

PMCID: PMC6481480 PMID: 28494088

Abstract

Background

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.

Objectives

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.

Search methods

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.

Selection criteria

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.

Data collection and analysis

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.

Main results

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; I² = 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; I² = 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; I² = 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; I² = 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).

Authors' conclusions

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).

Plain language summary

Local anaesthetic nerve blocks for people with a hip fracture

Background: Peripheral nerve blocks consist of an injection of local anaesthetics close to the nerves to transiently block pain transmission to the brain. This review examined evidence from randomized controlled trials that evaluated the use of peripheral nerve blocks to manage pain for people with a hip fracture.

Search dates: This is an update of a previously published review. We updated the search in August 2016.

Study characteristics: We included 31 trials (1760 adult participants: 897 randomized to peripheral nerve blocks and 863 to no regional blockade) performed in various countries and published between 1980 and 2016.

Study funding sources: Trials were funded by a charitable organization (n = 3), by a governmental organization (n = 1) or by departmental resources (n = 5), or did not specify the source of funding.

Key results: Compared with other modes of analgesia, peripheral nerve blocks used to treat hip fracture pain reduce pain on movement better within 30 minutes (equivalent to a difference of ‐3.4 on a scale from 0 to 10 between the two analgesic regimens). The risk of pneumonia is also reduced when peripheral nerve blocks are used to treat hip fracture pain. For every 7 people with a hip fracture, one less person will suffer from pneumonia. Studies noted no major complications related to peripheral nerve blocks and reported reduced time to first mobilization after hip fracture surgery (approximately 11 hours earlier). We did not identify enough trial participants to determine if regional blockade makes a difference in terms of acute confusion, myocardial ischaemia and death within six months after surgery. Peripheral nerve block given as a single injection led to reduced cost of analgesic drugs.

Quality of evidence: We rated the quality of evidence as high for reduction of pain on movement within 30 minutes, and as moderate for pneumonia, time to first mobilization and costs of analgesic drugs. We would need more information before we could draw final conclusions on effects of peripheral nerve blocks on the risk of acute confusional state, myocardial ischaemia and mortality.

Summary of findings

Summary of findings for the main comparison. Peripheral nerve blocks for hip fracture.

Peripheral nerve blocks for hip fracture
Patient or population: patients with hip fracture  Settings: trials performed in Argentina (n = 1), Austria (n = 1), Chile (n = 1), China (n = 2), Denmark (n = 2), France (n = 2), Geece (n = 3), Germany (n = 1), India (n = 1), Iran (n = 1), Ireland (n = 1), Israel (n = 1), Korea (n = 1), South Africa (n = 1), Spain (n = 2), Sweden (n = 1), Thailand (n = 1), Turkey (n = 2), United Kingdom (n = 5) and United States of America (n = 1)  Intervention: peripheral nerve blocks  Comparison: systemic analgesia
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	Number of participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Systemic analgesia	Peripheral nerve blocks
Pain on movement at 30 minutes after block placement   Follow‐up: 20‐30 minutes		Mean pain on movement at 30 minutes after block placement in the intervention groups was  1.41 standard deviations lower   (2.14 to 0.67 lower)		373  (8 studies)	⊕⊕⊕⊕  high^{a,b,c,d,e,f,g,h,i}	Equivalent to  ‐ 3.4 on a  scale from  0 to 10
Acute confusional state	Study population		RR 0.69   (0.38 to 1.27)	676  (7 studies)	⊕⊝⊝⊝  very low^{c,f,h,j,k,l,m,n}
	198 per 1000	136 per 1000   (75 to 251)
	Low
	150 per 1000	104 per 1000   (57 to 190)
	High
	250 per 1000	172 per 1000   (95 to 317)
Myocardial ischaemia	Study population		RR 0.2   (0.03 to 1.42)	20  (1 study)	⊕⊝⊝⊝  very low^{b,c,j,m,n,o,p,q}
	500 per 1000	100 per 1000   (15 to 710)
	Low
	100 per 1000	20 per 1000   (3 to 142)
	High
	500 per 1000	100 per 1000   (15 to 710)
Pneumonia	Study population		RR 0.41   (0.19 to 0.89)	131  (3 studies)	⊕⊕⊕⊝  moderate^{c,f,h,k,l,n,r,s,t}
	269 per 1000	110 per 1000   (51 to 239)
	Low
	50 per 1000	20 per 1000   (9 to 44)
	High
	200 per 1000	82 per 1000   (38 to 178)
Death   Follow‐up: 0‐6 months	Study population		RR 0.72   (0.34 to 1.52)	316  (7 studies)	⊕⊕⊝⊝  low^{c,f,m,n,o,q,s,u}
	98 per 1000	70 per 1000   (33 to 149)
	Low
	25 per 1000	18 per 1000   (9 to 38)
	High
	150 per 1000	108 per 1000   (51 to 228)
Time to first mobilisation		Mean time to first mobilisation in intervention groups was  11.25 hours lower   (14.34 to 8.15 lower)		155  (2 studies)	⊕⊕⊕⊝  moderate^{a,c,d,e,h,k,n,p,s,v,w}
Cost of analgesic regimens for single shot blocks		Mean cost of analgesic regimens for single shot blocks in intervention groups was  3.48 standard deviations lower   (4.23 to 2.74 lower)		75  (1 study)	⊕⊕⊕⊝  moderate^{a,c,l,n,p,q,s,v}
The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)  CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate  Very low quality: We are very uncertain about the estimate

Study	Purpose of blockade	Surgical anaesthesia	Block technique	Comparison
Altermatt 2013	Preoperative and postoperative analgesia	Unspecified	Continuous lumbar plexus with 0.1% bupivacaine in a patient‐controlled analgesia mode	IV morphine
Antonopoulou 2006	Postoperative analgesia	Spinal anaesthesia	Continuous femoral nerve block, nerve stimulator, loaded with 18 mL of 0.25% bupivacaine followed by an infusion of 0.125% levobupivacaine at 3‐4 mL/h	IM pethidine
Beaudoin 2013	Preoperative analgesia	Unspecified	Ultrasound‐guided femoral nerve block performed by an experienced operator with a 7.5 MHz linear probe, participant in Trendelenburg position, cross‐sectional view, 22 G Whitacre needle in‐plane and 25 mL of bupivacaine 0.5% and distal manual pressure for 5 minutes	IM morphine
Chudinov 1999	Preoperative and postoperative analgesia Surgery for some participants	Treatment group: psoas block alone (3/20) with a sciatic block (5/20), a spinal (11/20) or general anaesthesia (1/20) Control group: neuraxial block (19/20) or general anaesthesia (1/20).	Psoas, loss of resistance, Chayen's technique 0.8 mL/kg of bupivacaine 0.25%, operated side up (1 epidural spread)	IM meperidine and diclofenac
Coad 1991	Postoperative analgesia	General anaesthesia for all participants with etomidate, nitrous oxide, enflurane, fentanyl and vecuronium	Lateral cutaneous: 15 mL of 0.5% bupivacaine with epinephrine, Eriksson's technique Femoral (3‐in‐1): 15 mL of 0.5% bupivacaine with epinephrine, Winnie's technique	IM meperidine
Cuvillon 2007	Postoperative analgesia	Spinal anaesthesia for all participants	Continuous femoral nerve block. Nerve stimulator 0.3 to 0.5 mA. Non‐stimulating catheter passed 10‐15 cm past the needle tip loaded with 30 mL of 1.5% lidocaine followed by ropivacaine 0.2% at 10 mL/h for 48 hours	SC morphine
De La Tabla 2010	Preoperative analgesia	Unspecified	Femoral nerve block under dual guidance (ultrasound and nerve stimulator), catheter loaded with 15 mL of ropivacaine 0.2% followed by an infusion of the same solution at 5 mL/h and 10 mL every 30 minutes	IV metamizole and tramadol
Diakomi 2014	Preoperative analgesia (spinal positioning)	Spinal anaesthesia	Fascia iliaca block, Dalen's technique, landmarks, 40 mL of 0.5% ropivacaine	IV fentanyl
Domac 2015	Preoperative analgesia (spinal positioning) plus postoperative analgesia	Spinal anaesthesia	Fascia iliaca block with 15 mL of 0.5% bupivacaine and 15 mL of 2% lidocaine; 2‐3 cm below inguinal ligament at the junction of lateral 1/3 and medial 2/3 of a line from pubis tubercle to anterior iliac spine; 2 pops	IV morphine
Fletcher 2003	Preoperative analgesia	Unspecified	Fermoral (3‐in‐1 nerve block, Wiinie's technique with 20 mL of 0.5% bupivacaine and 5 minutes distal compression)	IV morphine
Foss 2007	Preoperative analgesia	Unspecified	Fascia iliaca block based on Dalen's landmarks with a 24 G blunted needle and 40 mL of 1% mepivacaine with epinephrine	IM morphine
Gille 2006	Preoperative and postoperative analgesia	Treatment group: spinal anaesthesia for 37/50 and general anaesthesia for 13/50 Control group: spinal anaesthesia for 38/50 and general anaesthesia for 12/50	Femoral non‐stimulating catheter: needle 18 G, catheter 20 G (Brown‐Perifix‐Plexus Anaesthesia); 0.5 mA and 0.1 msec. Catheters were advanced about 10 cm past the needle tip and fixed. Loading dose was 40 mL of prilocaine 1% followed 2 hours later by ropivacaine 0.2% 30 mL, repeated every 6 hours. Amount (up to 40 mL; n = 5) and intervals (up to every 4 hours; n = 8) or both (n = 6) adjusted on pain scores	IV metamizole plus oral tilidine and naloxone
Godoy 2010	Preoperative analgesia	Unspecified	Fascia iliaca compartment block, 21G long bevel needle, Dalen's technique with 0.3 mL/kg of 0.25% bupivacaine	IV non‐steroidal anti‐inflammatory drugs
Graham 2008	Preoperative analgesia	Unspecified	Femoral (3‐in‐1) nerve block, Winnie's technique, nerve stimulator and 30 mL of bupivacaine 0.5% (not exceeding 3 mg/kg)	IV morphine
Haddad 1995	Preoperative analgesia	Unspecified	Femoral nerve block with 0.3 mL/kg of bupivacaine 0,25%. Paraesthesia technique with a short bevel needle	IM pethidine, oral co‐dydramol and IM voltarol
Hood 1991	Postoperative analgesia	General anaesthesia for all participants with etomidate, nitrous oxide, isoflurane and alfentanil	Femoral nerve block (triple nerve block) with nerve stimulator < 1.0 mA and 35 mL of prilocaine 0.75% and distal digital pressure plus infiltration above the iliac crest with 8 mL of the same solution	IM papaveratum
Iamaroon 2010	Preoperative analgesia	Spinal anaesthesia	Femoral nerve block with nerve stimulator (0.2 to 0.4 mA) and 20 mL of bupivacaine 0.5% plus 10 mL of saline	IV fentanyl
Jadon 2014	Preoperative analgesia	Spinal anaesthesia	Femoral nerve block with nerve stimulator (0.3 to 0.5 mA) and 15 mL of lidocaine 2% plus 5 mL of distilled water	IV fentanyl
Jones 1985	Postoperative analgesia	General anaesthesia for all participants with thiopental, nitrous oxide, halothane, fentanyl and alcuronium	Lateral cutaneous nerve block with 15 mL of 0.5% bupivacaine, Eriksson's technique	IM pethidine
Kullenberg 2004	Preoperative analgesia	Unspecified	Femoral nerve block with 30 mL of 0.75% ropivacaine. Winnie's approach and nerve stimulator	IM ketobemidon plus tramadol and paracetamol
Luger 2012	Preoperative and postoperative analgesia	Spinal anaesthesia	Ultrasound‐guided femoral (3‐in‐1) nerve block (13‐6 MHz linear probe), catheter inserted ≥ 12‐15 cm past the needle tip) loaded with 30 mL of 0.25% bupivacaine followed by an infusion of 0.125% bupivacaine at 6 mL/h (motor blockade not evaluated) or Lumbar epidural analgesia with 0.125% bupivacaine at 8 mL/h	IV/SC piritramide or IV paracetamol
Mossafa 2005	Preoperative analgesia	Spinal anaesthesia	Fascia iliaca block with 20 mL of 1.5% lidocaine	IV fentanyl
Mouzopoulos 2009	Preoperative and postoperative analgesia	Epidural anaesthesia	Fascia iliaca block daily, Dalen's technique with 0.3 mL/kg of bupivacaine (0.25%?)	IV and analgesics
Murgue 2006	Preoperative analgesia	Unspecified	Femoral nerve block with nerve stimulator and 20 mL of mepivacaine	IV morphine or IV paracetamol and ketoprofen
Nie 2015	Postoperative analgesia	General anaesthesia with propofol, remifentanil and atracurium	Fascia iliaca block with landmarks (2‐3 cm below the inguinal ligament); catheter inserted at least 10 cm cranially and loaded with 20 to 30 mL (weight basis) of 0.5% ropivacaine followed by 0.25% bupivacaine at 0.1 mL/kg/h for 48 hours	IV patient‐controlled analgesia with fentanyl and tropisetron
Segado Jimenez 2009	Postoperative analgesia	Spinal anaesthesia	Landmarks. Obturator nerve with 15 mL of bupivacaine with a vasoconstrictive agent, proximal to the obturator orifice. Femoral lateral cutaneous (Brown) with 10 mL of the same solution	IV morphine
Spansberg 1996	Postoperative analgesia	Spinal anaesthesia	Femoral nerve block with nerve stimulator, non‐stimulating catheter advanced 8‐15 cm past needle tip. Inserted just before surgery. Loaded with 0.4 L/kg of bupivacaine 0.5%; continuous infusion with 0.14 mL/kg/h of bupivacaine 0.25% for 16 hours after surgery	IM morphine
Szucs 2012	Preoperative and postoperative analgesia	Spinal anaesthesia	Non‐stimulating catheter for femoral nerve block, inserted in the emergency department with a nerve stimulator, 0.4 mA and 0.1 msec, space dilated before catheter insertion with 10 mL of 2% lidocaine, catheter advanced 3 cm past the needle tip and 10 mL of 0.5% bupivacaine through the catheter followed by 0.25% bupivacaine infused at  4 mL per hour for 72 hours	IM morphine
Tuncer 2003	Postoperative analgesia	General anaesthesia for all participants with propofol, nitrous oxide, isoflurane, fentanyl, morphine and atracurium	Femoral (3‐in‐1) nerve block, nerve stimulator 0.1 mA, non‐stimulating catheter advanced 4‐5 cm past the needle tip. Loaded with 30 mL of 2% lidocaine with epinephrine followed by an infusion with bupivacaine 0.125% at 4 mL/h for 48 hours	IV morphine
White 1980	Intraoperative analgesia	General anaesthesia with thiopental, nitrous oxide, halothane and fentanyl or nitrous oxide and alfaxolone/alfadolone	Psoas block with 30 mL of 2% mepivacaine, side to be blocked uppermost, Chayen's technique or Spinal: 0.6 to 0.8 mL of hyperbaric cinchocaine	Conventional general anaesthesia
Yun 2009	Preoperative analgesia	Spinal anaesthesia	Fascia iliaca block, Dalen's technique with 30 mL of 0.375% ropivacaine	IV alfentanil

Study	Study authors' definition
Cuvillon 2007	Clinical evaluation "somnolence‐confusion"
Godoy 2010	"episodes of delirium"
Graham 2008	"acute confusional state"
Kullenberg 2004	"transient confusion"
Mouzopoulos 2009	"The primary outcome was perioperative delirium.  Diagnosis of the syndrome was defined using the Diagnostic  and Statistical Manual of Mental Disorders, 4th  edition (DSM‐IV), and Confusion Assessment Method  (CAM) criteria" "Daily patient assessments using the MMSE, DRS‐R‐  98, and Digit Span test [assessment of attention, range 0  (no attention) to 42 (good attention)] were used to enable  the DSM‐IV and CAM diagnoses and assess delirium  severity"
Nie 2015	"Presurgery cognitive status was estimated using the  mini‐mental state examination before and after surgery. The Confusion  Assessment Method was used to diagnose delirium pre‐ and postsurgery"
White 1980	"confused"

Study	Complications related to regional anaesthesia	Complications related to analgesic technique
Altermatt 2013	Not reported	Not reported
Antonopoulou 2006	No complications such as motor block. local  haematoma or infection, inadvertent arterial puncture, direct nerve  damage and cardiovascular or neurological toxicity were observed Five participants had accidental removal or the catheter: 4 during the procedure or while the catheter was secured and 1 while in the ward	Not reported
Beaudoin 2013	No other adverse events were noted during the study period, and no other adverse events were reported to study investigators	Four‐hour oxygen saturation (%) 96 (93–99) vs (%) 98 (95–99) for regional blockade Adverse events:  Hypotension, number (%) 3 (17) vs number (%) 0 (0) for regional blockade  Respiratory depression, number (%) 9 (50) vs number (%) 4 (22) for regional blockade  Nausea/vomiting, number (%) 5 (28) vs number (%) 5 (28) for regional blockade One participant had an episode of rapid atrial fibrillation requiring diltiazem, but the participant had a history of chronic atrial fibrillation
Chudinov 1999	No major complications were described in group regional blockade. Three participants developed local erythema at the catheter insertion site at the end of the study period No signs of local anaesthetic toxicity were documented One participant developed bilateral blockade (L1‐L3 on the opposite side)	Not reported
Coad 1991	No complications related to nerve blocks and no case of prolonged motor blockade	Not reported
Cuvillon 2007	Four catheters were prematurely removed: 1 by a confused participant, 2 by nurses (unexplained fever) and 1 by a surgeon (unconfirmed suspicion of local anaesthetic toxicity (ropivacaine blood level < 2 ng/mL))	More constipation (47% vs 19% for regional blockade)
De La Tabla 2010	Not reported	Not reported
Diakomi 2014	Complications such as local anaesthetic toxicity recorded as well (none reported in results section) Nor did complication rates vary between groups	Complications such as hypoventilation (breathing rate < 8 breaths/min) were recorded as well Moreover, the 2 groups did not differ in these parameters at any time point until study completion at 24 hours after surgery. Nor did complication rates vary between groups
Domac 2015	Not reported	Not reported
Fletcher 2003	Among study participants, none experienced adverse effects as a result of nerve block administration	No clinically important differences between groups with respect to pulse rate, oxygen saturation or respiratory rate at any time interval. Oxygen saturation 94.87%
Foss 2007	No side effects attributable to femoral nerve block were noted in any participants during their hospital stay	More participants (P = 0.05) were sedated in the morphine group at 180 minutes after block placement No difference was noted between groups in nausea and vomiting, with 3 participants in each group having these side effects Tendency toward lower saturation was noted in the opioid group at 60 and 180 minutes after the block despite oxygen supplementation (P = 0.08)
Gille 2006	One inadvertent arterial puncture and blood aspiration positive for 3 participants Two transient paraesthesias No catheter site infection Ten catheters accidentally removed	No respiratory depression from systemic analgesia and no allergic reactions All complications were reversible
Godoy 2010	The only complications were local bruises at the site of injection	Two participants with nausea, and 2 with nausea and vomiting
Graham 2008	No immediate complications occurred in either group	No immediate complications were noted in either group
Haddad 1995	No local or systemic complications of femoral nerve blocks were noted	Not reported
Hood 1991	No untoward sequelae were associated with nerve blocks All plasma prilocaine concentrations (maximum 3 pg/mL) were below the suggested threshold for toxicity for prilocaine of 6 pg/mL	Not reported
Iamaroon 2010	No adverse systemic toxicity of bupivacaine, such as seizure, arrhythmia or cardiovascular collapse was noted in the femoral nerve block group Neither vascular puncture nor paraesthesia occurred No complications, such as haematoma, infection or persistent paraesthesia, were observed within 24 hours after the operation	No participant in either group had hypoventilation (ventilatory rate < 10/min) or oxygen saturation < 95%
Jadon 2014	Not reported	In participants of fentanyl group, drowsiness was observed that required the presence of more persons for holding the participant during positioning SpO₂ was significantly lower in the fentanyl group (P = 0.001). However, no participant in either group had SpO₂ < 90% during the procedure Mean arterial blood pressure was significantly lower in the fentanyl group (P = 0.0019)
Jones 1985	No untoward sequelae associated with the nerve block were seen	Not reported
Kullenberg 2004	No complications related to the nerve blockade were noted in this study	Not reported
Luger 2012	Not reported	Not reported
Mossafa 2005	Not reported	Not reported
Mouzopoulos 2009	No complications of femoral nerve block administrations occurred, except 3 local haematomas developed at the injection site, which resolved spontaneously	Not reported
Murgue 2006	Not reported	Not reported
Nie 2015	No adverse effects, such as pain at the insertion site or paraesthesia, were observed No positive cultures were observed with the fascia iliaca block catheter tip, nor were any signs of infection noted in the current study	Not reported
Segado Jimenez 2009	We did not observe any complications in the realization of regional anaesthetic techniques during or subsequent to the regional anaesthetic techniques	The incidence of side effects (sleepiness, hypotension, constipation, pruritus) was greater in the group with no block than in groups with blocks (P < 0.01)
Spansberg 1996	No haematomas at the site of femoral catheters	Two participants in each group experienced nausea and vomiting
Szucs 2012	For 1 participant, the elastomeric pump failed, resulting in local anaesthetic administered over less than 54 hours instead of 72 hours, and another participant, suffering from acute confusional state, disconnected his pump after 12 hours	The incidence of nausea/vomiting, pruritus or excessive sedation was similar in the 2 groups
Tuncer 2003	Not reported	Side effects (vomiting and pruritus) were observed significantly more frequently with intravenous analgesia
White 1980	No participants showed any evidence of local anaesthetic toxicity	Not reported
Yun 2009	No adverse systemic toxicity of ropivacaine was noted, and neither vascular puncture nor paraesthesia was elicited No complications, such as haematoma or persistent paraesthesia, were observed in participants with a femoral nerve block within 24 hours after the operation	Hypoventilation (ventilatory rate 6–8/min) or pulse oximetric desaturation (oxygen saturation 88% or 89%) was encountered in 4 participants (20%) in the intravenous analgesia group. This was reverted with assisted manual mask ventilation All participants in the intravenous group experienced mild dizziness, and mild drowsiness was present in 12/20 of them

Date	Event	Description
16 August 2016	New search has been performed	We reran the search in August 2016
16 August 2016	New citation required and conclusions have changed	Two new authors joined the review We updated the search in June 2015 We updated the review and brought the methods up‐to‐date We found 55 new studies: 20 included, 13 excluded and 22 ongoing. We left no studies awaiting classification

Date	Event	Description
6 May 2015	New search has been performed	This review has been transferred to the Anaesthesia, Critical and Emergency Care Group by the Bone, Joint and Muscle Group
17 February 2009	New search has been performed	For the second substantive update (Issue 2, 2009), we made the following changes.     1. We included the following newly identified studies: Cuvillon 2007, Fletcher 2003, Foss 2005, Foss 2007, Gille 2006, Kullenberg 2004, Matot 2003, Murgue 2006 and Tuncer 2003.   2. We excluded the following studies: Gorodetskyi 2007, Mannion 2005, Marhofer 1998, Mutty 2007, Schiferer 2007, Turker 2003 and Piangatelli 2004.     We made no changes to the conclusions of the review
6 November 2008	Amended	We converted the review to new review format
21 November 2001	New citation required and conclusions have changed	In this substantive update (Issue 1, 2002), we included one newly identified study (Scheinin 2000). We made no changes to the conclusions of the review    For details on all updates, please see 'Notes'

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain on movement within 30 minutes of block placement	8	373	Std. Mean Difference (Random, 95% CI)	‐1.41 [‐2.14, ‐0.67]
2 Pain at rest within 30 minutes after block placement	7	322	Std. Mean Difference (Random, 95% CI)	‐0.80 [‐1.25, ‐0.35]
3 Pain at rest at 6 to 8 hours after surgery	5	286	Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.70, ‐0.06]
4 Pain on movement at 24 hours after surgery	4	195	Mean Difference (IV, Random, 95% CI)	‐0.39 [‐1.08, 0.30]
4.1 Surgical technique unspecified	3	169	Mean Difference (IV, Random, 95% CI)	0.09 [‐0.10, 0.29]
4.2 Arthroplasty for 38.4% of participants	1	26	Mean Difference (IV, Random, 95% CI)	‐1.94 [‐2.75, ‐1.13]
5 Pain at rest at 24 hours after surgery	8	435	Mean Difference (IV, Random, 95% CI)	‐0.68 [‐1.23, ‐0.13]
5.1 Single shot blocks	2	80	Mean Difference (IV, Random, 95% CI)	‐0.5 [‐0.90, ‐0.10]
5.2 Continuous blocks	6	355	Mean Difference (IV, Random, 95% CI)	‐0.78 [‐1.58, 0.03]
6 Pain on movement at 48 hours	2	129	Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.23, 0.40]
7 Pain at rest at 48 hours after surgery	5	335	Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.87, 0.13]
7.1 Psoas compartment block	1	40	Mean Difference (IV, Random, 95% CI)	‐1.10 [‐2.26, 0.06]
7.2 Femoral nerve block	3	191	Mean Difference (IV, Random, 95% CI)	0.06 [‐0.16, 0.28]
7.3 Fascia iliaca block	1	104	Mean Difference (IV, Random, 95% CI)	‐0.92 [‐1.47, ‐0.36]
8 Pain at rest at 72 hours after surgery	2	140	Mean Difference (IV, Random, 95% CI)	‐0.48 [‐1.83, 0.87]
8.1 Psoas compartment block	1	40	Mean Difference (IV, Random, 95% CI)	‐1.20 [‐1.77, ‐0.63]
8.2 Femoral nerve block	1	100	Mean Difference (IV, Random, 95% CI)	0.18 [0.03, 0.33]
9 Acute confusional state	7	676	Risk Ratio (M‐H, Random, 95% CI)	0.69 [0.38, 1.27]
9.1 Peripheral nerve block based on landmarks	4	501	Risk Ratio (M‐H, Random, 95% CI)	0.82 [0.23, 2.93]
9.2 Peripheral nerve block based on nerve stimulator	3	175	Risk Ratio (M‐H, Random, 95% CI)	0.56 [0.32, 0.98]
10 Pneumonia	3	131	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.19, 0.89]
11 Mortality	7	316	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.34, 1.52]
12 Time to first mobilization	2	155	Mean Difference (IV, Random, 95% CI)	‐11.25 [‐14.34, ‐8.15]
13 Costs of analgesic regimens	2		Std. Mean Difference (Random, 95% CI)	Subtotals only
13.1 Single shot blocks	1	75	Std. Mean Difference (Random, 95% CI)	‐3.48 [‐4.23, ‐2.74]
13.2 Continuous blocks	1	62	Std. Mean Difference (Random, 95% CI)	0.93 [0.37, 1.48]
14 Pressure sores	3	187	Risk Ratio (M‐H, Random, 95% CI)	0.47 [0.09, 2.53]
14.1 Single shot femoral nerve block (on admission)	2	125	Risk Ratio (M‐H, Random, 95% CI)	0.18 [0.02, 1.38]
14.2 Continous femoral nerve block (after surgery)	1	62	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.19, 4.90]
15 Opioid requirement	7	285	Std. Mean Difference (Random, 95% CI)	‐0.70 [‐0.96, ‐0.44]
15.1 Single shot blocks	5	245	Std. Mean Difference (Random, 95% CI)	‐0.73 [‐1.01, ‐0.44]
15.2 Continuous blocks	2	40	Std. Mean Difference (Random, 95% CI)	‐0.55 [‐1.18, 0.08]
16 Participant satisfaction	5	237	Std. Mean Difference (Random, 95% CI)	0.91 [0.62, 1.20]

Methods	RCT Approved by the ethics committee and informed consents obtained Setting: Chile Funding: unspecified NCT01961895
Participants	31 older than 60 years, ASA II‐III with risk factors for known coronary artery disease (≥ 2 risk factors for coronary heart disease as defined by Wallace 1987) and hip fracture within 48 hours of fracture Exclusion criteria: receiving orthopaedic treatment, coagulopathy (clinic or laboratory), sepsis or infection of the catheter insertion site of the lumbar plexus, neurological diseases evolving Also, disoriented, dementia, chronic renal failure stage IV National Kidney Foundation, glomerular filtration rate between 15 and 29 mL/min/1.73 m², unable to assess pain, non‐sinus rhythm or conduction abnormalities (right bundle branch block or left atrioventricular block) on admission EKG, with pacemaker, acute coronary syndrome or decompensated cardiovascular disease at entry, allergy to any drugs of the protocol and inability to understand or sign informed consent unaided
Interventions	Treatment group: continuous lumbar plexus started preoperatively and continued for 72 hours after surgery (n = 17) Control group: IV PCA with morphine (n = 14)
Outcomes	Ischaemic events per participant (extracted as P value): continuous EKG monitoring and serial cardiac enzymes
Notes	Conference abstract. Email sent on 25 May 2015. Study authors responded that the manuscript had not been submitted for publication yet and confirmed the registration number. They noted no major cardiac events during the entire period of observation
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"randomized", no details
Allocation concealment (selection bias)	Unclear risk	Not mentioned
Blinding of participants and personnel (performance bias)   All outcomes	Low risk	Double=blind (participant, caregiver, investigator)
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Double‐blind (participant, caregiver, investigator)
Incomplete outcome data (attrition bias)   All outcomes	Low risk	None lost to follow‐up
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Unclear risk	No details on participants enrolled

Methods	RCT Setting: Greece Funding; unspecified
Participants	84 participants (63 female and 21 male) with hip fracture
Interventions	Treatment group: continuous femoral nerve block with 0.125% levobupivacaine at 3‐4 mL/h, started after surgery (n = 49) Control group: IM pethidine (n = 35) Spinal anaesthesia and paracetamol after surgery for all participants
Outcomes	Pain scores during 24 hours (not included in analysis)
Notes	No complications such as motor blockade, local haematoma or infection, inadvertent arterial puncture, direct nerve damage and cardiovascular or neurological toxicity Conference abstract Email sent on 25 May 2015: no reply
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	"randomized", no details. Unequal groups: 48 and 35
Allocation concealment (selection bias)	Unclear risk	Not mentioned
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Not mentioned
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not mentioned
Incomplete outcome data (attrition bias)   All outcomes	Low risk	None lost to follow‐up No failed block Five accidental catheter dislodgements ‐ 4 during procedure of securing the catheter, 1 on the ward
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Unclear risk	No details for each group separately

Methods	RCT Approved by the ethics committee Setting: Israel Funding: unspecified
Participants	40 participants (30 female and 10 male) with a hip fracture undergoing surgery Excluded: patients with severe cardiac, pulmonary, renal or liver dysfunction; systemic infection; decubitus ulcer; dementia; aspirin or anticoagulant treatment; allergy to local anaesthetics  Mean age: 80 years (range 67‐96) Percentage female: 75% Lost to follow‐up: none No details on surgical technique provided
Interventions	Treatment group: psoas compartment block. Chayen's technique with loss of resistance to air (operated side up), using 2 mg/kg/body weight of 0.25% bupivacaine with adrenaline (0.8 mL/kg) and supplementary doses as required via a catheter inserted 2‐3 cm cephalad past the tip of the needle. Blocks were performed before surgery (16‐48 hours), within 6 hours of admission (n = 20). According to assessment, a sciatic nerve block (n = 5), general anaesthesia (n = 1) or spinal anaesthesia (n = 11) was added for surgery. Catheters were kept for 72 hours after surgery Control group: IM meperidine and diclofenac as required for pain relief (n = 20). Neuraxial block (spinal or epidural n = 19) or general anaesthesia (n =1) for surgery
Outcomes	Pain relief as assessed by VAS at 30 minutes after block placement and at 8, 24, 48 and 72 hours after surgery Complications of the block: 3 participants showed inflammation at the site of insertion; 1 had epidural spread. Local anaesthetic toxicity: none. No major complications associated with the block
Notes	Length of follow‐up: 72 hours after surgery
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Randomized trial: method not stated
Allocation concealment (selection bias)	Unclear risk	Not mentioned
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Not mentioned
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not mentioned
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No failed block. None lost to follow‐up
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Unclear risk	Groups well balanced. No details on surgical technique provided

Methods	RCT Setting: Spain Funding: unspecified
Participants	49 participants older than 65 years with a neck fracture scheduled for surgical treatment
Interventions	Treatment group: double guidance (ultrasound and nerve stimulator) femoral nerve block with 15 mL of 0.2% ropivacaine followed by infusion of 0.2% ropivacaine at 5 mL/h plus 10 mL every 30 minutes (n = 11) Control group: intravenous metamizole 2 G every 6 hours (n = 38) Rescue analgesia with 100 mg tramadol and ondansetron 4 mg
Outcomes	Pain scores at rest and on movement at 24 and 48 hours after surgery Death at 6 months
Notes	Conference abstract Additional information on pain scores received from study authors
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	No details and very unequal groups
Allocation concealment (selection bias)	Unclear risk	No details
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Not mentioned
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not mentioned
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No loss to follow‐up mentioned
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Low risk	Groups well balanced

Methods	RCT Setting: United Kingdom Funding: unspecified
Participants	Orthopaedic hospital in Stevenage, UK  50 participants with an extracapsular hip fracture  Mean age: 77 years (range 68‐89)  Percentage male: 30%  Lost to follow‐up: none Excluded: dementia, unable to rate their pain
Interventions	Treatment group: femoral nerve block inserted at the time of admission using 0.3 mL/kg 0.25% bupivacaine (n = 25) Control group: no injection (n = 25)
Outcomes	Pneumonia Mortality Wound infection Pressure sores No local or systemic complications of femoral nerve blocks
Notes	Length of follow‐up: 24 hours for analgesia, unclear for other outcomes ("short term"; taken as in hospital)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Sealed envelopes
Allocation concealment (selection bias)	Low risk	Sealed envelopes
Blinding of participants and personnel (performance bias)   All outcomes	High risk	No placebo injections used
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Admitting house surgeons and nursing staff who administered analgesia were unaware to which group participants had been allocated
Incomplete outcome data (attrition bias)   All outcomes	Low risk	None lost to follow‐up One failed block; data included
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Low risk	Groups well balanced

Methods	RCT Insitutional approval and informed consents obtained
Participants	Included: patients of both sexes, 18–70 years, weight > 50 kg, American Society of Anesthesiologists physical status I‐III, scheduled for fracture femur operation under central neuraxial block but unable to sit because of pain Excluded: could sit comfortably, any contraindication to spinal anaesthesia, FNB or local anaesthetic
Interventions	Treatment group: femoral nerve block with 20 mL lidocaine 1.5% (15 mL lidocaine 2% and 5 mL distilled water) with epinephrine 5 mcg/mL, nerve stimulator, quadriceps response at 0.3‐0.5 mA, insulated 50 mm 22 G needle (n = 23) Control group: fentanyl 1.0 mcg/kg IV (n = 21) Positioning for spinal 5 minutes after block placement or IV fentanyl. Additional fentanyl 0.5 mcg/kg every 5 minutes in both groups allowed if VAS scores ≥ 4 until VAS scores < 4 or a maximal dose of 3 mcg/kg (whichever came first). No participant required an additional dose of fentanyl
Outcomes	Pain scores on movement (positioning for the spinal) 5 minutes after block placement (scale 0‐10)
Notes	Study also includes participants with shaft fracture. We obtained results for pain scores on movement for participants with proximal fracture only from the study authors. However, we did not keep results in the analysis (see Effects of interventions) owing to the short delay between the block and the evaluation
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Patients were distributed in two groups through computer generated random numbers table"
Allocation concealment (selection bias)	Unclear risk	Not mentioned
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Not mentioned
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not mentioned
Incomplete outcome data (attrition bias)   All outcomes	Low risk	None lost to follow‐up. For 2 participants from each group, surgery was postponed owing to infection at the surgical site and a change in the surgical plan. One participant from each group was excluded owing to refusal for spinal anaesthesia on the table after initial consent. Therefore, 6 participants were subsequently excluded, leaving 60 participants for final analysis All participants for whom a pain score could be obtained during spinal positioning had their score analysed within their assigned group
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Low risk	"Demographic data and type of surgery were comparable in both the groups"

Methods	RCT Informed consents obtained Setting: United Kingdom Funding: unspecified
Participants	Orthopaedic hospital in London, UK  19 participants with an extracapsular hip fracture treated with a pin and plate or a sliding hip screw  Mean age: 82 years (range 67‐93)  Percentage female: 95%  Lost to follow‐up: none Excluded: other painful lesions, signs of moderate or severe dementia, < 65 years of age, systemic disease indicating an alternative method of anaesthesia (e.g. spinal)
Interventions	Tretament group: lateral cutaneous nerve of thigh block with 15 mL 0.5% bupivacaine and adrenaline (n = 10)  Control group: no block (control) (n = 9) All participants had general anaesthesia with fentanyl, thiopentone, suxamethonium, nitrous oxide, halothane. Blocks performed at completion of surgery
Outcomes	Death (24 hours)
Notes	One participant died within 24 hours of surgery, and results for this participant were not given Length of follow‐up: not stated
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	'Random envelopes'
Allocation concealment (selection bias)	Low risk	'Random envelopes' opened at completion of surgery
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Not mentioned
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Postoperative analgesia was prescribed before allocation to respective groups, with administration performed at the discretion of the nursing staff, who were unaware of whether a block had been performed. The dose of pethidine was 25 or 50 mg intramuscularly, depending on the participant's estimated weight ‐ not on general condition
Incomplete outcome data (attrition bias)   All outcomes	Low risk	One lost to follow‐up Results for 1 participant who died are not included: "One patient in Group 2 who died within the 24‐hour period is not included in analysis of the results: there are thus nine patients in each group"
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Low risk	Groups well balanced

Methods	RCT Setting: Sweden Funding: no conflict of interest declared, classified as departmental resources
Participants	Orthopaedic hospital in Sweden  80 participants with a hip fracture  Mean age: 82 years (range not stated)  Percentage female: 64%  Lost to follow‐up: not stated Excluded: inability to rate their pain
Interventions	Treatment group: femoral nerve block inserted at the time of admission with 30 mL ropivacaine (7.5 mg/mL) (n = 40). Mean bock duration 15.8 ± 5.6 hours. Four participants had their block during transportation to the hospital. The block was repeated for 3 participants owing to a long delay before surgery (23.9 hours, 26.3 hours and 30.9 hours) Control group: no injection (n = 40)
Outcomes	Confusion (Pfeiffer test, graded according to a 4‐degree scale (0‐3: no, light, moderate and pronounced confusion) at 48 hours Time to first mobilization Pressure sores Opioids used per 24 hours
Notes	Length of follow‐up: length of acute hospital stay (mean 11 days) No complication related to the nerve block All participants indicated that they would consider a new future blockade if this would be necessary
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Use of sealed envelopes
Allocation concealment (selection bias)	Low risk	Use of sealed envelopes
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Not mentioned
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not mentioned
Incomplete outcome data (attrition bias)   All outcomes	Low risk	None lost to follow‐up Five failed blocks; participants kept in their treatment groups
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Unclear risk	Groups well balanced except for a longer delay in arrival to surgery for the block group (15.5 hours vs 5.8 hours)

Methods	RCT Setting: Iran Funding: unspecified
Participants	40 participants with femoral neck fracture
Interventions	Treatment group: fascia iliaca block with 20 mL 1.5% lidocaine (n = 20) Control group: IV fentanyl 1.5 mcg/kg (n = 20) Lateral decubitus position for spinal anaesthesia
Outcomes	Pain on movement 5 minutes after block placement (positioning for spinal) Participant satisfaction
Notes	Conference abstract Email sent on 26 May 2015; no reply
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Randomized", no details
Allocation concealment (selection bias)	Unclear risk	Not mentioned
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Not mentioned
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not mentioned
Incomplete outcome data (attrition bias)   All outcomes	Low risk	None lost to follow‐up
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Unclear risk	No details

Methods	RCT Consents obtained Setting: South Africa Funding: unspecified
Participants	Orthopaedic hospital in Cape Town, South Africa  40 participants with a hip fracture undergoing surgery  Mean age: 79 years (range not stated).  Percentage female: 81%  Lost to follow‐up: none Excluded: fracture sustained more than 8 days before admission; < 60 years old; absolute contraindication to a regional technique, such as localized sepsis, suspicion of bacteraemic process or patients receiving anticoagulant therapy; overt or suspected endocrine disorder other than diabetes mellitus
Interventions	Treatment groups: psoas block (n = 16) or spinal (n = 20) plus 'light" general anaesthesia using althesin, nitrous oxide Control group: general anaesthesia with fentanyl, thiopentone, suxamethonium, nitrous oxide, halothane (n = 20)
Outcomes	Confusion Pneumonia Mortality
Notes	Length of follow‐up: 4 weeks Four of 20 participants allocated to receive psoas nerve block failed to achieve a satisfactory block; outcome for these participants was not given (other than for mortality) No participant showed evidence of toxicity to the local anaesthetic Trial also includes a group with spinal (n = 20) added to light general anaesthesia
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"randomly allocated", no details
Allocation concealment (selection bias)	Unclear risk	Not mentioned
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Not mentioned
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not mentioned
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Four failed psoas compartment blocks, no other losses to follow‐up
Selective reporting (reporting bias)	Low risk	All measurements mentioned in methods section given in results section
Other bias	Unclear risk	Groups well balanced, except for preoperative pneumonia: 1 in the psoas compartment block and 4 in the group general anaesthesia alone Not in intention‐to‐treat

Study	Reason for exclusion
Bech 2011	Different intervention: local anaesthetic infiltration
Bölükbasi 2013	No outcome of interest. Conference abstract. Not enough details on possible outcomes of interest in the abstract. Study authors contacted on 25 May 2015. Confirmed that they were the authors of the abstracts but did not provide requested information
Durrani 2013	Different population. 47 proximal fractures, 28 shaft fractures and 9 distal fractures. Mean age 42 years. Email sent 17 March 2016, to request separate data for participants with a proximal fracture. No reply
Foss 2005	Different intervention: epidural analgesia
Fujihara 2013	Not randomized: "The included patients were assigned to one of two groups in alternating order"
Ghimire 2015	Different intervention. Comparison between fascia iliaca block and femoral nerve block for positioning for spinal anaesthesia
Gorodetskyi 2007	Different intervention. This was a randomized study of 60 participants with a trochanteric hip fracture fixed with a sliding hip screw or a trochanteric external fixator. After surgery, participants were randomized to an active non‐invasive interactive neurostimulation device or to a sham device. The active device generated biphasic electrical impulses. Participants allocated to the active group had a reduced level of pain, a reduced analgesic requirement and a greater range of flexion of the injured limb. We excluded the study as it was not a study of nerve blocks
Hussain 2014	Different intervention. The amount of local anaesthetic used (bupivacaine 12.5 mg/kg of body weight) exceeds recommendations
Hwang 2015	No outcome of interest at our selected time points (a study may be legitimately excluded if outcomes of interest were not measured; Higgins 2011 Section 5.4.1). Here, pain intensity was measured at 2 and 3 hours after block placement only from the results of 2 conference abstracts for this study, and at 1, 4 and 24 hours after block placement in the third abstract. The third abstract also reported absence of a difference in opioid consumption "during the course of the study (no specific time point mentioned for this outcome) on preliminary results:12.0 mg of morphine equivalent (6 participants) versus 12.9 mg for the control group (8 participants); P value 0.88." This result was not retained in the analysis. Adding it would not change the conclusions for opioid consumption standardized mean difference ‐0.71 (95% confidence interval ‐0.94 to ‐0.48); I² statistic = 44%, with this result vs standardized mean difference ‐0.77 (95% confidence interval ‐0.98 to ‐0.56); I² statistic = 30% without. No complications were recorded in either group
Irwin 2012	Retrospective study
Kang 2013	Different intervention: local anaesthetic infiltration
Kumie 2015	Not a RCT. Single‐institution case control study
Mannion 2005	Different intervention. This was a randomized trial of 36 participants who were having hip fracture surgery. All participants had a psoas block and general anaesthesia. Participants were randomized into 3 groups. A control group received a psoas block and IV saline, another group received psoas block and IV clonidine 1 mg/kg and a third group received a psoas block and peripheral clonidine. The interval from time of completion of block to first supplementary analgesic administration was longer in the IV clonidine group. Results show no significant differences among groups regarding postoperative adverse effects. We excluded the study as investigators included no 'control' group that received no block
Manohara 2015	Different intervention. Comparison between ultrasound‐guided supra‐inguinal fascia iliaca block and femoral nerve block
Marhofer 1998	Different intervention. This was a randomized trial of 60 participants. 20 received a 3‐in‐1 block with ultrasound guidance with 20 mL 0.5% bupivacaine, 20 received 20 mL of 0.5% bupivacaine and 20 received 30 mL of 0.5% bupivacaine with nerve stimulator guidance. We excluded the study as investigators included no comparison with a group without nerve block
Matot 2003	Different intervention: epidural analgesia
McRae 2015	Different population: 6 participants with shaft fracture. Letter sent 17 March 2016, to request separate data for participants with a proximal fracture. No reply
Mutty 2007	Different population. This was a randomized trial comparing femoral nerve block vs no block for 54 participants with a femoral shaft or distal femoral fracture. We excluded the study as it included no proximal femoral fractures
Piangatelli 2004	Different intervention. This was a randomized study of 80 participants undergoing lower extremity surgery that compared 4 different methods. A lumbar plexus block with 30 mL 0.5% levobupivacaine or a lumbar plexus block with 30 mL 0.75% ropivacaine or a sciatic nerve block with 10 mL 0.75% ropivacaine or a sciatic nerve block with 10 mL 0.5% levobupivacaine. We excluded the study from this review, as investigators included no 'control' group without nerve block
Reavley 2015	Different intervention. Comparison between fascia iliaca block and femoral (3‐in‐1) block for preoperative analgesia in the emergency department
Scheinin 2000	Different intervention: epidural analgesia
Schiferer 2007	Different population. This was a randomized trial of 62 participants with femoral trauma who were randomized to receive at the site of the accident a femoral nerve block or intravenous metamizole for pain. Studiy provided a variety of causes for the femoral trauma, including 20 cases of hip fracture. The nerve block was shown to reduce the degree of pain as assessed by the visual analogue scale and to reduce anxiety and heart rate. We excluded the study as it included participants with other conditions. Trialists were unable to provide separate results for hip fracture participants
Segado Jimenez 2010	Study authors informed us that the trial included participants with hip fracture and participants without hip fracture undergoing elective hip arthroplasty. They could not give us data separately for participants with and without hip fracture: "I did not registered which patients were hip fractures, just the type of surgery"
Sia 2004	Different population. Femoral shaft fractures
Turker 2003	Different intervention. This was a randomized study of 30 participants who underwent partial hip replacement surgery. 15 received general anaesthesia plus epidural block with 15 mL of 0.5% bupivacaine, and 15 received general anaesthesia plus psoas compartment block with 30 mL of 0.5% bupivacaine. Both groups had similar pain scores, but the epidural group showed greater drops in mean arterial blood pressure from baseline and more complications. We excluded the study from this review because it did not include a control group that did not receive nerve block
Van Leeuwen 2000	Different intervention. This was a randomized study of 3 different combinations of doses of local anaesthetics given to produce a 'three in one' femoral nerve block. We excluded this study from the review because it did not include a 'control' group that did not receive nerve block

Trial name or title	Ultrasound‐guided femoral nerve block using 1% ropivacaine as a method of pain control in patients who present to emergency with a fractured hip
Methods	Parallel RCT Open label Approved by the ethics committee
Participants	Inclusion criteria: 18 years or older with radiological proof of fractured neck of femur Exclusion criteria: women lactating, pregnant or of childbearing potential who are not willing to avoid becoming pregnant during the study, < 18 years old, allergy to ropivacaine, allergy to paracetamol and morphine, anticoagulated patients and those with significant coagulation abnormalities that increase their risk of bleeding. localized injection site infection. neurological deficits in the distribution of the femoral nerve noted, consent denied, documented severe hepatic disease, unable to give consent themselves, history of heart block or on amiodarone, acute cardiac event in the last 3 months
Interventions	Treatment group: An ultrasound‐guided femoral nerve block will be placed with 1% ropivacaine. An ultrasound vascular probe is placed to locate structures anatomically: The main structures were the femoral nerve itself, the femoral artery and vein and the fascia iliaca. Then under real‐time ultrasound guidance via an out‐of‐plane approach, 15 mL of 1% ropivacaine is injected around the femoral nerve as visualized. A 2‐person technique is employed with the needle attached to the syringe of ropivacaine via a 90 cm minimum volume extension set. The probe and needle operator is present along with an assistant who injects the anaesthetic. Digital pressure is then placed for 30 seconds just distal to the injection site. The entire procedure takes about 15 to 20 minutes. Objective measure of the nerve block is assessed at 30 minutes by testing sensation over the anterolateral aspect of the thigh Control group: Both study and control groups will receive regular oral tablet paracetamol 1 G every 4 to 6 hours to a maximum dose of 4 G in 24 hours and parenteral (intravenous) morphine as required for pain control
Outcomes	Primary outcome: morphine use in patients for both groups at 24 hours Secondary outcomes: pain scores and subsequent pain scores to be looked at in each group and compared over the first 12 hours. Scores will range from 0 to 10, with 10 indicating the worst pain. Pain scores in both groups will be assessed at enrolment into the study, 30 minutes after enrolment or after nerve block has been given, then at 4 then 8 then 12 hours after enrolment
Starting date	04/04/2009
Contact information	Dr Edmond Park, Emergency Department, St Vincents Hospital, Victoria Street, Darlinghurst 2010 New South Wales +61 2 8382 2040, epark@stvincents.com.au
Notes	Recruiting

Trial name or title	A randomized controlled trial of fascia iliaca compartment block versus morphine for pain in fractured neck of femur in the emergency department: a pilot study ‐ fascia Iliaca compartment block versus parenteral morphine sulphate
Methods	RCT Open label
Participants	Inclusion criteria: suspected isolated hip fracture (clinical suspicion of hip fracture defined as the presence of painful, unilateral shortening and external rotation of the lower limb, preventing weight‐bearing), alert and oriented, willing to be randomized for pain relief as described, > 18 years of age Exclusion criteria: other significant injury, clinical suspicion of fracture other than to the hip, sensitivity to any study preparation, local infection at the injection site, symptoms/Injury > 8 hours, prehospital parenteral analgesia, unable to give informed consent as a result of current or pre‐existing physical or mental condition, known coagulopathy, taking warfarin or clopidogrel within 2 weeks, body mass index > 40
Interventions	Treatment group: fascia iliaca compartment block with bupivacaine 0.25% Control group: morphine
Outcomes	Primary outcome measure: comparison between experimental and control groups of the difference in maximum tolerable passive hip flexion from supine (verbal pain score ≤ 3), expressed in degrees measured with a goniometer at baseline (on arrival after recruitment but before randomization) vs 45 minutes post intervention Secondary objective: investigation of duration of effect, ease of use, failure rates and morphine‐sparing effect of using fascia iliaca block in this participant group
Starting date
Contact information	Nottingham University Hospitals NHS Trust
Notes

Trial name or title	Blocking the femoral nerve in patients with suspected hip fracture ‐ does it work in clinical practice?
Methods	Parallel RCT Double‐blind
Participants	Inclusion criteria: 132 participants with suspected hip fracture, ≥ 65 years old Exclusion criteria: more fractures incurred in the context of an accident, at home for more than 12 hours after the accident, hypersensitivity to local analgesics, infection, neurovascular problems, blockade not available within a specific period, patients for whom the attending physician considers that blockade could be harmful (e.g. atrioventricular block type II or III, elderly, severe liver disease, greatly reduced renal function)
Interventions	Treatment group: femoral nerve block with ropivacaine Control group: placebo, subcutaneous injection
Outcomes	Primary objective: pain scores Secondary outcomes: complications (decubitus ulcers), rehabilitation time, analgesic use
Starting date	24/10/2008
Contact information
Notes

PERMALINK

Peripheral nerve blocks for hip fractures

Joanne Guay

Martyn J Parker

Richard Griffiths

Sandra Kopp

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Summary of findings for the main comparison. Peripheral nerve blocks for hip fracture.

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Quality of evidence and summary of findings

Results

Description of studies

Results of the search

1.

Included studies

1. Anaesthetic techniques.

Excluded studies

Studies awaiting classification

Ongoing studies

Risk of bias in included studies

2.

3.

Allocation

Blinding

Incomplete outcome data

Selective reporting

Other potential sources of bias

Effects of interventions

Primary outcomes

1. Pain

1.1 Pain on movement and at rest within 30 minutes after block placement

1.1. Analysis.

4.

Quality of evidence for pain on movement at 30 minutes after block placement

1.2. Analysis.

1.2 Pain on movement and at rest at six to eight hours after surgery

1.3. Analysis.

1.3 Pain on movement and at rest at 24 hours after surgery

1.4. Analysis.

1.5. Analysis.

Pain on movement and at rest at 48 hours after surgery

1.6. Analysis.

1.7. Analysis.

Trial name or title	The FINOF (Femoral Nerve‐Block Intervention in Neck Of Femur Fracture) study ‐ FINOF
Methods	RCT Single‐blind
Participants	Inclusion criteria: ≥ 70 years of age, resident in own home or in warden‐aided flat, cognitively intact (as defined by a score ≥ 7 on the Abbreviated 10 point Mental Test Score (AMTS), prior fracture New Mobility Score ≥ 3, indicating independent indoor ambulation) Exclusion criteria: pre‐fracture hospitalization, contraindications to femoral nerve block analgesia, regular pre‐fracture opioid or glucocorticoid therapy, alcohol or substance abuse, morphine intolerance, postoperative surgical restrictions for ambulation
Interventions	Treatment group: femoral nerve block with ropivacaine 0.2% Control group: standard care
Outcomes	Primary endpoint(s): from day 1 to day 3 postoperatively: cumulative ambulation score, cumulative dynamic pain score postoperatively Secondary objective: to estimate the cost‐effectiveness of femoral nerve blockade vs usual care, to examine issues of compliance, acceptability to staff and participants
Starting date	20/04/2011
Contact information	Nottingham University Hospitals NHS Trust, United Kingdom; no contact provided
Notes

Trial name or title	Analgesic effect of a supplemental nerve block in patients with hip fracture
Methods	Parallel RCT Double‐blind
Participants	Inclusion criteria: clinical suspicion of hip fracture, successful sensory effect of femoral nerve block, mentally capable of comprehending and using verbal pain score and distinguishing between pain from fractured hip and pain from other location, arrival in the emergency department at times when one of the doctors who do the nerve blocks for this investigation are on call, possible visualization of necessary structures with ultrasound, verbal pain score (0‐10) > 3 at rest or > 5 with passive leg raise 30 minutes after femoral nerve block, informed consent, ≥ 18 years of age Exclusion criteria: hip fracture not confirmed by x‐ray, weight < 45 kg, previously included in this trial If participant wishes to be excluded, allergy to local anaesthetics or adrenocortical hormone, visible infection in the area of the point of needle injection
Interventions	Treatment group: femoral nerve block with bupivacaine 0.25% Control group: placebo
Outcomes	Primary outcome: frequency of sufficient analgesia 20 minutes after a supplemental obturator nerve block vs placebo Secondary outcomes: success rate, time to perform the block, onset time
Starting date	17/03/2015
Contact information	Department of Anaesthesia and Intensive Care, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, Denmark +4528782877 thomas.dahl.nielsen@clin.au.dk
Notes

Trial name or title	The effect of the use of fascia iliaca nerve blockade on patient positioning for spinal anaesthesia and the effect of continuous nerve blockade on postoperative pain and mobility outcomes in patients with hip fractures
Methods	RCT Double‐blind Approved by the ethics committee: Health and Social Care Research Ethics Committee (HSC REC 1) (Northern Ireland) approved on 18th of April 2008 (ref: 08/NIR01/20) Funding: governmental: Belfast Health and Social Care Trust (UK) (ref: RGHT 000559)
Participants	Target number of participants 100 participants ‐ 40 in first part of study and 60 in second part of study Inclusion criteria: ASA physical status class I‐IV, able to give written informed consent, requiring operative repair of fractured neck of femur, aged 18 years and over, either sex Exclusion criteria: history of dementia or difficulty in obtaining consent, history of allergy to any of the medications used in the study
Interventions	Treatment group: fascia iliaca block for positioning before spinal anaesthesia and continuous infusion after surgery Part 1: Participants randomized to receive fascia iliaca compartment block with 2 mg/kg 1% lignocaine or conventional sedation with 0.2 mg/kg IV ketamine and 0.025 mg/kg IV midazolam. At completion of surgery, a fascia iliaca block with 1 mg/kg 0.25% levobupivacaine will be performed in all participants    Part 2: participants randomized to receive a preoperative fascia iliaca block with 1 mg/kg of 0.25% levobupivacaine or 2 mg/kg of 1% lignocaine. After administration of fascia iliaca block, a catheter will be inserted below the fascia iliaca and secured in place. Participants will be reviewed in the postoperative period and bolus doses of 0.125% levobupivacaine will be administered through the fascia iliaca block catheter if visual analogue scale is greater than 4. The catheter will be removed no longer than 24 hours after surgery Control group: no block
Outcomes	Primary outcome measures: ‐ Part 1: comparison of pain score at rest and positioning for spinal anaesthesia in participants who have received a fascia iliaca compartment block or conventional sedation  Part 2: comparison between postoperative pain scores among participants receiving fascia iliaca blockade with lignocaine or levobupivacaine, and effects of bolus top‐up doses of low‐dose levobupivacaine on pain scores Secondary outcome measures: length of time to first request of additional analgesia, level of assistance required for transfer from sitting to standing position, incidence and severity of motor blockade, time to mobilization with walking aid, measurement of oxygen saturations without supplemental oxygen in both groups, incidence of all complications associated with analgesic techniques in both groups, incidence of nausea and/or vomiting within first 48 hours after surgery in both groups, use of blood products in all groups
Starting date	01/07/2009
Contact information	Ms Rosemary Hogg Department of Anaesthetics & Intensive Care Medicine, Queen's University Belfast, 2nd Floor, Mulhouse Building, Grosvenor Road  Belfast, BT12 6BJ, United Kingdom
Notes	Completed Protocol/serial number: RGHT000559 http://www.belfasttrust.hscni.net

Trial name or title	Femoral nerve blockade in hip fracture patients
Methods	RCT Approved by the ethics committee Funding: governmental: Umeå University (Sweden)
Participants	Target number of participants: 250 Inclusion criteria: both males and females, aged 70 years and above, all hip fracture patients admitted to the orthopaedic department Exclusion criteria: local infection, allergy to local anaesthesia, dying patients, pathologic hip fractures
Interventions	Treatment group: Participants in the intervention group will receive a femoral nerve blockade as soon as they arrive. Participants with pain scores > 4 will be given morphine IV according to the standard protocol (morphine 10 mg/mL, 1 to 5 mg when necessary) Control group: regular use of opioids Both groups will receive 1 G of paracetamol 4 times/d. Postoperative pain treatment will be given according to the standard protocol in both arms of the study. Total follow‐up for both arms will end at the time of discharge
Outcomes	Primary outcome measures: postoperative delirium, assessed 3 times a day; postoperative complications, such as decubital ulcers, infections, thrombosis, heart failure and pain. A cognitive test will be assessed in the ambulance pre‐hospital arrival and at 24 +/‐ 6 hours postoperatively. At days three to five, a more thorough assessment will be done including delirium, depression, cognitive status, quality of life and more Secondary outcome measures: mortality, orthopaedic recovery recorded at the time of discharge from the hospital, EQ‐5D, economics
Starting date	30/03/2009
Contact information	Prof Ola Winso Operationscentrum  Norrlands universitetssjukhus  Umea  SE‐901 85  Sweden
Notes	Completed http://www.umu.se/umu/index_eng.html

Trial name or title	Intra‐ and post‐operative analgesia for patients undergoing surgery for hip fracture ‐ role of fascia iliaca compartment block
Methods	RCT Double‐blind (participants and caregivers) Funding: governmental: Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NL, United Kingdom  +44 (0)20 7307 2622; dhmail@doh.gsi.org.uk, http://www.dh.gov.uk/Home/fs/en
Participants	40 adult participants of ASA I‐III admitted to Selly Oak Hospital with hip fracture and scheduled for fixation will be recruited after consent is obtained inclusion criteria: scheduled for hip fracture surgery Exclusion criteria: dementia/confusion, preoperative chest infection and/or poor respiratory function, temperature ≥ 38°C, white cell count > 11,000 mm³, respiratory rate > 25 per minute, auscultation and/or chest x‐ray evidence, SpO₂ < 90% on air, congestive cardiac failure, bed‐bound or use of ≥ 2 aids for mobilization pre‐fracture, malignancy, coagulopathy, known or suspected allergy to ropivacaine and/or morphine, local infection at site where the block is to be performed, refusal of permission to approach general practitioner
Interventions	Treatment group: fascia iliaca compartment block (n = 20) Control group: morphine (n = 20) Each participant will have a standard preoperative assessment, standard monitoring and recovery care and will be given assessments at 1, 3, 6 and 24 hours postop. Thereafter, data will be collected on a daily basis until 30 days postop/discharge/death, whichever is earlier. Our hospital already has a framework for data collection (Integrated Care Pathway). For our study, we will be using the same data
Outcomes	Primary outcome measures: total dose of morphine required during first 24 hours post‐op Secondary outcome measures: time to first dose of morphine postop, pain scores in recovery room and at 13, 16 and 24 hours after surgery, time to first appropriate response to verbal commands, time to discharge from recovery room, occurrence of nausea and vomiting in recovery and number of episodes during the first 24 hours postop, total dose of cyclizine required in the first 24 hours, need for granisetron during the first 24 hours, sedation scores at 1, 3, 6 and 24 hours, mental test scores at 1, 3, 6 and 24 hours, complications, rehabilitation outcomes, mortality
Starting date	04/04/2006
Contact information	Dr FA Levins, Anaesthetics, Selly Oak Hospital, Birmingham, B29 6JD, United Kingdom
Notes	DOI 10.1186 Protocol/serial number: N0265178818 Completed

Trial name or title	The FINOF ‐ Femoral nerve‐block Intervention in Neck Of Femur fracture study Approved by Nottingham Research Ethics Committee 2, 28th January 2011, ref: 10/H0408/113 Funding: governmental; Funder name: National Institute of Health Research (NIHR) (UK) ‐ Research for Patient Benefit (RfPB)
Methods	RCT
Participants	150 elderly patients admitted with an acute hip fracture Inclusion criteria: aged ≥ 70 years, resident in their own home or warden‐aided flat, cognitively intact (as defined by a score ≥ 7 on the Abbreviated 10 point Mental Test Score (AMTS), and prior fracture New Mobility Score ≥ 3 (indicating independent indoor ambulation) Exclusion criteria: prefracture hospitalization, contraindications to femoral nerve block analgesia, regular pre‐fracture opioid or glucocorticoid therapy, alcohol or substance abuse, morphine intolerance, postoperative surgical restrictions for ambulation
Interventions	Treatment group: femoral nerve block followed by continuous infusion Control group: standard analgesic care
Outcomes	Drug‐related adverse events, earlier recovery, shorter length of stay in hospital and overall, improved quality of life for patients suffering with an acute hip fracture Primary outcome measures: cumulative dynamic pain score, cumulative ambulation score measured from day 1 to day 3 postoperatively Secondary outcome measures: cumulative dynamic pain score preoperatively (at 30 minutes, 60 minutes, 12 hours after initial femoral nerve block), cumulative side effects (nausea, vomiting, constipation, delirium) (from admission to day 3 postoperatively),  cumulative calorific and protein intake (from admission to day 3 postoperatively), health‐related quality of life measured on the EUROQOL EQ‐5D, informing a cost‐effectiveness analysis, hospital length of stay, rehabilitation outcome measured by New Mobility Score, participant and staff experience (qualitative study)
Starting date	02/01/2012
Contact information	Dr Opinder Sahota, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, United Kingdom; opinder.sahota@nuh.nhs.uk
Notes	Completed: DOI 10.1186/ISRCTN92946117 EudraCT number: 2010‐023871‐25 http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=10929 http://www.nuh.nhs.uk/ http://www.ncbi.nlm.nih.gov/pubmed/24885267 Protocol: Sahota O, Rowlands M, Bradley J, Van de Walt G, Bedforth N, Armstrong S, Moppett I, Femoral nerve block Intervention in Neck of Femur fracture (FINOF): study protocol for a randomized controlled trial. Trials 2014, 15, 189, doi: 10.1186/1745‐6215‐15‐189. PubMed AbstractPublisher Full Text

Trial name or title	Improving pain and function in hip fracture
Methods	RCT Single‐blind (outcome assessor)
Participants	Inclusion criteria: adults (≥ 60 years) presenting to the MSMC ED from 8:00 to 20:00 with a radiographically confirmed hip fracture (femoral neck, intertrochanteric or pericapsular) Exclusion criteria: history of advanced dementia, presence of multiple trauma, pathological fractures, bilateral hip fractures, previous fracture or surgery at the currently fractured site, transferred from another hospital, cirrhosis or liver failure, able to self‐report pain intensity Other exclusion criterion: < age 60 because our focus is on treatment of pain in older adults
Interventions	Treatment group: femoral nerve block Control group: no intervention
Outcomes	Primary outcome measures: pain (11‐point numerical evaluated 3 times daily for the duration of hospital stay (average stay is 4 days)) Secondary outcome measures: delirium (confusion assessment method) evaluated 3 times daily for duration of hospital stay
Starting date	November 2008
Contact information	R. Sean Morrison, MD, and Knox Todd, MD, Beth Israel, New York, USA 10003
Notes	This study has been completed

Trial name or title	Perioperative analgesia by femoral perineural catheter for femoral neck fracture ‐ Study KTcol
Methods	Parallel RCT Double‐blind (participants, investigator)
Participants	Inclusion criteria: adults (≥ 18 years) with femoral neck fracture Exclusion criterion: contraindication with analgesia
Interventions	Treatment group: analgesic treatment with a femoral perineural catheter (inserted from hospital admission) with continuous infusion of ropivacaine Control group: placebo
Outcomes	Primary outcome measures: evaluation, in patients admitted in emergencies for suspicion of femoral neck fracture, the perioperative efficiency of an analgesic treatment provided with a femoral perineural catheter from hospital admission to 24 hours after surgical operation
Starting date	March 2009
Contact information	Guillaume Bouhours UHAngers, Angers, France
Notes

Trial name or title	Postoperative pain control among intrathecal 0.1 mg morphine, femoral nerve block or periarticular infiltration of 20 mL of 0.25% bupivacaine in patients post intramedullary hip screw
Methods	Parallel RCT Single‐blind (outcome assessor)
Participants	Inclusion criteria: 18‐90 years old, good consciousness, well co‐operated, can use patient‐controlled analgesia machine, ASA physical status I‐III, no contraindication for spinal anaesthesia, accept spinal anaesthesia, body weight > 30 kg, body mass index 20‐35 kg/m², no history of research drug allergy Exclusion criteria: previous history of hip surgery (the same side), pathological fracture, severe infection or bone cancer
Interventions	Treatment group 1: femoral nerve block, spinal anaesthesia plus femoral nerve block with 20 mL of 0.25% bupivacaine Treatment group 2: periarticular bupivacaine infiltration, spinal anaesthesia plus periarticular infiltration with 20 mL of 0.25% bupivacaine Control group 1: spinal anaesthesia with 0.5% bupivacaine alone Control group 2: spinal anaesthesia plus 0.1 mg of intrathecal morphine
Outcomes	Primary outcome measures: amount of morphine consumed during first 24 hours after surgery  Secondary outcome measures: efficacy of pain control, patient satisfaction, incidences of adverse events (nausea, vomiting, pruritus)
Starting date	September 2010
Contact information	Thitima Chinachoti, MD (Madihol University), Faculty of Medicine Siniraj Hospital, Bangok, Thailand, 10700
Notes

Trial name or title	Does femoral nerve catheterization reduce the incidence of post‐operative delirium in patients presenting for hip fracture repair?
Methods	Parallel RCT Open label
Participants	270 adults (≥ 50 years) presenting to Oschner Main Campus with a hip fracture Exclusion criteria: head trauma as reported in the medical record and/or participant response, high‐impact fracture as reported in the medical record, aphasia as reported in the medical record and/or participant response, deafness, blindness as reported in the medical record and/or participant response, true allergy (not sensitivity or side effects) to local anaesthetics or opiates, pregnant, inability to complete study activities preoperatively
Interventions	Treatment group: femoral nerve catheterization Control group: intravenous opioids
Outcomes	Primary outcome measure: number of participants developing delirium postoperatively during first 3 days after surgery Secondary outcome measures: hospital length of stay, pain score, consumption of pain medication for breakthrough pain relief
Starting date	March 2012
Contact information	Leslie Thomas, MD, Oschner Clinic Foundation, New Orleans, Louisianna, USA 70121
Notes	Recruiting