Strong evidence supports multimodal pain management after hip fracture surgery.

Five high strength (Mouzopoulos et al 14, Matot et al  16, Lamb et al  142, Kang et al  143, Gorodetskyi et al 144) and five moderate strength (Bech et al 145, Foss et al 146, Ogilvie-Harris et al 147, Spansberg et al 148, Tuncer et al 149) studies support this recommendation. Neurostimulation, local anesthetics, regional anesthetics, epidural anesthetics, relaxation, combination techniques, and pain protocols have been shown to reduce pain as well as improve satisfaction, improve function, reduce complications, reduce nausea and vomiting, reduce delirium, decrease cardiovascular events, and reduce opiate utilization. There are a large variety of techniques that result in modest but significant positive improvements in many clinical and patient-centered domains with minimal significant adverse outcomes noted. While no particular technique is recommended, using an array of pain management modalities is appropriate.
Risks and Harms of Implementing this Recommendation
Potential risks include medication risks and those associated with the particular procedures or techniques.
Future Research
Further study is necessary to define which modalities offer the most benefit at the lowest cost and risk. Further study is necessary to determine which combinations offer the most synergy. Additional study is necessary to determine if any particular modality improves functional and system outcomes as well as pain and satisfaction.
  1. (14) Mouzopoulos G, Vasiliadis G, Lasanianos N, Nikolaras G, Morakis E, Kaminaris M. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthop Traumatol 2009;10(3):127-133.
  2. (142) Lamb SE, Oldham JA, Morse RE, Evans JG. Neuromuscular stimulation of the quadriceps muscle after hip fracture: a randomized controlled trial. Arch Phys Med Rehabil 2002;83(8):1087-1092.
  3. (143) Kang H, Ha YC, Kim JY, Woo YC, Lee JS, Jang EC. Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: a randomized, controlled study. J Bone Joint Surg Am 2013;95(4):291-296.
  4. (144) Gorodetskyi IG, Gorodnichenko AI, Tursin PS, Reshetnyak VK, Uskov ON. Non-invasive interactive neurostimulation in the post-operative recovery of patients with a trochanteric fracture of the femur. A randomised, controlled trial. J Bone Joint Surg Br 2007;89(11):1488-1494.
  5. (145) Bech RD, Lauritsen J, Ovesen O, Emmeluth C, Lindholm P, Overgaard S. Local anaesthetic wound infiltration after internal fixation of femoral neck fractures: a randomized, double-blind clinical trial in 33 patients. Hip Int 2011;21(2):251-259.
  6. (146) 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(6):1197-1204.
  7. (147) Ogilvie-Harris DJ, Botsford DJ, Hawker RW. Elderly patients with hip fractures: improved outcome with the use of care maps with high-quality medical and nursing protocols. J Orthop Trauma 1993;7(5):428-437.
  8. (148) Spansberg NL, Anker-Moller E, Dahl JB, Schultz P, Christensen EF. The value of continuous blockade of the lumbar plexus as an adjunct to acetylsalicyclic acid for pain relief after surgery for femoral neck fractures. Eur J Anaesthesiol 1996;13(4):410-412.
  9. (149) Tuncer S, Sert OA, Yosunkaya A, Mutlu M, Celik J, Okesli S. Patient-controlled femoral nerve analgesia versus patient-controlled intravenous analgesia for postoperative analgesia after trochanteric fracture repair. Acute Pain 2003;4(3-4):105-108.
  10. (16) 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(1):156-163.