The Efficacy of Intravenous Analgesia and Various Nerve Blocks for Pain Management in Elderly Patients With Hip Fractures: A Meta-Analysis

Abstract

Pain management in elderly patients with hip fractures has received more and more attention, which is crucial for promoting recovery and reducing complications. At present, there are various and controversial analgesic methods for this population. This meta-analysis evaluated the analgesic effects and side effects of intravenous analgesia compared to different nerve block techniques, including femoral nerve block, fascia iliaca block or pericapsular nerve group block, in this patient group. The study was conducted following the PRISMA 2020 guidelines. A search was performed in October 2024 across PubMed, Web of Science, Cochrane Library, and Embase. Pain scores at different time points, supplemental analgesic morphine consumption, and adverse reactions were compared between intravenous analgesia and nerve blocks. Data were collected from 12 studies and 1157 elderly patients using intravenous analgesia and nerve block after hip fracture, with no differences in sample size, mean age, or percentage of females between the two groups at baseline. Compared to intravenous analgesia, nerve blocks showed significant advantages in the pain score of 2 h after block (SMD-0.80; 95% CI: −1.23 to −0.38; I² = 90%) and the supplemental analgesic morphine consumption (SMD = −0.46; 95% CI: −0.73 to −0.19; I² = 59%). The incidence of adverse reactions and the pain scores at various time points also demonstrated significant differences between the two groups. The application of nerve blocks in elderly patients with hip fractures demonstrates significant clinical advantages, particularly in postoperative pain management, decreasing opioid use, and reducing postoperative complications.

Keywords

aged / analgesia / hip fractures / meta-analysis / nerve block

References

[1] A. Szilágyi, B. Takács, R. Szekeres, et al., “Effects of Voluntary and Forced Physical Exercise on the Retinal Health of Aging Wistar Rats,” Geroscience 46, no. 5 (2024): 4707-4728.

[2] Y. Zhang, J. Zhang, and Z. Fu, “Role of Autophagy in Lung Diseases and Ageing,” European Respiratory Review 31, no. 166 (2022): 220134.

[3] C. H. Park, S. H. Lee, R. Lee, D. Y. Kim, M. R. Cho, and S. K. Song, “Effects of Body Mass Index on Mortality in Elderly Patients With Hip Fractures,” Medicine (Baltimore) 103, no. 31 (2024): e39157.

[4] A. Erichsen Andersson, B. M. Gillespie, M. Karlsson, et al., “Reduction of Early Surgical Site and Other Care Related Infections in 3553 Hip Fracture Patients: Lessons Learned From the 5-Year Safe Hands Project,” Antimicrobial Resistance and Infection Control 11, no. 1 (2022): 113.

[5] S. W. Lai, C. L. Lin, and K. F. Liao, “Use of Oral Corticosteroids and Risk of Hip Fracture in the Elderly in a Case-Control Study,” Frontiers in Pharmacology 8 (2017): 625.

[6] C. M. McDonough, M. Harris-Hayes, M. T. Kristensen, et al., “Physical Therapy Management of Older Adults With hip Fracture,” Journal of Orthopaedic and Sports Physical Therapy 51, no. 2 (2021): Cpg1-cpg81.

[7] C. Y. Wu, C. F. Tsai, Y. H. Hsu, and H. Y. Yang, “Exploring Mortality Risk Factors and Specific Causes of Death Within 30 Days After Hip Fracture Hospitalization,” Scientific Reports 14, no. 1 (2024): 27544.

[8] A. Haibier, A. Yusufu, L. Hang, and T. Abudurexiti, “Comparison of Clinical Outcomes and Complications Between Endoscopic and Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Diseases: A Systematic Review and Meta-Analysis,” Journal of Orthopaedic Surgery and Research 19, no. 1 (2024): 92.

[9] Y. Hattammaru, Y. Mio, T. Hascilowicz, I. Utsumi, Y. Murakami, and S. Omi, “Reduction of Leakage From Insertion Site During Continuous Femoral Nerve Block With Catheter-Through-Needle Versus Catheter-Over-Needle Technique for Postoperative Analgesia After Total Knee Arthroplasty: A Randomized Controlled Trial,” BMC Anesthesiology 22, no. 1 (2022): 11.

[10] R. Y. Turabi, K. J. Sheehan, S. Guerra, M. D. L. O'Connell, and D. Wyatt, “Barriers and Facilitators to Early Mobilisation and Weight-Bearing as Tolerated After Hip Fracture Surgery Among Older Adults in Saudi Arabia: A Qualitative Study,” Age and Ageing 53, no. 4 (2024): afae075.

[11] J. Q. Sheng, D. Xu, P. J. Hu, L. Li, and T. S. Huang, “Examining the Relationships Between Patients' Multimorbidity Trajectories and Prognostic Outcomes After the Initial Hip Fracture,” Scientific Reports 14, no. 1 (2024): 28329.

[12] L. Horváth, N. Németh, G. Fehér, Z. Kívés, D. Endrei, and I. Boncz, “Epidemiology of Peripheral Artery Disease: Narrative Review,” Life 12, no. 7 (2022): 1041.

[13] J. D. Petersen, V. D. Siersma, S. Wehberg, C. T. Nielsen, B. Viberg, and F. B. Waldorff, “Clinical Management of Hip Fractures in Elderly Patients With Dementia and Postoperative 30-Day Mortality: A Population-Based Cohort Study,” Brain and Behavior: A Cognitive Neuroscience Perspective 10, no. 11 (2020): e01823.

[14] J. A. Kanis, A. Odén, E. V. McCloskey, et al., “A Systematic Review of Hip Fracture Incidence and Probability of Fracture Worldwide,” Osteoporosis International 23, no. 9 (2012): 2239-2256.

[15] K. H. Jung, J. H. Park, J. Y. Song, J. W. Han, and K. B. Park, “State-Anxiety in Geriatric Patients Undergoing Surgical Treatment for Femoral Neck or Intertrochanteric Fractures,” Geriatric Orthopaedic Surgery & Rehabilitation 12 (2021): 21514593211063320.

[16] Y. Levi, B. Punchik, E. Zikrin, et al., “Intensive Inpatient vs. Home-Based Rehabilitation After Hip Fracture in the Elderly Population,” Frontiers in Medicine 7 (2020): 592693.

[17] A. R. Zullo, T. Zhang, F. L. Beaudoin, et al., “Pain Treatments After Hip Fracture Among Older Nursing Home Residents,” Journal of the American Medical Directors Association 19, no. 2 (2018): 174-176.

[18] G. W. Jing, Q. Xie, J. Tong, L. Z. Liu, X. Jiang, and L. Si, “Early Intervention of Perioperative Delirium in Older Patients (>60 Years) With Hip Fracture: A Randomized Controlled Study,” Orthopaedic Surgery 14, no. 5 (2022): 885-891.

[19] C. Snapp, B. Byrd, and M. Porter, “Reduction of Postoperative Delirium and Opioid Use in Hip Fracture Patients Through Utilization of Emergency Department Physician Administered Regional Nerve Blocks,” Geriatric Orthopaedic Surgery & Rehabilitation 15 (2024): 21514593241228073.

[20] R. Cowan, J. H. Lim, T. Ong, A. Kumar, and O. Sahota, “The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care,” Drugs & Aging 34, no. 1 (2017): 1-11.

[21] T. K. Ng, J. A. Lin, and S. Sasaki, “A Preliminary Analysis of a Modified Anterior Approach to Hip Pericapsular Neurolysis for Inoperable Hip Fracture Using the IDEAL Framework,” Healthcare (Basel) 10, no. 6 (2022): 1002.

[22] E. M. Soffin, M. M. Gibbons, E. C. Wick, et al., “Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery,” Anesthesia and Analgesia 128, no. 6 (2019): 1107-1117.

[23] A. Scurrah, C. T. Shiner, J. A. Stevens, and S. G. Faux, “Regional Nerve Blockade for Early Analgesic Management of Elderly Patients With Hip Fracture - A Narrative Review,” Anaesthesia 73, no. 6 (2018): 769-783.

[24] M. J. Page, J. E. McKenzie, P. M. Bossuyt, et al., “The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews,” BMJ 2021, no. 372 (2020): n71.

[25] R. Del Buono, E. Padua, G. Pascarella, et al., “Pericapsular Nerve Group Block: An Overview,” Minerva Anestesiologica 87, no. 4 (2021): 458-466.

[26] S. Fuchs-Lacelle and T. Hadjistavropoulos, “Development and Preliminary Validation of the Pain Assessment Checklist for Seniors With Limited Ability to Communicate (PACSLAC),” Pain Management Nursing 5, no. 1 (2004): 37-49.

[27] J. A. C. Sterne, J. Savović, M. J. Page, et al., “RoB 2: A Revised Tool for Assessing Risk of Bias in Randomised Trials,” BMJ 366 (2019): l4898.

[28] S. P. Hozo, B. Djulbegovic, and I. Hozo, “Estimating the Mean and Variance From the Median, Range, and the Size of a Sample,” BMC Medical Research Methodology 5 (2005): 13.

[29] K. Thorlund, S. D. Walter, B. C. Johnston, T. A. Furukawa, and G. H. Guyatt, “Pooling Health-Related Quality of Life Outcomes in Meta-Analysis-A Tutorial and Review of Methods for Enhancing Interpretability,” Resonance: Synthesis Methods 2, no. 3 (2011): 188-203.

[30] A. K. Fletcher, A. S. Rigby, and F. L. P. Heyes, “Three-In-One Femoral Nerve Block as Analgesia for Fractured Neck of Femur in the Emergency Department: A Randomized, Controlled Trial,” Annals of Emergency Medicine 41, no. 2 (2003): 227-233.

[31] N. B. Foss, B. B. Kristensen, M. Bundgaard, et al., “Fascia Iliaca Compartment Blockade for Acute Pain Control in Hip Fracture Patients: A Randomized, Placebo-Controlled Trial,” Anesthesiology 106, no. 4 (2007): 773-778.

[32] D. G. Monzón, J. Vazquez, J. R. Jauregui, and K. V. Iserson, “Pain Treatment in Post-Traumatic Hip Fracture in the Elderly: Regional Block vs. Systemic Non-Steroidal Analgesics,” International Journal of Emergency Medicine 3, no. 4 (2010): 321-325.

[33] R. S. Morrison, E. Dickman, U. Hwang, et al., “Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial,” Journal of the American Geriatrics Society 64, no. 12 (2016): 2433-2439.

[34] A. Unneby, O. Svensson, Y. Gustafson, and B. Olofsson, “Femoral Nerve Block in a Representative Sample of Elderly People With Hip Fracture: A Randomised Controlled Trial,” Injury 48, no. 7 (2017): 1542-1549.

[35] Y. Ma, J. Wu, J. Xue, F. Lan, and T. Wang, “Ultrasound-Guided Continuous Fascia Iliaca Compartment Block for Pre-Operative Pain Control in Very Elderly Patients With Hip Fracture: A Randomized Controlled Trial,” Experimental and Therapeutic Medicine 16, no. 3 (2018): 1944-1952.

[36] L. A. Beaupre, M. R. Menon, K. Almaazmi, S. H. Kang, S. Dieleman, and B. Tsui, “Preoperative Nerve Blocks for Hip Fracture Patients: A Pilot Randomized Trial,” Injury 52, no. 3 (2021): 548-553.

[37] C. Hao, C. Li, R. Cao, et al., “Effects of Perioperative Fascia Iliaca Compartment Block on Postoperative Pain and Hip Function in Elderly Patients With Hip Fracture,” Geriatric Orthopaedic Surgery & Rehabilitation 13 (2022): 21514593221092883.

[38] X. Lin, C. W. Liu, Q. Y. Goh, et al., “Pericapsular Nerve Group (PENG) Block for Early Pain Management of Elderly Patients With Hip Fracture: A Single-Center Double-Blind Randomized Controlled Trial,” Regional Anesthesia and Pain Medicine 48, no. 11 (2023): 535-539.

[39] Y. Tang, X. Zhang, S. Yi, et al., “Ultrasound-Guided Pericapsular Nerve Group (PENG) Block for Early Analgesia in Elderly Patients With Hip Fractures: A Single-Center Prospective Randomized Controlled Study,” BMC Anesthesiology 23, no. 1 (2023): 383.

[40] C. Gerlier, R. Mijahed, A. Fels, et al., “Effect of Early Ultrasound-Guided Femoral Nerve Block on Preoperative Opioid Consumption in Emergency Patients With Hip Fracture: A Randomized Trial,” European Journal of Emergency Medicine 31, no. 1 (2024): 18-28.

[41] W. Tze-Kit, H. Yung-Chak, L. Kwok-Hang, et al., “Randomized Controlled Trial on Analgesic Effect of Pre-Operative Fascia Iliaca Compartment Block in Geriatric Patients With Hip Fracture,” Journal of Orthopaedics, Trauma and Rehabilitation 31, no. 2 (2024): 187-194.

[42] L. Ackermann, E. S. Schwenk, Y. Lev, and H. Weitz, “Update on Medical Management of Acute Hip Fracture,” Cleveland Clinic Journal of Medicine 88, no. 4 (2021): 237-247.

[43] J. Guay and S. Kopp, “Peripheral Nerve Blocks for Hip Fractures in Adults,” Cochrane Database of Systematic Reviews 11, no. 11 (2020): Cd001159.

[44] M. A. Fernandez, X. L. Griffin, and M. L. Costa, “Management of Hip Fracture,” British Medical Bulletin 115, no. 1 (2015): 165-172.

[45] S. Shah, B. A. Bellows, A. A. Adedipe, J. E. Totten, B. H. Backlund, and D. Sajed, “Perceived Barriers in the Use of Ultrasound in Developing Countries,” Critical Ultrasound Journal 7, no. 1 (2015): 28.

[46] J. S. Lee, T. Bhandari, R. Simard, et al., “Point-of-Care Ultrasound-Guided Regional Anaesthesia in Older ED Patients with Hip Fractures: A Study to Test the Feasibility of a Training Programme and Time Needed to Complete Nerve Blocks by ED Physicians after Training,” BMJ Open 11, no. 7 (2021): e047113.

[47] A. Dizdarevic, F. Farah, J. Ding, et al., “A Comprehensive Review of Analgesia and Pain Modalities in Hip Fracture Pathogenesis,” Current Pain and Headache Reports 23, no. 10 (2019): 72.

[48] C. H. Kim, J. Y. Yang, C. H. Min, H. C. Shon, J. W. Kim, and E. J. Lim, “The Effect of Regional Nerve Block on Perioperative Delirium in Hip Fracture Surgery for the Elderly: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” Orthopaedics & Traumatology, Surgery & Research 108, no. 1 (2022): 103151.

[49] L. Li, L. Wang, C. Ma, et al., “Clinical Effect of ‘Fast-Track Management' Guided by ERAS Concept Under the Multi-Disciplinary Cooperation Mode of Femoral Intertrochanteric Fracture in the Elderly,” Biotechnology & Genetic Engineering Reviews 40, no. 3 (2024): 2393-2408.

[50] R. Griffiths, S. Babu, P. Dixon, et al., “Guideline for the Management of Hip Fractures 2020: Guideline by the Association of Anaesthetists,” Anaesthesia 76, no. 2 (2021): 225-237.

[51] J. Guay, M. J. Parker, R. Griffiths, and S. L. Kopp, “Peripheral Nerve Blocks for Hip Fractures: A Cochrane Review,” Anesthesia and Analgesia 126, no. 5 (2018): 1695-1704.

[52] M. Hards, A. Brewer, G. Bessant, and S. Lahiri, “Efficacy of Prehospital Analgesia With Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review,” Prehospital and Disaster Medicine 33, no. 3 (2018): 299-307.

[53] K. C. Roberts and W. T. Brox, “AAOS Clinical Practice Guideline: Management of hip Fractures in the Elderly,” Journal of the American Academy of Orthopaedic Surgeons 23, no. 2 (2015): 138-140.

[54] R. P. Chin, C. H. Ho, and L. P. Cheung, “Scheduled Analgesic Regimen Improves Rehabilitation After Hip Fracture Surgery,” Clinical Orthopaedics and Related Research 471, no. 7 (2013): 2349-2360.

[55] S. R. Dabbagh, M. R. Sarabi, R. Rahbarghazi, E. Sokullu, A. K. Yetisen, and S. Tasoglu, “3D-Printed Microneedles in Biomedical Applications,” iScience 24, no. 1 (2021): 102012.

[56] M. Yin, L. Xiao, Q. Liu, et al., “3D Printed Microheater Sensor-Integrated, Drug-Encapsulated Microneedle Patch System for Pain Management,” Advanced Healthcare Materials 8, no. 23 (2019): e1901170.

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.