ACUPUNCTURE FOR THE POSTOPERATIVE RECOVERY OF HIP FRACTURE PATIENTS: A PILOT RANDOMIZED CONTROLLED TRIAL
Phase: NA
Conditions: Hip Fracture Surgeries, Post-operative Hip Fractures Recovery
Sponsor: Khoo Teck Puat Hospital

 
 
 
 
 
 
 
Acupuncture for the Postoperative Recovery of 
Hip Fracture Patients: A Pilot Randomized 
Controlled Trial Study Protocol 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated 2 Sept 2025 

Abstract  
Background 
Hip surgery is a common and safe medical intervention to restore the functionality and mobility of the 
hip joint in patients suffering from hip fractures. Despite the advances in surgical techniques, a relatively 
large proportion of patients suffer from postoperative pain, joint dysfunction and loss of muscle 
strength1-8. These outcomes hinder rehabilitation, which consequently imposes significant economic 
burden for health systems. 
This study aims to assess if the addition of acupuncture to existing postoperative management will 
improve the following patient outcomes post hip surgery: 1. Postoperative pain and 2. Function 
(muscular strength and mobility) 
 
Methods 
Patients scheduled for hip surgery due to unilateral hip fracture, who fulfilled the inclusion and 
exclusion criteria, will be randomly allocated to either receive postoperative management ONLY 
(Conventional analgesics and physiotherapy) or with the addition of acupuncture post hip surgery. 
Acupuncture will be performed on patients in the intervention group 2x/week from postoperative week 
(POW 5), a total of 8 acupuncture treatments will be administered.   
The two primary outcomes which include the Harris Hip Score and Visual Analogue Scale will be 
assessed at the following time points: postoperative week (POW) 0, POW 6, postoperative month 
(POM) 6 and POM 12, while the secondary outcome Timed get Up and Go (TUG) will be assessed at 
the following time points: POW 6, POM 6 and 12. Besides, length of stay in hospital, any incidences 
of deep vein thrombosis, adverse events of analgesics and acupuncture will also be recorded. 
Hypothesis 
The addition of acupuncture to existing postoperative management will reduce pain and enhance 
functional recovery, better and faster than with postoperative management alone. 
(265 words) 
 
 

Introduction 
 
Hip fractures result in increased disability, morbidity, and mortality risks among the elderly population. 
A study in Singapore predicts a 30–50% increase in the incidence rates of hip fracture over the ensuing 
30 years. With an increasing life expectancy (an average of 83.1 years) and low total fertility rate (1.16 
births per woman), Singapore has a rapidly aging population and is likely to face significant health care 
and financial burdens from the rising numbers of hip fractures5.  
Hip surgery is a common and safe medical intervention to restore the functionality and mobility of the 
hip joint in hip fractures patients. The current surgical techniques used include internal fixation, partial 
hip replacement and total hip replacement. The current postoperative management for hip surgery is 
conventional analgesia and physiotherapy.  
Despite the advances in surgical techniques, a relatively large proportion of patients still suffer from 
chronic postoperative pain and joint dysfunction1-4. It has also been demonstrated in numerous studies 
that muscular mass and strength will decrease substantially after hip surgery6-8. These outcomes hinder 
rehabilitation, prolongs length of stay in hospital and time needed to regain independence, which 
impose great economic burden for patients, health systems and the society at large. 
Acupuncture is a key component of TCM and has proved its efficacy in pain control and various clinical 
symptoms through numerous clinical studies. Currently, in Singapore, acupuncture is used 
predominantly in the outpatient setting and has been widely accepted as a safe therapy with minimal 
side effects9.  
In recent years, numerous clinical studies have found acupuncture to be effective in the reduction of 
postoperative pain 10,11. There are also reports demonstrating the effectiveness of acupuncture in the 
recovery of muscle strength, but not in the postoperative patient 12-14.  
Besides, current literature suggest that acupuncture might be effective in reducing postoperative 
pain10,11 but not in improving functional recovery. There are also indications that acupuncture might aid 
in the recovery of muscle strength12-14, but these findings are not specific to rehabilitation post-surgery. 
Results from this study will provide data to guide decisions and determine the role of acupuncture in a 
rehabilitative setting to better improve patient outcomes. Should results show a positive effect of 
acupuncture in postoperative patients, it could serve as a foundation for future studies and eventually 
be included in the care pathways of a wider range of surgical procedures.  
 
 

Methods 
 
This is a single center randomized, single- blind, parallel trial. A total of 90 patients who meet the 
inclusion and exclusion criteria will be recruited and randomized to either receive standard post-
operative hip fracture management (physiotherapy and analgesic) or to receive acupuncture 
treatment in addition to standard care, in a ratio of 1:1. All patients are recruited from Singapore Khoo 
Teck Puat Hospital (KTPH) Hip Fracture Unit and acupuncture treatment will be administered in 
Admiralty Medical Centre, KTPH. 
 
This study protocol has received ethical approval from the National Healthcare Group Domain 
Specific Review Board (2019/01168)  
 
Written Informed Consent will be obtained from all study participants. Detailed information about the 
study and sufficient time will be provided for participants to understand the study and for clarifications. 
Patients will be also informed that they can withdraw from the study at any given point without any 
penalties.  
 
Recruitment criteria 
Inclusion criteria 
• 
Patients who have undergone hip surgerydue to unilateral hip fracture  
• 
Ambulatory with or without aid prior to hip fracture 
• 
Patients aged 40-99 (male), 55-99 (female) 
• 
Able provide consent for the study and acupuncture treatment 
• 
Able to attend treatment sessions 
 
Exclusion Criteria 
• 
Patients with morbid obesity (Body Mass Index >40) 
• 
Patients with communication barriers such as aphasia or language 
• 
Local or systemic infection or dermatological disease 
• 
Existing treatment with anti-neoplastic, oral corticoid or immunosuppressive drugs 
• 
Needle phobia or inability to stay still for 30min during acupuncture retention 
• 
History of psychiatric disease, kidney failure on peritoneal dialysis, substance abuse. 
• 
If there exist any postoperative complications that deviate from standard management resulting 
in interference of patient's clinical evaluation 
 
Randomization:  
Patients will be randomized to either Group A, where they receive postoperative management AND 
acupuncture, or Group B, where they receive postoperative management ONLY.  
The method of randomization is as follows: 1) KTPH CRU Biostatistician (non-study team member) will 
use a random number generator to create a random sequence for the first 45 subjects (Subject 1 to 
45), 45 subjects in each group, and repeat the process for the next 45 subjects (Subject 46 to 90).  
There will be a corresponding subject number in running sequence to each randomized generated 
number. The randomized numbers will then be categorized into 2 groups, odd numbers into either 
acupuncture or control group then even numbers into the other. 2) 90 opaque sealed envelopes will be 
prepared for 90 subjects. The subject number will be written on the front of each envelope. Inside each 
envelope, there is an insert stating the group which the subject is allocated to. 3) These sealed 
envelopes will be handed over to the study team. The study team member will take the relevant 
envelope in accordance with the subject number to check what group the subject is allocated to. 
Intervention 
Hip surgery will be carried out for all patients in Group A and B. Both groups A and B will undergo 
standard postoperative management program. Standard postoperative management program include: 
conventional analgesia and physiotherapy POD 1, 2 and 3, followed by 5x/week until discharge. Post-

discharge, patients will continue physiotherapy 1-2x/ week for 3 months depending on their rate of 
recovery. 
In addition to standard care, Acupuncture will be performed on patients in Group A 2x/week from 
postoperative week (POW) 5 to POW 8, a total of 8 acupuncture treatments will be administered. From 
the 2nd to 8th treatment, electro-acupuncture and infrared therapeutic lamp will be used. All treatment 
will be administered by registered TCM practitioners with at least 2 years of experience. The 
acupuncture needles to be used for this study are Kinhong/ Mac sterile acupuncture needles for single 
use. Either 0.25 x 50mm needles or 0.25 x 25mm needles will be employed depending on the 
acupuncture point and the depth of needling. The depth of needle insertion will range from 1-1.5cm, 
according to the thickness of the subcutaneous fatty tissue at the site of the acupuncture points. The 
needles will be left in situ for 20 minutes. Therapeutic effects are assessed to be optimal when the 
patient experiences a momentary local sensation of heaviness or numbness, termed De Qi in the 
classical acupuncture literature. Electrical stimulation will be delivered at 2Hz for 20 min, at an intensity 
below individual patient's pain threshold. 4 acupuncture points will be stimulated in pairs.  The following 
acupuncture points will be used bilaterally for this study:  
1) 
Li 4 (Hegu) 
2) 
St 36 (Zusanli) 
3) 
Sp 6 (Sanyinjiao) 
4) 
Sp 9 (Yinlingquan) 
5) 
Sp 10 (Xuehai) 
6) 
Kd 3 (Taixi) 
7) 
Gb 34 (Yanglinquan) 
8) 
Ren 6 (Qihai) 
9) 
Auricular point - Kuan  
10) Auricular point - Shen Men  
Outcome measures  
Primary Outcomes 1. Modified Harris Hip Score for assessing pain and function 2. Visual Analogue 
Scale (VAS)-100 for assessing the pain intensity. Secondary Outcomes 3. Timed get Up and Go (TUG) 
test for assessing function (Gait and speed). The TUG will be performed thrice during each assessment, 
and the average time will be taken. 4. Lower extremity muscle strength will be measured using a 
portable dynamometer. The subject's operated and non-operated side will be measured. The primary 
outcomes will be assessed at the following time points: at postoperative week (POW) 0, POW 6, 
postoperative month (POM) 6 and POM 12, while the secondary outcomes will be assessed at the 
following time points: POW 6, POM 6 and 12. Length of stay in hospital, any incidences of deep vein 
thrombosis, adverse events of analgesics and acupuncture will also be recorded.  
 

 
Fig 1: Flow chart showing  
This research will not uncover any incidental findings as no lab test and radiological examinations will 
be collected as part of this study. 
 
Informed Consent  
1. Ethics approval will be sought from the National Healthcare Group Domain Specific Review 
Board (NHG DSRB) following consultation with the KTPH clinical research unit and the in-
house statistician 
2. Patients will be provided with a detailed information pack with sufficient time to understand and 
ask questions 
3. If they are happy to proceed, a written consent form will be completed in keeping with guidance 
from the NHG DSRB 
4. Patients will be able to withdraw from the study at any given point 
 
 
 

Data storage 
1. Each patient will be provided with a unique identifier so that their progress can be tracked.   
2. No identifiable information will be stored 
3. Study data will be stored on a secure, password protected computer in the institution and no 
information will be stored on removable devices 
4. Any hard copies will also be stored in the patient’s individual medical records 
 
Statistical Analysis 
Two-sample t-test or non-parametric t-test will be used to compare continuous variables (e.g., KOOS, 
VAS) between group A and group B. Chi-square and Fisher’s exact test will be used to compare 
categorical variables (e.g., race) between group A and group B. Within each group, paired t-test or 
non-parametric test will be considered to compare baseline with each of follow-ups. Repeated 
ANOVA or generalized estimating equation (GEE) model (for missing data) will be considered to 
compare group A with group B over time while adjusting baseline covariates such as age, gender, 
ethnicity and baseline pain score. 
Data will be analyzed by the in house statistician from KTPH. 
 
Discussion 
 Although surgical techniques have advanced greatly, a relatively large proportion of hip fracture 
patients still suffer from chronic postoperative pain and joint dysfunction1-4. It has also been 
demonstrated in numerous studies that muscular mass and strength will decrease substantially after 
hip surgery6-8. These outcomes hinder rehabilitation, prolongs length of stay in hospital and time needed 
to regain independence, which impose great economic burden for patients, health systems and the 
society at large. 
Acupuncture is a key component of TCM and has proved its efficacy in pain control and various clinical 
symptoms through numerous clinical studies. Currently, in Singapore, acupuncture is used 
predominantly in the outpatient setting and has been widely accepted as a safe therapy with minimal 
side effects9.  
In recent years, numerous clinical studies have found acupuncture to be effective in the reduction of 
postoperative pain 10,11. There are also reports demonstrating the effectiveness of acupuncture in the 
recovery of muscle strength, but not in the postoperative patient 12-14.  
To our knowledge, there are currently no clinical studies being conducted to investigate the 
effectiveness of acupuncture on BOTH pain and functional recovery post hip surgery. Usichenko et al. 
demonstrated that auricular acupuncture could reduce analgesic requirement, but did not assess the 
effect that acupuncture has on enhancing functional recovery post hip surgery11. The overall aim of this 
proposal is to assess if the addition of acupuncture to existing postoperative management could 
decrease postoperative pain and enhance functional recovery of the post-surgical hip joint. Results from 
this study will provide data to guide decisions and determine the role acupuncture in the rehabilitative 
setting to better improve patient outcomes. We hypothesize that the addition of acupuncture to 
postoperative management will improve patient outcomes and hence, reduce length of hospital stay 
and enable faster return to independence and continued active lifestyle. This would consequently 
reduce the financial burden on the patients and health care institutions. 
 
Conclusion 
In summary, this study evaluates the impact of adding acupuncture to standard management of hip 
fracture patients after surgery. Results from this study will generate greater interest in the use of 
acupuncture among physicians, surgeons and various health bodies. This will result in wider national 

and possibly international-level collaborations to further investigate the use of acupuncture for other 
clinical symptoms. 
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