20 Effect of early surgery in elderly patients with a hip fracture: systematicreview and meta-analysis

Abstract

Objectives The effect of early surgery in elderly patients with hip fractures has been controversial during the last five decades due to equivocal evidence both in favour and against it. The objective of this study was to systematically assess all the available evidence on the effect(s) of early surgery compared with delayed surgery in elderly patients with hip fractures. Method A systematic review and meta-analysis was conducted. Searches for randomised controlled trials (RCTs) or prospective observational studies were conducted from inception to July 2017 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), and they were complemented with list of references searching, review of both clinical trials registers and archives of orthopaedic meetings. Two reviewers independently selected studies for inclusion, extracted data and evaluated risk of bias; and a third reviewer resolved discrepancies. Risk ratios (RR) were calculated for dichotomous data, and mean difference (MD) or standardised mean difference (SMD) was calculated for continuous data. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results 39 studies were included with 51 857 participants (range of mean age: 74 to 93 years). Three studies were RCTs and 36 were observational studies (OBS). The evidence from RCTs and OBS showed that early surgery reduces risk of all-cause mortality (RR 0.73, 95% confidence interval (CI) 0.65 to 0.83; I2 67%; low quality of evidence (LQE)). OBS showed reduced risk of all-cause mortality when surgery is performed within the first 48 hours upon hospital admission (RR 0.72, 95% CI 0.62 to 0.84; I2 65%; very LQE). OBS also showed a reduction of complications (RR 0.61, 95% CI 0.51 to 0.73; I2 64%; very LQE) and pain (RR 0.89, 95% CI 0.67 to 1.17; I2 0%; very LQE). RCTs showed that early surgery reduces length of stay (MD −6.73, 95% CI −12.92 to −0.54; I2 54%; very LQE) and improves functionality (SMD 0.32, 95% CI 0.04 to 0.59; I2 5%; LQE). Conclusions Low-quality evidence showed that early surgery reduces all-cause mortality at 6 and 12 months post-surgery, especially when it is performed during the first 48 hours after hospital admission. There was very low-quality evidence of a reduction in complications including pneumonia and pressure sores, and low-quality evidence for a reduced risk of urinary tract infection for early compared with delayed surgery. Reductions in length of hospital stay and improvement of postoperative functionality with early surgery were also observed but with very low- and low-quality of evidence respectively. There was very low-quality evidence for no effect of early surgery on postoperative pain.