Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Gunshot wounds to the lower extremities

In this article, we briefly mention the personal, social, and economic costs of gunshot injuries; describe the science of ballistics and how differences in ballistics affect gunshot wounds and their treatment; and review the general principles involved in managing gunshot injuries. We will summarize the strategies for treating adults with gunshot injuries to specific regions of the lower extremities--the hip, the femur, the knee, the tibia, and the foot.

Outcome after hip fracture in individuals ninety years of age and older

OBJECTIVE

To assess outcome after hip fracture in patients ninety years of age and older, as compared with a population of the same age and sex in the United States and younger patients with hip fractures.

DESIGN

Prospective, consecutive.

SETTING

University teaching hospital.

METHODS

Eight hundred fifty community-dwelling elderly people who sustained an operatively treated hip fracture were prospectively followed up.

MAIN OUTCOME MEASUREMENTS

The outcomes examined in this study were the patients' in-hospital mortality and postoperative complication rates, hospital length of stay, discharge status, mortality rate, place of residence, ambulatory ability, and independence in basic and instrumental activities of daily living twelve months after surgery.

RESULTS AND CONCLUSIONS

The mean patient age was 79.7 years (range 65 to 105 years). Seventy-six (8.9 percent) patients were ninety years of age and older. Patients who were ninety years of age and older had significantly longer mean hospital lengths of stay than younger individuals (p = 0.01). People ninety years of age and older were more likely to die during the hospital stay (p = 0.001) and within one year of surgery (p = 0.001). Patients who were ninety years of age and older were more likely to have a decrease in their basic activities of daily living status (p = 0.03) and ambulation level (p = 0.01). Younger individuals had a higher standard mortality ratio (1.48) than did patients who were ninety years of age and older (1.24). Being ninety years of age and older was not predictive of having a postoperative complication, of being placed in a skilled nursing facility at discharge or at one-year follow-up, or recovering of prefracture independence in instrumental activities of daily living.

Open reduction and internal fixation of tibial pilon fractures

Although it is evident that the fracture of the tibial plafond is a complex, often debilitating injury, its management is not clear. These injuries generally fall into one of two categories. The low-energy, rotational type of fracture has been shown to have excellent clinical and functional results with open reduction and internal fixation. The high-energy, compression type of fracture has had uniformly moderate results and historically high complication rates. Some authors think that bridging external fixation with or without limited internal fixation should be employed in high-energy fractures. Others believe that open reduction and internal fixation to avoid articular incongruence and development of axial malalignment is needed for good long-term outcome. The authors believe the latter. Staging the treatment of the patient can minimize development of soft tissue complications. The authors follow the recommendations of Patterson and Sirkin and believe that high-energy pilon fractures should be temporized with an external fixator with or without fibular plating to restore length. Any open would should be addressed at this time. Definitive fixation should be planned for between 10 and 14 days, by which time the soft tissue envelop is likely to be ready to accept the further insult of surgery. The surgical technique should be well planned for and include the use of meticulous soft tissue techniques and indirect reduction methods. With the proper attention to detail, long-term results will be maximized.