Mortality with later hip fracture surgery linked to medical reasons for delay

Late hip fracture surgery carries a higher mortality risk than early surgery, but mostly because of underlying medical reasons for the delay, according to a new study.

Researchers in Spain performed a prospective cohort study at a university hospital's hip fracture unit to determine how delayed surgery for hip fracture affected outcomes. A total of 2,250 consecutive elderly patients with hip fracture were included. The study's main outcome measures were time to surgery, reasons for delayed surgery, adjusted in-hospital mortality, and complication risk. The results appear in the Aug. 16 Annals of Internal Medicine.

All study patients were admitted to the hospital's hip fracture unit between August 2003 and September 2008. All were 65 years of age or older (mean age, 83.6 years), and the median time to hip surgery was 72 hours. Fifty-six patients (2.5%) had surgery immediately, 311 (13.8%) had surgery within 24 hours of admission, and 1,459 patients (64.9%) had surgery more than 48 hours after admission.

The most common reasons for delaying surgery longer than 48 hours were lack of operating rooms (60.7%) and acute medical problems (33.1%). Ninety-eight patients died (4.35%), while 1,031 (45.9%) had at least one postsurgical in-hospital medical complication. In patients clinically unstable at admission, these rates were 13.7% and 74.2%, respectively.

Longer time to surgery was associated with higher mortality rates and higher rates of medical complications. When the authors adjusted for age, dementia, chronic comorbidities and functionality, they found that these associations no longer persisted for delays of 120 hours or less but did persist for delays longer than 120 hours. When the authors adjusted for acute medical conditions as a cause of the delay, the risks were attenuated (P=0.06 for time effect on mortality; P=0.031 for time effect on medical complications).

The authors noted that reasons for clinical unsuitability for surgery varied, that all patients in their study received daily geriatric care, and that no patients were followed after discharge. They also pointed out that the most common reason for delayed surgery was lack of an operating room, highlighting the need for organizational improvements. However, they concluded that the association between late surgery for hip fracture and higher morbidity and mortality is mostly caused by medical reasons rather than by the delay itself. Very long delays in surgery continued to be associated with worse outcomes regardless of the reason for the delays.

An accompanying editorial noted that hip fracture patients are usually “medically complex,” that “medical reasons for delaying surgery are the rule rather than the exception,” and that clinicians should not delay surgery based on the current study's results.

“Although hip fracture is typically regarded as a surgical condition, the poor underlying health status of the patient population, coupled with the effects of hip fracture on functional status and existing comorbid conditions, means that nonsurgical aspects of care are critical to optimizing clinical outcomes,” the editorialists wrote.