For hip fracture operations, besides the general anesthesia (GA) and neuraxial block (NB) techniques, recently, the combined lumbar plexus and sciatic nerve block (CLSB) technique is recommended, especially for high-risk patients [6–10]. When compared with GA and NB, minimal hemodynamic disturbance and so less affected cardiovascular stability are the advantages of CLSB [6–11]. NB is argued to reduce mortality when compared with GA [1, 12, 13]; however, survival studies in hip fracture patients have not analyzed the effects of CLSB on mortality.

The patients were divided into three groups according to anesthesia type as general anesthesia group (GA), neuraxial block group (NB), and combined peripheral nerve block group (CPNB). CPNB term was preferred to define addition of lateral femoral cutaneous nerve block to CLSB.

Patients' anesthesia types were evaluated by anesthesiology charts and data. Gender, age at admission, trauma date, and days passed until surgery were obtained from patients' computerized data, hospital charts, and folders. All of the patients were prescribed low-molecular-weight heparin for anticoagulation from admission to hospital to postoperative 20 days. Patients were phoned for followup and questioned for activity status. If a patient was not available for followup, a family member was interviewed; if the patients were dead, date of death; if they survived, daily living activity questioned. Daily living activity was scored by using Barthel Activities of Daily Living Index.

The preoperative status of the patients was classified according to the American Society of Anesthesiologists' (ASA) physical scale status to predict operative risk.

The ASA status among three groups was significantly different (P < 0.001) with Kruskal-Wallis test. To compare the groups' ASA status with each other, Mann-Whitney test was used. There were no significant differences in the ASA status between GA-NB (P = 0.2599). However, the ASA status were significantly different between CPNB and GA (P < 0.001), and between CPNB and NB (P < 0.014). CPNB patients' health status was worse than the other groups. The ASA status of patients according to groups is shown thoroughly in Table 2.

ASA physical scale status is commonly used to classify the preoperative status of the hip fracture patients [18–20]. Hamlet et al. [18] reported that 3-year mortality was significantly less for ASA I and II patients (23%) than for ASA III, IV, and V patients (39%). Michel et al. [19] reported that in 114 patients treated for hip fracture, high ASA status (3 or 4) conferred a nine times increased risk for mortality at one year. However, in the review for anesthetic risk factors, Haljamäe [21] stated that because ASA classification considers only physical status factors, other risk-predictive factors such as age and sex of the patient and the type, site, and duration of surgery should also be included for individual cases. Our patients' hip fractures were either femoral neck or intertrochanteric femur fracture. Because of different surgery modalities for these fractures, we could not take into consideration the perioperative blood loss and duration of surgery, that are the major limitations of our study. Also, in our recent research about predictors of mortality after hip fracture [14], we did not find any relationship between comorbidities (systemic diseases) and mortality. So, rather than the quantity (count), we preferred the significance of the diseases, which is reflected better with ASA. But, besides ASA, we included the age, sex, and delay in surgery as risk factors for mortality in multivariate analysis. We found that ASA, age, and delay in surgery were significant predictors of mortality.

When the three groups of patients were compared, there were no significant differences for sex, delay in surgery, mean followup, and Barthel score. Similar to other studies [12, 22, 23], delay in surgery is associated with increased mortality in this study, but has no emphasis for comparison of these three groups' mortality. However, the mean age of the NB patients was significantly younger than GA and CPNB patients, which would decrease the mortality of NB patients [2, 4, 24–26]. Also, the ASA status of CPNB patients was significantly worse than GA and NB patients, that would increase the mortality of CPNB patients according to other studies [18–20].

The one-month mortality rate was not significantly different for the three (GA, NB, and CPNB) groups. However, both one-year and overall mortality rates were decreased for the regional group (NB + CPNB). Also estimated survival time was higher for regional group. In several studies, the reduction in morbidity and mortality had been shown with regional anesthesia [12, 13]. Although there was no significant difference, the one-month mortality rates were 19.1%, 8%, and 17.4% for GA, NB, and CPNB patients, respectively. We believe that the younger mean age and better ASA status of NB patients than CPNB patients caused this one-month difference. However, by the time, if the highrisk patients succeeded in surviving for one month, the survival rate of CPNB patients became almost equal to the NB patients, even though they were older than the NB patients (Figure 1). Confirming this, CPNB choice was an independent variable of decreased mortality; however, NB choice was not in multivariate Cox regression analyses (Table 3).

Naja et al. [10] treated 60 patients for hip fracture, 30 patients with general anesthesia, and 30 patients with combined sciatic-paravertebral nerve block. They reported that both the incidence of intraoperative hypotension and the postoperative need for intensive care unit admission was significantly reduced in patients treated with combined sciatic-paravertebral nerve block compared to patients receiving general anesthesia. Similarly, in their prospective randomized study, de Visme et al. [6] treated 29 patients for hip fracture, 15 patients received combined lumbar and sacral plexus block, and 14 patients received spinal anesthesia. They found that hypotension was to be longer lasting after spinal anesthesia and of a larger magnitude in patients over 85 years of age. CLSB, as a rising trend, is correlated with minimal hemodynamic disturbance and so less affected cardiovascular stability [6–11]. These advantages of CPNB promote us to operate high-risk (ASA III AND IV) hip fracture patients earlier without seeking medical treatment modalities for their systemic diseases.