N. H. Varady, B. T. Ameen, A. F. Chen, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Clin Orthop Relat Res. 2020 Mar;478(3):607-615. doi: 10.1097/CORR.0000000000001038.
Delayed time to surgery of at least 2 days after hospital arrival is well known to be associated with increased complications after standard hip fracture surgery; whether this association is present for pathologic hip fractures, however, is unknown.
QUESTIONS/PURPOSES: (1) After controlling for differences in patient characteristics, is delayed time to surgery (at least 2 days) for patients with pathologic hip fractures independently associated with increased complications compared with early surgery (fewer than 2 days)? (2) What preoperative factors are independently associated with major complications and mortality after surgery for pathologic hip fractures?
A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database of pathologic hip fractures (including femoral neck, trochanteric, and subtrochanteric fractures) from 2007 to 2017. This database was chosen over other databases given the high-quality preoperative medical history and postoperative complication (including readmissions, reoperations, and mortality) data collected from patient medical records through the thirtieth postoperative day. Patients were identified using Common Procedural Terminology codes for hip fracture treatment (THA, hemiarthroplasty, proximal femur replacement, intramedullary nail, and plate and screw fixation) with associated operative diagnoses for pathologic fractures as identified with International Classification of Diseases codes. A total of 2627 patients with pathologic hip fractures were included in this study; 65% (1714) had surgery within 2 days and 35% (913) had surgery after that time. Patient demographics, hospitalization information, and 30-day postoperative complications were recorded. Differences in characteristics between patients who underwent surgery in the early and delayed time periods were assessed with chi-square tests for categorical variables and t-tests for continuous variables. Delayed-surgery patients were more medically complex at the time of admission than early-surgery patients, including having higher American Society of Anesthesiologists classification (mean ± SD 3.18 ± 0.61 versus 2.94 ± 0.60; p < 0.001) and prevalence of advanced, "disseminated" cancer (53% versus 39%; p < 0.001). Propensity-adjusted multivariable logistic regression analyses were performed to assess the effect of delayed time to surgery alone on the various outcome measures. Additional independent risk factors for major complications and mortality were identified using backwards stepwise regressions.
After controlling for baseline factors, the only outcome associated with delayed surgery was extended postoperative length of stay (odds ratio 1.94 [95% CI 1.62 to 2.33]; p < 0.001). Delayed surgery was not associated with any postoperative complications, including major complications (OR 1.23 [95% CI 0.94 to 1.6]; p = 0.13), pulmonary complications (OR 1.24 [95% CI 0.83 to 1.86]; p = 0.29), and mortality (OR 1.26 [95% CI 0.91 to 1.76]; p = 0.16). Histories of chronic obstructive pulmonary disease (OR 2.48), congestive heart failure (OR 2.64), and disseminated cancer (OR 1.68) were associated with an increased risk of major complications, while dependent functional status (OR 2.27), advanced American Society of Anesthesiologists class (IV+ versus I-II, OR 4.81), and disseminated cancer were associated with an increased risk of mortality (OR 2.2; p ≤ 0.002 for all).
After controlling for baseline patient factors, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic hip fractures. These results are in contrast to the traditional dogma for standard hip fractures that surgery within 2 days of hospital arrival is associated with reduced complications. Although surgery should not be delayed needlessly, if the surgeon feels that additional time could benefit the patient, the results of this study suggest surgeons should not expedite surgery because of the risk of surgical delay observed for standard hip fractures.
Level III, therapeutic study.
众所周知，在到达医院后至少 2 天进行手术与标准髋关节骨折手术后并发症增加有关；然而，病理髋关节骨折是否存在这种关联尚不清楚。
问题/目的：（1）在控制患者特征差异的情况下，与早期手术（少于 2 天）相比，病理性髋部骨折患者的手术延迟时间（至少 2 天）是否与并发症增加独立相关？（2）手术后病理性髋部骨折的主要并发症和死亡率与哪些术前因素独立相关？
使用美国外科医师学会国家手术质量改进计划数据库（包括股骨颈、转子间和转子下骨折）进行回顾性研究，该数据库来自 2007 年至 2017 年的病理性髋部骨折。选择该数据库是因为与其他数据库相比，该数据库从患者病历中收集了高质量的术前病史和术后并发症（包括再入院、再次手术和死亡率）数据，直至术后第 30 天。使用髋关节骨折治疗的通用程序术语代码（THA、半髋关节置换术、股骨近端置换术、髓内钉和钢板和螺钉固定术）识别患者，并使用国际疾病分类代码确定与病理性骨折相关的手术诊断。本研究共纳入 2627 例病理性髋部骨折患者；65%（1714 例）在 2 天内接受手术，35%（913 例）在该时间后接受手术。记录患者的人口统计学特征、住院信息和 30 天术后并发症。使用卡方检验评估分类变量和 t 检验评估连续变量的手术早期和延迟期患者之间的特征差异。与早期手术患者相比，延迟手术患者在入院时的医疗复杂程度更高，包括更高的美国麻醉医师协会分类（平均±标准差 3.18±0.61 与 2.94±0.60；p<0.001）和更广泛的“播散性”癌症（53%与 39%；p<0.001）。采用多变量逻辑回归分析评估单独延迟手术时间对各种结局指标的影响。使用逐步回归分析确定主要并发症和死亡率的其他独立危险因素。
在控制基线因素后，唯一与延迟手术相关的结果是术后延长住院时间（比值比 1.94[95%置信区间 1.62 至 2.33]；p<0.001）。延迟手术与任何术后并发症无关，包括主要并发症（比值比 1.23[95%置信区间 0.94 至 1.6]；p=0.13）、肺部并发症（比值比 1.24[95%置信区间 0.83 至 1.86]；p=0.29）和死亡率（比值比 1.26[95%置信区间 0.91 至 1.76]；p=0.16）。慢性阻塞性肺疾病（比值比 2.48）、充血性心力衰竭（比值比 2.64）和播散性癌症（比值比 1.68）的病史与主要并发症的风险增加相关，而依赖的功能状态（比值比 2.27）、高级美国麻醉医师协会分类（IV+ 与 I-II，比值比 4.81）和播散性癌症与死亡率的风险增加相关（比值比 2.2；p≤0.002 均适用）。
在控制基线患者因素后，手术时间延迟与病理性髋部骨折手术后 30 天并发症的增加无关。这些结果与传统的髋部骨折治疗理论相悖，传统理论认为在到达医院后 2 天内进行手术与减少并发症有关。尽管不应该不必要地延迟手术，但如果外科医生认为额外的时间可能对患者有益，那么本研究的结果表明，由于观察到标准髋部骨折的手术延迟风险，外科医生不应该因为担心手术延迟而加快手术。
III 级，治疗性研究。
