Timing of Hip Fracture Surgery in the Elderly

Abstract

The effect of preoperative wait time for surgery is a long-standing subject of debate. Although there is disagreement among clinicians on whether early surgery confers a survival benefit per se, most reports agree that early surgery improves other outcomes such as length of stay, the incidence of pressure sores, and return to independent living. Therefore, it would seem prudent to surgically treat elderly patients with hip fractures within the first 48 hours of admission. However, the current body of evidence is observational in nature and carries the potential for bias inherent in such analyses. Evidence in the form of a large randomized controlled trial may ultimately be required to fully evaluate the impact of surgical timing on patients with fractures of the hip.

Introduction

Hip fractures are a significant cause of morbidity and mortality in the elderly patients. Nearly 300 000 hip fractures occur in the United States annually, and this number is expected to rise with the growth of elderly populations. ^1,2 Even with surgery, the incidence of postoperative complications is high, and patients face a difficult rehabilitation period, with 1-year mortality estimated to be 30%. ^3,4 Without surgery, the results are much poorer and surgery has become the standard of care for most elderly patients with fractures of the proximal femur. Much effort has been directed toward identifying prognostic factors that can improve outcomes for patients with this injury.

The effect of preoperative wait time for surgery is a long-standing subject of debate. Numerous studies have explored the association between the timing of surgical repair and clinical outcomes but with conflicting results. ^{5 –13} Current guidelines recommend surgery within 24 hours of hospital admission, with proponents arguing that early surgery improves functional outcomes and lowers mortality, length of hospital stay, and postoperative complications. ^{5 –9} On the other hand, delaying surgery may be necessary to stabilize patients with significant comorbidities. Several studies report that preoperative delay has no impact on mortality and that, on the contrary, precipitous surgery increases the risk of perioperative complications. ^8,10,11 Adding to the challenge of resolving this question is the lack of randomized controlled trials, which would offer more definitive evidence on the influence of surgical timing. Ethical considerations in designing such trials prevent their use and leave prospective and retrospective cohort studies as the best evidence currently available.

The aim of this review is to examine the current literature to better define the relationship between the timing of hip fracture surgery with mortality, length of hospital stay, and postoperative complications.

Surgical Timing and Mortality

Currently, there is lack of consensus within the orthopedic community on the relationship between timing of hip fracture surgery and mortality outcomes. Many authors have reported early surgery to have a beneficial effect on survivorship. Uzoigwe et al reported their results of 2056 patients operated within 12, 24, and after 36 hours. ⁵ The authors found increased mortality after 36 hours and progressively decreased mortality in patients operated within 24 and 12 hours. Hapuarachchi et al examined 146 patients who underwent hip fracture surgery and reported increased mortality after 24 and 48 hours compared to those who had surgery within 24 hours. ¹² An early systematic review of 16 published studies found that surgical delays beyond 48 hours increased 30-day and 1-year mortality. ¹⁴ A subsequent meta-analysis by Simunovic et al reported significantly less mortality for patients operated within 24 to 72 hours of hospital admission. ¹⁵ In the most recent review of 35 published studies involving 191 873 patients, Moja et al found that surgery conducted before 24 to 48 hours was associated with lower all-cause mortality, confirming earlier findings by Simunovic et al. ¹⁶

Other investigators have found that operative delay has less impact on mortality. In a prospective study of 850 patients with hip fracture, Al-Ani et al reported no significant difference in mortality rates at 24, 36, and 48 hours. ⁶ Moran et al conducted a prospective analysis of 2660 patients with hip fracture and found that surgical delay up to 4 days had no effect on mortality; beyond this 4-day threshold, however, the 90-day and 1-year mortality increased significantly. ¹¹ Orosz et al reported their results of 1178 patients who underwent hip fracture surgery and found that early surgery within 24 hours was not associated with improved mortality. ⁸ A systematic review of 52 published studies involving 291 143 patients was recently performed by Khan et al. They observed that when studies adjusted for confounding factors, they were less likely to report improved survival outcomes from early surgery. ¹⁷ When Vidán et al controlled for additional variables such as older age, dementia, and chronic comorbidities, they found that delaying surgery up to 5 days had no influence on mortality. ¹⁸ Based on their results, the authors concluded that patients with a poorer baseline health status underwent more delayed surgery and that this association alone accounted for the poorer outcomes in patients who had delays.

Surgical Timing and Length of Stay

There is good evidence to suggest that early surgery lessens hospital length of stay. Siegmeth et al prospectively studied 3628 patients who underwent hip fracture surgery over a 15-year period. They found that patients who underwent operation within 48 hours had their mean length of hospital stay shortened by 10.9 days. ¹³ When Al-Ani et al used 24 hours as the cutoff point, patients who received surgery within 24 hours had their median length of stay decreased by 4 days. ⁶ Similar findings were reported by Lefaivre et al who found that surgical delay was associated with delay in discharge after controlling for additional factors such as age, fracture type, and medical comorbidities. ¹⁹ In their prospective cohort study, Vidán et al demonstrated a positive correlation between preoperative waiting time beyond 5 days and longer in-hospital stay. ¹⁸ These authors and others ^{11,13 –15,18} have noted that the most common reason for preoperative delay is lack of operating room availability. Thus, these organizational challenges represent an area of improvement that may increase efficiency and patient outcomes.

Surgical Timing and Postoperative Complications

Early surgery has been shown to reduce the risk of pressure ulcer development, a serious complication that occurs with prolonged immobilization. In a retrospective study of 8383 patients with hip fracture, Grimes et al showed that delaying surgery for more than 96 hours significantly increased the incidence of pressure sores. ⁹ Similar findings were confirmed in systematic reviews performed by Khan et al ¹⁷ and Moja et al. ¹⁶

Al-Ani et al showed that early surgery may positively impact long-term functional outcomes. After adjusting for potential confounding factors, they observed that surgery performed within 36 hours increased the likelihood of returning to independent living within 4 months. ⁶ In accordance with these findings, Doruk et al reported earlier recovery of weight bearing and return to activities of daily living when surgery was performed within 5 days of admission. ⁷ There is also literature linking early surgery to reduced pain during hospitalization. ⁸

Conclusion

With the rising number of patients with hip fractures, there continues to be vigorous debate on the influence of surgical timing on clinical outcomes. Although there is disagreement among clinicians on whether early surgery confers a survival benefit per se, most reports agree that early surgery improves other outcomes such as length of stay, the incidence of pressure sores, and return to independent living. Therefore, it would seem prudent to surgically treat elderly patients with hip fractures within the first 48 hours of admission. It must be recognized, however, that the current body of evidence is observational in nature and as such carries the potential for bias inherent in such analyses. ²⁰ Evidence in the form of a large randomized controlled trial may ultimately be required to fully evaluate the impact of surgical timing on patients with hip fractures.