1. Early surgery for proximal femoral fractures is associated with lower complication and mortality rates Parag Kumar Jaiswal Arthroplasty Fellow

2. Acknowledgements Hoa KhongABJHI Chris SmithABJHI Pam RailtonResearch assistant and nurse extraordinaire Jim PowellAssociate Clinical Professor

3. Introduction Hip fractures are a significant cause of morbidity and mortality Nearly 300,000 hip fractures occur in the US annually Lack of consensus within the orthopaedic community on relationship bewteen timing of surgery and mortality outcomes

4. Uzoigwe et al 2013 – 2056 patients – Increased mortality after 36 hours Shiga et al 2008 (Can J Anaes) Meta-analysis – 16 studies found delay beyond 48 hours increased mortality rates Moja et al 2012 - 35 studies, 191,873 patients – Surgery conducted within 24 to 48 hours was associated with lower mortality

5. Moran et al JBJS 2005 analysis of 2660 – showed that there was no effect in mortality with surgical delay of up to 4 days Orosz et al. 2004 - In 1178 patients – Early surgery within 24 hours was not associated with improved survival Khan et al 2009 - Systematic review of 291,143 – observed that when adjusting for confounding variables, they were less likely to report improved survival

6. Hypothesis Delay in surgery by more than 48 hours will have and adverse effect on: – Mortality rate – Medical complication rates – Length of stay

7. Patients and Methods Retrospective cohort study All patients that underwent operative treatment for proximal femoral fractures in 15 centres throughout Alberta between April 2009 and 2013 Comprehensive data on: Demographics Date & time of presentation to emergency department Date & time taken to OR Date of discharge Medical co-morbidities

8. Databases Discharge abstract database – (DAD) National Ambulatory Care Reporting System – NACRS Using unique patient identifiers the two databases were merged

9. Statistical Analysis Multiple logistic regression were used for the outcomes of in-hospitality mortality and medical complications Cox-regression to calculate survival curves Multiple linear regression to determine how length of stay was affected

10. Co-factors and co-variates Age Gender Time to surgery – Within 48 hours – After 48 hours Dementia Charlson co-morbidity index – 0 – 1 – 2 or more

11. Results 14344 patients had procedures performed with recorded time to OR Excluded 60 as they were extreme outliers – Time to OR was greater than 30 days from presentation to emergency department Mean age 77.8 (range 18 to 105) 67.4% were females 75.5% patients received surgery within 48 hours

12. Charlson Co-morbidity index

13. Mortality Rate Variable Odds ratio 95% Confidence Interval for Odds ratio Lower Bound Upper Bound p value Age1.06 1.08 <0.001 Female0.60.480.68 <0.001 Male... No Dementia... 0.37 Dementia0.910.751.1 Surgery after 48 hours1.751.472.08 <0.001 Surgery within 48 hours... Charlson = 0... <0.001 Charlson = 11.831.422.36 Charlson = 2 or more4.653.735.8

14. Cox regression – timing of surgery Surgery within 48 hours Surgery after 48 hours

15. Cox Regression – Co-morbidity

16. Complications Medical complications included: – Thromboembolic event – MI – CVA – Pneumonia – Ileus – GI bleed 915/14282 (6.4%) had one complication 122 (0.9%) had more than one

17. Medical Complications Variable Odds ratio 95% Confidence Interval for Odds ratio Lower Bound Upper Bound p value <0.001 Age1.021.011.03 Female0.720.630.83 <0.001 Male... Surgery after 48 hours1.31.131.49 <0.001 Surgery within 48 hours... Charlson = 0... <0.001 Charlson = 11.661.362 Charlson = 2 or more5.14.32.

18. Thromboembolic event Variable Odds ratio 95% Confidence Interval for Odds ratio p value Lower Bound Upper Bound Age1.021.011.03 <0.001 Female0.820.651.03 Male... 0.084 Surgery after 48 hours1.61.282 Surgery within 48 hours... <0.001 Charlson = 0.. <0.001 Charlson = 11.10.81.49 Charlson = 22.742.133.52

19. Length of stay (LOS) Multiple linear regression model relies on a normal distribution of the dependent variable LOS has a positive skew following most surgical procedures Therefore data was transformed to log[LOS]

20. Length of stay

21. Multiple linear regression – LOG[LOS] Variable Magnitude of effect 95% Confidence Interval p value Lower Bound Upper Bound <0.001 Age0.140.120.17 Female-0.73-1.4-0.007 0.048 Male... Surgery after 48 hours1.50.722.24 <0.001 Surgery within 48 hours... Dementia4.433.55.4 <0.001 No Dementia... Charlson = 0... <0.001 Charlson = 12.121.243 Charlson = 2 or more 6.45.57.31

22. Summary Delay in surgery by greater than 48 hours results in – Higher mortality rate – Higher medical complication rate – Longer post-operative length of stay

23. Conclusion The message is unequivocal and clear Delay in surgery is not good! Patients should be medically optimised and prioritised to be undergo surgery in the next available trauma list

24. Thank You. Questions?