Temporal Trends in Hip Fractures: How Has Time-toSurgery Changed?

Document Type : RESEARCH PAPER


Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, USA


Background: Surgical fixation of hip fractures within 24–48 hours of hospital presentation is associated with decreased rates of postoperative morbidity and death, and recently, hospitals nationwide have implemented strategies to expedite surgery. Our aim was to describe how time-to-surgery and short-term complication rates have changed using the National Surgical Quality Improvement Program database from 2011 to 2017. Methods: We identified more than 73,000 patients aged ≥65 years who underwent surgical fixation. Poisson regression adjusting for comorbidities, surgery type, type of anesthesia, patient sex, and patient age was performed to quantify annual changes in time-to-surgery. Annual changes in 30-day postoperative complications were analyzed using a generalized linear model with binomial distribution. Results: A significant decrease in time-to-surgery was observed during the study period (mean 30 hours in 2011 versus 26 hours in 2017; p <0.001). Time-to-surgery decreased by 2% annually during the 7-year period (0.5 hour/year, 95% CI: -35, -23; p <0.001). The all-cause 30-day complication rate also decreased annually (annual risk difference: −0.35%, 95% CI: −0.50%, −0.20%; p <0.001). For individual complications, we found significant decreases in deep infection (-0.2%, P=0.002), reintubation (-0.3%, P=0.001), urinary tract infection (-2.5%, p <0.001), and death (-1.3%, P=0.03). We found significant but small increases of pulmonary embolism (0.3%, P=0.03) and myocardial infarction (0.1%, P=0.02). Higher rates of complications were associated with increased time-to-surgery (p <0.001). Conclusion: From 2011 to 2017, time-to-surgery for hip fracture decreased significantly, as did short-term postoperative rates of all-cause complications and death. Longer time-to-surgery was associated with increased number of complications. Level of evidence: III


1. Lewiecki EM, Wright NC, Curtis JR, Siris E, Gagel RF,
Saag KG, et al. Hip fracture trends in the United States,
2002 to 2015. Osteoporos Int. 2018; 29(3):717-722.
2. rauer CA, Coca-Perraillon M, Cutler DM, Rosen AB.
Incidence and mortality of hip fractures in the United
States. JAMA. 2009; 302(14):1573–9.
3. Burge R, Dawson-Hughes B, Solomon DH, Wong JB,
King A, Tosteson A. Incidence and economic burden
of osteoporosis-related fractures in the United States,
2005–2025. J Bone Miner Res. 2007; 22(3):465–75.
4. Klestil T, Röder C, Stotter C, Winkler B, Nehrer S,
Lutz M, et al. Impact of timing of surgery in elderly
hip fracture patients: a systematic review and metaanalysis.
Sci Rep. 2018; 8(1):13933.
5. Moja L, Piatti A, Pecoraro V, Ricci C, Virgili G, Salanti G,
et al. Timing matters in hip fracture surgery: patients 
operated within 48 hours have better outcomes. A
meta-analysis and meta-regression of over 190,000
patients. PLoS One. 2012;7(10):e46175.
6. Alvi HM, Thompson RM, Krishnan V, Kwasny MJ, Beal
MD, Manning DW. Time-to-Surgery for Definitive
Fixation of Hip Fractures: A Look at Outcomes Based
Upon Delay. Am J Orthop (Belle Mead NJ). 2018; 47(9).
7. Fu MC, Boddapati V, Gausden EB, Samuel AM, Russell
LA, Lane JM. Surgery for a fracture of the hip within 24
hours of admission is independently associated with
reduced short-term post-operative complications.
Bone Joint J. 2017; 99-B (9):1216-1222.
8. Judd KT, Christianson E. Expedited Operative Care of
Hip Fractures Results in Significantly Lower Cost of
Treatment. Iowa Orthop J. 2015; 35: 62–64.
9. Elfar JC, Daniel JL. Timing of Hip Fracture Surgery in 
the Elderly. Geriatr Orthop Surg Rehabil. 2014; 5(3):
10. Lisk R, Yeong K. Reducing mortality from hip fractures:
a systematic quality improvement programme. BMJ
Qual Improv Rep. 2014; 19; 3(1).
11. Sheehan KJ, Sobolev B, Guy P. Mortality by Timing of
Hip Fracture Surgery: Factors and Relationships at
Play. J Bone Joint Surg Am. 2017; 99(20):e106.
12. Bohl DD, Basques BA, Golinvaux NS, Miller CP,
Baumgaertner MR, Grauer JN. Extramedullary
compared with intramedullary implants for
intertrochanteric hip fractures: thirty-day outcomes
of 4432 procedures from the ACS NSQIP database. J
Bone Joint Surg Am. 2014; 96(22):1871-7.
13. Althausen PL, Mead L. Bundled payments for care
improvement: lessons learned in the first year. J
Orthop Trauma. 2016;30(suppl 5):S50–S53.
14. Iorio R, Bosco J, Slover J, Sayeed Y, Zuckerman JD.
Single institution early experience with the bundled
payments for care improvement initiative. J Bone
Joint Surg Am. 2017;99(1):e2.
15. Johnson DJ, Greenberg SE, Sathiyakumar V, Thakore
R, Ehrenfeld JM, Obremskey WT, et al. Relationship
between the Charlson Comorbidity Index and cost
of treating hip fracture: implications for bundled
payment. J Orthop Traumatol. 2015; 16(3):209–213.
16. Nikkel L, Fox E, Black K, Davis C, Andersen L, Hollenbeak
C. Impact of comorbidities on hospitalization costs
following hip fracture. J Bone Joint Surgery Am.
17. Konda SR, Lott A, Egol KA. The Coming Hip and Femur
Fracture Bundle: A New Inpatient Risk Stratification
Tool for Care Providers. Geriatr Orthop Surg Rehabil.
2018; 9:2151459318795311.
18. Wiener RS, Schwartz LM, Woloshin S. Time trends
in pulmonary embolism in the United States:
evidence of overdiagnosis. Arch Intern Med. 2011;
19. Hutchinson BD, Navin P, Marom EM, Truong MT,
Bruzzi JF. Overdiagnosis of Pulmonary Embolism by
Pulmonary CT Angiography. AJR Am J Roentgenol.
2015; 205(2):271-7.
20. DeMonaco NA, Dang Q, Kapoor WN, Ragni MV.
Pulmonary embolism incidence is increasing with
use of spiral computed tomography. Am J Med.
21. Jiménez D, de Miguel-Dí􀆴ez J, Guijarro R, Trujillo-Santos
J, Otero R, Barba R, et al. Trends in the Management
and Outcomes of Acute Pulmonary Embolism:
Analysis From the RIETE Registry. J Am Coll Cardiol.
2016; 67(2):162-170.
22. Huddleston JM, Gullerud RE, Smither F, Huddleston
PM, Larson DR, Phy MP, et al. Myocardial infarction
after hip fracture repair: a population-based study. J
Am Geriatr Soc. 2012; 60(11):2020-6.
23. Bernstein J, Roberts FO, Wiesel BB, Ahn J. Preoperative
Testing for Hip Fracture Patients Delays Surgery,
Prolongs Hospital Stays, and Rarely Dictates Care. J
Orthop Trauma. 2016; 30(2):78-80.
24. Zeltzer J, Mitchell RJ, Toson B, Harris IA, Close J.
Determinants of time to surgery for patients with hip
fracture. ANZ J Surg. 2014; 84(9):633-8.
25. Chacko AT, Ramirez MA, Ramappa AJ, Richardson
LC, Appleton PT, Rodriguez EK. Does late night hip
surgery affect outcome? J Trauma. 2011; 71(2):447-
53; discussion 453.
26. Alluri RK, Leland H, Heckmann N. Surgical research
using national databases. Ann Transl Med. 2016;
4(20): 393.
27. Parthasarathy M, Reid V, Pyne L, Groot-Wassink T. Are
we recording postoperative complications correctly?
Comparison of NHS Hospital Episode Statistics with
the American College of Surgeons National Surgical
Quality Improvement Program. BMJ Qual Saf. 2015;
28. Sathiyakumar V, Greenberg SE, Jahangir AA, Mir HH,
Obremskey WT, Sethi MK. Impact of type of surgery
on deep venous thrombi and pulmonary emboli: a
look at twenty seven thousand hip fracture patients.
Int Orthop. 2015; 39(10):2017-22. 
Volume 9, Issue 2
March 2021
Pages 224-229
  • Receive Date: 06 February 2020
  • Revise Date: 08 May 2020
  • Accept Date: 25 July 2020
  • First Publish Date: 01 March 2021