more HIP ARTICLES ONGOING ...The Earlier the Better for Hip Fracture Surgery
By Crystal Phend, Senior Staff Writer, MedPage Today
Published: September 13, 2010
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
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Minimizing delays in surgery for hip fracture may improve survival and reduce complications among older patients, according to a meta-analysis.
Earlier surgery reduced all-cause mortality compared with later surgery whether the cutoff for delay was 24, 48, or 72 hours (pooled relative risk 0.81, P=0.01), Nicole Simunovic, MSc, of McMaster University in Hamilton, Ontario, and colleagues reported online in CMAJ.
In unadjusted data from the trials, earlier surgery also reduced risk of inhospital pneumonia (RR 0.59, P=0.02) and pressure sores (RR 0.48, P<0.001).
Action Points
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■Explain to interested patients that minimizing delays in surgery for hip fracture may improve survival and reduce complications among older patients.
■Note that their postoperative complication findings might have been subject to publication bias since only studies with mortality data were included in the meta-analysis.
These results support guidelines recommending that surgery occur within 24 hours of hip fracture, which studies have shown leads to better functional outcomes and lower mortality and complications that can arise from prolonged bed rest, such as pressure sores, deep vein thrombosis, and urinary tract infections.
"However, those favoring a delay believe it provides the opportunity to optimize patients' medical status, thereby decreasing the risk of perioperative complications," the researchers noted.
The debate has also been fueled by the lack of consensus on what constitutes early surgery -- within 24, 48, or 72 hours, or even longer, they added.
Their meta-analysis included 16 observational studies with a total of 13,478 patients 60 or older who had had surgery for a low-energy hip fracture and for whom there was complete mortality data. Among these patients, 1,764 died.
The studies ranged in quality and size. Most used 24 hours as the threshold for an "unacceptable" operative delay, but five used 48 hours, one used 72 hours, and one used five days as the cutoff.
These thresholds were counted from time of injury to surgery in five but from the time of admission to surgery in the rest.
In the eight studies that reported reasons for delayed surgery, the most common were unavailability of an operating room or surgical personnel and investigation and stabilization of the patient's preoperative medical condition.
Earlier surgery (within whatever cutoff a study used) was associated with a 45% lower overall risk of death from any cause in the unadjusted data available from all the studies compared with later surgery (RR 0.55, P<0.001).
Leaving out a single study that looked only at medically-ill patients eliminated most of the between-study differences and yielded a significant benefit for early surgery for mortality at three to six months as well (RR 0.66, P=0.005).
Adjustment for age, sex, and fitness for surgery using the American Anesthetists Society score attenuated the effect down to a 19% risk reduction for one-year mortality, although the difference was still statistically significant at a P-value of 0.01.
This finding countered arguments that one important reason why mortality appears worse in patients whose surgery is delayed is because they are sicker on admission and more likely to die, the researchers noted.
They cautioned, though, that their postoperative complication findings might have been subject to publication bias since only studies with mortality data were included in the meta-analysis.
Moreover, the meta-analysis could only include available evidence, which was all from observational studies prone to selection, performance, attrition, and detection bias.
"Given the challenges in interpreting observational data, there is a need for additional well-designed prospective studies or a randomized trial to offer clear insights into the effects of early surgery in this patient population," they concluded in the paper.
Simunovic reported having no conflicts of interest to declare.
One co-author reported having received research grants from Smith and Nephew, Stryker, DePuy, Zimmer, the Canadian Institutes for Health Research, the Osteosynthesis and Trauma Care Foundation, the AO (Arbeitsgemeinschaft für Osteosynthesefragen) Foundation, the National Institutes of Health, the U.S. Department of Defense and the Orthopedic Trauma Association.
Primary source: CMAJ
Source reference:
Simunovic N, et al "Effect of early surgery after hip fracture on mortality and complications: Systematic review and meta-analysis" CMAJ 2010.
http://tinyurl.com/32gstze
1 comment
Joy E. Dill, RN (Retired) - Sep 14, 2010
Hip fractures used to be regarded as emergencies. I have been called out for hip surgery at 2:00AM.
The rule then was, "Nail 'em on arrival at the hospital"
'When I was a young RN the standard was "Buck's traction" for as long as it took to heal the Fx.
Usually the patient expired of pneumonia within a week. That's when it was decided to fix them as soon as possible.
A friend of mine went to a small hospital that did hip surgery at their convenience. Three days later the surgery was done. The next afternoon she was ambulated and dropped dead.
An old fashioned PE had struck! This was a healthy elderly lady and delayed surgery was, actually, the major cause of death. Splint them where they lie, then nail them ASAP. Save lives.
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