How the cause of surgical delay affects mortality in fragility hip fractures: A cohort study

Prompt surgery for fragility hip fractures is a cornerstone of care and a key metric within the Best Practice Tariff (BPT) in the United Kingdom. Yet, since 2011, time to theatre has steadily increased, BPT adherence has fallen, and paradoxically, mortality has reduced. It is still unclear if surgical delay is an independent predictor of mortality. Emerging evidence suggests that the causes of surgical delays may be more important determinants of mortality than the delay itself.

A cohort study of 1769 hip fracture patients above the age of 60 was conducted in a single centre in England. This study collected demographic data, timing to theatre (<36 h vs ≥36 h), reasons for any delays, 30-day mortality and 1-year mortality between March 2020 and December 2024.

The most common cause of delay was insufficient theatre capacity (N = 365, 20.6%), followed by delays awaiting medical stabilisation (N = 102, 5.8%). Age (Χ² 71.638 p < 0.001), ASA grade (Χ² 37.045 p < 0.001), sex (Χ² 27.721 p < 0.001), pre-admission residence (Χ² 36.772 p < 0.001), and reason for delay (Χ² 27.495 p = 0.007) were significant predictors of mortality. Delays due solely because of theatre unavailability did not increase 30-day (OR 0.784 p = 0.398) or 1-year mortality (OR 1.123 p = 0.474). In contrast, delays due to medical optimisation were associated with markedly higher 30-day (OR 3.573, p < 0.001) and 1-year mortality (OR 2.144, p = 0.005).

While early surgery remains beneficial, patients delayed solely due to administrative reasons did not demonstrate an associated increase in mortality. Mortality associated with operative delay was primarily associated amongst patients with concurrent acute illnesses and co-morbidities, independently increasing risk. To improve mortality, the focus must remain on pre-operative optimisation and robust orthogeriatric assessment, rather than surgical timing alone. Future iterations of the BPT may benefit from incorporating the cause of delay and physiological risk stratification to surgical timing targets to better align national incentives with clinical outcomes.