What is the place for non-operative management of neck of femur fractures – analysis of the Australia and New Zealand Hip Fracture Registry (ANZHFR)

Abstract

Background:

Hip fractures cause significant morbidity and mortality worldwide, a burden expected to rise with population ageing. Operative management remains the mainstay of treatment; however, a small number of patients receive non-operative treatment. The Australian and New Zealand Hip Fracture Registry (ANZHFR) began recording reasons for non-operative management in 2021. The study aimed to identify factors influencing the decision for non-operative management, compare outcomes between operative and non-operative treatment and compare palliative patients who died ⩽30 days to those who survived >30 days.

Methods:

A retrospective cohort study was conducted using ANZHFR data between 01 January 2021 and 31 December 2022, including patients aged ⩾50 years with a hip fracture. Patients were categorised as: operative or non-operative, the latter sub-categorised; palliative, not clinically indicated, or other. Demographic, clinical and fracture characteristics, length of stay, discharge destination and mortality at 30, 120 and 365 days were compared. A sub-analysis of the palliative group compared those who survived >30 days with those who died ⩽30 days.

Results:

Of 31,423 hip fracture patients, 30,734 (97.8%) underwent surgery, and 689 (2.2%) were managed non-operatively (438 palliative, 127 surgery not clinically indicated, 124 other). Palliative patients were older, frailer, less mobile, more likely to live in residential aged care, and to have dementia. Men and patients treated in Tasmania were more likely to receive palliative care. Non-displaced valgus impacted fractures were more common among the not clinically indicated group. 30-day mortality was highest in the palliated group (87.2%) and lowest in the operative group (7.3%). Age was the only factor associated with survival >30 days among palliated patients.

Conclusions:

This is the first registry-based analysis of non-operative hip fracture management by reason. It identified distinct demographic, clinical and geographical patterns that influenced non-operative care. The palliative cohort had the highest mortality; however, a small proportion of patients survived.