International Orthopaedics

, Volume 43, Issue 2, pp 441–448 | Cite as

Reasons for delaying surgery following hip fractures and its impact on one year mortality

  • Alejandro Lizaur-UtrillaEmail author
  • Blanca Gonzalez-Navarro
  • Maria F. Vizcaya-Moreno
  • Francisco A. Miralles Muñoz
  • Santiago Gonzalez-Parreño
  • Fernando A. Lopez-Prats
Original Paper



The purposes of this study were to identify the reasons for delayed surgery following hip fractures and analyze the impact of these reasons on 1-year mortality.


A prospective cohort study of 1234 patients with mean age of 83.1 (range 65–92, SD 8.0) who underwent hip fracture surgery compared three subgroups: (1) surgery within two days from admission (609 patients); (2) delayed surgery for medical reasons (286); and (3) delayed surgery for organizational causes (339). Medical reason was defined as the need of medical optimization of the patient prior to surgery. Pre-operative assessment was performed by the American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), Hodkinson mental status, Katz index for activities of daily living, and Short-Form (SF-12) questionnaire. Univariate analyses were used (chi-square and Fisher exact or Mantel-Haenszel tests for categorical data, and variance analysis, Student t test, or Mann-Whitney U test for continuous data). Logistic regression models were used for influence of variables on complications and one year mortality.


There were no significant differences in complications or one year mortality rates between patients with surgery within two days and those with delayed surgery for medical reasons. However, the patients with delayed surgery for organizational causes had significant higher rates of both complications and one year mortality compared to the other two groups (p = 0.001).


This study suggests that waiting time for hip fracture surgery more than two days was not associated with higher complication or mortality rate if waiting was to stabilize patients with active comorbidities at admission, compared to stable patients at admission with early surgery. Although early surgery within two days from admission is desirable for stable patients at admission, in patients with complex comorbidities, the surgery should be performed once they are optimized. However, the patients with delayed surgery for organizational reasons had a significant higher rate of post-operative complications and one year mortality compared to the other two groups.


Hip fracture Delayed surgery Early surgery Medical reasons Organizational reasons 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was not required by the institutional review board because the study was considered department evaluation.


  1. 1.
    Hu F, Jiang C, Shen J, Tang P, Wang Y (2012) Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis. Injury 43:676–685. CrossRefGoogle Scholar
  2. 2.
    Shiga T, Wajima Z, Ohe Y (2008) Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth 55:146–154. CrossRefGoogle Scholar
  3. 3.
    Anthony CA, Duchman KR, Bedard NA, Gholson JJ, Gao Y, Pugely AJ, Callaghan JJ (2017) Hip fractures: appropriate timing to operative intervention. J Arthroplast 32:3314–3318. CrossRefGoogle Scholar
  4. 4.
    Cha YH, Ha YC, Yoo JI, Min YS, Lee YK, Koo KH (2017) Effect of causes of surgical delay on early and late mortality in patients with proximal hip fracture. Arch Orthop Trauma Surg 137:625–630. CrossRefGoogle Scholar
  5. 5.
    National Institute for Health and Care Excellence (2011). NICE clinical guideline 124. The management of hip fractures in adults. Modified March 2014.
  6. 6.
    Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL (2002) The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med 112:702–709. CrossRefGoogle Scholar
  7. 7.
    Moran CG, Wenn RT, Sikand M, Taylor AM (2005) Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am 87:483–489. Google Scholar
  8. 8.
    Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM (2009) Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg (Br) 91:922–927. CrossRefGoogle Scholar
  9. 9.
    Lund CA, Møller AM, Wetterslev J, Lundstrøm LH (2014) Organizational factors and long-term mortality after hip fracture surgery: a cohort study of 6143 consecutive patients undergoing hip fracture surgery. PLoS One 9:e99308. CrossRefGoogle Scholar
  10. 10.
    Hagino T, Ochiai S, Senga S, Watanabe Y, Wako M, Ando T, Haro H (2015) Efficacy of early surgery and causes of surgical delay in patients with hip fracture. J Orthop 12:142–146. CrossRefGoogle Scholar
  11. 11.
    Orosz GM, Hannan EL, Magaziner J, Koval K, Gilbert M, Aufses A, Straus E, Vespe E, Siu AL (2002) Hip fracture in the older patient: reasons for delay in hospitalization and timing of surgical repair. J Am Geriatr Soc 50:1336–1340. CrossRefGoogle Scholar
  12. 12.
    Sheehan KJ, Sobolev B, Villán Villán YF, Guy P (2017) Patient and system factors of time to surgery after hip fracture: a scoping review. BMJ Open 7:e016939. CrossRefGoogle Scholar
  13. 13.
    Switzer JA, Bennett RE, Wright DM, Vang S, Anderson CP, Vlasak AJ, Gammon SR (2013) Surgical time of day does not affect outcome following hip fracture fixation. Geriatr Orthop Surg Rehabil 4:109–116. CrossRefGoogle Scholar
  14. 14.
    Lizaur-Utrilla A, Calduch Broseta JV, Miralles Muñoz FAS, Segarra Soria M, Diaz Castellano M, Andreu Gimenez L (2014) Eficacia de la asistencia compartida entre cirujanos e internistas para ancianos con fractura de cadera. Med Clin 143:386–391. CrossRefGoogle Scholar
  15. 15.
    American Society of Anesthesiologists (2008) Relative value guide. Online
  16. 16.
    Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47:1245–1251. CrossRefGoogle Scholar
  17. 17.
    Hodkinson HM (1972) Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 4:233–238. CrossRefGoogle Scholar
  18. 18.
    Katz S, Ford A, Moskowitz R, Jackson B, Jaffe M (1963) Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychological function. JAMA 185:914–919. CrossRefGoogle Scholar
  19. 19.
    Ware JE Jr, Kosinski M, Keller SD (1996) A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34:220–233. CrossRefGoogle Scholar
  20. 20.
    Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, Bhandari M (2010) Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ 182:1609–1616. CrossRefGoogle Scholar
  21. 21.
    Rodriguez-Fernandez P, Adarraga-Cansino D, Carpintero P (2011) Effects of delayed hip fracture surgery on mortality and morbidity in elderly patients. Clin Orthop Relat Res 469:3218–3221. CrossRefGoogle Scholar
  22. 22.
    Yonezawa T, Yamazaki K, Atsumi T, Obara S (2009) Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients. J Orthop Sci 14:566–573. CrossRefGoogle Scholar
  23. 23.
    Bohm E, Loucks L, Wittmeier K, Lix LM, Oppenheimer L (2015) Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority. Can J Surg 58:257–263. CrossRefGoogle Scholar
  24. 24.
    Fantini MP, Fabbri G, Laus M, Carretta E, Mimmi S, Franchino G, Favero L, Rucci P (2011) Determinants of surgical delay for hip fracture. Surgeon 9:130–134. CrossRefGoogle Scholar
  25. 25.
    Forni S, Pieralli F, Sergi A, Lorini C, Bonaccorsi G, Vannucci A (2016) Mortality after hip fracture in the elderly: the role of a multidisciplinary approach and time to surgery in a retrospective observational study on 23,973 patients. Arch Gerontol Geriatr 66:13–17. CrossRefGoogle Scholar
  26. 26.
    Li Y, Lin J, Wang P, Yao X, Yu H, Zhuang H, Zhang L, Zeng Y (2014) Effect of time factors on the mortality in brittle hip fracture. J Orthop Surg Res 9:37. CrossRefGoogle Scholar
  27. 27.
    Smith T, Pelpola K, Ball M, Ong A, Myint PK (2014) Pre-operative indicators for mortality following hip fracture surgery: a systematic review and meta-analysis. Age Ageing 43:464–471. CrossRefGoogle Scholar
  28. 28.
    Chassot PG, Delabays A, Spahn DR (2007) Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 99:316–328. CrossRefGoogle Scholar
  29. 29.
    Pailleret C, Ait Hamou Z, Rosencher N, Samama CM, Eyraud V, Chilot F, Baillard C (2017) A retrospective comparison between delayed and early hip fracture surgery in patients taking clopidogrel: same total bleeding but different timing of blood transfusion. Int Orthop.
  30. 30.
    Ricci WM, Brandt A, McAndrew C, Gardner MJ (2015) Factors affecting delay to surgery and length of stay for patients with hip fracture. J Orthop Trauma 29:109–114. CrossRefGoogle Scholar
  31. 31.
    Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA (2011) Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med 155:226–233. CrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Alejandro Lizaur-Utrilla
    • 1
    • 2
    Email author
  • Blanca Gonzalez-Navarro
    • 1
  • Maria F. Vizcaya-Moreno
    • 3
  • Francisco A. Miralles Muñoz
    • 1
  • Santiago Gonzalez-Parreño
    • 1
  • Fernando A. Lopez-Prats
    • 2
  1. 1.Orthopaedic Surgery, Elda University HospitalMiguel Hernandez UniversityEldaSpain
  2. 2.Traumatology and OrthopaediaMiguel Hernandez UniversityElcheSpain
  3. 3.Clinical Research Group, Faculty of Health SciencesUniversity of AlicanteAlicanteSpain

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