Effect of derotation boot versus skin traction on pain in patients with intertrochanteric fractures a randomized controlled trial

Abstract Intertrochanteric hip fractures in older adults are often associated with severe pain, and inadequate preoperative analgesia increases the risk of delirium, immobility, and mortality. Although skin traction (ST) is widely used for temporary stabilization, its analgesic effectiveness remains poorly supported, and it may cause discomfort in frail patients. The derotation boot (DB) has emerged as a promising alternative, but its clinical value remains unclear due to limited comparative data. The primary objective of this study was to determine whether the DB provides non-inferior preoperative pain relief compared to ST. Secondary objectives included evaluating morphine consumption, patient comfort, delirium incidence, perioperative complications, operative time, and blood loss. This multicenter, non-inferiority randomized controlled trial was conducted across two Level I and one Level II trauma centers. Patients aged ≥ 60 years with acute intertrochanteric fractures were randomized to receive either DB or ST. Pain was assessed using the Visual Analog Scale (VAS) at 1 h, 24 h, and immediately before surgery. Secondary outcomes included total morphine use, comfort (measured by the Immobilization Comfort Questionnaire), delirium, intraoperative blood loss, complications, and surgical duration. Ninety-seven patients were enrolled (DB: 48; ST: 49), with a mean age of 80.8 ± 10.2 years in the DB group and 78.3 ± 9.4 years in the ST group. DB was non-inferior to ST for pain control at 1 h (VAS 4.6 vs. 5.7; β = −1.464; p < 0.001) and 24 h (1.9 vs. 2.7; β = −1.048; p = 0.006), with no significant difference immediately before surgery (p = 0.657). Comfort was significantly higher with DB (82.0 vs. 76.8; p = 0.0015). Other outcomes showed no significant group differences. The derotation boot demonstrated non-inferior pain control compared with skin traction at 1 h, 24 h, and immediately before surgery, with improved early comfort. Superiority of the derotation boot was not demonstrated at the final preoperative assessment. Trial Registration : Thai Clinical Trials Registry (ID: TCTR20230908004) from 01.02.2023.