British Journal of Anaesthesia 102 (1): 11116 (2009)

doi:10.1093/bja/aen345

PAIN Postoperative pain after hip fracture is procedure specic

N. B. Foss1 2*, M. T. Kristensen2 3, H. Palm2 and H. Kehlet4
4

Department of Anesthesiology, 2Department of Orthopedic Surgery, 3Department of Physiotherapy and Section of Surgical Pathophysiology 4074, Rigshospitalet Copenhagen University, Copenhagen DK-2100, Denmark
*Corresponding author: Department of Anesthesiology, Rigshospitalet, Copenhagen DK-2100, Denmark. E-mail: nbf@comxnet.dk/nicoli.bang.foss@hh.hosp.dk
Background. Hip fracture patients experience high pain levels during postoperative rehabilitation. The role of surgical technique on postoperative pain has not been evaluated previously. Methods. One hundred and seventeen hip fracture patients were included in a descriptive prospective study. All patients received continuous epidural analgesia and were treated according to a standardized perioperative rehabilitation programme. Resting pain, pain on hip exion, and walking were measured during daily physiotherapy sessions on a verbal ve-point rating scale during the rst four postoperative days. Patients were stratied into four groups according to surgical procedure: screws or pins, arthroplasty, dynamic hip screw (DHS), and intramedullary hip screw (IMHS). Results. Cumulated pain levels were signicantly different between surgical procedures both for hip exion (P0.002) and for walking (P0.02) with highest dynamic pain levels for patients who had either DHSs or IMHSs compared with arthroplasty or parallel implants. There were signicant negative correlations between ambulatory capacity assessed by the cumulated ambulation score and both the dynamic cumulated pain scores on hip exion (r20.43, P,0.001) and walking (r20.36, P0.004). Conclusions. Postoperative pain levels after surgery for hip fracture are dependent on the surgical procedure, which should be taken into account in future studies of analgesia and rehabilitation. Br J Anaesth 2009; 102: 11116 Keywords: complications, fracture; pain, postoperative Accepted for publication: October 19, 2008
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Postoperative pain levels after hip fracture are high during ambulation1 2 and may worsen outcome after hip fracture.3 Regional analgesia has been shown to facilitate rehabilitation in orthopaedic procedures,4 6 epidural analgesia minimizes pain as a restricting factor for physiotherapy after hip fracture surgery,2 and perioperative regional analgesia has been shown to have the potential to reduce perioperative morbidity in hip fracture patients.7 8 However, hip fracture patients are a heterogenous group treated surgically with parallel screws, arthroplasty, dynamic hip screws (DHSs) or intra-medullary hip screws (IMHSs) according to the fracture type, patient age and prefracture functional level.9 10 Previous studies of pain and regional anaesthetic techniques after hip fracture surgery have not examined the inuence of surgical procedure on pain

levels in the postoperative period. We therefore conducted a descriptive, prospective study of resting and dynamic pain in the postoperative period after hip fracture surgery in patients treated according to a standardized multimodal perioperative care programme,11 including perioperative continuous epidural analgesia.2

Methods
Patients and design
From January 2003 to June 2006, 981 patients admitted to the Hvidovre University Hospital hip fracture unit were screened for inclusion into this descriptive prospective study. Of these 75 were admitted from other hospital

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Foss et al.

wards, 258 were not living in their own home, 129 were not cognitively intact, 25 had other simultaneous fractures, 39 were not capable of independent indoor ambulation, and 12 had a history of substance abuse or were on regular opioid therapy. Of the remaining 443 patients, seven had contraindications to placement of an epidural catheter, 29 could not participate in the physiotherapy programme, and 30 were excluded because they did not receive the standardized pain regimen as a result of inclusion in another study.2 A total of 260 patients otherwise eligible for inclusion were not included due to unavailability of the investigators, leaving 117 included patients available for analysis. There were no important differences in age, American Society of Anaesthesiologists (ASA) score, functional level, or fracture type between included patients and those eligible for inclusion but not included in the analysis because of unavailability of investigators. The study is a part of Hvidovre University Hospitals Hip Fracture Project, which was evaluated by the Local Ethics Committee, who had no objections to the project and concluded that no written patient consent was necessary. The study was approved by the Danish data protection agency.

Procedures
On arrival in the emergency room patients received regional analgesia by a fascia iliaca compartment blockade with 40 ml of bupivacaine 0.25% or mepivacaine 1% both with epinephrine 1:200 000.12 After X-ray examination conrmed a hip fracture, the patients were then taken to the postanaesthesia care unit where an epidural catheter was inserted in the L23 or L34 interspace and tested with 60 mg lidocaine 2% with epinephrine 1:200 000. Epidural analgesia was provided with a bolus of 25 mg bupivacaine 0.25% followed by a continuous epidural infusion of bupivacaine 0.125% and morphine 50 mg ml21 at a rate of 4 ml h21 before operation and in the postoperative phase. Anaesthesia for surgery was provided by topping up the epidural with 50 mg of bupivacaine 0.5% in increments of 5 ml and 1 mg of epidural morphine (2 mg for patients ,70 yr). No premedication was given, but slight sedation with propofol was provided at a rate of 1040 mg kg21 min21 on patient request. Standardized uid and transfusion therapy were given in the entire perioperative phase.2 13 After operation, the patients received bupivacaine 0.125% and morphine 50 mg ml21 4 ml h21 continued until 8.00 a.m. on the fourth postoperative day. All patients received additional analgesia with acetaminophen 1 g 6 hourly and the rst 28 patients received rofecoxib 25 mg once daily from the time of admission. This ceased to be or practice when rofecoxib was removed from the market. Rescue medication was provided as morphine bolus intravenously.2 From admission until the fourth postoperative day, patients received supplemental oxygen therapy 2 litre min21 when supine. Immediately after surgery, the patients were on regular diet supplemented by three daily protein drinks.

The department used the Danish national guidelines for surgical technique for the various fracture types: undisplaced intracapsular fractures were operated on with two parallel implants (Olmed screws or Hansson pins). In displaced intracapsular fractures, the treatment depended on the age of the patient. If the patient was 75 yr or younger, the fracture was reduced and internally xed with the above mentioned two parallel implants. If the patient was older than 75 yr, an uncemented hemiarthroplasty was inserted. If the hemiarthroplasty was not stable perioperatively, a cemented hemiarthroplasty was inserted. All stable trochanteric and basocervical fractures received a DHS, whereas the unstable trochanteric and subtrochanteric fractures received an IMHS. Wound drains were not used. After operation, the patients were mobilized if at all possible on the day of operation, and an intensive physiotherapy programme comprising two daily 30 min sessions, started on the rst postoperative day (Day 1). Discharge criteria from the hip fracture unit were standardized: the ability to independently get in and out of bed and to and from a place of eating, the ability to independently perform bathroom visits and the ability to walk with the walking aid to be used in the home. Patients were primarily rehabilitated in the orthopaedic ward and discharged to their home.

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Study parameters
Data were gathered prospectively. ASA classication, type of surgery, length of stay, and 30-day mortality were all registered, the latter established through the Danish civil register. Prefracture functional level expressed by the new mobility score (0 9, with 0 5 indicative of poor walking function) was recorded upon admission.14 Mental status, assessed by a validated nine-point Danish version of the abbreviated mental status test was taken upon admission.15 Physiotherapy sessions were conducted by specially assigned project physiotherapists. The sessions were initiated with an assessment of pain made before the start of physiotherapy after the patient had been resting in bed for 15 min. Dynamic pain was assessed during the treatment sessions on 458 exion of the hip while supine and upon walking either assisted or independently. Pain was measured as reported by the patient on a ve-point verbal ranking score (VRS) from 0 to 4 with the categories none, light, moderate, severe, and intolerable pain. During the physiotherapy session, the patients were evaluated on their ambulatory capacity by the cumulated ambulation score (CAS),16 which allows day-to-day measurements of functional mobility in hip fracture patients in the early postoperative phase. The CAS (018) has been validated and found to be predictive of postoperative rehabilitation outcome.16

Statistics
A composite pain score, representing the cumulated pain score for the rst 4 days for each physical function, was

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calculated by adding the scores of the individual days. Tests for signicant intergroup differences between the four fracture types were made using KruskallWallis non-parametric ANOVA, while testing for between group differences where relevant were made with the MannWhitney test. Correlations were measured by Spearman rank correlation and the x 2 test was used for testing the signicance of categorical data. Pain data are presented as median (2575 percentiles). All data analyses were conducted with SPSS for windows version 10.1 (SPSS inc., Chicago, IL, USA).

moderate pain or higher (VRS 2 4) on either hip exion or walking is presented in Figure 2. Signicant negative correlations were found between the CAS and both the dynamic cumulated pain score pain on hip exion (r20.43, P,0.001) and the cumulated pain score on walking (r20.36, P0.004); there was no signicant correlation between cumulated pain at rest and the CAS.

Discussion
Pain after hip fracture surgery according to procedure type has not previously been studied in detail. We found signicant differences in dynamic pain between procedures, with hip arthroplasty and parallel implants having the lowest pain levels and DHS and IMHS the highest. We also found a signicant inverse correlation between dynamic pain and ambulation scores during the rst four postoperative days. Previous studies have documented high pain levels after hip fracture surgery with conventional analgesic methods.1 Postoperative epidural analgesia with local anaesthetics and low-dose opioids has been documented to reduce postoperative myocardial ischaemia,8 improve analgesia and minimize pain as a limiting factor for postoperative rehabilitation.2 Limitations in postoperative rehabilitation because of motor block have not been demonstrated.2 The risk/ benet ratio of regional analgesic methods is theoretically dependent on the postoperative pain level of the surgical procedure, since patients with low levels of postoperative pain will potentially be more hampered by indwelling catheters, delivery systems and any residual motor or urinary bladder blockade compared with their potential gains in ambulation due to attenuation of dynamic pain, whereas the opposite seems to be the case with patients with moderate to high levels of dynamic pain. As such, optimal postoperative pain therapy should therefore be procedure specic to minimize unwanted side effects.17 Procedures with parallel pins or screws are in principle minimally invasive, with small amounts of tissue trauma and low blood loss leaving the intracapsulary fractured bone in situ; arthroplasty has a larger incision and amount of tissue trauma but essentially removes the fracture site; whereas DHS and IMHS procedures have moderate to

Results
During the inclusion period, 117 patients qualied for inclusion. Of these, 28 participated in a randomized study comparing epidural and opioid analgesia (only patients receiving standardized epidural analgesia were included).2 Patient characteristics are shown in Table 1. Included patients had a high prefracture functional and mental status as evidenced by the new mobility and mental scores. This was reected in a 30-day mortality of only 2%. There were no important differences in characteristics between patients according to surgical procedure. Pain scores at rest and during physiotherapy stratied by the type of surgical procedure are presented in Table 2. Pain scores at rest were low, with patients almost uniformly reporting no pain at rest and no signicant differences between the different types of surgery. Dynamic pain scores showed a consistent trend on all four postoperative days, with patients with arthroplasty reporting the lowest pain levels and patients with DHS and IMHS reporting higher scoreshighest for IMHS. These differences reached statistical signicance for hip exion on Days 2 and 4 (P0.02) and on Day 1 for walking (P0.02). The cumulated pain scores for the rst 4 days are presented in Figure 1. There were signicant differences between the four types on surgery for both hip exion (P0.002) and walking (P0.02) pain scores. The patients with arthroplasty procedures had the lowest dynamic pain levels with DHS and IMHS procedures having signicantly higher pain levels on hip exion and hip exion plus walking, respectively. The percentage of patients reporting either slight pain or higher (VRS 1 4) at rest or

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Table 1 Characteristics of hip fracture patients in the study of pain and type of surgery. Type of surgery: DHS, dynamic hip screw; IMHS, intramedullar hip screw; ASA, American Society of Anaesthesiologists classication. Data are presented as median (range) for numeric data Number of patients Age Female sex ASA III IV New mobility score (0 9) Mental score (0 9) Delay to surgery (h) Intraoperative bleeding (ml) Hospitalization (days) 30-day mortality Screws/pins 9 80 (67 91) 8 (90%) 3 (33%) 6 (3 9) 9 (6 9) 20 (10 36) 100 (20 150) 11 (6 22) 0 Arthroplasty 44 82 (73 94) 40 (91%) 13 (30%) 8 (3 9) 9 (5 9) 19 (3 54) 275 (50 1400) 13 (6 80) 1 (2%) DHS 49 81 (41 98) 32 (65%) 13 (27%) 9 (2 9) 9 (6 9) 19 (5 47) 200 (0 1400) 14 (4 70) 1 (2%) IMHS 15 81 (69 97) 12 (80%) 4 (27%) 7 (2 9) 9 (6 9) 21 (8 47) 300 (100 700) 16 (10 52) 0

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Table 2 Pain at rest and during mobilization in 117 hip fracture patients according to type of surgery. Pain score is a verbal ranking score (VRS) 0 4. Values given are median (25 75 percentiles). Test for signicant differences between groups with KruskallWallis non-parametric ANOVA Number of patients Screws/pins 9 Arthroplasty 44 DHS 49 IMHS 15 P-value
Percentage with VRS 14

100 90 80 70 60 50 40

Pain at rest

Percentage with VRS 24

Pain at rest Day 1 0 (0 0) Day 2 0 (0 0) Day 3 0 (0 0) Day 4 0 (0 0) Pain on 458 hip exion Day 1 1 (0 2) Day 2 1 (0 2) Day 3 1 (0 1) Day 4 0 (0 1) Pain on walking Day 1 2 (0 2) Day 2 1 (0 2) Day 3 1 (1 1) Day 4 1 (1 2) Cumulated 10 (6 17) ambulation score (0 18)

0 0 0 0 1 0 0 0 1 1 1 1 9

(0 0) (0 0) (0 0) (0 0) (0 1) (0 1) (0 1) (0 1) (0 2) (0 1) (0 1) (0 2) (6 13)

0 0 0 0 1 1 1 1 1 1 1 1 9

(0 0) (0 0) (0 0) (0 0) (0 2) (0 2) (0 2) (0 2) (1 2) (0 2) (1 2) (1 2) (9 12)

0 0 0 0 1 1 1 1 2 2 1 1 9

(0 0) (0 0) (0 0) (0 0) (1 2) (1 3) (0 1) (0 2) (2 2) (1 2) (1 3) (1 2) (8 9)

0.30 0.82 0.89 0.42 0.08 0.02 0.39 0.02 0.02 0.2 0.35 0.65 0.36

Day 1 30 20 10 0 Screws/pins Arthroplasty DHS IMHS Type of surgery 100 90 80 70 60 50 40 Day 1 30 20 10 Day 2 Day 3 Day 4 Screws/pins Arthroplasty DHS Type of surgery 100 90 Pain on walking IMHS Pain on hip flexion Day 2 Day 3 Day 4

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Cumulated pain 12 * 10 Cumulated VRS (Days 14) 8 6 4 2 0 Screws/pins Arthroplasty DHS IMHS Rest P=0.21 Hip flexion P=0.002 * *

Percentage with VRS 24

Walking P=0.02

80 70 60 50 40 Day 1 30 20 10 0 Screws/pins Arthroplasty DHS Type of surgery IMHS Day 2 Day 3 Day 4

Type of surgery

Fig 1 Cumulated pain score for the rst four postoperative days in 117 hip fracture patients according to type of surgery. *Indicates values signicantly different (P,0.05) from the pain values for the same activity in the arthroplasty group. VRS, verbal ranking score.

high levels of tissue trauma and leave the fractured bone in situ.13 Correspondingly, patients with elective hip joint surgery with arthroplasty has previously been shown to have moderate initial pain levels that quickly taper off 24 h postsurgery,18 which is in contrast to data on dynamic pain after hip fracture surgery in a mixed cohort of procedures.2 This suggests that pain levels after surgery for hip fracture are heterogeneous and procedure specic. The present study applied a standardized pain regimen within a standardized perioperative care pathway11 and as such minimized confounding factors. However, the study is limited in its size, and the distribution of procedures within the group is skewedmirroring the daily clinical

Fig 2 Percentage of 117 hip fracture patients reporting any pain at rest, or moderate or higher dynamic pain in hip exion and walking during physiotherapy.

pattern of procedure types in hip fracture patients. Thus, the pain data for pins/screws and IMHS are less robust than that for the most common procedures, DHS and arthroplasty. The patients that were included in this study represent the ttest members of the hip fracture population, although there is no evidence to suggest that more fragile patients should have a different distribution of pain according to procedure type.

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Our data showed very low levels of postoperative resting pain irrespective of procedure, probably due to the effective epidural regimen which provides superior pain relief at rest compared with conventional opioid analgesia, which also accounts for the very low levels of supplemental opioid analgesia administered under the regimen.2 Dynamic pain levels were signicantly different between groups when cumulated over the entire period both for hip exion and walking. Pain levels were also consistent during all four postoperative days. Pain on walking was moderate or higher in 50% of patients with DHS during all 4 days and in 80% of patients with IMHS on the rst day. Therefore, a large portion of these patients actually had inadequate pain therapy during physiotherapy, despite receiving epidural analgesia. Male sex was more frequent in patients receiving a DHS procedure, but in previous studies of postoperative pain, pain levels have not been sex-dependent in elderly patients (only one patient in the DHS group was less than 65 yr of age).19 Previous studies have found pertrochanteric fractures to be associated with reduced postoperative rehabilitation outcomes,16 which may be explained by increased postoperative pain levels as these fractures usually, have a DHS procedure.20 We found a signicant inverse association between the cumulated dynamic pain scores and ambulation scores supporting the assumption that inadequate pain therapy has a negative impact on rehabilitation.2 3 Although the correlation was signicant, it was not very strong, probably due to the heterogeneity of the population, with many other factors such as preoperative ambulatory capacity determining postoperative rehabilitation. In order to reinforce the signal and simplify data analysis, a cumulated pain score was used. Since pain scores are ordinal by nature this is similar to constructing a composite score, a method used in many pain studies.21 24 The present study has important implications for future studies of perioperative care in hip fractures. Thus, studies of regional analgesic techniques, both neuraxial and peripheral, may have different benets vs side effects in the different surgical procedures as the relationship between pain relieffacilitating ambulationand motor and urinary bladder blockade will be procedure specic. In addition, the optimal duration of regional analgesia could be procedure specic. In summary, we found dynamic pain after hip fracture surgery to be procedure specic and highest in patients receiving DHS or IMHS procedures. Consequently, in future studies of postoperative pain therapy and rehabilitaion after hip fracture surgery, patients should be stratied according to surgical technique and fracture type.

Funding
This work received nancial support from IMK Almene Fond, Copenhagen, Denmark.

References
1 Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. J Pain Symptom Manage 2000; 19: 240 8 2 Foss NB, Kristensen MT, Kristensen BB, Jensen PS, Kehlet H. Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial. Anesthesiology 2005; 102: 1197 204 3 Morrison RS, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain 2003; 103: 303 11 4 Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998; 87: 88 92 5 Capdevila X, Barthelet Y, Biboulet P Ryckwaert Y, Rubenovitch J, , dAthis F. Effect of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999; 91: 8 15 6 Chelly JE, Greger J, Gebhard R, et al. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty 2001; 16: 436 45 7 Matot I, Oppenheim-Eden A, Ratrot R, et al. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology 2003; 98: 156 63 8 Scheinin H, Virtanen T, Kentala E, et al. Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture a randomized controlled trial. Acta Anaesthesiol Scand 2000; 44: 1061 70 9 Parker MJ, Gurusamy K. Internal xation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev 2006; 18: CD001708 10 Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2005; 19: CD000093 11 Kehlet H, Dahl JB. Anaesthesia, surgery and challenges in postoperative recovery. Lancet 2003; 362: 1921 8 12 Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology 2007; 106: 773 8 13 Foss NB, Kehlet H. Hidden blood loss after hip fracture surgery. J Bone Joint Surg (Br) 2006; 88: 1053 9 14 Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. Br J Bone Joint Surg 1993; 75: 797 8 15 Quereshi KN, Hodkinson HM. Evaluation of a ten-question mental test in the institutionalised elderly. Age Ageing 1974; 3: 152 7 16 Foss NB, Kristensen MT, Kehlet H. Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: the cumulated ambulation score. Clin Rehabil 2006; 20: 701 8 17 Kehlet H, Wilkinson RC, Fischer HB, Camu F, Prospect Working Group. PROSPECT: evidence-based, procedure-specic postoperative pain management. Best Pract Res Clin Anaesthesiol 2007; 21: 149 59

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Acknowledgements
This paper should be attributed to Departments of Anesthesiology, Orthopedic Surgery, and Physiotherapy, Hvidovre University Hospital, Copenhagen DK-2650, Denmark.

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18 Moiniche S, Hjortso NC, Hansen BL, et al. The effect of balanced analgesia on early convalescence after major orthopaedic surgery. Acta Anaesthesiol Scand 1994; 38: 328 35 19 Aubrun F, Salvi N, Coriat P, Riou B. Sex- and age-related differences in morphine requirements for postoperative pain relief. Anesthesiology 2005; 103: 156 60 20 Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P and the , Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am 2007; 89: 470 5

21 Littman GS, Walker BR, Schneider BE. Reassessment of verbal and visual analog ratings in analgesic studies. Clin Pharmacol Ther 1985; 38: 16 23 22 Jensen MP, Chen C, Brugger AM. Postsurgical pain outcome assessment. Pain 2002; 99: 101 9 23 Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized double-blind placebo-controlled trial. Ann Surg 2003; 238: 651 60 24 Callesen T, Bech K, Thorup J, et al. Cryoanalgesia: effect on postherniorrhaphy pain. Anesth Analg 1998; 87: 896 9

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