When Is Nonoperative Geriatric Hip Fracture Preferred? | Orthopedics This Week

When Is Nonoperative Geriatric Hip Fracture Preferred?

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Don’t often hear about older hip fractures being done nonoperatively? That’s because it doesn’t happen so much. But when it does, how do patients fare?

A multicenter team just undertook a study to find out. Their work, “Nonoperative Geriatric Hip Fracture Treatment is Associated with Increased Mortality: A Matched Cohort Study,” appears in the Journal of Orthopaedic Trauma.

Co-author Patrick Schottel, M.D., an orthopedic surgeon at the University of Vermont Medical Center in Burlington, explained the background for his study to OTW, “Throughout my medical and orthopaedic training in Washington, DC, New York City and Houston, I found that it was rare for a geriatric hip fracture to be treated nonoperatively. However, once I became an attending at the University of Vermont Medical Center, I noticed that we were treating a higher proportion of patients nonoperatively.”

“As no randomized control trial exists for operative versus nonoperative geriatric hip fracture treatment, I decided to perform a comparative outcome study utilizing our institutional hip fracture database.”

“We found that nonoperatively treated geriatric hip fracture patients had a very high inpatient, 30-day and 1-year mortality. It was significantly higher than a matched operative cohort at all time points.”

“It was surprising that the one-year mortality in 77 nonoperatively treated geriatric hip fracture patients at our academic medical center was 84.4% compared to 36.4% in the operative cohort.”

“Nonoperative management of geriatric hip fracture patients is associated with increased mortality compared to a matched operative cohort. Patients who are contemplating nonoperative management should be made aware of the increased mortality associated with that decision.”

“The intent of this paper was not to advocate that all geriatric hip fracture patients should have operative treatment of their injury. While we matched operative and nonoperative patients based on age, sex, fracture location, Charlson comorbidity index, living location, dementia and history of cardiac arrhythmia, I still believe that there is significant selection bias.”

“One of the most difficult things to quantify is a patient’s desire to live and we were unable to account for that. While on paper two patients may appear to have had a similar injury and medical comorbidities, their life expectancy can be drastically different. While operative management of geriatric hip fractures is the preferred treatment as it improves pain and mortality, there is a proportion of our reported mortality difference between the two treatments that is due to our institution’s ability to accurately sort out who wanted to live and who didn’t.”

“We often had our medicine co-management service consult the palliative care team to discuss the patient’s goals of care and current quality of life.”

“I think that discussion was fundamental in understanding what the patient and their family wanted.”

“It resulted in more patients not wanting to push on and opt for nonoperative management and comfort care. Therefore, I hope our findings can be shared with patients so they can make a more informed decision when choosing between operative and nonoperative management.”

“This could potentially result in fewer operations for patients who might otherwise not want further medical intervention and ensure nonoperatively treated patients fully understand the repercussions of that decision.”


3 thoughts on “When Is Nonoperative Geriatric Hip Fracture Preferred?

  1. “nonoperative management and comfort care.” is an oxymoron. it is impossible to make anyone with a fresh fracture “comfortable” without narcotizing them to the hilt. And in the elderly that is tantamount to euthanasia.
    The surgery is a 30 minute intervention that can be done well even by orthopedic trainees.

  2. This is not surprising since the main reason to treat non-operatively is poor health or limited life expectancy of the patient. One still needs to consider alleviation of pain in these people .

  3. Almost all hip fractures should be treated surgically. Even in high risk non-ambulatory patients the non-operatively treated fracture will be painful, limiting mobilization and nursing care. The hip fractures don’t kill people, but the complications of bed rest do kill people. About 80% of patients with hip fracture treated in bed without surgery will die within 3 months, much greater risk than the risk of surgery. Hip fracture is a marker for serious underlying medical vulnerability, often one not yet diagnosed. It is almost never the result of a simple uncomplicated fall. If a patient with osteoporosis slips they put out their hand to break the fall, and might have wrist or humerus fracture. They must be more compromised to land on their hip unprotected. The proper treatment is mobilization out of bed and thorough evaluation by an internist. Surgery without undue delay is usually and almost always the best option for allowing that mobilization.

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