Is Delayed Time to Surgery Associated with Increased Short-term Complications in Patients with Pathologic Hip Fractures?
Authors: Varady Nathan H. , Ameen Bishoy T. , Chen Antonia F. 
Published: November 2019

Abstract

Background
Delayed time to surgery of at least 2 days after hospital arrival is well known to be associated with increased complications after standard hip fracture surgery; whether this association is present for pathologic hip fractures, however, is unknown.

Questions/purposes
(1) After controlling for differences in patient characteristics, is delayed time to surgery (at least 2 days) for patients with pathologic hip fractures independently associated with increased complications compared with early surgery (fewer than 2 days)? (2) What preoperative factors are independently associated with major complications and mortality after surgery for pathologic hip fractures?

Methods
A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database of pathologic hip fractures (including femoral neck, trochanteric, and subtrochanteric fractures) from 2007 to 2017. This database was chosen over other databases given the high-quality preoperative medical history and postoperative complication (including readmissions, reoperations, and mortality) data collected from patient medical records through the thirtieth postoperative day. Patients were identified using Common Procedural Terminology codes for hip fracture treatment (THA, hemiarthroplasty, proximal femur replacement, intramedullary nail, and plate and screw fixation) with associated operative diagnoses for pathologic fractures as identified with International Classification of Diseases codes. A total of 2627 patients with pathologic hip fractures were included in this study; 65% (1714) had surgery within 2 days and 35% (913) had surgery after that time. Patient demographics, hospitalization information, and 30-day postoperative complications were recorded. Differences in characteristics between patients who underwent surgery in the early and delayed time periods were assessed with chi-square tests for categorical variables and t-tests for continuous variables. Delayed-surgery patients were more medically complex at the time of admission than early-surgery patients, including having higher American Society of Anesthesiologists classification (mean ± SD 3.18 ± 0.61 versus 2.94 ± 0.60; p < 0.001) and prevalence of advanced, “disseminated” cancer (53% versus 39%; p < 0.001). Propensity-adjusted multivariable logistic regression analyses were performed to assess the effect of delayed time to surgery alone on the various outcome measures. Additional independent risk factors for major complications and mortality were identified using backwards stepwise regressions.

Results
After controlling for baseline factors, the only outcome associated with delayed surgery was extended postoperative length of stay (odds ratio 1.94 [95% CI 1.62 to 2.33]; p < 0.001). Delayed surgery was not associated with any postoperative complications, including major complications (OR 1.23 [95% CI 0.94 to 1.6]; p = 0.13), pulmonary complications (OR 1.24 [95% CI 0.83 to 1.86]; p = 0.29), and mortality (OR 1.26 [95% CI 0.91 to 1.76]; p = 0.16). Histories of chronic obstructive pulmonary disease (OR 2.48), congestive heart failure (OR 2.64), and disseminated cancer (OR 1.68) were associated with an increased risk of major complications, while dependent functional status (OR 2.27), advanced American Society of Anesthesiologists class (IV+ versus I-II, OR 4.81), and disseminated cancer were associated with an increased risk of mortality (OR 2.2; p ≤ 0.002 for all).

Conclusions
After controlling for baseline patient factors, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic hip fractures. These results are in contrast to the traditional dogma for standard hip fractures that surgery within 2 days of hospital arrival is associated with reduced complications. Although surgery should not be delayed needlessly, if the surgeon feels that additional time could benefit the patient, the results of this study suggest surgeons should not expedite surgery because of the risk of surgical delay observed for standard hip fractures.

Level of Evidence
Level III, therapeutic study.