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Original Investigation
March 2, 2022

Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study

Author Affiliations
  • 1Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
  • 2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
  • 3Geriatrics Section, Department of Internal Medicine, Amsterdam University Medical Center location AMC, Amsterdam, the Netherlands
  • 4Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
  • 5Department of Orthopaedic Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
  • 6Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
  • 7Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
  • 8Department Trauma TopCare, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
  • 9Department of Orthopaedic Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
  • 10Department of Orthopaedic Surgery, Isala, Zwolle, the Netherlands
JAMA Surg. 2022;157(5):424-434. doi:10.1001/jamasurg.2022.0089
Key Points

Question  Is nonoperative management of proximal femoral fractures a viable treatment option for selected frail patients with limited life expectancy compared with operative management?

Findings  In this cohort study of 172 frail patients with proximal femoral fractures, 88 opted for nonoperative management and 84 opted for operative management after a shared decision-making process. In patients who chose nonoperative management, the health-related quality of life was not inferior to that in patients who received surgical treatment and treatment was highly satisfactory.

Meaning  Findings from this study suggest that, following shared decision-making, nonoperative management is a viable option for frail institutionalized patients with a proximal femoral fracture at the end of life and that surgery should not be a foregone conclusion for these patients.

Abstract

Importance  Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population.

Objective  To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy.

Design, Setting, and Participants  This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <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).

Exposures  Shared decision-making (SDM) followed by nonoperative or operative fracture management.

Main Outcomes and Measures  The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire).

Results  Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8.

Conclusions and Relevance  Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.

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1 Comment for this article
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Perhaps there is a surgical protocol to offer via shared decision making that is more desirable and more effective
Steven Zeitzew, M.D. | West Los Angeles Veterans Administration Healthcare Center
I wonder if there is a subgroup of the surgical treatments used in this study that a subgroup analysis might suggest is more desirable than non-surgical treatment. I am concerned about the dramatic increases in early mortality and the diminished palliation in the non-surgical group described here, and suspect a subgroup analysis might reveal a pathway that would be more desirable to more patients than both of these surgical and non-surgical groups.

Hip fractures treated without surgery are very painful. Pain and fracture instability make nursing care difficult. Patients dislike the side effects from the high required doses of
analgesics, and even then as this study shows patients do not get equivalent pain palliation.

Surgical stabilization can be performed with low risk rapidly giving better palliation. The following protocol for high risk patients has proved effective.

Internal fixation with sliding hip screw, 2-hole side plate, (and when indicated anti-rotation screw) can be performed quickly for many suitable femoral neck and intertrochanteric hip fractures with monitored anesthesia care and local field block anesthesia through a short 10cm lateral incision. The patient is treated on a traction table, reduction obtained with only gentle positioning (bring hip out of flexion, add adduction, then internal rotation, then minimal traction to take off slack, and check with fluoroscopy to refine the reduction) and maintained with minimal traction. The key is anatomic reduction and satisfactory hardware position with short tip-apex distance confirmed with fluoroscopy. In these high risk patients an incision can be made straight down to bone laterally just distal to the vastus tubercle, through the vastus lateralis using electrocautery after incising the skin. The bone is quickly exposed with a Key Elevator. After internal fixation hardware is in place traction is released and the fracture site is compressed. The short incision can be quickly closed in layers. Multi-modal analgesia can be provided. Patients have sufficient immediate pain relief from this low risk low discomfort surgery for comfortable nursing care and bed to chair mobility with assistance. Stability is sufficient to allow weight bearing with physical therapy. The patients require lower doses of narcotic analgesics. The morbidity of that protocol is low, and it provides good early palliation.

I would value seeing a subgroup analysis stratified by the type of surgical or non-surgical care provided. That kind of analysis might help refine your shared decision making tool to guide the care of future patients and improve their quality of life. I suspect that we can better preserve both life and quality of life with judiciously selected surgical treatment. We can provide better guidance via shared decision making if we can identify better treatment than the current standard for this select high risk group of patients.
CONFLICT OF INTEREST: None Reported
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