The multimodal approach to pain management has been enthusiastically embraced in the hope that the undesirable side effects and consequences of traditional reliance on narcotic medications can be overcome. Orthopaedic surgical procedures are painful. Postsurgical pain has well-documented negative consequences, and poorly controlled postoperative pain not only slows recovery but also leads to unacceptable levels of patient dissatisfaction.
In the past two decades, techniques of continuous infusion of narcotics partially controlled by the patient either by an intravenous route or through the continuation of the epidural route after surgery has been very successful in helping to manage postoperative pain. Epidural patient-controlled anesthesia is especially attractive for lower-extremity surgery because narcotics can be mixed with local anesthetics, lowering the dose and toxicity of the narcotic while achieving very dramatic pain control. Unfortunately, this excellent control of pain has unwanted consequences. Patients who experience satisfactory pain relief when using epidural patient-controlled anesthesia often require a urinary catheter, experience nausea presumably from the epidural narcotic, and have relatively profound postural hypotension that limits their ability to mobilize out of bed while their pain is being controlled. The unintended consequence is an acceptable level of pain but discomfort from nausea and an in-hospital stay lengthened by relative immobility in the immediate postoperative period.
Multimodal and preemptive strategies to prevent postoperative pain have been improved by recent advances in the understanding of neuronal plasticity and how undertreated acute pain can lead to chronic pain. Also, clarifying the role that local inflammation plays in injured tissue, increasing the sensitization of nociceptors, has led to drug therapies incorporating nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) agents to preemptively control postoperative pain. Blocking the pain signal by a variety of methods, including narcotics, anti-inflammatory drugs, and peripheral nerve blockade (multimodal), has improved postoperative pain management and the overall quality and efficiency of care1-3.
Kang et al. applied these principles to the challenge of pain following hip fracture repair. They chose a single-blinded randomized trial of patients treated with hemiarthroplasty to determine whether their multimodal intervention, which consisted of preoperative oxycodone and celecoxib combined with large-volume periarticular injection, would improve postoperative pain control and patient mobility compared with fentanyl patient-controlled anesthesia alone. They found that their multimodal pain management provides additional pain relief until the fourth postoperative day, improves patient satisfaction at discharge, and reduces total narcotic consumption for postoperative pain management. They could not demonstrate a benefit in terms of better mobility or other long-term clinical advantages.
The study has several weaknesses. The control group did not receive a placebo, and the patients were aware of the arm of the study to which they had been assigned. The intervention group was likely biased by a placebo-like effect. The type of anesthesia was not standardized. I was particularly disappointed that the study was stopped before total recruitment based only on the primary outcome reaching significance. This left the study underpowered for the secondary outcomes, weakening the study’s impact.
Nevertheless, the study demonstrates the value of a multimodal approach to postoperative pain management in a challenging scenario. Preemptive pain management is not really possible for patients with a hip fracture, but Kang et al. showed better pain control in spite of this.
At our institution, we have begun to consider providing patients who have a hip fracture with a peripheral nerve block on admission to decrease pain from the fracture during the preoperative period. We should also recognize how many variables other than those measured affect outcome. New pathways and protocols in hospitals often take time to catch on. The enthusiasm of the multidisciplinary team often warms slowly, which could have impacted the outcomes measured in this study. In my own experience, once the multidisciplinary team fully embraced our new clinical pathways that incorporated multimodal pain management better results were realized.
Thus, despite the weaknesses in this study, I am a believer. The authors did show a short-term benefit of a multimodal approach to pain management in patients with a hip fracture. Much larger study cohorts will be needed to discern if real clinical benefits can be realized in terms of avoidance of complications and faster recovery. There is still much to be learned about postoperative pain management, and I am encouraged by these modest successes.