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      Timing Matters in Hip Fracture Surgery: Patients Operated within 48 Hours Have Better Outcomes. A Meta-Analysis and Meta-Regression of over 190,000 Patients

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          Abstract

          Background

          To assess the relationship between surgical delay and mortality in elderly patients with hip fracture. Systematic review and meta-analysis of retrospective and prospective studies published from 1948 to 2011. Medline (from 1948), Embase (from 1974) and CINAHL (from 1982), and the Cochrane Library. Odds ratios (OR) and 95% confidence intervals for each study were extracted and pooled with a random effects model. Heterogeneity, publication bias, Bayesian analysis, and meta-regression analyses were done. Criteria for inclusion were retro- and prospective elderly population studies, patients with operated hip fractures, indication of timing of surgery and survival status.

          Methodology/Principal Findings

          There were 35 independent studies, with 191,873 participants and 34,448 deaths. The majority considered a cut-off between 24 and 48 hours. Early hip surgery was associated with a lower risk of death (pooled odds ratio (OR) 0.74, 95% confidence interval (CI) 0.67 to 0.81; P<0.000) and pressure sores (0.48, 95% CI 0.38 to 0.60; P<0.000). Meta-analysis of the adjusted prospective studies gave similar results. The Bayesian probability predicted that about 20% of future studies might find that early surgery is not beneficial for decreasing mortality. None of the confounders (e.g. age, sex, data source, baseline risk, cut-off points, study location, quality and year) explained the differences between studies.

          Conclusions/Significance

          Surgical delay is associated with a significant increase in the risk of death and pressure sores. Conservative timing strategies should be avoided. Orthopaedic surgery services should ensure the majority of patients are operated within one or two days.

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          Most cited references32

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          Early versus delayed invasive intervention in acute coronary syndromes.

          Earlier trials have shown that a routine invasive strategy improves outcomes in patients with acute coronary syndromes without ST-segment elevation. However, the optimal timing of such intervention remains uncertain. We randomly assigned 3031 patients with acute coronary syndromes to undergo either routine early intervention (coronary angiography or = 36 hours after randomization). The primary outcome was a composite of death, myocardial infarction, or stroke at 6 months. A prespecified secondary outcome was death, myocardial infarction, or refractory ischemia at 6 months. Coronary angiography was performed in 97.6% of patients in the early-intervention group (median time, 14 hours) and in 95.7% of patients in the delayed-intervention group (median time, 50 hours). At 6 months, the primary outcome occurred in 9.6% of patients in the early-intervention group, as compared with 11.3% in the delayed-intervention group (hazard ratio in the early-intervention group, 0.85; 95% confidence interval [CI], 0.68 to 1.06; P=0.15). There was a relative reduction of 28% in the secondary outcome of death, myocardial infarction, or refractory ischemia in the early-intervention group (9.5%), as compared with the delayed-intervention group (12.9%) (hazard ratio, 0.72; 95% CI, 0.58 to 0.89; P=0.003). Prespecified analyses showed that early intervention improved the primary outcome in the third of patients who were at highest risk (hazard ratio, 0.65; 95% CI, 0.48 to 0.89) but not in the two thirds at low-to-intermediate risk (hazard ratio, 1.12; 95% CI, 0.81 to 1.56; P=0.01 for heterogeneity). Early intervention did not differ greatly from delayed intervention in preventing the primary outcome, but it did reduce the rate of the composite secondary outcome of death, myocardial infarction, or refractory ischemia and was superior to delayed intervention in high-risk patients. (ClinicalTrials.gov number, NCT00552513.) 2009 Massachusetts Medical Society
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            Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression.

            Mortality associated with hip fracture is high in elderly patients. Surgical repair within 24 hr after admission is recommended by The Royal College of Physicians' guidelines; however, the effect of operative delay on mortality remains controversial. The objective of this study was to determine whether operative delay increases mortality in elderly patients with hip fracture. Published English-language reports examining the effect of surgical delay on mortality in patients who underwent hip surgery were identified from electronic databases. The primary outcome was defined as all-cause mortality at 30 days and at one year. Effect sizes with corresponding 95% confidence intervals were calculated by using a DerSimonian-Laird randomeffects model. Sixteen prospective or retrospective observational studies (257,367 patients) on surgical timing and mortality in hip fracture patients were selected. When a cut-off of 48 hr from the time of admission was used to define operative delay, the odds ratio for 30-day mortality was 1.41 (95% CI = 1.29-1.54, P < 0.001), and that for one-year mortality was 1.32 (95% CI = 1.21-1.43, P < 0.001). In hip fracture patients, operative delay beyond 48 hr after admission may increase the odds of 30-day all-cause mortality by 41% and of one-year all-cause mortality by 32%. Potential residual confounding factors in observational studies may limit definitive conclusions. Although routine surgery within 48 hr after admission is hard to achieve in most facilities, anesthesiologists must be aware that an undue delay may be harmful to hip fracture patients, especially those at relatively low risk or those who are young.
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              Association of timing of surgery for hip fracture and patient outcomes.

              Previous studies of surgical timing in patients with hip fracture have yielded conflicting findings on mortality and have not focused on functional outcomes. To examine the association of timing of surgical repair of hip fracture with function and other outcomes. Prospective cohort study including analyses matching cases of early ( 24 hours) surgery with propensity scores and excluding patients who might not be candidates for early surgery. Four hospitals in the New York City metropolitan area. A total of 1206 patients aged 50 years or older admitted with hip fracture over 29 months, ending December 1999. Function (using the Functional Independence Measure), survival, pain, and length of stay (LOS). Of the patients treated with surgery (n = 1178), 33.8% had surgery within 24 hours. Earlier surgery was not associated with improved mortality (hazard ratio, 0.75; 95% confidence interval [CI], 0.52-1.08) or improved locomotion (difference of -0.04 points; 95% CI, -0.49 to 0.39). Earlier surgery was associated with fewer days of severe and very severe pain (difference of -0.22 days; 95% CI, -0.41 to -0.03) and shorter LOS by 1.94 days (P<.001), but postoperative pain and LOS after surgery did not differ. Analyses with propensity scores yielded similar results. When the cohort included only patients who were medically stable at admission and therefore eligible for early surgery, the results were unchanged except that early surgery was associated with fewer major complications (odds ratio, 0.26; 95% CI, 0.07-0.95). Early surgery was not associated with improved function or mortality, but it was associated with reduced pain and LOS and probably major complications among patients medically stable at admission. Additional research is needed on whether functional outcomes may be improved. In the meantime, patients with hip fracture who are medically stable should receive early surgery when possible.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2012
                3 October 2012
                : 7
                : 10
                : e46175
                Affiliations
                [1 ]Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
                [2 ]University of Milan, Milan, Italy
                [3 ]Clinical Epidemiology Unit, IRCCS Galeazzi Orthopedic Institute, Milan, Italy
                [4 ]Epidemiological Observatory, ASL Milano, Milan, Italy
                [5 ]Department of Oto Specialised Surgical Sciences, University of Florence, Florence, Italy
                [6 ]Clinical and Molecular Epidemiology Unit and Clinical Trials and Evidence-Based Medicine Unit, Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece
                [7 ]Department of Oncology, Hematology and Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
                Johns Hopkins Bloomberg School of Public Health, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: LM AP GB. Performed the experiments: AP VP LG LM. Analyzed the data: AP CR GV GS. Wrote the paper: LM AP VP. Critical revision of the intellectual content of the manuscript: LM AP VP CR GV GS LG AL GB.

                Article
                PONE-D-12-04093
                10.1371/journal.pone.0046175
                3463569
                23056256
                cd57d3b4-293d-459f-a2e3-240cf6082db2
                Copyright @ 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 9 February 2012
                : 30 August 2012
                Page count
                Pages: 13
                Funding
                This review was funded by the Istituto di Ricovero e Cura a Carattere Scientifico Galeazzi. Another source of institutional support was the Department of Public Health of the University of Milan. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine
                Clinical Research Design
                Meta-Analyses
                Critical Care and Emergency Medicine
                Critical Care Team Organization
                Perioperative Critical Care
                Geriatrics
                Non-Clinical Medicine
                Health Care Policy
                Health Risk Analysis
                Health Systems Strengthening
                Evidence-Based Medicine
                Health Care Quality
                Health Services Research
                Public Health
                Preventive Medicine
                Surgery
                Orthopedic Surgery

                Uncategorized
                Uncategorized

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