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Role of Fracture and Repair Type on Pain and Opioid Use After Hip Fracture in the Elderly.

Strike S A, et al.

Journal: Geriatr Orthop Surg Rehabil. 2013; 4(4):103-108. 31 references. 
Reprint: Simon C. Mears, MD, PhD, c/o Elaine P. Henze, Bj, Medical Editor and Director, Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave. #A665, Baltimore, MD 21224, USA. Email: ehenze I@jhmi.edu 
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.

Editor's Note:
It seems valuable to be able t predict, or at least, understand opioid requirements in a vulnerable population, especially the elderly. This study points out that medical outcomes are often counterintuitive and here patients with femoral neck (FN) fractures required significantly more postoperative opioid analgesic than patients with intertrochanteric (IT) fractures in the immediate postoperative period, suggesting a need to pay particular attention to pain control after FN fracture repair. There were no differences in postoperative pain or opioid analgesic used by surgical repair or fracture type. Unstable fractures did not require more analgesia contrary to expectations.

Class: Disease state: Hip fracture in the elderly.

The role of hip fracture type or type of surgical repair as factors influencing postoperative pain, postoperative analgesic requirements, and delirium have been examined by only a few studies. The authors hypothesized that patients with femoral neck (FN) and intertrochanteric (IT) fractures would not have significantly different postoperative pain scores or analgesic requirements, and that patients with unstable fractures would have more postoperative pain and higher analgesic requirements than patients with stable fractures.The study population was 231 patients with a mean age of 81.5 + 7.1 years and there were no differences in gender, time to surgery or prefracture comorbidities between patients with FN and IT fractures. There were no differences in intraoperative dose (mg/kg) of opioid medication or admission to or days in the intensive care unit. There were a higher percentage of patients with prefracture dementia who underwent hemiarthroplasty (HA, n = 20, 23%) or received an intramedullary hip screw (IHS, n = 34, 29.6%) or percutaneous screws (n = 11, 61.1%) than other procedures (n = 6; P = .005). FN fracture patients were younger (P = .002), were more likely to receive spinal anesthesia (P = .016), were less likely to have received a red blood cell transfusion (P = .011), and received fewer units of packed red blood cells than patients with IT fractures (P < .001).No difference in pain was noted throughout the postoperative period for FN versus IT fractures (P = .692), or stable versus unstable fractures (P = .320). In postoperative pain there was no difference by type of surgical repair (P > .060). The use of patient-controlled analgesia (PCA) did not affect reported pain with respect to fracture type (P = .607), stability (P = .590), or type of surgical repair (P = .787). While patients with dementia reported significantly less pain (P < .001), inclusion of dementia in the model did not reveal differences in pain with respect to fracture type (P = .992), stability (P = .441), or type of surgical repair (P > .236). There was a significant difference in the number of patients who were prescribed a postoperative PCA by type of surgical procedure (HA = 29, 33.3%; screw = 1, 5.6%; IHS =72, 62.6%; other =3, 27.3%) but not by fracture type. Patients with FN fractures had higher postoperative analgesic requirements. Although patients with dementia consumed significantly less opioid, inclusion of dementia in the model did not reveal additional differences in opioid consumptions with respect to fracture type (P = .049), stability (P = .379), or type of surgical repair (P > .129).This study showed no difference in pain scores between fracture types and fixation methods and did not support the hypothesis that unstable fractures would be more painful than stable fractures. The study did support the hypothesis that there was no difference in pain scores among fixation methods.

Important Points:

Patients with FN fractures required significantly more postoperative opioid analgesic than patients with IT fractures in the immediate postoperative period, suggesting a need to pay particular attention to pain control after FN fracture repair. There were no differences in postoperative pain or opioid analgesic used by surgical repair or fracture type.

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