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Fascia iliaca block for pain control in hip fracture patients
El bloqueo iliofascial en el tratamiento analgésico de la fractura de cadera del anciano
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"apellidos" => "Anglés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servei de Anestesiologia i Reanimació, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El bloqueo iliofascial en el tratamiento analgésico de la fractura de cadera del anciano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1866 "Ancho" => 1591 "Tamanyo" => 109481 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">General pattern of patient selection.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Life expectations of the population at large are increasing every year. From 2010 to 2040 the world population over 65 will double and will account for 14% of the worldwide population. This increase will come about more rapidly in developed countries and there will be more people with osteoporosis, leading to a greater number of fractures as a result.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">1</span></a> Hip fractures are of greater relevance due to their high incidence and their associated morbidity and mortality. In 1990 there were 1.6 million hip fractures worldwide and it is estimated that this figure will increase to 6 million in the year 2050.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Most patients with hip fractures present with intense pain on their arrival at the emergency department, and effective pain control is an essential objective in any hospital.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> However, insufficient analgesia is a constant in both North American and European hospitals. Pain is not correctly assessed, the powerful analgesics are underused and delay in treatment initiation is commonplace.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the Spanish Society of Pain the mean time for receiving analgesia is 43<span class="elsevierStyleHsp" style=""></span>min.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">5</span></a> The standard of the Royal College of Emergency Medicine in United Kingdom is that 100% of patients with moderate or severe pain must receive analgesia during the first hour they are admitted to the emergency services.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Badly controlled pain, particularly in elderly patients, is associated with a higher risk of suffering from delirium, longer hospital stays and a worse quality of life.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The treatment of pain in these patients has traditionally been based on the use of non steroid anti-inflammatory drugs (NSAIDS),<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">8</span></a> which often have renal, cardiovascular and gastrointestinal side effects, or with opiates,<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">9,10</span></a> which are also associated with many side effects (nausea, constipation, confusion), particularly in elderly patients.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">11–13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Regional anaesthesia is an alternative for better treatment of pain and for reducing the consumption of NSAIDS and opiates. Fascia iliaca block is a relatively novel analgesia technique for pain control in elderly patients with hip fractures.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">14</span></a> The National Institute of Health and Care Excellence (NICE) recommends considering the use of a neurological block in these patients.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Fascia iliaca block provides effective pain management, is easy to perform and is associated with a very low risk of adverse effects.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">16–18</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In Spain there is no extended use of fascia iliaca block as an analgesic treatment in elderly patients with a hip fracture. However, the recent appearance of multidisciplinary orthogeriatric units which include anaesthetists may promote the introduction of this analgesic technique.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The Orthogeriatric Unit of our Hospital established an acute pain control protocol in patients who were admitted to the emergency department with proximal femoral fractures. The early administration of analgesia, fascia iliaca block and the performance of surgery within 24<span class="elsevierStyleHsp" style=""></span>h were the three main keystones.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The objective of this study was to assess the analgesic efficacy of fascia iliaca block performed in the emergency department on patients over 65 years of age with a clinical diagnosis of fracture due to the fragility of the proximal femur.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The duration of the effect of the fascia iliaca block and the rate of compliance with this analgesic technique, together with analysis of delay in administration of the analgesia and delay for surgery were secondary objectives of this study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0060" class="elsevierStylePara elsevierViewall">The analgesic protocol of the patient with a proximal femoral fracture due to fragility includes the fascia iliaca block since its approval by the Orthogeriatric Unit, in June 2013. It is administered on arrival at the emergency department prior to diagnostic imaging tests. The fascia iliaca block is performed without the use of a neuro-stimulator, or ultrasound guide, by the trauma resident doctors and attending physicians who received the patient. All patients who received fascia iliaca block were recorded prospectively.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Inclusion criteria</span><p id="par0065" class="elsevierStylePara elsevierViewall">Patients who were 65 years of age or older with a clinical diagnosis of a proximal femoral fracture and who did not present with any of the exclusion criteria were included.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Exclusion criteria</span><p id="par0070" class="elsevierStylePara elsevierViewall">Patients being treated with oral anti-coagulants were excluded from treatment, and also those who presented with allergies to local anaesthesia, who had skin infections at the inoculation site and minimum pain on arrival at the emergency department on the visual analogue scale (VAS) ≤2.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Training</span><p id="par0075" class="elsevierStylePara elsevierViewall">Prior to the introduction of this analgesic technique, the residents and attending physicians of the orthopaedic and trauma surgery unit were given training on how to perform the block by the Anaesthesia Department. This training consisted of a theoretical session and in performing the block during surgery supervised by an anaesthesia assistant.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Technique and analgesia</span><p id="par0080" class="elsevierStylePara elsevierViewall">The technique of administration is that described by Dalens et al.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">19</span></a> A line is drawn from the pectin pubis to the anterior superior iliac spine and then divided into three equal parts. For safety's sake it is always a good idea to feel the femoral artery, which normally occupies the most medial third of the line. The puncture site is located laterally to the neurovascular bundle, at a safe distance from it, right between the middle part and the lateral part and approximately 2<span class="elsevierStyleHsp" style=""></span>cm distal to this line (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Puncture is made with an 18<span class="elsevierStyleHsp" style=""></span>G Tuohy needle, since its angled point enables resistance to be detected with greater ease. Once it has passed through the skin it has to overcome its first resistance which is the fascia lata (normally at this point we would recommend an inclination of the needle of 70°, in caudocraneal direction, with respect to the patient's skin. The second resistance is the fascia iliaca. Once this has been overcome, we would recommend increasing the approach angle of the needle to 30–40° and inserting it by 1<span class="elsevierStyleHsp" style=""></span>cm more, approximately. Once this virtual space has been reached and with prior suction to ensure that the tip of the needle is not inside a vessel, we proceed with the injection of 0.3<span class="elsevierStyleHsp" style=""></span>ml/kg of levobupivacaine at 0.25%. The volume of the deposited local anaesthetic has cephalad spreading and enters into contact with the femoral nerve, the femorocutaneous nerve and lastly the obturator.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Once the block has been administered 1<span class="elsevierStyleHsp" style=""></span>g of intravenous paracetamol every 8<span class="elsevierStyleHsp" style=""></span>h and 3<span class="elsevierStyleHsp" style=""></span>mg of subcutaneous rescue morphine is administered, with prior pain evaluation by the nurse, in accordance with the VAS.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Variables</span><p id="par0095" class="elsevierStylePara elsevierViewall">The following variables were recorded:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0100" class="elsevierStylePara elsevierViewall">Pain on arrival at the emergency department and 15–30<span class="elsevierStyleHsp" style=""></span>min after having had the block, valued on the VAS or the PAINAD scale (in patients with mental impairment).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0105" class="elsevierStylePara elsevierViewall">The need to administer rescue analgesia and the VAS of the patient at the time of administration.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0110" class="elsevierStylePara elsevierViewall">Compliance with the analgesic technique.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0115" class="elsevierStylePara elsevierViewall">Delay in analgesia administration.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0120" class="elsevierStylePara elsevierViewall">Delay for surgical intervention.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0125" class="elsevierStylePara elsevierViewall">Patients’ age.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Sex.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0135" class="elsevierStylePara elsevierViewall">Anaesthetic risk according to the American Society of Anesthesiologists (ASA).</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0140" class="elsevierStylePara elsevierViewall">Type of fracture.</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Pain assessment scales</span><p id="par0145" class="elsevierStylePara elsevierViewall">The VAS is an effective tool for measuring the intensity of pain. It consists of a horizontal line measuring 10<span class="elsevierStyleHsp" style=""></span>cm where symptom extremes are expressed at both ends. On the left is the absence of pain or low pain intensity (usually described as “no pain”) and on the right that of the greatest intensity (usually described as “the worst pain imaginable”). The patient is invited to mark a point along this line which corresponds to the level of pain intensity they are feeling at that time. The result is the distance in millimetres from 0 to that marked by the patient.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The Pain Assessment in Advanced Dementia (PAINAD) scale contains non-verbal aspects. It is composed of five elements: breathing, negating, facial expression, body language and capacity for relief. Each element is given a score on the scale, and the total scores may range from 0 (no pain) to 10 (intense pain), equivalent to those of the VAS, with the following cut-off points: 1–3 (mild pain), 4–6 (moderate pain) and 7–10 (intense pain).<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical analysis</span><p id="par0155" class="elsevierStylePara elsevierViewall">A descriptive analysis was made of the sample. The quantitative variables were expressed as means and standard deviation, and the categorical variables as frequencies and percentages. For comparison of qualitative variables, the chi-square test was used and for comparison of means the Student's <span class="elsevierStyleItalic">t</span>-test was used for independent or paired data, in keeping with the ANOVA test.</p><p id="par0160" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">p</span> value under 0.05 was established for a bilateral significance for statistical contrasts. The SPSS 17.0 (SPSS Inc., Chicago, IL, U.S.A.) programme was used for statistical analysis.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0165" class="elsevierStylePara elsevierViewall">During a period of one year (January–December 2016), 216 patients were admitted to our emergency department with the diagnosis of a proximal femoral fracture. The data which enabled us to analyse the effectiveness of the fascia iliaca block were collected from 91 patients (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Patient sample characteristics where the effectiveness of the block is analysed are contained in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">The mean age of patients was 84 (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7.005) and over three quarters of patients (86%) were female. 56% of patients presented with an ASA III anaesthetic risk. Proximal femoral fractures were extra capsular in 62 cases and intra capsular in 29.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Statistically significant differences were observed between the VAS values before and after performing of the block (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). The mean pre-block VAS was 6.16 (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.82). After the block the mean VAS was 2.99 (95% CI: 2.45–3.53%).</p><p id="par0185" class="elsevierStylePara elsevierViewall">45% of the patients received rescue morphine at some time during the 24<span class="elsevierStyleHsp" style=""></span>h in the hospital and in 26% of cases it was necessary to administer it under 8<span class="elsevierStyleHsp" style=""></span>h after the block administration 80% of the patients presented with a VAS over 3 when they were administered the morphine. The mean duration of the analgesic effect of the fascia iliaca block was 6.5<span class="elsevierStyleHsp" style=""></span>h (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.8).</p><p id="par0190" class="elsevierStylePara elsevierViewall">The compliance rate of the analgesia protocol was 84%, with the block being administered in 148 patients (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0195" class="elsevierStylePara elsevierViewall">The block was administered, on average, in 16<span class="elsevierStyleHsp" style=""></span>min (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10.33).</p><p id="par0200" class="elsevierStylePara elsevierViewall">The median delay for surgical intervention was 1 day (RIQ 25–75%: 1–2).</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0205" class="elsevierStylePara elsevierViewall">The introduction of the fascia iliaca block as analgesic treatment for the patient who presented with a fracture of the femoral at the emergency department is valid, safe and effective.</p><p id="par0210" class="elsevierStylePara elsevierViewall">For Reavley et al.,<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a> both the fascia iliaca block and the 3-in-1 block are equivalent in the reduction of the VAS points in patients with femoral neck fractures. As a result they believe the emergency department staff may trust in this analgesic technique.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Godoy Monzón et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a> report similar results, for whom the fascia iliaca block is as effective as the NSAIDS, particularly for the first 8<span class="elsevierStyleHsp" style=""></span>h after its administration. In their study they emphasise that use of the fascia iliaca block has enabled the disuse of narcotics, thereby preventing their deleterious effects. Similarly to Reavley et al., they consider that the block leads to faster pain control in the emergency department. In our series narcotics were not necessary in 55% of cases.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Chaudet et al.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> not only refer to the effectiveness of the block but also underline that its administration in the emergency department on the patient's arrival is particularly beneficial. Up until 2015, with the exception of Foss et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">16</span></a> and Luger et al.,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">2</span></a> the majority of published studies refer to the administration of the block during the postoperative period. However, the most recent publications now defend the usefulness of its administration at the stage prior to surgery.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">16–18,22,23</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Finally, Callear and Shah<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">14</span></a> suggest that all hospitals which receive patients with proximal femoral fractures should have an established clinical guideline which includes regional anaesthesia in its pain control strategy for patients. Their study suggests that a single administration of the block in the emergency department, when the patient arrives, reduces the needs for the administration of analgesics during the whole postoperative period.</p><p id="par0230" class="elsevierStylePara elsevierViewall">The NICE recommends taking into consideration the use of the neurological block under two circumstances:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">1.</span><p id="par0235" class="elsevierStylePara elsevierViewall">When paracetamol or opiates do not provide sufficient pain relief.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">2.</span><p id="par0240" class="elsevierStylePara elsevierViewall">To limit opiate administration.</p></li></ul></p><p id="par0245" class="elsevierStylePara elsevierViewall">According to this guide, the recommendation of paracetamol administration every 6<span class="elsevierStyleHsp" style=""></span>h was necessary and the administration of rescue opiates. NSAID use is not recommended.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">The learning curve for the block technique is very short. In our hospital we consider it necessary to give previous training to the professionals who will be performing the blocks.</p><p id="par0255" class="elsevierStylePara elsevierViewall">In the study by Foss et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">16</span></a> all researchers were resident anaesthetists with an average experience of one year. They had received standard training in the practice of neurological blocks, but had had no specific training in fascia iliaca block administration.</p><p id="par0260" class="elsevierStylePara elsevierViewall">For the Danish researchers Høgh et al.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a> the learning curve is very simple, and therefore the fascia iliaca block is practised by any resident doctor in the emergency department, after a short training session.</p><p id="par0265" class="elsevierStylePara elsevierViewall">Lastly, the article by Obideyi and the fascia iliaca block administered by trained nurses is of relevance.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">We did not observe any complications relating to the administration of the fascia iliaca block in patients. Reavley et al.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a> explain that the anatomical references for the performance of the block may be easily identified, as is the location of the inoculation site which is at a safe distance from the neurovascular bundle. There is minimum risk of intravenous inoculation from anaesthesia or the probability of neurological injury. Specifically the risk recorded from neurological injury is .03%.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a> Sporadic cases have been published on the associated complications of a defective administration of the fascia iliaca block. Shelley and Haldane<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">27</span></a> published one case of an injection in the retroperitoneum. Atchabahian and Brown<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a> published a case of transitory neuropathy and Blackford and Westhoffen<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a> published a case of accidental puncture of the bladder. Godoy Monzón et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a> described in some cases the appearance of small skin blisters at the inoculation site minor skin.</p><p id="par0275" class="elsevierStylePara elsevierViewall">The fascia iliaca block was effective 15<span class="elsevierStyleHsp" style=""></span>min after administration, although after 7<span class="elsevierStyleHsp" style=""></span>h its effect began to wane. In the randomised prospective study by Godoy Monzón et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a> highly significant pain relief was felt 15<span class="elsevierStyleHsp" style=""></span>min after administration of the block compared with that of NSAIDS, although the effect began to wane 8<span class="elsevierStyleHsp" style=""></span>h after administration.</p><p id="par0280" class="elsevierStylePara elsevierViewall">In our series, 26% of the patients required the administration of rescue morphine less than 8<span class="elsevierStyleHsp" style=""></span>h after block administration. The percentage of effective blocks was 74%. Foss et al. present an effective block percentage of 67%, which they consider low compared with other previous studies, where the effective block percentages were higher (81–96%).<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">16,30,31</span></a> This lower percentage of effective blocks is attributed to the fact that although the administration technique is relatively simple, there is a minor learning curve, and in their block study, they were not administrated by a limited number of specialists. In our series there was also a major variability between the professionals who had used the technique.</p><p id="par0285" class="elsevierStylePara elsevierViewall">Ultrasound-guided block administration and the placing of continuous infusion catheters could improve effectiveness and duration of the analgesia.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">22,32,33</span></a> However, in our opinion both procedures increase the complexity of the technique and limit the number of specialists who may practice it. For this reason, we do not consider these as valid alternatives for the administration of early analgesia in emergency services. Both could, however, be used in postoperative analgesia.</p><p id="par0290" class="elsevierStylePara elsevierViewall">The compliance rate of the new strategy was high (84%), which shows that the involvement of this analgesic technique had a considerable impact on the specialists who had administered it in the emergency department. Although pain treatment is a basic clinical practice, in patients with hip fractures it is often insufficient, incorrectly assessed, powerful analgesics are underused and delay in treatment is common.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">11</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">In the study by Hwang et al.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">34</span></a> 36% of patients with hip fractures and who stated they were in pain in the emergency department did not receive any type of analgesia, 7% received non-opioid analgesic drugs and the remaining 57% received opiates.</p><p id="par0300" class="elsevierStylePara elsevierViewall">As previously mentioned, the fascia iliaca block is one of the three keystones upon which our analgesic strategy is based. The second keystone is early administration. Once the patient presents at the hospital the block is immediately administered, based on clinical diagnosis and prior to carrying out imaging studies. The patients receive the analgesia after an average of 15<span class="elsevierStyleHsp" style=""></span>min. We therefore complied with the Royal College of Emergency Medicine in United Kingdom standard in that 100% of patients with moderate or severe pain receive analgesia during the first hour after their arrival at the emergency department.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a> We improved the 43<span class="elsevierStyleHsp" style=""></span>min mean waiting time for patients in Spanish hospitals to receive analgesia.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">5</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Early administration has also been reflected in other articles,<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">17,35</span></a> and is mainly explained by the following mechanisms:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">1.</span><p id="par0310" class="elsevierStylePara elsevierViewall">Because it can be carried out on clinical suspicion of proximal femoral fracture prior to imaging studies.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">2.</span><p id="par0315" class="elsevierStylePara elsevierViewall">Because it is a simple technique to put into practice which may be carried out by the professionals who normally work at the emergency department, without the need to locate specialists who are often unavailable.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">3.</span><p id="par0320" class="elsevierStylePara elsevierViewall">Because it is not necessary to use a scan to perform it, which could delay its administration, require specific training in ultrasound and increase the cost of the procedure.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a></p></li></ul></p><p id="par0325" class="elsevierStylePara elsevierViewall">Lastly, the third keystone of the analgesic strategy is early surgery. Most patients were referred to surgery during the first to 24<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0330" class="elsevierStylePara elsevierViewall">In 2011 The Association of Anaesthetists of Great Britain and Ireland published a guideline for proximal femoral fracture management. The third point of the summary is that surgery is the best analgesic for a hip fracture.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">36</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">Early surgery, in under 48<span class="elsevierStyleHsp" style=""></span>h, is not only performed for analgesic reasons of course. It is currently the treatment base strategy for hip fracture patients, since numerous retrospective studies have reported a report in mortality and complications of patients who are not operated on as soon as possible. This is therefore one of the most essential objectives of the orthogeriatric units and the fast-track protocols in proximal femoral fracture patients.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0340" class="elsevierStylePara elsevierViewall">The fascia iliaca block is a reproducible, effective and safe analgesic technique. Its learning curve is short, administration technique is simple and there is a very low risk of adverse effects. All of these factors promote its administration to the patient on arrival at the emergency department with consequent early and effective analgesia as a result.</p><p id="par0345" class="elsevierStylePara elsevierViewall">The fascia iliaca block is an essential keystone in the analgesic strategy of hip fracture patients. The other two keystones of this strategy are early analgesia and reduced delay to surgery.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Level of evidence</span><p id="par0350" class="elsevierStylePara elsevierViewall">Evidence level IV.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical disclosures</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Protection of human and animal subjects</span><p id="par0360" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Confidentiality of data</span><p id="par0365" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Right to privacy and informed consent</span><p id="par0370" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0355" class="elsevierStylePara elsevierViewall">All the authors declare that there is no type of conflict of interests which could have weighted or influenced their actions or the study outcome.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres941116" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec914333" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres941115" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec914332" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Inclusion criteria" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Exclusion criteria" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Training" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Technique and analgesia" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Variables" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Pain assessment scales" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Level of evidence" ] 10 => array:3 [ "identificador" => "sec0075" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-04-11" "fechaAceptado" => "2017-07-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec914333" "palabras" => array:4 [ 0 => "Iliofascial block" 1 => "Hip fracture" 2 => "Pain" 3 => "Orthogeriatrics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec914332" "palabras" => array:4 [ 0 => "Bloqueo iliofascial" 1 => "Fractura de cadera" 2 => "Dolor" 3 => "Ortogeriatría" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pain treatment for patients with hip fracture has been based on the use of nonsteroidal anti-inflammatories and opioid derived drugs. These medications have been associated with multiple adverse effects. Fascia iliaca block is a recent pain management alternative for these patients.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The objective of this study was to evaluate the effectiveness of fascia iliaca block performed in the emergency room (ER) for patients over 65 years of age with hip fracture.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A cohort of 216 patients, from January to December 2016, was studied prospectively. Analysed variables were pain upon arrival at ER, pain after fascia iliaca block, need for rescue medication, protocol compliance, delay in analgesia administration and delay for surgery.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Differences between visual analogue scale (VAS), before and after the fascia iliaca block, were statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001). Pre-block VAS recorded was 6.16 (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.82). The mean VAS reduction after the block was 2.99 (95% CI: 2.45–3.53%). Twenty-six percent of patients required morphine as rescue medication in the first 8<span class="elsevierStyleHsp" style=""></span>h after diagnosis. Compliance with protocol administration was of 84%. Fascia iliaca block was performed in a mean time of 16<span class="elsevierStyleHsp" style=""></span>min (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10.33) after diagnosis. The median delay for surgery was 1 day (RIQ 25–75%: 1–2).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Fascia iliaca block is a reproducible, safe and effective technique for pain management. It is a keystone in pain treatment for patients with a proximal femur fracture at our institution. Other objectives in our pain management protocol include early analgesia administration and reduction of time to surgery.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La analgesia en pacientes con fractura de cadera se ha basado en la utilización de antiinflamatorios no esteroideos y opiáceos, que se asocian a múltiples efectos secundarios. El bloqueo iliofascial es una alternativa analgésica relativamente novedosa en el tratamiento del dolor de estos pacientes.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo es evaluar la eficacia analgésica del bloqueo iliofascial realizado en Urgencias a pacientes mayores de 65<span class="elsevierStyleHsp" style=""></span>años con fractura de cadera.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Entre enero y diciembre de 2016 fueron estudiados prospectivamente 216 pacientes. Las variables analizadas fueron: dolor al llegar a Urgencias y después del bloqueo, necesidad de rescate, cumplimiento del protocolo, demora en la administración de la analgesia y demora para la cirugía.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se observaron diferencias estadísticamente significativas entre los valores de EVA antes y después del bloqueo (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). La puntuación EVA media pre-bloqueo fue de 6,16 (DE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2,82). Tras el bloqueo, la disminución media de la EVA fue de 2,99 (IC<span class="elsevierStyleHsp" style=""></span>95%: 2,45-3,53%). El 26% de los pacientes recibieron morfina de rescate en las primeras 8<span class="elsevierStyleHsp" style=""></span>h. La tasa de cumplimiento del protocolo analgésico fue del 84%. El bloqueo se administró en 16<span class="elsevierStyleHsp" style=""></span>mins de media (DE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10,33). La mediana de demora para intervención quirúrgica fue de 1<span class="elsevierStyleHsp" style=""></span>día (RIQ 25-75%: 1-2).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El bloqueo iliofascial es una técnica analgésica reproducible, efectiva y segura. Constituye un pilar fundamental en la estrategia analgésica de los pacientes con fractura de cadera en nuestro centro. Los otros dos pilares incluyen la analgesia precoz y la disminución de la demora para la intervención quirúrgica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Castillón P, Veloso M, Gómez O, Salvador J, Bartra A, Anglés F. El bloqueo iliofascial en el tratamiento analgésico de la fractura de cadera del anciano. Rev Esp Cir Ortop Traumatol. 2017;61:383–389.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1267 "Ancho" => 950 "Tamanyo" => 214290 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Puncture site.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1866 "Ancho" => 1591 "Tamanyo" => 109481 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">General pattern of patient selection.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Result \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84 (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7.01) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78 women (86%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">ASA</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 (39%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 (56%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Type of fracture</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pertrocanteric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 (49%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Subtrocanteric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (19%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Subcapital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (32%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">S<span class="elsevierStyleItalic">ide</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 (50%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 (50%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592740.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Sample characteristics.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0190" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International Population Reports, P95/09-1, An Aging World: 2008" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 3 | 11 |
| 2024 October | 42 | 5 | 47 |
| 2024 September | 36 | 5 | 41 |
| 2024 August | 43 | 11 | 54 |
| 2024 July | 40 | 10 | 50 |
| 2024 June | 23 | 2 | 25 |
| 2024 May | 27 | 5 | 32 |
| 2024 April | 39 | 7 | 46 |
| 2024 March | 57 | 6 | 63 |
| 2024 February | 31 | 4 | 35 |
| 2024 January | 39 | 9 | 48 |
| 2023 December | 47 | 14 | 61 |
| 2023 November | 37 | 14 | 51 |
| 2023 October | 37 | 10 | 47 |
| 2023 September | 23 | 4 | 27 |
| 2023 August | 23 | 8 | 31 |
| 2023 July | 34 | 14 | 48 |
| 2023 June | 40 | 3 | 43 |
| 2023 May | 66 | 11 | 77 |
| 2023 April | 55 | 8 | 63 |
| 2023 March | 37 | 10 | 47 |
| 2023 February | 35 | 3 | 38 |
| 2023 January | 21 | 4 | 25 |
| 2022 December | 22 | 10 | 32 |
| 2022 November | 32 | 8 | 40 |
| 2022 October | 27 | 19 | 46 |
| 2022 September | 31 | 8 | 39 |
| 2022 August | 26 | 4 | 30 |
| 2022 July | 22 | 9 | 31 |
| 2022 June | 73 | 18 | 91 |
| 2022 May | 36 | 7 | 43 |
| 2022 April | 25 | 11 | 36 |
| 2022 March | 26 | 7 | 33 |
| 2022 February | 33 | 6 | 39 |
| 2022 January | 28 | 9 | 37 |
| 2021 December | 47 | 12 | 59 |
| 2021 November | 33 | 5 | 38 |
| 2021 October | 50 | 11 | 61 |
| 2021 September | 47 | 16 | 63 |
| 2021 August | 53 | 9 | 62 |
| 2021 July | 30 | 9 | 39 |
| 2021 June | 22 | 8 | 30 |
| 2021 May | 26 | 9 | 35 |
| 2021 April | 77 | 21 | 98 |
| 2021 March | 33 | 13 | 46 |
| 2021 February | 18 | 6 | 24 |
| 2021 January | 14 | 12 | 26 |
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