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

Abstract

Purpose: 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. Methods: 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. Results: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). Conclusions: 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.

Mortality After Distal Femur Fractures in Elderly Patients

“…This idea is further supported by studies showing, after adjusting for patient age, gender, and comorbidities, surgical delay greater than 1 day does not lead to an increase of mortality [21,24,30,47]. However, other studies have shown, even after adjusting for comorbidities, surgical delay greater than 48 hours led to an increase in 30-day and 1-year mortality rates [7,34,37,41,50]. Despite the conflicting evidence, we support early surgical intervention in healthy patients and those with minor physiologic abnormalities and attempt to delay surgery only in patients requiring physiologic stabilization or additional preoperative workup [46].…”

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

“…Traditionally, surgery was postponed until patients had recovered from any acute illness and were deemed 'fit' for anaesthesia and surgery, resulting in pre-operative delay. There is now very strong evidence that delay from hospital admission to surgery increases mortality, lengthens hospital stay and delays functional recovery [67,68]. Delays normally relate to either organisational (51%) or medical (44%) problems, both of which are amenable to managed reduction [69].…”

Contemporary management of femoral neck fractures: the young and the old

“…Numerous studies have reported the correlation between time to surgery and increased mortality [57, 71••, 72-76]. Shiga and colleagues' meta-analysis of 16 observational studies demonstrated increased mortality rates at 30 days and one year of 41 % and 32 % respectively when surgery was delayed more than 48 hours [73]. Other studies suggest similar mortality rates.…”