European Journal of Cardiovascular Medicine

Neck of femur (NOF) fractures are prevalent among the elderly and necessitate surgical intervention. Effective postoperative pain management is essential for early mobilization, reduced morbidity, and improved patient outcomes[1,2]. The fascia iliaca compartment block (FICB) is a regional anesthetic technique targeting the femoral, obturator, and lateral femoral cutaneous nerves, providing effective analgesia for NOF fractures[3,4].

Two primary FICB approaches exist: the traditional infrainguinal approach (I-FICB), typically performed using a landmark-based technique, and the suprainguinal approach (S-FICB), which employs ultrasound guidance to optimize local anesthetic spread[5-7]. Emerging evidence suggests that S-FICB may offer superior analgesic coverage and duration, yet comparative data in the NOF fracture population remain limited. This study aims to evaluate the analgesic efficacy, duration, opioid requirements, and complications of S-FICB versus I-FICB in patients undergoing NOF fracture surgery.

Recent evidence suggests that the S-FICB offers better analgesic spread and duration, but comparative clinical data in the NOF fracture population remains limited.

Objectives

The primary objective of this study was to compare the duration and quality of postoperative analgesia provided by the suprainguinal (S-FICB) and infrainguinal (I-FICB) approaches of the fascia iliaca compartment block in patients undergoing surgery for neck of femur fractures. Additionally, the study aimed to assess and compare the total analgesic requirements, particularly the need for rescue opioids, and to evaluate the incidence of block-related complications associated with each technique.

Study Design

This prospective, randomized, single-center study was conducted at Department of Anaesthesiology, Government Erode Medical College and Hospital, Perundurai, Erode, TamilNadu from January 2023 to August 2024, with approval from the Institutional Review Board and written informed consent from all participants.

Participants

Participants Eligible patients were aged ≥65 years, classified as ASA I–III, and scheduled for NOF fracture surgery. Exclusion criteria included coagulopathy, allergy to local anesthetics, infection at the injection site, or pre-existing neuropathy.

Randomization

Randomization and Interventions Ninety patients were randomly assigned (1:1) to two groups using computer-generated randomization:

• Group S (S-FICB, n=45): Suprainguinal FICB performed under ultrasound guidance with 30 mL of 0.25% bupivacaine.
• Group I (I-FICB, n=45): Infrainguinal FICB performed using a landmark-based technique with the same volume and dose of bupivacaine.

Outcome Measures The primary outcome was the duration of analgesia, defined as the time from block administration to the first request for rescue analgesia. Secondary outcomes included Numeric Rating Scale (NRS) pain scores (0–10) at 0, 1, 2, 6, 12, and 24 hours postoperatively, total analgesic consumption, and incidence of complications (e.g., hematoma, nerve injury, nausea, or vomiting).

Statistical Analysis Data were analyzed using SPSS v25. Continuous variables (e.g., analgesia duration, NRS scores) were expressed as mean ± standard deviation and compared using the independent t-test. Categorical variables (e.g., complications) were analyzed using the Chi-square test. A p-value <0.05 was considered statistically significant.

• Group S (n=45): Suprainguinal FICB under ultrasound guidance using 30 mL of 0.25% bupivacaine.
• Group I (n=45): Infrainguinal FICB using landmark technique with same volume/dose.

Statistical Analysis

Data analyzed using SPSS v25. Continuous variables expressed as mean ± SD, compared using t-test. Categorical variables analyzed using Chi-square test. Significance set at p < 0.05.

Table 1: Participant Demographics

No significant differences in baseline characteristics (p > 0.05)

Table 1 shows the demographic profiles of the two study groups—S-FICB and I-FICB—were comparable. The mean age in both groups was similar (75 years in S-FICB vs 76 years in I-FICB), with a balanced gender distribution (25M/20F in S-FICB vs 23M/22F in I-FICB). The prevalence of comorbidities was also comparable (60% in S-FICB vs 55% in I-FICB). There were no statistically significant differences in any baseline characteristics between the two groups (p > 0.05), indicating a well-matched study population.

Table 2: Duration of Analgesia

Table 2 shows Patients in the S-FICB group experienced a significantly longer duration of postoperative analgesia (16.33 ± 5.69 hours) compared to those in the I-FICB group (12.67 ± 4.32 hours). This difference was statistically significant with a p-value < 0.01, indicating the superior analgesic duration of the suprainguinal approach.

Table 3: Postoperative Pain Scores (NRS)

Table 3 shows At all recorded time intervals (0, 1, 2, 6, 12, and 24 hours postoperatively), patients in the S-FICB group consistently reported lower Numeric Rating Scale (NRS) pain scores compared to the I-FICB group. The differences in pain scores were statistically significant at every time point (p < 0.05), demonstrating the superior analgesic efficacy of the suprainguinal approach throughout the first 24 hours after surgery.

Rescue Analgesic Requirement

The requirement for rescue analgesics was significantly lower in the S-FICB group compared to the I-FICB group. A smaller number of patients in the suprainguinal group needed additional postoperative analgesia, indicating more effective and sustained pain control. This difference was statistically significant (p < 0.01), further supporting the superior analgesic profile of the suprainguinal approach.

Table 4: Complications

Table 4 shows the incidence of hematoma or nerve injury was significantly lower in the S-FICB group (2.5%) compared to the I-FICB group (10%), with a p-value < 0.05, indicating a reduced complication rate with the suprainguinal approach. The occurrence of nausea and vomiting was comparable between both groups, with no statistically significant difference (NS) observed.

This randomized controlled trial demonstrates the superiority of the suprainguinal fascia iliaca compartment block (S-FICB) over the infrainguinal approach (I-FICB) for postoperative analgesia in neck of femur fracture surgery[8]. Key findings include a longer duration of analgesia, lower pain scores across all time points, reduced opioid requirements, and fewer complications in the S-FICB group. These results are likely attributable to the enhanced precision of ultrasound guidance, which facilitates optimal anesthetic spread to the targeted nerves[9-11].

Our findings are consistent with previous studies by Bullock et al. (2016), Bansal et al. (2022), and Muniyappa et al. (2023), which reported improved efficacy and safety with S-FICB[12-15]. The reduced complication rate in the S-FICB group underscores the advantage of ultrasound guidance over landmark-based techniques, which may be less reliable in elderly patients with variable anatomy.

Limitations:

Limitations of this study include its single-center design and relatively small sample size, which may limit generalizability. Additionally, the landmark-based I-FICB may have underperformed compared to an ultrasound-guided I-FICB, potentially exaggerating the observed differences. Future research should explore continuous catheter techniques and assess functional outcomes, such as time to mobilization and rehabilitation progress, to further elucidate the clinical impact of S-FICB.

The suprainguinal fascia iliaca compartment block offers superior postoperative analgesia compared to the infrainguinal approach in patients with neck of femur fractures. With longer analgesia duration, lower pain scores, reduced opioid requirements, and fewer complications, S-FICB is recommended as the preferred technique for postoperative pain management in this population.

Source of Support: Nil,

Conflict of Interest: None declared

Acknowledgments:

The authors would like to thank all of the study participants and the administration of Department of Anaesthesiology, Government Erode Medical College and Hospital, Perundurai, Tamilnadu, India  for granting permission to carry out the research work.

Ethical statement:

The study was approved by the institutional human ethics committee, Government Erode Medical College and Hospital, Perundurai. Informed written consent was obtained from all the study participants and only those participants willing to sign the informed consent were included in the study. The risks and benefits involved in the study and the voluntary nature of participation were explained to the participants before obtaining consent. The confidentiality of the study participants was maintained.

Authors’ contributions:

Dr Dinesh Kumar K- conceptualization, data curation, investigation, methodology, project administration, visualization, writing—original draft, writing—review and editing; Dr Kousalya T-conceptualization, methodology, writing—original draft, writing—review and editing; Dr Karthi V M & Dr.Panneerselvam Periasamy- conceptualization, visualization, supervision, writing—original draft. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. All authors have read and agreed to the published version of the manuscript.

DATA AVAILABILITY:

All datasets generated or analyzed during this study are included in the manuscript.

INFORMED CONSENT:

Written informed consent was obtained from the participants before enrolling in the study

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