María T. Vidán, MD, PhD; Elisabet Sánchez, MD; Yassira Gracia, RN; Eugenio Marañón, MD; Javier Vaquero, MD, PhD; José A. Serra, MD, PhD
Grant Support: Dr. Vidán was partially supported by a Program for research intensification grant of the Fondo de Investigaciones Sanitarias del Instituto de Salud Carlos III, Ministry of Science and Innovation, Spain (INT 09/078).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2655.
Reproducible Research Statement:Study protocol: Available (in Spanish) from Dr. Vidán (e-mail, email@example.com). Statistical code: Available from Dr. Vidán. Data set: Not available.
Requests for Single Reprints: María T. Vidán, MD, PhD, Department of Geriatric Medicine, Hospital General Universitario Gregorio Marañón, Dr. Esquerdo 46, 28007 Madrid, Spain; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Vidán, Sánchez, Gracia, Marañón, and Serra: Department of Geriatric Medicine, Hospital General Universitario Gregorio Marañón, Dr. Esquerdo 46, 28007 Madrid, Spain.
Dr. Vaquero: Department of Orthopedic Surgery, Hospital General Universitario Gregorio Marañón, Dr. Esquerdo 46, 28007 Madrid, Spain.
Author Contributions: Conception and design: M.T. Vidán, E. Sánchez.
Analysis and interpretation of the data: M.T. Vidán, J.A. Serra.
Drafting of the article: M.T. Vidán.
Critical revision of the article for important intellectual content: M.T. Vidán, J. Vaquero, J.A. Serra.
Final approval of the article: M.T. Vidán, E. Sánchez, Y. Gracia, E. Marañón, J. Vaquero, J.A. Serra.
Provision of study materials or patients: J. Vaquero.
Administrative, technical, or logistic support: Y. Gracia, J. Vaquero.
Collection and assembly of data: M.T. Vidán, E. Sánchez, Y. Gracia, E. Marañón.
Vidán M., Sánchez E., Gracia Y., Marañón E., Vaquero J., Serra J.; Causes and Effects of Surgical Delay in Patients With Hip Fracture: A Cohort Study. Ann Intern Med. 2011;155:226-233. doi: 10.7326/0003-4819-155-4-201108160-00006
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Published: Ann Intern Med. 2011;155(4):226-233.
The clinical effect of surgical delay in older patients with hip fracture is controversial. Discrepancies among study findings may be due to confounding that is caused by the reason for the delay or a differential effect on patient risk subgroups.
To assess the effect of surgical delay on hospital outcomes according to the cause of delay.
Prospective cohort study.
A hip fracture unit in a university hospital in Spain.
2250 consecutive elderly patients with hip fracture.
Time to surgery, reasons for surgical delay, adjusted in-hospital death, and risk for complications.
Median time to surgery was 72 hours. Lack of operating room availability (60.7%) and acute medical problems (33.1%) were the main reasons for delays longer than 48 hours. Overall, rates of hospital death and complications were 4.35% and 45.9%, respectively, but were 13.7% and 74.2% in clinically unstable patients. Longer delays were associated with higher mortality rates and rates of medical complications. After adjustment for age, dementia, chronic comorbid conditions, and functionality, this association did not persist for delays of 120 hours or less but did persist for delays longer than 120 hours (P = 0.002 for overall time effect on death and 0.002 for complications). The risks were attenuated after adjustment for the presence of acute medical conditions as the cause of the delay (P = 0.06 for time effect on mortality and 0.31 on medical complications). Risk for urinary tract infection remained elevated (odds ratio, 1.54 [95% CI, 0.99 to 2.44]). No interaction between delay and age, dementia, or functional status was found.
This was a single-center study without postdischarge follow-up.
The reported association between late surgery and higher morbidity and mortality in patients with hip fracture is mostly explained by medical reasons for surgical delay, although some association between very delayed surgery and worse outcomes persists.
Renal Consultants of Houston, Houston Texas, 77019 USA
September 23, 2011
Is hyponatremia a risk factor for delayed surgery after hip fracture?
We read with interest the paper by Vidan et al. (1). In their report they mention that late surgery in patients with hip fracture is mostly explained by medical reasons, among them marked electrolyte abnormalities. Unfortunately the authors failed to specify which type. In 1999 our group first reported that bone fractures secondary to falls was the initial presentation in 25 % of people with hyponatremia (2). Moreover recent information indicates a higher incidence of hyponatremia among elderly patients (> 65 years) presenting to the emergency departments with a bone fracture, principally hip fractures (3). Genkam et al. evaluated the incidence of hyponatremia ( Na < 135 mmol/l) in 513 elderly patients presenting to the emergency department with a bone fracture and compared them to a sex and aged match control group of ambulatory patients (4). Patient with bone fracture had a significantly higher incidence of hyponatremia than controls (13% vs. 3.9%), with an adjusted odds ratio for bone fracture associated with hyponatremia of 4.16. Several studies have shown that patients with hyponatremia have significant disorders in gait and attention with a consequent high incidence of falls. Renneboog et al evaluated the incidence of falls among 122 elderly patients admitted through the emergency department with asymptomatic chronic hyponatremia (mean Na 126 mmol/l) compared to 244 normonatremic matched controls (5). The incidence of falls was 21.3% in the hyponatremic group compared to 5.3% in the controls, with an adjusted odds ratio for falls in patients with hyponatremia of 67 (95% confidence: 7.5-607; P <.001). So to the end we would like to know the incidence of hyponatremia in patients admitted for hip fracture surgery in the study by Vidan et al. (1).
Juan Carlos Ayus, MD, FACP, FASN Director of Clinical Research Renal Consultants of Houston, Houston Texas, 77019 USA email@example.com
Armando Luis Negri MD, FACP Institute for Metabolic Research, del Salvador University, Buenos Aires, Argentina firstname.lastname@example.org
Michael L. Moritz MD Division of Nephrology, Children's Hospital of Pittsburgh of UPMC, The University of Pittsburgh School of Medicine, Pittsburgh, PA, 15201 USA email@example.com
1. Vid?n MT, S?nchez E, Gracia Y, Mara??n E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study.Ann Intern Med. 2011;155(4):226-33.
2. Ayus JC, Arieff AI. Chronic hyponatremic encephalopathy in postmenopausal women: association of therapies with morbidity and mortality. JAMA 1999;281:2299-304.
3. Ayus JC, Moritz ML. Bone disease as a new complication of hyponatremia: moving beyond brain injury. Clin J Am Soc Nephrol 2010;5:167 -8. 4. Gankam Kengne F, Andres C, Sattar L, Melot C, Decaux G. Mild hyponatremia and risk of fracture in the ambulatory elderly. QJM 2008;101:583-8.
5. Renneboog B, Musch W, Vandemergel X, Manto MU, Decaux G. Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. Am J Med 2006;119:71 e1-8.
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