Causes and Effects of Surgical Delay in Patients With Hip Fracture A Cohort Study

Background: The clinical effect of surgical delay in older patients with hip fracture is controversial. Discrepancies among study findings may be due to confounding that is caused by the reason for the delay or a differential effect on patient risk subgroups. Objective: To assess the effect of surgical delay on hospital outcomes according to the cause of delay. Design: Prospective cohort study. Setting: A hip fracture unit in a university hospital in Spain. Patients: 2250 consecutive elderly patients with hip fracture. Measurements: Time to surgery, reasons for surgical delay, adjusted in-hospital death, and risk for complications. Results: Median time to surgery was 72 hours. Lack of operating room availability (60.7%) and acute medical problems (33.1%) were the main reasons for delays longer than 48 hours. Overall, rates of hospital death and complications were 4.35% and 45.9%, respectively, but were 13.7% and 74.2% in clinically unstable patients. Longer delays were associated with higher mortality rates and rates of medical complications. After adjustment for age, dementia, chronic comorbid conditions, and functionality, this association did not persist for delays of 120 hours or less but did persist for delays longer than 120 hours (P = 0.002 for overall time effect on death and 0.002 for complications). The risks were attenuated after adjustment for the presence of acute medical conditions as the cause of the delay (P = 0.06 for time effect on mortality and 0.31 on medical complications). Risk for urinary tract infection remained elevated (odds ratio, 1.54 [95% CI, 0.99 to 2.44]). No interaction between delay and age, dementia, or functional status was found. Limitation: This was a single-center study without postdischarge follow-up. Conclusion: The reported association between late surgery and higher morbidity and mortality in patients with hip fracture is mostly explained by medical reasons for surgical delay, although some association between very delayed surgery and worse outcomes persists.