Surgical Treatment of Neck of Femur Fracture Using Regional Anaesthesia in Elderly Patients

Correspondence:
Dr Firas Husban
P.O.BOX 996
Amman 11953
Jordan
E-Mail: fhusban@yahoo.com

INTRODUCTION

The fracture of the proximal femur in an elderly patient is a common and important cause of mortality and functional loss^1,2. It is a challenge for the orthopaedic surgeon. Most of the elderly population have varying degrees of pre-existing medical illnesses e.g. cerebral dysfunction, cardiovascular, respiratory, renal, metabolic and other locomotor problems; no current literature advocated non-surgical treatment for these fractures. These patients should be fully evaluated and resuscitated before being taken to the operating room. The best time for surgery is controversial. In one study, surgery in the first 24 hours increased the one year mortality³, but in another, the first year mortality doubled if surgery was delayed for three days⁴.

Reports on the mortality rates after fractures of the proximal femur in the elderly are variable³, and one study reported a higher mortality following spinal anesthesia than following general anesthesia⁵. In a meta-analysis of 106 published reports on the outcome of displaced fractures of the femoral neck, the mortality rates varied from 6-13% in the first postoperative month to 21-36% one year postoperatively⁶. The type of surgery (fracture fixation, hemi of total hip arthroplasty) was not found to affect mortality rate, but to affect the quality of life, state of ambulation, degree of pain, failure rate and the need for a second operation^7,8. In elderly, at risk patients, it is wise to choose surgery with the least possibility of needing revision⁹. The correlation between the mortality rate and the type of anesthesia is still controversial. General and spinal anesthesia derange the metabolic state, hormonal, fluid and electrolyte balance and function of all organs; specific complications are cardiac and respiratory depression, chest infection, hypotension, deep venous thrombosis, liver dysfunction and ileus^10,11,12. In comparison, the effect of peripheral nerve block remains local. In meta-analysis including 17 comparative and randomized studies, shows a smaller mortality rate in the first month after the surgery when the regional anesthesia is used¹³. At least, regional anesthesia reduces the intraoperative hypotension and the need for postoperative intensive care unit¹⁴.

The aim of this study is to evaluate our experience in regional anaesthesia in patients with fracture of neck of femur, who were considered high risk for general anaesthesia.

MATERIALS AND METHODS

Between January 1999 and December 2007, we treated 49 elderly patients with fracture of the proximal femur, whose ages ranged from 70-95 years with a mean age of 78 years. 17 patients (12 females and 5 males) with a mean age of 80 years had a displaced intra-capsular fracture of the neck of the femur (Garden III-IV). 32 patients (24 males and 8 females) with a mean age of 78 years had an extra-capsular fracture of the neck of femur. These patients were selected from a large group of patients with fracture of the proximal femur, because they had three or more serious preexisting systemic illnesses (e.g. hypertension, uncontrolled diabetes mellitus, cardiac insufficiency, pulmonary dysfunction, cerebral dysfunction, renal, and metabolic or other locomotor illnesses). Upon investigation and evaluation by an internist and anesthesiologist they were consider high-risk patients for general or spinal anesthesia. All were categorized as ASA class III-IV.

Patients received treatment to stabilize their condition within 24-48 hours prior to surgery. The surgical technique under peripheral nerve block was discussed with each patient and their family. Oxygen tension, ECG and blood pressure were recorded every 5 minutes throughout surgery. A mixture of lignocaine 0.5%, (4 mg/kg body weight) and bupivacaine 0.5% (21/kg body weight) was prepared and divided into four syringes. The areas for each nerve block were scrubbed and draped, care was taken to inject under strict aseptic technique, and for each nerve block repeated aspirations were performed to avoid injection into blood vessels.

Femoral Nerve Block

With the patient in a supine position, the femoral artery is palpated as it emerges from under the inguinal ligament. A 22-gauge needle is inserted 5 cm below the inguinal ligament just lateral to the palpating finger. Parasthesia is sought as the needle pierces the subcutaneous fat. If this is not obtained, the needle is moved fanwise from medial to lateral and a 20 ml mixture of 16ml lignocaine 0.5% (80mg) and 4ml bupivacaine 0.5% (20mg) of local anesthetic is injected.

Lateral Femoral Cutaneous Nerve Block

With the patient supine the anterior superior iliac spine is palpated and at a point 3 cm medial to the anterior superior iliac spine and just inferior to the inguinal ligament a 6 cm 22 gauge block needle is inserted perpendicular to the skin. When the needle has passed beneath the fascia, parasthesia may be elicited. The exact depth depends on the amount of soft tissue but usually it is 1.5-4.5 cm. If the bone is contacted prior to obtaining parasthesia, the needle is withdrawn to subcutaneous tissue and the procedure is repeated in a fanwise direction. Once parasthesia is elicited 20ml of the anesthetic mixture (80 mg lignocaine 20 mg bupivacaine) is injected.

Obturator Nerve Block

The patient is supine with legs slightly spread apart. The spine of the pubic bone on the involving side is identified, and a skin wheal is made 3 cm lateral and inferior to it. The skin and subcutaneous tissue is infiltrated by 10 ml of 0.5% lignocaine. The 9 cm block needle is inserted perpendicular to the skin wheal until the upper part of the inferior pubic ramus is contacted at a depth of 1.5-3 cm, the needle is redirected to slip past the inferior ramus and just underneath the superior pubic ramus and is then advanced an additional 4.5 cm in a lateral and slightly inferior direction. The needle tip should now lie in the area of the obturator foramen. Parasthesia is only occasionally elicited. 10 ml of the anesthetic mixture (40 mg lignocaine+ 10 mg bupivacain) is infiltrated as the needle is moved back and forth slowly.

Sciatic Nerve Block

With the patient supine, the hip is flexed as in the lithotomy position and held by an assistant, just above the gluteal fold and in the middle high way between the ischial tuberosity and the greater trochanter a skin wheal is made. A 9 cm 22 gauge needle is inserted perpendicular to the skin. Parasthesia is usually obtained as the needle is advanced to a depth of 6 - 7.5 cm. If parasthesia is not obtained the needle should be pulled and moved fanwise from medial to lateral until parasthesia is obtained. Then 20 ml of the anesthetic mixture (80 mg lingocaine +20 mg bupivacain) is infiltrated.

The solution was injected over a two-minute period after confirmation of position and repeated aspiration. The onset of blockade was assessed at 2 minute intervals. After 10-25 minutes the patient was ready and placed on the operating table (Fracture table in cases of extra-capsular fracture). An intravenous injection of a sedative and analgesic combination (1.5-3 mg midazolam with 20-30 mg ketamine) had been used for all cases starting surgery.

All patients received prophylactic second or third generation cephalosporin with the first dose at the start of surgery and continued for five days. Closed reduction under image intensifier and internal fixation by a compression hip screw and a sliding five holes plate was performed for the extra-capsular femoral fractures. An Austin Moore Hemiathroplasty was performed for the intra-capsular fractures of the neck of the femur, through a posterior approach. The surgery time was 40-60 minutes. Postoperatively the patients received an average of one hour in the recovery room, and they then went back to the ward, and were allowed to take their next meal. Most of the patients needed further analgesic doses of diclofenac or pethidine after 3-6 hours for 24 hours and irregular doses of non-steroidal anti-inflammatory drugs upon request in the successive days. Next morning every effort was made to mobilize patients and medical care was continued until discharge from hospital in one to two weeks. The patients were seen at the outpatient clinic after four weeks.

RESULTS

All 49 patients with fractures of the proximal femur had successful pain free surgery without intraoperative or immediate postoperative complications. The patients' blood pressure, ECG and urine output were steady throughout the operation and in the recovery room. Post-operative analgesia for 3-6 hours was achieved and post-operative confusion was minimal. The patients were able to eat shortly after their operation and were out of bed in less than 24 hours. The average stay in hospital was 10 days. At discharge 80% were able to walk with assistance. 5 patients did not keep their 4 week follow-up appointment. The two patients who died after the operation were over 80 years old and the main cause of death was multiple systemic failure due to different chronic diseases such as end stage of diabetes mellitus, hypertension, congestive heart failure, and septicemia. The mortality rate
was 6% in the first six weeks. 10 patients (4 males and 6 females) developed mild to moderate urinary tract infection, which resolved after removal of the Foley's catheter and antibiotics. One patient with a pin and plate fixation was readmitted after discharge with a deep wound infection. This responded to treatment and he was discharged after 3 weeks. 6 of the 11 non-ambulatory patients developed pressure sores on the buttocks and heels. None of the patients needed to be admitted to the intensive care unit postoperatively or developed a clinically obvious deep venous thrombosis, pulmonary embolism, or stroke during the first 6 weeks, the remaining patients did not show worsening of their medical status.

DISCUSSION

We have limited our study to a short-term follow-up of 6 weeks to compare it with similar short term studies of surgery performed under general and spinal anesthesia^5,15,16. The number of patients in our study was relatively small because surgery of the fractures of the proximal femur under peripheral nerve anesthesia is not a routine practice in our hospital. The ASA physical status of elderly patients was found to be a good predictor of mortality within one month of surgery. There was 2% mortality in patients of class ASA I and 25% morbidity in patients of class ASA IV¹⁴. In a post-operative multi-centre trial of mortality, six weeks following general or spinal anesthesia for hip fracture surgery in elderly patients in hospital, mortality varied from 2.7% to 28%. There was no difference between general and spinal anesthesia, but delaying surgery increased the rate of mortality³. Our 6 weeks mortality rate was low (6%) compared to other series^{3,4,6,16,17,18}. The complication rates were 2% wound infection, 2.5% pneumonia, 20% urinary tract infection and 12% bed sores.

We found that surgery on the hip region under peripheral nerve blocks has the following advantages:
A) It avoids post-operative mental confusion, which may occur in 30% to 50% of patients after general anesthesia¹⁹.
B) It avoids hypothermia resulting from loss of the shivering reflex²⁰.
C) It avoids respiratory depression, chest infection and atelactasis^11,18.
D) It avoids cardiac depression and failure.
E) It avoids overloading by intravenous and electrolyte imbalance.
F) It avoids loss of automatic tone, postural hypotension and urine retention²¹.
G) It avoids decrease of renal blood flow and decrease in glomerular filtration rate^10,11.
H) It avoids hepatic derangement^10,11.
I) It preserves the gastrointestinal function and avoids constipation and mucosal atrophy^10,11.
J) Early mobilization decreases the influence of deep venous thrombosis, pulmonary embolism, bed sores and shortening hospital stay.
K) Intraoperative communication can be maintained with the patient.

Care must be taken not to exceed the recommended dosage of 25 mg / kg body weight for plain bupivacaine and 5.5% mg / kg body weight for plain lignocaine²². We used intravenous ketamine to increase the analgesic effect and combined it with midazolam for sedation. Patients tolerated the procedures well. Occasionally there was a little discomfort during infiltration of the local anesthetic in a special position e.g. for the obturator and sciatic blocks.

CONCLUSION

There are several physiological and psychological benefits to clients in humour, and is seen as an important refinement by older adults. Based on research and other scholarly views, humour is a suitable method to encourage with older adults in both community and long-term care settings. Nurses need to think about humour as a communication tool to decrease tension and demolish barriers between nurses and older clients.

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