Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis

Abstract

We aimed to assess the impact of timing of surgery in elderly patients with acute hip fracture on morbidity and mortality. We systematically searched MEDLINE, the Cochrane Library, Embase, PubMed, and trial registries from 01/1997 to 05/2017, as well as reference lists of relevant reviews, archives of orthopaedic conferences, and contacted experts. Eligible studies had to be randomised controlled trials (RCTs) or prospective cohort studies, including patients 60 years or older with acute hip fracture. Two authors independently assessed study eligibility, abstracted data, and critically appraised study quality. We conducted meta-analyses using the generic inverse variance model. We included 28 prospective observational studies reporting data of 31,242 patients. Patients operated on within 48 hours had a 20% lower risk of dying within 12 months (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.66-0.97). No statistical significant different mortality risk was observed when comparing patients operated on within or after 24 hours (RR 0.82, 95% CI 0.67-1.01). Adjusted data demonstrated fewer complications (8% vs. 17%) in patients who had early surgery, and increasing risk for pressure ulcers with increased time of delay in another study. Early hip surgery within 48 hours was associated with lower mortality risk and fewer perioperative complications.

Figure 1

PRISMA flow chart.

Figure 2

Effects of early and delayed surgery on short- and long-term mortality using 48 hours and 24 hours as cut-offs (summary of results of random-effects meta-analyses and sensitivity analysis).

Figure 3

Perioperative complications (adjusted and unadjusted data); Mariconda 2015: effect estimate presented is odds ratio (OR) not RR and based on adjusted data so no event rates displayed; Abbreviations: CI: confidence interval.

Figure 4

Pneumonia, pressure ulcers, urinary tract infection, thromboembolic events (unadjusted data); Abbreviations: CI: confidence interval.

Figure 5

Cut-off 48 hours - short- and long-term mortality adjusted and sensitivity analyses incl. unadjusted data.

Figure 6

Cut-off 36 hours - short- and long-term mortality adjusted and sensitivity analyses incl. unadjusted data.

Figure 7

Cut-off 24 hours - short- and long-term mortality adjusted and sensitivity analyses incl. unadjusted data.

Figure 8

Cut-off 18 hours - short- and long-term mortality adjusted and unadjusted data (not pooled).

Figure 9

Cut-off 12 hours - short- and long-term mortality adjusted and unadjusted data (not pooled).

Figure 10

Cut-off 6 hours - short- and long-term mortality adjusted and unadjusted data.

Figure 11

Cut-off 72 hours - short- and long-term mortality adjusted and unadjusted data.