Hip fracture type may determine regional anesthesia benefits

By Eleanor McDermid

Use of regional anesthesia may reduce the risk for mortality and pulmonary complications among patients undergoing surgery for hip fracture, research shows.

But the effect was confined to patients with intertrochanteric fractures, whereas patients with femoral neck fractures did equally well with regional and general anesthesia, report Mark Neuman (University of Pennsylvania School of Medicine, Philadelphia, USA) and colleagues.

"While it is important to note that our subgroup analyses should be regarded as preliminary until replicated in further work, the observation that certain groups of hip fracture patients may have more to gain from the use of regional anesthesia highlights the need for further research to define subsets of the hip fracture population in which this technique may be beneficial," they write in Anesthesiology.

"These subsets may include the oldest-old, patients with advanced functional disability or frailty, and patients with baseline risk factors for pulmonary complications."

There were 18,158 patients in the study, of whom 29% received regional anesthesia. Pulmonary complications occurred in 6.8% of patients who received regional anesthesia, compared with 8.1% of those given general anesthesia. This difference persisted after accounting for confounders, with regional anesthesia associated with a 25% reduction in the risk for pulmonary complications.

Rates of mortality and cardiovascular complications were similar in both groups, but after accounting for confounders, a 29% reduction in mortality risk emerged for patients given regional versus general anesthesia.

When assessed according to fracture site, patients with femoral neck fractures had a nonsignificant reduction of about 20% in the risk for all endpoints, whereas those with intertrochanteric fractures had a nonsignificant reduction in cardiovascular complication risk, but a 43% reduction in mortality risk and a 37% reduction in the risk for pulmonary complications.

Neuman et al suggest that the larger benefit derived from regional anesthesia by patients with intertrochanteric fractures may be due to the greater baseline vulnerability in this group, which itself could be caused by greater initial frailty in patients who have intertrochanteric fractures, compared with those who have femoral neck fractures.

"Given the high rate of mortality associated with hip fracture, as well as the large and growing worldwide public health burden attributed to complications of hip fracture care, our findings highlight a potential opportunity to improve outcomes among a growing population of vulnerable surgical patients," they conclude.

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