Ganta Abhishek, Merrell Lauren A, Herbosa Carolyn, Egol Kenneth A, Konda Sanjit R
Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and.
Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, NY.
J Orthop Trauma. 2025 Feb 1;39(2):68-74. doi: 10.1097/BOT.0000000000002934.
To identify which hip fracture patients benefit the most from operative repair within 24 hours of Emergency Department presentation based on patient risk stratification.
Retrospective Cohort.
Academic Medical Center.
Patients operatively treated for an AO/OTA 31 A, 31 B, or 32 A hip fracture.
Each patient was placed into an "individualized risk quartile" (Individual Risk Quartile) using a validated risk stratification tool (The Score for Trauma Triage in the Geriatric and Middle-Aged [Score for Trauma Triage and Geriatric Middle Aged], a tool proven to predict inpatient mortality in trauma patients). Patients were risk stratified into minimal-, low-, moderate-, and high-risk IRQs. In each cohort, patients were separated into 3 groups based on their time from Emergency Department arrival to surgery (<24 hours, >24 hours and <48 hours, and >48 hours). Each of these 12 groups was analyzed for complications (minor inpatient complications included acute kidney injury, urinary tract infection, decubitus ulcer, and acute blood loss anemia, while major inpatient complications included sepsis or septic shock, pneumonia, acute respiratory failure, stroke, myocardial infarction, cardiac arrest, and deep vein thrombosis or pulmonary embolism), mortality rates, and hospital quality measures (length of stay and readmission rates). The results were compared across cohorts.
A total of 2472 patients were identified: the mean age of the cohort was 80.6 ± 10.3 and was predominantly female (69%) and white (71%). The data demonstrated improved outcomes (complications, mortality rates, hospital quality measures) across all patients (nonrisk stratified) for surgery within 24 hours compared with surgery between 24 hours and 48 hours and surgery greater than 48 hours (all outcomes P < 0.050). However, these effects were not evenly distributed among the IRQs. In the IRQ4 cohort, major complication rates progressed from 20% to 25% to 34% as a function of time to surgery ( P = 0.007). IRQ1 did not demonstrate similar results ( P = 0.756), with the rates essentially static across surgery time points (3%-2% to 4%). A similar trend was seen when analyzing mortality at 1 year for highest risk patients, with similar 1-year mortality rates across operating room windows of IRQs 1-3 (IRQ1: P = 0.061, IRQ2: P = 0.259, IRQ3: P = 0.524) but increased in IRQ4 with increasing time to surgery (21% vs. 33% vs. 33%, P = 0.006).
This study demonstrates a differential impact of expedited time to surgery on patients when stratified by the risk profile. The lowest risk hip fracture patients do not fare worse if operated on within 48 hours as compared to 24 hours.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
基于患者风险分层，确定哪些髋部骨折患者在急诊科就诊后24小时内进行手术修复获益最大。
回顾性队列研究。
学术医疗中心。
接受AO/OTA 31 A、31 B或32 A型髋部骨折手术治疗的患者。
使用经过验证的风险分层工具（老年和中年创伤分诊评分[老年和中年创伤分诊评分]，一种已被证明可预测创伤患者住院死亡率的工具）将每位患者分为“个体化风险四分位数”（个体风险四分位数）。患者被风险分层为极低、低、中、高风险的个体风险四分位数。在每个队列中，根据患者从急诊科到达至手术的时间（<24小时、>24小时且<48小时、>48小时）分为3组。对这12组中的每一组进行并发症（轻微住院并发症包括急性肾损伤、尿路感染、压疮和急性失血性贫血，而主要住院并发症包括脓毒症或脓毒性休克、肺炎、急性呼吸衰竭、中风、心肌梗死、心脏骤停以及深静脉血栓形成或肺栓塞）、死亡率和医院质量指标（住院时间和再入院率）分析。对各队列的结果进行比较。
共纳入2472例患者：队列的平均年龄为80.6±10.3岁，主要为女性（69%）和白人（71%）。数据表明，与24小时至48小时以及大于48小时进行手术相比，所有患者（未进行风险分层）在24小时内进行手术的结局（并发症、死亡率、医院质量指标）有所改善（所有结局P<0.050）。然而，这些影响在个体风险四分位数中分布并不均匀。在个体风险四分位数4队列中，主要并发症发生率随手术时间从20%升至25%再升至34%（P=0.007）。个体风险四分位数1未显示类似结果（P=0.756），各手术时间点的发生率基本稳定（3%-2%至4%）。在分析最高风险患者1年死亡率时也观察到类似趋势，个体风险四分位数1-3的各手术室时间段1年死亡率相似（个体风险四分位数1：P=0.061，个体风险四分位数2：P=0.259，个体风险四分位数3：P=0.524），但个体风险四分位数4中随着手术时间增加死亡率升高（21%对33%对33%，P=0.006）。
本研究表明，按风险特征分层时，加快手术时间对患者有不同影响。风险最低的髋部骨折患者在48小时内进行手术与24小时内进行手术相比，预后并不更差。
预后III级。有关证据水平的完整描述，请参阅作者指南。
