Multimodal Analgesia
Multimodal analgesia incorporating preoperative nerve block is recommended to treat pain after hip fracture.

Rationale

This recommendation combines and updates information contained in 2014 CPG recommendations on Preoperative Regional Anesthesia and Postoperative Multimodal Analgesia. We identified a total of 28 high- or moderate-quality studies (Aprato 2018, Clemmesen 2018, Ergenoglu 2015, Godoy-Monzon 2010, Gorodetskyi 2007, Kang 2013, Ma 2018, Moppett 2015, Morrison 2016, Parras 2016, Phruetthiphat 2021, Unneby 2017, Unneby 2020, Wennberg 2019, Wennberg 2019, Zhang 2020, Zhou 2019, Cooper 2019, Newman 2013, Nie 2015, Rowlands 2018, Temelkovska 2014, Uysal 2020, Unneby 2020, Xu 2020, Matot 2003, Mouzopoulos 2009, Zhang 2019) addressing diverse aspects of perioperative multimodal analgesia for hip fracture patients. Analgesic approaches, dosing regimens, comparators, and outcomes assessed varied markedly across available studies.

Ten high-quality studies (Wennberg 2019, Ma 2018, Wennberg 2019, Unneby 2017, Unneby 2020, Morrison 2016, Aprato 2018, Monzon 2010, Zhou 2019, Ergenoglu 2015) and nine moderate-quality studies (Mouzopoulos 2009, Xu 2020, Rowlands 2018, Zhang 2019, Unneby 2020, Uysal 2020, Cooper 2019, Newman 2013, Matot 2003) specifically assessed use of regional anesthesia before surgery as a component of a perioperative multimodal analgesic approach. 17 of 19 identified studies assessed either fascia iliaca compartment block (FICB) or femoral nerve block (FNB), with or without obturator nerve block; 1 moderate-quality study (Matot 2003) assessed continuous epidural analgesia. 1 high-quality study (Zhou 2019) and 2 moderate-quality studies compared preoperative FICB to preoperative FNB with or without obturator nerve block (Zhou 2019, Cooper 2019, Newman 2013); 1 high-quality study compared FICB to intra-articular hip injection (Aprato 2018). All other identified studies compared a preoperative regional block to routine opioid- and non-opioid based pain management, with or without performance of a sham nerve block procedure in the control arm. 

Among studies comparing preoperative regional anesthesia (including FNB, FICB, or epidural) to non-regional anesthesia control, regional anesthesia was associated with decreased pain severity compared to control in 5 high-quality studies (Monzon 2010, Ma 2018, Wennberg 2019, Unneby 2017, Morrison 2016) and 4 moderate-quality studies (Rowlands 2018, Zhang 2019, Uysal 2020, Xu 2020). Regional anesthesia was associated with decreased requirements for parenteral analgesia versus control in one high-quality study (Morrison 2016). Results varied with regard to the association between regional anesthesia receipt and adverse outcomes; while some studies reported lower rates of delirium (Mouzopoulos 2009), cardiovascular events (Matot 2003), postoperative complications (Ma 2018) and severe opioid-related adverse events (Morrison 2016) with regional anesthesia, findings were inconsistent across studies reviewed, with some reporting no difference or worsened outcomes with regional anesthesia observed for these endpoints. One high-quality study (Morrison 2016) observed improved recovery of ambulation at post-operative day 3 and at 6 weeks with regional anesthesia. 

Among studies comparing FICB to FNB, one high-quality study (Zhou 2019) and one moderate-quality study (Newman 2013) found improved pain VAS score with preoperative FNB vs FICB. In one high-quality study (Zhou 2019), analgesic requirements and rates of nausea were lower with FNB vs FICB. One high-quality study (Aprato 2018) found better pain control and lower systemic analgesic requirements with intra-articular hip injection vs preoperative FICB. 

Five high-quality studies (Kang 2013, Gorodetskyi 2007, Zhang 2020, Clemmesem 2018, Phruetthiphat 2021) and five moderate quality studies (Mouzopoulos 2009, Matot 2003, Temelkovska-Stevanovska 2014, Nie 2015, Ogilvie-Harris 1993) assessed aspects of multimodal analgesia for hip fracture patients other than preoperative regional anesthesia. Identified studies examined a range of approaches including: standardized pain treatment protocols; neurostimulation; pre- or intra-operative dexmedetomidine infusion; preoperative methylprednisolone; intra-operative or postoperative regional anesthetics; and postoperative periarticular anesthetic injections. Improved pain outcomes were observed for postoperative periarticular injections (Phruetthiphat 2021, Kang 2013), postoperative FNB (Temelkovska-Stevanovska 2014); and neurostimulation (Gorodetskyi 2007). Neither intraoperative dexmedetomidine (Zhang 2020) nor preoperative methylprednisolone (Clemmesen 2018) were associated with improved pain scores versus control. Association between adjunctive pain therapies and postoperative outcomes varied across modalities evaluated. 

Benefits/Harms of Implementation

Risks associated with pain treatment approaches are likely to vary across modalities and should be interpreted with regard to the risks of alternative treatments, such as opioids. Certain techniques, such as epidural anesthesia, may be contraindicated in the presence of anticoagulant therapy or coagulopathy. Appropriate provider training in pain management techniques, adequate monitoring for potential procedure-related complications, and availability of rescue medications and other resources is essential to ensuring patient safety. 

Outcome Importance

Treatment of pain represents a major priority for many hip fracture patients and their families; additional outcomes assessed in studies reviewed here, such as delirium and functional recovery, may also carry substantial importance to patients. 

Cost Effectiveness/Resource Utilization

 Identified studies did not assess cost-effectiveness or resource utilization; these are likely to vary according to the specific pain treatment modality under consideration. 

Acceptability

Preoperative FNB and FICB both appear to be broadly acceptable to patients; limited information is available on the acceptability of other pain treatment modalities reviewed here.

Feasibility

FNB and FICB can be performed feasibly in emergency departments, perioperative care settings, and other hospital areas with appropriate provider training and access to necessary monitors and rescue treatments. Feasibility of other multimodal analgesic approaches may vary according to the modality evaluated.

Future Research

Future research on preoperative regional anesthesia for hip fracture patients may focus on impacts on complications and patient-centered end-outcomes, such as functional recovery after fracture. Additional research is needed to define optimal or preferred strategies for multimodal analgesia. Such research may examine outcomes for regimens that incorporate agents not evaluated in identified studies, such as gabapentin, and should evaluate impacts on complications and patient-centered end outcomes in addition to pain outcomes.