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Transcript of Early surgery for proximal femoral fractures is associated with lower complication and mortality...
![Page 1: Early surgery for proximal femoral fractures is associated with lower complication and mortality rates Parag Kumar Jaiswal Arthroplasty Fellow.](https://reader034.fdocuments.in/reader034/viewer/2022051018/56649e625503460f94b5de41/html5/thumbnails/1.jpg)
Early surgery for proximal femoral fractures is associated with lower complication and
mortality rates
Parag Kumar JaiswalArthroplasty Fellow
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Acknowledgements
Hoa Khong ABJHIChris Smith ABJHIPam Railton Research assistant
and nurse extraordinaireJim Powell Associate Clinical
Professor
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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
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• 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
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• 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
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Hypothesis
• Delay in surgery by more than 48 hours will have and adverse effect on:– Mortality rate– Medical complication rates– Length of stay
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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
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Databases
• Discharge abstract database– (DAD)
• National Ambulatory Care Reporting System– NACRS
• Using unique patient identifiers the two databases were merged
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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
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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
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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
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Charlson Co-morbidity index
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Mortality Rate
Variable Odds ratio
95% Confidence Interval for Odds ratio
Lower Bound
Upper Bound p value
Age 1.06 1.06 1.08 <0.001
Female 0.6 0.48 0.68
<0.001Male . . .
No Dementia . . .0.37
Dementia 0.91 0.75 1.1 Surgery after 48 hours 1.75 1.47 2.08
<0.001Surgery within 48 hours . . . Charlson = 0 . . .
<0.001
Charlson = 1 1.83 1.42 2.36
Charlson = 2 or more 4.65 3.73 5.8
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Cox regression – timing of surgery
Surgery within 48 hours
Surgery after 48 hours
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Cox Regression – Co-morbidity
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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
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Medical Complications
Variable Odds ratio
95% Confidence Interval for Odds ratio
Lower Bound
Upper Bound p value
<0.001Age 1.02 1.01 1.03
Female 0.72 0.63 0.83 <0.001Male . . .
Surgery after 48 hours 1.3 1.13 1.49 <0.001
Surgery within 48 hours . . . Charlson = 0 . . .
<0.001
Charlson = 1 1.66 1.36 2
Charlson = 2 or more 5.1 4.32 .
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Thromboembolic event
Variable Odds ratio
95% Confidence Interval for Odds ratio
p value
Lower Bound
Upper Bound
Age 1.02 1.01 1.03 <0.001
Female 0.82 0.65 1.03
Male . . . 0.084
Surgery after 48 hours 1.6 1.28 2
Surgery within 48 hours . . . <0.001
Charlson = 0 . .
<0.001
Charlson = 1 1.1 0.8 1.49
Charlson = 2 2.74 2.13 3.52
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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]
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Length of stay
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Multiple linear regression – LOG[LOS]
VariableMagnitude
of effect
95% Confidence Interval
p valueLower Bound
Upper Bound
<0.001Age 0.14 0.12 0.17
Female -0.73 -1.4 -0.007 0.048Male . . .
Surgery after 48 hours 1.5 0.72 2.24 <0.001Surgery within 48 hours . . .Dementia 4.43 3.5 5.4 <0.001No Dementia . . .
Charlson = 0 . . .
<0.001
Charlson = 1 2.12 1.24 3
Charlson = 2 or more 6.4 5.5 7.31
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Summary
• Delay in surgery by greater than 48 hours results in– Higher mortality rate
– Higher medical complication rate
– Longer post-operative length of stay
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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
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Thank You.
Questions?