Is surgery necessary for a hip fracture?
Background: The majority of people with hip fractures are elderly, and the majority of these fractures are treated surgically, which requires anesthesia. The hip fracture is usually caused by a simple fall. Affected patients often have many other medical problems associated with aging that place them at high risk of death from anesthesia. The most common forms of anesthesia are 'general anesthesia' and 'regional anesthesia'. General anesthesia means loss of consciousness (artificial sleep). Regional anesthesia means injecting a solution containing a local anesthetic (local anesthetic) inside the spine (neuraxial block) or around the nerves outside the spine (peripheral nerve block) to prevent pain in the fractured leg. We reviewed the evidence on the effect of regional anesthesia procedures in patients undergoing surgery for a broken hip.
Study features: The evidence is current to March 2014. We included a total of 31 studies (3231 participants) in our review. Of these 31 studies, 28 (2976 participants) provided data for the meta-analyzes. The average age of the participants varied between 75 and 86 years. The studies were published between 1977 and 2013 and thus covered a wide range of clinical approaches and technological improvements over time. Two studies were funded by an anesthetic agent manufacturer or by a body with a commercial interest, one received non-profit funding, and one public funding. We carried out the search again in February 2017. Potentially relevant new studies have been added to the list of "Studies pending classification" and will be included in the results as part of the review update.
Main results: The study reports of many of the studies showed suboptimal methodological quality, and the number of participants included was often insufficient to allow a definitive conclusion to be formulated for many of the endpoints examined. We found no differences in mortality after one month (11 studies with 2152 participants) between neuraxial blocks and general anesthesia. We also found no differences between these two forms of anesthesia in two to twelve of the studies in the incidence of pneumonia, heart attacks, cerebrovascular events (e.g. strokes), acute states of confusion, congestive heart failure, acute kidney failure, pulmonary embolism, the number of patients who received red transfusions Blood cells received, the duration of the operation and the length of the hospital stay. We also found no differences in the risk of deep vein thrombosis when effective prophylactic drugs (such as low molecular weight heparin) were used against postoperative blood clot formation. Without prophylaxis with effective anticoagulant drugs, the risk of developing deep vein thrombosis with neoaxial blockages was lower.
Quality of the evidence: The quality of the evidence was very low in terms of mortality, the incidence of pneumonia, heart attacks, cerebrovascular events, acute states of confusion, the reduced incidence of deep vein thrombosis in the absence of effective prophylaxis, and the discharge of patients home. This means that any effect estimates are subject to a high degree of uncertainty.
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