Pärt Prommik1,2,3, Kaspar Tootsi4,5, Toomas Saluse5, Aare Märtson4,5, Helgi Kolk4,5. 1. Department of Traumatology and Orthopaedics, University of Tartu, Tartu, Estonia. part.prommik@ut.ee. 2. Traumatology and Orthopaedics Clinic, Tartu University Hospital, Tartu, Estonia. part.prommik@ut.ee. 3. Institute of Sport Sciences and Physiotherapy, University of Tartu, Tartu, Estonia. part.prommik@ut.ee. 4. Department of Traumatology and Orthopaedics, University of Tartu, Tartu, Estonia. 5. Traumatology and Orthopaedics Clinic, Tartu University Hospital, Tartu, Estonia.
Abstract
A notable proportion of hip fracture patients receive nonoperative management, but such practice is seldom analysed. Although highly variable reasons underpin hip fracture nonoperative management, none of these practices conclusively outweigh the superiority of operative management. Nonoperative management should be only considered when surgery is not an option. PURPOSE: Reasons underpinning hip fracture (HF) nonoperative management (NOM) are seldom analysed. This study aims to identify the reasons behind NOM and assess the accuracy of these decisions using these patients' survival compared with those treated with operative management (OM). METHODS: This is a retrospective cohort study based on population-wide administrative health data, including patients aged ≥ 50 with an index HF diagnosis between January 2009 and September 2017. NOM patients were subgrouped according to their expected prognoses, and their survival up to 36 months was compared with those treated surgically. RESULTS: From a total of 11,210 included patients, 6.8% (766) received NOM. Varying reasons lead to NOM, dividing them further into five distinct subgroups: (I) 46% NOM decision due to poor expected prognosis with OM; (II) 29% NOM decision due to poor expected prognosis for mixed reasons; (III) 15% NOM decision due to good expected prognosis with NOM; (IV) 8.0% NOM decision due to patient's refusal of OM; and (V) 1.3% NOM decision due to occult HF. Only poor prognosis and patients who refused OM (I, II, IV) had worse survival than OM patients. However, a relatively high proportion of the poor prognosis patients survived 1 year (29%). CONCLUSION: Although there was high variability in reasons underpinning HF NOM, none of these practices conclusively outweigh OM's superiority. NOM should be considered with utmost care and only for patients for whom OM is out of the question - well-defined medical unfitness or carefully considered refusal by understanding the increased mortality risk.
A notable proportion of hip fracture patients receive nonoperative management, but such practice is seldom analysed. Although highly variable reasons underpin hip fracture nonoperative management, none of these practices conclusively outweigh the superiority of operative management. Nonoperative management should be only considered when surgery is not an option. PURPOSE: Reasons underpinning hip fracture (HF) nonoperative management (NOM) are seldom analysed. This study aims to identify the reasons behind NOM and assess the accuracy of these decisions using these patients' survival compared with those treated with operative management (OM). METHODS: This is a retrospective cohort study based on population-wide administrative health data, including patients aged ≥ 50 with an index HF diagnosis between January 2009 and September 2017. NOM patients were subgrouped according to their expected prognoses, and their survival up to 36 months was compared with those treated surgically. RESULTS: From a total of 11,210 included patients, 6.8% (766) received NOM. Varying reasons lead to NOM, dividing them further into five distinct subgroups: (I) 46% NOM decision due to poor expected prognosis with OM; (II) 29% NOM decision due to poor expected prognosis for mixed reasons; (III) 15% NOM decision due to good expected prognosis with NOM; (IV) 8.0% NOM decision due to patient's refusal of OM; and (V) 1.3% NOM decision due to occult HF. Only poor prognosis and patients who refused OM (I, II, IV) had worse survival than OM patients. However, a relatively high proportion of the poor prognosis patients survived 1 year (29%). CONCLUSION: Although there was high variability in reasons underpinning HF NOM, none of these practices conclusively outweigh OM's superiority. NOM should be considered with utmost care and only for patients for whom OM is out of the question - well-defined medical unfitness or carefully considered refusal by understanding the increased mortality risk.
Entities:
Keywords:
Clinical decision-making; Hip fracture; Nonoperative management; Operative management
Authors: Peter Cram; Lin Yan; Eric Bohm; Paul Kuzyk; Lisa M Lix; Suzanne N Morin; Sumit R Majumdar; William D Leslie Journal: J Am Geriatr Soc Date: 2016-11-14 Impact factor: 5.562
Authors: Joan D Penrod; Ann Litke; William G Hawkes; Jay Magaziner; Kenneth J Koval; John T Doucette; Stacey B Silberzweig; Albert L Siu Journal: J Am Geriatr Soc Date: 2007-03 Impact factor: 5.562
Authors: Cornelis L P van de Ree; Mariska A C De Jongh; Charles M M Peeters; Leonie de Munter; Jan A Roukema; Taco Gosens Journal: Geriatr Orthop Surg Rehabil Date: 2017-07-07
Authors: Pärt Prommik; Helgi Kolk; Pirja Sarap; Egon Puuorg; Eva Harak; Andres Kukner; Mati Pääsuke; Aare Märtson Journal: Acta Orthop Date: 2019-01-23 Impact factor: 3.717
Authors: Thomas Marcus Paulus Nijdam; Duco Willem Pieter Marie Laane; Jelle Friso Spierings; Henk Jan Schuijt; Diederik Pieter Johan Smeeing; Detlef van der Velde Journal: BMJ Open Date: 2022-08-10 Impact factor: 3.006