Mortality, Morbidity, and Treatment-Related Outcomes Following Pathological Hip Fractures: An 8-Year Single-Center Experience

Introduction

One of the most common sites for metastasis is the bones; 70% of individuals with metastatic prostate and breast cancer suffer from bone metastasis. There are a variety of solid tumors that might result in bone metastasis, such as lung, colorectal, thyroid, and gynecological ^[1]. In comparison to native hip fractures, pathologic hip fractures carry increased risks of pulmonary embolism, deep vein thrombosis (DVT), prolonged length of stay (LOS) exceeding 5 days, and 30-day readmissions ^[2]. Furthermore, patients with pathological fractures exhibit a significantly elevated mortality rate within the first 120 days postoperatively, in contrast to individuals with non-pathological fractures ^[3]. Patients with bone metastasis, particularly in the proximal femur, face a higher risk of morbidity and mortality due to mechanical stress during weight-bearing activities. As a result, 29% of patients with bone metastasis experience pathological fractures ^[4,5]. Furthermore, a meta-analysis of pre-operative predictors for early mortality after hip fracture surgery revealed that the presence of metastatic cancer significantly increases the risk of 30-day mortality ^[6]. In addition, the comparison of surgical treatment options and their results for pathological hip fractures is a significant area of study. For instance, in a multicenter study, outcomes and complications for hemiarthroplasty (HA) and total hip arthroplasty (THA) were compared in the treatment of pathological femoral neck fractures. The results showed that there were no discernible differences in reoperations, complications, perioperative 90-day mortality, or functional outcome scores between the two treatment options ^[7]. Moreover, a study comparing HA and THA for Pathologic Proximal Femur Fractures also demonstrated no significant differences in 30-day complications ^[8]. A retrospective study was conducted to evaluate the 30-day mortality rates associated with surgical intervention within 2 days versus more than 2 days following a pathological hip fracture. The results indicated that a delay in surgery did not correlate with an increased incidence of post-operative complications. However, it was noted that postponing the surgery resulted in a longer post-operative LOS ^[9].

To our knowledge, this is the first study in Saudi Arabia to report factors affecting the mortality and morbidity after surgical management for pathological hip fractures. Understanding treatment-related outcomes in pathological hip fractures is essential for orthopedic surgeons when balancing operative risk, survival benefit, and perioperative morbidity.

Materials and Methods

A retrospective study was conducted using the database from 2016 to 2024. Institutional review board (IRB) approval number 0000082924 was approved on March 12, 2024. All patients who had a histologically and/or radiologically confirmed pathological hip fracture and were either treated conservatively or surgically by THA, HA, open reduction and internal fixation, or closed reduction and internal fixation were included. Patients younger than 18 years old or with missing relative post-operative data were excluded.

Patient characteristics recorded included sex, age, body mass index (BMI), use of anticoagulant drugs, type of fracture (femoral neck fracture, intertrochanteric fracture, and femoral head fracture), type of treatment (conservative treatment, surgical treatment by THA, HA, open reduction and internal fixation, or closed reduction and internal fixation), American Society of Anesthesiologists classification, chronic diseases, LOS, complications (change in gait, DVT, refracture, leg length discrepancy, bleeding, and infection), death, and follow-up data were obtained for up to 1 year.

The research protocol underwent ethical review and received formal approval from the author’s affiliated institution. Given the retrospective nature of the study, the IRB granted a waiver of informed consent, as no direct patient contact or intervention was involved, and all data were anonymized to ensure confidentiality.

Statistical analyses were performed using the IBM Statistical Package for the Social Sciences statistics for macOS, version 29.0.1.0 (IBM Corp., Armonk, NY, USA). Data were initially screened for completeness and accuracy prior to analysis. The distribution of continuous variables was assessed using the Shapiro–Wilk test. Normally distributed data were presented as means and standard deviations (SD), whereas non-normally distributed variables were reported as medians and interquartile ranges. Categorical variables were expressed as frequencies and percentages. Univariate analysis was conducted to evaluate associations between clinical and demographic variables and relevant outcomes. The independent samples t-test was used for comparing means of normally distributed continuous variables, whereas the Mann–Whitney U test was applied for non-normally distributed data. Categorical variables were analyzed using the Chi-square test or Fisher’s exact test, where appropriate. All statistical tests were two-sided, and a P < 0.05 was considered to indicate statistical significance. Multivariate analysis was not performed due to the limited sample size in order to avoid model overfitting.

Results

Discussion

This study aimed to assess factors affecting mortality and morbidity after pathologic hip fracture management. Our study findings suggest that there is a significant association between type of treatment and mortality rate. Patients who were managed conservatively had a higher mortality rate. In addition, anticoagulation use and osteoporosis have been shown to increase the LOS significantly. There is a lack of evidence in local studies on a similar topic, making this study a one-step forward in identifying associations in an under-studied area. The significance of our results may add to the existing global evidence, but with unique demographic characteristics of the Saudi population.

Several variables affected the mortality rate differently, one of which was type of treatment. Type of treatment showed a statistically significant association, with conservative treatment associated with increased mortality (0.007). Similarly, Tan et al. found that conservative management of hip fractures has increased mortality rate significantly in multiple periods of time, which are inpatient, 30-day, and 1-year ^[10]. Moreover, Tay found similar results with conservative management in comparison to surgical treatment over 2 years. The mortality rate in the 1st year was 10% for the conservatively treated group compared to 4.4% for the other group. In the 2nd year, the mortality rate was 15.3% for the population who were treated conservatively compared to 9.1% for the population who were treated surgically (P < 0.05) ^[11]. In addition, contradicting what was suggested by our findings, Padrón-Monedero et al. found that the risk of mortality increases with age and male gender. People aged 74–84 and people aged more than 85 had odds ratios (ORs) of mortality of 2.11 and 4.10, respectively, after adjusting for comorbidities, compared to people aged 65–74. Males had an increased risk of mortality with an OR of 1.77 compared to females ^[12].

One of the parameters that our study analyzed was the LOS. One of the factors that increased the LOS was anticoagulant use (0.011). On the contrary, Leer-Salvesen et al. found no significant difference between direct oral anticoagulant users and non-users (0.34) ^[13]. Moreover, Lott et al. were not able to find a significant association between anticoagulated and non-anticoagulated groups after controlling for age, Charlson comorbidity index, and anesthesia type ^[14]. In addition, similar to our results, Nirantharakumar et al. found that the diagnosis of diabetes did not affect the LOS significantly ^[15]. Moreover, contrary to what we found, Knoll et al. suggested that the diagnosis of hypertension was independently linked with increased hospital stay by 10% (<0.05). On the other hand, diabetes did not seem to increase LOS significantly ^[16]. Furthermore, although osteoporosis and LOS were not associated in other research papers, our analysis suggests a significant association in which osteoporosis increased the LOS (0.03). From an orthopedic perspective, these findings support a lower threshold for surgical intervention in pathological hip fractures when medically feasible. Conservative management should be reserved for patients with prohibitive surgical risk. Early identification of patients on anticoagulant therapy and those with osteoporosis may facilitate perioperative optimization, discharge planning, and reduction in prolonged hospitalization.

This study is subject to several limitations. The retrospective design limits causal inference, and residual confounding cannot be excluded. The use of convenience sampling restricts the generalizability of the findings, as the included patients may not fully represent the broader population. In addition, the relatively small sample size may have reduced statistical power. Despite these limitations, the study provides clinically relevant insight into outcomes following pathological hip fractures.

Conclusion

This study provides clinically relevant insight into morbidity and mortality related to pathological hip fractures. In addition, our results suggest that surgical treatment is superior to conservative management in reducing mortality. Comorbidities had no apparent effect on mortality according to our results. LOS was increased by several factors, including pre-operative anticoagulant use and osteoporosis.

Clinical Message

This study provides local evidence on outcomes following pathological hip fractures in Saudi Arabia. In this cohort, conservative management was associated with higher mortality, whereas no deaths occurred among surgically treated patients. Pre-operative anticoagulant use and osteoporosis were significantly associated with prolonged hospital stay. These findings highlight the importance of considering surgical treatment when clinically feasible and optimizing patients’ perioperative care. Given the retrospective design and small sample size, the results should be interpreted as associations rather than proof of causation.

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About the Authors

• 

  Ali H Alyami

• 

  Mohammed S Thabet

• 

  Abdulrahman Alrefaei

• 

  Ibrahim Althobaiti

• 

  Ghassan Binyaseen

• 

  Majd A Saemaldahar