The consequences of out-of-hours hip fracture surgery: insights from a retrospective nationwide study

Abstract

Purpose The study aimed to investigate the association between out-of-hours surgery and postoperative mortality in hip fracture patients. Furthermore, internal fixation and arthroplasty were compared to determine if a difference could be observed in patients operated with these techniques at different times during the day. Methods All patients above 18 of age years in Sweden who underwent hip fracture surgery between 2008 and 2017 were eligible for inclusion. Pathological fractures, non-operatively managed fractures, or cases whose time of surgery was missing were excluded. The cohort was subdivided into on-hour (08:00–17:00) and out-of-hours surgery (17:00–08:00). Poisson regression with adjustments for confounders was used to evaluate the association between out-of-hours surgery and both 30-day and 90-day postoperative mortality. Results Out-of-hours surgery was associated with a 5% increase in the risk of both 30-day [adj. IRR (95% CI) 1.05 (1.00–1.10), p = 0.040] and 90-day [adj. IRR (95% CI) 1.05 (1.01–1.09), p = 0.005] mortality after hip fracture surgery compared to on-hour surgery. There was no statistically significant association between out-of-hours surgery and postoperative mortality among patients who received an internal fixation. Arthroplasties performed out-of-hours were associated with a 13% increase in 30-day postoperative mortality [adj. IRR (95% CI) 1.13 (1.04–1.23), p = 0.005] and an 8% increase in 90-day postoperative mortality [adj. IRR (95% CI) 1.08 (1.01–1.15), p = 0.022] compared to on-hour surgery. Conclusion Out-of-hours surgical intervention is associated with an increase in both 30- and 90-day postoperative mortality among hip fracture patients who received an arthroplasty, but not among patients who underwent internal fixation.

Dementia is a surrogate for frailty in hip fracture mortality prediction

“…Logistic regression (LR) models were constructed with 30-day, 90-day, and 1-year postoperative mortality as the response variables [ 31 , 32 ]. The variables that were included as potential predictors were age, sex, ASA classification, type of surgery, type of fracture, out-of-hours surgery, time to surgery, ongoing beta-blocker therapy, CCI, RCRI, comorbidities including dementia, arrhythmia, hypertension, previous myocardial infarctions, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), connective tissue diseases, diabetes mellitus, peptic ulcer disease, liver disease, hemiplegia, chronic kidney disease, local cancer, and metastatic carcinoma, as well as measurements of frailty [ 5 , 7 , 36 , 39 – 42 , 44 – 48 ]. Out-of-hours surgery was defined as surgery initiated between 17:00 and 8:00 [ 44 ].…”

Implementation of a Dedicated Orthopaedic Trauma Room in Hip and Femur Fracture Care: A 17-Year Analysis

“…[7][8][9]22 In addition, a recent study found that hip fracture repair occurring during "out-of-hours" (17:00-08:00) was associated with a 5% increase in 30-and 90-day mortality risk compared with "on-hour" (08:00-17:00). 23 We recognize that measuring in-hospital mortality is a distinctly different assessment than measuring 30-and 90-day postoperative mortality rates associated with hip fracture care. In-hospital mortality, which was looked at in our study, represents only a limited sample of patients experiencing mortality after hip fracture surgery.…”

Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study

“…Subsequently, subgroup analyses were performed by repeating the regression analyses with specific subgroups of patients who were deemed to potentially be at a higher risk of suffering adverse events as a result of the choice of anesthesiological method used. These subgroups were selected since prior studies have observed an association between them and postoperative outcomes; they consisted of patients who underwent internal fixation or arthroplasty, had an extended surgical duration (surgical duration >100 min), had a reduced surgical fitness (ASA classification ≥3), had an elevated RCRI (RCRI ≥2), had an increased comorbidity burden (CCI ≥7), had a diagnosis of dementia prior to surgery, underwent surgery out-of-hours (17:00-08:00), and geriatric patients (aged ≥65 years) 5 18–22 24 25 31 32. An extended surgical duration was defined as any operation that lasted >100 min, as this was the 90th percentile for all operations in this dataset.…”

“…5 14 18 19 Furthermore, several other risk factors have been associated with an increased risk of adverse postoperative outcomes. [20][21][22][23][24][25] However, the latest meta-analyses have not conducted any subgroup analyses taking into account these different risk factors. Therefore, the aim of the current study was to evaluate the association between mode of anesthesia and postoperative morbidity as well as mortality within a general hip fracture population as well as within specific subgroups.…”

“…Some of the indices commonly used to assess the risk of postoperative events in these patients are the American Society of Anesthesiologists (ASA) classification, the Charlson Comorbidity Index (CCI) and the Revised Cardiac Risk Index (RCRI) 5 14 18 19. Furthermore, several other risk factors have been associated with an increased risk of adverse postoperative outcomes 20–25. However, the latest meta-analyses have not conducted any subgroup analyses taking into account these different risk factors.…”