Anaesthesia For Hip Fracture Surgery in Adults (Review) : Parker MJ, Handoll HHG, Griffiths R

Anaesthesia for hip fracture surgery in adults (Review)
Parker MJ, Handoll HHG, Grifths R
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 1 http://www.thecochranelibrary.com
Anaesthesia for hip fracture surgery in adults (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 1 Mortality - 1 month. Analysis 1.2. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 2 Mortality - 1 month (random effects model). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.3. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 3 Mortality - 3 months. Analysis 1.4. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 4 Mortality - 6 months. Analysis 1.5. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 5 Mortality - 12 months. Analysis 1.6. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 6 Mortality - early and up to 1 month. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.7. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 7 Length of operation (mins). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.8. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 8 Operative hypotension. Analysis 1.9. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 9 Operative hypotension (random effects model). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.10. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 10 Operative blood loss (ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.11. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 11 Patients receiving blood transfusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.12. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 12 Transfusion requirements (ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.13. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 13 Postoperative hypoxia. Analysis 1.14. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 14 Length of hospital stay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.15. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 15 Pneumonia. . . Analysis 1.16. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 16 Myocardial infarction. Analysis 1.17. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 17 Cerebrovascular accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.18. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 18 Congestive cardiac failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.19. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 19 Renal failure. . . Analysis 1.20. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 20 Acute confusional state. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.21. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 21 Urine retention. . Analysis 1.22. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 22 Vomiting. . . . Analysis 1.23. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 23 Deep vein thrombosis. Analysis 1.24. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 24 Pulmonary embolism (Peto odds ratio plot - showing heterogeneity). . . . . . . . . . . . . . . . . . . . . . . Analysis 1.25. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 25 Pulmonary embolism (random effects model). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 1 2 2 3 3 5 11 13 14 14 18 40 43 44 45 45 46 47 48 49 50 51 51 52 52 53 54 55 56 57 58 59 59 60 60 61 62
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Analysis 1.26. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 26 Pulmonary embolism (fatal and non-fatal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.1. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 1 Mortality - 1 month. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.2. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 2 Length of operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.3. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 3 Pneumonia. Analysis 2.4. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 4 Confusional state. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.5. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 5 Deep vein thrombosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.1. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 1 Incomplete or unsatisfactory analgesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.2. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 2 Operative hypotension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.3. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 3 Mean fall in arterial blood pressure (mmHg). . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.4. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 4 Mean dose of ephedrine used (mg). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.5. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 5 Adverse effects. Analysis 3.6. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 6 Postoperative confusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.1. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 1 Mortality - during hospital stay. Analysis 4.2. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 2 Myocardial infarction. . . Analysis 4.3. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 3 Congestive cardiac failure. Analysis 4.4. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 4 Pulmonary embolism. . . Analysis 4.5. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 5 Length of hospital stay (discharge home). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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[Intervention Review]
Anaesthesia for hip fracture surgery in adults

Martyn J Parker1 , Helen HG Handoll2 , Richard Grifths3
1 Orthopaedic Department, Peterborough
and Stamford Hospitals NHS Foundation Trust, Peterborough, UK. 2 Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, University of Teesside, Middlesborough, UK. 3 Department of Anaesthesia, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK Contact address: Martyn J Parker, Orthopaedic Department, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough District Hospital, Thorpe Road, Peterborough, Cambridgeshire, PE3 6DA, UK. martyn.parker@pbh-tr.nhs.uk.
Editorial group: Cochrane Bone, Joint and Muscle Trauma Group. Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009. Review content assessed as up-to-date: 10 June 2004. Citation: Parker MJ, Handoll HHG, Grifths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000521. DOI: 10.1002/14651858.CD000521.pub2. Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT Background The majority of people with hip fracture are treated surgically, requiring anaesthesia. Objectives To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults. Search strategy We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (November 2003), MEDLINE (1996 to February week 2 2004), EMBASE (1988 to 2004 week 10) and reference lists of relevant articles. Selection criteria Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional (spinal or epidural) anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The primary outcome was mortality. Data collection and analysis Two reviewers independently assessed trial quality and extracted data. Main results Twenty two trials, involving 2567 predominantly female and elderly patients, comparing regional anaesthesia with general anaesthesia were included. All trials had methodological aws and many do not reect current anaesthetic practice. Pooled results from eight trials showed regional anaesthesia to be associated with a decreased mortality at one month (56/811 (6.9%) versus 86/857 (10.0%)); however, this was of borderline statistical signicance (relative risk (RR) 0.69, 95% condence interval (CI) 0.50 to 0.95). The results from six trials for three month mortality were not statistically signicant, although the condence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), RR 0.92, 95% CI 0.71 to 1.21). The reduced numbers of trial participants at one year, coming exclusively from two trials, preclude any useful conclusions for long-term mortality (80/354 (22.6%) versus 78/372 (21.0%), RR 1.07, 95% CI 0.82 to 1.41).
Anaesthesia for hip fracture surgery in adults (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1
Regional anaesthesia was associated with a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/130 (47%); RR 0.64, 95% CI 0.48 to 0.86). However, this nding is insecure due to possible selection bias in the subgroups in whom this outcome was measured. Regional anaesthesia was also associated with a reduced risk of acute postoperative confusion (11/117 (9.4%) versus 23/120 (19.2%), RR 0.50, 95% CI 0.26 to 0.95). There was insufcient evidence to draw any conclusions from a further four included trials, involving a total of 179 participants, which compared other methods of anaesthesia (a light general with spinal anaesthesia; intravenous ketamine; nerve blocks). Authors conclusions Overall, there was insufcient evidence available from trials comparing regional versus general anaesthesia to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.
PLAIN LANGUAGE SUMMARY Anaesthesia for hip fracture surgery in adults The majority of people with hip fracture are elderly and are treated surgically, which requires anaesthesia. The most common types of anaesthesia are general and spinal. General anaesthesia, which involves a loss of consciousness, typically includes inhalation of gases. Spinal (regional) anaesthesia involves an injection into the space around the spinal cord, to prevent pain in the involved limb. There was less mental confusion immediately after surgery in people given spinal anaesthesia, but there was not enough evidence to tell if regional anaesthesia was superior for any other outcome.
BACKGROUND
The scope of this review, originally published in Issue 4, 1999, was expanded in the second update, published in Issue 4, 2001, to cover other methods of anaesthesia. The main focus remains the comparison of regional versus general anaesthesia. The term proximal femoral fracture, or hip fracture, refers to a fracture of the femur in the area of bone immediately distal to the articular cartilage of the hip, to a level of about ve centimetres below the lower border of the lesser trochanter. The majority of these fractures occur in an elderly population with an average age of around 80 years. Females predominate over males by about four to one (Parker 1993) and the injury is usually the result of a simple fall. Whilst the hip fracture is usually the only injury, the patients frequently have many other medical problems associated with aging. An estimated 1.7 million hip fractures occurred worldwide in the year 1990 (WHO study group 1994). The number of hip fracture patients continues to rise, due to a combination of an increasingly elderly population and an increase in the age specic incidence. A prediction for global numbers of 6.26 million hip fractures by the year 2050 has been made (Melton 1993). The majority of these fractures are treated surgically; thus hip fracture surgery represents one of the most common emergency orthopaedic procedures. Surgical treatment may be either xation of the fracture or replacement of the femoral head with an arthroplasty. Internal xation involves using screws or pins, either alone or in combination with a side plate applied to the femur, or by the use of an intramedullary nail with a cross screw inserted into the femoral head. Arthroplasty involves excision of the fractured area of bone and replacement with a partial or total hip replacement, which may be cemented in place. General anaesthesia refers to the use of a variety of intravenous and or inhalation drugs to render the patient unconscious. The patient may breathe spontaneously or require mechanical ventilation following the administration of neuromuscular blocking agents. Potential complications of general anaesthesia include adverse reactions to the drugs used, difculty in maintaining or establishing an airway, intraoperative hypotension, aspiration of gastric contents, postoperative nausea, respiratory depression and damage to the teeth or upper airways.
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Regional anaesthesia for hip fracture surgery refers to the injection of a local anaesthetic into the epidural or subarachnoid space at the lumbar spine. Injection into the subarachnoid space, often termed spinal anaesthesia, is the most commonly used method for hip fracture surgery. In some cases the patient also receives sedatives whilst the block is inserted and possibly during the surgery itself. The main complication of a regional technique is intraoperative hypotension, which may lead to cerebrovascular or myocardial ischaemia or infarction. Other problems may be an inadequate regional block, the rare complications of damage to local structures and headache secondary to leakage of cerebrospinal uid from the dural puncture site. Specic advantages of regional anaesthesia may be a reduction in the incidence of thrombotic episodes and a reduced operative blood loss (Modig 1988). These may be a consequence of an increased peripheral limb blood ow in combination with reduced venous tone. Alternatively they may arise from an alteration of blood viscosity and coagulability, as a result of changes in the metabolic and neurohumoral responses to surgery (Modig 1983). Other forms of anaesthesia used for hip fracture surgery are the insertion of local nerve blocks around the hip. These may be supplemented with sedatives, analgesics or other parenteral drugs. A lumbar plexus block refers to injection of a local anaesthetic agent into the area of the lumbar plexus close to the transverse process of the fourth lumbar vertebra (Winnie 1974). Only the plexus on the side of the fracture needs to be blocked, which may reduce the incidence of complications such as intraoperative hypotension. A sacral plexus block refers to the injection of a local anaesthetic agent in the area around the sacral nerves (Mansour 1993). The use of nerve blocks preoperatively or in conjunction with general anaesthesia is considered in another Cochrane review (Parker 2001). An alternative type of anaesthetic involves the use of intravenous ketamine on its own. Ketamine renders the patient unconscious, thereby acting as a general anaesthetic, and has analgesic effects. No consensus exists as to which is the best method of anaesthesia. Thus the choice of anaesthesia used for hip fracture surgery is often determined by the personal preference of the anaesthetist concerned, following assessment of the patients medical state and preferably, if possible, consultation with the patient. Thus the choice of anaesthesia used for hip fracture surgery is often determined by the personal preference of the anaesthetist concerned, following assessment of the patients medical state and, if possible, after consultation with the patient. A general review of anaesthesia for hip fracture surgery (Covert 1989) summarised the possible advantages of different anaesthetic methods using information from eight of the randomised trials on this subject. In a meta-analysis, using Bayesian methods, of 11 randomised trials of regional versus general anaesthesia for surgical repair of hip fractures, Sorensen 1992 concluded that the superiority of one method over the other was unproven. Not all currently available randomised trials were
included and, moreover, some trial data from two studies were duplicated in the analysis. A more recent meta-analysis of randomised trials for all types of surgery has demonstrated a reduction of early postoperative mortality and morbidity with epidural or spinal anaesthesia (Rodgers 2000).
OBJECTIVES
To determine the optimum anaesthetic technique for hip fracture surgery. Different types of anaesthesia, namely regional (either spinal or epidural), inhalation general anaesthesia, local nerve blocks and intravenous ketamine anaesthesia were compared. Variations in anaesthetic drug dosage and delivery or supplementary regional blocks were not considered within this review. The following null hypotheses were tested within the trials included so far in this review: (1) There is no difference in outcome between regional anaesthesia (spinal or epidural) and general anaesthesia. (2) There is no difference in outcome between regional anaesthesia (spinal or epidural) supplemented with a light general anaesthetic and general anaesthesia alone. (3) There is no difference in outcome between regional anaesthesia (spinal or epidural) and regional nerve blocks alone. (4) There is no difference in outcome between anaesthesia using ketamine (with or without a benzodiazepine) and inhalation general anaesthesia.
METHODS
Criteria for considering studies for this review
Types of studies All randomised controlled trials comparing different methods of anaesthesia were included. Quasi-randomised trials (for example, alternation), and trials in which the treatment allocation was inadequately concealed, were considered for inclusion.
Types of participants Skeletally mature patients undergoing hip fracture surgery.

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Types of interventions (1) Regional anaesthesia (if necessary supplemented by sedatives) achieved by injection of local anaesthetic into the epidural or subarachnoid spaces. This type of anaesthesia is also referred to as spinal or epidural. (2) General anaesthesia using intravenous or inhalation agents to render the patient unconscious. Unless otherwise stated, general anaesthesia refers to general anaesthesia using inhalation agents in this review. (3) Intravenous ketamine. (4) Local nerve blocks (if necessary supplemented by sedatives) when used as the primary method of anaesthesia. Trials testing other methods of anaesthesia as the primary method of anaesthesia were considered for inclusion. Trials comparing the use of local nerve blocks in conjunction with general anaesthesia and the use of nerve blocks preoperatively, are evaluated in another Cochrane review (Parker 2001). Also not considered in this review were trials comparing different types of drugs or techniques of individual methods of anaesthesia.
Types of outcome measures The primary outcome measure was mortality (at 1 month, 3 months, 6 months and 1 year). In addition, data were extracted from each study for outcomes in the following four categories. The majority of outcomes in the rst category (peri-operative outcomes) are surrogate or intermediate outcomes: these are marked with an asterisk (*). As such they have an inexact relationship with important clinical outcomes that would be directly experienced by the patient. Some of these surrogate outcomes, such as fall in haemoglobin levels and hypotension, mainly serve to prompt remedial intervention to reduce the risk of a serious clinical event. We have included these outcomes in order to provide a full picture of the results of the included trials. (a) Peri-operative outcomes: - length of operation (in minutes) * - hypotension (intraoperative or immediately postoperative) * - operative blood loss (in millilitres) * - transfusion requirements - fall in haemoglobin level* - need for supplementary drugs to complete anaesthetic * - changes in body temperature * - pre- and postoperative arterial blood gases * - changes in catecholamines and other stress response chemicals during and after surgery * - intraoperative cardiac arrhythmias * - time to mobilisation - length of hospital stay (in days) (b) Complications specic to the method of treatment: - aspiration pneumonia - post-dural puncture headache - damage to the upper airways or mouth from devices used for
general anaesthesia - secondary intervention required for anaesthetic complications or failure - any other adverse effects as detailed in each study (new in second update) (c) General postoperative complications: (unless otherwise specied, the denition for these complications will be as detailed in each study, or by post-mortem) - pneumonia - myocardial infarction - cerebrovascular accident - congestive cardiac failure - renal failure - cardiac arrhythmias - acute confusional state - urine retention (requiring catheterization) - postoperative nausea and /or vomiting - deep vein thrombosis (diagnosis conrmed by post-mortem, venography, isotope scanning, ultrasound or plethysmography, whether this was performed routinely or only as clinically indicated) - pulmonary embolism (diagnosed by isotope scanning, angiography or post-mortem) (d) Final outcome measures: - mortality (primary outcome) - change in mental function - functional status - return of patient to their pre-fracture place of residence
Search methods for identication of studies

We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (November 2003). The specialised register is compiled from multiple databases, including regular searches of the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE (which combines subject specic terms with the optimal trial search strategy (Alderson 2004a)), EMBASE and CINAHL, and handsearch results. For further details see the search strategy in the groups module in The Cochrane Library. In addition we searched MEDLINE (1996 to February week 2 2004), EMBASE (1988 to 2004 week 10) and reference lists of relevant articles. In MEDLINE (OVID-WEB) the following search strategy was combined with the rst two levels of the optimal trial search strategy (Alderson 2004a). 1. exp Hip Fractures/ 2.((hip$ or femur$ or femoral$ or trochant$ or pertrochant$ or intertrochant$ or subtrochant$ or intracapsular$ or extracapsular$) adj4 fracture$).tw. 3. or/1-3 4. exp Anesthesia/
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5. ((an?esthet$ or an?esthesia) adj4 (regional$ or local$ or general or spinal or epidural)).tw. 6. or/4-5 7. and/3,6 The generic hip fracture search strategy for EMBASE is shown in Appendix 1. Articles of all languages were considered and translated if necessary.
Data collection and analysis

Data for the outcome measures listed above were independently extracted by two reviewers, and checked by at least one of the other two reviewers. In addition each trial was assessed without masking for its quality of methodology. Any differences were resolved by discussion between the reviewers. Quality assessment The main assessment was by the quality of concealment of allocation which was scored either A, B or C according to the criteria in the Cochrane Reviewers Handbook (Alderson 2004b), or 3, 2, 1 or 0 as described below (item 1). A further eight aspects of methodology were also rated. Though the scores of the individual items were summed, this was to gain an overall impression rather than for quantitative purposes. (1) Trials with clear concealment of allocation (e.g. numbered sealed opaque envelopes drawn consecutively) were coded as A and scored 3. Those in which there was a possible chance of disclosure of assignment were coded as B and scored 2. Those in which allocation concealment was not stated, or unclear, were coded as B and scored 1. Those where allocation was clearly not concealed, such as trials using quasi-randomisation (e.g. even or odd date of birth), were coded as C and scored 0. (2) Were the inclusion and exclusion criteria clearly dened? Score 1 if text states type of patients included and those excluded; otherwise score 0. (3) Were the outcomes of trial participants who withdrew or who were excluded after allocation described and included in an intention to treat analysis? This particularly applies to people allocated to regional anaesthesia where it was not achieved due to technical difculties. Score 1 if these people were either detailed separately or included in the analysis group to which they were allocated, or if text states that no withdrawals occurred; otherwise score 0. (4) Were the treatment and control groups adequately described at entry? Score 1 if a minimum of four admission details were given (e.g. age, sex, mobility, fracture type, function score, ASA grade, mental test score); otherwise score 0. (5) Were the care programmes other than trial options identical? Score 1 if text states they were; otherwise score 0. (6) Were the outcome measures clearly dened in the text? Score 1 if yes; otherwise score 0. (7) Were the outcome assessors blind to treatment group? Score 1 if yes; otherwise score 0.
(8) Was the timing of outcome measures appropriate?This was considered to be a minimum of three-months follow up for all surviving trial participants. Score 1 if yes; otherwise score 0. (9) Was loss to follow up reported and if so were less than ve per cent of trial participants lost to follow up? Score 1 if yes; otherwise score 0. Data analysis Heterogeneity between comparable trials was tested using a standard chi squared test and, latterly, the I-squared test (Higgins 2003). Relative risks and 95% condence intervals were calculated for dichotomous outcomes. Mean differences and 95% condence intervals were calculated for continuous outcomes. Results of comparable groups of trials were pooled using xed effect and random effects models and 95% condence intervals. Both Peto odds ratio and relative risk plots were viewed and a note was taken of where there was statistically signicant heterogeneity (P < 0.1) using either method. The results for the random effects model are presented when there is signicant heterogeneity in the results of individual trials. Any tests of interaction, calculated to determine if the results for subgroups were signicantly different, are based on odds ratio results.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded studies. Of 13 newly identied studies for this update, four studies (Biffoli 1998; Casati 2003; Kamitani 2003; Svarting 1986) were included, seven excluded and two placed in References to studies awaiting assessment. Further details have been requested for one study ( Dougall 1988) in the latter category; we have already received conrmation that this was a different trial to McKenzie 1984. The other potential trial (Yao 1997) in this category is reported in Chinese. One study (Wajima 1995) previously in Studies awaiting assessment is now included upon being translated from Japanese. Another article, reporting mortality data for an additional 61 trial participants, was identied for McLaren 1978. In all, 50 studies were identied of which 26 trials were included in this review, 22 were excluded and two are pending. Of the 22 excluded studies: three were not randomised trials; 14 involved comparisons outside the scope of this review; two (Tonczar 1981; Wickstrom 1982) involved neuroleptic general anaesthesia which was considered to be no longer appropriate for hip fracture surgery; one (Darling 1994) only reported one outcome, the rate of clearance of injected indocyanine green, which was considered not to have direct clinical relevance; one (El-Zahaar 1995) involving a mixed population of orthopaedic patients did not provide separate data for hip fracture patients; and one (Dyson 1988) with a
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factorial design which focused on a comparison outside the review scope, did not provide any results for the spinal versus general anaesthesia comparison. Further details of these are given in the Characteristics of excluded studies table. The 26 included trials involved a total of 2746 predominantly female and elderly hip fracture patients. Translations were obtained for three trial reports in French, one in German, one in Italian and two in Japanese. Twenty two trials were published as full reports in peer-reviewed journals; the four exceptions (Brichant 1995; Eyrolle 1998; Tasker 1983; Ungemach 1993) being only available as conference abstracts. Two trial reports were available for Davis 1981, one of which focused on a subgroup of trial participants monitored for deep vein thrombosis. Four references, one again which focused on a subgroup of trial participants monitored for deep vein thrombosis, were available for McKenzie 1984. Though these at rst appeared to be reports of separate trials, further details supplied by another trialist indicated that all the references applied to one study. Twenty two included trials involving 2567 patients compared spinal or epidural anaesthesia with general anaesthesia. One study (White 1980) of 40 participants, which compared a light general anaesthetic in conjunction with spinal anaesthesia versus general anaesthesia, is considered separately. A further group of 20 trial participants were allocated to receive a psoas nerve block in conjunction with general anaesthesia, which is outside the scope of this review but included in another Cochrane review on localised nerve blocks (Parker 2001). Two studies compared spinal anaesthesia with nerve blocks (de Visme 2000; Eyrolle 1998). The remaining trial (Spreadbury 1980) compared ketamine anaesthesia with inhalation general anaesthesia in 60 patients. Further details of the individual trials are given in the Characteristics of included studies table. Additional information on trial methodology and results would be welcomed from the authors of any of the studies, or from authors of trials that have not been identied.
Risk of bias in included studies

Treatment allocation was considered to be denitely concealed (Cochrane code A) in only one study (McKenzie 1984), which used sealed envelopes and random numbers. Allocation concealment was possible (Cochrane code B) in a further six studies (Brown 1994; Casati 2003; Couderc 1977; de Visme 2000; Maurette 1988; Racle 1986) which gave incomplete details of their methods of randomisation, as well as the 14 studies which did not provide any details. Allocation was not concealed in the only overtly quasi-randomised trial (Adams 1990) which allocated treatment by the date of operation. The methodology scores using the scoring system described earlier were: Regional versus general anaesthesia
1 2 3 4 5 6 7 8 9 Total (maximum 11) -----------------------------------0 0 0 1 0 0 0 0 1 2 Adams 1990 1 1 0 1 1 1 1 1 0 7 Berggren 1987 1 1 0 0 0 1 0 0 1 4 Biffoli 1998 1 1 0 1 1 1 1 1 0 7 Bigler 1985 1 1 0 1 1 1 0 0 1 6 Bredahl 1991 1 1 0 0 0 1 1 0 0 4 Brichant 1995 2 1 0 1 0 1 0 0 1 6 Brown 1994 2 1 0 1 1 1 0 0 1 7 Casati 2003 1 1 0 1 1 1 0 0 1 6 Davis 1981 2 1 0 1 0 1 0 1 0 6 Davis 1987 1 1 0 1 1 1 1 0 0 6 Juelsgaard 1998 1 0 0 1 0 1 0 0 1 4 Kamitani 2003 2 1 0 1 0 1 0 0 1 6 Maurette 1988 1 0 0 1 0 1 0 0 1 4 McLaren 1978 3 0 0 0 0 1 0 1 1 6 McKenzie 1984 2 1 0 0 1 1 0 1 1 7 Racle 1986 1 1 1 1 1 1 0 0 1 7 Svarting 1986 1 0 0 0 0 1 0 0 0 2 Tasker 1983 1 0 0 0 0 0 0 0 0 1 Ungemach 1993 1 1 0 1 0 1 1 1 1 7 Valentin 1986 1 0 0 0 0 1 0 0 1 3 Wajima 1995 Light general anaesthesia combined with spinal anaesthesia versus general anaesthesia 1 2 3 4 5 6 7 8 9 Total (maximum 11) -----------------------------------1 1 0 1 0 1 0 0 0 4 White 1980 Regional (spinal) anaesthesia versus local nerve blocks 1 2 3 4 5 6 7 8 9 Total (maximum 11) -----------------------------------2 1 0 1 1 1 0 0 1 7 de Visme 2000 1 0 0 0 0 0 0 0 1 2 Eyrolle 1998 Ketamine versus general anaesthesia 1 2 3 4 5 6 7 8 9 Total (maximum 11) -----------------------------------1 1 0 1 1 0 0 0 1 5 Spreadbury 1980 Two items meriting specic comment are items 3 (intention to treat) and 7 (assessor blinding). Only one trial satised the criteria for the rst item. The other trials scored zero. Some because no information was available for trial participants or on whether any participants were withdrawn from the study. Others because trial participants who had been withdrawn or excluded were not included in the baseline or outcome analyses, or because an intention to treat analysis was not done. The extent of assessor blinding was usually limited to select outcomes in most of the trials scoring on this item.
Effects of interventions
The outcome measures listed earlier were extracted for each study and, where appropriate data were available, summarised in the
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graphs. The results are presented using the xed effect model except where there is statistically signicant heterogeneity between study results (P < 0.1) where the random effects model is applied. Since the primary outcome for this review, as stated in the protocol, is mortality, this is considered rst. Other outcomes are presented in the categories listed under Types of outcome measures. As explained, these include surrogate or intermediate outcomes, such as peri-operative hypotension, body temperature and arterial blood gases. Although such outcomes may be predictive of important clinical outcomes, the relationship is usually not an exact one and some conditions, such as operative hypotension, may be remedied to reduce the risk of a serious clinical event occurring. Thus the results of such outcomes are not accurate guides of hard clinical outcomes and may be misleading. Regional versus general anaesthesia Mortality Mortality was not reported in the nine short-term studies, involving 392 patients. (The primary foci of these trials were body temperature (Bredahl 1991), deep vein thrombosis (Brichant 1995), oxygen saturation (Brown 1994), blood pressure and plasma levels of cortisol associated with cementation of a hip prosthesis (Svarting 1986) and cognitive/psychological function (Biffoli 1998; Casati 2003; Kamitani 2003; Maurette 1988; Wajima 1995) respectively.) Where possible, data for mortality up to one, three, six and 12 months were deduced or extracted from study reports, and pooled, for these four pre-specied time periods. Data for three months and beyond were extracted from graphs for two studies (Davis 1987; Valentin 1986). Additional mortality data were obtained for McKenzie 1984 from another trialist. Mortality data for undened follow-up periods, or for under one month were provided by four studies (Adams 1990; Bigler 1985; Tasker 1983; Ungemach 1987). The data for the rst two studies, which were for early deaths during hospital stay, and those for Ungemach 1987, which were at two weeks, were pooled with those for one month in an extra analysis. Tasker 1983 reported, without providing denominators, that the difference in mortality was not statistically different between the two groups (4 versus 6). Results for all these studies are shown in the graphs (01.01 to 01.06). The reduced mortality for regional anaesthesia at one month (56/811 (6.9%) versus 86/857 (10.0%)) was of borderline statistical signicance when evaluated using the xed effect method (relative risk (RR) 0.69, 95% condence interval (CI) 0.50 to 0.95), but not statistically signicant when using the random effects model (RR 0.68, 95% CI 0.44 to 1.05). Based on the I-squared statistic (31%), there was some but not substantial heterogeneity/inconsistency between the studies. There was a similar pattern when the results from the three studies (Adams 1990; Bigler 1985; Ungemach 1987), which provided data on deaths during hospital stay or under one month, were pooled with the data for one month mortality (see graph 01.06). The difference in
mortality between the two groups was smaller and not statistically signicant at subsequent follow-up times: three-months mortality (graph 01.03: 86/726 (11.8%) versus 98/765 (12.8%), RR 0.92, 95% CI 0.71 to 1.21); six-months mortality (graph 01.04: 103/613 (16.8%) versus 115/651 (16.1%), RR 1.04, 95% CI 0.81 to 1.33); and 12-months mortality (graph 01.05: 80/354 (22.6%) versus 78/372 (21.0%), RR 1.07, 95% CI 0.82 to 1.41). Notably, the number of trials and associated data for pooling shrank at each time interval, with only the two largest trials (McKenzie 1984; Valentin 1986) contributing to the 12-months analysis. Feedback obtained from an external referee (Ballantyne 2004) prompted some consideration of these results in terms of the vintage of the trials contributing data and the high mortality gures in McLaren 1978. Two actions were taken. Firstly, the trials were ordered according to their year of publication (Reader, please sort by year for graph 01.01). This reveals a potential, but statistically untested, trend in the results towards a reduced early mortality for regional anaesthesia in earlier studies. Secondly, removal of the data for McLaren 1978, which has an unusually high mortality rate in the general anaesthesia group (28%), resulted in a statistically non-signicant difference in mortality at one month (RR 0.79, 95% CI 0.56 to 1.12: graph not shown). Other outcomes (a) Peri-operative outcomes Length of operation Most studies that recorded this outcome reported a statistically non-signicant increase in the time taken to complete the operation for regional anaesthesia (Adams 1990; Berggren 1987; Bigler 1985; Maurette 1988; McKenzie 1984; Racle 1986). One study ( Svarting 1986) had a signicant increase and two studies (Bredahl 1991; Kamitani 2003) a non-signicant increase for general anaesthesia. Five studies found no difference between the two groups (Biffoli 1998; Casati 2003; Davis 1981; Juelsgaard 1998; White 1980). Prior to the inclusion of data from two new trials (Kamitani 2003; Svarting 1986), the pooling of data from six studies showed a statistically signicant increase of around ve minutes for regional anaesthesia (weighted mean difference 4.8 minutes, 95% CI 1.1 to 8.6 minutes). This has now changed in that there is now no statistically signicant difference between the two groups. Moreover, the result from Svarting 1986 is signicantly different from the other trials; the addition of this trial changed the chi squared value from 7.45 (P = 0.28) to 15.95 (P = 0.03) and the Isquared value from 20% (low heterogeneity) to 56% (substantial heterogeneity). The adoption of the random effects model (shown in graph 01.07) shows minimal difference between the two groups (weighted mean difference 0.8 minutes, 95% CI -5.4 to 6.9 minutes). Hypotension The denition of hypotension, when stated, was a greater than a 30% reduction in systolic blood pressure (Berggren 1987; Svarting 1986); a 33% fall (Juelsgaard 1998); a 40 mmHg fall (Couderc
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1977); and a 20% fall from the baseline in four studies (Casati 2003; Davis 1987; Maurette 1988; Racle 1986). Two studies (Adams 1990; Davis 1981) stated, without data for pooling, that the drop in systolic blood pressure was signicantly greater in the regional anaesthesia group. Bigler 1985 reported no signicant difference in the maximum drop of systolic blood pressure (48 versus 51 mmHg). Pooling of data from 11 studies ( Berggren 1987; Biffoli 1998; Brown 1994; Casati 2003; Couderc 1977; Davis 1987; Juelsgaard 1998; Maurette 1988; McLaren 1978; Racle 1986; Svarting 1986) showed hypotension to be more common after regional anaesthesia. This difference was statistically signicant when viewed using the xed effect model (graph 01.08: 172/501 (34.3%) versus 137/521 (26.3%), RR 1.30, 95% CI 1.08 to 1.55) but not when adopting the random effects model (graph 01.09: RR 1.10, 95% CI 0.79 to 1.55), which is probably more appropriate given the signicant heterogeneity of trial results (chi squared = 21.23, P = 0.01; I-squared = 57.6%). This signicant heterogeneity persisted when we explored the effect of removing each of the trials in turn. Operative blood loss Pooled data for ve studies (Bredahl 1991; Davis 1981; Kamitani 2003; McKenzie 1984; Svarting 1986) showed a statistically signicant decrease in operative blood loss for regional anaesthesia (graph 01.10: weighted mean difference -85 ml, 95% CI -162 to 9 ml). There was substantial heterogeneity in these trial results (Isquared = 53%). Five other studies contained insufcient data to enable pooling. Adams 1990 and Juelsgaard 1998 reported a nonsignicant increase in blood loss for regional anaesthesia; McLaren 1978 reported no signicant difference; Ungemach 1987 reported no difference; and Casati 2003 and Valentin 1986 reported a signicantly increased blood loss in the general anaesthesia group. Transfusion requirements Nine studies gave data for blood transfusion, which are presented as either the numbers of patients who were transfused in four studies (Adams 1990; Bigler 1985; Davis 1981; Svarting 1986), or the mean volume of blood transfused (transfusion requirement) (Couderc 1977; Juelsgaard 1998; Kamitani 2003; Maurette 1988; Racle 1986). Similar proportions of patients received transfusion in each group in the rst four studies (graph 01.11: 64/123 (52.0%) versus 73/135 (54.1%)). In contrast the transfusion requirements were greater in the regional anaesthesia group but there was signicant heterogeneity (chi squared = 30.27, P < 0.00001; I-squared = 90.1%) in the trial results and the pooled result applying the random effects model was not statistically signicant (graph 01.12: weighted mean difference 100 ml, 95% CI -53 to 252 ml). Juelsgaard 1998 reported statistically non-signicantly lower mean values of blood volume transfused over the operative and peri-operative period for the regional anaesthesia group (237 ml versus 257 ml). Bigler 1985 reported the mean falls in haemoglobin to be greater in the regional anaesthesia group (22% versus 19%, not signicant). Kamitani 2003 found no difference between the two groups in postoperative haemoglobin levels.
Pre- and postoperative arterial blood gases The reports of eight studies (Berggren 1987; Brown 1994; Couderc 1977; Davis 1981; Kamitani 2003; McLaren 1978; McKenzie 1984; Svarting 1986) contained data for blood gases taken either preoperatively, operatively or postoperatively. In addition, Biffoli 1998 reported on postoperative hypoxia. Pooled data from Biffoli 1998 and Berggren 1987, which reported numbers of trial participants with postoperative arterial oxygen tension of less than 60 mmHg, are presented in graph 01.13 (11/58 (19%) versus 17/59 (29%), RR 0.67, 95% CI 0.36 to 1.22). Brown 1994, in a study of postoperative oxygen saturation in 20 people, found signicantly lower oxygen saturation for the group who received general anaesthesia. Davis 1981 reported that the general anaesthesia group showed a postoperative fall in oxygen saturation in the early postoperative period, which was not seen after regional anaesthesia. By the rst postoperative day there was no signicant difference between the two groups. Kamitani 2003 reported no statistically signicant difference between the two groups in oxygen saturation levels postoperatively and at 12 and 18 hours; however, the oxygen saturation was 1.6% higher in the general anaesthesia group at six hours. McKenzie 1984 reported a signicant decrease in the oxygen saturation at one hour postoperatively in those who received general anaesthesia compared with those who received regional anaesthesia. In contrast, two studies (Couderc 1977; McLaren 1978) reported no difference in the mean arterial oxygen or carbon dioxide tensions for the two types of anaesthesia. Svarting 1986 observed a distinct deterioration in arterial oxygen tension in both groups on cementation of a Thomson prosthesis; additional oxygen was considered necessary for eight spinal anaesthesia patients during their operations. Length of hospital stay Most studies reporting this found no difference in the length of hospital stay. Juelsgaard 1998 observed that the results for hospital stay were affected by a lack of rehabilitation facilities. Adams 1990 reported 21 days for regional versus 20 days for general anaesthesia. Berggren 1987 stated there was no difference in length of hospital stay between the two groups, as did Casati 2003 (median stay: 12 versus 14 days). Davis 1987 reported an average of 16 days for both groups, and Racle 1986, 20 days for both groups. Valentin 1986 reported a median stay of 10 days for regional anaesthesia and 11 days for general anaesthesia. Finally, McKenzie 1984 recorded a mean of 38 days for regional anaesthesia against 43 days for general anaesthesia. Summation of the two studies which quoted standard deviations (McKenzie 1984; Racle 1986), shown in the graphs, demonstrated no difference in the length of hospital stay between groups (graph 01.14: weighted mean difference -0.2 days, 95% CI -5.2 to 4.8 days). Other peri-operative outcomes Other peri-operative outcomes recorded were changes in body temperature (Bredahl 1991), serum catecholamine and endocrine levels (Adams 1990; Svarting 1986; Tasker 1983), bradycardia ( Casati 2003), ECG changes (Juelsgaard 1998), pain and analgesic
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use (Casati 2003; Kamitani 2003), and time to ambulation (Bigler 1985; Valentin 1986). Ungemach 1993 used a scoring system calculated from data on consciousness, respiration, circulation, laboratory tests and blood loss. Bredahl 1991, who recorded body temperatures of 30 patients, concluded that temperature changes during the peri-operative period were unrelated to the type of anaesthesia. Adams 1990 reported raised serum adrenaline and noradrenaline levels at the end of the operation for a subgroup of 32 trial participants, the rise in levels being greater in those who received a general anaesthetic. Svarting 1986 found signicantly increased plasma cortisol levels after cementation in the general anaesthesia group. Tasker 1983, in a study of 100 patients, reported a signicantly greater increase in plasma noradrenaline and cortisol levels after general anaesthesia in comparison with regional anaesthesia. There was no report of intraoperative cardiac arrhythmias. Bradycardia (heart rate < 50 beats/min) was observed in three patients during general anaesthesia in Casati 2003. Juelsgaard 1998 reported a signicant increase in the overall number of ST segment depressions for those in the spinal anaesthesia group (125 versus 16 events). Pain at one hour post surgery was worse in the general anaesthesia group in Casati 2003 but not at three, six or 12 hours. Kamitani 2003 reported there was no difference between the two groups in diclofenac use. Bigler 1985 reported a signicant reduction in the mean time from surgery to ambulation of 3.3 days after regional anaesthesia versus 5.1 days after general anaesthesia. Valentin 1986 however reported no difference in the time to ambulation for patients in the two groups. Postoperative scores (calculated from data on consciousness, respiration, circulation, laboratory tests and blood loss) in Ungemach 1993 were reported as better in the spinal group, but it was not clear by how much and how this was manifested. (b) Complications specic to the method of treatment Davis 1981 was the only study to report on aspiration pneumonia, with two cases in the general anaesthesia group. These have been included under the complication of pneumonia. A persistent headache, lasting three days, in one person in the spinal anaesthesia group was noted in Bigler 1985. McLaren 1978 reported that there were no post-anaesthetic headaches. There was no mention within the included studies of other complications such as damage to the upper airways or mouth from equipment used during general anaesthesia. Failure of spinal anaesthesia, usually resulting in the secondary use of general anaesthesia, was reported in both studies conducted by Davis et al (Davis 1981; Davis 1987). Spinal anaesthesia, often performed by junior staff, was unsuccessful in eight out of 72 patients (11.1%) in Davis 1981 and in 30 out of 259 patients (11.6%) in Davis 1987. Davis 1987 also referred to a 10% failure rate in the study of Valentin 1986. The treatment of these spinal anaesthesia failures in the analyses presented by these three trials
has further implications regarding intention to treat analysis. For instance, it may be that the excluded trial participants had different characteristics and outcomes than those participants in which spinal anaesthesia was successful. The eight patients in Davis 1981 were incorrectly analysed in the general anaesthesia group, whereas the 30 patients in Davis 1987 were analysed in the spinal anaesthesia group, and lastly, Valentin 1986 chose to exclude them from the analysis. (c) General postoperative complications Data for most of the life threatening complications such as pneumonia, myocardial infarction, cerebral vascular accident, congestive cardiac failure and pulmonary embolism were only available as causes for deaths in many of the trial reports. To reect this, the data from fatal events have been subgrouped separately from those listed as complications, or not wholly associated with deaths, in trial reports. Pneumonia Pneumonia or chest infection was reported in nine studies (Adams 1990; Berggren 1987; Bigler 1985; Davis 1981; Davis 1987; Juelsgaard 1998; McKenzie 1984; McLaren 1978; Racle 1986). Pooling of the results indicates no statistically signicant difference between the two anaesthetic methods (graph 0.15: 21/574 (3.7%) versus 29/612 (4.7%), RR 0.76, 95% CI 0.44 to 1.30). Myocardial infarction This complication was reported in seven studies (Couderc 1977; Davis 1981; Davis 1987; Juelsgaard 1998; McKenzie 1984; McLaren 1978; Racle 1986). Summation of the results from six trials showed no statistically signicant difference in myocardial infarction between the two groups (graph 01.16: 5/502 (1.0%) versus 11/531 (2.1%), RR 0.55, 95% CI 0.22 to 1.37). Cerebrovascular accident This complication was reported in seven studies (Berggren 1987; Bigler 1985; Couderc 1977; Davis 1981; Davis 1987; McKenzie 1984; Racle 1986). Pooling of results showed no statistically signicant difference in cerebrovascular accidents between the two groups (graph 01.17: 10/529 (1.9%) versus 6/556 (1.1%), RR 1.51, 95% CI 0.64 to 3.57). Congestive cardiac failure This complication was reported in seven studies (Adams 1990; Berggren 1987; Bigler 1985; Davis 1981; Davis 1987; Juelsgaard 1998; Racle 1986). Pooling of data showed no statistically signicant difference between the two groups (graph 01.18: 12/454 (2.6%) versus 12/477 (2.5%), RR 1.05, 95% CI 0.49 to 2.23). Renal failure Renal failure was reported in ve studies (Adams 1990; Davis 1981, Davis 1987; McLaren 1978; Racle 1986). Summation of results in the graph demonstrated no statistically signicant difference between anaesthetic techniques (graph 01.19: 3/438 (0.7%) versus 5/474 (1.1%), RR 0.76, 95% CI 0.23 to 2.49). Post operative cardiac arrhythmia
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More abnormal cardiac rhythms were detected in the general anaesthesia group in Couderc 1977. However, Couderc 1977 reported that there was no difference in the overall electrocardiographic results; these included results for other peri-operative changes in the cardiogram. Acute confusional state This complication and/or underlying cognitive dysfunction was reported in seven small studies (Berggren 1987; Biffoli 1998; Bigler 1985; Casati 2003; Kamitani 2003; Racle 1986; Wajima 1995). Summation of the limited results showed a signicant reduction in the regional anaesthesia group (graph 01.20: 11/117 (9.4%) versus 23/120 (19.2%), RR 0.50, 95% CI 0.26 to 0.95). In the subgroup of 38 patients who were not confused at trial entry, Biffoli 1998 found slightly better result in the spinal anaesthesia group (mean difference -0.97, 95% CI -1.91 to -0.03) in the Organic Brain Syndrome score (0: no confusion to 36: total confusion) at 48 hours. Wajima 1995 reported no statistically signicant differences between the two anaesthetic groups in the Hasegawa Dementia Scale scores at one week post surgery. Urine retention Pooling of the data from the two studies (Berggren 1987; Bigler 1985) reporting this complication showed similar results for the two anaesthetic techniques (graph 01.21: 10/48 (20.8%) versus 10/49 (20.4%), RR 1.02, 95% CI 0.47 to 2.23). Kamitani 2003 found no difference in the urine output of the two groups. Postoperative vomiting Pooling of the data from the two studies (Bigler 1985; McLaren 1978) reporting this complication again showed similar results for the two anaesthetic techniques (graph 01.22: 2/46 (4.3%) versus 3/49 (6.1%), RR 0.70, 95% CI 0.12 to 3.94). Deep vein thrombosis Deep vein thrombosis was the primary outcome for one study ( Brichant 1995), and for two subgroups of patients from a further two studies (Davis 1981; McKenzie 1984). Awareness of the risk of deep vein thrombosis was evident in several other studies who did not report this outcome, with various prophylactic interventions being deployed: Dextran 70 (Berggren 1987); early mobilisation (Bigler 1985); anti-vitamin K and early mobilisation (Couderc 1977); heparin and active movement (Racle 1986) and anti-embolic stockings (Valentin 1986). Patients in Brichant 1995 also received thromboembolic prophylaxis with low molecular weight heparin and anti-embolism stockings. Venography screening was used to detect deep vein thrombosis in two studies (Brichant 1995; McKenzie 1984) and brinogen scanning in Davis 1987. Pooled data, grouped by method of diagnosis, include two deaths whose underlying cause was deep vein thrombosis from McLaren 1978. Signicantly fewer thromboses were detected in patients in the regional anaesthesia group (graph 01.23: 39/129 (30%) versus 61/130 (47%); RR 0.64, 95% CI 0.48 to 0.86). Though the difference in incidence rates was consistent between trials, whether measured by venography, brinogen update or at post-mortem,
these results have to be viewed with caution since these were the results of subgroups of patients for whom data from venography or brinogen were available. In turn, the patients specially monitored for deep vein thrombosis were also subgroups of the trial populations in two studies (Davis 1981; McKenzie 1984). Pulmonary embolism Pulmonary embolism was reported in 10 studies (Adams 1990; Berggren 1987; Bigler 1985; Brichant 1995; Couderc 1977; Davis 1981; Davis 1987; McKenzie 1984; McLaren 1978; Racle 1986) but mostly as a reason for death rather than through active monitoring for non-fatal pulmonary embolism. Pooling the results from nine studies using Peto odds ratios (graph 01.24) showed statistically signicant heterogeneity (chi squared = 15.11, P = 0.06; Isquared = 47.1%). Summation of results from nine studies using the random effects model to allow for this heterogeneity showed no statistically signicant difference in overall incidence of pulmonary embolism in the two groups (graph 01.25: 9/605 (1.5%) versus 13/640 (2.0%), RR 0.88, 95% CI 0.32 to 2.39). The source of heterogeneity resides mainly in the signicantly different results in trials presenting results for fatal pulmonary embolism, and those presenting results for non-fatal pulmonary embolism. These are analysed in separate subgroups in graph 01.26 (test for interaction, based on Peto odds ratio results: P = 0.003). Composite outcome Ungemach 1993 used a scoring system that was based on laboratory tests, cardiopulmonary evaluation and complications such as heart failure, thrombosis and apoplexy. No difference between the two groups was found in the scores at two weeks. (d) Final outcome measures Mortality has already been considered above. Changes in mental function Two studies (Bigler 1985; Maurette 1988) reported on long-term changes in mental function. Bigler 1985 reported that there was no persistent impairment in mental function, and no signicant differences between the two groups in the mental scores achieved at three months. Maurette 1988 performed psychological evaluations on 33 patients and found no signicant difference relating to the type of anaesthesia. Functional outcome No study reported on the difference in functional outcomes between groups. Only McKenzie 1984 provided limited data on the location of trial participants at 12 months, but not for the return of participants to their previous residence. Light general anaesthesia combined with spinal anaesthesia versus general anaesthesia The only study (White 1980) in this category involved only 20 patients in each group. No trial participants died within the onemonth follow up period of the study. The mean length of operation was 58 minutes in both groups. There was no signicant difference in the mean postoperative blood oxygen or carbon dioxide levels
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between the two groups. Complications reported were pneumonia (4 versus 5 cases), confusional states (3 in each group), deep vein thrombosis (1 in the general anaesthesia group) and postoperative vomiting (1 in each group). Results for most of these outcomes are presented in the graphs (02.01 to 02.05). Regional (spinal) anaesthesia versus local nerve blocks Two studies, involving 79 patients, were included. One study ( Eyrolle 1998) compared spinal anaesthesia with a lumbar plexus block in 50 people; supplementary intravenous propofol sedation was performed when necessary. The other study (de Visme 2000) compared spinal anaesthesia with a lumbar plexus block in conjunction with a sacral plexus block and iliac crest block (for lateral cutaneous nerve of the thigh). Intravenous alfentanil or sedatives were also used if necessary. Both studies only reported on outcome during the peri-operative period and did not report on postoperative complications or mortality. Results where available and appropriate are given in the graphs. In Eyrolle 1998, the need for propofol supplementation, of dosage greater than 1 mg/kg/hr, was signicantly less common in the spinal group (5/25 versus 19/25). No cases of incomplete or unsatisfactory anaesthesia in the spinal group were reported in de Visme 2000 as opposed to four cases of incomplete anaesthesia and one case, requiring repeated sedation that was judged as unsatisfactory, in the nerve block group (0/14 versus 5/15). Overall, the need for supplementary sedation was signicantly less in the spinal group (graph 03.01: 5/39 versus 24/40; RR 0.23, 95% CI 0.10 to 0.50). A fall in mean arterial blood pressure of more than 20% occurred in signicantly more patients in the spinal group (graph 03.02: 18/25 versus 3/25; RR 6.0, 95% CI 2.02 to 17.83) in Eyrolle 1998. The mean fall in arterial blood pressure was also signicantly greater in the spinal group in de Visme 2000 (graph 03.03: mean difference 16 mmHg, 95% CI 1.3 to 30.7 mmHg). In both trials, signicantly higher doses of ephedrine were used to stabilise blood pressure in the spinal group (graph 03.04: weighted mean difference 5.96 mg, 95% CI 4.46 to 7.45 mg). Pain as measured by the visual analogue scale (VAS) was stated as showing no difference between groups in Eyrolle 1998. Eleven trial participants failed to complete the VAS in de Visme 2000, who considered that VAS rating for pain was unsatisfactory when there were cases of sensorial deciency. Insertion difculty was signicantly more common in the spinal group in Eyrolle 1998 (10/25 cases versus 3/25). In contrast, the mean time to administer the spinal was reported as being statistically signicantly lower in the spinal group in de Visme 2000 (12 versus 18 minutes; reported P = 0.013). Adverse effects, including ve cases of urinary retention, were more common in the spinal group in Eyrolle 1998 (graph 03.05: 6/25 versus 1/25; RR 6.00, 95% CI 0.78 to 46.29). No adverse effects of the techniques were reported by de Visme 2000. Postoperatively, similar numbers of trial participants had impaired cognitive function in de Visme 2000 (graph 03.06: 5/14 versus 6/15); this was reected in the comparable mini-mental test scores
(mean 15.5 versus 14.5). Ketamine versus general anaesthesia The only study included in this category (Spreadbury 1980) involved 60 female patients. The limited results available are summarised in the graphs (04.01 to 04.05). Data were presented for early deaths (within 14 days) and late deaths (time unspecied, in hospital). These showed no difference in the overall mortality during hospital stay (9/30 (30%) versus 9/30 (30%)). Data presented for the complications of myocardial infarction (1 case), congestive cardiac failure (2 cases) and pulmonary embolism (3 cases) were all derived from causes of death for the seven early deaths. The mean length of hospital stay for the 39 trial participants who returned home was 36 days for the ketamine group against 24 days for the general anaesthesia group. This difference is statistically signicant and is related to the higher incidence of unsatisfactory surgical results in the ketamine group (see below). Although the general anaesthesia group mobilised more quickly than the ketamine group, Spreadbury 1980 reported that the differences were not statistically signicant. The proportions of people who returned home were similar (19/30 versus 20/30). Spreadbury 1980 also reported that the numbers of patients who experienced dreams and hallucinations were similar for the two groups (4 versus 5 patients). They stated however that the dreams were more likely to be unpleasant after general anaesthesia. Spreadbury 1980 also reported the incidence of unsatisfactory surgical results, either due to later dislocation of the prosthesis or an unstable xation, which subsequently required bed rest or traction. There were 7/30 (23%) such cases for the ketamine group against 3/30 (10%) for general anaesthesia.
DISCUSSION
Regional versus general anaesthesia Many of the studies within this review involved small numbers of participants and reported only a few outcome measures. The trial reports of all studies indicated a poor level of methodological rigour, in particular regarding concealment of allocation, assessor blinding and intention to treat analysis. Despite these limitations, there is a reasonable agreement between trials for many of the outcome measures reported, particularly for mortality. It remains possible that some of the differences in outcome within the studies could be related to the differences in the experience, and competence, of the anaesthetists. Inexperience with the anaesthetic techniques could be inferred in some studies. For example, there was a high failure rate of spinal anaesthesia, often performed by junior staff, of over 11% in both Davis 1981 and Davis 1987. However, there was no evidence that the seniority of the anaesthetists applying the different methods of anaesthesia differed in any given trial. A further consideration, raised at editorial review (Ballantyne 2004), is that many of the included trials are relatively old and do
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not represent contemporary practice nor account for the advances in safety in the eld of anaesthesia. Hip fractures occur predominantly in the frail elderly who have multiple other medical conditions. The high mortality within this group of patients often results from these other medical conditions rather than being a direct consequence of the hip fracture and its treatment. Regional anaesthesia may reduce short-term mortality, yet this nding is borderline in that it is statistically signicant when using the xed effect model but not with the random effects model. Notably, both models give very similar point estimates of effect (relative risk = 0.69 (xed) and 0.68 (random)). The effect of the removal of the oldest trial (McLaren 1978), which has an excessive mortality in the general anaesthesia group, also shows the weakness of the evidence. Nonetheless, the three-months mortality result retains a potential for a reduction in mortality in the regional anaesthesia group. There is no evidence of substantial differences between regional and general anaesthesia in terms of long-term mortality, although the small numbers of people with long-term follow up, available from two trials of poor methodology, means that we cannot exclude clinically relevant differences. It is plausible that changing one aspect of hip fracture treatment (the type of anaesthesia) could affect long-term mortality: potentially, regional anaesthesia could enable the group of very frail elderly to survive the initial surgery, only for death to ensue later from other medical complications. In their comprehensive review of regional anaesthesia, Rodgers et al (Rodgers 2000) found that postoperative mortality up to 30 days was signicantly reduced for all types of surgery (general, orthopaedic, urological and vascular) by about a third (odds ratio = 0.70, 95% CI 0.54 to 0.90). This is consistent with the point estimate of effect in this review. Rodgers et al concluded that their ndings supported a more widespread use of neuraxial blockade [spinal/epidural anaesthesia]. It was notable that over half the trials with at least 10 deaths per trial involved patients with hip fracture; thus enhancing the contribution of the ndings of these trials to the overall result. Rodgers 2000 considered that a lack of statistical power in individual trials and meta-analyses could be the principal reason for a conclusion that neuraxial blockade had no important effect on mortality. In fact, our conclusions are still phrased in a more tentative way than Rodgers et al imply and, although there is a lack of statistical power in our review, we also consider that there is an important lack of longer-term outcome data. Given that the evidence from the trials in our review of hip fracture is insufcient to show a statistically signicant reduction in mortality at one month, an important consideration is whether we should draw on the results from Rodgers 2000 in making our conclusions. The comparison of regional versus general anaesthesia has been identied as a clinical question where the focus on a subgroup of studies (i.e. on hip fracture patients) could miss an important effect; namely the mortality associated with general anaesthesia compared with regional anaesthesia across different surgical
procedures (Oxman 2001). There are others, however, who are not convinced that the ndings of Rodgers 2000 apply or should be applied to all surgical groups (McCullock 2001; Hughes 2000). Also questioned, and pertinent to both reviews, is the relevance of older trials to current anaesthetic practice (Higham 2001). Anaesthetic techniques, equipment and drugs have changed in recent years, with important advances in safety, and there is often greater use of antithrombotic prophylaxis. The inclusion of older studies in Rodgers 2000 and in previous versions of this review may therefore have biased results in favour of regional anaesthesia. There is general agreement that further research is warranted. Returning to this review on hip fractures. Because of the low incidence of many of the complications following surgery, no individual study had numbers large enough to determine if any difference exists. As much of the data for many of these complications was for fatal complications, these results are far from complete. Some possible, although unconrmed, trends for regional anaesthesia were for less myocardial infarction, more cerebrovascular accidents and less fatal pulmonary embolism but more non-fatal pulmonary embolism. Pooled data from ve small trials, involving a total of 237 patients, showed signicantly fewer cases of acute confusion when regional anaesthesia was used. This was a consistent nding between ve trials, of which four specically focused on mental functioning, and was supported by the results of two other trials with the same focus. These attributes strengthen the nding of lower incidence of acute confusion with regional anaesthesia but it would still be prudent to have conrmation of this and, importantly too, to gather evidence on whether there is persistent impairment in mental function.
Pooled results for deep vein thrombosis showed a statistically signicant reduction in the incidence of deep vein thrombosis in the regional anaesthesia group. This should not be considered conclusive as the data were from subgroups of trial participants who had been selected by their compliance with a method of diagnosis, and thus the effect, and certainly the effect size, may have been distorted. The effects of thromboembolic prophylaxis may also affect the incidence of thromboembolic complications. The routine use of thromboembolic prophylaxis was mentioned in six studies (Berggren 1987; Bigler 1985; Brichant 1995; Couderc 1977; Racle 1986; Valentin 1986). It is also possible that thromboembolic prophylaxis may have been withheld in those receiving regional anaesthesia in some studies. The results do suggest a trend towards a reduced risk of thromboembolic complications with regional anaesthesia but, because of the small number of trials that reported this outcome and the heterogeneity of results, rm conclusions cannot be made for this outcome. In our previous update (Issue 4, 2001), where we reported that operations with regional anaesthesia took approximately 5 to 10 minutes longer than general anaesthesia, we stated that such a nding
12
would be expected from clinical practice. We suggested that may be due to the time taken to administer the regional anaesthesia and then the time taken for the analgesic effect to occur. The inclusion of evidence from two new trials, which resulted in a nding of no signicant difference, undermines our previous statements and emphasises the lack of robustness in the underlying evidence. Another statistically signicant nding is the increased blood loss for general anaesthesia from data pooled from ve trials. However, where reported, similar numbers received blood transfusion and transfusion requirements were greater in the regional anaesthesia group in some trials. Though these results seem contradictory, one explanation might be that, because regional anaesthesia decreased blood pressure more than general anaesthesia, blood transfusion was triggered due to the haemodynamic state rather than as a consequence of blood loss, particularly if during regional anaesthesia the patients blood had become diluted with clear intravenous uids (Carlisle 2004). Regional anaesthesia results in vasodilatation of the lower limbs and this results in an increased tendency to operative hypotension, as demonstrated by the results. In addition, the increased blood ow to the lower limbs with alterations in coagulability and viscosity of the blood, may be the reason for the reduced incidence of venous thrombosis. It is possible that the benets of the reduced thromboembolic complications may be negated if thromboembolic prophylaxis is used . There was a tendency for more hypotension with regional anaesthesia. This may result in a predisposition to an increased incidence of cerebrovascular complications as hypotension is one of the aetiological factors for this complication. However, there are insufcient data to conrm this in this review and the care that needs to be taken in the interpretation of surrogate outcomes, such as hypotension, has already been mentioned (see start of Results). Juelsgaard 1998 specically targeted patients with known coronary artery disease. Whilst appropriate, the numbers of participants in the trial were too small to determine which type of anaesthesia is best for this specic patient population. None of the trials evaluated cost. Though regional anaesthesia is cheaper with respect to drug costs incurred during the administration of the anaesthetic, cost evaluation should cover the whole process. Light general anaesthesia combined with spinal anaesthesia versus general anaesthesia The sole study to address this question (White 1980) involved only 20 participants in each group. There was no statistically signicant difference between techniques for any of the outcome measures reported. Because of the small numbers of participants involved, no conclusions about the lack of difference between the two techniques can be made. Regional (spinal) anaesthesia versus local nerve blocks
The two included trials (de Visme 2000; Eyrolle 1998) involved only 79 participants in total. In addition there was incomplete reporting of outcomes and no follow up of trial participants. The limited results available suggest that the local nerve blocks are associated with a reduced risk of operative hypotension but have a greater risk of incomplete or unsatisfactory analgesia. Because of the limited information, no conclusions can be made on the use of nerve blocks compared with spinal anaesthesia.
Ketamine versus general anaesthesia The sole trial (Spreadbury 1980) comparing ketamine with general anaesthesia involved only 60 participants. The only key difference was a reduction in the 14-day mortality for ketamine, which related to a reduction in the risk of early fatal thromboembolic complications. However, this difference in mortality did not persist, and the mortality during hospital stay was equal in both groups. The numbers of participants were too small to show if the increase in unsatisfactory surgical results in the ketamine group was a signicant factor of ketamine use.
AUTHORS CONCLUSIONS Implications for practice

Overall, there was insufcient evidence available from randomised trials comparing regional versus general anaesthesia for hip fracture surgery to conrm or rule out clinically important differences. In addition, the relevance of evidence from older trials in the context of current anaesthetic and peri-operative practice is unclear. Based on the available evidence, regional anaesthesia may reduce acute postoperative confusion but no denite conclusions can be drawn for mortality or other outcomes. Due to the limited data available, it is not possible to determine the roles of nerve blocks, ketamine or spinal anaesthesia with light general anaesthesia for hip fracture anaesthesia.
Implications for research

Well designed randomised trials, with active follow up of at least six months, of regional versus general anaesthesia involving large numbers of patients and which record, at minimum, the primary clinical outcomes of death, postoperative complications, and long-term outcomes, would help clarify the relative merits of regional and general anaesthesia in contemporary health care practice. Large trials with subgroup analysis may be able to determine if patients with specic medical conditions (such as cardiac disease, previous stroke) are better managed with one of these two forms of anaesthesia.
13
Given the importance of assessing outcome based on what matters to patients, qualitative studies of patient preferences and values would inform this topic.
ACKNOWLEDGEMENTS
We thank Susan Urwin for her contribution as a co-reviewer to the original version of the review. We would like to thank the following for useful comments from editorial review of the original review: Gordon Drummond (Department of Anaesthetics, University of Edinburgh), William Gillespie, Rajan Madhok, Gordon Murray, Tom Pedersen (Department of Anaesthesiology, Copenhagen University Hospital) and Marc Swiontkowski. We thank William Gillespie, Leeann Morton and Lesley Gillespie for their help with the rst update. For the second update, we are grateful to Lesley Gillespie, William Gillespie, Peter Herbison, Leeann Morton, Tom Pedersen, Janet Wale and Tony Wildsmith for their assistance and helpful feedback at editorial review. For this update, we are very grateful to Jayne Elms, William Gillespie, Lesley Gillespie, Peter Herbison and Janet Wale of the Musculoskeletal Injuries Group, and Jane Ballantyne, John Carlisle, Jane Cracknell and Ann Moller of the Anaesthesia Group for their assistance and/or helpful and insightful feedback at editorial review. We are indebted to Lesley Gardner and Norifumi Kuratani for translations. Helen Handolls work on the rst two versions of the review was supported by the Chief Scientist Ofce, Department of Health, The Scottish Ofce, UK.
REFERENCES
References to studies included in this review

Adams 1990 {published data only} Adams HA, Wolf C, Michaelis G, Hempelmann G. Postoperative course and endocrine stress response of geriatric patients with fractured neck of femur [Postoperativer verlauf und endokrine strebreaktion geriatrischer patienten mit huftnahen frakturen; prospektivrandomisierte studie zum vergleich von spinalanasthesin und halothanintubatinosnarkosen]. Anasthesie, Intensivtherapie, Notfallmedizin 1990;25:26370. [MEDLINE: 1991023367] Berggren 1987 {published data only} Berggren D, Gustafson Y, Eriksson B, Bucht G, Hansson L-H, Reiz S, et al.Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Anesthesia and Analgesia 1987;66: 497504. [MEDLINE: 1987211148]
Biffoli 1998 {published data only} Biffoli F, Piacentino V, Meconcelli G, Guidi F, Dal Poggetto L, Bacci I, et al.The effect of anesthesiologic technique on the mental state of elderly patients submitted for orthopedic surgery of the lower limbs [Inuenza della condotta anestesiologica sullo stato mentale di soggetti anziani sottoposti a chirurgia ortopedica dellarto inferiore]. Minerva Anestesiologica 1998;64(1-2):139. Bigler 1985 {published data only} Bigler D, Adelhoj B, Petring OU, Pederson NO, Busch P, Kalhke P. Mental function and morbidity after acute hip surgery during spinal and general anaesthesia. Anaesthesia 1985;40:6726. [MEDLINE: 1985277121] Bredahl 1991 {published data only} Bredahl C, Hindsholm KB, Frandsen PC. Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and
14
general anaesthesia. Acta Anaesthesiologica Scandinavica 1991;35: 54852. [MEDLINE: 1991377412] Brichant 1995 {published data only} Brichant JF, Blom-Peters L, Buffels R, Lamy M. Central neural blockage failed to decrease deep venous thrombosis in patients undergoing hip surgery and receiving low molecular weight heparin. [Abstract]. British Journal of Anaesthesia 1995;74 Suppl 1:75. Brown 1994 {published data only} Brown AG, Visram AR, Jones RDM, Irwins MG, Bacon-Shone J. Preoperative and postoperative oxygen saturation in the elderly following spinal or general anaesthesia - an audit of current practice. Anaesthesia and Intensive Care 1994;22:1504. [MEDLINE: 1994270545] Casati 2003 {published data only} Casati A, Aldegheri G, Vinciguerra E, Marsan A, Fraschini G, Torri G. Randomized comparison between sevourane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery. European Journal of Anaesthesiology 2003;20 (8):6406. Couderc 1977 {published data only} Couderc E, Mauge F, Duvaldestin P, Desmonts J-M. Comparative results of general and peridural anesthesia for hip surgery in the very old patient. [Resultats comparatifs de lanesthesie generale et peridurale chez le grand vieillard dans la chirurgie de la hanche]. Anesthesie, Analgesie, Reanimation 1977;34(5):98798. [MEDLINE: 78185115] Davis 1981 {published data only} Davis FM, Laurenson VG. Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients. Anaesthesia and Intensive Care 1981;9:3528. [MEDLINE: 1982089249] Davis FM, Quince M, Laurenson VG. Deep vein thrombosis and anaesthetic technique in emergency hip surgery. BMJ 1980;281: 15289. Davis 1987 {published data only} Davis FM, Woolner DF, Frampton C, Wilkinson A, Grant A, Harrison RT, et al.Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. British Journal of Anaesthesia 1987;59:10808. [MEDLINE: 1988024611] de Visme 2000 {published data only} de Visme V, Picard F, Le Jouan R, Legrand A, Savry C, Morin V. Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly. Regional Anesthesia and Pain Medicine 2000;25(2):15862. Eyrolle 1998 {published data only} Eyrolle L, Zetlaoui P, Belbachir A, Rosencher N, Conseiller C. Regional anaesthesia for femoral neck fracture surgery: comparison of lumbar plexus block and spinal anaesthesia [Abstract]. British Journal of Anaesthesia 1998;80 Suppl 1:112. Juelsgaard 1998 {published data only} Juelsgaard P, Sand NP, Felsby S, Dalsgaard J, Jakobsen KB, Brink O, et al.Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, singledose spinal or general anaesthesia. European Journal of Anaesthesiology 1998;15(6):65663.
Kamitani 2003 {published data only} Kamitani K, Higuchi A, Asashi T, Yoshida H. Postoperative delirium after general anesthesia vs. spinal anesthesia in geriatric patients. Masui - Japanese Journal of Anesthesiology 2003;52(9): 9725. Maurette 1988 {published data only} Maurette P, Castagnera L, Vivier C, Erny P. Comparative repercussions of general and spinal anesthesia on psychological functions of the aged subject [Repercussions comparees de lanesthesie generale et de la rachianesthesie sur les fonctions psychiques du sujet age]. Annales Francaises d Anesthesie et de Reanimation 1988;7:3058. [MEDLINE: 89075140] McKenzie 1984 {published and unpublished data} McKenzie PJ, Wishard HY. Anaesthesia for fractured neck of femur (letter). BMJ 1981;282:399400. [MEDLINE: 81111251] McKenzie PJ, Wishart HY, Dewar KMS, Gray I, Smith G. Comparison of the effects of spinal anaesthesia and general anaesthesia on postoperative oxygenation and perioperative mortality. British Journal of Anaesthesia 1980;52:4953. [MEDLINE: 80198011] McKenzie PJ, Wishart HY, Gray I, Smith G. Effects of anaesthetic technique on deep vein thrombosis: a comparison of subarachnoid and general anaesthesia. British Journal of Anaesthesia 1985;57: 8537. [MEDLINE: 1985280155] McKenzie PJ, Wishart HY, Smith G. Long-term outcome after repair of fractured neck of femur; comparison of subarachnoid and general anaesthesia. British Journal of Anaesthesia 1984;56:5814. [MEDLINE: 1984203273] McLaren 1978 {published data only} McLaren AD. Mortality studies. A review. Regional Anesthesia 1982;7(Suppl 4):S1724. McLaren AD, Stockwell MC, Reid VT. Anaesthetic techniques for surgical correction of fractured neck of femur: a comparative study of spinal and general anaesthesia in the elderly. Anaesthesia 1978;33:104. [MEDLINE: 1978121768] Racle 1986 {published data only} Racle JP, Benkhadra A, Poy JY, Gleizal B, Gaudray A. Comparative study of general and spinal anesthesia in elderly women in hip surgery [Etude comparative de lanesthesie generale et de la rachianestesie chez la femme agee dans la chirurgie de la hanche]. Annales Francaises d Anesthesie et de Reanimation 1986;5:2430. [MEDLINE: 1986213298] Spreadbury 1980 {published data only} Spreadbury TH. Anaesthetic techniques for surgical correction of fractured neck of femur: a comparative study of ketamine and relaxant anaesthesia in elderly women. Anaesthesia 1980;35: 20814. [MEDLINE: 1980218116] Svarting 1986 {published data only} Svartling N, Lehtinen A-M, Tarkkanen, L. The effect of anaesthesia on changes in blood pressure and plasma cortisol levels induced by cementation with methylmethacrylate. Acta Anaesthesiologica Scandinavica 1986;30(3):24752. Tasker 1983 {published data only} Tasker TPB, Raitt DG, Kohn RLJ, Vater M, Crawshaw C. Subarachnoid block or general anaesthesia?: a study of the stress response during and after surgery for prosthetic replacement of
15
fractured neck of femur [abstract]. Journal of Bone and Joint Surgery. British Volume 1983;65:660. Ungemach 1993 {published data only} Ungemach JW, Andres FJ, Eggert E, Schoder K. The role of anaesthesia in geriatric patients with hip fractures: A prospective study. European Journal of Anaesthesiology. 1993; Vol. 10, issue 5: 380. Valentin 1986 {published data only} Valentin N, Lomholt B, Jensen JS, Hejgaard N, Kreiner S. Spinal or general anaesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients. British Journal of Anaesthesia 1986;58:28491. [MEDLINE: 1986131270] Wajima 1995 {published data only} Wajima Z, Kurosawa H, Inoue T, Yoshikawa T, Ishikawa G, Shitara T, et al.Changes in dementia rating scale scores of elderly patients with femoral neck fracture during perioperative period [Japanese]. Masui - Japanese Journal of Anesthesiology 1995;44(11):148997. White 1980 {published data only} White IW, Chappell WA. Anaesthesia for surgical correction of fractured femoral neck: a comparison of three techniques. Anaesthesia 1980;35:110710. [MEDLINE: 81083959]
Dyson 1988 {published data only} Dyson A, Henderson AM, Chamley D, Campbell ID. An assessment of postoperative oxygen therapy in patients with fractured neck of femur. Anaesthesia and Intensive Care 1988;16: 40510. El-Zahaar 1995 {published data only} El-Zahaar MS, Al-Kawally HM, Said AS. A double-blind randomized study of the effects of torniquet use and type of anesthetic techniques on the incidence of deep vein thrombosis (DVT) in orthopedic surgery. Journal of Neurological & Orthopaedic Medicine & Surgery 1995;16(2):704. Favarel 1996 {published data only} Favarel Garrigues JF, Sztark F, Petitjean ME, Thicoipe M, Lassie P, Dabadie P. Hemodynamic effects of spinal anaesthesia in the elderly: single dose versus titration through a catheter. Anesthesia and Analgesia 1996;82:3126. Hemmingsen 1991 {published data only} Hemmingsen C, Nielsen JE. Intravenous ketamine for prevention of severe hypotension during spinal anaesthesia. Acta Anaesthesiologica Scandinavica 1991;35(8):7557. Marhofer 1999 {published data only} Marhofer P, Faryniak B, Oismuller C, Koinig H, Kapral S, Mayer N. Cardiovascular effects of 6% hetastarch and lactated Ringers solution during spinal anesthesia. Regional Anesthesia & Pain Medicine 1999;24(5):388404. Matot 2003 {published data only} Matot I, Oppenheim-Eden A, Ratrot R, Baranova J, Davidson E, Eylon S, et al.Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology 2003;98(1):15663. Maurette 1993 {published data only} Maurette P, Bonada G, Djiane V, Erny P. A comparsion between lidocaine alone and lidocaine with meperidine for continous spinal anesthesia. Regional Anesthesia 1993;18:2905. Naja 2000 {published data only} Naja Z, el Hassan MJ, Khatib H, Ziade MF, Lonnqvist PA. Combined sciatic-paravertebral nerve block vs. general anaesthesia for fractured hip of the elderly. Middle East Journal of Anesthesiology 2000;15(5):55968. Nishikawa 2002 {published data only} Nishikawa K, Yamakage M, Omote K, Namiki A. Prophylactic IM small-dose phenylephrine blunts spinal anaesthesia-induced hypotensive response during surgical repair of hip fracture in the elderly. Anesthesia and Analgesia 2002;95(3):7516. Owen 1982 {published data only} Owen H, Hutton P. Doxapram and the fractured femur. Anaesthesia 1982;37:3014. Sinclair 1997 {published data only} Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 1997;315: 90912.
16
References to studies excluded from this review

Alonso Chico 2003 {published data only} Alonso Chico A, Cruz Pardos P, Alvarez Grau J, Pachoco Jimenez A, Arregui Martinez de Lejarza M, Sanchez Garcia ML, et al.Comparison of the hemodynamic response in subarachnoid anesthesia with bupivacaine versus bupivacaine with fentanyl in traumatology surgery in elderly patients [Comparacion de la respuesta hemodinamica en la anestesia subaracnoidea con bupivacaina frente a bupivacaina con fentanilo en cirugia traumatologica en ancianos]. Revista Espanola de Anestesiologia y Reanimacion 2003;50(1):1722. Barna 1981 {published data only} Barna B. Comparison of spinal and general anesthesia in the surgical treatment of hip fractures [A spinalis es az altalanos anaesthesia osszehasonlitasa csipotaji toresek multejeinek erzesteleniteseben]. Orvosi Hetilap 1981;122:11358. Ben-David 2000 {published data only} Ben-David B, Frankel R, Arzumonov T, Marchevsky Y, Volpin G. Minidose bupivacaine-fentanyl spinal anesthesia for surgical repair of hip fracture in the aged. Anesthesiology 2000;92(1):610. Coleman 1988 {published data only} Coleman SA, Boyce WJ, Cosh PH, McKenzie PJ. Outcome after general anaesthesia for repair of fractured neck of femur: a randomised trial of spontaneous v. controlled ventilation. British Journal of Anaesthesia 1988;60:437. Critchley 1995 {published data only} Critchley LA, Stuart JC, Conway F, Short TG. Hypotension during subarachnoid anaesthesia: haemodyamic effects of ephedrine. British Journal of Anaesthesia 1995;74:3738. Darling 1994 {published data only} Darling JR, Murray JM, Hainsworth AM, Trinick TR. The effect of isourane or spinal anesthesia on Indocyanine green disappearance rate in the elderly. Anesthesia and Analgesia 1994;78:7069.
Sutcliffe 1994 {published data only} Sutcliffe AJ, Parker MJ. Mortality after spinal and general anaesthesia for surgical xation of hip fractures. Anaesthesia 1994; 49:23740. Tonczar 1981 {published data only} Tonczar L, Hammerle AF. The impairment of stress parameters by hip joint close operations and the inuence of anaesthesia. Preliminary results of a prospective study (authors translation) [Auswirkungen huftgelenksnaher operationen auf das verhalten von stressparametern und ihre beeinussung durch anasthesie. Vorlauge ergebnisse einer prospektiven studie]. Unfallchirurgie 1981;7(3):13841. Ungemach 1987 {published data only} Ungemach JW. Inhalation anesthesia or balanced anesthesia?A comparative perioperative study in geriatric patients [Inhalationsanaesthesie oder balancierte anaesthesie ?: Eine vergleichende perioperative studie geriatrischer patienten]. Anaesthesist 1987;36:28891. Van Gessel 1989 {published data only} Van Gessel EF, Forster A, Gamulin Z. Surgical repair of hip fractures using continuous spinal anesthesia: comparison of hypobaric solutions of tetracaine and bupivaciane. Anesthesia and Analgesia 1989;68(3):27681. Wickstrom 1982 {published data only} Wickstrom I, Holmberg I, Stefansson T. Survival of female geriatric patients after hip fracture surgery. A comparison of 5 anesthetic methods. Acta Anaesthesiologica Scandinavica 1982;26:60714.
Carlisle 2004 Carlisle J. personal communication June 2004. Covert 1989 Covert CR, Fox GS. Anaesthesia for hip surgery in the elderly. Canadian Journal of Anaesthesia 1989;36:3119. Higgins 2003 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:55760. Higham 2001 Higham H, Mishra P, Foex P. Reduction of postoperative mortality and morbidity. Research into modern anaesthesia techniques and perioperative medicine is needed [multiple letters]. BMJ 2001;322 (7295):1182. Hughes 2000 Hughes JC, Barratt S, Jonathan R, Wilson T, Hollis S, Norris A, et al.Rapid responses to Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:1493-7. Available at: http://bmj.bmjjournals.com/cgi/content/full/321/ 7275/1493#responses (accessed 19/08/2004). Mansour 1993 Mansour NY. Reevaluating the sciatic nerve block: another landmark for consideration. Regional Anesthesia 1993;18:3223. McCullock 2001 McCulloch TJ, Loadsman JA. Reduction of postoperative mortality and morbidity. Little information was given on inclusion criteria [multiple letters]. BMJ 2001;322(7295):1182. Melton 1993 Melton LJ III. Hip fractures: a worldwide problem today and tomorrow. Bone 1993;14 Suppl 1:S18. Modig 1983 Modig J, Borg T, Bagge L, Saldeen T. Role of extradural and of general anaesthesia in brinolysis and coagulation after total hip replacement. British Journal of Anaesthesia 1983;55:625. Modig 1988 Modig J. Regional anaesthesia and blood loss. Acta Anaesthesiologica Scandinvica Supplementum 1988;89:448. Oxman 2001 Oxman AD. The Cochrane Collaboration in the 21st century: ten challenges and one reason why they must be met. In: Egger M, Davey Smith G, Altman DG editor(s). Systematic reviews in health care. Meta-analysis in context. 2nd Edition. London, UK: BMJ, 2001:45973. Parker 1993 Parker MJ, Pryor GA. Hip fracture management. Oxford: Blackwell Scientic Publications, 1993. Parker 2001 Parker MJ, Grifths R, Appadu BN. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures (Cochrane Review). Cochrane Database of Systematic Reviews 2001, Issue 3.[Art. No.: CD001159. DOI: 10.1002/14651858.CD001159]
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References to studies awaiting assessment

Dougall 1988 {published data only} Dougall JR, Caird FI, Wishart HY, Spence AA. Spinal versus general anaesthesia for patients with femoral neck fractures: studies of post-operative physical and mental well-being [abstract]. European Journal of Anaesthesiology 1988;5:52. Yao 1997 {published data only} Yao CZ, Zhang Z, Diao YC, Zhu C, Jin MC. Surgical repair of the fracture of neck of femur using spinal anesthesia with hypobaric bupivacaine [Original title in Chinese]. Chinese Journal of Anesthesiology 1997;17(5):3067.
Additional references
Alderson 2004a Alderson P, Green S, Higgins JPT, editors. MEDLINE highly sensitive search strategies for identifying reports of randomized controlled trials in MEDLINE. Cochrane Reviewers Handbook 4.2.2 [updated March 2004]; Appendix 5b. In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd. Oxford. Alderson 2004b Alderson P, Green S, Higgins JPT, editors. Quality assessment of studies. Cochrane Reviewers Handbook 4.2.2 [updated March 2004]; Section 6. In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.. Ballantyne 2004 Ballantyne J. personal communication June 13 2004.
Rodgers 2000 Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al.Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:14937. Sorensen 1992 Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures. A meta-analysis. Anesthesiology 1992;77:1095104. WHO study group 1994 WHO study group. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO; 1994 WHO technical report series no.: 843. Winnie 1974 Winnie AP, Ramamurthy S, Durrani Z, Radonjic R. Plexus blocks for lower extremity surgery. Anesthesiology Reviews 1974;1:116.
References to other published versions of this review

Urwin 2000 Urwin SC, Parker MJ, Grifths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. British Journal of Anaesthesia 2000;84(4):4505. Indicates the major publication for the study
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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Adams 1990 Methods Participants Quasi-randomised trial: by the date of operation Orthopaedic hospital in Gieben, Germany 56 patients with a proximal femoral fracture. Mean age 79/81 years (range 63-91). Male: 18% Number lost to follow-up: not stated Spinal anaesthesia using 0.5% bupivacaine and 4% mepivacaine versus General anaesthesia using halothane, nitrous oxide/oxygen, vecuronium, succinylcholine, atropine Length of follow up: period of hospital stay Mortality - during hospital stay Length of operation Hypotension Operative blood loss Transfusion requirements Length of hospital stay Blood levels of catecholamines, ADH and adrenaline (see notes) Pneumonia (f ) Congestive cardiac failure (f ) Renal failure Pulmonary embolism (f ) Published in German Abstract and diagrams are contradictory for endocrine (ADH, adrenalin)results
Interventions
Outcomes
Notes
Risk of bias Item Allocation concealment? Authors judgement No Description C - Inadequate
Berggren 1987 Methods Participants Randomised trial: method not stated Orthopaedic hospital in Umea, Sweden. 57 patients with a femoral neck fracture Mean age 77/78 years (range 65-92 years). Male: 19% Number lost to follow-up: 4 (7%)
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Berggren 1987
(Continued)
Interventions
Both groups premedicated with pethidine 25-50 mg. Spinal anaesthesia with 2% prilocaine in the epidural space, mean volume used 12.5 ml versus General anaesthesia with thiopentone 3-4 mg/kg, atropine 0.25-0.5 mg IV, succinylcholine ventilated with nitrous oxide and oxygen and halothane and succinylcholine infusion Length of follow up: 12 months Mortality - 1 year (see notes) Length of operation Operative hypotension Intraoperative blood loss (not split by treatment groups) Hypoxaemia Length of hospital stay Pneumonia Cerebrovascular accident Congestive cardiac failure Confusional state Urine retention Urinary tract infection Pulmonary embolism Total medical complications 4 died by 1 year, 1 in the epidural group on 1st post-op day, the other 3 (group not given) by 5 months. Patients were interviewed at 6 and 12 months regarding living conditions and walking ability - data not presented.
Outcomes
Notes
Risk of bias Item Allocation concealment? Biffoli 1998 Methods Participants Randomised trial: method not stated District hospital in Italy. 60 patients with a femoral neck fracture aged 70 years and above Mean age 83 years (range not stated) Male: 13% Number lost to follow-up: probably none Spinal anaesthesia with a mean dose of 12.7 mg hyperbaric bupivacaine 1% versus General anaesthesia with propofol 1 mg/kg, atracurium besilate 0.5 mg/kg, nitrous oxide, isourane, atracurium infusion of 0.5 mg/kg/hr and fentanyl [fentanile] 1 ug/kg as required Authors judgement Unclear Description B - Unclear
Interventions
20
Biffoli 1998
(Continued)
Outcomes
Length of follow up: 2 days Length of operation (intervention) Operative hypotension Postoperative hypoxia Confusional state In Italian. Patient group split into 2 groups depending on preoperative mental state: 38 who were not confused and 22 who were.
Notes
Risk of bias Item Allocation concealment? Bigler 1985 Methods Participants Randomised trial: method not stated Place and country of study not stated 40 patients with a proximal femoral fracture Mean age 79 years. Male: 17.5% Loss to follow-up: not known Spinal anaesthesia with 3 ml of 0.75% bupivacaine versus General anaesthesia using atropine, fentanyl, pancuronium, nitrous oxide/oxygen, diazepam and suxamethonium Length of follow up: 3 months Mortality - early Length of operation Hypotension (maximum drop in systolic blood pressure) Transfusion requirements Fall in haemoglobin Pneumonia Cerebrovascular accident Congestive cardiac failure Confusional state Urine retention Postoperative vomiting Pulmonary embolism Time till ambulation Mental function Headache Authors judgement Unclear Description B - Unclear
Interventions
Outcomes
21
Bigler 1985
(Continued)
Notes Risk of bias Item Allocation concealment? Bredahl 1991 Methods Participants Randomised trial: method not stated Orthopaedic hospital Aalborg, Denmark 30 female patients with a proximal femoral fracture Mean age 79 years (range 60-90). Male: 0% Loss to follow-up: not stated, but 2 excluded due to incomplete data. Spinal anaesthesia with 2.5-3 ml of 0.5% bupivacaine versus General anaesthesia using thiopentone, pethidine, pancuronium, nitrous oxide/oxygen, IPPV, and suxamethonium Length of follow up: 3 days Length of operation Operative blood loss Change in body temperature (up to 3 hours) Authors judgement Unclear Description B - Unclear
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Brichant 1995 Methods Participants Randomised trial: method not stated Orthopaedic hospital in Brussels, Belgium 106 patients with proximal femoral fracture Age: not stated. Male: % not stated Number lost to follow-up: not stated Authors judgement Unclear Description B - Unclear
22
Brichant 1995
(Continued)
Interventions
Spinal (subarachnoid or epidural) anaesthesia with bupivacaine versus General anaesthesia administered according to local practice Length of follow up: 10 days Deep vein thrombosis (venography) Pulmonary embolism Haemorrhagic complications Thrombocytopenia Conference abstract only All patients had subcutaneous nadroparin for DVT prophylaxis
Outcomes
Notes
Risk of bias Item Allocation concealment? Brown 1994 Methods Participants Randomised trial: use of random numbers table Orthopaedic hospital in Hong Kong 20 patients with a proximal femoral fracture Mean age 77 years (range 66-91). Male: 50% Number lost to follow-up: not stated Pre-medication with pethidine or temazepam Spinal (subarachnoid)anaesthesia with 0.2 mg/kg hyperbaric bupivacaine versus General anaesthesia using thiopentone or propofol, isourane or enurane, atracurium and nitrous oxide/ oxygen Length of follow up: 2 days (up to 44 hours) Hypotension Oxygen saturation Authors judgement Unclear Description B - Unclear
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Authors judgement Unclear Description B - Unclear
23
Casati 2003 Methods Participants Randomised trial: by sealed envelopes Orthopaedic hospital in Milan, Italy 30 patients of ASA grade II or III undergoing hemiarthroplasty for a proximal femoral fracture. Mean age 84 years (range 67-94). Male: 7% Number lost to follow-up: 0 Spinal anaesthesia with 7.5 mg of hyperbaric bupivacaine versus General anaesthesia with sevourane inhalation and laryngeal mask airway Length of follow up: 7 days & hospital discharge Length of operation Operative blood loss Operative hypotension Bradycardia Time in theatre recovery department Mini mental test score (day 1 and 7) Confusion (day 7) Pain Length of hospital stay Fentanyl (1 ug/kg) given before induction of either general or spinal anaesthesia
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Couderc 1977 Methods Participants
Authors judgement Unclear
Description B - Unclear
Randomised study: by drawing of lots Orthopaedic hospital in Paris, France 100 patients with a proximal femoral fracture Mean age 86 years. (Inclusion criterion: 80+ years; range not stated). Male: 14% Number lost to follow-up: not stated Spinal anaesthesia with 0.5% bupivacaine and adrenaline versus General anaesthesia with thiopentone, pancuronium or succinylcholine, dextromoramide or methoxyurane, nitrous oxide/oxygen Length of follow up: 3 months Mortality - 11 days, 3 months
24
Interventions
Outcomes
Couderc 1977
(Continued)
Hypotension Transfusion requirements Oxygenation and carbon dioxide levels Myocardial infarction (f ) Cerebrovascular accident (f ) Pulmonary embolism (f ) Notes In French Complete data for fatal myocardial infarction, congestive heart failure and pulmonary embolism not provided.
Risk of bias Item Allocation concealment? Davis 1981 Methods Participants Randomised trial: method not stated Orthopaedic hospital Christchurch, New Zealand 132 patients with a proximal femoral fracture Mean age 81/78 years (Inclusion criterion: 50+, range not given). Male: 15% Number lost to follow-up: 0 Spinal anaesthesia using tetracaine 0.5% in 51 patients and 0.5% cinchocaine in 13 patients. Ketamine also used for sedation in 8 patients. Sedation also provided with diazepam (mean dose 9 mg) versus General anaesthesia with diazepam (2.5-30 mg) mean dose 9.5 mg, fentanyl 1-3 ug/kg, nitrous oxide and oxygen, IPPV, pancuronium (mean dose 6 mg) Length of follow up : 1 month Mortality - 1 month Duration of anaesthesia (Length of operation) Postoperative blood gases Hypotension Operative blood loss Fall in haematocrit Pneumonia (f ) Aspiration pneumonia (f ) Myocardial infarction (f ) Cerebrovascular accident Congestive cardiac failure Renal failure Cardiac arrhythmias Deep vein thrombosis (brinogen)
25
Interventions
Outcomes
Davis 1981
(Continued)
Pulmonary embolism (f ) Notes 8 failed spinals who had a general anaesthesia were placed in the general anaesthesia group. Results for DVT were available for 76 out of a subgroup of 90 patients who were monitored using I125 brogen scanning
Risk of bias Item Allocation concealment? Davis 1987 Methods Participants Randomised trial: method not stated Orthopaedic hospitals in New Zealand - multicentre study 549 patients with a proximal femoral fracture Mean age 79.5 years (range not stated). Male: 22% Number lost to follow-up: 0, but 11 excluded Spinal anaesthesia with sedation with diazepam. Tetracaine, nupercaine or bupivacaine for spinal versus General anaesthesia with pre-oxygenation, IV induction with thiopentone, IPPV maintained with nitrous oxide/oxygen, non-depolarizing neuromuscular blocker, fentanyl Length of follow up: 3 to 30 months Mortality - 1 month, 3 & 6 months (estimated from graph) Hypotension Length of hospital stay Pneumonia (f ) Myocardial infarction (f ) Cerebrovascular accident (f ) Congestive cardiac failure (f ) Renal failure (f ) Pulmonary embolism (f ) 11.3% of patients originally allocated to spinal anaesthesia were given general anaesthesia due to failed spinals. These were retained in the spinal group for analysis purposes. There was 1 non fatal anaphylactoid reaction at induction of general anaesthesia Authors judgement Unclear Description B - Unclear
Interventions
Outcomes
Notes
Risk of bias Item Allocation concealment? Authors judgement Unclear Description B - Unclear
26
de Visme 2000 Methods Participants Randomised trial: method by hospital pharmacy before transfer to the operating theatre Orthopaedic hospital in Brest, France 29 patients with a proximal femoral fracture Mean age 85 years (range 68-97). Male: 17% Number lost to follow-up: none Spinal anaesthesia with sedation using alfentanil and 3 ml 0.5% plain bupivacaine for the spinal versus Lumber plexus, sacral plexus and iliac crest block rst with sedation using alfentanil. 30 ml and 10 ml of 1.33% lidocaine and adrenaline [epinephrine] were used for the lumbar and sacral blocks and 5 ml 1% lidocaine for the iliac crest block (for lateral cutaneous nerve) Length of follow up: not stated but probably 5 days Length of operation Time to perform the anaesthetic Hypotension Use of adrenaline [epinephrine] during surgery Postoperative cognitive function Pain levels in the recovery room Need for supplementation of analgesia
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Eyrolle 1998 Methods Participants Randomised trial: method not stated Orthopaedic hospital in Paris, France 50 patients with a proximal femoral fracture Mean age 82 years (range not stated) Male: % not stated Number lost to follow-up: none probably Spinal anaesthesia with 0.5% bupivacaine versus lumber plexus block using 2% lidocaine, 0.5% bupivacaine with 1:200,000 epinephrine. A light sedation with propofol intravenously, as required Length of follow up: not stated Ease of insertion Hypotension
27
Interventions
Outcomes
Eyrolle 1998
(Continued)
Use of propofol during surgery (associated with discomfort) Use of epinephrine during surgery Postoperative cognitive function Pain levels post-operatively Adverse effects (including urinary retention) Notes Risk of bias Item Allocation concealment? Juelsgaard 1998 Methods Participants Randomised trial: method not stated Orthopaedic hospital in Aarhus, Denmark 29 followed-up out of 54 patients with proximal femoral fracture and known coronary artery disease For 29 patients included in this review: Age: mean 80.9 years (range 65-99) Male: 13% Number lost to follow-up: 0, but 11 excluded from original trial population Spinal anaesthesia with 2.5 ml of 0.5% bupivacaine in the subarachnoid space versus General anaesthesia with fentanyl 1-2 mcg/kg, 1-4 mg/kg thiopentone, 0.5 mg/kg atracurium, nitrous oxide and oxygen, enurane Length of follow up: 1 month Mortality - 1 month Length of operation Hypotension (33% reduction from baseline) Peri- and postoperative blood loss Transfusion requirements Pneumonia (f ) Congestive cardiac failure (f ) Myocardial infarction ECG analysis Length of hospital stay The study also included 14 patients allocated to incremental spinal anaesthesia. These patients have not been included in this review Authors judgement Unclear Description B - Unclear Conference abstract only
Interventions
Outcomes
Notes
Risk of bias Item Authors judgement Description

28
Juelsgaard 1998
(Continued)
Allocation concealment? Kamitani 2003 Methods Participants
Unclear
B - Unclear
Randomised trial: method not stated 40 patients with a femoral neck fracture Mean age 82 years (range - not stated). Male: 10% Number lost to follow-up: 0 Spinal anaesthesia with 3 ml of 0.5% isobaric bupivacaine versus General anaesthesia with propofol (0.5-1 mg), vecuronium (0.5-1 mg/kg), nitrous oxide, sevourane and fentanyl (0.1-0.2 mg/kg) and local eld block with local anaesthesia Length of follow up: 4 days Length of surgery Length of anaesthesia Intraoperative blood loss Transfusion requirements Haemoglobin Urine output Oxygen saturation Delirium (day 1,2,3 & 4) Analgesic use In Japanese
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Maurette 1988 Methods Participants
Randomised trial: by random draw Orthopaedic hospital Bordeaux, France 35 patients with a proximal femoral fracture Mean age 83 years (range not stated). Male: % not stated Number lost to follow-up: not stated, but 2 excluded as they failed to participate in post-op tests
29
Maurette 1988
(Continued)
Interventions
Spinal anaesthesia with 1.5 mg/kg prilocaine versus General anaesthesia using thiopentone, spontaneous ventilation, nitrous oxide/oxygen, enurane, dextromoramide Length of follow up: 3 days Length of operation Hypotension Transfusion requirements Psychological evaluation In French
Outcomes
Notes Risk of bias Item Allocation concealment? McKenzie 1984 Methods Participants
Randomised trial: use of envelopes containing random numbers Orthopaedic hospital in Glasgow, Scotland 150 patients with fractured neck of femur. Mean age 75 years (range not stated). Male: % not stated Number lost to follow-up: 0, but 2 excluded due to postponement of operation Spinal anaesthesia with 0.5% hyperbaric cinchocaine 1.3-1.5 ml. Supplemented by small doses of diazepam if required versus General anaesthesia induced with althesin 1-3 ml, suxamethonium 50 mg, nitrous oxide and oxygen, halothane and spontaneous respiration Length of follow up: 12 months Mortality - at 1, 3, 6 and 12 months Length of operation Operative blood loss Length of hospital stay Pneumonia (f ) Myocardial infarction (f ) Cerebrovascular accident (f ) Deep vein thrombosis (venography) Pulmonary embolism (f ) Location at 12 months
Interventions
Outcomes
30
McKenzie 1984
(Continued)
Notes
Additional information supplied by Dr McLaren indicated that all the references refered to one study. Additional data on mortality supplied. The venography study for DVT detection involved a subgroup of 40 patients
Risk of bias Item Allocation concealment? Authors judgement Yes Description A - Adequate
McLaren 1978 Methods Participants Randomised trial: method not stated Orthopaedic hospital in Glasgow, Scotland 116 patients with fractured neck of femur Mean age 76 years. Male: % not stated. Number lost to follow-up: none for the original report of 55 cases. Loss to follow up not reported in the later study report (1982) of 116 cases. No premedication Spinal anaesthesia with 0.5 ml hyperbaric cinchocaine 0.5%. Patients sedated with 10% althesin in 5% dextrose during operation. versus General anaesthesia with althesin 50 mcg/kg, pancuronium bromide 0.1 mg/kg, IPPV, nitrous oxide, oxygen and fentanyl 0.05 mg as needed Length of follow up: 1 month minimum Mortality - 1 month Length of operation Hypotension Postoperative oxygenation Blood loss Pneumonia (f ) Vomiting Myocardial infarction (f ) Renal failure (f ) Deep vein thrombosis (f ) Pulmonary embolism (f ) Headache (none) The original paper in 1978 reported the results for 55 cases. A later report in 1982 of the same study gave the outcome for 116 patients. The latter report was used for the outcomes of mortality at one month, fatal pneumonia, fatal pulmonary embolism, fatal renal failure and fatal myocardial infarction. The original paper was used for the other outcomes for 55 patients. The methodology assessment was based on the 1978 report.
Interventions
Outcomes
Notes
31
McLaren 1978
(Continued)
Risk of bias Item Allocation concealment? Racle 1986 Methods Participants Randomised study: use of random numbers table Orthopaedic hospital in Cedex, France. 70 female patients with a proximal femoral fracture Mean age: 82 years (Inclusion criterion: 75+, range not given). Male: 0% Number lost to follow-up: not stated Spinal anaesthesia with 3 ml 0.5% bupivacaine + adrenaline versus General anaesthesia using thiopentone, vecuronium, fentanyl, nitrous oxide/oxygen, enurane Length of follow up: 3 months Mortality - 1, 3 months Length of operation Hypotension Transfusion requirements Length of hospital stay Pneumonia Myocardial infarction Cerebrovascular accident (f ) Congestive cardiac failure Renal failure (f ) Confused state Pulmonary embolism In French Authors judgement Unclear Description B - Unclear
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment?
32
Spreadbury 1980 Methods Participants Randomised: method not stated Orthopaedic hospital in Warwick, England 60 female patients with a proximal femoral fracture Mean age 84 years (range not stated). Male: % not stated Number lost to follow-up: none Ketamine anaesthesia using atropine pre-medication: ketamine 2 mg/kg at induction then ketamine 1 mg/kg as required. Also optional diazepam versus General anaesthesia using premedication of atropine 0.6 mg then a general anaesthetic using drugs and method chosen by the anaesthetist Length of follow up: not stated Mortality - 14 days, during hospital stay Myocardial infarction (f ) Congestive cardiac failure (f ) Pulmonary embolism (f ) Time to mobilisation Length of hospital stay Return of patients back home Occurrence of dreams or hallucinations after operation Unsatisfactory surgical results
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Svarting 1986 Methods Participants Randomised trial: method not stated University hospital in Helsinki, Finland 30 patients with a proximal femoral fracture treated with a Thompson prosthesis. (ASA grade II OR III.) Mean age 77 years (range not stated). Male: 13% Number lost to follow-up: none likely Both groups premedicated with pethidine and atropine Spinal anaesthesia using 3 ml of 0.5% isobaric bupivacaine into the subarachnoidal space versus General anaesthesia using fentanyl, thiopental, pancuronium bromide, nitrous oxide/oxygen, then atropine and neostigmine
33
Interventions
Svarting 1986
(Continued)
Outcomes
Length of follow up: not stated Length of operation Hypotension Operative blood loss Transfusion requirements Arterial oxygen tension Plasma cortisol levels Emphasis in the article on the connection of the results with the use of methylmethacrylate cement for the Thompson prosthesis
Notes
Risk of bias Item Allocation concealment? Tasker 1983 Methods Participants Randomised trial: method not stated Orthopaedic hospital in Leicester, England 100 patients with a proximal femoral fracture. Mean age not stated. Male: % not stated Number lost to follow-up: not stated Spinal versus general anaesthesia Exact method of anaesthesia not stated Length of follow up: not stated Mortality Plasma catecholamines, cortisol Conference abstract only Authors judgement Unclear Description B - Unclear
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Ungemach 1993 Methods
Randomised trial: method not stated, mention of pairs
34
Ungemach 1993
(Continued)
Participants
Orthopaedic hospital in Mannheim, Germany 114 patients with a proximal femoral fracture. Mean age 79 years (range not stated). Male: 16% Number lost to follow-up: not stated Spinal anaesthesia with 3-4 ml of 0.5% hyperbaric bupivacaine versus General anaesthesia with isourane, fentanyl, nitrous oxide/oxygen Length of follow up: 2 weeks Mortality - 2 weeks Score based on conscious level, respiration, circulation, blood lost and laboratory tests taken at 2 hours. Score based on lab tests, cardiopulmonary situation and complications (e.g. heart failure, thrombosis and apoplexy) at 2 weeks post-operatively Conference abstract only
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Valentin 1986 Methods Participants
Randomised trial: method not stated Orthopaedic hospital in Hellerup, Denmark 662 patients with a proximal femoral fracture Mean age 79 years (range 50 - 100). Male: 20% Number lost to follow-up: 2 (0.3%), 84 patients excluded Spinal anaesthesia with 3-4 ml isotonic bupivacaine and sedation with fentanyl 0.05-0.1 mg IV versus General anaesthesia with enurane and nitrous oxide/oxygen with or without thiopentone at induction or neurolept anaesthesia with droperidol, fentanyl and nitrous oxide/oxygen Length of follow up: 24 months Mortality - 1 month, 3, 6 and 12 months (read from graphs) Length of operation Operative blood loss Time to ambulation Length of hospital stay
Interventions
Outcomes
Notes
Anaesthesia for hip fracture surgery in adults (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 35
Valentin 1986
(Continued)
Risk of bias Item Allocation concealment? Wajima 1995 Methods Participants Randomised trial: method not stated Hospital in Higashine, Japan 41 patients with a femoral neck fracture Mean age 80 (range: inclusion criteria ages 70-90 years). Male: 22% Number lost to follow-up: Probably none Spinal anaesthesia with continuous infusion of bupivacaine and butorphanol for 72 hours postoperatively versus General anaesthesia with thiopental, succinylcholine, nitrous oxide and sevourane Length of follow up: 1 week Hasegawa dementia scale score(presented graphically) In Japanese Authors judgement Unclear Description B - Unclear
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? White 1980 Methods Participants
Randomised trial: method not stated Orthopaedic hospital in Cape Town, South Africa 40 of 60 patients in trial with a proximal femoral fracture. Mean age 79 years (range not stated). Male: 8% Number lost to follow-up: 0 Spinal anaesthesia with 0.6-0.8 ml hyperbaric cinchocaine and light general anaesthesia with althesin, fentanyl, nitrous oxide/oxygen versus General anaesthesia with thiopentone, suxamethonium, nitrous oxide/oxygen, halothane, fentanyl versus Psoas nerve block with 30 ml 2% mepivacaine and light general anaesthesia with fentanyl and althesin
36
Interventions
White 1980
(Continued)
(not included in review) Outcomes Length of follow up: minimum 4 weeks Mortality - 1 month Length of operation Postoperative blood gases (oxygen and carbon dioxide) Pneumonia Confusional state Deep vein thrombosis Vomiting The 20 Psoas nerve block group patients were not included in this review
Notes Risk of bias Item Allocation concealment?
(f ): Fatal - outcomes, such as pneumonia, only reported as a reason for death ABBREVIATIONS ASA : American Society of Anaesthetists IPPV: intermittent positive pressure ventilation IV: intravenous
Characteristics of excluded studies [ordered by study ID]
Alonso Chico 2003
This randomised trial of 60 hip fracture patients compared spinal anaesthesia with bupivacaine and fentanyl versus bupivacaine alone. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia. Translation of the article from Hungarian revealed it is a comparative study of 100 spinal anaesthetics and 100 general anaesthetics for hip fracture patients. The study was excluded as there was no randomisation of patients. This randomised trial of 20 hip fracture patients compared spinal anaesthesia with bupivacaine and fentanyl versus bupivacaine alone. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia. A randomised trial of 152 patients comparing general anaesthesia with spontaneous respiration with general anaesthesia with controlled ventilation. The study was excluded as it involved a change in the types of drugs used only, not a change in the method of anaesthesia.
Barna 1981
Ben-David 2000
Coleman 1988
37
(Continued)
Critchley 1995
A randomised trial of 30 hip fracture patients comparing spinal anaesthesia with ephedrine alone or with ephedrine and colloid. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia. A randomised trial of 10 patients with spinal anaesthetic and 10 with general anaesthesia to assess the rate of clearance of a bolus dose of Indocyanine green between the two anaesthetic techniques. There was no difference in the rate of disappearance of the indocyanine green between the two techniques and no other outcomes were reported. The study was excluded as it was not felt relevant to this review as no clinical outcomes were reported. A randomised trial of 60 patients which tested the use of postoperative oxygen in two groups that had already been divided into those receiving general anaesthesia and those receiving spinal anaesthesia. No results were provided for the anaesthetic comparison save the general statement that there was no statistical difference in mean oxygen tensions between the two anaesthesia groups. The trial was excluded due to the lack of outcome data for the anaesthesia comparison. This study was a randomised comparison of general versus epidural anaesthesia in 214 patients undergoing either hip or femoral surgery (117 patients), or tibial surgery (97 patients). This trial was excluded because separate results for patients having surgery for a hip fracture were not presented. A randomised trial of 60 hip fracture patients comparing the haemodynamic effects of a single dose of spinal bupivacaine versus a continuous titrated dose. Outcome measures were the onset of anaesthesia and haemodynamic variables. The trial was excluded as it was not considered a comparison of different forms of anaesthesia, only of a modication of anaesthetic technique. A trial of 30 patients having osteosynthesis of a hip fracture under spinal anaesthesia. They were randomised to receive either ketamine or fentanyl intravenously during the procedure. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia. This randomised trial of 24 hip fracture patients compared 500 ml of intravenous hetastarch with 1500 ml of lactated Ringers solution given preoperatively. All patients received spinal anaesthesia. The study was excluded as it was not a comparison of anaesthetic methods. This study involved 68 patients with hip fractures who either had known coronary artery disease or were at high risk for coronary artery disease. Patients were randomised to receive a usual care analgesic regimen or intramuscular meperidine, or continuous epidural infusion of local anaesthetic and opiate. The study was excluded as it compared techniques outside the scope of this review. A randomised trial of 34 hip fracture patients comparing continuous spinal anaesthesia with lidocaine alone versus lidocaine with meperidine. The trial was excluded as it was a trial of different drugs with the same anaesthetic technique, not a comparison of different types of anaesthesia. This trial compared 30 patients who selected general anaesthesia with 30 who selected a nerve stimulator guided combined sciatic-paravertebral nerve block. All patients had hip fracture surgery. The study was excluded as there was no randomisation of patients. This was a trial of 90 patients having hip fracture surgery under spinal anaesthesia. Patients were randomised to receive intramuscular phenylephrine or saline. It was excluded as it was not a comparison of different types of anaesthesia.
38
Darling 1994
Dyson 1988
El-Zahaar 1995
Favarel 1996
Hemmingsen 1991
Marhofer 1999
Matot 2003
Maurette 1993
Naja 2000
Nishikawa 2002
(Continued)
Owen 1982
A randomised trial of a single dose of doxapram on the post-operative arterial oxygen tension in hip fracture patients. The trial was excluded as it was not a comparison of anaesthetic techniques. A randomised trial of 40 patients with a hip fracture surgically treated under general anaesthesia. Patients were randomised to have either conventional intra-operative uid management or colloid uid challenges. The study was excluded as it was not a comparison of different types of anaesthesia. A comparative study of 1333 patients with general versus spinal anaesthesia. The study was excluded as there was no randomisation of patients. A randomised trial of 14 patients comparing neuroleptic anaesthesia with spinal anaesthesia. The study was excluded as it involved a neuroleptic anaesthesia and the only outcome measures were plasma catecholamines, cortisol, blood pressure and changes in heart rate. A randomised trial of 50 hip fracture patients using either enurane or enurane and fentanyl. The trial was excluded as it was a comparison of different drugs within one type of anaesthesia (general anaesthesia)and not a comparison of different anaesthetic techniques. A randomised trial of 30 hip fracture patients comparing spinal anaesthesia with either hypobaric tetracaine or hypobaric bupivacaine. The trial was excluded as it was a not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia. This was a report of two quasi-randomised trials (based on dates of birth) with a month in-between, reported as one study. The rst study compared epidural versus ketamine intravenous infusion versus neurolept general anaesthesia in 129 hip fracture patients. The second study compared enurane general anaesthesia versus halothane general anaesthesia in 40 hip fracture patients. The rst study was excluded as it was considered that neuroleptic anaesthesia was no longer applicable or relevant for hip fracture surgery. A comparison of nonconcurrent treatment groups was also not considered appropriate. The second study was excluded as it was a comparison of different drugs within one type of anaesthesia (general anaesthesia)and not a comparison of different anaesthetic techniques.
Sinclair 1997
Sutcliffe 1994
Tonczar 1981
Ungemach 1987
Van Gessel 1989
Wickstrom 1982
39
DATA AND ANALYSES
Comparison 1. Regional (spinal or epidural) versus general anaesthesia

No. of studies 8 8 6 3 2 11 8 11 11 5 4 4 2 2 9 6 3 6 4 2 7 4 3 7 3 4 5 3 2 5 2 2 No. of participants 1668 1668 1491 1264 726 1878 446 1022 1022 378 258 243 117 218 1186 1019 167 1033 934 99 1085 856 229 931 623 308 912 724 188 237 97 95
Outcome or subgroup title 1 Mortality - 1 month 2 Mortality - 1 month (random effects model) 3 Mortality - 3 months 4 Mortality - 6 months 5 Mortality - 12 months 6 Mortality - early and up to 1 month 7 Length of operation (mins) 8 Operative hypotension 9 Operative hypotension (random effects model) 10 Operative blood loss (ml) 11 Patients receiving blood transfusion 12 Transfusion requirements (ml) 13 Postoperative hypoxia 14 Length of hospital stay 15 Pneumonia 15.1 Fatal (reason for death only) 15.2 Other (non fatal or fatal) 16 Myocardial infarction 16.1 Fatal (reason for death only) 16.2 Other (non fatal or fatal) 17 Cerebrovascular accident 17.1 Fatal (reason for death only) 17.2 Other (non fatal or fatal) 18 Congestive cardiac failure 18.1 Fatal (reason for death only) 18.2 Other (non fatal or fatal) 19 Renal failure 19.1 Fatal (reason for death only) 19.2 Other (non fatal or fatal) 20 Acute confusional state 21 Urine retention 22 Vomiting
Statistical method Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Random, 95% CI) Mean Difference (IV, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size 0.69 [0.50, 0.95] 0.68 [0.44, 1.05] 0.92 [0.71, 1.21] 1.04 [0.81, 1.33] 1.07 [0.82, 1.41] 0.73 [0.54, 0.99] 0.76 [-5.37, 6.90] 1.30 [1.08, 1.55] 1.10 [0.79, 1.55] -85.28 [-161.95, 8.61] 0.95 [0.77, 1.17] 99.75 [-52.99, 252.48] 0.67 [0.36, 1.22] -0.21 [-5.21, 4.78] 0.76 [0.44, 1.30] 1.00 [0.52, 1.94] 0.42 [0.16, 1.13] 0.55 [0.22, 1.37] 0.44 [0.13, 1.50] 0.76 [0.20, 2.96] 1.51 [0.64, 3.57] 1.22 [0.40, 3.71] 2.07 [0.53, 8.06] 1.05 [0.49, 2.23] 1.34 [0.44, 4.10] 0.85 [0.30, 2.40] 0.76 [0.23, 2.49] 0.79 [0.18, 3.46] 0.72 [0.10, 5.13] 0.50 [0.26, 0.95] 1.02 [0.47, 2.23] 0.70 [0.12, 3.94]
40
23 Deep vein thrombosis 23.1 Fatal (underlying reason for death only) 23.2 Other: venography diagnosis 23.3 Other: brinogen scan diagnosis 24 Pulmonary embolism (Peto odds ratio plot - showing heterogeneity) 25 Pulmonary embolism (random effects model) 26 Pulmonary embolism (fatal and non-fatal) 26.1 Fatal (reason for death only) 26.2 Non fatal
4 1 2 1 9
259 55 128 76 1245
Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Peto Odds Ratio (Peto, Fixed, 95% CI)
0.64 [0.48, 0.86] 0.22 [0.01, 4.43] 0.72 [0.47, 1.11] 0.60 [0.40, 0.88] 0.72 [0.31, 1.69]
9 9 6 4
1245
Risk Ratio (M-H, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
0.88 [0.32, 2.39] Subtotals only 0.43 [0.17, 1.10] 3.46 [0.74, 16.29]
1030 255
Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Comparison 2. Spinal and light general anaesthetic versus general anaesthetic
Outcome or subgroup title 1 Mortality - 1 month 2 Length of operation 3 Pneumonia 4 Confusional state 5 Deep vein thrombosis
No. of studies 1 1 1 1 1
No. of participants
Statistical method Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size Totals not selected Totals not selected Totals not selected Totals not selected Totals not selected
Comparison 3. Regional (spinal or epidural) versus lumbar plexus nerve blocks
Outcome or subgroup title 1 Incomplete or unsatisfactory analgesia 1.1 Regional (spinal) block versus lumbar plexus block 1.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block 2 Operative hypotension 2.1 Regional (spinal) block versus lumbar plexus block 3 Mean fall in arterial blood pressure (mmHg)
No. of studies 2 1 1
No. of participants 79 50 29
Statistical method Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size 0.23 [0.10, 0.50] 0.26 [0.12, 0.59] 0.10 [0.01, 1.61]
1 1 1
Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)
Totals not selected Not estimable Totals not selected

41
3.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block 4 Mean dose of ephedrine used (mg) 4.1 Regional (spinal) block versus lumbar plexus block 4.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block 5 Adverse effects 5.1 Regional (spinal) block versus lumbar plexus block 5.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block 6 Postoperative confusion 6.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block
Mean Difference (IV, Fixed, 95% CI)
Not estimable
2 1 1
79 50 29
Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)
5.96 [4.46, 7.45] 5.8 [4.28, 7.32] 10.0 [2.24, 17.76]
2 1 1
Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected Not estimable Not estimable
1 1
Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected Not estimable
Comparison 4. Intravenous ketamine versus general anaesthesia
Outcome or subgroup title 1 Mortality - during hospital stay 2 Myocardial infarction 3 Congestive cardiac failure 4 Pulmonary embolism 5 Length of hospital stay (discharge home)
No. of studies 1 1 1 1 1
No. of participants
Statistical method Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)
Effect size Totals not selected Totals not selected Totals not selected Totals not selected Totals not selected
42
Analysis 1.1. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 1 Mortality 1 month.
Review: Anaesthesia for hip fracture surgery in adults
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 1 Mortality - 1 month
Study or subgroup
Regional n/N
General n/N 0/29 9/68 16/279 2/14 13/75 17/60 5/35 24/297
Risk Ratio M-H,Fixed,95% CI
Weight
Berggren 1987 Davis 1981 Davis 1987 Juelsgaard 1998 McKenzie 1984 McLaren 1978 Racle 1986 Valentin 1986
1/28 3/64 17/259 4/15 8/73 4/56 2/35 17/281
0.6 % 10.4 % 18.3 % 2.5 % 15.2 % 19.5 % 5.9 % 27.7 %
3.10 [ 0.13, 73.12 ] 0.35 [ 0.10, 1.25 ] 1.14 [ 0.59, 2.22 ] 1.87 [ 0.40, 8.65 ] 0.63 [ 0.28, 1.44 ] 0.25 [ 0.09, 0.70 ] 0.40 [ 0.08, 1.93 ] 0.75 [ 0.41, 1.36 ]
Total (95% CI)
811
857
100.0 %
0.69 [ 0.50, 0.95 ]
Total events: 56 (Regional), 86 (General) Heterogeneity: Chi2 = 10.10, df = 7 (P = 0.18); I2 =31% Test for overall effect: Z = 2.30 (P = 0.021)
0.01
0.1
10
100
Favours regional
Favours general
43
Analysis 1.2. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 2 Mortality 1 month (random effects model).
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 2 Mortality - 1 month (random effects model)
Study or subgroup
Regional n/N
General n/N 0/29 9/68 16/279 2/14 13/75 17/60 5/35 24/297
Risk Ratio M-H,Random,95% CI
Weight
Berggren 1987 Davis 1981 Davis 1987 Juelsgaard 1998 McKenzie 1984 McLaren 1978 Racle 1986 Valentin 1986
1/28 3/64 17/259 4/15 8/73 4/56 2/35 17/281
1.8 % 9.3 % 21.8 % 6.8 % 17.1 % 12.7 % 6.5 % 23.9 %
3.10 [ 0.13, 73.12 ] 0.35 [ 0.10, 1.25 ] 1.14 [ 0.59, 2.22 ] 1.87 [ 0.40, 8.65 ] 0.63 [ 0.28, 1.44 ] 0.25 [ 0.09, 0.70 ] 0.40 [ 0.08, 1.93 ] 0.75 [ 0.41, 1.36 ]
Total (95% CI)
811
857
100.0 %
0.68 [ 0.44, 1.05 ]
Total events: 56 (Regional), 86 (General) Heterogeneity: Tau2 = 0.11; Chi2 = 10.10, df = 7 (P = 0.18); I2 =31% Test for overall effect: Z = 1.75 (P = 0.080)
0.01
0.1
10
100
Favours regional
Favours general
44
Analysis 1.3. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 3 Mortality 3 months.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 3 Mortality - 3 months
Study or subgroup
Regional n/N
General n/N 0/29 12/50 31/279 17/75 5/35 33/297
Weight
Berggren 1987 Couderc 1977 Davis 1987 McKenzie 1984 Racle 1986 Valentin 1986
1/28 7/50 36/259 16/73 4/35 22/281
0.5 % 12.5 % 31.0 % 17.4 % 5.2 % 33.4 %
3.10 [ 0.13, 73.12 ] 0.58 [ 0.25, 1.36 ] 1.25 [ 0.80, 1.96 ] 0.97 [ 0.53, 1.77 ] 0.80 [ 0.23, 2.73 ] 0.70 [ 0.42, 1.18 ]
Total (95% CI)
726
765
100.0 %
0.92 [ 0.71, 1.21 ]
Total events: 86 (Regional), 98 (General) Heterogeneity: Chi2 = 4.59, df = 5 (P = 0.47); I2 =0.0% Test for overall effect: Z = 0.59 (P = 0.55)
0.01
0.1
10
100
Favours regional
Favours general
Study or subgroup
Regional n/N
General n/N 42/279 21/75 42/297
Weight
Davis 1987 McKenzie 1984 Valentin 1986
44/259 20/73 39/281
39.6 % 20.3 % 40.0 %
1.13 [ 0.77, 1.66 ] 0.98 [ 0.58, 1.65 ] 0.98 [ 0.66, 1.47 ]
Total (95% CI)
613
651
100.0 %
1.04 [ 0.81, 1.33 ]
0.01
0.1
10
100
Favours regional
Favours general
45
Study or subgroup
Regional n/N
General n/N 25/75 53/297
Weight
McKenzie 1984 Valentin 1986
26/73 54/281
32.4 % 67.6 %
1.07 [ 0.69, 1.67 ] 1.08 [ 0.76, 1.52 ]
Total (95% CI)
354
372
100.0 %
1.07 [ 0.82, 1.41 ]
0.01
0.1
10
100
Favours regional
Favours general
46
Analysis 1.6. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 6 Mortality early and up to 1 month.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 6 Mortality - early and up to 1 month
Study or subgroup
Regional n/N
General n/N 3/32 0/29 1/20 9/68 16/279 2/14 13/75 17/60 5/35 3/57 24/297
Weight
Adams 1990 Berggren 1987 Bigler 1985 Davis 1981 Davis 1987 Juelsgaard 1998 McKenzie 1984 McLaren 1978 Racle 1986 Ungemach 1993 Valentin 1986
4/24 1/28 1/20 3/64 17/259 4/15 8/73 4/56 2/35 3/57 17/281
2.8 % 0.5 % 1.1 % 9.6 % 17.0 % 2.3 % 14.1 % 18.1 % 5.5 % 3.3 % 25.7 %
1.78 [ 0.44, 7.21 ] 3.10 [ 0.13, 73.12 ] 1.00 [ 0.07, 14.90 ] 0.35 [ 0.10, 1.25 ] 1.14 [ 0.59, 2.22 ] 1.87 [ 0.40, 8.65 ] 0.63 [ 0.28, 1.44 ] 0.25 [ 0.09, 0.70 ] 0.40 [ 0.08, 1.93 ] 1.00 [ 0.21, 4.75 ] 0.75 [ 0.41, 1.36 ]
Total (95% CI)
912
966
100.0 %
0.73 [ 0.54, 0.99 ]
0.01
0.1
10
100
Favours regional
Favours general
47
Analysis 1.7. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 7 Length of operation (mins).
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 7 Length of operation (mins)
Study or subgroup
Regional N Mean(SD) 35 (10) 67 (35.8) 60 (22.9) 54.7 (21.8) 80.5 (12.8) 82.2 (22.2) 125 (35.5) 60 (15.49)
General N 29 20 13 21 15 75 35 15 Mean(SD) 31 (10) 59 (44.7) 65 (22) 66.2 (22.6) 71.5 (20.9) 77.2 (27.7) 116 (5.9) 78 (23.24)
Mean Difference IV,Random,95% CI
Weight
Berggren 1987 Bigler 1985 Bredahl 1991 Kamitani 2003 Maurette 1988 McKenzie 1984 Racle 1986 Svarting 1986
28 20 15 19 18 73 35 15
21.3 % 4.8 % 8.8 % 11.1 % 12.7 % 17.5 % 12.9 % 10.8 %
4.00 [ -1.19, 9.19 ] 8.00 [ -17.10, 33.10 ] -5.00 [ -21.65, 11.65 ] -11.50 [ -25.27, 2.27 ] 9.00 [ -3.12, 21.12 ] 5.00 [ -3.08, 13.08 ] 9.00 [ -2.92, 20.92 ] -18.00 [ -32.13, -3.87 ]
Total (95% CI)
223
223
100.0 %
0.76 [ -5.37, 6.90 ]
Heterogeneity: Tau2 = 38.81; Chi2 = 15.95, df = 7 (P = 0.03); I2 =56% Test for overall effect: Z = 0.24 (P = 0.81)
-100
-50
50
100
Favours regional
Favours general
48
Analysis 1.8. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 8 Operative hypotension.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 8 Operative hypotension
Study or subgroup
Regional n/N
General n/N 13/29 0/30 0/10 12/15 20/50 67/279 9/14 6/15 1/29 9/35 0/15
Risk Ratio M-H,Fixed,95% CI 1.43 [ 0.88, 2.34 ] 7.00 [ 0.38, 129.93 ] 0.0 [ 0.0, 0.0 ] 0.58 [ 0.32, 1.06 ] 0.70 [ 0.40, 1.22 ] 1.58 [ 1.21, 2.04 ] 1.24 [ 0.78, 1.98 ] 0.42 [ 0.12, 1.39 ] 3.35 [ 0.37, 30.21 ] 1.11 [ 0.51, 2.40 ] 9.00 [ 0.53, 153.79 ]
Berggren 1987 Biffoli 1998 Brown 1994 Casati 2003 Couderc 1977 Davis 1987 Juelsgaard 1998 Maurette 1988 McLaren 1978 Racle 1986 Svarting 1986
18/28 3/30 0/10 7/15 14/50 98/259 12/15 3/18 3/26 10/35 4/15
Total (95% CI)
501
521
1.30 [ 1.08, 1.55 ]
0.001 0.01 0.1 Favours regional
10 100 1000 Favours general
49
Analysis 1.9. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 9 Operative hypotension (random effects model).
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 9 Operative hypotension (random effects model)
Study or subgroup
Regional n/N
General n/N 13/29 0/30 0/10 12/15 20/50 67/279 9/14 6/15 1/29 9/35 0/15
Risk Ratio M-H,Random,95% CI 1.43 [ 0.88, 2.34 ] 7.00 [ 0.38, 129.93 ] 0.0 [ 0.0, 0.0 ] 0.58 [ 0.32, 1.06 ] 0.70 [ 0.40, 1.22 ] 1.58 [ 1.21, 2.04 ] 1.24 [ 0.78, 1.98 ] 0.42 [ 0.12, 1.39 ] 3.35 [ 0.37, 30.21 ] 1.11 [ 0.51, 2.40 ] 9.00 [ 0.53, 153.79 ]
Berggren 1987 Biffoli 1998 Brown 1994 Casati 2003 Couderc 1977 Davis 1987 Juelsgaard 1998 Maurette 1988 McLaren 1978 Racle 1986 Svarting 1986
18/28 3/30 0/10 7/15 14/50 98/259 12/15 3/18 3/26 10/35 4/15
Total (95% CI)
501
521
1.10 [ 0.79, 1.55 ]
50
Analysis 1.10. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 10 Operative blood loss (ml).
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 10 Operative blood loss (ml)
Study or subgroup
Regional N Mean(SD) 190 (186) 304 (232) 68.4 (55.8) 277.7 (308.4) 377 (166.54)
General N 13 68 21 75 15 Mean(SD) 321 (432.7) 468 (445.3) 116.8 (121.2) 261.7 (317.8) 583 (278.85)
Weight
Bredahl 1991 Davis 1981 Kamitani 2003 McKenzie 1984 Svarting 1986
15 64 19 73 15
7.5 % 20.5 % 33.6 % 24.1 % 14.3 %
-131.00 [ -384.35, 122.35 ] -164.00 [ -284.14, -43.86 ] -48.40 [ -105.99, 9.19 ] 16.00 [ -84.89, 116.89 ] -206.00 [ -370.37, -41.63 ]
Total (95% CI)
186
192
100.0 %
-85.28 [ -161.95, -8.61 ]
Heterogeneity: Tau2 = 3693.46; Chi2 = 8.49, df = 4 (P = 0.08); I2 =53% Test for overall effect: Z = 2.18 (P = 0.029)
-1000
-500
500
1000
Favours regional
Favours general
Analysis 1.11. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 11 Patients receiving blood transfusion.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 11 Patients receiving blood transfusion
Study or subgroup
Regional n/N
General n/N 9/32 7/20 52/68 5/15
Weight
Adams 1990 Bigler 1985 Davis 1981 Svarting 1986
9/24 9/20 45/64 1/15
11.0 % 10.0 % 71.9 % 7.1 %
1.33 [ 0.63, 2.84 ] 1.29 [ 0.60, 2.77 ] 0.92 [ 0.75, 1.13 ] 0.20 [ 0.03, 1.51 ]
Total (95% CI)
123
135
100.0 %
0.95 [ 0.77, 1.17 ]
0.01
0.1
10
100
Favours regional
Favours general
51
Analysis 1.12. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 12 Transfusion requirements (ml).
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 12 Transfusion requirements (ml)
Study or subgroup
Regional N Mean(SD) 1100 (400) 14.7 (64.2) 600 (150) 488.6 (282.8)
General N 50 21 15 35 Mean(SD) 1000 (300) 20 (66.9) 300 (150) 480 (292.8)
Weight
Couderc 1977 Kamitani 2003 Maurette 1988 Racle 1986
50 19 18 35
23.2 % 28.1 % 25.3 % 23.4 %
100.00 [ -38.59, 238.59 ] -5.30 [ -45.95, 35.35 ] 300.00 [ 197.22, 402.78 ] 8.60 [ -126.26, 143.46 ]
Total (95% CI)
122
121
100.0 %
99.75 [ -52.99, 252.48 ]
Heterogeneity: Tau2 = 21205.58; Chi2 = 30.27, df = 3 (P<0.00001); I2 =90% Test for overall effect: Z = 1.28 (P = 0.20)
-1000
-500
500
1000
Favours regional
Favours general
Analysis 1.13. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 13 Postoperative hypoxia.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 13 Postoperative hypoxia
Study or subgroup
Regional n/N
General n/N 14/29 3/30
Weight
Berggren 1987 Biffoli 1998
10/28 1/30
82.1 % 17.9 %
0.74 [ 0.40, 1.38 ] 0.33 [ 0.04, 3.03 ]
Total (95% CI)
58
59
100.0 %
0.67 [ 0.36, 1.22 ]
0.01
0.1
10
100
Favours regional
Favours general
52
Analysis 1.14. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 14 Length of hospital stay.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 14 Length of hospital stay
Study or subgroup
Regional N Mean(SD) 38.8 (55.5) 20.09 (10.6)
General N 75 35 Mean(SD) 42.9 (69.3) 20.05 (11.4)
Mean Difference IV,Fixed,95% CI
Weight
McKenzie 1984 Racle 1986
73 35
6.1 % 93.9 %
-4.10 [ -24.30, 16.10 ] 0.04 [ -5.12, 5.20 ]
Total (95% CI)
108
110
100.0 %
-0.21 [ -5.21, 4.78 ]
Heterogeneity: Chi2 = 0.15, df = 1 (P = 0.70); I2 =0.0% Test for overall effect: Z = 0.08 (P = 0.93)
-100
-50
50
100
Favours regional
Favours general
53
Analysis 1.15. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 15 Pneumonia.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 15 Pneumonia
Study or subgroup
Regional n/N
General n/N
Weight
1 Fatal (reason for death only) Adams 1990 Davis 1981 Davis 1987 Juelsgaard 1998 McKenzie 1984 McLaren 1978 1/24 2/64 5/259 2/15 5/73 1/56 1/32 4/68 4/279 0/14 3/75 5/60 3.0 % 13.4 % 13.3 % 1.8 % 10.3 % 16.7 % 1.33 [ 0.09, 20.26 ] 0.53 [ 0.10, 2.80 ] 1.35 [ 0.37, 4.96 ] 4.69 [ 0.24, 89.88 ] 1.71 [ 0.42, 6.91 ] 0.21 [ 0.03, 1.78 ]
Subtotal (95% CI)
491
528
58.5 %
1.00 [ 0.52, 1.94 ]
Total events: 16 (Regional), 17 (General) Heterogeneity: Chi2 = 4.46, df = 5 (P = 0.49); I2 =0.0% Test for overall effect: Z = 0.00 (P = 1.0) 2 Other (non fatal or fatal) Berggren 1987 Bigler 1985 Racle 1986 1/28 1/20 3/35 2/29 2/20 8/35 6.8 % 6.9 % 27.7 % 0.52 [ 0.05, 5.40 ] 0.50 [ 0.05, 5.08 ] 0.38 [ 0.11, 1.30 ]
Subtotal (95% CI)

Total events: 5 (Regional), 12 (General)
83
84
41.5 %
0.42 [ 0.16, 1.13 ]
Total (95% CI)
574
612
100.0 %
0.76 [ 0.44, 1.30 ]
0.01
0.1
10
100
Favours regional
Favours general
54
Analysis 1.16. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 16 Myocardial infarction.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 16 Myocardial infarction
Study or subgroup
Regional n/N
General n/N
Weight
1 Fatal (reason for death only) Davis 1981 Davis 1987 McKenzie 1984 McLaren 1978 0/64 2/259 0/73 0/56 1/68 1/279 2/75 3/60 11.4 % 7.5 % 19.3 % 26.5 % 0.35 [ 0.01, 8.53 ] 2.15 [ 0.20, 23.62 ] 0.21 [ 0.01, 4.21 ] 0.15 [ 0.01, 2.90 ]
Subtotal (95% CI)

452
482
64.7 %
0.44 [ 0.13, 1.50 ]
Heterogeneity: Chi2 = 2.45, df = 3 (P = 0.48); I2 =0.0% Test for overall effect: Z = 1.31 (P = 0.19) 2 Other (non fatal or fatal) Juelsgaard 1998 Racle 1986 1/15 2/35 0/14 4/35 4.0 % 31.3 % 2.81 [ 0.12, 63.83 ] 0.50 [ 0.10, 2.56 ]
Subtotal (95% CI)

50
49
35.3 %
0.76 [ 0.20, 2.96 ]
Total (95% CI)

502
531
100.0 %
0.55 [ 0.22, 1.37 ]
0.01
0.1
10
100
Favours regional
Favours general
55
Analysis 1.17. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 17 Cerebrovascular accident.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 17 Cerebrovascular accident
Study or subgroup
Regional n/N
General n/N
Weight
1 Fatal (reason for death only) Couderc 1977 Davis 1987 McKenzie 1984 Racle 1986 2/50 3/259 0/73 0/35 2/50 0/279 1/75 1/35 23.7 % 5.7 % 17.6 % 17.8 % 1.00 [ 0.15, 6.82 ] 7.54 [ 0.39, 145.24 ] 0.34 [ 0.01, 8.27 ] 0.33 [ 0.01, 7.91 ]
Subtotal (95% CI)

417
439
64.8 %
1.22 [ 0.40, 3.71 ]
Heterogeneity: Chi2 = 2.75, df = 3 (P = 0.43); I2 =0.0% Test for overall effect: Z = 0.34 (P = 0.73) 2 Other (non fatal or fatal) Berggren 1987 Bigler 1985 Davis 1981 3/28 0/20 2/64 0/29 1/20 1/68 5.8 % 17.8 % 11.5 % 7.24 [ 0.39, 134.12 ] 0.33 [ 0.01, 7.72 ] 2.13 [ 0.20, 22.87 ]
Subtotal (95% CI)

112
117
35.2 %
2.07 [ 0.53, 8.06 ]
Heterogeneity: Chi2 = 2.00, df = 2 (P = 0.37); I2 =0% Test for overall effect: Z = 1.05 (P = 0.30)
Total (95% CI)

529
556
100.0 %
1.51 [ 0.64, 3.57 ]
56
Analysis 1.18. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 18 Congestive cardiac failure.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 18 Congestive cardiac failure
Study or subgroup
Regional n/N
General n/N
Weight
1 Fatal (reason for death only) Adams 1990 Davis 1987 Juelsgaard 1998 2/24 3/259 1/15 2/32 3/279 0/14 13.6 % 22.8 % 4.1 % 1.33 [ 0.20, 8.80 ] 1.08 [ 0.22, 5.29 ] 2.81 [ 0.12, 63.83 ]
Subtotal (95% CI)

298
325
40.5 %
1.34 [ 0.44, 4.10 ]
Heterogeneity: Chi2 = 0.29, df = 2 (P = 0.87); I2 =0.0% Test for overall effect: Z = 0.51 (P = 0.61) 2 Other (non fatal or fatal) Berggren 1987 Bigler 1985 Davis 1981 Racle 1986 2/28 1/29 2/64 1/35 0/29 1/20 5/68 1/35 3.9 % 9.4 % 38.4 % 7.9 % 5.17 [ 0.26, 103.18 ] 0.69 [ 0.05, 10.39 ] 0.43 [ 0.09, 2.11 ] 1.00 [ 0.07, 15.36 ]
Subtotal (95% CI)

156
152
59.5 %
0.85 [ 0.30, 2.40 ]
Total (95% CI)
454
477
100.0 %
1.05 [ 0.49, 2.23 ]
57
Analysis 1.19. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 19 Renal failure.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 19 Renal failure
Study or subgroup
Regional n/N
General n/N
Weight
1 Fatal (reason for death only) Davis 1987 McLaren 1978 Racle 1986 1/259 1/56 0/35 0/279 2/60 1/35 7.7 % 31.0 % 24.1 % 3.23 [ 0.13, 78.95 ] 0.54 [ 0.05, 5.75 ] 0.33 [ 0.01, 7.91 ]
Subtotal (95% CI)

350
374
62.9 %
0.79 [ 0.18, 3.46 ]
Heterogeneity: Chi2 = 1.13, df = 2 (P = 0.57); I2 =0.0% Test for overall effect: Z = 0.31 (P = 0.75) 2 Other (non fatal or fatal) Adams 1990 Davis 1981 1/24 0/64 1/32 1/68 13.8 % 23.4 % 1.33 [ 0.09, 20.26 ] 0.35 [ 0.01, 8.53 ]
Subtotal (95% CI)

88
100
37.1 %
0.72 [ 0.10, 5.13 ]
Total (95% CI)

438
474
100.0 %
0.76 [ 0.23, 2.49 ]
0.01
0.1
10
100
Favours regional
Favours general
58
Analysis 1.20. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 20 Acute confusional state.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 20 Acute confusional state
Study or subgroup
Regional n/N
Control n/N 7/29 1/20 3/15 1/21 11/35
Weight
Berggren 1987 Bigler 1985 Casati 2003 Kamitani 2003 Racle 1986
4/28 1/20 1/15 0/19 5/35
29.5 % 4.3 % 12.9 % 6.1 % 47.2 %
0.59 [ 0.19, 1.80 ] 1.00 [ 0.07, 14.90 ] 0.33 [ 0.04, 2.85 ] 0.37 [ 0.02, 8.50 ] 0.45 [ 0.18, 1.17 ]
Total (95% CI)
117
120
100.0 %
0.50 [ 0.26, 0.95 ]
Total events: 11 (Regional), 23 (Control) Heterogeneity: Chi2 = 0.55, df = 4 (P = 0.97); I2 =0.0% Test for overall effect: Z = 2.12 (P = 0.034)
0.01
0.1
10
100
Favours regional
Favours general
Analysis 1.21. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 21 Urine retention.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 21 Urine retention
Study or subgroup
Regional n/N
Control n/N 6/29 4/20
Weight
Berggren 1987 Bigler 1985
5/28 5/20
59.6 % 40.4 %
0.86 [ 0.30, 2.51 ] 1.25 [ 0.39, 3.99 ]
Total (95% CI)
48
49
100.0 %
1.02 [ 0.47, 2.23 ]
Total events: 10 (Regional), 10 (Control) Heterogeneity: Chi2 = 0.21, df = 1 (P = 0.65); I2 =0.0% Test for overall effect: Z = 0.05 (P = 0.96)
0.01
0.1
10
100
Favours regional
Favours general
59
Analysis 1.22. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 22 Vomiting.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 22 Vomiting
Study or subgroup
Regional n/N
General n/N 2/20 1/29
Weight
Bigler 1985 McLaren 1978
1/20 1/26
67.9 % 32.1 %
0.50 [ 0.05, 5.08 ] 1.12 [ 0.07, 16.95 ]
Total (95% CI)
46
49
100.0 %
0.70 [ 0.12, 3.94 ]
0.01
0.1
10
100
Favours regional
Favours general
Analysis 1.23. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 23 Deep vein thrombosis.
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 23 Deep vein thrombosis
Study or subgroup
Regional n/N
General n/N
Weight
1 Fatal (underlying reason for death only) McLaren 1978 0/26 2/29 3.9 % 0.22 [ 0.01, 4.43 ]
Subtotal (95% CI)

Total events: 0 (Regional), 2 (General) Heterogeneity: not applicable
26
29
3.9 %
0.22 [ 0.01, 4.43 ]
Test for overall effect: Z = 0.99 (P = 0.32) 2 Other: venography diagnosis Brichant 1995 McKenzie 1984 14/46 8/20 13/42 16/20 22.2 % 26.2 % 0.98 [ 0.52, 1.84 ] 0.50 [ 0.28, 0.89 ]
Subtotal (95% CI)
66
62
0.01 0.1 1 10 100
48.4 %
0.72 [ 0.47, 1.11 ]
Favours regional
Favours general
(Continued . . . )
60
(. . .
Study or subgroup Regional n/N Total events: 22 (Regional), 29 (General) Heterogeneity: Chi2 = 2.47, df = 1 (P = 0.12); I2 =60% Test for overall effect: Z = 1.50 (P = 0.13) 3 Other: brinogen scan diagnosis Davis 1981 17/37 30/39 47.8 % General n/N Risk Ratio M-H,Fixed,95% CI Weight
Continued) Risk Ratio
M-H,Fixed,95% CI
0.60 [ 0.40, 0.88 ]
Subtotal (95% CI)

Total events: 17 (Regional), 30 (General) Heterogeneity: not applicable
37
39
47.8 %
0.60 [ 0.40, 0.88 ]
Test for overall effect: Z = 2.59 (P = 0.0095)
Total (95% CI)
129
130
100.0 %
0.64 [ 0.48, 0.86 ]
0.01
0.1
10
100
Favours regional
Favours general
Analysis 1.24. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 24 Pulmonary embolism (Peto odds ratio plot - showing heterogeneity).
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 24 Pulmonary embolism (Peto odds ratio plot - showing heterogeneity)
Study or subgroup
Regional n/N
General n/N 0/32 0/29 0/20 0/42 4/68 1/279 3/75 5/60 0/35
Peto Odds Ratio Peto,Fixed,95% CI
Weight
Adams 1990 Berggren 1987 Bigler 1985 Brichant 1995 Davis 1981 Davis 1987 McKenzie 1984 McLaren 1978 Racle 1986
1/24 2/28 2/20 1/46 0/64 0/259 1/73 1/56 1/35
4.6 % 9.2 % 9.1 % 4.7 % 18.2 % 4.7 % 18.3 % 26.7 % 4.7 %

0.001 0.01 0.1 Favours regional 1 10 100 1000 Favours general
10.31 [ 0.20, 541.25 ] 7.95 [ 0.48, 130.33 ] 7.79 [ 0.47, 129.11 ] 6.77 [ 0.13, 342.76 ] 0.14 [ 0.02, 1.00 ] 0.15 [ 0.00, 7.35 ] 0.37 [ 0.05, 2.68 ] 0.27 [ 0.05, 1.37 ] 7.39 [ 0.15, 372.38 ]
(Continued . . . )
61
Study or subgroup
Regional n/N
General n/N
Weight
(. . . Continued) Peto Odds Ratio

Peto,Fixed,95% CI
Total (95% CI)
605
640
100.0 %
0.72 [ 0.31, 1.69 ]
Analysis 1.25. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 25 Pulmonary embolism (random effects model).
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 25 Pulmonary embolism (random effects model)
Study or subgroup
Regional n/N
General n/N 0/32 0/29 0/20 0/42 4/68 1/279 3/75 5/60 0/35
Weight
Adams 1990 Berggren 1987 Bigler 1985 Brichant 1995 Davis 1981 Davis 1987 McKenzie 1984 McLaren 1978 Racle 1986
1/24 2/28 2/20 1/46 0/64 0/259 1/73 1/56 1/35
9.0 % 9.9 % 10.0 % 8.9 % 10.4 % 8.8 % 16.2 % 17.8 % 8.9 %
3.96 [ 0.17, 93.17 ] 5.17 [ 0.26, 103.18 ] 5.00 [ 0.26, 98.00 ] 2.74 [ 0.11, 65.59 ] 0.12 [ 0.01, 2.15 ] 0.36 [ 0.01, 8.77 ] 0.34 [ 0.04, 3.22 ] 0.21 [ 0.03, 1.78 ] 3.00 [ 0.13, 71.22 ]
Total (95% CI)
605
640
100.0 %
0.88 [ 0.32, 2.39 ]
62
Analysis 1.26. Comparison 1 Regional (spinal or epidural) versus general anaesthesia, Outcome 26 Pulmonary embolism (fatal and non-fatal).
Comparison: 1 Regional (spinal or epidural) versus general anaesthesia Outcome: 26 Pulmonary embolism (fatal and non-fatal)
Study or subgroup
Regional n/N
General n/N
Weight
1 Fatal (reason for death only) Adams 1990 Bigler 1985 Davis 1981 Davis 1987 McKenzie 1984 McLaren 1978 1/24 1/20 0/64 0/259 1/73 1/56 0/32 0/20 4/68 1/279 3/75 5/60 3.0 % 3.4 % 30.0 % 9.9 % 20.4 % 33.2 % 3.96 [ 0.17, 93.17 ] 3.00 [ 0.13, 69.52 ] 0.12 [ 0.01, 2.15 ] 0.36 [ 0.01, 8.77 ] 0.34 [ 0.04, 3.22 ] 0.21 [ 0.03, 1.78 ]
Subtotal (95% CI)

496
534
100.0 %
0.43 [ 0.17, 1.10 ]
Heterogeneity: Chi2 = 4.60, df = 5 (P = 0.47); I2 =0.0% Test for overall effect: Z = 1.77 (P = 0.077) 2 Non fatal Berggren 1987 Bigler 1985 Brichant 1995 Racle 1986 2/28 1/20 1/46 1/35 0/29 0/20 0/42 0/35 24.4 % 24.8 % 25.9 % 24.8 % 5.17 [ 0.26, 103.18 ] 3.00 [ 0.13, 69.52 ] 2.74 [ 0.11, 65.59 ] 3.00 [ 0.13, 71.22 ]
Subtotal (95% CI)

129
126
100.0 %
3.46 [ 0.74, 16.29 ]
63
Analysis 2.1. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 1 Mortality - 1 month.
Comparison: 2 Spinal and light general anaesthetic versus general anaesthetic Outcome: 1 Mortality - 1 month
Study or subgroup
Spinal (+) n/N
General n/N 0/20
Risk Ratio M-H,Fixed,95% CI 0.0 [ 0.0, 0.0 ]
White 1980
0/20
0.01
0.1
10
100
Favours spinal (+)
Favours general
Analysis 2.2. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 2 Length of operation.
Comparison: 2 Spinal and light general anaesthetic versus general anaesthetic Outcome: 2 Length of operation
Study or subgroup
Spinal (+) N Mean(SD) 58 (23)
General N 20 Mean(SD) 58 (25)
Mean Difference IV,Fixed,95% CI 0.0 [ -14.89, 14.89 ]
White 1980
20
-100
-50
50
100
Favours spinal (+)
Favours general
64
Analysis 2.3. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 3 Pneumonia.
Comparison: 2 Spinal and light general anaesthetic versus general anaesthetic Outcome: 3 Pneumonia
Study or subgroup
Spinal (+) n/N
General n/N 5/20
White 1980
4/20
0.01
0.1
10
100
Favours spinal (+)
Favours general
Analysis 2.4. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 4 Confusional state.
Comparison: 2 Spinal and light general anaesthetic versus general anaesthetic Outcome: 4 Confusional state
Study or subgroup
Spinal (+) n/N
General n/N 3/20
White 1980
3/20
0.01
0.1
10
100
Favours spinal (+)
Favours general
65
Analysis 2.5. Comparison 2 Spinal and light general anaesthetic versus general anaesthetic, Outcome 5 Deep vein thrombosis.
Comparison: 2 Spinal and light general anaesthetic versus general anaesthetic Outcome: 5 Deep vein thrombosis
Study or subgroup
Spinal (+) n/N
General n/N 1/20
White 1980
0/20
0.01
0.1
10
100
Favours spinal (+)
Favours general
Analysis 3.1. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 1 Incomplete or unsatisfactory analgesia.
Comparison: 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 1 Incomplete or unsatisfactory analgesia
Study or subgroup
Regional n/N
Nerve blocks n/N
Weight
1 Regional (spinal) block versus lumbar plexus block Eyrolle 1998 5/25 19/25 78.1 % 0.26 [ 0.12, 0.59 ]
Subtotal (95% CI)

Heterogeneity: not applicable
25
25
78.1 %
0.26 [ 0.12, 0.59 ]
Total events: 5 (Regional), 19 (Nerve blocks) Test for overall effect: Z = 3.21 (P = 0.0013) 2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block de Visme 2000 0/14 5/15 21.9 % 0.10 [ 0.01, 1.61 ]
Subtotal (95% CI)

14
15
21.9 %
0.10 [ 0.01, 1.61 ]
Total events: 0 (Regional), 5 (Nerve blocks) Test for overall effect: Z = 1.63 (P = 0.10)
Total (95% CI)
39
40
100.0 %
0.23 [ 0.10, 0.50 ]
Total events: 5 (Regional), 24 (Nerve blocks) Heterogeneity: Chi2 = 0.48, df = 1 (P = 0.49); I2 =0.0% Test for overall effect: Z = 3.66 (P = 0.00025)
10 100 1000 Favours nerve blocks
66
Analysis 3.2. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 2 Operative hypotension.
Comparison: 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 2 Operative hypotension
Study or subgroup
Regional (spinal) n/N
Nerve block n/N
1 Regional (spinal) block versus lumbar plexus block Eyrolle 1998 18/25 3/25 6.00 [ 2.02, 17.83 ]
0.01
0.1
10
100
Favours regional
Favours nerve block
Analysis 3.3. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 3 Mean fall in arterial blood pressure (mmHg).
Comparison: 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 3 Mean fall in arterial blood pressure (mmHg)
Study or subgroup
Regional N Mean(SD)
Nerve block N Mean(SD)
2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block de Visme 2000 14 46 (22) 15 30 (18) 16.00 [ 1.31, 30.69 ]
-100
-50
50
100
Favours regional
Favours nerve block
67
Analysis 3.4. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 4 Mean dose of ephedrine used (mg).
Comparison: 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 4 Mean dose of ephedrine used (mg)
Study or subgroup
Regional N Mean(SD)
Nerve block N Mean(SD)
Weight
1 Regional (spinal) block versus lumbar plexus block Eyrolle 1998 25 7 (2.8) 25 1.2 (2.7) 96.3 % 5.80 [ 4.28, 7.32 ]
Subtotal (95% CI)

25
25
96.3 %
5.80 [ 4.28, 7.32 ]
Test for overall effect: Z = 7.46 (P < 0.00001) 2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block de Visme 2000 14 13 (14) 15 3 (5) 3.7 % 10.00 [ 2.24, 17.76 ]
Subtotal (95% CI)

14
15
3.7 %
10.00 [ 2.24, 17.76 ]
Test for overall effect: Z = 2.53 (P = 0.012)
Total (95% CI)
39
40
100.0 %
5.96 [ 4.46, 7.45 ]
Heterogeneity: Chi2 = 1.08, df = 1 (P = 0.30); I2 =8% Test for overall effect: Z = 7.80 (P < 0.00001) Test for subgroup differences: Chi2 = 1.08, df = 1 (P = 0.30), I2 =8%
-100
-50
50
100
Favours regional
Favours nerve block
Analysis 3.5. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 5 Adverse effects.
Comparison: 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 5 Adverse effects
Study or subgroup
Regional (spinal) n/N
Nerve block n/N
1 Regional (spinal) block versus lumbar plexus block Eyrolle 1998 6/25 1/25 6.00 [ 0.78, 46.29 ]
2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block de Visme 2000 0/14 0/15 0.0 [ 0.0, 0.0 ]
0.01
0.1
10
100
Favours regional
Favours nerve block
68
Analysis 3.6. Comparison 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 6 Postoperative confusion.
Comparison: 3 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 6 Postoperative confusion
Study or subgroup
Regional n/N
Nerve block n/N
2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block de Visme 2000 5/14 6/15 0.89 [ 0.35, 2.28 ]
0.01
0.1
10
100
Favours regional
Favours nerve blocks
Analysis 4.1. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 1 Mortality - during hospital stay.
Comparison: 4 Intravenous ketamine versus general anaesthesia Outcome: 1 Mortality - during hospital stay
Study or subgroup
Ketamine n/N
General n/N 9/30
Spreadbury 1980
9/30
0.01
0.1
10
100
Favours ketamine
Favours general
69
Analysis 4.2. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 2 Myocardial infarction.
Comparison: 4 Intravenous ketamine versus general anaesthesia Outcome: 2 Myocardial infarction
Study or subgroup
Ketamine n/N
General n/N 1/30
Spreadbury 1980
0/30
0.01
0.1
10
100
Favours ketamine
Favours general
Analysis 4.3. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 3 Congestive cardiac failure.
Comparison: 4 Intravenous ketamine versus general anaesthesia Outcome: 3 Congestive cardiac failure
Study or subgroup
Ketamine n/N
General n/N 2/30
Spreadbury 1980
0/30
0.01
0.1
10
100
Favours ketamine
Favours general
70
Analysis 4.4. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 4 Pulmonary embolism.
Comparison: 4 Intravenous ketamine versus general anaesthesia Outcome: 4 Pulmonary embolism
Study or subgroup
Ketamine n/N
General n/N 3/30
Spreadbury 1980
0/30
0.01
0.1
10
100
Favours ketamine
Favours general
Analysis 4.5. Comparison 4 Intravenous ketamine versus general anaesthesia, Outcome 5 Length of hospital stay (discharge home).
Comparison: 4 Intravenous ketamine versus general anaesthesia Outcome: 5 Length of hospital stay (discharge home)
Study or subgroup
Ketamine N Mean(SD) 36 (12)
General N 20 Mean(SD) 24 (8)
Mean Difference IV,Fixed,95% CI 12.00 [ 5.57, 18.43 ]
Spreadbury 1980
19
-100
-50
50
100
Favours ketamine
Favours general
71
APPENDICES Appendix 1. Search strategy for EMBASE (OVID-WEB)
EMBASE 1. exp Hip Fracture/ 2. ((hip$ or ((femur$ or femoral$) adj3 (neck or proximal))) fracture$).tw. 3. or/1-2 4. exp Randomized Controlled trial/ 5. exp Double Blind Procedure/ 6. exp Single Blind Procedure/ 7. exp Crossover Procedure/ 8. Controlled Study/ 9. or/4-8 10. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed)adj3 (trial or study)).tw. 11. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw. 12. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw. 13. (cross?over$ or (cross adj1 over$)).tw. 14. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw. 15. or/10-14 16. or/9,15 17. limit 16 to human 18. and/3,17
WHATS NEW
Last assessed as up-to-date: 10 June 2004.
4 September 2008
Amended
Converted to new review format.
HISTORY
Protocol rst published: Issue 4, 1997 Review rst published: Issue 4, 1999
72
11 June 2004
New citation required and conclusions have changed
For the third update, rst appearing in Issue 4, 2004, the trial search was updated to February 2004. The following changes were made: (1) Five studies comparing spinal versus general anaesthesia were newly included (Biffoli 1998; Casati 2003; Kamitani 2003; Svarting 1986; Wajima 1995). (2) Additional data were obtained for McLaren 1978 resulting in the number of patients being increased from 55 to 116 for some of the outcomes. (3) Seven studies were newly excluded and two added to Studies awaiting assessment. (4) Format changes to conform to the revised Cochrane Style Guide. (5) There were substantive changes to the conclusions of the review, reecting new ndings on post-operative confusion and in response to editorial comments. For details of previous updates see Notes
CONTRIBUTIONS OF AUTHORS
Martyn Parker (MP) initiated the review and wrote the rst draft of the protocol. Helen Handoll (HH) identied the trial studies. Susan Urwin and Richard Grifths independently assessed trial quality and extracted data. The other two reviewers (HH and MP) independently checked these results and entered the review into RevMan. All reviewers critically reviewed successive drafts of the review. The updates were compiled by MP and HH with RG independently extracting data. Martyn Parker is the guarantor of the review.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT Internal sources

University of Teesside, Middlesbrough, UK. Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK.
73
External sources
No sources of support supplied
NOTES
This review and rst update was published under the title: General versus spinal/epidural anaesthesia for surgery for hip fractures in adults. The title was changed in the second update to reect an expansion in the scope of the review to include comparisons of all forms of anaesthesia. This review was rst updated in Issue 4, 2000. The trial search was updated to August 1999 and one small trial (Juelsgaard 1999) was included. A consumer synopsis was added and relative risks instead of Peto odds ratios were presented for dichotomous outcomes. There were no signicant changes to the conclusions of the review. The second update, rst appearing in Issue 4, 2001, involved an expansion of the scope of the review to include comparisons of all forms of anaesthesia; as reected in the changed review title. The trial search was updated to December 2000. Three new trials were included; one comparing general versus spinal anaesthesia (Ungemach 1993) and two (Eyrolle 1998; de Visme 2000) comparing spinal anaesthesia with lumbar plexus blocks. Considerations of surrogate outcomes led to a slight amendment to the conclusions of the review.
INDEX TERMS Medical Subject Headings (MeSH)

Anesthesia [ methods]; Hip Fractures [ surgery]; Length of Stay; Postoperative Complications; Randomized Controlled Trials as Topic
MeSH check words

Aged; Female; Humans; Male
74

Anaesthesia For Hip Fracture Surgery in Adults (Review) : Parker MJ, Handoll HHG, Griffiths R

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Anaesthesia for hip fracture surgery in adults (Review)

Parker MJ, Handoll HHG, Grifths R

Anaesthesia for hip fracture surgery in adults

Criteria for considering studies for this review

Types of participants Skeletally mature patients undergoing hip fracture surgery.

Search methods for identication of studies

Data collection and analysis

Risk of bias in included studies

AUTHORS CONCLUSIONS Implications for practice

Implications for research

References to studies included in this review

References to studies excluded from this review

References to studies awaiting assessment

References to other published versions of this review

Characteristics of included studies [ordered by study ID]

Risk of bias Item Allocation concealment? Authors judgement No Description C - Inadequate

Authors judgement Unclear

Authors judgement Unclear

Authors judgement Unclear

Risk of bias Item Authors judgement Description

Allocation concealment? Kamitani 2003 Methods Participants

Authors judgement Unclear

Authors judgement Unclear

Notes Risk of bias Item Allocation concealment?

Authors judgement Unclear

Authors judgement Unclear

Notes Risk of bias Item Allocation concealment? Ungemach 1993 Methods

Authors judgement Unclear

Randomised trial: method not stated, mention of pairs

Authors judgement Unclear

Authors judgement Unclear

Notes Risk of bias Item Allocation concealment?

Authors judgement Unclear

Characteristics of excluded studies [ordered by study ID]

Alonso Chico 2003

Van Gessel 1989

DATA AND ANALYSES

Comparison 1. Regional (spinal or epidural) versus general anaesthesia

259 55 128 76 1245

Comparison 2. Spinal and light general anaesthetic versus general anaesthetic

Comparison 3. Regional (spinal or epidural) versus lumbar plexus nerve blocks

Totals not selected Not estimable Totals not selected

Mean Difference (IV, Fixed, 95% CI)

5.96 [4.46, 7.45] 5.8 [4.28, 7.32] 10.0 [2.24, 17.76]

Totals not selected Not estimable Not estimable

Totals not selected Not estimable

Comparison 4. Intravenous ketamine versus general anaesthesia

Risk Ratio M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1/28 3/64 17/259 4/15 8/73 4/56 2/35 17/281

0.6 % 10.4 % 18.3 % 2.5 % 15.2 % 19.5 % 5.9 % 27.7 %

Total (95% CI)

0.69 [ 0.50, 0.95 ]

Risk Ratio M-H,Random,95% CI

Risk Ratio M-H,Random,95% CI

1/28 3/64 17/259 4/15 8/73 4/56 2/35 17/281

1.8 % 9.3 % 21.8 % 6.8 % 17.1 % 12.7 % 6.5 % 23.9 %

Total (95% CI)

0.68 [ 0.44, 1.05 ]

General n/N 0/29 12/50 31/279 17/75 5/35 33/297

Risk Ratio M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1/28 7/50 36/259 16/73 4/35 22/281