The risk for complications increases the longer surgery is delayed beyond the first 24 hours after a hip fracture, researchers say.
Among patients with fractured hips in Ontario Province, Canada, 6.5% of those who waited more than a day for surgery died within the following month compared with 5.8% of a matched group of patients who got the surgery more promptly.
“Targeting surgery within 24 hours represents a significant change in practice because 66% of the patients in this study did not receive surgery within this timeframe,” write Daniel Pincus, MD, from the University of Toronto, Ontario, Canada, and colleagues in an article published online November 28 in JAMA.
US and Canadian guidelines recommend surgery within 48 hours of a hip fracture; surgery within 36 hours is used as an indicator of care quality in the United Kingdom. Adherence ranges from 14.7% to 95.3%, the researchers found.
One reason for the variation in guidelines and adherence could be weaknesses in available data, they write. For example, previous studies may not have taken into consideration the likelihood that medically complex patients are more likely both to suffer complications and to have delays in surgery. Other studies have arbitrarily chosen cutoff points to separate patients who received prompt surgery from those whose surgery was delayed.
To avoid these problems, Dr Pincus and colleagues analyzed the records of patients undergoing surgery for hip fractures in the Ontario Province of Canada between April 1, 2009, and March 31, 2014. After excluding those with prior hip fractures, missing data, elective hospital admission, or a variety of other factors, the study population included 42,230 patients.
The patients’ mean age was 80.1 years, and 70.5% were women. The mean time to surgery was 38.8 hours.
The researchers graphed the rate of complications vs hours waiting for surgery and found a threshold at 24 hours when the rate of complications increased. Overall, 33.6% of patients were treated before this cutoff, and 66.4% after it.
“This is the first study, to our knowledge, to analyze time as a continuous variable in hours and empirically identify a time-to-surgery threshold associated with increased complications after hip fracture,” they write.
Those receiving surgery in the first day were more likely to be men, have medical comorbidities, arrive from other healthcare institutions, and be treated at academic or higher-volume centers.
To adjust for such variables, the researchers created matched cohorts of 13,731 patients, each matched by demographics, comorbidities, diagnosis, fracture type, surgery duration, timing of surgery (night, evening, weekend or business hours), hospital and surgeon characteristics, transfer from other healthcare institutions, discharge disposition, and year.
Of the matched patients who received surgery in the first 24 hours, 898 died in 30 days vs 790 of those who waited longer, for an absolute difference of 0.79% (95% confidence interval [CI], 0.23% – 1.35%). The difference in mortality remained significant when looking at mortality over the course of 90 and 365 days.
Moreover, the risk for each type of complication considered was higher in the group that waited longer, with the exception of hardware removal and postoperative hip dislocation.
Table. Early vs Delayed Surgery Complications
| 30-Day Outcome, % | ≤24 Hours, n = 13,731 | >24 Hours, n = 13,731 | P Value |
| Mortality | 5.8 | 6.5 | .006 |
| Pulmonary embolism | 0.7 | 1.2 | <.001 |
| Deep venous thrombosis | 0.8 | 1.0 | <.11 |
| Myocardial infarction | 0.8 | 1.2 | .001 |
| Pneumonia | 3.7 | 4.6 | <.001 |
| Hardware removal | 0.4 | 0.3 | .49 |
| Postoperative hip dislocation | 0.2 | 0.2 | .58 |
To further adjust for confounding variables, the researchers conducted several other types of statistical analysis.
Still, the researchers acknowledged that as they were retrospectively analyzing this data, they could not rule out variables, such as unidentified morbidities, that could confound the results.
Also, they did not look at all complications, only those considered most likely to be associated with a delay in surgery: They did not include major bleeding, for example. In addition, it is possible that fat embolism was misclassified as pulmonary embolism.
Despite those limitations, they argue that the findings are worth considering because they are based on a large, diverse sample. Also, because the study was in a public health setting, the researchers had good access to follow-up data about complications.
In an accompanying commentary, Mark S. Vrahas, MD, and Harry C. Sax, MD, both from Cedars Sinai Medical Center in Los Angeles, California, write that the study adds significantly to the evidence for surgery within 24 hours of a hip fracture. “When it comes to improving care for patients with hip fracture, timing appears to be important,” they conclude.
The small absolute difference in mortality between patients receiving early surgery and those receiving later surgery could explain why earlier studies with smaller sample sizes have not shown a difference in this outcome, they write.
It is hard to get surgeons to perform surgery outside normal working hours, they acknowledge. A move toward bundled payments, creating incentives for improved outcomes, could nudge some in this direction, they write.
The authors of the study and the authors of the commentary have disclosed no relevant financial relationships.
JAMA. 2017;318(20):1994-2003. Article abstract, Editorial extract
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