Original Research

Time-to-Surgery for Definitive Fixation of Hip Fractures: A Look at Outcomes Based Upon Delay

Publish date: September 7, 2018

References

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RESULTS

A study population of 6036 hip fractures was identified and divided into 3 groups of 2012 subjects each based upon time-to-surgery. The groups were successfully matched for surgery type, age (≥75 years old), gender, and ASA class. In each group, 594 of the 2012 (29.5%) patients were male, 1525 (75.8%) were ≥75 years of age, 9 (.5%) were ASA Class I, 269 (13.4%) were ASA Class II, 1424 (70.8%) were ASA class III, and 309 (15.4%) were ASA class IV.

Significant differences in preoperative comorbidity burden and preoperative lab values were identified between the 3 cohorts. Increased time-to-surgery was associated with differences in race (P < .001), elevated BMI (P = .010), higher rates of congestive heart failure (P < .001), hypertension medication (P = .020), bleeding disorders (P < .001), blood transfusion within 72 hours of surgery (P < .001), and systemic sepsis (P = .001). Delay to surgery was also associated with lower preoperative sodium (P = .005), blood urea nitrogen (P = .013), serum WBC (P < .001), hematocrit (P < .001), and platelets (P < .001) (Table 1).

The unadjusted analyses revealed no association between time-to-surgery and return to OR (P = .554) nor readmission (P = .285). However, increasing time-to-surgery was associated with an increase in overall complications (P = .034), total length of hospital stay (P < .001), and 30-day mortality (P = .039) (Table 2).

Table 2. Estimated Event Rates from Matched Cohorts (Unadjusted)

	Time From Presentation to Definitive Fixation
Outcomes	<24 hours	24-48 hours	>48 hours	P-value
Overall complication rate	15.30%	15.30%	17.90%	0.034
Total length of stay	5.4	6.7	10.9	<0.001
(mean days, 95% confidence interval)	(5.2, 5.7)	(6.5, 7.0)	(10.3, 11.5)	<0.001
Time from OR to discharge	-ref-	0.96	0.74	<0.001
(Hazard ratio)	-ref-	(0.90,1.02)	(0.69, 0.79)	<0.001
Return to OR	2.40%	2.40%	2.00%	0.554
Readmission	9.60%	8.40%	8.30%	0.285
30-day mortality rate	5.80%	5.30%	7.20%	0.039

Abbreviation: OR, operating room.

The adjusted analysis controlling for preoperative demographic and comorbidity variables revealed trends toward the increased overall complications and 30-day mortality with increased time-to-surgery; these trends showed no statistical significance (P = .143 and P = .08). No statistical relationship was observed between return to OR nor readmission and time-to-surgery. Increasing time-to-surgery remained significantly associated with the increased total length of hospital stay (P < .001). The adjusted analysis also revealed that the delay of >48 hours in time-to-surgery resulted in a longer surgery-to-discharge time (P < .001) (Table 3). No evidence of violation of the proportional hazards assumption was observed in the unadjusted nor adjusted clustered proportional hazards models (Wald test, P = .27 and P = .25, respectively).

Table 3. Estimated Event Rates from Matched Cohorts (Adjusted^a)

	Time from Presentation to Definitive Fixation
Outcomes	<24 hours	24-48 hours	>48 hours	P-value
Overall complication rate	11.70%	10.70%	12.60%	0.143
Total length of stay	4.2	5.1	7.6	<0.001
(mean days, 95% confidence interval)	(4.0, 4.5)	(4.8, 5.5)	(7.1, 8.3)	<0.001
Time from OR to discharge	-ref-	1.03	0.87	<0.001
(Hazard ratio)	-ref-	(0.97, 1.09)	(0.81, 0.92)	<0.001
Return to OR	2.10%	2.10%	1.60%	0.541
Readmission	7.20%	6.40%	6.00%	0.304
30-day mortality rate	4.20%	3.70%	5.20%	0.08

^aModel adjusted for race, hypertension medication, cancer, bleeding disorders, transfusion within 72 hours before surgery, emergency status, wound infection, anesthesia type (general), body mass index (18.5-25), history of chronic obstructive pulmonary disease, and preoperative levels of creatinine, platelet count, white blood cell count, and hematocrit.

Continue to: DISCUSSION...

References

5. Zuckerman JD. Hip fracture. N Engl J Med. 1996;334(23):1519-1525. doi:10.1056/NEJM199606063342307.

6. Marottoli RA, Berkman LF, Cooney LM Jr. Decline in physical function following hip fracture. J Am Geriatr Soc. 1992;40(9):861-866. doi:10.1111/j.1532-5415.1992.tb01980.x.

7. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481. doi:10.1056/NEJMp1011024.

11. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am. 2005;87(3):483-489. doi:10.2106/JBJS.D.01796.

18. Rae HC, Harris IA, McEvoy L, Todorova T. Delay to surgery and mortality after hip fracture. ANZ J Surg. 2007;77(10):889-891. doi:10.1111/j.1445-2197.2007.04267.x.

19. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291(14):1738-1743. doi:10.1001/jama.291.14.1738.

35. ACS National Surgical Quality Improvement Program. American College of Surgeons Web site. https://www.facs.org/quality-programs/acs-nsqip?. Accessed March 14, 2013.

Time-to-Surgery for Definitive Fixation of Hip Fractures: A Look at Outcomes Based Upon Delay

References

RESULTS

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