Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
Dr. Alvi is an Adult Joint Reconstruction Orthopedic Surgeon, Barrington Orthopedic Specialists, Schaumburg, Illinois. Dr. Thompson is Assistant Professor, Department of Orthopaedic Surgery, and Associate Director, Center for Cerebral Palsy, David Geffen School of Medicine, The University of California, Los Angeles, Los Angeles, California. Dr. Krishnan is a General Surgery Resident, Lenox Hill Hospital/Northwell Health, New York, New York. Dr. Kwasny is Professor of Preventive Medicine, Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University, Chicago, Illinois. Dr. Beal is Associate Professor and Program Director; and Dr. Manning is Associate Professor and Vice Chairman Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Address correspondence to: Hasham M. Alvi, MD, Barrington Orthopedic Specialists, 929 W. Higgins Road, Schaumburg, IL 60195 (tel, 847-285-4200; email, Halvi@barrringtonortho.com).
Hasham M. Alvi, MD Rachel M. Thompson, MD Varun Krishnan, MDMary J. Kwasny, ScD Matthew D. Beal, MD David W. Manning, MD . Time-to-Surgery for Definitive Fixation of Hip Fractures: A Look at Outcomes Based Upon Delay. Am J Orthop.
September 7, 2018
References
Despite the best efforts to optimize surgical care and postoperative rehabilitation following hip fracture, elderly patients feature alarmingly high in-hospital and 1-year mortality rates of 4.35% to 9.2%1-4 and 36%,5 respectively. Those who survive are unlikely to return to independent living, with only 17% of the patients following hip fracture being able to walk independently 6 months postoperatively, and 12% being able to climb stairs6. Possibly, these poor outcomes reflect a preoperative medical comorbidity burden rather than a measure of medical or surgical quality. Given the absence of consensus regarding optimal time-to-surgery, treating physicians often opt to delay surgical intervention for the purposes of medically optimizing highly comorbid patients without significant data to suggest clinical benefit of such practice.
Numerous investigators have attempted to identify the modifiable risk factors for complication after surgical care of elderly hip fracture patients. However, consensus guidelines of care are missing. This condition is largely due to the difficulties in effectively modifying preoperative demographic and medical comorbidities on a semi-urgent basis. However, timeliness to surgery is one area for study that the care team can affect. Although time-to-surgery is dependent on multiple factors, including time of presentation, day of week of admission, difficulties with scheduling, and administrative delays, the care team plays a role in hastening or retarding time-to-surgery. Several studies have considered various time cut-offs (24, 48, 72, and 120 hours) to define early intervention, but none have defined a specific role for early or delayed surgery. Several investigators have discovered a positive association between delayed time-to-surgery and mortality;4,8-14 however, the most rigorously conducted studies that stringently control for preoperative comorbidities and demographics conclude that variance in time-to-surgery causes no effect on the in-hospital or 1-year mortality risk.1-3,15-18
Other investigators have shown that with early surgical intervention for hip fracture, patients experience shorter hospital stays,1,3,16,17,19-22 less days in pain,19 decreased risk of decubitus ulcers,15,17,19,22 and an increased likelihood of independence following fracture,22-25 regardless of preoperative medical status. Despite this evidence of improved outcomes with early surgery, 40% to 54% of hip fracture patients in the United States experience surgical delays of more than 24 to 48 hours. Additionally, with the recent (2013) national estimates of cost per day spent in the hospital falling between $1791 to $2289,26 minimizing the days spent in the hospital would likely lead to significant cost-savings, presuming no adverse effect on health-related outcomes. To this end, we hypothesize that the value (outcomes per associated cost)7 of hip fracture surgical care can be positively influenced by minimizing surgical wait-times. We assessed the effect of early surgical intervention, within 24 or 48 hours of presentation, on 30-day mortality, postoperative morbidity, hospital length of stay, and readmission rates in a comorbidity-adjusted population from a nationally representative cohort.
