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      Does time from fracture to surgery affect mortality and intraoperative medical complications for hip fracture patients? : an observational study of 73 557 patients reported to the Norwegian Hip Fracture Register

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          Abstract

          Aims

          The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR).

          Patients and Methods

          A total of 83 727 hip fractures were reported to the NHFR between 2008 and 2017. Pathological fractures, unspecified type of fractures or treatment, patients less than 50 years of age, unknown delay to surgery, and delays to surgery of greater than four days were excluded. We studied total delay (fracture to surgery, n = 38 754) and hospital delay (admission to surgery, n = 73 557). Cox regression analyses were performed to calculate relative risks (RRs) adjusted for sex, age, American Society of Anesthesiologists (ASA) classification, type of surgery, and type of fracture. Odds ratio (OR) was calculated for intraoperative medical complications. We compared delays of 12 hours or less, 13 to 24 hours, 25 to 36 hours, 37 to 48 hours, and more than 48 hours.

          Results

          Mortality remained unchanged when total delay was less than 48 hours. Total delay exceeding 48 hours was associated with increased three-day mortality (RR 1.69, 95% confidence interval (CI) 1.23 to 2.34; p = 0.001) and one-year mortality (RR 1.06, 95% CI 1.04 to 1.22; p = 0.003). More intraoperative medical complications were reported when hospital delay exceeded 24 hours.

          Conclusion

          Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications. Cite this article: Bone Joint J 2019;101-B:1129–1137.

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          Most cited references20

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          Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression.

          Toshiya Shiga, Zen'ichiro Wajima, Yoko Ohe (2008)
          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.
          Article 0 comments Cited 150 times – based on 0 reviews     Review now
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            Association of timing of surgery for hip fracture and patient outcomes.

            Megan McLaughlin, L. Kristopher Siu, Linda R. Morrison … (2004)
            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.
            Article 0 comments Cited 141 times – based on 0 reviews     Review now
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              Bone cement implantation syndrome.

              A.J. Donaldson, H.E. Thomson, N.J. Harper … (2009)
              Bone cement implantation syndrome (BCIS) is poorly understood. It is an important cause of intraoperative mortality and morbidity in patients undergoing cemented hip arthroplasty and may also be seen in the postoperative period in a milder form causing hypoxia and confusion. Hip arthroplasty is becoming more common in an ageing population. The older patient may have co-existing pathologies which can increase the likelihood of developing BCIS. This article reviews the definition, incidence, clinical features, risk factors, aetiology, pathophysiology, risk reduction, and management of BCIS. It is possible to identify high risk groups of patients in which avoidable morbidity and mortality may be minimized by surgical selection for uncemented arthroplasty. Invasive anaesthetic monitoring should be considered during cemented arthroplasty in high risk patients.
              Article 0 comments Cited 131 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Title: The Bone & Joint Journal
                Abbreviated Title: The Bone & Joint Journal
                Publisher: British Editorial Society of Bone & Joint Surgery
                ISSN (Print): 2049-4394
                ISSN (Electronic): 2049-4408
                Publication date Created: September 2019
                Publication date (Print): September 2019
                Volume: 101-B
                Issue: 9
                Pages: 1129-1137
                Affiliations
                [1 ]Department of Clinical Medicine, University of Bergen, Bergen, Norway.
                [2 ]The Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.
                Article
                DOI: 10.1302/0301-620X.101B9.BJJ-2019-0295.R1
                PubMed ID: 31474142
                SO-VID: e172c809-5b4b-4474-927f-a3dd095bbe08
                Copyright © © 2019
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