In our study, no significant difference was found in VAS score values and the mean morphine dosage administered per day between the patients with intertrochanteric fractures who underwent skin traction and the control group without traction. Therefore, in terms of pain alleviation, applying skin traction for these patients was only an extra burden on the patients and the caregivers. This is an important finding, as the standard protocol in many countries is to apply skin traction for all patients with intertrochanteric fractures [20, 21].
Before the introduction of fixation devices, treatment for intertrochanteric fractures was completely non-operative, consisting of prolonged bedrest (10 to 12 weeks) in traction until fracture healing occurred. It goes without mentioning that this approach was time-consuming and accompanied different complications, including decubitus ulcers, joint contractures, thromboembolic complications, and increased mortality rate. Since then, and with the introduction of fixation devices, there have been significant improvements in the management of intertrochanteric fractures . However, preoperative traction application (skin or even sometimes skeletal) has still remained in the treatment protocols of these types of fractures in many countries (including ours) over time. In addition, due to the significant reported differences in pain thresholds between different races , we hypothesized that the results of this research might be different from other studies from other regions.
Interestingly, no explanation regarding the rationale behind skin traction application for patients with specifically intertrochanteric fractures has been given to the best of our knowledge.
There are, however, several theories in the literature. One theory, in patients with proximal femoral fractures, is that the skin-traction application decreases the chance of instant pain and future non-union and avascular necrosis (AVN) by preventing the external rotation of the fractured site, the occlusion of the vascular supply, and the risk of tamponade. It has also been suggested that patients would have a better range of motion in the no traction group, allowing them to move their legs in a position with the slightest intracapsular pressure and, therefore, less pain [13, 18, 30]. On the other hand, using digital subtraction angiography, Xiao et al. reported that skin traction might impair the blood perfusion to the femoral head and could be one of the major causes of AVN in patients with femoral head fractures .
based on a Cochrane review article done by Handoll et al., a well-designed clinical trial is needed, especially for specific fracture types, to evaluate the cost-benefit ratio for traction application in patients . In a review article on lower extremity traction written by Matullo et al., it was concluded that despite its’ steady use throughout medicine, traction application lacks relevant scientific evidence .
Intertrochanteric fractures are more common in patients ageing 65 and older. Pharmackokinetics and pharmacodynamics are more complex in elderly patients and they usually experience higher peak effect and longer duration of actions of opioids. This could potentially lead to higher complication rates in terms of delirium, constipation, pulmonary suppression, dependence, etc. . Because of the mentioned adverse events, physicians might be reluctant to prescribe opioids for these patients, and patients’ pain might not be controlled effectively. On the other hand, both opioid narcotics and uncontrolled perioperative pain have been reported to be associated with increased incidence of delirium, and consequently poorer functional outcomes [34,35,36]. Therefore, the addition of another pain control method would help with less opioid administration and thus decreased opioid related adverse events, and better pain control at the same time.
In addition, most of the studies on pain management in these patients are focused on the post-operative pain, as if patients’ preoperative pain is not recognized as serious pain. While in a recent study conducted by Unneby et al. even though all of the patients received femoral nerve blockades and proper intravenous analgesics, the preoperative pain perceived by patients was describes as “Hovering between heaven and hell” meaning that their pain intensity ranged from having no pain to the worst pain they had ever experienced . They also reported that some patients did not remember their pain or the pain management they had received due to their memory loss; therefore, having no verbal complaint regarding pain does not necessarily imply the absence of pain in geriatric patients and proper pain management options with least possible adverse events must be introduced for these patients.
Rasi et al. conducted a similar clinical trial to ours with a smaller cohort on 40 patients with intertrochanteric fractures. They divided patients into two groups, each consisting of 20 participants with intertrochanteric fractures, and measured their VAS scores multiple times until 24 h postadmission. They reported that only the last VAS score at the end of the 24 h postadmission between the two groups was significant, but interestingly there was no significant difference between the two groups in terms of analgesic administration . However, we believe that our study provides more realistic information regarding the decrease in patients’ pain as we followed up with the patients until one day after surgery; additionally, we studied a higher number of patients showing that our study has a higher power.
Kobayashi et al. performed a retrospective comparative cohort study on 56 patients with intertrochanteric fractures. Eighteen patients underwent skin traction application; for the rest, the skin traction was not applied. In their study, there was no significant difference between the two groups in terms of preoperative pain at 12 h before surgery (measured by Verbal Rating Score (VRS)). Still, the VRS of the patients for whom skin traction was applied were significantly lower than others at 24–60 h after admission. However, interestingly, the two groups did not have any significant differences in terms of analgesic needs based on patients’ requests . We believe that our study provides more reliable results than theirs as our study provides a more reliable methodology (randomized controlled trial). In addition, they used VRS for pain measurement, while most current studies on preoperative pain relief in patients with hip fractures are based on VAS measurements.
Rosen et al. randomly allocated 100 patients (55 patients with femoral neck fractures and 45 with intertrochanteric fractures) into skin-traction and pillow placement groups. Their study noted better immediate pain relief in the group without traction. On the other hand, they found out that if patients had mean initial VAS scores of more than five, the patients who underwent skin traction experienced slightly more pain reduction . However, we believe that our results differed from Rosen et al.’s study as our patients experienced more pain at the time of diagnosis compared to their patients (the mean VAS score of our patients within the first hour of diagnosis was 6.2 ± 1.4, which was higher than all the reported VAS scores in their study). This could be because of the difference in pain conception due to racial differences, emphasizing the importance of conducting this trial in our region again.
Saygi et al. divided 108 patients with hip fractures (intertrochanteric fractures and collum femoris fractures) into three groups: in group one, two-kg skin traction was applied; in group two, skin traction without weight was applied; and in group three, a pillow was put beneath the fractured limb. They evaluated the traction’s placebo effect, and better pain relief was obtained in the group with the placebo. They believed their result was due to semiflexion and external rotation and the placebo effect of the without-weight traction kit . Their findings are valuable as they offer the benefits of the placebo effect of the non-weighing traction on patients’ pain relief. We think skin traction might be helpful in cases where the operation is delayed due to the background disease of the patient, and there is no alternative option for the patient’s condition but to use a placebo.
We also measured the postoperative VAS scores, which were not reported in either of the mentioned studies, as we hypothesized that the placebo effect of skin traction might affect the pain perception in patients postoperatively. Interestingly, the postoperative VAS scores in both groups were significantly lower than the preoperative measurements. This can be because of the fixation of the fracture, postoperative analgesics administered to the patients or the mental relief for them undergoing the ultimate treatment. It has been suggested that patients’ satisfaction does not always reflect the quality of pain management but rather patients’ expectations and perceptions . It has also been reported that a positive relationship exists between patients’ satisfaction and the severity of side effects while managing postoperative pain with analgesics . Therefore, our study’s reported postoperative VAS scores might reflect on the patients’ satisfaction with undergoing surgery (as their definite treatment) rather than their pain.
Anderson et al. studied 252 patients with different types of proximal femur fractures. They randomly allocated the patients to skin traction and the control group with a nurse-free bed (method of nursing the injured limb was not specified in this study). They reported no differences in pain suffered, analgesia injection, frequency of pressure ulcers, or ease of operations between these two groups . We found their methodology inspiring and evaluated if the results would be the same in patients with only intertrochanteric fractures.
Over the years, multiple studies reported that skin traction might not affect the severity of the pain and the dosage of required analgesics for patients with different types of hip fractures [13,14,15,16, 18, 41, 42]. However, our study is among the few controlled trials in the literature that has specifically evaluated the effect of skin traction on the prescribed morphine in patients with intertrochanteric fractures. The mean morphine dosage administered per day in our study was not significantly different between the two groups. This was in concordance with the results of the VAS score analysis. Therefore, no adjustment of the two effects was needed. Resell et al. studied 153 patients with displaced cervical and trochanteric hip fractures with the same study method as ours and found out that the patients in the traction group even needed more analgesic dosage, although not significantly different . This study was repeated on 123 patients comparing the skin-traction effect with the Lasse pillow effect on pain relief. There was no clinically significant difference in pain relief or analgesic usage between the two groups . Although both methodologies were thorough, in our humble opinion, their results could not be generalized to both fracture types they included in their study. As mentioned, we exclusively studied patients with intertrochanteric hip fractures.
There is an agreement in the literature that skin traction does not cause short-term severe complications for patients with different types of hip fractures. In addition to the surgery and hospitalization related complications (UTI, DVT, PE), pressure ulcers, mechanical shearing, allergy to the strapping, and blockage of blood supply to the affected limb are reported as direct complications of skin traction [1, 4, 15, 18]. In our study, no significant differences in complication rates between the two groups were noticed.
In addition, the mean time from admission to surgery in all the patients (which in our study equals to the length of time that patients were in skin traction) was 5.6 ± 1.4 days, and there was no significant difference between the two groups in terms of length of time from admission to surgery.
Early surgery has been reported to be associated with fewer in-hospital complications, improved functional outcomes, increased return to independent living, and decreased overall mortality [43, 44]; however, it is important to find the correct timing for the operation, and make a distinction between complications which could happen due to the delay in surgery, and the complications that are potential causes for the delay to surgery.
Beaupre at al. reported that 20 to 40 h of delay in surgery was associated with highest survival rate in patients older than 80 years of age; however, they mentioned that in patients who are 60 years old or younger, surgery can be delayed without any decrease in mortality rate. Therefore, they suggested that sub-prioritization of patients should be based on patients characteristics, rather than the national benchmarks ; Even though their study results are valid, we assume that mortality rate should not be the only predictive factor for determining the proper time to surgery, and other potential minor and major complications should also be considered as well. Lefaivre et al. reported that in their study, delay to surgery of more than 24 h was accompanied with minor complications, while more than 48 h of delay to surgery significantly increased the risk of major medical complications . On the other hand, Grimes at al. performed a retrospective cohort study on 8383 patients with deferent types of hip fractures and reported that longer time to surgery was only associated with increased risk of decubitus ulcer formation and no short-term or long-term (up to 18 years) mortality after adjusting for other medical problems; however, in their study, the median time to surgery was 23 h and 92% of patients underwent surgery within 72 h postadmission .
In an observational study on 83,727 patients with hip fracture performed by Leer-Salvesen et al., it was reported that delay to surgery of more than 48 h was associated with increased three day mortality, and 1 year mortality. Also, patients with delay to surgery of more than 24 h, experienced more intraoperative complications. In their study, the mean pre-hospital delay was six hours, and the mean in-hospital delay was 22 h. They reported that there was no significant effect of total delay to surgery as long as the patients underwent medical intervention within 48 h postadmission; however, mortality increased in patients who were operated on after 48 h of admission. Even though they adjusted their results based on patients’ fracture types, they ultimately suggested that preoperative patient stabilization should not be used as an argument to delay surgical intervention . On the other hand, Rijckevorsel et al. reported that longer than 48 h of delay in surgery due to only non-medical reasons, was associated with higher pressure ulcer and UTI; however, delay in surgery was not related to 30-day mortality rate and post-operative length of hospital stay. In their study, patients with surgery delays due to optimizing patients’ medical condition were excluded, as authors claimed that there are previous studies, suggesting that postponement of surgery in such conditions would improve the outcome and would not affect the mortality rate [49, 50].
To improve the surgical outcomes, many countries have established time to surgery benchmarks for patients with hip fractures, which reflect the quality of care. For example, within 48 h and 36 h of admission have been set as the national benchmarks in Canada and the UK respectively. Unfortunately, there is no such national time to surgery benchmarks in our country, which could be one of the reasons behind the observed long delay in surgery in our study. Especially, surgical interventions for patients with stable intertrochanteric hip fractures are not considered urgent, and patients might not be prioritized for immediate surgeries; considering that skin traction and morphine administration are currently the only methods of pain alleviation in our country, prolonging the time to surgery period could potentially cause further delirium and other opioid related complications in these patients. We believe that introducing time to surgery benchmarks in the national hip fracture approach protocols would be a critical step toward improving the surgery outcomes and patients’ satisfaction.
In addition, even though patients with intertrochanteric hip fractures are usually older and more susceptible to experiencing severe forms of COVID-19 due to their background diseases, no prioritization was made for this group of patients in our hospital during the COVID-19 pandemic. Malik-Tabassum et al. performed an observational study on patients with different types of hip fractures in the UK, and compared the patients outcomes during 50 days of COVID-19 pandemic (period C) to two same dates within the past 2 years of the study before the pandemic (periods A and B). They reported that the mean length of inpatient stay during period C was significantly shorter than periods A and B; however, there was no significant difference in complication rates, return to the OR, and 30 day mortality rate, and the proportion of the patients discharged to their pre-admission residence during all three periods. They also mentioned that during period C, a multidisciplinary decision was made to prioritize surgery for patients with hip fractures despite the lack of available operating room’s capacity. In addition, they reported that no member of the on-call structure, junior ward cover, or provision of orthogeriatrc care was redeployed to other specialties ; however, in our medical center, almost 20% of the orthopedic residents were redeployed to the COVID-19 centers. Also, in our hospital all of the patients have to be consulted by a cardiologist and an anesthesiologist before surgery, and during the study period, the number of available cardiologists and anesthesiologists were limited as many of them were redeployed to COVID-19 centers. In addition, all the patients had to wait for the COVID-19 PCR test result before undergoing surgery which caused further delay in surgery. We believe that with more proper resource and staff management, time to surgery for this group of frail patients could have been shorter and further studies and newer protocols (for both critical and uncritical times) are needed to reduce the time to surgery, and improve the surgery outcomes.
Based on a systematic review written by Abou-Setta et al. most of the common pain control strategies for patients with hip fracture have low to moderate effects, and the evidence on pain management after hip fractures is surprisingly sparse . In this systematic review it was also reported that using nerve blockades (including 3-in-1, combined lumbosacral plexus, fascia iliaca compartment, femoral nerve, lumbar plexus plus sciatic nerve, posterior lumbar plexus, psoas compartment, obturator nerve, epidural and combined blockades) were significantly related to less supplemental pain medication administration and delirium incidence. In addition, nerve blockade and neuraxial anesthesia had similar results in terms of acute pain, use of additional pain medications and delirium. Also, they outlined that adding other agents to plain local anesthesia did not affect the outcomes outside the operating room and increasing dose of local anesthetic for the hip fracture surgery was associated with increased risk of hypotension . Nerve blockades are available in most medical centers; however, they are not used clinically because of a common belief that the additional required time and effort does not outweigh their benefits. However, considering the lack of enough evidence supporting the effect of skin tractions on pain relief in patients with intertrochanteric fractures, we suggest that the focus of the medical approach to pain management shifts toward alternative and more effective pain relief options including nerve blockades.
Our study had some limitations. Due to the COVID-19 pandemic, we decreased the number of VAS measurements to protect our personnel and patients from unnecessary contacts. In addition, even though everyday emphasis was made on not using any other analgesics, there was no controlling for the use of non-opioid/narcotic pain relief medications during both pre- and post-operative periods by patients separately. Also, although we evaluated many patients with specifically intertrochanteric fractures, we did not separate patients with different types of surgery approaches for intertrochanteric fractures (extramedullary fixation (dynamic hip screw) and intramedullary nail (Gamma nail) fixation surgeries); however, we compared the duration of surgery for both groups. As mentioned in the results section, their difference was not statistically significant, meaning the two groups probably had the same heterogeneity in terms of intertrochanteric fracture surgery types. In addition, we did not have enough time to follow up with the patients to report the surgery’s long-term complications. This, however, seems to be a limitation in many previous studies [1, 4, 13, 16, 18, 22, 38, 39]. We recommend that future studies focus on using better preoperative pain management techniques (including nerve blockades) in patients with intertrochanteric fractures with longer follow-ups.