• María T Vidán, Elisabet Sánchez, Yassira Gracia, Eugenio Marañón, Javier Vaquero, and José A Serra.
• Hospital General Universitario Gregorio Marañón, Madrid, Spain. mvidan.hgugm@salud.madrid.org
• Ann. Intern. Med. 2011 Aug 16;155(4):226-33.

BackgroundThe clinical effect of surgical delay in older patients with hip fracture is controversial. Discrepancies among study findings may be due to confounding that is caused by the reason for the delay or a differential effect on patient risk subgroups.ObjectiveTo assess the effect of surgical delay on hospital outcomes according to the cause of delay.DesignProspective cohort study.SettingA hip fracture unit in a university hospital in Spain.Patients2250 consecutive elderly patients with hip fracture.MeasurementsTime to surgery, reasons for surgical delay, adjusted in-hospital death, and risk for complications.ResultsMedian time to surgery was 72 hours. Lack of operating room availability (60.7%) and acute medical problems (33.1%) were the main reasons for delays longer than 48 hours. Overall, rates of hospital death and complications were 4.35% and 45.9%, respectively, but were 13.7% and 74.2% in clinically unstable patients. Longer delays were associated with higher mortality rates and rates of medical complications. After adjustment for age, dementia, chronic comorbid conditions, and functionality, this association did not persist for delays of 120 hours or less but did persist for delays longer than 120 hours (P = 0.002 for overall time effect on death and 0.002 for complications). The risks were attenuated after adjustment for the presence of acute medical conditions as the cause of the delay (P = 0.06 for time effect on mortality and 0.31 on medical complications). Risk for urinary tract infection remained elevated (odds ratio, 1.54 [95% CI, 0.99 to 2.44]). No interaction between delay and age, dementia, or functional status was found.LimitationThis was a single-center study without postdischarge follow-up.ConclusionThe reported association between late surgery and higher morbidity and mortality in patients with hip fracture is mostly explained by medical reasons for surgical delay, although some association between very delayed surgery and worse outcomes persists.Primary Funding SourceNone.

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