Balancing risks in febrile hip fracture patients: is surgical delay more dangerous than infection?

Fever often delays urgent hip fracture surgery due to infection concerns. This study found that operating early, despite fever, did not increase complications or death compared to waiting. Thus, early surgery appears to be a feasible option for selected patients, avoiding the risks associated with surgical delay.

The optimal timing of hip fracture surgery in patients with preoperative fever remains uncertain. Although early surgery generally improves outcomes, fever often prompts delays because of concerns about underlying infection.

We retrospectively reviewed 208 patients (median age 83 years, 58% women) with low-energy hip fractures and documented preoperative fever (T > 38 °C) treated at a tertiary trauma center from 2012 to 2023. Patients were categorized by surgical timing: early (≤48 h, n = 108) or delayed (>48 h, n = 100). The primary outcome was one-year all-cause mortality, obtained from the national registry. Secondary outcomes were postoperative length of hospital stay and deep surgical site infection requiring surgical intervention.

One-year mortality was 20.4% (22/108) in the early group and 31.0% (31/100) in the delayed group (p = 0.079). Median postoperative length of stay was shorter after early surgery (6 days, IQR 4-11) than after delayed surgery (9 days, IQR 5-14; p = 0.031). Deep surgical site infection occurred in 1/108 (0.9%) early patients and 4/100 (4.0%) delayed patients (p = 0.148). Patients selected for early surgery had fewer systemic signs of illness, including lower CRP levels, less desaturation, and less frequent bacterial infections-suggesting that clinical judgment influenced surgical timing. Among patients with confirmed bacterial etiology, early surgery did not increase deep surgical site infection rates or one-year mortality compared to delayed surgery.

Early surgery in febrile hip fracture patients may be safe when guided by individualized assessment. Our findings support developing structured clinical criteria to aid surgical timing decisions, warranting further validation through larger prospective studies.