BACKGROUND: Approximately 300,000 hip fractures occur yearly within the US. This number is projected to double by 2050. Mortality/Complication rates for all patients with hip fractures approach 30%. In spite of the high complication rate associated with hip fractures in the elderly, surgical repair of these fractures is often undertaken at night. Multiple studies have found that work done at night is more likely to result in complications. There is, however, little evidence regarding the effect of the time of day on the outcome of surgical repair of hip fractures. We present a retrospective study comparing the outcomes of surgery for hip fractures based on the time of day of surgery. Our hypothesis was that hip fracture patients who have surgery in the evening or night have worse outcomes than those who have surgery during the day.
METHODS: A retrospective study of 1552 consecutive patients with a diagnosis of intertrochanteric, subtrochanteric, or femoral neck fracture from 2005 to 2010. 860 pts met the inclusion criteria (age?50 years old, isolated injury, and surgical treatment of the fracture). Surgeries were grouped by time of surgical incision into an AM group (07:00 - 15:59) and a PM group (16:00 - 06:59). Records were analyzed for age, comorbidities, ASA score, 30-day mortality, re-admission, re-operation, time to surgery, procedure length, total time in the operating room (OR), intra-operative fracture, and medical complications (myocardial infarction, cardiac event, stroke, central nervous system event, pneumonia, urinary tract infection, post-operative wound infection, bleeding requiring transfusion of 3 or more red blood cell units).
RESULTS: 860 patients met the inclusion criteria. 660 patients underwent surgery in the time period designated as the AM group. 200 patients underwent surgery in the time period designated as the PM group. There was no statistical difference between the groups regarding age, ASA score, Charlson comorbidity index, gender, or fracture type. The overall 30-day mortality was 7.8%. The total complication rate was 28%. There was no significant difference found in either 30-day mortality or total complication rate based on the time of day that the surgery was performed (P=0.88 and P=0.86 respectively). This remained unchanged when ASA score, Charlson comorbidity index, and age were taken into account. A multivariate analysis of the risk factors collected was performed to determine which factors did affect outcomes in our study. Age (Odds Ratio=1.034/year), Charlson score (OR= 1.155/point), ASA score (OR=1.405/point), and total OR time (OR=1.688/hour) were all found to predict adverse outcomes. Female gender was found to be protective (OR=0.679). Type of surgery, fracture site, total surgery time, and surgery time of day did not predict adverse outcomes.
CONCLUSION: In our study population, surgical time of day did not affect the 30-day mortality or number of complications. As the number of hip fractures increases, the demands on orthopaedic surgeons will increase as well. Surgical treatment within 48 hours has been shown to reduce morbidity and mortality of hip fractures. Our study shows that operating after hours did not increase the risk of adverse events surrounding surgery. Age, ASA score, Charlson comorbidity index, and total time in the OR were predictive of adverse outcomes. This information may be used to discuss the risks of the surgical repair of hip fractures with patients and their families.