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

Abstract

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.

Figures

Figure 1

Flow of studies through the systematic review.

Figure 2

Stratified analysis by time of death. Forest plot of unadjusted relative risks for the effect of early compared with delayed surgery for hip fracture on all-cause mortality assessed in hospital or at 30 days (short-term), at three to six months (medium-term) or at one year (long-term) (random-effects model based on inverse variance method). Studies used a cut-off for delay of 24 hours, except as indicated otherwise. *Study used a cut-off of 48 hours for delay. †Data based on patients who had medical illness in combination with hip fracture. ‡Study used a cut-off of 72 hours for delay. §Study used a cut-off of 5 days for delay. CI = confidence interval, RR = relative risk.

Figure 3

Forest plot of unadjusted relative risks for the effect of preoperative timing on specific postoperative complications assessed in hospital (random-effects model). Studies used a cut-off for delay of 24 hours, except as indicated otherwise. *Study used a cut-off of 48 hours for delay. CI = confidence interval, RR = risk ratio.