Acceptable time of surgical delay for hip fracture surgery in elderly patients: comparison between American Society of Anaesthesiologists physical status classes I–II versus classes III–IIV
Keywords:Surgical delay, Hip fracture, Elderly, ASA physical status
Background: Elderly patients with high American Society of Anaesthesiologists (ASA) physical status (classes III–IV) have higher reported postoperative mortality for hip fracture. Whether the acceptable time of surgical delay among patients with high ASA scores (classes III–IV) and those with low ASA scores (classes I–II) is different has not been clearly investigated.
Methods: A retrospective cohort study was conducted on 2,035 patients aged ≥60 years who underwent hip fracture surgery between January 2005 and December 2020. The 1-year mortality rate was compared between patients with waiting times beyond the indexed day versus those within the indexed day of 1 to 5. The least time point detecting a significant difference was considered the acceptable time of surgical delay.
Results: There were 1,099 cases (54.0%) in the high ASA group. In the low ASA group, the 1-year mortality rate was significantly lower than the high ASA group (3.5% versus 6.5%, p=0.003), and patients with a waiting time >4 days had a higher mortality rate than those receiving surgery ≤4 days (5.4% vs. 1.8%, OR 2.98, 95%CI 1.40–6.34, p=0.003). For the high ASA group, patients with a waiting time >2 days had a higher mortality rate than those receiving surgery ≤2 days (7.2% versus 3.1%, OR 2.31, 95% CI 1.01–5.25, p=0.036).
Conclusions: The elderly with hip fractures in ASA classes I–II could wait for surgery up to 4 days and 2 days in ASA classes III–IV without a significantly increased 1-year mortality.
Klestil T, Röder C, Stotter C, Winkler B, Nehrer S, Lutz M, et al. Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Sci Rep. 2018;8(1):13933.
Holt G, Smith R, Duncan K, Finlayson DF, Gregori A. Early mortality after surgical fixation of hip fractures in the elderly: an analysis of data from the Scottish hip fracture audit. J Bone Jt Surg Br. 2008;90(10):1357-63.
Castellanos SC, Marco FL, Domínguez EB, Gálvez EMV, Pérez BM. Does delaying surgery for "healthy" hip fracture patients have increased complications and mortality? Injury. 2022;53(10):3209-13.
Moja L, Piatti A, Pecoraro V, Ricci C, Virgili G, Salanti G, et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One. 2012;7:e46175.
Khan SK, Karla S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692-7.
Leung F, Lau TW, Kwan K, Chow SP, Kung AWC. Does timing of surgery matter in fragility hip fractures? Osteoporos Int. 2010;21(4):s529-34.
Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182(15):1609-16.
Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am. 2005;87(3):483-9.
Lizaur-Utrilla A, Martinez-Mendez D, Collados-Maestre I, Miralles-Muñoz FA, Marco-Gomez L, Lopez-Prats FA. Early surgery within 2 days for hip fracture is not reliable as healthcare quality indicator. Injury. 2016;47(7):1530-5.
Doruk H, Mas MR, Yildiz C, Sonmez A, Kyrdemir V. The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly. Arch Gerontol Geriatr. 2004;39(2):179-85.
Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155(4):226-33.
Shoda N, Yasunaga H, Horiguchi H, Matsuda S, Ohe K, Kadono Y, et al. Risk factors affecting inhospital mortality after hip fracture: retrospective analysis using the Japanese Diagnosis Procedure Combination Database. BMJ Open. 2012;2(3):e000416.
Rodriguez-Fernandez P, Adarraga-Cansino D, Carpintero P. Effects of delayed hip fracture surgery on mortality and morbidity in elderly patients. Clin Orthop Relat Res. 2011;469(11):3218-21.
Kim SD, Park SJ, Lee DH, Jee DL. Risk factors of morbidity and mortality following hip fracture surgery. Korean J Anesthesiol. 2013;64(6):505-10.
Yeoh CJ, Fazal MA. ASA grade and elderly patients with femoral neck fracture. Geriatr Orthop Surg Rehabil. 2014;5(4):195-9.
Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status - historical perspectives and modern developments. Anaesthesia. 2019;74(3):373-9.
Bennett A, Li H, Patel A, Kang K, Gupta P, Choueka J, et al. Retrospective qnalysis of geriatric patients undergoing hip fracture surgery: delaying surgery is associated with increased morbidity, mortality, and length of stay. Geriatr Orthop Surg Rehabil. 2018;9:2151459318795260.
Greve K, Modig K, Talbäck M, Bartha E, Hedström M. No association between waiting time to surgery and mortality for healthier patients with hip fracture: a nationwide Swedish cohort of 59,675 patients. Acta Orthop. 2020;91(4):396-400.
Lewis PM, Waddell JP. When is the ideal time to operate on a patient with a fracture of the hip? : a review of the available literature. Bone Joint J. 2016;98-B(12):1573-81.
Wayne WD. Biostatistics: a foundation of analysis in the health sciences. 7th ed. New York: John Wiley & Sons. 1999.
Muhm M, Arend G, Ruffing T, Winkler H. Mortality and quality of life after proximal femur fracture-effect of time until surgery and reasons for delay. Eur J Trauma Emerg Surg. 2013;39(3):267-75.
Muhm M, Klein D, Weiss C, Ruffing T, Winkler H. Mortality after proximal femur fracture with a delay of surgery of more than 48 h. Eur J Trauma Emerg Surg. 2014;40(2):201-12.
Al-Ani AN, Samuelsson B, Tidermark J, Norling A, Ekström W, Cederholm T, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am. 2008;90(7):1436-42.
Amphansap T, Nitiwarangkul L. One-year mortality rate after osteoporotic hip fractures and associated risk factors in Police General Hospital. Osteoporos Sarcopenia. 2015;1(1):75-9.
Chaysri R, Leerapun T, Klunklin K, Chiewchantanakit S, Luevitoonvechkij S, Rojanasthien S. Factors related to mortality after osteoporotic hip fracture treatment at Chiang Mai University Hospital, Thailand, during 2006 and 2007. J Med Assoc Thai. 2015;98(1):59-64.
Yoshizawa T, Nishino T, Mishima H, Ainoya T, Yamazaki M. Rehabilitation in a convalescent rehabilitation ward following an acute ward improves functional recovery and mortality for hip fracture patients: a sequence in a single hospital. J Phys Ther Sci. 2017;29(6):1102-7.
Cha YH, Ha YC, Yoo JI, Min YS, Lee YK, Koo KH. Effect of causes of surgical delay on early and late mortality in patients with proximal hip fracture. Arch Orthop Trauma Surg. 2017;137(5):625-30.
Lee TC, Ho PS, Lin HT, Ho ML, Huang HT, Chang JK. One-year readmission risk and mortality after hip fracture surgery: a national population-based study in Taiwan. Aging Dis. 2017;8(4):402-9.
Liu SK, Ho AW, Wong SH. Early surgery for Hong Kong Chinese elderly patients with hip fracture reduces short-term and long-term mortality. Hong Kong Med J. 2017;23(4):374-80.
Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. 2008;90(1):34-42.
Morri M, Ambrosi E, Chiari P, Magli AO, Gazineo D, D' Alessandro F, et al. One-year mortality after hip fracture surgery and prognostic factors: a prospective cohort study. Sci Rep. 2019;9(1):18718.
Kilci O, Un C, Sacan O, Gamli M, Baskan S, Baydar M, et al. Postoperative mortality after hip fracture surgery: a 3 years follow up. PLoS One. 2016;11(10):e0162097.
Kastanis G, Topalidou A, Alpantaki K, Rosiadis M, Balalis K. Is the ASA score in geriatric hip fractures a predictive factor for complications and readmission? Scientifica (Cairo). 2016;7096245.
Haywood KL, Griffin XL, Achten J, Costa ML. Developing a core outcome set for hip fracture trials. Bone Joint J. 2014;96-B(8):1016-23.