Proximal femoral fractures in the elderly: does operative delay for medical reasons affect short-term outcome?

The association between surgical fixation of hip fractures within 24 hours and mortality : a systematic review and meta-analysis

AIMS

The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures.

METHODS

MEDLINE and Embase were searched from inception to June 2020. Reference lists were manually assessed to identify additional papers. Primary comparative research studies that recruited patients aged over 60 years, with non-pathological primary proximal femoral fractures that were treated surgically, were included. Studies that did not include a group operated on within 24 hours or which reported time to surgery in calendar days were excluded. Two investigators extracted data on study characteristics, methods, and outcomes. The pre-defined primary outcome was 30-day mortality. Secondary outcomes were complications and mortality at other time points. Relative risks (RRs) with 95% confidence intervals (CIs) were aggregated and were grouped by study-level characteristics.

RESULTS

This review included 46 studies (January 1991 to June 2020), comprising 521,857 hip fractures with 64,047 postoperative deaths. No randomized controlled trials were eligible for inclusion. In a pooled analysis of 15 studies, RR of mortality at 30 days comparing time to surgery < 24 hours with > 24 hours was 0.86 (95% CI 0.82 to 0.91; I 2 = 69%; 95% CI 50% to 81%; p-value for heterogeneity < 0.001). The association was stronger in observational studies that did not adjust for confounders than in those that adjusted for multiple covariates. In a pooled analysis of six studies, the RR of mortality at 30 days comparing time to surgery < 24 hours with 24 to 36 hours was 0.87 (95% CI 0.81 to 0.93; I 2 = 65%; 95% CI 16% to 85%; p-value for heterogeneity = 0.014).

CONCLUSION

This meta-analysis indicates reduced mortality for patients operated within 24 hours compared with those operated on beyond 24 hours or within 24 to 36 hours. Where resources allow and there is no specific reversible contraindication to early surgery, we recommend that hip fractures should be surgically treated within 24 hours. Cite this article: Bone Joint J 2021;103-B(7):1176-1186.

Surgery for a fracture of the hip within 24 hours of admission is independently associated with reduced short-term post-operative complications

AIMS

We aimed to characterise the effect of expeditious hip fracture surgery in elderly patients within 24 hours of admission on short-term post-operative outcomes.

PATIENTS AND METHODS

Patients age 65 or older that underwent surgery for closed femoral neck and intertrochanteric hip fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program between 2011 and 2014. Multivariable propensity-adjusted logistic regressions were performed to determine associations between early surgery within 24 hours and post-operative complications, controlling for selection bias in patients undergoing early surgery based on observable characteristics.

RESULTS

A total of 26 051 patients were included in the study; 5921 (22.7%) had surgery within 24 hours of admission, while 20 130 (77.3%) patients had surgery after 24 hours. Propensity-adjusted multivariable logistic regressions demonstrated that surgery within 24 hours was independently associated with lower odds of respiratory complications including pneumonia, failure to extubate, or reintubation (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.67 to 0.90), and extended length of stay (LOS) defined as ≥ 6 days (OR 0.84, 95% CI 0.78 to 0.90).

CONCLUSION

In elderly patients with hip fractures, early surgery within 24 hours of admission is independently associated with less pulmonary complications including pneumonia, failure to extubate, and reintubation, as well as shorter LOS. Cite this article: Bone Joint J 2017;99-B:1216-22.

Does timing of surgery matter in fragility hip fractures?

The effect of delay of surgery on the geriatric hip fractures has been a subject of interest in the past two decades. While the elderly patients will not tolerate long periods of immobilization, it is still unclear how soon these surgeries need to be performed. A review of existing literature was performed to examine the effect of timing of surgery on the different outcome parameters of these patients. Although there is conflicting evidence that early surgery would improve mortality, there is widespread evidence in the literature that other outcomes including morbidity, the incidence of pressure sores, and the length of hospital stay could be improved by shortening the waiting time of hip fracture surgery. We concluded that it is beneficial to the elderly patients to receive surgical treatment as an urgent procedure as soon as the body meets the basic anesthetic requirements.

Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis

BACKGROUND

Guidelines exist for the surgical treatment of hip fracture, but the effect of early surgery on mortality and other outcomes that are important for patients remains unclear. We conducted a systematic review and meta-analysis to determine the effect of early surgery on the risk of death and common postoperative complications among elderly patients with hip fracture.

METHODS

We searched electronic databases (including MEDLINE and EMBASE), the archives of meetings of orthopedic associations and the bibliographies of relevant articles and questioned experts to identify prospective studies, published in any language, that evaluated the effects of early surgery in patients undergoing procedures for hip fracture. Two reviewers independently assessed methodologic quality and extracted relevant data. We pooled data by means of the DerSimonian and Laird random-effects model, which is based on the inverse variance method.

RESULTS

We identified 1939 citations, of which 16 observational studies met our inclusion criteria. These studies had a total of 13 478 patients for whom mortality data were complete (1764 total deaths). Based on the five studies that reported adjusted risk of death (4208 patients, 721 deaths), irrespective of the cut-off for delay (24, 48 or 72 hours), earlier surgery (i.e., within the cut-off time) was associated with a significant reduction in mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68-0.96, p = 0.01). Unadjusted data indicated that earlier surgery also reduced in-hospital pneumonia (RR 0.59, 95% CI 0.37-0.93, p = 0.02) and pressure sores (RR 0.48, 95% CI 0.34-0.69, p < 0.001).

INTERPRETATION

Earlier surgery was associated with a lower risk of death and lower rates of postoperative pneumonia and pressure sores among elderly patients with hip fracture. These results suggest that reducing delays may reduce mortality and complications.

Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients

BACKGROUND

Existing reports describe the decline of the mortality rate by conducting surgery for hip fractures within 24 h; however, the theory is still controversial. We have compared the perioperative mortality rate, improvement of mobility, and duration of hospital stay for early surgery (within 24 h) and delayed surgery (beyond 24 h) between two groups.

METHODS

We studied 536 cases of proximal femoral fracture in patients >60 years who were treated between September 2003 and December 2006. There were 91 men and 445 women, who had a total of 257 femoral neck fractures and 279 trochanteric fractures. In all, 270 patients were operated on within 24 h after injury and were defined as the early group; 266 patients were treated surgically more than 24 hours after injury and were defined as the delayed group. Based on admission laboratory tests, co-morbidity, dementia, preoperative mobility, and residential environment before injury, we compared the duration of hospital stay, mobility at discharge, and mortality rates between the early group and the delayed group.

RESULTS

There was no significant difference in duration of hospital stay between the two groups. Improvement of mobility was 52% in the early group and 41% in the delayed group, with the difference being significant (P < 0.05). Inpatient mortality rate was 5.6% in the early group and 2.6% in the delayed group, but the difference was not significant. In the early group, men with co-morbidity, dementia, and abnormal laboratory values upon admission showed a significantly higher mortality rate.

CONCLUSIONS

Early surgery was useful for improving mobility, but it showed a higher mortality rate in patients with a compromised somatic condition at the time of the injury. For independent patients with a stabilized somatic condition, surgery should be performed within 24 h. For unstable cases, we believe it is better to provide early surgery after stabilizing the patient's condition to the greatest possible extent.

Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients

In order to define the optimum timing of surgery for a hip fracture, we performed a systematic review of published evidence. Data was extracted by two independent reviewers and the methodology of each study was assessed. Fifty-two studies involving 291,413 patients were identified. Outcomes measured were mortality, post-operative complications, length of hospital stay and percentage of patients discharged home. We found no randomised trials. For the 25 studies involving 282,470 participants that undertook adjustment for confounding factors, early surgery was associated with a reduced hospital stay. These studies produced conflicting results regarding mortality and morbidity being increased or unaffected by delaying surgery. None of these studies reported any adverse outcomes for early surgery. Those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. In conclusion early surgery (within 48h of admission) after a hip fracture reduces hospital stay and may also reduce complications and mortality.

[Influence of operation time point on the frequency of early complications after surgical femoral neck fracture treatment]

AIM

The current publication deals with surgically treated medial and lateral femoral neck fracture of patients aged 60 and older.

MATERIAL/METHODS

All patients were evaluated who received operative treatment between day of trauma and day 14 after trauma. Therefore, 30,254 patients (77,44%) were included. All early complications observed during hospital treatment were recorded as general and special complications, and we calculated whether the day of operation influenced the occurrence of early complications. Statistically significant differences were gained for revision operations.

RESULTS

If the primary operation was performed on days 2 to 3 or 4 to 5 after trauma, fewer revisions necessary. Similar results were gained for revisions due to seroma and haematoma or postoperative bleeding. In these cases, fewer revision operations were performed when primary treatment was achieved on day 2 or 3.

CONCLUSIONS

From the data presented, it is postulated that early complications provide no decisive reason for treating femoral neck fracture as an emergency. However, considering late complications such as the rate of femoral head necrosis, treatment for retaining the femoral head should be performed as early as possible. German guidelines suggest early but not emergency treatment in case of operations not saving the femoral head. Emergency operation within 6 h is not mandatory.

Economic consequences of operative delay for hip fractures in a non-profit institution

This retrospective study evaluated the economic consequences of delaying hip fracture surgery in 191 elderly patients. Data was collected regarding fracture type, surgery, timing of surgery, background diseases, postoperative hospital stay, and complications. In addition, calculation of the drugs administered to the patients, cost of the surgery, blood transfusion, physiotherapy, laboratory examinations, radiographs, and any financial data were evaluated. Spending more resources for performing hip surgery within 48 hours is more cost-effective than delaying surgery past the third day.

Comorbid conditions in old patients with femur fractures

BACKGROUND AND METHODS

The incidence of preexisting medical diseases (comorbid conditions) and their influence on the high rate of falls, associated severe injuries, operative treatment, and outcome including mortality rate, duration of hospitalization, and rehabilitation success was retrospectively evaluated in a group of 102 patients (mean age, 81 years; 81% women) with femoral fractures. A comparison of polymorbidity rates in a control group of 102 patients (mean age, 79 years; 86% women) with proximal humeral fractures was added.

RESULTS

The associated polymorbidity rate among patients with femoral fractures (FF) usually was statistically significantly higher than among patients with proximal humeral fractures (PHF) despite a comparable age and sex distribution: 80% of the patients with FF presented with cardiovascular (p < or = 0.001), 41% with pulmonary (p < 0.001), 67% with gastrointestinal (p < or = 0.001), 71% with neurologic (p < or = 0.001), 55% with urologic (p < or = 0.001), 75% with musculoskeletal (p < or = 0.1), and 61% with psychiatric (p < or = 0.001) disorders and complaints. Ninety percent of the patients used different medications (diuretics, cardiac agents, anticoagulants, antidiabetic agents, steroids, hypnotics, analgesics, psychotropic agents). The postoperative mortality rate was 11%, and the mean hospitalization period was 30 days. Forty-nine percent of the patients were discharged to their homes. Only 56% of the patients with PHF, however, presented with cardiovascular, 8% with pulmonary, 11% with gastrointestinal, 8% with neurologic, 9% with urologic, 64% with musculoskeletal, and 10% with psychiatric disorders.

CONCLUSION

The polymorbidity in the old patient probably is a major intrinsic cause of the high incidence of falls and associated severe femoral fractures. It influences the perioperative and postoperative medical and anesthesiologic treatment, the postoperative mortality rate, and the duration and success of the postoperative rehabilitation phase.