The Surgical Timing Gap in Elderly Hip Fracture Management: A Regional Systems Analysis

Timely surgical management of hip fractures in elderly patients is a key determinant of outcomes. International guidelines recommend early surgery; however, data on system-level contributors to delay in Saudi Arabia remain limited.

The aim of this study is to evaluate surgical timing in elderly hip fracture patients in the Medina region, identify patient-, provider-, and system-level factors contributing to delay, and assess the impact of delayed surgery on clinical outcomes.

This retrospective cohort systems analysis included 400 patients aged ≥60 years admitted with femoral neck, intertrochanteric, or subtrochanteric hip fractures to two regional hospitals. Patients were stratified into early (≤48 hours) and delayed (>48 hours) surgery groups. Descriptive statistics, bivariate analyses, and multivariable logistic regression were performed to identify predictors of delay. Outcomes included length of stay, postoperative complications, and in-hospital mortality.

Only 22.0% of patients underwent surgery within 48 hours. The median time to surgery was 88.2 hours. Delayed surgery was associated with older age (p = 0.052) and higher ASA class (p = 0.029). Weekend admission (31.7% vs. 14.0%; p = 0.009), a greater number of preoperative consultations (p = 0.002), and operating room list deferral (25.2% vs. 0%; p < 0.001) were significantly associated with delay. In multivariable analysis, independent predictors of delay included older age (aOR 1.04; p = 0.015), intertrochanteric fracture (aOR 2.07; p = 0.048), weekend admission (aOR 2.84; p = 0.029), longer laboratory turnaround time (aOR 1.02; p = 0.012), and increased number of consultations (aOR 1.88; p < 0.001). Delayed surgery was associated with a longer hospital length of stay (median 8 vs. 6 days; p < 0.001), while postoperative complications (p = 0.312) and in-hospital mortality (p = 0.527) did not differ significantly between groups.

Surgical delay in elderly hip fracture patients in the Medina region is common and is driven predominantly by modifiable system-level factors rather than patient-related clinical instability. Addressing organizational barriers, particularly weekend service gaps, consultation burden, and operating room access, may substantially improve timeliness and efficiency of hip fracture care.