Non-medical surgical delay increases one-year mortality following hip fracture

Aims

This study aimed to assess the association between surgical delay due to non-medical reasons and one-year mortality in patients with hip fracture, and to explore whether a dose-response relationship exists between increasing time to surgery and mortality risk.

Methods

A retrospective cohort analysis was performed using prospectively collected data from the Nottingham Hip Fracture Database. A total of 5,414 patients aged ≥ 60 years admitted with a fragility femoral fracture to a major trauma centre between April 2016 and March 2023 were reviewed. Time to theatre was measured from emergency department arrival to anaesthetic start. Delays beyond 36 hours were categorized as either medical or logistical. The primary outcome was all-cause one-year mortality with a secondary outcome being length of stay (LOS). Multivariable Cox proportional hazards models were used to assess associations, adjusting for age, sex, comorbidity, and cognition.

Results

Of the cohort, 38.5% (n = 2,083) experienced surgical delay beyond 36 hours; 27.5% (n = 1,490) due to limited surgical capacity and 11.0% (n = 593) due to medical unfitness. After adjusting for age, sex, comorbidity, and cognition, delay due to logistical factors was associated with a 20% increase in one-year mortality (hazard ratio (HR) 1.20 (95% CI 1.06 to 1.36); p = 0.004). A secondary analysis excluding medically unfit patients demonstrated a stepwise increase in hazard with increasing time to theatre, suggesting a dose-response effect. LOS was also increased with delay to theatre by one day in this cohort.

Conclusion

Delayed surgery beyond 36 hours, due to lack of surgical capacity, is independently associated with increased mortality following hip fracture. These findings reinforce the need for protected surgical capacity and prioritization of prompt surgery to improve outcomes in this vulnerable population.

Cite this article: Bone Joint J  2026;108-B(8):1021–1028.