Nonoperative Management an Option for Frail Hip Fracture Patients

NEW YORK (Reuters Health) – For frail institutionalized patients with limited life expectancy who have sustained a hip fracture, nonoperative management is a viable option as part of a shared decision-making process, researchers say.

“In this non-randomized study, quality of life was comparable for frail, institutionalized patients that underwent surgery for a proximal femoral fracture and for those who choose not to be operated on,” Dr. Pieter Joosse of Noordwest Ziekenhuisgroep in the Netherlands told Reuters Health by email.

“Patient autonomy, end-of-life discussions and advanced care planning should play a role in the decision whether to operate or not in this selected group of patients,” he said, “but surgery should not be a foregone conclusion.”

“Further research should address the question of which patients will benefit from surgery and who should refrain in order to avoid surgical and medical complications evolving in a painful and unsuccessful rehabilitation process,” he added.

As reported in JAMA Surgery, Dr. Joosse and colleagues conducted a multicenter cohort study in the Netherlands between September 2018 and April 2020, with a 6-month follow-up.

Among 172 frail, institutionalized patients (mean age, 88; 78%, women) with proximal femoral fractures, 88 opted for nonoperative management and 84 opted for operative management after shared decision-making.

The term frail implied the presence of at least one of the following characteristics: malnutrition (BMI <18.5) or cachexia; severe comorbidities (American Society of Anesthesiologists physical status class of IV or V); or severe mobility issues (Functional Ambulation Category 2 or less).

The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D-5L) utility score by proxies and caregivers. Secondary outcomes included pain level, adverse events and treatment satisfaction.

The EQ-5D-5L utility scores in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 vs. 0.26; week 2: 0.19 vs. 0.28; and week 4: 0.24 vs. 0.34).

Adverse events (AEs) were less frequent in the nonoperative group (67, vs. 167 in the operative group).

Significantly more patients in the operative group experienced at least 1 AE (68 vs. 46) or multiple AEs (47 vs. 16).

Pressure ulcers were the most common AE in both groups (operative: 35; nonoperative: 31).

The operative group more frequently required antibiotic therapy (33 vs. 7) and blood transfusion (24 vs. 2), and one third developed delirium.

The twelve readmissions (14%) in the operative group were associated with surgery-related AEs or recurrent falls with new traumatic injuries.

After initially opting for nonoperative management, two patients were treated surgically within the index admission because of progressive pain.

Treatment satisfaction was high in both groups.

The 30-day mortality rate was 83% in the nonoperative group and 25% in the operative group, with 26 proxies and caregivers (51%) in the nonoperative group rating the quality of dying as good-almost perfect.

Dr. Kevin Chung of the University of Michigan Medical School in Ann Arbor, author of a related editorial, commented in an email to Reuters Health, “This is a powerful article that will remind surgeons to advocate for the patient rather than the instinctive drive to fix a fracture.”

“At the end of life,” he said, “we should always remind ourselves that patient dignity and preference must be considered to avoid conducting operations that cannot enhance function or promote well being. Comfort and mitigating pain are sacrosanct in our guiding principle, which is do no harm.”

SOURCE: and JAMA Surgery, online March 2, 2022.

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