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Manuscript_772f74327d2e9337bb6e49588e24c464

1 Review Article

3 Pain relief differentiated according to the length of time that preoperative skin

4 traction was carried out for hip fractures: A systematic review and meta-analysis

6 Takaomi Kobayashi, M.D.a,*, Hiroshi Ureshino, M.D., Ph.D.b,*, Tadatsugu Morimoto,

7 M.D., Ph.D.a,*, Motoki Sonohata, M.D., Ph.D.a, Masaaki Mawatari, M.D., Ph.D.a

9 a
Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, 5-1-1

10 Nabeshima, Saga 849-8501, Japan; bDivision of Hematology, Respiratory Medicine and

11 Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University,

12 5-1-1 Nabeshima, Saga 849-8501, Japan.

13

14 *
The authors equally contributed to this work.

15

16 Corresponding Author: Takaomi Kobayashi, M.D.

17 Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, 5-1-1

18 Nabeshima, Saga 849-8501, Japan.

19 Tel: +81-952-34-2343, Fax: +81-952-34-2059, Email: takaomi_920@yahoo.co.jp

20

1
© 2021 published by Elsevier. This manuscript is made available under the Elsevier user license
https://www.elsevier.com/open-access/userlicense/1.0/
21

22 Acknowledgments: The authors would like to thank Brian Quinn

23 (http://www.japan-mc.co.jp/about/) for the English language review.

24

25 Conflict of interest: The authors declare that they have no conflict of interest.

26

27 Author contributions: TK, HU, and TM are accountable and responsible for the

28 conception and design of the study, or acquisition of data, or analysis and interpretation

29 of data, drafting the article or revising it critically for important intellectual content, and

30 final approval of the version to be submitted. TK, HU, and TM equally contributed to

31 this work. MS and MM are accountable and responsible for drafting the article or

32 revising it critically for important intellectual content and final approval of the version

33 to be submitted.

2
 1 Review Article

3 Pain relief differentiated according to the length of time that preoperative skin traction

4 was carried out for hip fractures: A systematic review and meta-analysis

6 Abstract

7 Aim: To conduct a systematic review and meta-analysis on articles pertaining to pain relief

8 differentiated by time within 24 h of preoperative skin traction for hip fracture.

9 Method: PubMed, Google Scholar, Cochrane Library, Web of Science, and MEDLINE were

10 searched for relevant articles published in the English language on comparison of pain relief

11 between preoperative skin traction and no traction for hip fracture.

12 Results: Five studies involving 413 patients with hip fractures (skin traction, n=207; no

13 traction, n=206) were included. The visual analog scale (VAS) score within one hour

14 postadmission in the skin traction group was significantly smaller than that in the no traction

15 group (Mean difference [MD] = -0.41, 95% confidence interval [CI]: -0.63 to -0.20,

16 p=0.0001). In contrast, there was no significant difference in the VAS scores of the two

17 groups at 4–6 h (MD = 0.16, 95% CI: -0.13 to 0.45, p=0.27), 12 h (MD = -0.16, 95% CI:

18 -0.68 to 0.36, p=0.55), and 24 h (MD = -0.11, 95% CI: -0.99 to 0.77, p=0.80) postadmission.

19 Conclusions: Evidence indicates that preoperative skin traction for hip fracture can provide

20 pain relief within one hour postadmission, but not at 4–6, 12, and 24 h postadmission.

21 Accordingly, alternative preoperative pain relief methods for hip fractures should be carefully

22 considered.

23
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24 Keywords: hip fractures; skin traction; no traction; pain; time

2
25 Introduction

26 Hip fracture is a major worldwide issue (Veronese et al., 2018) and a debilitating condition

27 that requires definitive surgery (Pincus et al., 2017). Before surgical intervention, several

28 preoperative treatments for hip fracture patients (e.g., skin traction, skeletal traction, splints,

29 nerve blockade, and pillow care) have been developed in anticipation of pain relief, reduced

30 analgesic needs, ease of fracture reduction at surgery, and reduction of blood transfusions

31 (Biz et al., 2019; Endo et al., 2013; Jerre et al., 2000; Kobayashi et al., 2020; Manafi Rasi et

32 al., 2015; Matullo et al., 2016; Rosen et al., 2001; Saygi et al., 2010; Tosun et al., 2018;

33 Wennberg et al., 2019; Yip et al., 2002; Yuenyongviwat et al., 2020). Among the

34 preoperative treatments, skin traction was still a common practice in many countries until the

35 introduction of surgery in the 1950s (Biz et al., 2019; Endo et al., 2013; Jerre et al., 2000;

36 Kobayashi et al., 2020; Manafi Rasi et al., 2015; Rosen et al., 2001; Saygi et al., 2010; Tosun

37 et al., 2018; Yip et al., 2002; Yuenyongviwat et al., 2020).

38

39 Background/literature

40 Pain relief is one of the most important preoperative managements, as hip fractures are quite

41 painful (Barnes, 2002; Endo et al., 2013; Jerre et al., 2000; Kobayashi et al., 2020; Manafi

42 Rasi et al., 2015; Rosen et al., 2001; Saygi et al., 2010; Yip et al., 2002; Yuenyongviwat et al.,

43 2020). Nevertheless, the pain relief provided by preoperative skin traction for hip fracture has

44 been a matter of debate (Barnes, 2002; Endo et al., 2013; Handoll et al., 2011; Jerre et al.,

45 2000; Kobayashi et al., 2020; Manafi Rasi et al., 2015; Parker et al., 2006; Rosen et al., 2001;

46 Saygi et al., 2010; Yip et al., 2002; Yuenyongviwat et al., 2020). Several authors have found

47 that pain relief depends on the duration of skin traction (Barnes, 2002; Endo et al., 2013;

3
48 Manafi Rasi et al., 2015; Yip et al., 2002), and recently advocated the possibility of pain

49 relief after 24–60 h of skin traction (Barnes, 2002; Endo et al., 2013; Kobayashi et al., 2020;

50 Manafi Rasi et al., 2015; Yip et al., 2002). On the other hand, pain relief differentiated by

51 time within 24 h of skin traction remains unclear (Barnes, 2002; Endo et al., 2013; Jerre et al.,

52 2000; Kobayashi et al., 2020; Manafi Rasi et al., 2015; Parker et al., 2006; Rosen et al., 2001;

53 Saygi et al., 2010; Yip et al., 2002). We herein describe the results of a systematic review and

54 meta-analysis of the relevant peer reviewed literature on pain relief differentiated by time

55 within 24 h of preoperative skin traction in patients with hip fractures. The hypothesis of the

56 present systematic review and meta-analysis was that skin traction achieved better pain relief

57 at any time within 24 h for hip fracture in comparison to no traction.

58

59 Methods

60 Search strategy and criteria

61 The protocol of the systematic review was registered at the International Prospective Register

62 of Systematic Reviews (PROSPERO registration no. CRD42020215130). The present

63 meta-analysis was carried out according to the Preferred Reporting Items for Systematic

64 Review and Meta-Analysis (PRISMA) statement (Moher et al., 2009). PubMed, Google

65 Scholar, Cochrane Library, Web of Science, and MEDLINE were searched for relevant peer

66 reviewed articles published in the English language on the application of preoperative skin

67 traction as a pain relief method in patients with hip fractures. All searches were conducted on

68 April 20th, 2021. The search term used in PubMed was as follows: (skin

69 traction[Title/Abstract]) AND (fracture[Title/Abstract] OR fractures[Title/Abstract]) AND

70 (pain[Title/Abstract]). Other databases were searched using similar search strategies. The

4
71 following articles were excluded: articles that did not compare the pain score differentiated

72 by time within 24 h between preoperative skin traction and no traction in patients with hip

73 fractures; articles that did not specify the details of the pain score; and articles that were

74 review articles, case reports (n < 3), commentary, editorial, insights articles, or proceedings.

75 Unpublished studies were not searched in this systematic review and meta-analysis. The

76 reference lists of the records identified the through database search were screened. No ethics

77 committee or institutional review board approval was required, as this was a systematic

78 review and meta-analysis.

79

80 Quality assessment

81 We used the Cochrane Consumers & Communicating Review Group’s Study Quality Guide

82 (Ryan et al., 2013) to evaluate the quality of included studies. The following domains were

83 analyzed: random sequence generation, allocation concealment, blinding of participants and

84 personnel, incomplete outcome data, selective reporting, and other bias. Two reviewers (TK

85 and HU) screened the extracted literature and performed data extraction, to ensure the

86 consistency of the results. Any disagreement was resolved by a discussion between the two

87 reviewers.

88

89 Data extraction

90 Data were extracted by two independent reviewers (TK and HU). The following data were

91 extracted: the selected studies (i.e., first author, publication year, and study design),

92 participant (i.e., sample size, fracture types, age, and gender), intervention (i.e., details of skin

93 traction), comparison (i.e., details of no traction), and outcome (i.e., pain score).

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 94 Data analysis and statistical methods

95 Statistical analyses were performed by one author (TK). Review Manager Software version

96 5.3 (The Cochrane Collaboration, Oxford, United Kingdom) was used for the meta-analysis.

97 The mean value and standard deviation (SD) of the VAS score and number of subjects were

98 entered. The Χ2 test and I2 statistics were applied to assess heterogeneity: insignificant

99 heterogeneity (I2 0% to <25%), low heterogeneity (I2 25% to <50%), and significant

100 heterogeneity (I2 50–100%). If significant heterogeneity occurred (p < 0.10 and I2 > 50%),

101 random-effects models were used for the analysis. Otherwise, fixed-effects models were used.

102 The mean difference (MD) and 95% confidence interval (CI) were used for data processing

103 of the pain score. P values of <0.05 were considered to indicate statistical significance.

104

105 Data/results

106 Search results and study characteristics

107 Fig. 1 shows a flow chart of our methodology. A total of 163 records were identified through

108 the initial database search. After screening, eight records underwent full text review and three

109 full-text records (Kobayashi et al., 2020; Yip et al., 2002; Yuenyongviwat et al., 2020) were

110 excluded due to lack of data on the pain score. There were no eligible articles identified from

111 the reference lists of the records identified through the database search. Finally, five studies

112 (two randomized controlled trials [Endo et al., 2013; Rosen et al., 2001] and three

113 quasi-randomized controlled trials [Jerre et al., 2000; Manafi Rasi et al., 2015; Saygi et al.,

114 2010]) involving 413 patients with hip fractures (207 patients received skin traction and 206

115 patients did not receive skin traction) were eligible for inclusion in this review and are

116 summarized in Table 1 based on the participant, intervention, comparison, and outcome

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117 (PICO) methodology (Eriksen et al., 2018). Pain was assessed by the visual analog scale

118 (VAS) in all studies. None of the studies included cases in which pain relief methods other

119 than skin traction and pain medication were applied.

120

121 Risk of bias assessment

122 Fig. 2 shows the quality assessment of the eligible studies. In three studies (Jerre et al., 2000;

123 Manafi Rasi et al., 2015; Saygi et al., 2010), there was considered to be a high risk of

124 selection bias (random sequence generation and allocation concealment) because there was

125 no description of the random sequence generation (Jerre et al., 2000; Manafi Rasi et al.,

126 2015) or because allocation was based on the order of the admission to the hospital (Saygi et

127 al., 2010). The other studies generated the allocation sequence using a sealed envelope

128 opened at the time of intervention by colleagues who were not involved in the study (Endo et

129 al., 2013) or using a software program (Rosen et al., 2001). For all studies (Endo et al., 2013;

130 Jerre et al., 2000; Manafi Rasi et al., 2015; Rosen et al., 2001; Saygi et al., 2010),

131 performance bias (blinding of participants and personnel) was a major quality defect, as the

132 intervention (skin traction) was visible, and thus was not blinded. In four studies [Jerre et al.,

133 2000; Manafi Rasi et al., 2015; Rosen et al., 2001; Saygi et al., 2010], the detection bias

134 (blinding of outcome assessment) was unclear as they did not describe who measured the

135 pain score (Jerre et al., 2000; Manafi Rasi et al., 2015; Rosen et al., 2001; Saygi et al., 2010).

136 In two studies (Manafi Rasi et al., 2015; Saygi et al., 2010), there was considered to be a high

137 risk of reporting bias (selective reporting) as there was a significant difference in the pain

138 score between the skin traction and no traction groups. In one study (Rosen et al., 2001),

139 there was a high risk of other bias, as there was a significant difference in the fracture types

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140 between the skin traction and no traction groups (baseline). In two studies (Manafi Rasi et al.,

141 2015; Saygi et al., 2010), the risk of other bias was considered to be unclear because there

142 was no comparison of the time from injury to admission between the skin traction and no

143 traction groups (pre-randomization administration that could influence the effect of the

144 intervention). There was no evidence of attribution bias (incomplete outcome data).

145

146 Risk of publication bias

147 Fig. 3 shows a funnel plot of the pain relief within one hour postadmission. There was

148 heterogeneity among studies, indicating a lack of smaller studies with negative results.

149 However, no values were outside the range of acceptability and close to the no-effect line.

150

151 Meta-analysis results

152 The VAS score within one hour postadmission was provided in five studies (Endo et al.,

153 2013; Jerre et al., 2000; Manafi Rasi et al., 2015; Rosen et al., 2001; Saygi et al., 2010) (Fig.

154 4a). A fixed model was used, as there was no heterogeneity (I2 = 30%, p = 0.22). The VAS

155 score within one hour postadmission in skin traction group was significantly smaller than that

156 in the no traction group (MD = -0.41, 95% CI: -0.63 to -0.20, p = 0.0001).

157 The VAS score at 4–6 h postadmission was reported in three studies (Jerre et al.,

158 2000; Manafi Rasi et al., 2015; Saygi et al., 2010) (Fig. 4b). A fixed model was used, as there

159 was no heterogeneity (I2 = 18%, p = 0.29). There was no significant difference between the

160 two groups in the VAS score at 4–6 h postadmission (MD = 0.16, 95% CI: -0.13 to 0.45, p =

161 0.27).

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162 The VAS score at 12 h postadmission was recorded in three studies (Jerre et al.,

163 2000; Manafi Rasi et al., 2015; Saygi et al., 2010) (Fig. 4c). A random model was used

164 because of significant heterogeneity (I2 = 58%, p = 0.09). No significant difference was

165 detected between the two groups in the VAS score at 12 h postadmission (MD = -0.16, 95%

166 CI: -0.68 to 0.36, p = 0.55).

167 The VAS score at 24 h postadmission was mentioned in two studies (Endo et al.,

168 2013; Manafi Rasi et al., 2015) (Fig. 4d). A random model was used, as there was significant

169 heterogeneity (I2 = 90%, p = 0.001). There was no significant difference between the two

170 groups in the VAS score at 24 h postadmission (MD = -0.11, 95% CI: -0.99 to 0.77, p =

171 0.80).

172

173 Discussion

174 The main findings of this meta-analysis were as follows: (1) preoperative skin traction within

175 one hour postadmission for hip fracture provided pain relief; and (2) preoperative skin

176 traction at 4–6, 12, and 24 h postadmission for hip fracture provided no pain relief.

177 Guidelines from many countries recommend hip fracture surgery within 24–48 h

178 after admission to improve clinical outcomes (i.e., mobility, complication, and mortality)

179 (Kobayashi et al., 2020; Pincus et al., 2017), while emergency surgery is sometimes difficult

180 because of comorbidities, complex medical situations related to high-energy trauma, and/or a

181 lack of availability of necessary staff (Endo et al., 2013; Kobayashi et al., 2020; Yip et al.,

182 2002; Yuenyongviwat et al., 2020). In both emergency and delayed surgery, the most severe

183 pain is likely to be experienced immediately after admission, and the pain remains constant or

184 decreases with time until surgical stabilization (Endo et al., 2013; Jerre et al., 2000; Manafi

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185 Rasi et al., 2015; Resch et al., 1998; Rosen et al., 2001; Saygi et al., 2010; Yuenyongviwat et

186 al., 2020). Preoperative skin traction can contribute to pain relief within one hour

187 postadmission, and thus skin traction within one hour postadmission could also be a

188 preoperative treatment option for hip fracture, from a viewpoint of pain relief immediately

189 after admission.

190 The possible mechanisms of pain relief within one hour of preoperative skin

191 traction for hip fracture may include a placebo effect, relief of muscle spasm, rest for the

192 diseased joint or limb, reduction of skeletal dislocation, protection against further fracture

193 displacement, and/or protection against damage to the periarticular vessels and soft tissues

194 (Jerre et al., 2000; Manafi Rasi et al., 2015; Matullo et al., 2016; Saygi et al., 2010).

195 We should keep in mind that there may be a consensus on no other benefit than

196 pain relief with preoperative skin traction for patients with hip fractures (e.g., reduced

197 analgesic needs [Anderson et al., 1993; Barnes, 2002; Endo et al., 2013; Jerre et al., 2000;

198 Kobayashi et al., 2020; Manafi Rasi et al., 2015; Needoff et al., 1993; Resch et al., 2005;

199 Rosen et al., 2001; Saygi et al., 2010; Yip et al., 2002], ease of fracture reduction at surgery

200 [Biz et al., 2019; Endo et al., 2013; Jerre et al., 2000; Yip et al., 2002], and reduction of blood

201 transfusion [Finsen et al., 1992; Yip et al., 2002]).

202 Preoperative skin traction is associated with many disadvantages. For instance,

203 preoperative skin traction can cause allergy due to the use of adhesive strapping (Finsen et al.,

204 1992), and is associated with medical cost (Anderson et al., 1993; Finsen et al., 1992;

205 Needoff et al., 1993; Resch et al., 2005; Shabat et al., 2002). Its long term (≥24 h) use or use

206 with a weight of ≥3 kg can cause some complications (e.g., pressure sores [Jerre et al., 2000;

207 Saygi et al., 2010], skin slough [Resch et al., 1998], and deep vein thrombosis [Endo et al.,

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208 2013; Tosun et al., 2018]). Importantly, preoperative skin traction can complicate nursing

209 care and requires advanced nursing skills (e.g., bed transfer, posture change, and rewinding

210 elastic bandages and track bands [Anderson et al., 1993; Kobayashi et al., 2020; Yip et al.,

211 2002]). In addition, there may be nurses who have not experienced applying and/or

212 maintaining preoperative skin traction. Thus, preoperative skin traction for hip fractures does

213 not seem particularly effective from the viewpoint of the nursing care/time. Considering these

214 issues, preoperative pain relief methods should be carefully considered (e.g., pain medication,

215 splints, nerve blockade, pillow care, skin traction, and skeletal traction [Biz et al., 2019; Endo

216 et al., 2013; Jerre et al., 2000; Kobayashi et al., 2020; Manafi Rasi et al., 2015; Matullo et al.,

217 2016; Rosen et al., 2001; Saygi et al., 2010; Tosun et al., 2018; Wennberg et al., 2019; Yip et

218 al., 2002; Yuenyongviwat et al., 2020]). Further investigations on the benefits and

219 complications of these pain relief methods differentiated by time are required.

220

221 Limitations

222 The present study was associated with some limitations. First, a database bias and English

223 language bias may exist because of the database search. Second, this analysis was limited

224 according to the quality of the studies, as shown in Fig. 2. Third, there is a potential

225 publication bias in this analysis, as illustrated in Fig. 3; studies that fail to reject the null

226 hypothesis (or negative studies) may tend to remain unpublished. Furthermore, unpublished

227 studies were not searched in this systematic review and meta-analysis. Nevertheless, the risk

228 of publication bias could be acceptable, as all values were inside the range of acceptability

229 and close to the no-effect line. Fourth, data from 413 patients were included and a greater

230 number would help to increase the significance of the findings. Fifth, the evaluation of the

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231 cognitive function and its handling differed among studies. The cognitive function was

232 assessed according to comprehension of time and place (Endo et al., 2013), answering

233 questions regarding the levels of pain that the patient experienced and a mini-mental status

234 exam (Rosen et al., 2001), or a simple mental score (Saygi et al., 2010), whereas it was not

235 assessed in two studies (Jerre et al., 2000; Manafi Rasi et al., 2015). Sixth, the pain

236 medications differed among the studies, being 3 mg of intravenous morphine as required

237 (Manafi Rasi et al., 2015), loxoprofen (60 mg) or diclofenac sodium (25 mg) every 4 h as

238 required (Endo et al., 2013), oral paracetamol tablets 3 times a day routinely and parenteral

239 tramadol on demand (Saygi et al., 2010), a standardized as-needed pain medication protocol

240 adjusted for body weight (Rosen et al., 2001), or not mentioned (Jerre et al., 2000). In

241 addition, the timing of the administration of pain medications was also not stated, which was

242 a major limitation and which may have impacted the VAS at each time point. Seventh, the

243 details of skin traction (i.e., 2–3 kg) differed slightly among the studies, as shown in Table 1.

244 The classic advice is 2–4 kg of skin traction (Anderson et al., 1993; Needoff et al., 1993; Yip

245 et al., 2002), indicating that our findings can apply to globally standard treatments. To apply

246 a greater load (>4 kg), skeletal traction may be required (Ryan et al., 2013; Shabat et al.,

247 2002). Eighth, the details of no-traction treatment were not mentioned in two studies (Jerre et

248 al., 2000; Manafi Rasi et al., 2015), as shown in Table 1. Finally, the time from injury to

249 admission was not mentioned in three studies (Manafi Rasi et al., 2015; Rosen et al., 2001;

250 Saygi et al., 2010), which may have influenced the VAS.

251

252

253

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254 Conclusion

255 This systematic review and meta-analysis provides sufficient evidence to conclude that

256 preoperative skin traction can provide pain relief within one hour postadmission, but not at 4–

257 6, 12, and 24 h postadmission. Accordingly, alternative preoperative pain relief methods for

258 hip fractures should be carefully considered.

259

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260 References

261 Anderson, G.H., Harper, W.M., Connolly, C.D., et al., 1993. Preoperative skin

262 traction for fractures of the proximal femur. A randomised prospective trial. J. Bone. Joint.

263 Surg. Br. 75(5), 794–796.

264 Barnes, P., 2002. Preoperative pillow placement under the injured extremity had

265 better analgesic effects than skin traction for hip fracture. Evid. Based. Nurs. 5(1), 24.

266 Biz, C., Fantoni, I., Crepaldi, N., et al., 2019. Clinical practice and nursing

267 management of pre-operative skin or skeletal traction for hip fractures in elderly patients: a

268 cross-sectional three-institution study. Int. J. Orthop. Trauma. Nurs. 32, 32–40.

269 Endo, J., Yamaguchi, S., Saito, M., et al., 2013. Efficacy of preoperative skin

270 traction for hip fractures: a single-institution prospective randomized controlled trial of skin

271 traction versus no traction. J. Orthop. Sci. 18(2), 250–255.

272 Eriksen, M.B., Frandsen,T.F., 2018. The impact of patient, intervention,

273 comparison, outcome (PICO) as a search strategy tool on literature search quality: A

274 systematic review. J. Med. Libr. Assoc. 106(4), 420–431.

275 Finsen, V., Børset, M., Buvik, G.E., et al., 1992. Preoperative traction in patients

276 with hip fractures. Injury 23(4), 242–244.

277 Handoll, H.H., Queally, J.M., Parker, M.J., 2011. Pre-operative traction for hip

278 fractures in adults. Cochrane Database Syst. Rev. (12), CD000168.

279 Jerre, R., Doshé, A., Karlsson, J., 2000. Preoperative skin traction in patients with

280 hip fractures is not useful. Clin. Orthop. Relat. Res. (378), 169–173.

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281 Kobayashi, T., Lefor, A.K., Hotta, K., et al., 2020. Pain relief after more than 24

282 hours of preoperative skin traction in patients with intertrochanteric fractures: A retrospective

283 comparative cohort study. Int. J. Orthop. Trauma. Nurs. 37, 100754.

284 Manafi, Rasi, A., Amoozadeh, F., Khani, S., et al., 2015. The effect of skin traction

285 on preoperative pain and need for analgesics in patients with intertrochanteric fractures: A

286 randomized clinical trial. Arch. Trauma. Res. 4(2), e12039.

287 Matullo, K.S., Gangavalli, A., Nwachuku, C., 2016. Review of lower extremity

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289 Moher, D., Liberati, A., Tetzlaff, J., et al., 2009. Preferred reporting items for

290 systematic reviews and meta-analyses: the PRISMA statement. PLoS. Med. 6(7), e1000097.

291 Needoff, M., Radford, P., Langstaff, R., 1993. Preoperative traction for hip

292 fractures in the elderly: a clinical trial. Injury 24(5), 317–318.

293 Parker, M.J., Handoll, H.H., 2006. Pre-operative traction for fractures of the

294 proximal femur in adults. Cochrane Database Syst. Rev. (3), CD000168.

295 Pincus, D., Ravi, B., Wasserstein, D., et al., 2017. Association between wait time

296 and 30-day mortality in adults undergoing hip fracture surgery. J. Am. Med. Assoc. 318(20),

297 1994–2003.

298 Resch, S., Bjärnetoft, B., Thorngren, K.G., 2005. Preoperative skin traction or

299 pillow nursing in hip fractures: a prospective, randomized study in 123 patients. Disabil.

300 Rehabil. 27(18-19), 1191–1195.

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301 Resch, S., Thorngren, K.G., 1998. Preoperative traction for hip fracture: a

302 randomized comparison between skin and skeletal traction in 78 patients. Acta. Orthop.

303 Scand. 69(3), 277–279.

304 Rosen, J.E., Chen, F.S., Hiebert, R., et al., 2001. Efficacy of preoperative skin

305 traction in hip fracture patients: a prospective, randomized study. J. Orthop. Trauma. 15(1),

306 81–85.

307 Ryan, R., Hill, S., Prictor, M., et al., 2013. Cochrane consumers and

308 communication review group study quality guide. http://cccrg.cochrane.org/author-resources.

309 Accessed October 2020.

310 Saygi, B., Ozkan, K., Eceviz, E., et al., 2010. Skin traction and placebo effect in the

311 preoperative pain control of patients with collum and intertrochanteric femur fractures. Bull.

312 NYU. Hosp. Jt. Dis. 68(1), 15–17.

313 Shabat, S., Gepstein, R., Mann, G., et al., 2002. Deep skin slough following skin

314 traction for hip fractures. J. Tissue Viability 12(3), 108–112.

315 Tosun, B., Aslan, O., Tunay, S., 2018. Preoperative position splint versus skin

316 traction in patients with hip fracture: An experimental study. Int. J. Orthop. Trauma. Nurs. 28,

317 8–15.

318 Veronese, N., Maggi, S., 2018. Epidemiology and social costs of hip fracture.

319 Injury 49(8):1458–1460.

320 Wennberg, P., Norlin, R., Herlitz, J., et al., 2019. Pre-operative pain management

321 with nerve block in patients with hip fractures: A randomized, controlled trial. Int. J. Orthop.

322 Trauma. Nurs. 33, 35–43.

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323 Yip, D.K., Chan, C.F., Chiu, P.K., et al., 2002. Why are we still using pre-operative

324 skin traction for hip fractures? Int. Orthop. 26:361–364.

325 Yuenyongviwat, V., Jiarasrisatien, C., Iamthanaporn, K., et al., 2020. Balanced

326 suspension versus pillow on preoperative pain for proximal femur fractures: A randomized

327 controlled trial. Adv. Orthop. 2020, 3073892.

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328 Figure legends

329 Fig. 1. Flow chart of the paper selection.

330 Fig. 2. Risk of bias summary. A review of the authors’ judgment on each category of risk of

331 bias for each of the five included studies.

332 Fig. 3. Funnel plot of the pain relief within one hour postadmission.

333 Fig. 4. Forest plot diagram showing pain relief (a) within one hour postadmission, (b) at 4–6

334 h postadmission, (c) at 12 h postadmission, and (d) at 24 h postadmission.

18
Table 1. Summary of the selected studies based on the PICO methodology
Author, Year Study design Participants Intervention Comparison Outcome
Manafi Rasi Quasi-RCT 40 patients with hip 3 kg of skin traction. No traction. There was no significant
et al., 2015 fracture (trochanteric 20 patients with hip 20 patients with hip difference in the VAS
fractures, 40) fracture (trochanteric fracture (trochanteric scores between the traction
Age (years), 68.7 ± 7.4 fractures, 20) fractures, 20) group and the no-traction
[60–85] Age (years), 69.5 ± 8.2 Age (years), 67.8 ± 6.6 group at 30 minutes
Gender (men/women), Gender (men/women), 4/16 Gender (men/women), 7/13 postadmission (6.3 ± 1.3
11/29 [5–8] vs. 6.4 ± 1.1 [4–9],
p=0.895), 6 h
postadmission (5.3 ± 1.0
[5–8] vs. 5.3 ± 1.0 [4–9],
p=0.291), and 12 h
postadmission (4.1 ± 0.8
[3–6] vs. 4.6 ± 1.0 [3–6],
p=0.086). However, the
VAS score in the traction
group was significantly
lower than that in the
no-traction group at 24 h
postadmission (2.7 ± 0.8
[2–5] vs. 3.3 ± 0.9 [2–5],
 p=0.042).
Endo et al., RCT 81 patients with hip 3 kg of skin traction. A pillow beneath the The VAS scores were 4.2 ±
2013 fracture (trochanteric 41 patients with hip injured leg. 0.6 and 2.8 ± 0.4 in the
fractures, 46; neck fracture (trochanteric 40 patients with hip traction group, and 4.8 ±
fractures, 35) fractures, 23; neck fracture (trochanteric 0.6 and 2.5 ± 0.3 in the
Age (years), 75.3 ± 12.2 fractures, 18) fractures, 23; neck no-traction group on
Gender (men/women), Age (years), 74.7 ± 14.4 fractures, 17) admission and at 24 h
17/64 Gender (men/women), 8/33 Age (years), 76.0 ± 9.5 postadmission,
Gender (men/women), 9/31 respectively.
Jerre et al., Quasi-RCT 120 patients with hip 3 kg of skin traction with a No traction. The VAS scores were 3.1 ±
2000 fracture (trochanteric traction sled beneath the 60 patients with hip 2.2, 3.1 ± 2.4, and 3.6 ± 3.0
fractures, 60; neck injured leg. fracture (trochanteric in the traction group, and
fractures, 60) 60 patients with hip fractures, 30; neck 3.2 ± 2.1, 3.5 ± 2.5, and 4.0
Age (years), 79.9 [50–96] fracture (trochanteric fractures, 30) ± 2.5 in the no-traction
Gender (men/women), fractures, 30; neck Age (years), 79.0 [50–94] group at 1 hour
29/91 fractures, 30) Gender (men/women), postadmission, 4 h
Age (years), 80.8 [59–96] 14/46 postadmission, and 12 h
Gender (men/women), postadmission,
15/45 respectively.

Saygi et al., Quasi-RCT 72 patients with hip 2 kg of skin traction with a A pillow beneath the The VAS scores were 6.9 ±
2010 fracture (trochanteric pillow beneath the injured injured leg. 1.1, 5.0 ± 0.8, and 3.6 ± 0.8
 fractures, 41; neck leg. 36 patients with hip in the traction group, and
fractures, 31) 36 patients with hip fracture (trochanteric 6.9 ± 1.3, 4.7 ± 0.7, and 3.4
Age (years), 75.4 ± 16.8 fracture (trochanteric fractures, 21; neck ± 0.8 in the no-traction
[19–100] fractures, 20; neck fractures, 15) group at 15 minutes
Gender (men/women), fractures, 16) Age (years), 74.9 ± 16.2 postadmission, 4 h
24/48 Age (years), 76.2 ± 17.7 [19–98] postadmission, and 12 h
[29–100] Gender (men/women), postadmission,
Gender (men/women), 11/25 respectively.
13/23
Rosen et al., RCT 100 patients with hip 5 pound (2.3 kg) of skin A pillow beneath the The VAS scores were 4.6 ±
2001 fracture (trochanteric traction. injured leg. 2.4 in the traction group,
fractures, 57; neck 50 patients with hip 50 patients with hip and 4.7 ± 2.9, in the
fractures, 43) fracture (trochanteric fracture (trochanteric no-traction group at 15
Age (years), 77.8 ± 8.5 fractures, 31; neck fractures, 26; neck minutes postadmission.
[50–97] fractures, 19) fractures, 24)
Gender (men/women), Age (years), 77.9 ± 6.6 Age (years), 77.9 ± 10.1
22/78 Gender (men/women), N/A Gender (men/women), N/A

PICO, participant, intervention, comparison, and outcome; VAS, visual analog scale; N/A, not available; RCT, randomized controlled trial;
Quasi-RCT, quasi-randomized controlled trial. Values (age and VAS score) are expressed as the mean ± standard deviation [range].