Impact of surgical timing on complications and mortality in periprosthetic hip fractures compared to native hip fractures.

INTRODUCTION: Timely surgery within the next calendar day is recommended for native hip fractures (NHF) according to NICE guidelines. In contrast, no standardized fast-track protocols exist for periprosthetic hip fractures (PPFx), potentially resulting in surgical delays. This study aimed to evaluate time to surgery and reasons for delay in surgically treated PPFx patients, and to assess complications and mortality according to surgical timing. A previously published NHF cohort was used as a clinically relevant benchmark reflecting the established geriatric native hip fracture pathway.

MATERIALS AND METHODS: We retrospectively analyzed 217 surgically treated PPFx patients at a university level-one trauma center. Time to surgery, reasons for delay, complications, length of stay, and mortality were assessed. Outcomes were analyzed within the PPFx cohort according to surgical timing, defined as early surgery within the next calendar day versus delayed surgery. To improve comparability with the NHF benchmark cohort (all aged ≥75 years), additional analyses were performed in an age-restricted PPFx subgroup including patients aged ≥ 75 years.

RESULTS: Median time to surgery was significantly longer in the overall PPFx cohort than in the NHF benchmark cohort (43.6 h [IQR 21.1-85.7] vs. 16.8 h [IQR 9.7-23.1], p < 0.001). Similar findings were observed in the age-restricted PPFx subgroup (42.8 h [IQR 21.1-68.2], p < 0.001 vs. NHF). Early surgery occurred in 43.8% of the overall PPFx cohort and 39.8% of the age-restricted PPFx subgroup, compared with 91.1% of NHF patients. Delays in PPFx were mainly related to surgeon availability and logistical factors, whereas NHF delays were predominantly patient-related. General and local complication rates did not differ significantly between early and delayed surgery in either the overall or age-restricted PPFx cohort. In the overall PPFx cohort, mortality did not differ significantly between early and delayed surgery at 30, 60, or 90 days, although six-month mortality was higher after delayed surgery. Kaplan-Meier analysis showed no significant difference in overall survival between early and delayed PPFx surgery in the overall cohort or age-restricted subgroup. Compared with NHF, mortality was lower in the overall PPFx cohort at 60 days, 90 days, and six months. After age restriction, 60- and 90-day mortality differences were attenuated and no longer statistically significant, whereas six-month mortality and overall survival remained significantly different.

CONCLUSION: PPFx patients experienced substantially longer surgical delays than NHF patients, predominantly due to organizational and logistical factors. Delayed surgery in PPFx was not associated with increased complication rates or reduced overall survival. Compared with the NHF benchmark cohort, PPFx patients showed a more favorable survival profile despite longer surgical delays. These findings support prioritizing appropriate expertise and resources for selected PPFx cases while emphasizing the need to improve surgical logistics and dedicated care pathways.