Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis

Background

Guidelines exist for the surgical treatment of hip fracture, but the effect of early surgery on mortality and other outcomes that are important for patients remains unclear. We conducted a systematic review and meta-analysis to determine the effect of early surgery on the risk of death and common postoperative complications among elderly patients with hip fracture.

Methods

We searched electronic databases (including MEDLINE and EMBASE), the archives of meetings of orthopedic associations and the bibliographies of relevant articles and questioned experts to identify prospective studies, published in any language, that evaluated the effects of early surgery in patients undergoing procedures for hip fracture. Two reviewers independently assessed methodologic quality and extracted relevant data. We pooled data by means of the DerSimonian and Laird random-effects model, which is based on the inverse variance method.

Results

We identified 1939 citations, of which 16 observational studies met our inclusion criteria. These studies had a total of 13 478 patients for whom mortality data were complete (1764 total deaths). Based on the five studies that reported adjusted risk of death (4208 patients, 721 deaths), irrespective of the cut-off for delay (24, 48 or 72 hours), earlier surgery (i.e., within the cut-off time) was associated with a significant reduction in mortality (relative risk RR] 0.81, 95% confidence interval CI] 0.68–0.96, p = 0.01). Unadjusted data indicated that earlier surgery also reduced in-hospital pneumonia (RR 0.59, 95% CI 0.37–0.93, p = 0.02) and pressure sores (RR 0.48, 95% CI 0.34–0.69, p < 0.001).

Interpretation

Earlier surgery was associated with a lower risk of death and lower rates of postoperative pneumonia and pressure sores among elderly patients with hip fracture. These results suggest that reducing delays may reduce mortality and complications.Among elderly patients, hip fracture is associated with a one-year mortality rate ranging from 14% to 36%¹ and also with profound temporary and sometimes permanent impairment of independence and quality of life.² As the elderly population increases, the annual number of hip fractures globally is expected to exceed 7 million over the next 40 to 50 years.³Current guidelines⁴ indicate that surgery for hip fracture should be performed within 24 hours of injury, as earlier surgery has been associated with better functional outcome, shorter hospital stay, shorter duration of pain and lower rates of nonunion, postoperative complications and mortality.^5–11Proponents of early treatment argue that this approach minimizes the length of time a patient is confined to bed rest, thereby reducing the risk of associated complications, such as pressure sores, deep vein thrombosis and urinary tract infections.⁸ However, those favouring a delay believe it provides the opportunity to optimize patients’ medical status, thereby decreasing the risk of perioperative complications.⁸ A further challenge to resolving the debate is the lack of an accepted definition of early surgery.¹² Uncertainty exists about whether 24, 48 or 72 hours, or a longer period, should be considered to represent an “unacceptable delay” for hip fracture surgery.We undertook a systematic review and meta-analysis to inform this debate. More specifically, we addressed the following question: Among patients 60 years of age or older who underwent surgery for hip fracture, what was the effect of early surgery, relative to delayed surgery, on all-cause mortality and postoperative complications?