Copyright © 2005 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Early Mortality After Hip Fracture: Is Delay Before Surgery Important?"
by Christopher G. Moran, MD, FRCS(ED), et al.

Commentary & Perspective by
Joseph D. Zuckerman, MD*,
New York University-Hospital for Joint Diseases, New York, NY

There is a general agreement that a basic principle for the treatment of patients who sustain a hip fracture is that operative management should be performed as soon as possible after the patient has been admitted to the hospital. Although the timing of operative intervention may have an impact on fracture healing in some situations, the primary rationale for minimizing operative delay is to decrease the risk of complications associated with prolonged recumbency and the prevalence of postoperative morbidity and mortality. This is particularly true for elderly patients, a group that sustains the overwhelming majority of these injuries. Although this basic principle of management has been examined by several investigators, the results have not always supported this "tried and true" principle of management1-3. Because of the relative paucity of studies addressing this issue, the article "Early Mortality after Hip Fracture: Is Delay Before Surgery Important?" is an important contribution that enhances our ability to optimize our treatment approach.

Moran et al. conducted a prospective observational study of 2660 patients who underwent surgery at one large university hospital. They found that, for medically stable patients, an operative delay of more than four days resulted in an increase in the ninety-day and one-year mortality compared with that of patients who underwent surgery within four days of admission. The authors also determined that patients who were admitted with an acute medical comorbidity that required stabilization preoperatively had a significantly increased risk of thirty-day mortality compared with patients without comorbidities. However, the authors did not find that the increased mortality could be specifically related to operative delay. This finding is in conflict with reports by other authors who have found that operative delay in medically compromised patients decreased mortality4, although others have identified an increased mortality risk5. We have studied this question previously and found that an operative delay of more than two days after admission significantly increased the risk of mortality one year after fracture6. By controlling for age, gender, and severity of preexisting medical conditions, the relationship between operative delay and increased mortality remained.

The strength of the current study is primarily in the large number of patients included. Previous studies that have addressed the issue of operative delay and postoperative mortality in patients with hip fracture have utilized far fewer patients. In addition, the prospective data collection and the confirmed follow-up on each and every patient in the study adds further strength to the conclusions.

An important unanswered question remains. "What is the definition of operative delay?" This has been defined differently by different authors. Some have focused on operative delay of more than twenty-four hours, some have utilized forty-eight hours, while others have used one week or more7. This may help explain the different results that have been reported by different authors. In addition, it is now well recognized that the patients who sustain a hip fracture are a relatively heterogeneous group. Although they tend to be elderly, they may present without medical comorbidities or may have serious comorbidities; they may be independent, community ambulators or they may be dependent home ambulators. Therefore, studies of patients who have sustained a hip fracture should be carefully analyzed so that these important differences are controlled for in any statistical analysis.

In summary, the results of this study provide additional support for an important treatment principle: operative management of these patients should proceed expeditiously, with careful attention to stabilization of concurrent comorbidities.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Hamlet WP, Lieberman JR, Freedman EL, Dorey FJ, Fletcher A, Johnson EE. Influence of health status and the timing of surgery on mortality in hip fracture patients. Am J Orthop. 1997;26:621-7.
2. Villar RN, Allen SM, Barnes SJ. Hip fractures in healthy patients: operative delay versus prognosis. Br Med J (Clin Res Ed). 1986;293:1203-4.
3. Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112:702-9.
4. Sexson SB, Lehner JT. Factors affecting hip fracture mortality. J Orthop Trauma. 1987;1:298-305.
5. White BL, Fisher WD, Laurin CA. Rate of mortality for elderly patients after fracture of the hip in the 1980's. J Bone Joint Surg Am. 1987;69:1335-40.
6. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77:1551-6.
7. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop. 1984;186:45-56.