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SICOT e-Newsletter

Issue No. 53 - February 2013

Worldwide News

Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture. A randomised control study
Hyun Kang, Yong-Chan Ha, Jin-Kun Kim, Young-Cheol Woo, Jae-Sung Lee. Eui-Chan Jang
The Journal of Bone and Joint Surgery, American Edition. 2013. Jan:95;1-6

Abstract: Background: Appropriate pain management affects outcome after hip fracture surgery. Although multimodal pain management is commonly used for pain control for patients undergoing elective surgery, few studies have evaluated its use in those undergoing hip fracture surgery. This prospective randomized study was designed to determine the clinical value of multimodal pain management with preemptive pain medication and intraoperative periarticular multimodal drug injections in patients undergoing bipolar hip hemiarthroplasty. Methods: Of eighty-two cognitively intact elderly patients about to undergo bipolar hemiarthroplasty after a hip fracture, forty-three were randomly assigned to receive preemptive pain medication and intraoperative periarticular injections (Group I) and thirty-nine were assigned to not receive preemptive medication and injections (Group II). These two groups were compared with regard to the pain level on postoperative days one, four, and seven; at discharge; and when they started walking and standing exercises. Total amounts of fentanyl used, the frequency of use of patient-controlled analgesia, patient satisfaction at discharge, and perioperative complications were recorded. Results: Group I had a lower pain level than Group II on postoperative days one and four, but no intergroup difference in pain level was observed on postoperative day seven. The total amount of fentanyl used and the frequency of use of patient controlled analgesia were also lower in Group I. Patient satisfaction at discharge was higher in Group I. No significant intergroup differences were found in the times until the patients walked or performed standing exercises or in the complications. Conclusions: Multimodal pain management provides additional pain relief until the fourth postoperative day, improves patient satisfaction at discharge, and reduces total narcotic consumption for postoperative pain management after hip hemiarthroplasty for hip fractures.

Comment by Syah Bahari

This is a very well-designed randomised control study that highlighted an optimised postoperative pain management after bipolar hemiarthroplasty for hip fracture.

The authors acknowledged the need for an evidence-based approach in optimising postoperative pain after bipolar hemiarthroplasty for hip fractures. Elderly patients are likely to have significant co-morbidities and on multiple medications, thus their pain management is likely to be sub-optimised due to possible side effects or drugs interaction that may affect respiratory, cardiac, renal or cognitive functions.

The authors designed the study with a clear primary end point which was postoperative pain score measured using the Visual Analog Scale (VAS). Secondary end points such as the frequency of PCA usage, fentanyl consumption, drug side effects and complications were also recorded.

Bias was limited by standardising the surgical procedure to posterior approach and performed by a single surgeon. Exclusion criteria using Mini Mental State Examination (MMSE) and Delirium Rating Scale (DRS) excluded patients with cognitive impairment. Statistical analysis of the data was well designed with pilot study to assess the postoperative pain score. The scoring system was also performed by an assessor blinded to the randomization.

The results of the study showed that multimodal pain management was effective. This resulted in the reduction of VAS and fentanyl consumption in the first four days. Nevertheless, they noted no significant difference in walking ability, pain level or length of stay at the time of discharge. However, patients with multimodal pain management were more satisfied with their treatment.

There were limitations to the study which the authors acknowledged and explained.

Overall, I think this is a very good evidence-based study that I would use in my postoperative pain management algorithm.