Background

Elderly patients with hip fractures are often malnourished and in a catabolic state upon admission to hospital. Waiting time for surgery is commonly unpredictable, and often more than 24 hours. Due to an assumed stress-induced delayed gastric emptying time with a possible associated risk of aspiration, fasting guidelines are the same as for other trauma patients. This leads to prolonged fasting time in these patients who are often metabolically compromised, with negative effects on post-operative recovery and prolonged hospital stay. The aim of this study was to investigate if 400 ml of a carbohydrate-rich beverage could be given to patients with a hip fracture 2–3 hours before surgery without carrying a risk of pulmonary aspiration.

Several studies have evaluated the association between timing of hip fracture surgery and mortality in elderly patients. The evaluation of functional outcome is lacking.

We studied the effect of delayed surgery on the patient’s ability to return to independent living, the incidence of pressure sore and total length of hospital stay. Days of hospital stay included the post-operative period and the rehabilitation admission in the first 4 months following the operation.

Patients older than 50 years of age, admitted to two major hospitals in Stockholm during one year were included in the study (n = 853). To eliminate the effect of time interval between injury and admission, all patients who arrived to the hospital later than 24 hours of the injury (n=75) were excluded. Patients with pathological fracture (n = 30) were also excluded. The time intervals between hospital admission and the operation were evaluated against the patient post-operative independent living at 4 months follow up.

We divided the patients into two groups depending on delay to surgery. We performed a comparison of those patients who operated within 24 hours with those who hade been operated more than 24 hours after the admission. Moreover we repeated the analysis using 36 and 48 hours cut-off points.

After adjustment for age, ASA, walking ability, living with some one, gender and reason for delay, the late operated groups had a significantly decreased OR for return to independent living at 36 and 48 hours cutoff points (OR 0.5 respectively 0.3) but not at 24 hour cut-off point. The incidence of pressure sore in the late operated groups was significantly increased at all 3 cutoff points after adjustment for age, ASA, walking ability, dementia, and duration of surgery (OR 2.2, 3.4 and 4.2 respectively).

The median length of hospital stay was significantly increased in the late operated groups (14 versus 18 days at 24 hours, 15 versus 19 days at 36 hours, and 15 versus 21 days at 48 hours cut-off point). Linear regression analysis with adjustment for age, ASA, walking ability, dementia, gender and place of residence showed that there was a significant relationship between waiting time for operation (hours) and length of hospital stay (days) (B 0.148, P 0.002). Accordingly for every 6.75 hours delay in surgery, the total hospital stays increased by one day.

Our conclusion is that early operation of patients with hip fracture is associated with a significantly improved ability to return to independent living, a reduced incidence of decubitus ulcers and reduction in the length of hospital stay before the 4-month follow up.