Nonoperative Management of Frail Patients With Proximal Femoral Fracture

Nonoperative management of proximal femoral fractures selected through shared decision-making has been found to be a viable option for frail institutionalized patients with limited life expectancy, according to the results of a study published in JAMA Surgery.

The prospective FRAIL-HIP study enrolled institutionalized frail patients aged 70 years and older with limited life expectancy and a proximal femoral fracture from 25 hospitals in the Netherlands from September 1, 2018, to April 25, 2020. The patients were followed up for 6 months.

Frail was defined as having at least 1 of the following: malnutrition (body mass index <18.5 kg/m²) or cachexia; severe comorbidities with an American Society of Anesthesiologists’ physical status class of IV or V; or severe mobility issues with a Functional Ambulation Category ≤2.

The primary outcome was health-related quality of life (HRQOL) as reported by patient proxies and caregivers and indicated by the utility scores on the EuroQol 5 Dimension 5 Level (EQ-5D) questionnaire.

A total of 172 patients (median age, 88 years; 78% women) were included, of whom 88 had nonoperative fracture management and 84 had operative fracture management.

In the nonoperative management group, the EQ-5D utility score was within the set 0.15 noninferiority limit of the 95% CI 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]).

In the operative management group, 19 of 66 (29%) patients regained mobility during the study period, although 66 of 84 patients (79%) were mobile before the injury. In the nonoperative management group, 78 patients (89%) remained bedbound.

More patients in the nonoperative management group experienced pain after 1 week compared with those in the operative management group (75 of 85 [88%] vs 56 of 84 [67%]; P =.001), although this finding was not observed after 2 weeks (11 [55%] vs 37 [53%]; P >.99).

Adverse events occurred more frequently in the operative management group (167) vs the nonoperative management group (67). Pressure ulcers were the most frequently occurring adverse event in both groups (operative group: 35 [42%]; nonoperative group: 31 [35%]).

The 30-day mortality rate was 83% (n=73) in the nonoperative management group and 25% (n=21) in the operative management group. A total of 83 patients (94%) in the nonoperative management group and 40 patients (48%) in the operative management group died 6 months following the injury.

In the nonoperative management group, the quality of dying was rated as “good-almost” perfect by 26 proxies (51%), with 2 proxies (4%) rating the process as “terrible-poor.” In the operative management group, the quality of dying was rated as “intermediate” by most proxies (13 [62%]).

The investigators noted that selection bias may have occurred, and participants’ levels of cognitive function and preinjury HRQOL were not assessed. Also, preoperative HRQOL questionnaires were not administered owing to the expected recall bias, with the hypothesis that prefracture HRQOL would be overestimated, particularly in the nonoperative management group.

“Following the [shared decision-making] process, nonoperative management of proximal femoral fractures is a viable treatment option for institutionalized frail patients with limited life expectancy,” stated the researchers. “A return to preinjury levels of independence or mobility was achieved in some patients who were surgically treated, and a postoperative period without [adverse events] was rare. Surgery in this specific patient population should not be a foregone conclusion.”

Disclosure: One of the study authors declared an affiliation with a medical technology company. Please see the original reference for a full list of authors’ disclosures.

Reference

Loggers SAI, Willems HC, Van Balen R, et al; for the FRAIL-HIP Study Group. Evaluation of quality of life after nonoperative or operative management of proximal femoral fractures in frail institutionalized patients: the FRAIL-HIP study. JAMA Surg. Published online March 2, 2022. doi:10.1001/jamasurg.2022.0089