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Operative Timing of Hip Fracture Surgery:

- Discussion:
  - it has long been recognized that following any significant trauma or elective surgery, the body undergoes a catabolic state, which means that the body's ability to withstand further stress (such as additional surgery) diminishes with time; 
             - add to this, the effect of immobilization due to pain (pressure sores, atelectasis, poor diet) and the cumulative effect of narcotics on the elderly population;
             - the take home message from this theory is that the patient is at their healthiest state on day one and their medical fitness decreases with time.
    - this theory has been supported by multiple studies; 

- Parker MJ, et al (1992): prospective consecutive series of 765 pts w/ proximal femoral frx to determine if the time interval between injury and surgery influenced the outcome;
             - patients in whom surgery had been delayed for medical reasons were excluded;
             - divided the patients into four groups depending on the delay to surgery;
             - analysis of pre- and postoperative characteristics showed the groups to be similar;
             - mortality in the four groups was not significantly different but morbidity was increased by delay, particularly with regard to the incidence of pressure sores;
             - ref: The timing of surgery for proximal femoral fractures.   

- Rogers FB, et al (1995): 
             - to determine the effect of the timing of fracture fixation and the physiologic status on admission of elderly patients with hip fractures from low impact falls on resource utilization and outcome; 
             - patients who were fixed late also had a significantly higher infectious morbidity (p = 0.00469), length of stays (p = 0.0226), and total hospital cost  (p = 0.0001), compared with those fixed early or immediate, despite having no difference in average acuity upon discharge (p = 0.3883);
             - delay in frx fixation, in elderly pts who are physiologically stable on admission, significantly increases M and M and adversely affects resource utilization;
             - ref: Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls. 

- Zuckerman JD, et al (1995): prospectively studied 367 patients who had a frx of the hip, to determine the effect of an operative delay on postoperative complications and on the one-year mortality rate; 
          - when the factors of the patient's age and sex and the number of pre-existing medical conditions were controlled, it was found that an operative delay beyond this period approximately doubled the risk of the patient dying before the end of the first postoperative year; 
          - operative delay of more than 2 days is an important predictor of mortality within 1 yr for elderly pts who have a frx of the hip and who are cognitively intact, able to walk, and living at home before frx;
          - ref: Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip.  

- Beringer TR, et al (1996): to ascertain the influence of surgical delay on outcome after proximal femoral fracture in elderly females 
          - medically fit elderly pts presenting with proximal femoral frx have improved survival with early surgery within 24 hours of admission;
          - ref: Audit of surgical delay in relationship to outcome after proximal femoral fracture.   

- Hoenig H, et al (1997): retrospective medical record review to determine the relationship of surgical repair of acute hip fracture within 2 days of hospital admission; 
           - earlier surgery was associated with a shorter length of hospital stay (5 fewer days, P < .001) w/o a statistically signficant increase in medical complications;
           - patients who ambulated earlier had shorter lengths of stay (6.5 fewer days, P < .001), were more likely to return to the community (OR, 1.45; 95% CL, 1.16, 1.81), and had better 6-month survival (OR, 2.8; 95% CL, 2.06, 3.88), and pts younger than 85 yrs  had fewer in-hospital complications (11% vs 4%, P < .001);
           - authors found that surgical repair within the first 2 days of hospitalization and more than 5 PT/OT sessions per week were associated with better health outcomes in a nationally representative sample of elderly patients with hip fracture; 
           - ref: What is the role of timing in the surgical and rehabilitative care of community-dwelling older persons with acute hip fracture? 

- Fox HJ, et al (1994): 142 consecutive patients with proximal femoral fractures were audited prospectively over a 1-year period; 
           - potential to improve outcome in proximal femoral fractures by stabilizing fractures within 24 h, adopting measures additional to antibiotic prophylaxis to reduce infection and ensuring that patients do not develop pressure sores; 
           - ref: Factors affecting the outcome after proximal femoral fractures.  

- Hamlet WP, et al (1997):
           - purpose of the study was to determine relationship of preop health status and time to surgery to mortality and late functional outcome in hip frx patients; 
           - overall mortality was 14% at 1 year, which rose to 26% at 2 years, and 33% at 3 years;
           - 3-year mortality was significantly less for ASA I and II patients (23%) than for ASA III, IV, and V patients (39%);
           - significant difference in mortality between patients having surgery within 24 hours of admission (20%) and those having surgery beyond 24 hours (50%);
           - in ASA I and II patients, the relative risk of death was 4.5 times greater if surgery occurred after 24 hours from admission. 
           - ref: Influence of health status and the timing of surgery on mortality in hip fracture patients.   

- references:
           - Current Concepts Review.  Timing of Operative Treatment of Fractures in Patients Who Have Multiple Injuries.
           - Early versus delayed stabilization of femoral fractures. A prospective randomized study.
           - The timing of surgery for proximal femoral fractures.
           - Intracapsular pressure and caput circulation in nondisplaced femoral neck fractures.
           - Significance of urgent (within 6h) internal fixation in the management of fractures of the neck of the femur.
           - The influence of immediate surgical treatment of proximal femoral fractures on mortality and quality of life. Operation within six hours of the fracture versus later than six hours.  
           - Morbidity and mortality after hip fracture: the impact of operative delay
           - Delayed fixation of displaced femoral neck fractures in younger adults  
           - Early Operation on Patients with a Hip Fracture Improved the Ability to Return to Independent Living. A Prospective Study of 850 Patients.
           - Morbidity and mortality among patients with hip fractures surgically repaired within and after 48 hours.
           - The effects of time-to-surgery on mortality and morbidity in patients following hip fracture.
           - Association of timing of surgery for hip fracture and patient outcomes.
           - Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur.
           - Does delay to theatre for medical reasons affect the peri-operative mortality in patients with a fracture of the hip?
           - The Role of Preoperative Cardiac Investigation in Emergency Hip Surgery