Elsevier

Injury

Volume 40, Issue 7, July 2009, Pages 692-697
Injury

Review
Timing of surgery for hip fractures: A systematic review of 52 published studies involving 291,413 patients

https://doi.org/10.1016/j.injury.2009.01.010Get rights and content

Abstract

In order to define the optimum timing of surgery for a hip fracture, we performed a systematic review of published evidence. Data was extracted by two independent reviewers and the methodology of each study was assessed. Fifty-two studies involving 291,413 patients were identified. Outcomes measured were mortality, post-operative complications, length of hospital stay and percentage of patients discharged home.

We found no randomised trials. For the 25 studies involving 282,470 participants that undertook adjustment for confounding factors, early surgery was associated with a reduced hospital stay. These studies produced conflicting results regarding mortality and morbidity being increased or unaffected by delaying surgery. None of these studies reported any adverse outcomes for early surgery. Those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality.

In conclusion early surgery (within 48 h of admission) after a hip fracture reduces hospital stay and may also reduce complications and mortality.

Introduction

The theoretical advantage of allowing a delay from admission to surgery for a hip fracture is that it will allow some time for physiological stabilisation after the injury. This may be particularly relevant after an extracapsular fracture, in which a more extensive blood loss from the fracture site occurs. Other potential advantages of delaying surgery are that it allows more time for assessment of the patient and for correction of dehydration and fluid replacement. Many hip fracture patients are found to be hypovolaemic at the time of surgery.29 Possible adverse effects of delaying surgery are there may be an increase in the incidence of the complications of recumbency, namely pressure sores, thromboembolic complications, urinary infection and pneumonia. This may even be reflected in an increase in mortality. Delaying surgery will prolong the pain and discomfort involved with the injury and may also increase the length of hospital stay and may possibly reduce the chance of a successful rehabilitation and the patient returning home.

This study aimed to review previous published studies on this topic with the aim of developing a consensus from the literature for the optimum timing of surgery for an acute hip fracture.

Section snippets

Materials and methods

The search strategy was using Medline and Pubmed searches on all studies from 1960 till October 2007, which had timing (or delay) of surgery and hip fractures in the abstract. In addition retrieved articles were studied for mention of other relevant studies within the list of references. We included only those studies which reported on the timing of surgery related to outcomes of mortality (within the follow-up period of that study), post-operative medical complications, length of hospital stay

Results

Table 2 lists the characteristics and methodology assessment score of the included studies. Table 3 details the results for the included studies for the outcomes of mortality, post-operative complications, length of hospital stay and the failure of patients to return back to where they were admitted from. The studies are listed grouped for those with similar methodology.

Amongst prospective studies with adjustment, Moran et al.’s study37 included 28 cases out of the 2148 patients studied who had

Discussion

Ideally the question of the timing of surgery should be resolved with a randomised trial with a large number of patients, but because of the ethical issues involved such a study is unlikely to be undertaken. We have identified only one study47 which randomised 70 hip fracture patients to either intensive physiological monitoring on an intensive care unit over the perioperative period or ‘standard monitoring’. The mean time to surgery was 3.7 days in the standard group vs. 6.5 days in

Conclusions

In conclusion the results of this review indicate that delaying surgery may not affect mortality but it is likely to increase morbidity, particularly the incidence of pressure sores and will increase hospital stay. Delaying surgery will inevitably prolong the distress involved from this injury. Therefore patients admitted to hospital with a hip fracture, in whom there are no specific conditions that can be improved prior to surgery, should have their operation as soon as possible after

Conflict of interest

The authors declare that they have no conflict of interest in connection with this paper.

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