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The Importance of Surgical Timing After Hip Fracture

Many older adults who have a hip fracture never make it back home again. They transfer from the hospital to a transition unit, skilled nursing facility, or extended care facility. Doctors are actively searching for ways to change this fact.

One area of research is to look for risk factors that can be changed to help patients return home or to an independent living situation. Studies have already been done that show the importance of general health before fracture, mental status, and preinjury walking ability.

In this study, researchers from Sweden investigate the effect of the timing of surgery after hip fracture. They looked at timing as it related to returning to independent living and on the development of pressure ulcers. Over 700 patients with an acute hip fracture were included.

Medical records were reviewed for the following information: time of admission, time of surgery, duration of surgery, and any pressure ulcers that developed. Specific type of surgery was also recorded.

The time to surgery was calculated from the time the patient came into the emergency department to the time of the operation. Delays could occur because of the patient's health or for system-based reasons (e.g., unavailability of the operating room, surgeon, or anesthesiologist). Specifically, the authors compared patients who had the surgery in the first 24-hours and those who had the surgery after 24 hours (e.g., 36 or 48 hours later).

Treatment included repairing the fracture using a metal plate, wires, and/or screws or reconstructing the hip. Reconstruction was with a hemiarthroplasty or total hip replacement. The hemiarthroplasty removes the head of the femur and replaces it but leaves the hip socket intact.

About half of the patients had hip surgery within the first 24 hours. Three-fourths had it within the first 36 hours and 87 per cent within 48 hours of admission. Two-thirds of the delays were due to hospital staffing or other medical-related issues. The remaining one-third were delayed because of specific patient-related factors.

Delays in surgery definitely increased the risk of pressure ulcers. The longer the delay, the greater the risk. Pain and prolonged immobility associated with an untreated hip fracture contribute to this problem.

And for every 6 hour and 45 minute delay of surgery, the hospital stay increased by one day. It was noted that almost 10 per cent of patients in the study had dementia. This seemed to contribute to a failure to return to independent living, but was not investigated further at this time. The death rate was not different between the group who had surgery in the first 24-hours and those who had surgery 36 to 48 hours later.

Another concern pointed out is the physical effects of fasting during the delay. While the patient is waiting for the operation, food and drink are withheld. This is a precaution against vomiting during anesthesia. But a reduced caloric intake and dehydration can lead to muscle loss and weakness. This condition persists after surgery and can impact healing negatively.

Overall, it looks like a delay in surgery does increase the risk of pressure ulcers, a longer hospitalization, and less chance of returning home. Since many of the delays were related to problems on the medical side of things (e.g., inadequate resources, lack of support services), one way to reduce these problems is to address system-related delays.

References: Amer N. Al-Ani, MD, et al. Early Operation on Patients with a Hip Fracture Improved the Ability to Return to Independent Living. In The Journal of Bone and Joint Surgery. July 2008. Vol. 90-A. No. 7. Pp. 1436-1442.

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