1 Introduction

Hip fracture is one of the most common consequences of a fall in the elderly age group. The incidence of hip fractures in the elderly, especially in elderly women is high. The risk of a 50 year old woman developing a hip fracture in her remaining life is 29%, which is much higher than the equivalent risk of developing a breast cancer, stroke or dementia.¹ In the elderly age group, the usual mechanism of a hip fracture is a low energy trauma caused by a fall. Hip fractures are an important cause of morbidity and mortality in the elderly population, worldwide.^2,3 Mortality in the month following a hip fracture ranges from 5% to 10% and it reaches up to 30% after a year.^4–6 The increase in mortality risk following a hip fracture can persist up to 10 years.¹³ The quality of life also deteriorates rapidly following a hip fracture. Literature shows that up to 30% of the survivors of hip fracture have a high grade of disability.^4,5,7 The mortality risk in the immediate months following the fracture is high. The in-hospital mortality rates following a hip fracture varies from 3.7% to 12%.^9,10

Guidelines by the American Academy of Orthopaedic Surgeons (AAOS) recommend that surgical management of hip fractures within 48 h may provide better outcomes.⁸ Time to surgery includes the time from fracture to admission and also the time from admission to surgery. A thorough literature review reveals that most published studies investigating timing of hip fracture study and mortality risk are from the developed world.^14–16 These studies took into account the timing of surgery from the time of admission, without considering the delays in admission. This may be relevant in the developed world, but in developing countries like India, this could be inaccurate due to the delays in admission. To our knowledge, there has not been any previous published studies finding the relation between timing of hip fracture surgery and mortality in the context of developing countries taking into account the delay in admission. Hence we conducted a retrospective observational study to analyze the relationship between timing of surgery from the occurrence of fracture and in-hospital mortality in a tertiary hospital in Kerala, India

2 Materials and methods

Data of patients reporting to a tertiary hospital with a primary diagnosis of hip fracture between January 1, 2005 and December 31, 2009 were collected. Inclusion criteria were age equal or more than 60 years, intracapsular neck of femur fracture and intertrochanteric fracture. The exclusion criteria were age below 60 years, those with other fractures besides a hip fracture, and conservatively treated patients.

We defined timing of surgery as the duration of time from occurrence of the fracture to the surgery. According to this, early surgery was defined as when done within 48 h and delayed surgery when done after 48 h of occurrence of the fracture. Clinical and operative records were reviewed to note demographic parameters, timing of fracture and subsequent surgery, type of surgery performed, co-morbidities, length of hospital stay and cause of death in cases of mortality.

Charlson comorbidity Index (CCI)²¹ was calculated to assess the comorbidity burden for each patient. All data were analyzed using SPSS software for windows (version 22, SPSS Inc., Illinois, USA). Pearson Chi-square test was used to find out significant associations. Multivariate analysis with in-hospital mortality as the outcome was performed. No potential confounders were found. The level of α for statistical significance was set at 0.05

3 Results

A total of 173 patients were identified. Out of these, 144 patients fulfilled the inclusion criteria. Table 1 shows patient characteristics. The mean age was 77 years (range 60–98 years) and 58.3% (N = 84) were women. The most common type of fracture was intracapsular fracture neck of femur (51.4%; N = 74) and internal fixation was the commonly employed surgical technique (56.9%, N = 82). 40.2% (N = 58) patients received an early surgery.

With regard to in-hospital mortality, 8.3% (N = 12) patients died during their hospital stay. The causes of death were respiratory failure (N = 4; 33%), heart failure (N = 3; 25%), massive internal bleeding (N = 2; 16%), renal failure (N = 2; 16%), and cardiac asystole (N = 1; 8%). Table 2 shows association of various factors with in-hospital mortality. Multivariate analysis showed that timing of surgery was significantly associated with in-hospital mortality. Delay in surgery caused an 8 fold increase in in-hospital mortality (OR: 8.3, 95% CI 1.04–66.64, p = 0.01), whereas age, gender, fracture type and active medical problems or comorbidity burden as measured by Charlson comorbidity index were not found to be associated with in-hospital mortality (Table 2). Fig. 1 shows the comparison of in hospital mortality in the early and delayed surgery groups. Further, the mean duration of hospital stay was 11.05 days (interquartile range 8–13.25 days) for the early surgery group and 16.21 days (interquartile range 11–17 days) for the delayed surgery group. Early surgery decreased the mean duration of hospital stay by 5 days.

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Fig. 1 Timing of surgery and In-hospital mortality (n = 144).

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4 Discussion

As we defined timing of surgery as the duration of time from occurrence of the fracture to the surgery, this includes the time from the fracture to hospital admission as well as the time from admission to the surgery. This would be relevant in the context of developing countries like India where there are potential causes for delay in reporting to hospital. These could be poor socioeconomic status, low health literacy and inadequate access to healthcare. In addition, many patients initially admitted to a hospital may require transfer to another hospital due to lack of orthopaedic surgical capability.

Unlike other conditions like a stroke or an acute myocardial infarction, which has much higher public awareness regarding early recognition and management, hip fracture is seldom recognized as an emergency condition. We believe that even in developed countries, many are unaware of the seriousness of a hip fracture and the importance of an early diagnosis in improving survival, despite the high mortality rates following a hip fracture. In a prospective study conducted in New York by Orosz et al 17% of elderly hip fracture patients reported to hospital after 24 h of the fracture and that the most common reason for the delay was underestimating the seriousness of the injury.¹² A similar study in Canada by Vidal et al found out that 10% of hip fracture patients got admitted in a hospital at least 2 days following the fracture.¹⁸ This shows the low level of awareness of the seriousness of a hip fracture and the importance of early management among people, even in developed countries.

Most patients presenting with a hip fracture are older and usually have comorbidities which may have to be stabilized before they are fit for surgery. The investigations required to diagnose the comorbidities and also the treatment required to make them stable before the surgery may demand time which leads to a delay in surgery. We found that comorbidities namely hypertension, COPD, ischemic heart disease and higher Charlson Comorbidity scores were associated with delay in the time to surgery. Literature also provides evidence that a big part of the delay for the surgeries was to obtain medical clearance for the patient.¹² Pincus et al identified comorbidities like hypertension and diabetes as the major causes of delay in hip fracture surgery and stated that the greater the severity of the comorbidities, longer was the pre-operative wait time.²³ However, even when patients are medically optimized, many patients may still have to wait because of unavailability of orthopaedic surgical capabilities or surgeons. In a study by Orosz et al to evaluate the various causes for delay in surgery for hip fractures on 571 patients, they reported that 123 patients received surgery after 48 h and out of these, 43 patients (35%) were delayed to stabilize their medical conditions whereas 78 patients (63%) received a delayed surgery in spite of being medically fit for surgery, due to the unavailability of surgeons or operating rooms.¹²

Our results reveal a 8 fold increase in the risk of in-hospital mortality for patients receiving surgery after 48 h compared to those who received surgery before 48 h, which was statistically significant (p = 0.01; Table 2). However the other factors, namely, the age at fracture, gender, fracture type, active medical conditions or higher score on Charlson comorbidity index were not associated with in-hospital mortality. Thus, our study finds a significant relation between delay in time from fracture to surgery and increase in the risk of in-hospital mortality.

Vidal et al reported that mortality following a hip fracture was associated with time from fracture to hospital admission as well as time from fracture to surgery.¹⁹ Pincus et al reported that increased pre-operative wait time more than 24 h was associated with increased 30 day mortality risk (6.5% v/s 5.8%; absolute RD, 0.79; 95% CI, 0.23–1.35) and greater risk of complications following the surgery.²³ This could mean that early reporting and management of hip fractures could significantly decrease the mortality risk following the fracture.

From the literature, we also noticed that some studies did not find a statistically significant relation between timing of surgery and mortality.^22,20 This could be probably because these studies were conducted in developed countries with better socioeconomic status, health literacy and better access to healthcare, or because they did not consider the time from occurrence of fracture to admission. Interestingly, some studies analyzing the relationship between timing of surgery and mortality following hip fracture excluded patients who reported to a hospital after 48 h of the fracture.¹¹

There are several limitations for this study. Firstly, being an observational and retrospective study, it is prone to bias when compared to clinical trials.¹⁷ As it is not a multicentric study, the study population was limited. We were also not able to analyze the various causes for delays in the surgery due to the study design we undertook. Even though we cannot generalize our results due to the limitations of our study design, we believe that our findings are similar to the pattern of treatment in many parts of the country. Despite these limitations, we believe that our findings have important implications, particularly with respect to developing countries.

Further studies considering time from fracture to surgery and its relation with mortality need to be done especially in developing countries which face a rise in elderly population. Also, public awareness regarding high mortality risk immediately following a hip fracture and the importance of early detection, reporting and management needs to be improved.

5 Conclusions

Timing of surgery could be a potential risk factor for in-hospital mortality. This could be true not only for our study setting, but other regions and developing countries which share similar healthcare facilities. Based on our results, if the association between timing of surgery and in-hospital mortality is causal, many short term mortalities following a hip fracture in the elderly could be prevented by early reporting of hip fractures and better timing of surgeries. In addition, public awareness regarding the importance of early reporting of hip fractures needs to be improved and the importance of early detection and management should be stressed. Future research should be aimed at analysing the factors determining delayed reporting for hip fractures and its consequences.

Funding

No Funding received for this work.

Conflicts of interest

None.