Surgery or palliation for hip fractures in patients with advanced malignancy?

Age and Ageing, Nov, 1997 by Penny Mcnamara, Kiran Sharma

Introduction

The management of fractured neck of femur in elderly patients is costly in terms of numbers of hospital consultant episodes, bed occupancy [1] and individual suffering. One-third of elderly women who have fractured their necks of femur will die within 1 year and one-quarter of the survivors are more disabled than before the event [2, 3].

The aim of management is to rehabilitate patients so that they can return to their own homes as quickly as possible. Although elderly patients pose anaesthetic risks, surgical management offers the best chance of a successful outcome. The alternative--conservative management--means a longer hospital stay with increasing risks of thrombo-embolism and bronchopneumonia associated with prolonged immobility. Furthermore, conservative management can create nursing problems in lifting and transferring the patient.

Patients with advanced cancer not infrequently sustain fractures to the neck of femur, both pathological and non-pathological and, whilst the management of pathological fractures in patients with malignancy has been investigated, there has been no previous work on the population in palliative care units, i.e. those with advanced cancer [4, 5].

The investigators, both working in hospice medicine, felt that there were inevitably some patients who were too near death to contemplate surgery. We therefore sought to investigate the management of patients with advanced cancer who sustained fractUres of the lower limb in order to ascertain whether surgical approach should be applied to this vulnerable group of patients.

Methods

Eleven palliative care units, comprising the South Thames West Palliative Medicine Collaborative Audit Group, took part in the survey. Each centre entered patients who had been referred to the unit and then subsequently sustained a fracture of a lower limb. Age, sex and primary site of malignancy were recorded. The performance status in the week before the fracture was indicated using the Eastern Co-operative Oncology (ECOG) scale (Table 1). The reason for the chosen management was documented.

Table 1. Eastern Co-operative Oncology Group performance
status scale

Grade   Status

0       Fully active; able to carry on all pre-disease performance
           without restriction
1       Restricted in physically strenuous activity but ambulatory
           and able to carry out light work
2       Ambulatory and able to carry out all self-care but unable
          to carry out any work activities; up and about more than
          50% of waking hours
3       Capable of only limited self-care; confined to bed or chair
        more than 50% of waking hours
4       Completely disabled; cannot carry on any self-care; totally
        confined to bed or chair

Subsequent recordings of the ECOG score, comments on pain control and placement of the patient were documented 14 days, 28 days, 3 months, 6 months and 1 year after the fracture took place. The date and place of death were also recorded and the participating doctors were asked to comment on any problems they had encountered with patient management.

Results

During the study period, 44 patients were recruited. Forty had sustained a fractured neck of femur and four a fractured shaft of femur. The 40 with fractured necks of femur were analysed. There were 24 women and 16 men with an average age of 70 years (range 41-101). In 21 patients the fracture was judged from the history and the x-ray appearance to be pathological. In 16 it was thought not to be pathological and in three the diagnosis was unclear (no patient had histological confirmation). In four patients the fracture occurred in an area previously treated with radiotherapy. A further patient was undergoing radiotherapy to the hip at the time of fracture; the incident occurred during transfer to the treatment table. Radiotherapy was not given to any of the patients after the fracture occurred.

The distribution of patients by ECOG score is shown in Table 2. As might be expected for this population, a high level of physical dependency is seen, with over half the patients being confined to bed or chair for more than 50% of the day in the week before entering the study.

Table 2. Distribution of Eastern Co-operative Oncology Group scores

Score     No. of patients

  0            2
  1            5
  2           12
  3           19
  4            2

Of the 40 patients recruited, there had been an initial plan for surgical management in 31 (78%), but only 28 (70%) received surgery. In one patient the fracture was considered inoperable, while two patients died before surgery. Twelve patients received conservative measures.

Restoration of mobility, with a view to rehabilitation and return home, was the most common reason for referring a patient for surgery. This was recorded for 20 of the 31 patients in whom surgery was the planned management. In one of these 20, pain control was an additional factor. In another patient pain control alone was cited as the reason for referral. For seven patients the anticipated outcome and reason for the chosen management was not recorded, but in three patients referred for surgery `imminent death' was documented. The nature of the fracture (pathological or not) did not seem to influence the decision to refer for surgery, but in one patient a pathological fracture was considered inoperable by the orthopedic surgeons.