Abstract OBJECTIVE:
To study the differences in outcomes of early versus delayed surgery in patients with intertrochanteric fractures.  METHODS:
The retrospective chart review was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients who underwent surgery for intertrochanteric hip fractures from 2005 to 2010. A gap of \u3e48hours between the event and the surgery was considered a delayed procedure and its impact on outcome was assessed.  RESULTS:
Of the 190 patients, 138(72.6%) were in the early group and 52(27.3%) in the delayed group. The most common cause for delay of surgery was electrolyte imbalance in 14(27%) patients. Patients with delayed surgery had more comorbidites and higher ASA grades compared to those that underwent early surgery (p  CONCLUSIONS:
In patients with multiple comorbid conditions, expedited optimisation for surgery may be warranted to reduce mortality

Kumar, Santosh

Noordin, Shahryar

Rashid, Rizwan Haroon

Shah, Adil Aijaz

Shakoor, Amarah

English

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryNovember 2015Do delays in surgery affect outcomes in patientswith inter-trochanteric fractures?Adil Aijaz ShahSantosh KumarAga Khan UniversityAmarah ShakoorAga Khan UniversityRizwan Haroon RashidAga Khan University, rizwan.haroonrashid@aku.eduShahryar NoordinAga Khan University, shahryar.noordin@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surgRecommended CitationShah, A., Kumar, S., Shakoor, A., Rashid, R., Noordin, S. (2015). Do delays in surgery affect outcomes in patients with inter-trochanteric fractures?. JPMA: Journal of the Pakistan Medical Association, 65(11), S21-s24.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/582IntroductionHip fracture is defined as a fracture occurring in the areabetween the lower edge of the femoral head and 5cmbelow the lesser trochanter.1 It is quite predictably amatter of global public health concern with 1.6 billion hipfractures being reported worldwide each year.2 Most ofthese fractures occur in the elderly who are alreadysuffering from multiple comorbid conditions. Statistically,in the United States, the incidence of hip fractures is 63per 100,000 per year in females and 34 per 100,000 peryear in males.3The anatomical classification of hip fractures includesneck of femur fracture, intertrochanteric fracture andsubtrochanteric fracture. The neck of femur fracture istermed intracapsular, while intertrochanteric andsubtrochanteric fractures are termed extracapsularfractures.4 When one delves deeper into the causes of hipfractures, one finds that almost 95% relate to fall, 2% aredue to road traffic accidents (RTAs) and <2% arepathological fractures consequent of a metabolicdisease.5 Hip fractures are associated with advancing age,increased number of comorbid conditions, such ashypertension (HTN), uncontrolled diabetes, urinary tractinfection (UTI) and other causes, and increaseddependency on others when performing activities of dailylife. The usual patient classically presents with hip pain,inability to bear weight, shortening of the limb and anexternally rotated foot.6Given the predominant age group that hip fractures occurin, they are understandably associated with significantmorbidity, mortality and disability. It has been found thathip fractures in the elderlyhaving dementia are associatedwith 5% inpatient mortality and 10% mortality within30% days of hospital admission.7 The time lag betweenthe fracture and obtaining surgery is a crucial factoraffecting the overall prognosis of the patient. Accordingto the National Institute for Health and Clinical Excellence(NHS) guidelines for the management of hip fracture, it isrecommended that surgery should be ideally performedon the day of admission or the day after admission.Comorbidities should be identified immediately so thatsurgery is not delayed beyond 48 hours.8The current study was planned to toassess the differencesin the outcome of early versus delayed surgery in patientswith intertrochanteric fractures.Materials and MethodsThe retrospective chart review was conducted at AgaKhan University Hospital (AKUH), Karachi,and comprisedVol. 65, No.11 (Suppl. 3), November 201529th Pak Orthocon 2015 S-21ORIGINAL ARTICLEDo delays in surgery affect outcomes in patients with inter-trochantericfractures?Adil Aijaz Shah,1 Santosh Kumar,2 Amarah Shakoor,3 Rizwan Haroon,4 Shahryar Noordin5AbstractObjective: To study the differences in outcomes of early versus delayed surgery in patients with intertrochantericfractures.Methods: The retrospective chart review was conducted at Aga Khan University Hospital, Karachi, and compriseddata of patients who underwent surgery for intertrochanteric hip fractures from 2005 to 2010. A gap of >48hoursbetween the event and the surgery was considered a delayed procedure and its impact on outcome was assessed.Results: Of the 190 patients, 138(72.6%) were in the early group and 52(27.3%) in the delayed group. The mostcommon cause for delay of surgery was electrolyte imbalance in 14(27%) patients. Patients with delayed surgeryhad more comorbidites and higher ASA grades compared to those that underwent early surgery (p<0.05). Inpatientmortality was significantly higher in the delayed group (p=0.006). Multivariate analysis showed that highermortalitywas associated with delay in surgery.Conclusions: In patients with multiple comorbid conditions, expedited optimisation for surgery may be warrantedto reduce mortality.Keywords: Intertrochanteric fracture, Comorbid conditions, Early group, Delayed group, Mortality.(JPMA 65: S-21 (Suppl. 3); 2015)1Trauma outcomes Research fellow, Center for Surgery and Public Health,Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA,2,4Department of Surgery, 3Medical Student, 5Department of OrthopedicSurgery, Aga Khan Medical University Hospital, Karachi, Pakistan.Correspondence: Rizwan Haroon. Email: orthopodriz@gmail.comdata of patients who presented with intertrochanteric hipfractures and underwent a dynamic hip screw fixationbetween January 2005 and December 2010. Those withpathological hip fractures, poly-trauma patients andpatients with missing records were excluded. Earlysurgeries were defined to be those performed within 48hours of presentation, while delayed surgeries were thoseperformed after 48 hours.9 The study population wasdivided into two groups: early surgical repair group versusdelayed surgical repair group.Descriptive analysis was done to study variables such asage, gender, comorbid conditions, American Society ofAnaesthesiologists(ASA) grade and their relation tosurgery outcomes based on how much time delay eachpatient faced before undergoing optimisation andsubsequent surgical management.ResultsOf the 190 patients, 138(72.6%) were in the early groupand 52(27.3%) in the delayed group. In the early groupthere were 66 (48%) females and 72 (52%) males. In thedelayed group there were 28 (54%) females and 24 (46%)males.In the early group, 54 (39%) patients had no comorbidconditions, while 46 (33%) showed multiplecomorbidities. In the delayed surgery group, 36 (69%)patients hadmultiple comorbid conditions (p<0.05). Mostpatients in the early group were ASA level II and III, whilein the delayed group the majority of patients were ASAlevel III and IV (p<0.05) (Table-1).In the pre-injury functional class status, majority ofpatients in the early group were functional Class I and II,while delayed group patients were in functional Class IIIwith 26 (50%) patients performing daily activities onlywith external help. In the early group 83 (60%) patientswere given general anaesthesia, while in the delayedgroup regional anaesthesia was utilised in 29 (55%)patients (p<0.05).When observing time of surgery in bothgroups, 79 (57%) surgeries in the early group and 34 (65%)in the delayed group took place during the daytimeworking hours.The most common cause for delay of surgery waselectrolyte imbalance, which was seen in 51 (27%)patients. A further 32 (17%) patients had delayed surgerybecause of the need for optimisation for other diseases,such as thyrotoxicosis, combined HTN and diabetesmellitus (DM), and UTI with DM.Around 4 (3%) patients in the early groupdeveloped UTIpost-operatively compared to 4 (8%) in the delayed group(p>0.05). Wound infection was seen in 3 (2%) patients inthe early group compared to 3 (5%) in the delayed group(p>0.05) (Table 2). Around 2 (1%) patients in the earlygroup did not survive compared to 5 (10%) in the delayedgroup (p<0.05). Multivariate analysis showed that delay insurgery was an independent predictor for mortality(p<0.05).DiscussionHip fractures represent an increasingly importanthealthcare concern as they are associated with significantmorbidity and mortality and show a disturbinglyescalating incidence in the elderly population.10 Patientfactors associated with a speedy recovery and regainingmost of the pre-fracture walking ability after surgeryinclude male gender, young age, absence of pre-existingdementia and use of a walking cane before theinjury.11Other factors relating to an uneventful recovery includefactors such as delay in surgery, surgical technique, post-op care and rehabilitation. Despite all efforts, themortality rate within elderly patients within the first yearof fracture repair is reported tobe as high as 14-36%.12Generally, an increased mortality rate is seen in patientssuffering frommultiple risk factors such as advancing age,male gender, poorly-controlled medical conditions,psychiatric issues and nursing home institutionalisation.13However, out of all the risks posing threat to the patient, afew can be very well controlled by the efforts of theprimary surgical team alone. These include avoidingoperative management before stabilisation of coexistingmedical conditions without causing undue delays andminimising postoperative complications with goodpostoperative care and rehabilitation. Although most ofJ Pak Med Assoc (Suppl. 3)S-22 29th Pak Orthocon 2015Table-1: American Society of Anaesthesiologists (ASA) level.P= 0.004 ASA Level TotalI II III IVEarly Group 15 59 59 5 138Delayed Group 1 10 30 11 52Total 16 69 89 16 190Table-2: Postoperative Complications.Postoperative complicationsUTI DVT Wound Infection MortalityEarly Group (n=138) 4 0 3 1Delayed Group (n=52) 4 1 3 5P value 0.144 0.27 0.20 0.006Total (n=190) 8 1 6 6UTI: Urinary tract infectionDVT: Deep vein thrombosis.these factors are universally agreed upon, but surgeonsoften find it difficult to decide how much of a surgicaldelay is acceptable in favour of initial medicaloptimisation of existing comorbid conditions.There is an inconsistent perception that delay in surgicaltreatment of hip fracture patients is associated with anincrease in postoperative complications and mortality.Some surgeons perceive that the standard of careregarding hip fracture management involves operatingwithin 24 hours of presentation, while others operate on acase to case basis.14 Many, however, agree that surgerymust be attempted at most within 48 hours ofpresentation for every patient without any medical co-morbid conditions.15,16 Our study also shows lowmortality maybe among patients who underwent surgicalfixation within 48 hours of admission. However, studiescomparing time to surgery and mortality have generallyhad conflicting results.17-22 These studies usually hadsmall sample sizes and, hence, their results cannot begeneralised.Grimes et al.23 in their retrospective study ofapproximately 8380 patients undergoing surgical hipfracture fixation concluded that delay in surgery seemedto have no adverse effect on patient outcomes if theirmedical illnesses were adjusted for. This study exploredboth the primary outcomes in the form of long-termmortality and secondary outcomes as 30-day patientmortality, decubitus ulcers, bacterial infections,myocardial infections and thrombo-embolism. Data wasadjusted for medical illnesses which revealed thatsurgical delay had no effect on patient outcomes apartfrom developing decubitus ulcers. This is in sharpcontrast to our study results with a much smaller samplesize which showed that surgical delay is indeedassociated with postoperative complications and ahigher rate of mortality when compared to patients inthe early surgical group.However, unlike conventional assumptions, surgical delayis not a measure of comorbidity or a higher ASA grade.Our study has recognized surgical delay as anindependent factor leading to poor outcomes for a hipfracture surgery patient independent of ASA grade andmedical comorbid conditions. In patients with severalcomorbid conditions, expedited optimisation for surgerymay be warranted to reduce mortality.The limitations of our study include a retrospective designwith small sample size and limited follow-up. Futureprospective studies need to study outcomes of thesepatient cohorts from both early and delayed surgerycategories. As high-risk patients tend to be optimisedprior to surgery, the bias may explain the potential ofhigher mortality in the delayed surgery group.ConclusionDelay in surgery is associated with increased mortalityand postoperative complications leading to a difficultrehabilitation period and significant morbidity. Patientswith intertrochanteric fractures should be optimised ona priority basis in order to mitigate the risk of morbidityand high rate of mortality. Patients who are operatedafter 48 hours have a higher 30-day mortality comparedto those who are operated within 48 hours ofadmission. This association is independent of comorbidconditions and ASA grade. Further large-scaleprospective studies need to clarify these potentialassociations so that hip fracture surgery guidelines canbe made evidence-based.References1. Gillespie WJ. Extracts from "clinical evidence": hip fracture. BMJ2001;322:968-75.2. Johnell O, Kanis JA. An estimate of the worldwide prevalence anddisability associated with osteoporotic fractures. Osteoporos Int2006;17:1726-33.3. LaVelle DG. Chapter 52 - Fractures and Dislocations of the Hip. In:Canale ST, Beaty JH, eds. Campbell's Operative Orthopaedics. 11thed. Philadelphia, PA: Mosby; 2007.4. Haentjens P, Autier P, Barette M, Venken K, Vanderschueren D,Boonen S, et al. Survival and functional outcome according to hipfracture type: a one-year prospective cohort study in elderlywomen with an intertrochanteric or femoral neck fracture. Bone2007;41:958-64.5. Fuller GF. Falls in the elderly. Am Fam Physician 2000;61:2159-68.6. Christmas C. Hip Fracture. Ann Intern Med 2011;155:ITC6-1.doi:10.7326/0003-4819-155-11-201112060-01006.7. Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E.Patient risk factors, operative care, and outcomes among oldercommunity-dwelling male veterans with hip fracture. J Bone JointSurg Am 2008;90:34-42.8. Chesser TJ, Handley R, Swift C. New NICE guideline to improveoutcomes for hip fracture patients. Injury 2011;42:727-9.9. Verbeek DOF, Ponsen KJ, Goslings JC, Heetveld MJ. Effect ofsurgical delay on outcome in hip fracture patients: a retrospectivemultivariate analysis of 192 patients. Int Orthop 2008;32:13-18.10. Koval KJ, Zuckerman JD. Hip fractures are an increasinglyimportant public health problem. Clin Orthop Relat Res1998;348:2.11. Koval KJ, Zuckerman JD. Functional recovery after fracture of thehip.J Bone Joint Surg Am 1994;76:751-8.12. Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluationand treatment of femoral neck fractures. J Am Acad Orthop Surg1994;2:141-149.13. White BL, Fisher WD, Laurin CA. Rate of mortality for elderlypatients after fracture of the hip in the 1980's. J Bone Joint SurgAm 1987;69:1335-1340.14. March LM, Chamberlain AC, Cameron ID, Cumming RG, BrnabicAJ, Finnegan TP, et al. How best to fix a broken hip. Fractured Neckof Femur Health Outcomes Project Team. Med J Aust1999; 170:489-494.15. Lyons AR. Clinical outcomes and treatment of hip fractures. Am JMed 1997;103(Suppl 1):S51-S63.Vol. 65, No.11 (Suppl. 3), November 201529th Pak Orthocon 2015 S-2316. Morrison RS, Chassin MR, Siu AL. The medical consultant's role incaring for patients with hip fracture. Ann Intern Med 1998;128(Pt1): 1010-1020.17. Hamlet WP, Lieberman JR, Freedman EL, Dorey FJ, Fletcher A,Johnson EE. Influence of health status and the timing of surgeryon mortality in hip fracture patients. Am J Orthop (Belle Mead NJ)1997; 26: 621-7.18. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracturemortality. Relation to age, treatment, preoperative illness, timeof surgery, and complications. ClinOrthopRelat Res 1984; 186:45-56.19. Ho V, Hamilton BH, Roos LL. Multiple approaches to assessing theeffects of delays for hip fracture patients in the United States andCanada. Health Serv Res 2000; 34: 1499-1518.20. Hamilton BH, Hamilton VH, Mayo NE. What are the costs ofqueuing for hip fracture surgery in Canada? J Health Econ 1996;15: 161-185.21. Dolk T. Operation in hip fracture patients - analysis of the timefactor. Injury 1990; 21: 369-372.22. Davis TR, Sher JL, Porter BB, Checketts RG. The timing of surgeryfor intertrochanteric femoral fractures. Injury 1988; 19: 244-246.23. Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effectsof time-to-surgery on mortality and morbidity in patientsfollowing hip fracture. Am J Med 2002; 112: 702-9.J Pak Med Assoc (Suppl. 3)S-24 29th Pak Orthocon 2015

Do delays in surgery affect outcomes in patients with inter-trochanteric fractures?

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Do delays in surgery affect outcomes in patients with inter-trochanteric fractures?

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