Several variables are associated with the research question. Most components have a direct effect on outcomes and have been part of discussions in many studies.
Quality of life
In our study, even though patients that were operated within 48 hours had a better quality of life index and they progressed rapidly in rehabilitation, it wasn't statistically significant to be concluded likewise. The mean of difference of SF-12 physical score in the < 48 hours group was -14.29 ± 5.43, while in the > 48 hours group it was -11.59 ± 5.29. The difference was found to be statistically not significant (p>0.05), showing a comparable difference between the two groups.
Surprisingly, the delayed fixation group had a lesser drop in mental satisfaction compared to the early fixation group.The mean of difference of SF-12 mental score in the < 48 hours group was -5.66 ± 4.06, while in the > 48 hours group it was -3.82 ± 2.32. The difference was found to be statistically significant (p<0.05), showing a larger difference in the < 48 hours in comparison to the > 48 hours
Reasons for delay
The most common reason of the delay in our center was late presentation and delay for insurance clearance. In the > 48 hours group, 14 (48.3%) were delayed due to late presentation, 7 (24.1%) patients were delayed due to insurance clearance delay, 4 (13.8%) patients were delayed due to medical optimization, 3 (10.3%) patients were delayed because they were on anticoagulant therapy and 1 (3.4%) patient was delayed due to theatre/surgeon unavailability.
In literature, the most common reasons for operative delay include the unavailability of the operating room and/or surgical personnel (administrative), and investigation and stabilization of the patient’s preoperative medical condition (medical-related)(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.
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. In a retrospective analysis of 406 patients with proximal femur fractures, Kenzora et al(16) found higher 1-year mortality after operative fixation on the first hospital day compared with the second through fifth hospital days (34% versus 5.8%). However, they also reported that a large number of medically unfit patients underwent earlier surgery. Sicker patients may benefit from a delay in order to optimize their medical condition and including these patients in the early surgery group may have diluted the true effect of postponing surgery. For example, Zagrodnick and Kaufner (17)noted a lower in-hospital mortality rate with preoperative stabilization of medical conditions. A prospective study examining a subgroup of 60 acutely ill, hip fracture patients showed a reduction in mortality with surgery delayed more than 24 hours.However, these analyses and observations are not sensitive or powerful enough to detect the effect of early and delayed surgery on unhealthy patients alone. 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 patients within the study period. Surgical timing does not appear to have a significant effect on the number of complications patients may experience after surgery.(20)Yet some studies have shown a significant association between surgical delay (i.e., >24 hours) 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 mean length of hospital stay. In our study, The mean hospital stay in the <48 hours group was 4.66 ± 0.67 days, while in the > 48 hours group it was 5.59 ± 0.98 days.
It is expected that the longer a patient is required to wait for surgery, the longer they are in the hospital due to the preoperative wait alone. And while early surgery appears to have a large significant effect on reducing the length of stay, it is difficult to establish whether this effect is maintained over and above the preoperative interval. Future studies should calculate and report on the postoperative length of stay in relation to operative timing to resolve this issue.
The Economic Burden Of Surgical Delay
Health care resources incurred by hip fracture patients can includel hospitalization, rehabilitation, chronic care, long term home care, and informal care. Costs are substantially higher for individuals who do not return to the community and require long-term home care or sustain another hip fracture.
Prompt surgical intervention may not only avoid unnecessary discomfort for the patient and facilitate early mobilization and rehabilitation, but also reduce health care costs. Shabat et al. (26)studied the economic effects of delay to surgical fixation in hip fractures and found that spending more resources to expedite the surgery within 48 hours of injury is more cost-effective than delaying surgery past 72 hours.