Despite an apparent modest decline over recent years in the rate of hip fracture in the United States,1,2 this injury remains a leading cause of excessive morbidity and premature mortality among the elderly.3 Several factors may be contributing to a decreased risk of sustaining a hip fracture.1,2 Nevertheless, hip fracture is still one of the most common injuries among the elderly—the incidence rate rises exponentially with age3—and the aging of the population will therefore ensure that hip fracture continues to be a major clinical challenge and public health problem for the foreseeable future.
A variety of factors have been shown to influence outcomes of hip fracture surgery, including participation in rehabilitation therapy. The clinical importance of early mobilization and prompt participation in physical therapy is now widely recognized and, because postoperative pain can impair mobility and delay physical therapy, much attention is now being paid to finding more effective ways of controlling pain after hip fracture surgery.
TREATMENT ACCORDING TO FRACTURE TYPE
There are several different types of hip fracture, including subcapital femoral neck fracture, a basicervical femoral fracture, intertrochanteric femur fracture, and subtrochanteric femur fracture (Fig. 1).4 This classification is important because it dictates the treatment approach.
Subcapital femoral neck fracture requires either hemiarthroplasty—replacement of only the ball of the hip—or total hip arthroplasty (Fig. 2). The paradigm seems to be shifting toward total hip arthroplasty, which is supported by the latest literature.5 Total hip arthroplasty is particularly beneficial in active patients, because it typically results in a greater level of functionality; hemiarthroplasty in a patient who is very active usually leads to revision after approximately 5 years and conversion at that time to a total hip replacement. Hemiarthroplasty, however, is generally adequate for obtunded or delirious patients, those with a history of dementia, and the very elderly with a low level of mobility.
Basicervical femoral neck fractures, however, are generally treated with dynamic hip screws (DHS), derotational screw, or intramedullary (IM) nail (Fig. 3). Intertrochanteric fractures, which account for approximately half of all hip fractures,3 are the most common type. These fractures are also typically treated with either DHS or IM nail, depending on stability. And finally, subtrochanteric fractures are generally treated with IM nail.
CLASSICAL PAIN MANAGEMENT
All these procedures are accompanied by a high degree of pain. Yet the management of pain in patients undergoing surgical repair of hip fractures has traditionally been heavily dependent on the use of opioid drugs, including both intravenous (IV) and oral administration, as well as patient-controlled analgesia. This approach not only provides suboptimal analgesia but also has the potential to compromise outcomes.
Oversedation with opioid drugs, which is commonplace, inhibits communication between the patient and the health care team, and can delay ambulation and rehabilitation therapy—patients who have received high doses of opioids tend to be less able to ambulate during the day of surgery. Consequently, these patients may be more likely to require a skilled nursing facility, which adds further cost to the overall health care system. Moreover, the frequency of complications and readmissions seems to be higher when patients are discharged to a skilled nursing facility.6 And finally, of course, the potential for a wide range of undesirable and potentially dangerous adverse events using opioid drugs is widely recognized.
MULTIMODAL PAIN MANAGEMENT
The concept of multimodal analgesia was initially proposed over 20 years ago7 and has much of its origins in elective surgery, particularly joint replacement. It has been unequivocally established that pain associated with surgery is a complex and multifactorial phenomenon involving both the peripheral and central nervous systems,8 with multiple pain pathways contributing to the perception of postoperative pain. Although opioids are highly effective in blocking nociceptive pain through inhibition of the mu receptors, they do not block other pathways, such as the inflammatory cascade.
Multimodal analgesia involves the use of several anesthetic and analgesic modalities that are strategically combined to block pain perception at different sites in the peripheral and central nervous systems (Fig. 4).7 In addition to opioids, multimodal regimens commonly include medications, such as IV acetaminophen, nonsteroidal antiinflammatory drugs, selective cyclooxygenase-II inhibitors, regional nerve blocks, dexamethasone, and the gabapentinoids (ie, gabapentin, pregabalin). Pregabalin, however, should be used very judiciously in elderly hip fracture patients because it can cause oversedation and delirium at quite low doses in this population.
This balanced, multifaceted approach provides more effective control of postoperative pain than opioid drugs alone. It also allows lower doses of opioids to be used as part of the multimodal regimen, thereby reducing the risk of opioid-related adverse events and complications. And by simultaneously reducing postoperative pain and minimizing the degree of sedation, multimodal analgesia may facilitate more rapid recovery and improve certain outcome measures that are related to recovery time (eg, length of hospital stay). In fact, multimodal analgesia is one of the advances that have made it possible to perform total joint arthroplasty on an outpatient basis.
EFFECTIVENESS OF MULTIMODAL ANALGESIA IN HIP FRACTURE
Although many surgeons have anecdotally witnessed the benefits of multimodal analgesia in their own hip fracture patients, few studies have evaluated the effectiveness of this approach in hip fracture surgery.9 One prospective randomized study, however, has provided important insight in this setting. That study evaluated the clinical value of multimodal pain management with preemptive pain medication and intraoperative periarticular injections in 82 cognitively intact elderly patients undergoing bipolar hip hemiarthroplasty. The patients were randomly assigned to receive 1 of 2 pain management regimens:
- Multimodal analgesia with preemptive pain medication and intraoperative periarticular injections (group I; n = 43)
- No preemptive medication or intraoperative periarticular injections (group II; n = 39).
The investigators found that group I (multimodal regimen) had less pain compared with group II on postoperative days 1 and 4. By day 7, there was no intergroup difference in pain level, but much of the patients' recovery occurred within that period from days 1 through 4, so it is likely that there was insufficient residual pain at day 7 to show a difference between the treatment groups.
In addition, the total amount of fentanyl used and the frequency of use of patient-controlled analgesia were both also lower in the multimodal group. Postoperative pain is one of the biggest drivers of patient satisfaction, so it is therefore not surprising that satisfaction at discharge was also higher in the multimodal group. The study did not show any significant intergroup differences in the times until the patients walked or performed standing exercises, or in the rate of complications.
PROCEDURE-SPECIFIC MULTIMODAL ANALGESIA
The nature of the surgery being performed has been found to influence the type, location, intensity, and duration of pain,10 and the idea has emerged in recent years that pain management regimens should be procedure-specific.11,12 The following protocol has been used extensively in patients who undergo hip fracture surgery at our institution and has been found to be highly effective for controlling pain and minimizing the time to rehabilitation.
In the preoperating area, patients are given celecoxib, pregabalin, IV acetaminophen, and oxycodone, together with metoclopramide to control nausea. It is important to be cautious when administering oxycodone to elderly patients—life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients, and patients with significant chronic obstructive pulmonary disease or compromised respiratory function should be monitored closely, as even usual therapeutic doses of oxycodone may decrease respiratory drive in those individuals to the point of apnea. It is prudent to not administer oxycodone to patients older than 75 years.
Administering some of these medications while the patient is in the emergency department can be very beneficial—the goal should always be to preempt the pain as much as possible, rather than “chase the pain.” Patients with hip fracture, of course, do already have some pain when they are admitted, but immediate administration of a multimodal cocktail can begin to bring that pain under control while preempting their operative pain.
The intraoperative regimen varies somewhat, but it typically includes infiltration of the short-acting local anesthetic, bupivacaine HCl, together with morphine (10 mg in most cases), and ketorolac (15–60 mg).
Intraoperatively, spinal anesthesia is a very good adjunct because it helps reduce or eliminate the use of anesthetic gas. It is preferable not to use gas at all in this population when it can be avoided, and to administer propofol instead, as it is generally safer and produces less sedation immediately after the operation.
A cortisone derivative, such as triamcinolone or dexamethasone, can also be added. Long-acting liposomal bupivacaine is not available at all institutions. However, where the surgeon does have the option of infiltrating this medication into the surgical site during the procedure, it can be effective in maintaining a consistent level of analgesia once the other intraoperative medications begin to wear off.
Postoperatively, patients should continue on most of the medications that they received preoperatively, such as celecoxib, pregabalin, IV acetaminophen, oxycodone, or an acetaminophen and hydrocodone combination. Ideally, by receiving adequate multimodal analgesia throughout the entire patient journey, they are comfortable enough to ambulate early and fully participate in their rehabilitation therapy.
CASE: HIP FRACTURE IN A VERY ACTIVE 61-YEAR-OLD WOMAN
This recent case at our institution describes a very common presentation of hip fracture. The patient was a 61-year-old very active woman who had experienced a fall. Her medical history included breast cancer, and she had hypothyroidism, for which she was taking levothyroxine. On physical examination, the patient had pain with shortened range of motion in the left hip and was neurovascularly intact. X-rays confirmed that the patient had a displaced femoral neck fracture (Fig. 5).
The patient received the following preoperative medications for management of her pain:
- Celecoxib 200 mg;
- Pregabalin 75 mg;
- Oxycodone 10 mg;
- IV acetaminophen 1 g;
- Metoclopramide 10 mg for nausea.
Intraoperatively, the patient received the following medications:
- Bupivacaine HCl infiltration into the surgical site;
- Morphine 10 mg;
- Ketorolac 30 mg;
- Spinal anesthesia.
Because the patient was very active before her fall, she underwent total hip replacement (Fig. 6). Because of the multimodal analgesic regimen that she received, beginning before surgery, she was able to ambulate on the day of surgery and was discharged home on day 1 after surgery. She returned to the clinic 2 weeks later, walking without any assistive device, almost completely recovered, and reporting that she was extremely satisfied with her care and outcome.
There is now some clinical study evidence, supported by extensive anecdotal experience, showing that strategically balanced, procedure-specific multimodal analgesia provides effective pain relief in hip fracture patients through postoperative day 4, which is the most critical recovery period. In addition to providing effective pain management, multimodal analgesia also reduces the total amount of opioid medication required for postoperative pain management. Such a reduction in turn decreases the risk of opioid-related adverse events. Patient satisfaction tends to be enhanced using a multimodal regimen, rather than an opioid-dependent approach, and in the current era of fee-for-performance surgery, patient satisfaction is rapidly becoming an invaluable endpoint.
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