Physical Activity Outcome in Early Vs Delayed Elderly Hip Fracture Surgery

The study aimed to find if an earlier fixation of proximal hip fractures in the elderly, leads to a better outcome, physically and mentally. Current guidelines recommend that hip fracture surgery should be done within 24 hours of injury. But those favoring a delay in surgery believe that it provides sufficient time to medically optimize patients, and thereby decrease the risk for perioperative complication. Our study was carried out in a tertiary care center. A total of 58 patients was enrolled in the study. Analysis showed, in comparison with the delayed fixation group, the early fixation group didn‟t enjoy a statistically better physical quality of life at the end of 6 months, but mental health scores were significantly above the delayed fixation group. It also showed the most common reason for the delay was late presentation followed by delayed insurance clearance. An increased hospital stay was also seen for the delayed fixation group.

of nonunion, lower rates of complications and mortality. Even though guidelines suggest that a delay in surgery of more than 24 hours may not unequivocally impact mortality, these data recommend early surgery on the premise that elderly (>50-60 years of age) hip fracture patients are at risk of complications and merit early intervention on humane grounds. [2].
Advocates of early treatment argue that this approach minimizes the duration of time a patient is restricted to bed rest, thereby reducing the risk of associated complications, such as urinary tract infections, deep vein thrombosis, pressure sores, and pneumonia [3].
However, proponents of delay in the timing of surgery believe that it provides ample opportunity to medically optimize patients, and thereby cut back on the risk for perioperative complications [4]. A hiccup in the attempt to resolve this uncertainty is the lack of a conventional definition of "early surgery". Ambiguity exists about whether 24, 48, 72, hours or more should be considered an "undesirable delay" for hip fracture surgery. None of the studies have focussed on the mental health perspective that we have considered here.

Review of literature
Hip fractures represent a progressively important health care problem. There is a conflicting perception that surgical delay in hip fracture patients is associated with an increase in the duration of hospital stay [5] postoperative complications, and mortality [6]. Studies addressing physical activity and mental health outcomes in such patients have rarely been done before. In the past, studies have stated that early surgery, operated within 24 hours, is independently associated with a reduced duration of hospital stay [7].
In a large prospective observational study, a link was found between surgery within 24 hours and fewer major postoperative complications, in a group of healthier patients, defined as elderly individuals who are devoid of abnormal clinical findings, aortic stenosis, dementia, and end-stage renal disease. But at the end of 6 months, there was no association with mortality (P = 0.09). Another retrospective study in 57,315 patients reported an increase in mortality up to 1 year, in the group with a longer delay to surgery.
This association was very much strong in patients younger than 70 years of age with no co-morbidities [8,9]. Considering that life expectancy will be on the rise in the next decade [8], the burden to the healthcare system from hip fractures and their consequences will even greater in the near future. The prognosis of elderly individuals with proximal hip fractures depends primarily on age, comorbidities, anticoagulation therapy, and the general health status [9]. In addition to these, mounting evidence indicates that timing of surgical fixation might play a major role in patient survival after hip fracture [10,11]. A systematic review in 2010 reported that risk of mortality in elderly patients was reduced by 19% with early surgery (within 24-72 h) [6]. These results reinforced the findings of previous reviews showing that delay of surgery beyond 48 hours increased the mortality within 1 year by 32% [6]. Studies have also shown delayed surgery increased the risk of pneumonia [12].
Although many evidence-based articles recommend surgery of acute hip fracture within the first 48 hours [13], these recommendations are still controversial.
Some studies argue that delayed surgical fixation provides valuable time for patients to achieve a better medical condition, which can reduce the risk of perioperative complications, including pneumonia, bleeding, deep venous thrombosis, urinary tract infection, pulmonary embolism, and decubital ulcerations [14]. In clinical practice, delayed surgery of hip fractures is quite common because of a limited capacity of operating rooms or personnel, or the need

Materials and Methods
This study was a prospective, observational design which took place in a tertiary orthopaedic centre with 24 hours availability of orthopaedic operating room and anaesthetist on call. Patients above age of 60 years, who presented with low energy falls and sustained proximal femur fracture viz, neck of Femur, Inter-trochanteric, Sub-trochanteric, were included in the study. Patients who sustained pathological fractures, multiple fractures, high energy trauma like road traffic accidents, and also patients who weren"t mobile before the fall due to cerebro-vascular or other events, were excluded from the study. Considering that there will be difference in SF-12 score of 10 units between early fixation and delayed fixation, a sample size of 25 subjects in each group was needed to achieve 80% power with 5% level of significance. We evaluated the changes in physical activity by using a self reported questionnaire which was measured in terms of SF-12 Questionnaire score. SF-12 Questionnaire score was calculated as per questionnaire answered by the patient or the patient attender either in person, telephonically or via email.
Sample T tests were performed to evaluate the changes in SF-12 Questionnaire score from before the fall [pre-fall], to 6 months after surgery. P value <0.05 was considered significant.

Observation and Results
58 patients made the criteria and were included in the study. Follow-up was done till September 2018. 29 (50.0%) patients were operated within 48 hours of the incident and the rest 29 (50.0%) patients were operated beyond 48 hours of the incident. Table 1

SF-12 Physical score
We have done the comparison on the basis of the difference of SF-12 physical score (physical score at pre-fall-physical score at 6 months).  Table 2: Comparison of mean SF-12 physical score at prefall and at 6 months between < 48 hours and > 48 hours group. Unpaired "t" test applied. P value < 0.05 was taken as statistically significant

SF-12 Mental score
We have done the comparison based on the difference of SF-12 mental score (mental score at pre-fallmental score at 6 months).     [15]. There may be a differential effect for those patients delayed for administrative reasons alone compared to those delayed for the optimization of acute medical conditions consequent to their fractured hip.

Mortality
The study period was small to contain such an aspect to our study. We had 2 deaths in our study group which was due to long-term terminal end-stage organ failure, had to be excluded from the study. Further, other studies have shown that less healthy patients may still benefit from surgery within 24 hours [18]. The current evidence suggests that while surgical fixation delay of more than 24 hours may not impact mortality, there is no theoretical advantage for healthier patients to wait for surgery. In fact, there is the potential for increased complications and poorer outcomes [19]. In the case of medically unfit patients, this effect is less clear.

Post operative complications
We did not have any surgical complications for our and the increased incidence of pressure ulcers [21] and avascular necrosis, both complications consistent with extended bed rest [22]. Two prospective studies that adjusted for patients" preoperative health status, age, and gender found a significant and nonsignificant association between time to surgery and a patient"s return to independent living status. Where the type of surgery has been shown to affect hip fracture patient outcomes, [20] Al-Ani et al. still found a significantly improved ability of patients undergoing earlier surgery to return to independent living even after adjustment for treatment modality, pre-fracture living status, and walking ability [27]. In a prospective study of 1206 patients, those who had surgical fixation within 24 hours had significantly fewer post operative days of severe pain [23]. Pain can cause stress reaction and subsequent insulin resistance to amplify the process of muscle loss and weakness, which can delay patient rehabilitation and increase the risk of delirium.
However, most of these studies are flawed by retrospective design and heterogeneity. In the absence of a prospective, randomized study comparing delayed and expeditious surgery, it is tough to know whether surgical fixation delay adversely affects outcomes directly or if the delay in surgery is simply mirroring the underlying morbidities that adversely affect these complications.

Duration of Hospital Stay
Regardless of the cut-off for delay (e.g., 24, 48, 72 hours) early surgical treatment of a hip fracture injury is associated with a shorter hospital stay based on both unadjusted [24] and adjusted analyses [25]. For most studies, as the operative delay increased, so did the

Conclusion
The  [27]. A dedicated trauma operating room not only reduced the time to dynamic hip screw and closed femoral nailing procedures, but also allow more of these surgeries to be performed during daytime hours, which may reduce postoperative complications [28].

Limitations
Our study has several potential limitations. Major bulk of our patients who got operated late presented to us one day after the injury. Most of them took primary care elsewhere and chose to get operated in our center for multiple reasons. Delay caused by insurance clearance was also another non-modifiable factor.
More number of patients may have shown a better picture. We lacked data on socio-economical status and of functional status prior to admission, two factors that may have affected patient selection for surgery, time to surgery, and the outcome of these elderly patients. One can assume that early surgery may be a surrogate of closer medical attention and reflect a "better" overall health status of the patient.