Comparison of Analgesic Efficacy of Suprainguinal Fascia Iliaca and Quadro-iliac Blocks in Hip Fracture Surgery

Comparison of the Postoperative Analgesic Efficacy of Ultrasound-Guided Suprainguinal Fascia Iliaca Block and Quadro-Iliac Plane Block in Patients Undergoing Hip Fracture Surgery

Hip fractures are common in the elderly and are associated with significant morbidity and mortality. Effective early analgesia is crucial for facilitating mobilization, reducing pulmonary complications, and improving overall outcomes. Although opioids are traditionally used for postoperative pain management, their adverse effects have led to increased interest in multimodal analgesia, particularly peripheral nerve blocks.

The suprainguinal fascia iliaca block (SIFI) is a modified technique that allows wider spread of local anesthetic, providing more effective blockade of the femoral, obturator, and lateral femoral cutaneous nerves. The quadro-iliac plane block (QIPB), a recently described interfascial block, is performed at the level of the anterior superior iliac spine and may also affect branches of the lumbar and sacral plexus.

While both techniques have been shown to provide effective analgesia and reduce opioid consumption, there is no study directly comparing them. Therefore, this study aims to compare the postoperative analgesic efficacy of SIFI and QIPB in patients undergoing hip fracture surgery.

Hip fractures are a significant health problem, particularly in the elderly, often resulting from osteoporosis, impaired balance, and falls, and leading to functional loss and increased dependency. The main subtypes include femoral neck, intertrochanteric, and subtrochanteric fractures. Surgical management typically involves internal fixation techniques such as proximal femoral nail (PFN), while complex fractures involving the acetabulum may require partial or total hip arthroplasty. Total hip arthroplasty is generally preferred in cases with acetabular involvement or advanced joint degeneration, whereas partial hip arthroplasty is commonly performed when the acetabulum is intact.

Adequate early postoperative analgesia is essential for both patient comfort and the prevention of complications. Insufficient pain control is associated with an increased risk of pulmonary complications, deep vein thrombosis, pressure ulcers, delayed mobilization, and even mortality. Opioid analgesics, widely used in postoperative pain management, are associated with significant side effects such as nausea, vomiting, constipation, sedation, and respiratory depression. Therefore, multimodal analgesia protocols have gained prominence, aiming to reduce opioid consumption and provide a safer and more comfortable postoperative period. Peripheral nerve blocks play a major role within these approaches.

Among anatomically suitable blocks for hip surgery are the suprainguinal fascia iliaca block (SIFI) and the quadro-iliac plane block (QIPB). SIFI is a proximal modification of the classical fascia iliaca block, targeting a wider spread to block the femoral, lateral femoral cutaneous, and obturator nerves. It is performed under ultrasound guidance by injecting local anesthetic into the potential space between the iliacus muscle and the fascia iliaca at the level of the anterior superior iliac spine (ASIS). Systematic reviews have shown that SIFI provides lower postoperative pain scores and significantly reduces opioid requirements, and is more effective than the classical technique in facilitating early mobilization.

QIPB, described by Tulgar et al. in 2024, is a novel anatomically based interfascial block. In this technique, after ultrasound imaging at the level of the posterior iliac crest using a convex probe, local anesthetic is injected into the potential plane between the iliacus muscle and the iliac wing. This region encompasses pathways of the femoral, obturator, lateral femoral cutaneous, genitofemoral, and ilioinguinal nerves, allowing for a broad क्षेत्र of neural coverage. Prospective observational studies by Marrone et al. and Turan et al. have demonstrated that QIPB provides effective early analgesia, reduces opioid consumption, and facilitates mobilization.

Although studies evaluating the analgesic efficacy of SIFI and QIPB exist, no randomized controlled trial directly comparing these two techniques has been identified. Additionally, methodological differences such as timing of block application, assessment points, and patient populations are present in the literature. In this study, the effects of SIFI and QIPB on postoperative 24-hour opioid consumption will be compared. Blocks will be performed preoperatively in the operating room under ultrasound guidance, and local anesthetic doses will be standardized for patient safety. The primary aim is to evaluate the analgesic efficacy of these two regional block techniques and to contribute to the existing gap in the literature.

Inclusion Criteria:

• Patients aged 18 years and older
• ASA physical status I-III
• Hemodynamically stable patients
• Scheduled for surgical treatment of hip fracture
• Body mass index (BMI) ≤ 35 kg/m²
• Provided written informed consent

Exclusion Criteria:

• Refusal to participate
• ASA physical status IV-V
• Hemodynamically unstable patients
• Surgery not completed as planned
• Infection at the block site
• History of allergy to local anesthetics or tramadol
• Presence of neuromuscular or peripheral nerve diseases
• Chronic pain conditions
• Coagulopathy or ongoing anticoagulant therapy
• High-dose opioid use within the last 3 days
• Severe hepatic or renal insufficiency
• Diabetes mellitus
• Pregnancy or breastfeeding
• NRS score >7 for four consecutive hours despite multimodal analgesia
• Inability to understand or use assessment tools (e.g., NRS, QoR-15)
• Inability to communicate in Turkish
• Inability to use PCA device due to technical reasons