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

doi:10.1093/bja/aen345

PAIN
Postoperative pain after hip fracture is procedure specific
N. B. Foss1 2*, M. T. Kristensen2 3, H. Palm2 and H. Kehlet4
1
Department of Anesthesiology, 2Department of Orthopedic Surgery, 3Department of Physiotherapy and
4
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 rehabilita-
tion. 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 accord-
ing to a standardized perioperative rehabilitation programme. Resting pain, pain on hip flexion,
and walking were measured during daily physiotherapy sessions on a verbal five-point rating
scale during the first four postoperative days. Patients were stratified into four groups accord-
ing to surgical procedure: screws or pins, arthroplasty, dynamic hip screw (DHS), and intra-
medullary hip screw (IMHS).
Results. Cumulated pain levels were significantly different between surgical procedures both
for hip flexion (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
significant negative correlations between ambulatory capacity assessed by the cumulated ambu-
lation score and both the dynamic cumulated pain scores on hip flexion (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

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 rehabilita-
tion in orthopaedic procedures,4 6 epidural analgesia mini-
mizes 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 periopera-
tive morbidity in hip fracture patients.7 8 However, hip
fracture patients are a heterogenous group treated surgi-
cally 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 influence 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 standar-
dized 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 con-
cluded 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 epi-
nephrine 1:200 000.12 After X-ray examination confirmed a
hip fracture, the patients were then taken to the post-
anaesthesia care unit where an epidural catheter was inserted
in the L23 or L34 interspace and tested with 60 mg lido-
caine 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 premedi-
cation was given, but slight sedation with propofol was pro-
vided at a rate of 1040 mg kg21 min21 on patient request.
Standardized fluid 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 postopera-
tive day. All patients received additional analgesia with acet-
aminophen 1 g 6 hourly and the first 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 mor-
phine 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.
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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 intra-
capsular fractures, the treatment depended on the age of
the patient. If the patient was 75 yr or younger, the fracture
was reduced and internally fixed with the above mentioned
two parallel implants. If the patient was older than 75 yr, an
uncemented hemiarthroplasty was inserted. If the hemiar-
throplasty was not stable perioperatively, a cemented hemiar-
throplasty 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 phy-
siotherapy programme comprising two daily 30 min ses-
sions, started on the first postoperative day (Day 1).
Discharge criteria from the hip fracture unit were stan-
dardized: the ability to independently get in and out of
bed and to and from a place of eating, the ability to inde-
pendently 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 dis-
charged to their home.
Study parameters
Data were gathered prospectively. ASA classification, 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 phy-
siotherapy after the patient had been resting in bed for 15
min. Dynamic pain was assessed during the treatment ses-
sions on 458 flexion of the hip while supine and upon
walking either assisted or independently. Pain was measured
as reported by the patient on a five-point verbal ranking
score (VRS) from 0 to 4 with the categories none, light,
moderate, severe, and intolerable pain. During the phy-
siotherapy session, the patients were evaluated on their
ambulatory capacity by the cumulated ambulation score
(CAS),16 which allows day-to-day measurements of func-
tional mobility in hip fracture patients in the early postopera-
tive 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 first 4 days for each physical function, was
 Procedures and pain in hip fractures
calculated by adding the scores of the individual days. Tests
for significant intergroup differences between the four frac-
ture 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 significance of categ-
orical data. Pain data are presented as median (2575 per-
centiles). All data analyses were conducted with SPSS for
windows version 10.1 (SPSS inc., Chicago, IL, USA).
Results
During the inclusion period, 117 patients qualified 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 reflected 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 stratified 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 significant 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 significance for hip flexion on Days 2 and 4
(P0.02) and on Day 1 for walking (P0.02).
The cumulated pain scores for the first 4 days are pre-
sented in Figure 1. There were significant differences
between the four types on surgery for both hip flexion
(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 signifi-
cantly higher pain levels on hip flexion and hip flexion
plus walking, respectively. The percentage of patients
reporting either slight pain or higher (VRS 1 4) at rest or
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 classification. Data are presented as median (range) for numeric data
Screws/pins
Number of patients 9 44
Age 80 (67 91)
Female sex 8 (90%)
ASA III IV 3 (33%)
New mobility score (0 9) 6 (3 9)
Mental score (0 9) 9 (6 9)
Delay to surgery (h) 20 (10 36)
Intraoperative bleeding (ml) 100 (20 150)
Hospitalization (days) 11 (6 22)
30-day mortality 0 1 (2%)
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moderate pain or higher (VRS 2 4) on either hip flexion
or walking is presented in Figure 2.
Significant negative correlations were found between the
CAS and both the dynamic cumulated pain score pain on hip
flexion (r20.43, P,0.001) and the cumulated pain score
on walking (r20.36, P0.004); there was no significant
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 sig-
nificant 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 significant inverse correlation between
dynamic pain and ambulation scores during the first 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 post-
operative myocardial ischaemia,8 improve analgesia and
minimize pain as a limiting factor for postoperative rehabili-
tation.2 Limitations in postoperative rehabilitation because
of motor block have not been demonstrated.2 The risk/
benefit 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 cath-
eters, 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 postopera-
tive pain therapy should therefore be procedure specific 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
Arthroplasty DHS IMHS
49 15
82 (73 94) 81 (41 98) 81 (69 97)
40 (91%) 32 (65%) 12 (80%)
13 (30%) 13 (27%) 4 (27%)
8 (3 9) 9 (2 9) 7 (2 9)
9 (5 9) 9 (6 9) 9 (6 9)
19 (3 54) 19 (5 47) 21 (8 47)
275 (50 1400) 200 (0 1400) 300 (100 700)
13 (6 80) 14 (4 70) 16 (10 52)
1 (2%) 0
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 Foss et al.

Table 2 Pain at rest and during mobilization in 117 hip fracture patients 100 Pain at rest
according to type of surgery. Pain score is a verbal ranking score (VRS) 0 4.
Values given are median (25 75 percentiles). Test for significant differences 90
between groups with KruskallWallis non-parametric ANOVA 80

Percentage with VRS 14

Number of Screws/pins Arthroplasty DHS IMHS P-value 70
patients 9 44 49 15
60
Pain at rest 50
Day 1 0 (0 0) 0 (0 0) 0 (0 0) 0 (0 0) 0.30
Day 2 0 (0 0) 0 (0 0) 0 (0 0) 0 (0 0) 0.82 40
Day 1
Day 3 0 (0 0) 0 (0 0) 0 (0 0) 0 (0 0) 0.89 30
Day 4 0 (0 0) 0 (0 0) 0 (0 0) 0 (0 0) 0.42 Day 2
Pain on 458 hip flexion 20
Day 1 1 (0 2) 1 (0 1) 1 (0 2) 1 (1 2) 0.08 Day 3
10
Day 2 1 (0 2) 0 (0 1) 1 (0 2) 1 (1 3) 0.02
Day 3 1 (0 1) 0 (0 1) 1 (0 2) 1 (0 1) 0.39 0 Day 4
Day 4 0 (0 1) 0 (0 1) 1 (0 2) 1 (0 2) 0.02 Screws/pins Arthroplasty DHS IMHS
Pain on walking Type of surgery
Day 1 2 (0 2) 1 (0 2) 1 (1 2) 2 (2 2) 0.02
Day 2 1 (0 2) 1 (0 1) 1 (0 2) 2 (1 2) 0.2 100 Pain on hip flexion
Day 3 1 (1 1) 1 (0 1) 1 (1 2) 1 (1 3) 0.35
Day 4 1 (1 2) 1 (0 2) 1 (1 2) 1 (1 2) 0.65 90
Cumulated 10 (6 17) 9 (6 13) 9 (9 12) 9 (8 9) 0.36 80

Percentage with VRS 24

ambulation
score (0 18) 70
60
50
Cumulated pain 40
12 Day 1
30
* *
Day 2
* 20
10
Day 3
Cumulated VRS (Days 14)

10
8 0 Day 4
Screws/pins Arthroplasty DHS IMHS
Type of surgery
6 Rest
P=0.21
100 Pain on walking
Hip flexion
4 P=0.002 90
Walking 80
Percentage with VRS 24

2 P=0.02
70
60
0
Screws/pins Arthroplasty DHS IMHS 50

Type of surgery 40
Day 1
Fig 1 Cumulated pain score for the first four postoperative days in 117 30
hip fracture patients according to type of surgery. *Indicates values Day 2
20
significantly different (P,0.05) from the pain values for the same Day 3
10
activity in the arthroplasty group. VRS, verbal ranking score.
0 Day 4
Screws/pins Arthroplasty DHS IMHS
high levels of tissue trauma and leave the fractured bone Type of surgery
in situ.13 Correspondingly, patients with elective hip joint
Fig 2 Percentage of 117 hip fracture patients reporting any pain at rest,
surgery with arthroplasty has previously been shown to or moderate or higher dynamic pain in hip flexion and walking during
have moderate initial pain levels that quickly taper off physiotherapy.
24 h postsurgery,18 which is in contrast to data on
dynamic pain after hip fracture surgery in a mixed cohort pattern of procedure types in hip fracture patients. Thus,
of procedures.2 This suggests that pain levels after surgery the pain data for pins/screws and IMHS are less robust
for hip fracture are heterogeneous and procedure specific. than that for the most common procedures, DHS and
The present study applied a standardized pain regimen arthroplasty. The patients that were included in this study
within a standardized perioperative care pathway11 and as represent the fittest members of the hip fracture popu-
such minimized confounding factors. However, the study lation, although there is no evidence to suggest that more
is limited in its size, and the distribution of procedures fragile patients should have a different distribution of pain
within the group is skewedmirroring the daily clinical according to procedure type.

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 Procedures and pain in hip fractures
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 supplemen-
tal opioid analgesia administered under the regimen.2
Dynamic pain levels were significantly different between
groups when cumulated over the entire period both for hip
flexion 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 first
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 out-
comes,16 which may be explained by increased postopera-
tive pain levels as these fractures usually, have a DHS
procedure.20 We found a significant 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 significant, it was not very strong, prob-
ably 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 analy-
sis, a cumulated pain score was used. Since pain scores are
ordinal by nature this is similar to constructing a compo-
site 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 per-
ipheral, may have different benefits vs side effects in the
different surgical procedures as the relationship between
pain relieffacilitating ambulationand motor and
urinary bladder blockade will be procedure specific. In
addition, the optimal duration of regional analgesia could
be procedure specific.
In summary, we found dynamic pain after hip fracture
surgery to be procedure specific and highest in patients
receiving DHS or IMHS procedures. Consequently, in
future studies of postoperative pain therapy and rehabili-
taion after hip fracture surgery, patients should be stratified
according to surgical technique and fracture type.
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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Funding
This work received financial support from IMK Almene
Fond, Copenhagen, Denmark.
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