Introduction

With the intensification of the global aging population, approximately 100 million hip fractures require surgical treatment and comprehensive perioperative management every year, which poses a huge challenge to orthopedic doctors and also imposes a burden on the economies and medical resources of various countries. Ongoing evidence reports that the number of people more than 60 years old in China has reached 249 million, occupying nearly 20% of the total population by 2018.1,2 It is expected that the elderly population will reach 450 million by 2050, accounting for over 30% of the global population by 2050.1,2 Femoral neck fracture (FNF) is a common cause of mortality, immobility, and economic burden in the elderly due to various comorbidities and difficulties in postoperative recovery.3–5 Despite significant improvements in current management, mortality still ranges from 26% to 37% with first-year follow-up.6,7

Pain management is an important part of perioperative management for the elderly with hip fractures. Increasing research has reported that pain control is closely related to post-operative outcomes, hospital stay, postoperative recovery, and even mortality.8,9 Poor pain control is also associated with postoperative delirium, depressive symptoms and other adverse outcomes in older adults,10,11 which may impair their daily lives, reduce their quality of life, and even increase mortality. Cyclooxygenase (COX)-2 inhibitors have acceptable gastrointestinal toxicity and are widely established for the clinical management of pain control.12,13 Celecoxib, the first COX-2 inhibitor, is commonly utilized for relieving postoperative pain in hip surgeries and its potential mechanism.14–18 However, related studies on the effect of using OC pre-operatively on postoperative delirium, mortality, and functional outcomes are relatively scarce. Our aim is to evaluate the effect of using preoperative OC in elderly patients with FNF on delirium and functional outcomes, as well as mortality.

Materials and Methods Ethics Statement

The study was approved by the Institutional Review Board of affiliated hospital of Jiangnan University before data collection and analysis (LS2024039) in compliance with the Helsinki and an exemption from the informed consent was obtained. All data were anonymized before the analysis to safeguard patient privacy.

Patients

This retrospective study included FNF patients who received surgery between Jan. 2020 and May. 2024. According to using OC preoperatively (200mg QD) or not, patients were divided into OC group and non-OC group. All patients were treat with OC postoperatively (200mg QD). The inclusion criteria as follows: (1) patients with Garden III or IV type; (2) >60 years old; (3) no comorbidity was caused at the time of IF; (4) more than 1-year follow-up. The exclusion criteria were as follows: (1) patients with a history of hip fracture or hip surgery; (2) patients with open or pathological fractures; (3) patients with multiple injuries or fractures; (4) more than 48 hours since injury.

Data Collection

In the present study, we collected data, consisting of patient characteristics (age, gender, body mass index, BMI, residence, and a history of smoking or alcohol), injury-related data (fracture type, injury mechanism, and length of time from injury to admission), in-hospital data (American Society of Anesthesiologists, ASA, type of anesthesia, intraoperative blood loss, and duration of operation, Hb level at admission, blood transfusion, VAS at admission, VAS 1st day after surgery, VAS 3rd day after surgery, VAS at discharge, length of hospital stay, and deep vein thrombosis (DVT) at admission), comorbidities (coronary heart disease, heart failure, arrhythmia, hypertension, diabetes, myocardial infarction, cerebral hemorrhage, and cerebral infarction), complications after surgery (heart failure, respiratory failure, cerebral infarction, arrhythmia, pneumonia, delirium, anemia, DVT, electrolyte disturbance, and hypoproteinemia), and functional outcomes (independent walking, use of walking aids, use of wheelchair, bedridden, and death) as well as mortality (30-day mortality, 90-day mortality, and 12-month mortality).

Statistical Analysis

SPSS (version 27.0 SPSS Inc., Chicago, IL) was used with a significant level (p<0.05). For continuous variables, the Mann–Whitney U-test or t-test was performed according to whether the data met normality criteria or not. The chi-square test was employed for data analysis on count data. We performed propensity score matching (PSM) analysis based on the results of logistic regression analysis with a 1:1 ratio to adjust for discrepancies in baseline characteristics between the two groups to lower selection bias. After PSM, we used univariate regression analyses to observe the effect of OC on complications after surgery and functional outcomes, as well as mortality, then we investigated the association between VAS scores and other variables, such as age, gender, or BMI by Spearman correlation analysis.

Results

As shown in Figure 1, we collected 1211 patients with FNF in our hospital from Jan 2020 to May 2024. According to inclusion criteria and exclusion criteria, we removed 303 patients. Then, 908 patients, including 414 in non-OC group and 494 in OC group. Finally, 215 patients were included after PSM analysis.

Figure 1 Flow diagram of included patients.

Before PSM analysis, there was no significant difference in gender, residence, injury type, time from injury to surgery, type of anesthesia, blood transfusion, VAS at admission, DVT at admission, patients with a history of smoking, drinking, hypertension, coronary heart disease, heart failure, arrhythmia, myocardial infarction, cerebral hemorrhage, or cerebral infarction between two groups. However, age (p<0.001), age group (p=0.001), BMI (p=0.037), Garden classification (p<0.001), ASA (p<0.001), Hb level at admission (p<0.001), VAS at admission (p=0.012) and a history of diabetes (p=0.018) were significant differences between the two groups before PSM analysis, but there was no marked difference after PSM analysis (Table 1).

Table 1 Comparisons of Patient Characteristics at Baseline Before and After Propensity Score Match

Table 2 and Figure 2 showed obviously lower VAS scores on the 1st day after surgery, 3rd day after surgery and at discharge in OC group, implying the important role of OC preoperatively in pain control after surgery. We then investigated the effect of OC preoperatively in elderly patients with FNF on complications, functional outcomes, as well as mortality. We found that the rate of delirium was significantly lower in OC group, but no close relationship between the use of OC and mortality. Spearman correlation analysis showed that OC preoperatively had the highest correlation with VAS scores at the time of 1st day after surgery and the lowest correlation with VAS scores at discharge (Table 3).

Table 2 Patient Outcome Analyses After Propensity Score Matching

Table 3 The Association of VAS Scores with Other Variables

Figure 2 VAS score at different times in two groups (ns: no significant; ***: <0.0001).

Discussion

Based on previous research, almost two-thirds of patients experienced moderate-to-severe pain before surgery,19,20 yet over 70% of patients still do not receive pain management.19 To our knowledge, various factors, including poor treatment compliance, concerns about side effects, and inconsistent prescription practices among clinicians, contribute to inconsistent and insufficient pain management.21 Pain management is of utmost importance in the perioperative management of elderly hip fractures, and it is also a huge challenge for clinicians. Poor pain control can lead to many adverse consequences, such as anxiety, poor postoperative function recovery, and even increased mortality.

Guo21 has explored the effect of intravenous paracetamol preoperatively in older patients with intertrochanteric fractures on the reverse events and found the beneficial effects of intravenous paracetamol preoperatively on pain control, pain-related complications, and functional recovery. Increasing evidence has reported the good safety and efficacy of treatment with the COX2-selective inhibitor, celecoxib, in pain management of femoral head necrosis, knee and hip osteoarthritis.22–24 To date, no study has investigated the efficacy of OC preoperatively on delirium and functional outcomes, as well as mortality in patients with FNF.

Therefore, we conducted a retrospective study to explore the effect of OC preoperatively in patients with FNF with 12-month follow-up by PSM analysis. Before PSM analysis, age, age group, BMI, Garden classification, ASA, Hb level at admission, and a history of diabetes were significantly different in two groups, but there was no marked difference after PSM analysis. Then, we found that VAS scores at the time of the 1st day after surgery, the 3rd day after surgery, and at discharge were markedly lower in OC group. Additionally, a lower delirium rate and better functional outcomes were found in OC group. Our findings showed no significant difference in mortality at 30-day, 90-day, and 12-month between the two groups.

Prior research has reported that pain management was correlated with length of hospital stay or even mortality.8,9 However, Guo21 did not find a close relationship between pain control and function recovery and even mortality, which was similar to our findings. In our study, 4.2% (18 of 430) of all patients died at the final follow-up, and the mortality of the non-OC group and OC group in 12 months were 3.7% and 4.6% after PSM, respectively, which was significantly lower than previous data.25,26 This may be related to the race of the subjects or a distinct fracture. Furthermore, we found 85.6% (127 patients with independent walking and 57 patients with walking aids) of patients receiving OC preoperatively obtained good function recovery, while 67.0% (110 patients with independent walking and 34 patients with walking aids) of patients without OC preoperatively achieved good function recovery.

Previous research has reported that poor pain control can cause some adverse events, such as postoperative complications, depressive symptoms, and other outcomes in older adults,10,11 which may reduce their quality of life, and even increase mortality. Therefore, pain control during the perioperative period plays a crucial role in reducing adverse events in older patients with FNF. In our study, OC preoperatively can dramatically reduce VAS scores from 6.0 points at admission to 3.1 points at the 1st day after surgery, 2.2 points at the 3rd day after surgery, and 1.7 points at discharge, which is markedly lower than in non-OC group. Our findings implied that OC preoperatively is an effective management. Additionally, we used Spearman correlation analysis to find that OC preoperatively had the highest correlation with VAS scores at the time of 1st day after surgery and the lowest correlation with VAS scores at discharge.

We also compare the rate of complications after surgery in two groups. We first matched comorbidities in two groups using PSM analysis, which can lower the potential confounding biases. Surprisingly, only the rate of postoperative delirium was significantly lower in OC group and in non-OC group, but there was no obvious difference in other complications, such as heart failure, and diabetes. To the best of our knowledge, postoperative delirium is a relatively rare complication after hip surgery, but it is a main cause for mortality after surgery. According to prior research, the rate of delirium was over 50% after hip fracture repair.27–30 Poor pain control is also associated with postoperative delirium,10,11 implying that pain control is an important role in preventing delirium.

To our knowledge, this is the first study to evaluate the functional outcomes of OC preoperatively in patients with FNF after PSM analysis. This quantitative analysis may improve the confidence of orthopedic surgeons in pain control for patients with FNF and be beneficial for clinicians to seek the possibility of establishing future outcomes of adverse functions, and to establish reasonable medical care goals for this vulnerable population. However, one drawback is that it is a retrospective, single-center observational study. In addition, we did not exclude other unknown factors, such as the laboratory indicators during the perioperative period, for analysis, which may affect our results.

In conclusion, regarding FNF patients with moderate-to-severe pain, using preoperative OC can be more likely to relieve pain, reduce pain-related complications like delirium, and obtain better functional recovery. Our findings underline that preoperative OC can help clinicians and nursing staff effectively control pain and its related complications.

Data Sharing Statement

The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding authors.

Ethics Approval and Consent to Participate

The study was approved by the Institutional Review Board of affiliated hospital of Jiangnan university before data collection and analysis (LS2024039) in compliance with the Helsinki and an exemption from the informed consent was obtained. All data were anonymized before the analysis to safeguard patient privacy.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare no competing interests in this work.

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