Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators.
BACKGROUND
We hypothesized that undergoing surgery as soon as possible reduces early mortality in patients with a proximal femoral fracture. Our aim was to evaluate the association between surgical delay and early mortality in these patients.


METHODS
We performed a retrospective analysis of prospectively collected data from the Danish Fracture Database and the Civil Registration System on patients who were fifty years of age or older and had undergone surgery for a proximal femoral fracture. Femoral head fracture (classified as OTA/AO 31C per the OTA/AO classification system), high-energy trauma, pathological fractures, multiple fractures, and surgeries performed with implants not commonly used were excluded. End points were adjusted odds ratios for thirty-day and ninety-day mortality.


RESULTS
For the 3517 surgeries included in this study, the median patient age was 82.0 years (range, fifty-one to 107 years), 2458 patients (70%) were female, and 1720 surgeries (49%) were performed because of a trochanteric fracture. Within twelve hours, 722 of the surgeries (21%) had been performed; within twenty-four hours, 2482 surgeries (71%); within thirty-six hours, 3024 surgeries (86%); within forty-eight hours, 3242 surgeries (92%); and within seventy-two hours, 3353 surgeries (95%). Unsupervised surgeons with an education level below that of an attending surgeon performed the surgery in 1807 (51%) of all cases. The thirty-day mortality was 380 (10.8%) and the ninety-day mortality was 612 (17.4%). The risk of thirty-day mortality increased with a surgical delay of more than twelve hours (odds ratio, 1.45; p = 0.02), more than twenty-four hours (odds ratio, 1.34; p = 0.02), and more than forty-eight hours (odds ratio, 1.56; p = 0.02); the risk of ninety-day mortality increased with a surgical delay of more than twenty-four hours (odds ratio, 1.23; p = 0.04). An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality (odds ratio, 1.28; p = 0.035) and ninety-day mortality (odds ratio, 1.26; p = 0.016). Increasing American Society of Anesthesiologists score and male sex significantly increased both thirty-day and ninety-day mortality.


CONCLUSIONS
In this study, a surgical delay of more than twelve hours significantly increased the adjusted risk of thirty-day mortality and a surgical delay of more than twenty-four hours significantly increased the adjusted risk of ninety-day mortality. The adjusted risk of both thirty-day and ninety-day mortality increased significantly when the education level of the surgeon was below that of an attending surgeon. The study findings challenge orthopaedic departments to facilitate fast surgical treatment supported by attending orthopaedic surgeons.
Department of Orthopaedic Surgery (A.M.N., K.G., H.P., and A.T.) and Clinical Research Centre (T.K.), Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark. E-mail address for A.M. Nyholm: rienyholm@gmail.com.
Anne Marie
AM
Nyholm
Department of Orthopaedic Surgery (A.M.N., K.G., H.P., and A.T.) and Clinical Research Centre (T.K.), Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark. E-mail address for A.M. Nyholm: rienyholm@gmail.com.
Kirill
K
Gromov
Department of Orthopaedic Surgery (A.M.N., K.G., H.P., and A.T.) and Clinical Research Centre (T.K.), Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark. E-mail address for A.M. Nyholm: rienyholm@gmail.com.
Henrik
H
Palm
Department of Orthopaedic Surgery, Odense University Hospital, Sønder Boulevard 29, DK-5000 Odense C, Denmark.
Michael
M
Brix
Department of Orthopaedic Surgery (A.M.N., K.G., H.P., and A.T.) and Clinical Research Centre (T.K.), Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark. E-mail address for A.M. Nyholm: rienyholm@gmail.com.
Thomas
T
Kallemose
Department of Orthopaedic Surgery (A.M.N., K.G., H.P., and A.T.) and Clinical Research Centre (T.K.), Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark. E-mail address for A.M. Nyholm: rienyholm@gmail.com.
Anders
A
Troelsen
D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D015331:Cohort Studies; D016208:Databases, Factual; D003718:Denmark; D005260:Female; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary / Q000379:methods / Q000401:mortality*; D006620:Hip Fractures / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome