Role of Periarticular Multimodal Drug Injection Administered Intraoperatively in Pain Management and Opioid Consumption in Elderly Patients with Femoral Neck Fractures Undergoing Hemiarthroplasty

Abstract

Objective: To determine the effect of intraoperative periarticular multimodal drug injection (PMDI) on postoperative pain scores and opioid consumption compared with conventional systemic analgesia in elderly patients with femoral neck fractures undergoing hemiarthroplasty.

Methodology: Quasi-experimental study conducted in the Department of Orthopaedics, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from 2^nd October 2025 to 1^st January 2026. A total of 136 patients aged 60–80 years with Garden type III or IV femoral neck fractures were enrolled using non-probability consecutive sampling and allocated equally into two groups (n = 68 each). The intervention group received intraoperative PMDI (0.25% bupivacaine 20 mL, ketorolac 30 mg, epinephrine 0.3 mg, with normal saline to a total volume of 40 mL), while the control group received standard systemic analgesia. Pain was assessed using the Visual Analog Scale (VAS) at 24 and 72 hours, and total tramadol consumption (mg per patient) was recorded over the first three postoperative days. Comparisons were made using the Mann–Whitney U test; p ≤ 0.05 was considered significant.

Results: The median age was 65 years (IQR 6) and median BMI was 24.0 kg/m² (IQR 2.41). Baseline characteristics were comparable between groups. Postoperative VAS scores were significantly lower in the PMDI group than controls (median 2.0 [1.0–2.88] vs 4.5 [3.5–5.38]; U = 525.5, Z = −7.807, p < 0.001). Total opioid consumption was also significantly reduced in the PMDI group (median 100 mg [50–150] vs 250 mg [150–300]; U = 390.0, Z = −8.465, p < 0.001). No significant association was found between VAS scores or opioid consumption and gender, age category, or Garden classification (all p > 0.05).

Conclusion: Intraoperative PMDI significantly reduces postoperative pain and opioid consumption in elderly patients undergoing hemiarthroplasty for femoral neck fracture.

Keywords: Analgesia, Hemiarthroplasty, Multimodal, Opioid, Pain management, Periarticular injection.