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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.

Department of Trauma and Orthopaedics, University Hospital Nottingham, Derby Road, Nottingham NG7 2UH, United Kingdom.

Investigation performed at the Department of Trauma and Orthopaedics, University Hospital Nottingham, Nottingham, United Kingdom

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They 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 authors are affiliated or associated.

NOTE: The authors thank the following clinicians for allowing their patients to be included in this study: Mr. N. Badhe, Mr. N.D. Downing, Mr. D.M. Hahn, Mr. M. Hatton, Mr. B.J. Holdsworth, Mr. C.J. Howell, Mr. J.B. Hunter, Mr. P.J. James, Mr. A.R. Manktelow, Mr. J.A. Oni, Mr. P.J. Radford, Ms. B.E. Scammell, and Mr. E.P. Szypryt. They also thank Dr. Sarah Armstrong, Statistician (University of Nottingham), and Christopher White, Audit Clerk in Trauma and Orthopaedics, for their assistance with this study.

E-mail address for M. Sikand:

Copyright 2005 by The Journal of Bone and Joint Surgery, Incorporated
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