Background: Hip fracture is associated with high mortality among the
elderly. Most patients require surgery, but the timing of the operation
remains controversial. Surgery within twenty-four hours after admission has
been recommended, but evidence supporting this approach is lacking. The
objective of this study was to determine whether a delay in surgery for hip
fractures affects postoperative mortality among elderly patients.
Methods: We conducted a prospective, observational study of 2660
patients who underwent surgical treatment of a hip fracture at one university
hospital. We measured mortality rates following the surgery in relation to the
delay in the surgery and the acute medical comorbidities on admission.
Results: The mortality following the hip fracture surgery was 9%
(246 of 2660) at thirty days, 19% at ninety days, and 30% at twelve months. Of
the patients who had been declared fit for surgery, those operated on without
delay had a thirty-day mortality of 8.7% and those for whom the surgery had
been delayed between one and four days had a thirty-day mortality of 7.3%.
This difference was not significant (p = 0.51). The thirty-day mortality for
patients for whom the surgery had been delayed for more than four days was
10.7%, and this small group had significantly increased mortality at ninety
days (hazard ratio = 2.25; p = 0.001) and one year (hazard ratio = 2.4; p =
0.001). Patients who had been admitted with an acute medical comorbidity that
required treatment prior to the surgery had a thirty-day mortality of 17%,
which was nearly 2.5 times greater than that for patients who had been
initially considered fit for surgery (hazard ratio = 2.3, 95% confidence
interval = 1.6 to 3.3; p < 0.001).
Conclusions: The thirty-day mortality following surgery for a hip
fracture was 9%. Patients with medical comorbidities that delayed surgery had
2.5 times the risk of death within thirty days after the surgery compared with
patients without comorbidities that delayed surgery. Mortality was not
increased when the surgery was delayed up to four days for patients who were
otherwise fit for hip fracture surgery. However, a delay of more than four
days significantly increased mortality.
Level of Evidence: Therapeutic Level II. See Instructions
to Authors for a complete description of levels of evidence.