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Hip fracture...Part 3..Why delay repair?

The main reason to delay surgery is to optimize the patient's medical conditions.

Many patients with hip fractures have preexisting chronic diseases such as diabetes, congestive heart failure, coronary artery disease, or anemia. These conditions produce neuropathy, visual impairment, or weakness, which may have contributed to the fall and hip fracture.

In addition, an elderly patient who is found on the floor at home with a fractured hip may have been there a long time without access to food or water, predisposing him or her to dehydration, electrolyte disturbances, and rhabdomyolysis with renal failure.

Any of these conditions, if not assessed, treated, or stabilized preoperatively, may lead to perioperative complications such as myocardial ischemia and infarction, delirium, and nutritional compromise.

These complications increase in-hospital and overall mortality and also lead to a delay in weight-bearing and rehabilitation.Therefore, a delay in surgical intervention of 24 to 48 hours after admission is advocated to correct metabolic disturbances and to optimize chronic medical conditions, which may improve overall outcomes.

In contrast to prior studies noting increased mortality with operative delay, recent studies noted no significant difference in mortality rates after immediate hip fracture repair vs delayed repair after controlling for the severity of medical conditions.

In a retrospective analysis of 406 patients with proximal femoral fractures, Kenzora et al noted a higher 1-year mortality rate after operative repair on the first hospital day compared with the second through fifth hospital days (34% vs 5.8%, P < .00001); this difference remained significant in the subgroup with three or fewer medical problems.
 No explanations for delays in surgery were given, but the authors postulated that physiologic changes induced by a fractured hip, such as immobilization, dehydration, and other metabolic disturbances, coupled with the stress of surgery itself, contributed to the increased mortality with early repair.
Harries and Eastwood noted no difference in short-term outcome if surgery was delayed to optimize the patient's medical condition.

Zagrodnick and Kaufner noted a lower in-hospital mortality rate (18.9% vs 9.1%) with preoperative stabilization of medical conditions.

The largest study to date regarding the timing of surgery was done by Grimes et al, who retrospectively evaluated 8,383 patients with hip fractures operatively repaired between 1983 and 1993. Delaying surgery more than 24 hours from admission was associated with a higher long-term mortality rate in unadjusted analyses compared with prompt surgery (ie, < 24 hours from admission). However, when adjusted for demographic variables and for severity of underlying medical problems, no significant association was found. Mortality at 30 days and postoperative morbidity measures were similar, although those who underwent delayed surgery had twice the risk of developing decubitus ulcers.
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