Hip fractures have a profound impact on the health of older Americans and represent a major clinical challenge. The incidence of hip fractures is high and increases with age; although it is often viewed as a health issue that predominantly affects women, this injury also occurs in a considerable number of men. At age 50 years, the approximate rates of hip fracture owing to low-impact injury are 23.9 and 22.5 per 100,000 population for women and men, respectively; by age 80 years, those rates increase more than 50-fold in women, to 1289.3 per 100,000 population, and almost 30-fold in men, to 630.2 per 100,000 population (Table 1).1
The mortality rate because of hip fracture is also very high. Approximately 1 in 4 women who sustain a hip fracture owing to low-impact injury will die within 1 year, and 1 in 3 men will die within 1 year1 Moreover, many people who have had a hip fracture are unable to return to their prefracture level of function, and 25%–50% of individuals still have not returned home 1 year after a fracture (Fig. 1).1
CONSEQUENCES OF HIP FRACTURE PAIN
Hip fractures are accompanied with a considerable amount of pain. That pain imposes an additional burden on the patient, including increased risk of delirium, depression, and sleep disturbance (Table 2). A major reason for depression after hip fracture, particularly among patients who are older than 65, is their loss of independence. Therefore, early mobilization and getting patients back to their normal lifestyle are keys to successful management. In addition, pain owing to hip fracture often results in altered responses to treatment for other comorbidities. When pain is not effectively managed, patients are not able to walk and they did before their injury, and they are more likely to have compromised pulmonary and cardiac function. As a consequence, preexisting comorbidities can become aggravated.
IMPLEMENTATION OF HIP FRACTURE PAIN MANAGEMENT
At many clinics, initial assessment of the patient who has sustained a hip fracture tends to focus on radiologic evaluation of the injury and planning the surgical repair. However, a more integrated treatment plan that provides a more comprehensive assessment of health, function, disease, and social situation, with an emphasis on comorbidities, pain relief, hydration, oxygenation, nutrition, elimination, delirium, and early mobilization, has been shown to improve patient function after surgery.2
Nevertheless, narcotic pain medications, which heavily sedate and confuse patients, are generally administered automatically in the emergency room, and the patients often are unable to meaningfully discuss their health or proposed treatment with the orthopedic surgeon. It therefore behooves surgeons to encourage healthcare professionals in the emergency room to move away from the prevailing narcotic-driven mindset and consider alternative agents, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. It is also important for healthcare professionals who manage elderly patients immediately after hip fracture to be aware that these individuals tend to require much lower doses of pain medication than other patients.
At some medical centers, the anesthesiologist is performing a nerve block on patients with hip fracture as soon as they are admitted to the emergency room. Observational studies have shown that earlier surgery after hip fracture is associated with better functional outcomes, shorter hospital stays and duration of pain, and lower rates of complications and mortality.3–10
Orthopaedic surgeons should therefore encourage the medical staff and hospital administration to allow scheduling for hip fracture patients as expeditiously as possible.
One way for the orthopaedic surgeon to facilitate this process is by blocking time for surgeries early in the morning and later in the afternoon or evening. When patients are admitted during the night, they can undergo surgery first thing in the morning; when they are admitted during the day, they can undergo surgery the same day. This approach is efficient for the surgeon and beneficial for the patient. By performing the surgery the same day, it is possible in most cases to have the patient out of bed and ambulating the next day.
The timing of surgery, of course, has implications for pain management—and vice versa. It is important that the orthopedic surgeon and anesthesiologist have a dialogue preoperatively about anesthetic and analgesic options. Specifically, the type of anesthetic that will be administered (ie, general, spinal, epidural), whether the patient will receive a nerve block, and whether nonopioid agents will be used during the procedure.
Therefore, the pain management process has essential preoperative, intraoperative, and postoperative components (Table 3). Even after the surgery, the medical doctor should not be the only clinician who is responsible for managing the patient's pain—postoperative pain has been shown to affect outcomes, and outcomes in turn can have a considerable impact on the orthopedic surgeon's practice. Therefore, the surgeon has a vested interest in ensuring that the patient's pain is managed optimally at all stages.
Today, there is widespread recognition and acceptance of the benefits of multimodal analgesia. Multiple pain pathways are known to exist; a balanced multimodal approach combines several anesthetic and analgesic modalities in a rational way to block the different pathways. Multimodal analgesia can provide more effective control of postoperative pain than narcotic agents alone, reduce the risk of opioid-related adverse events and complications, and improve some outcome measures.11–13
Even using multimodal analgesia, however, pain management after hip fracture is not a one-size-fits-all recipe—each patient presents quite different characteristics that can influence their pain perception. So, the appropriate analgesic regimen should take into account the medical and mental status of the patient, the characteristics of their fracture, and the requirements of their treatment plan, particularly with respect to time to ambulation.
Often, the families of elderly people who have sustained a hip fracture push for high doses of pain medication in an effort to obliterate their relative's pain altogether. In those situations, it is incumbent on the surgeon to explain to the family why it is more important to avoid oversedating the patient than to avoid all pain. Clearly, however, this situation presents a dilemma for both the surgeon and the facility—the degree of pain experienced by the patient is one of the strongest drivers of Press Ganey scores, which have a direct bearing on reputation and profitability.
ASSESSING THE COMPARATIVE EFFECTIVENESS OF PAIN MANAGEMENT INTERVENTIONS
Data on the comparative effectiveness of different approaches to pain management in patients undergoing surgery for hip fracture are not clear cut. In an effort to compare the effectiveness of pain management interventions for controlling both acute and chronic pain in nonpathologic hip fracture patients after low-energy trauma, a Cochrane database review examined data from 83 different pain management studies.14 In addition to comparing effectiveness with respect to acute and chronic pain control, this systematic review also examined the effect of pain management interventions on a wide range of outcomes other than pain (ie, mortality, mental status, ability to participate in rehabilitation), compared with the usual standard of care or other interventions, for up to 1-year postfracture (Table 4). Most of the subjects in the studies were women over 75 years of age, with no cognitive impairment.
Several different interventions were covered by this review (Fig. 2).
Narcotic medications and non-narcotic medications (ie, NSAIDs, acetaminophen) are both generally considered to be pharmacologic components of the usual standard of care for pain management after hip fracture.
Neuraxial (epidural or spinal) anesthesia, which involves injection of anesthetic into either the epidural space or subarachnoid space in the spinal column, is considered to have fewer side effects and risks than general anesthesia. Although patients usually recover their senses earlier with this approach, compared with general anesthesia, it is nevertheless necessary for them to wait for the anesthetic to wear off before they can walk.
Nerve Blocks (Regional Blocks)
Injection of anesthetics into nerve bundles prevents the generation and conduction of nerve impulses to the spinal cord and brain.
Preoperative skin or skeletal traction is a traditional approach after hip fracture for stabilizing the fractured leg, reducing pain, and improving fracture reduction.
Transcutaneous Electrical Nerve Stimulation (TENS)
Electrical energy is applied to peripheral nerves to reduce the perception of pain. It involves varying amplitudes and frequencies, depending on the indication.
After hip fracture surgery, rehabilitation is an integral part of the usual standard of care. The goals are to increase mobility and reduce pain by improving muscle strength and range of motion. Participation in rehabilitation, however, can be limited by delirium and the degree of pain experienced by the patient.
Complementary and Alternative Medicine
Various systems, practices, and products that are not part of conventional medicine are sometimes used in an effort to manage pain after hip fracture. These approaches include acupressure (application of pressure at body sites away from the pain locale) and Jacobson's relaxation technique (alternating between contracting and relaxing the muscles).
Multimodal Analgesic Regimens
Combination of several anesthetic and analgesic modalities in a rational way to block different pain pathways, as described above.
Overall, the findings of this systematic review indicate that there simply are not enough well-designed studies to unequivocally show which pain management approaches work well after hip fracture. However, certain approaches do not seem to be effective. Interestingly, although more than one-third of the studies included neuraxial anesthesia (with or without other agents, such as fentanyl and meperidine), collectively they showed no consistent benefit over general anesthetics. Moreover, there was no significant difference between continuous epidural anesthesia versus spinal anesthesia.
Similarly, several studies assessed the effectiveness of traction, yet they failed to demonstrate any meaningful benefit. This observation has important cost implications—facilities using traction could potentially make substantial financial savings without any decline in the quality of pain management.
Some data suggested that acupressure, relaxation therapy, and TENS may be associated with potentially clinically meaningful reductions in pain. However, there simply were not enough studies assessing these approaches to draw any firm conclusions.
Whereas the large number of studies looking at nerve blocks showed this modality to be effective in reducing acute pain, the strength of the evidence is moderate. Furthermore, these studies provided very little information about the use of nerve blocks with other additional analgesia, or on how nerve blockade may affect ambulation, mobility, and longer-term outcomes.
Unfortunately, despite the broad range of systemic analgesic agents that are available today, very few are covered by this systematic review. Consequently, the evidence is not helpful in guiding the selection of systemic drugs after hip fracture. In addition, many of the studies in this review were conducted before widespread use of multimodal analgesia regimens. Only 2 studies examined this approach, and neither included pain control among the endpoints. Yet, a number of experts believe that adequate evidence now exists for employing multimodal analgesia after hip fracture.15–17
In the elderly population, there is always particular concern about side effects with anesthesia and analgesia because they tend to be more serious in this population. However, the available evidence is inadequate to reliably estimate the adverse impact of the various pain management interventions in hip fracture patients.14
The high incidence of hip fracture, together with the associated morbidity, mortality, and cost of care, makes the management of hip fracture patients highly important from the perspective of both public health and orthopedic practice. The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgery patients in general,18 and orthopedic surgeons must consider all opportunities to improve outcome in patients who are undergoing surgery for hip fracture.
After hip fracture, pain is an important determinant of function, which determines length of stay and final outcome, and effective analgesia decreases the time required to achieve necessary clinical processes in patient recovery.19 Prospectively, collected data on patients admitted with hip fracture to 4 New York hospitals indicate that improved pain control may decrease length of stay, enhance functional recovery, and improve long-term functional outcomes.20 Yet, there is a lack of well-designed clinical studies to guide pain management strategies in this population.
This shortage of reliable data may be due, in large part, to the absence of a consensus for core health outcomes that should be reported in clinical trials of patients with a hip fracture.21 Nevertheless, it is clear that the prevailing opioid-dependent model of analgesia presents multiple drawbacks and risks that can compromise outcomes in the hip fracture population. Other interventions, such as nerve blocks and multimodal analgesia, should therefore be considered. For the time being, these approaches may have to be evaluated on the evidence provided by individual studies, rather than a larger body of data.
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