Fractures & Trauma Joint Replacement

Hip Fracture Surgery in Frail Patients — Knowing When to Say When

End of life hip fractures don't need to lead to surgery — and it can be avoided

What’s the Claim?

Frail patients near the end of life shouldn’t receive unnecessary surgery. In this multi-center study involving 172 patients (average age, 88; 78% women), quality of life among frail institutionalized patients with limited life expectancy managed without surgery after hip fractures was no different from those who were treated surgically. The authors state in their conclusion, “...surgery should not be a foregone conclusion for this patient population.”

How’s It Stack Up?

This is a great topic — we’ve all seen patients in this situation, and we’ve all struggled with the decision. And there’s just not much out there on it. The authors used the EuroQol 5 (EQ-5D) utility score, a dementia-specific QOL instrument (QUALIDEM), pain levels, adverse events, mortality, treatment satisfaction, and quality of dying questions in their evaluation, making it feel quite holistic in its approach and results.

Prior work suggests that about 60% of the proxies who help nursing home residents make their decisions feel that comfort care is the way to go, and that foregoing even life-sustaining treatment aligns well with their patients’ care goals. Doing surgery on someone who may only have a few months to live is not something to take lightly. There are alternatives, and they’re worth exploring. This study did a nice job considering them.

What’s Our Take?

When applying a study like this to one’s practice, it’s important to make sure to mirror the patients they actually studied. This study was limited to patients over the age of 70 with femoral neck or pertrochanteric fractures who lived in skilled nursing facilities and who were considered “frail,” defined as at least one of the following: BMI < 18.5 or cachexia, severe comorbidities or ASA score of IV or V, or patients who needed at least the assistance of another person to walk (and some patients were less mobile than that). In that group, these findings suggest we really need to think twice about operating.

Based on this, in that setting, nonsurgical management — which might include a palliative-care consultation and certainly should include adequate analgesia — makes a lot of sense. The latter is important; there were some signs in this study that pain was undertreated in the nonsurgical group, and pain control is something we really need to get right if we’re going to recommend against surgery.