Open Journal of Orthopedics, 2013, 3, 193-198 Published Online August 2013 (
Copyright © 2013 SciRes. OJO
Causes of Surgical Delay and Demographic Characteristics
in Patients with Hip Fracture*
Sjöstrand Desirée1, Hommel Ami1, Johansson Anders2#
1Department of Clinical Sciences, Lund University and Skane University Hospital, Lund, Sweden; 2Sections of Anaesthesiology and
Intensive Care, Department of Clinical Sciences, Lund University and Skane University Hospital, Lund, Sweden.
Received June 19th, 2013; revised July 15th, 2013; accepted July 25th, 2013
Copyright © 2013 Sjöstrand Desirée et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Several studies analyze how surgical delay affects patien ts with hip fracture. The aim of this study was to
identify the causes of surgical delay and demographic characteristics in patients with hip fracture who had delays longer
than 24 hours from admission to hospital. Methods: Quantitative retrospective register study of 484 patients was con-
secutively included during the period November 1, 2010 and October 31, 2011 in the University Hospital in Lund (Swe-
den). Results: A frequen cy of 29.4% had a su rgical delay longer than 24 hours. The main reaso ns for delays to surgery
were lack of theatre facilities (54%), medical unstable patient (16%) and anticoagulan t treatment (10%). Of all patients,
69% (n = 332) wer e women and 31% (n = 151) were men. The mean age for women were 83.6 (CI 83 - 85) vs. 79 (CI
77 - 81 ) f or men , re sp ec ti ve ly . T he mos t c o mmo n t yp e o f h ip fr ac tu re wa s di splaced cervical hip fracture (39%, n = 188)
with a majority of fractures in male patients. In total, women suffered hip fractures to a greater extent than men (69% vs.
31%, p = 0.016), but no relationship was found with respect to the fracture type and age (p = 0.358). Conclusion: The
main result demonstrated that d elays longer than 24 hou rs were due to lack of theatre facilities. Further researches have
to be done in order to investigate whether lack of theatre facilities depends on improper operation planning and/or on
lack of medical staff.
Keywords: Orthopedics; Hip Fracture; Surgical Delay; Register Study
1. Introduction
Hip fracture is one of the conditions that have become a
major problem with significant post-fracture disability,
reduced quality of life as well as increasing mortality [1].
The number and the proportion of older persons are
growing in practically all countries [2]. With the in-
creasing proportion of elderly in the worldwide popula-
tion, the number of cases of hip fracture will inevitably
rise [3,4]. It is estimated that the annual number of hip
fractures worldwide will rise from 1.7 million in 1990 to
around 6.3 million by 2050. Each year in Sweden (with
around 9 million inhabitants), approximately 18,000 pa-
tients are hospitalized and operated due to hip fractures
Despite a growing awareness of the impact on quality
of life and on outcome after hip fracture, the surgical
delay is still an abundant problem among hip fracture
patients [7-11]. Several studies have shown that delayed
surgery in patien ts with hip fracture pro longs hospitaliza-
tion and increases morbidity, the number of complica-
tions, physical and psychological suffering and mortality
[10,12,13]. However, some recently published studies
have suggested that there is a correlation between early
surgery and decrease in postoperative complications.
Patients with hip fracture who were operated within 24
hours from admission have fewer complications and
lowered mortality risk than those patients who had to
wait longer for surgery [3,8,9,14,15]. Regardless of this
knowledge, some studies indicate that a significant number
of patients suffer according surgical delay and some
studies point out improper operation planning and/or
staff unavailability at the surgical d epartment [11,16]. To
our knowledge, th ere are no publish ed trials with the aim
of explicitly identifying the causes of surgical delay in
patients with hip fracture.
*Conflict of interest: We declare there isn’t any conflict of interest.
Funding: This research needed no funding.
Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture
Copyright © 2013 SciRes. OJO
2. Material and Methods
The study was approved by the Ethics Committee of the
Medical Faculty of the Lund University (VEN 128-11)
and has been performed in accordance with the declara-
tion of Helsinki. Study sample includes entirely 484 pa-
tients undergoing surgery for hip fracture during the pe-
riod November 1, 2010 and October 31, 2011 at Skåne’s
University Hospital in Lund (Sweden). Both patients
who underwent surgery within 24 hours and patients with
surgical delays longer than 24 hours were included. The
reason for this was to exactly identify the proportion of
individuals who underwent surgery later than 24 hours
after admission and to precisely descr ibe the wh ole group
of hip fracture patients during the study period. One pa-
tient was excluded from the study and the reason was
that the patient passed away before surgery was possible.
All data for the study were collected from the Swedish
National Hip Register , RIKSHÖFT. The main purpose of
the registry is to ensure co n tinu ou s quality and to create a
high quality of care for hip fracture patients across the
country [13]. The registry consists of several forms which
are used to collect data about the patient, the treatment,
the functional outcome and the rehabilitation outcome.
For this study we created a new document with variables
from these forms which were considered relevant to the
purpose of the study. These variables were: age, gender,
fracture type, date of arrival, time of arrival, start time
for surgery, surgery within 24 hour and reason for delay.
In order to identify if there was any connection between
the number of delays and day of arrival we conv erted the
category date of arrival to day of the week of arrival.
Afterwards and to determine whether the number of de-
lays was affected by the time of arrival, we divided the
day into 4 intervals: 7:00 to 12:00, 12:01 to 17:00, 17:01
to 9:00 p.m. and 9:01 p.m. to 6:59, respectively. The reg-
ister was checked by authorized personnel and a further
regular check of the collected data was carried out in
order to ensure the reliability of the study: the data of
every twentieth patient was compared to the original
from the Swedish National Hip Register.
Data were analyzed using the Statistical Package for So-
cial Sciences (SPSS 14.0). Results are presented using
descriptive statistics according to numbers of patients (n),
mean/median, standard deviation (SD) and proportions
where appropriate.
A comparative analysis was performed to identify sta-
tistical differences between fracture type and gender,
fracture type and age, number of delays and day of the
week of arrival, delays and time of arrival, delays and
age, and between delays and gender. Normal distribution
was determined by Kolmogorov-Smirnov test. Compari-
son analyses were carried out with confidence interval
(CI) for age, Chi-Square test was used for nominal data
and for differences of proportions, and Fisher’s exact test
was used when variables were less than 5. Ratio data was
analyzed with Student’s t-test. A statistically significant
differe n ce w a s re garded a s p < 0. 05.
3. Results
3.1. Demographics
The study group enrolled in the study consisted of 483
hip fracture patients, 69% (n = 332) were female and
31% (n = 151) were men. Age ranged between 22 and 98
years in men and between 45 and 102 years in women.
Mean age for men w as 79 (CI 77 - 81) and 83.6 ( CI 83 -
85) for women, respectively. The most common type of
hip fracture was the displaced cervical hip fracture (39%,
n = 188) with a clear majority of fractures in male pa-
tients. Overall, women suffer hip fractures to a greater
extent than men (69% vs. 31%, p = 0.016) (Table 1).
However, no statistically significant relationship was
found with respect to the fracture type and age (p =
3.2. Surgical Delay and Effect of Age and
A number 29.4% (n = 142) patients had to wait over 24
hours before surgery with no significant difference be-
tween the “24-hour target” and gender (p = 0.516). The
patients who were operated in within 24 hours from
admission were significant older (p = 0.022) (Table 2).
3.3. Causes of Surgical Delay
The most common reason for surgical delay was “lack of
theatre facilities” (54%, n = 76) followed by “medically
unstable patient” (16%, n = 22) and “patient on antico-
agulant th erapy” (10%, n = 14) (Table 3).
3.4. Surgical Delay and Effect of Time of Day
and Day of the Week of Admission
When day of the week of admission was surveyed the
largest number of patients arrived at the hospital on
Thursday and a minimum number of patients on Sundays
with no statistical differences between the number of
delays to surgery and the day of the week (p = 0.248,
Table 4). Depict Time of day of admission showed that
the majority of patients arrived at the hospital between
12:01 and 17:00 (Table 5), with no differences between
the time points (p = 0.345). The largest proportion of
patients had to wait between 24 and 48 hours for surgery
(Table 6). The mean waiting time for patients with de-
layed surgery was 40 ± 29 hours with a mean median
value of 30 hours.
Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture
Copyright © 2013 SciRes. OJO
Table 1. Incidence of fracture types.
Gender Fracture type
Cervical Displaced cervical Basocervical Trochanteric 2
fragment Trochanteric
+ 2 fragment Subtrochanteric Total (n)
Men 9.9% 51% 2% 13.2% 15.9% 7.9% 151
Women 12.9% 33.6% 4.2% 19.8% 18.9% 10.5% 332
Total 12% 39% 3.5% 17.8% 18% 9.7% 483
Analysis be t ween gender and frequency of fractures, p = 0. 0 16, Pearson’s chi-squared test.
Table 2. Compliance with 24-hour goal.
Compliance with 24-hour goal Mean age (±SD)
Yes 83 ± 11
No 80 ± 11
Difference between “24-hour goal” according to age: p = 0.022, T-test.
Table 3. Causes of surgical delay.
Cause of delay Total (n) P ercent (%)
Delayed examinati on 1 <1
Repeated X-ray 1 <1
Diagnosis after CT scan 5 4
Diagnosis after MRI 3 2
Administrative delay 3 2
Lack of theatre facilities 76 54
Surgeon not available 1 <1
Anesthesiologist not available 1 <1
Medically unstable patient 22 16
Gastrointestinal haemorrhage 2 1
To determine the diagnosis 9 6
Recent myocardial infarction 2 1
Anticoagulant therapy 14 10
Other 1 <1
Total 142 <101
4. Discussion
The purpose of th is study was to identify the cause of the
delay to surgery in patients with hip fracture in Skåne,
southern Sweden. The variables analyzed were consi-
dered important for the development and assurance of
care for this patient population. In summary, the results
showed that the main reason for surgical delay was lack
of theatre facilities (54%) and Medical unstable patient
According lack of theatre facilities we could not find
Table 4. Number of delays to surgery and day of the week
of admission.
Day of the week Total (n) Percent (%)
Monday 74 15.3
Tuesday 73 15.1
Wednesday 77 15.9
Thursday 81 16.9
Friday 63 13.0
Saturday 65 13.4
Sunday 50 10.3
Total 483 100
p = 0.248, Pe arson’s c h i-squared te st.
Table 5. Time of day of admission.
Time Total (n) Percent (%) Number delays
7:00 to 12:00 101 20.9 30
12:01 to 17:00 172 35.5 59
17:01 to 21:00 99 20.7 28
21:01 to 06:59 111 22.9 25
Total 483 100 142
p = 0.345, Pe arson’s c h i-squared te st.
Table 6. Number of patients within the different time points
that underwent surgery later than 24 hours from admission.
Hours to surgery MonTu Wen Thur FriSatSun
24 - 48 hours 141725 23 14208
48 - 72 hours 3 31 2 2 10
More than 72 h 2 20 1 4 0 0
Total 192226 26 20218
p = 0.248, Fi sh er’s exact test.
information why the absence occurred. A probable rea-
son could be improper operation planning or staff un-
availability in the surgical department, since these are
known issues [11]. Similar results emerged in an Aus-
Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture
Copyright © 2013 SciRes. OJO
tralian study by Hamish et al. [16] where 58% of the
delays were due to lack of theater facilities and 33% due
to medical unstable patient. Hommel et al. [9] describes
comparable findings in Sweden.
In present study, there was a significant difference in
age between men and women (men 79 vs. women 84).
The fact that women suffer more frequently than men of
hip fractures and that affected women are older than men
agrees well with the nation al register [17] and with other
studies [3,15,18]. Several published studies on this topic
show similar distribution of gender [3,9,15,18]. The
overwhelming proportion of women who are usually
seen in the majority of the studies can be explained by
two reasons: the fact that women have a higher life
expectancy and that women have an increased tendency
to osteoporosis [2]. Most of the studies in which the topic
hip fracture is surveyed exclude patients over 60 - 65
years. In our study, no patients were excluded because of
According to the National Board of Health and Wel-
fare guidelines for the care and treatment of patients with
hip fractures the most common fracture type is the dis-
placed cervical fracture [19]. Our analysis showed simi-
lar results. However, we found that women suffered
more than men of this particular fracture (59.5% vs.
40.5%) as women were more disposed to hip fractures.
This fact is confirmed by RIKSHÖFT annual reports.
When the reports for the past six years were analyzed
[17,20-24], it demonstrated that the fracture types fol-
lowed the same pattern as in our study and that the
distribution for fracture type was similar for both sexes.
This outcome is confirmed by Gjersten et al. [4], in th eir
study 72% of the participants were wo men and 38.1% of
all fractures were classified as displaced cervical frac-
tures. In terms of frequency distributions of gender, age
and fracture type, our study is comparable with other
studies concerning the subject.
Regarding the relationship between late surgery (not
within 24-hour) and gender we found no significant
difference. This is in contrast with Novack et al. [3]
study in which the proportion of males not operated was
higher than that of female patients (21.8% vs. 16.1%,
respectively). Additionally, they found no differences
according to age whether our analysis revealed a sig-
nificant correlation between to “surgery within 24 hours”.
Patients who met the “24-hour target” after arrival to the
hospital were older than the group of patients with de-
layed surgery.
Regarding the fulfillment of the “24-hour target”, our
result showed that surg ery was started within 24 hou rs in
70.6% of the cases. This figure corresponds well with the
figures of the regions Center for Operational Planning
and Analysis [2 5]. However, international surgical delays
are often defined in different ways and make it more
difficult to compare and evalua te our results. In the study
by Novack et al. [3] the authors reported only the number
of patients who underwent surgery within 48 hours from
arrival to the hospital.Of the included 4633 patients,
there were 17.6% who did not undergo surgery and
29.1% who underwent surgery within 48 hours. These
proportions cor responds to a Spanish study by Librero et
al. [15] that demonstrated an amounts of 24.7% of
patients were receiving surgery within the first days after
arrival to the hospital.
The OECD health report analyzed how health care
quality indicators have been between 1999 and 2004 in
OECD countries [26]. When time to surgery in hip frac-
ture patients was surveyed this issue demonstrated sig-
nificant differences between countries. The proportions of
patients who underwent surgery within 48 hours of arri-
val at the hospital were as follows: Sweden 93.5%,
Norway 93%, Finland 86%, Netherlands 80.4%, Canada
79.5%, Iceland 73.1%, Denmark 68.1%, Mexico 65.1%,
UK 61.5%, Italy 32.7% and Portugal 50.1%. It is clear
that there are considerable differences between the va-
rious countries in the wo rld in terms of quality indicators
for patie nts with hi p f rac ture.
When we analyzed Day of the week and Time of arri-
val, no correlation could be confirmed. Correspond-
ingly, Novack et al. [3] demonstrated that there was no
difference in surgical delay depending on which day of
the week the patients arrived at the hospital. According
to our result the largest proportion of patients who had
delayed surgery waited between 24 and 48 hours before
surgery. These findings agree well to the results of other
studies [15,27].
We believe that there is some strength with present
study. Before the start of the study and with regard to the
study purpose, appropriate data collections were discussed
with coordinator of the Swedish National Hip Registry.
We enrolled all patients from one year in an effort to
minimize the risk of bias that could influence of dif-
ferences in staffing, due to decreased production during
summer and national holidays. We also believe that the
study is based on a sufficiently large sample where the
drop out is minimal and therefore we consider the results
Even if there have been significant improvements to
streamline the management of hip fracture patients, the
hospital of Lund has not been able to meet Region
Skåne’s goal (surgery within 24 hours from admission
into hospital for at least 80% of all patients with hip
fracture) during the period, though only 70.6% of the
patients had surgery within the first day. If the main
reason for the result was due to improper planning at the
surgical department or due to understaffing had to be
investigated. Altho ugh it h as been difficult to find stud ies
within the subject (e.g. cause of delay to surgery), we
Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture
Copyright © 2013 SciRes. OJO
believe that our study could contribute to future actions
and measurements, in order to further optimize the health
care program for these patients and a prospective study
might be useful in order to better identify the causes of
the surgical delay.
5. Conclusion
The causes of delay to surgery within 24 hours occurred
in 29.4% of all patients with hip fracture. The main rea-
sons for delays were lack of theatre facilities (54%),
medical unstable patient (16%) and anticoagulant treat-
ment (10%). The most common type of hip fracture was
displaced cervical hip fracture (39%) with a majority of
fractures in male patients.
[1] A. Hommel, “Improved Safety and Quality of Care for
Patients with a Hip Fracture,” Ph.D. Dissertation, Lunds
Universitet, Institutionen för Hälsa, Vård Och Samhälle,
[2] WHO, “Sweden: “Nutrition for Older Persons,” 2011.
[3] V. Novack, A. Jotkowitz, O. Etzion and A. Porath, “Does
Delay in Surgery after Hip Fracture Lead to Worse Out-
comes? A Multicenter Survey,” International Journal for
Quality in Health Care, Vol. 19, No. 3, 2007, pp. 170-176.
[4] J.-E. Gjertsen, L.-B. Engesæter, O. Furnes, L.-I. Havelin,
K. Steindal, T. Vinje and J.-M. Fevang, “The Norwegian
Hip Fracture Register Experiences after the First 2 Years
and 15,576 Reported Operations,” Acta Orthopaedia, Vol.
79, No. 5, 2008, pp. 583-583.
[5] National Board of Health and Welfare, “Sweden: Fall-
skador i Vården,” 2011.
[6] RIKSHÖFT, “Sweden: Höftfrakturer; 2009a,” 2009.
[7] J. Richmond, G.-B. Aharonoff, J.-D. Zuckerman and K.-J.
Koval, “Mortality Risk after Hip Fracture,” Journal of
Orthopaedic Trauma, Vol. 17, No. 1, 2003, pp. 53-56.
[8] P. Vestergaard, L. Rejnmark and L. Mosekilde, “Increased
Mortality in Patients with a Hip Fracture-Effect of Pre-
Morbid Conditions and Post-Fracture Complications,”
Osteoporosi International, Vol. 18, No. 12, 2007, pp.
1583-1593. doi:10.1007/s00198-007-0403-3
[9] A. Hommel, K. Ulander, K. B. Björkelund, P.-O. Norman,
H. Wingstrand and K.-G. Thorngren, “Influence of Opti-
mised Treatment of People with Hipfracture on Time to
Operation, Length of Hospital Stay, Reoperations and
Mortality within 1 Year,” International Journal of the
Care of the Injured, Vol. 39, No. 10, 2008, pp. 1164-1174.
[10] S.-K. Khan, S. Kalra, M. M. Thiruvengada and M. J.
Parker, “Timing to Surgery for Hip Fractures: A System-
atic Rewiew of 52 Published Studies Involving 291,413
Patients,” International Journal of the Care of the Injured,
Vol. 40, No. 7, 2009, pp. 692-697.
[11] N. Simunovic, P. J. Devereaux and M. Bhandari, “Sur-
gery for Hip Fractures: Does Surgical Delay Affect Out-
comes?” Indian Journal Orthopaedia, Vol. 45, No. 1,
2011, pp. 27-32. doi:10.4103/0019-5413.73660
[12] K. B. Björkelund, “Acute Confusional State in Elderly Pa-
tients with Hip Fracture. Identification of Risk factors and
Intervention Using a Prehospital and Perioperative Man-
agement Program,” Ph.D. Dissertation, Lunds Universitet,
Institutionen för Hälsa, Vård Och Samhälle, 2008.
[13] RIKSHÖFT, “Sweden: Om Rikshöft; 2009b,” 2011.
[14] A. Bottle and P. Aylin, “Mortality Associates with Delay
in Operation after Hip Fracture: Observational Study,”
British Medical Journal, Vol. 332, No. 7547, 2006, pp.
947-951. doi:10.1136/bmj.38790.468519.55
[15] J. Librero, S. Peiró, E. Leutscher, J. Merlo, E. Bernal-
Delgado, M. Ridao, N. Martínez-Lizaga and G. Sanfélix-
Gimeno, “Timing of Surgery for Hip Fracture and In-Hos-
pital Mortality: A Retrospective Population-Based Cohort
Study in the Spanish National Health System,” BMC
Health Services Research, Vol. 12, No. 15, 2012.
[16] C. R. Hamish, I. A. Harris, L. Mcevoy and T. Todovora,
“Delay to Surgery and Mortality after Hip Fracture,” The
Australian and New Zealand Journal of Surgery, Vol. 77,
No. 10, 2007, pp. 889-891.
[17] RIKSHÖFT-SAHFE, “Annual Report 2009,” 2012.
[18] K. B. Björkelund, A. Hommel, K.-G. Thorgren, L. Gus-
tafson, S. Larsson and D. Lundberg, “Reducing Delirium
in Elderly Patients with Hip Fracture: A Multi-Factorial
Intervention Study,” Acta Anaesthesiologica Scandinavia,
Vol. 54, No. 6, 2010, pp. 678-688.
[19] National Board of Health and Welfare, “Guidelines for
Care and Treatment in Patients with Hip Fracture,” So-
cialstyrelsen, Stockholm, 2003.
[20] RIKSHÖFT-SAHFE, “Annual Report 2005,” 2011.
[21] RIKSHÖFT-SAHFE, “Annual Report 2006,” 2011.
[22] RIKSHÖFT-SAHFE, “Annual Report 2007,” 2011.
[23] RIKSHÖFT-SAHFE, “Annual Report 2008,” 2011.
Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture
Copyright © 2013 SciRes. OJO
[24] RIKSHÖFT-SAHFE, “Annual Report 2010,” 2012.
[25] Center for Operational Planning and Analysis, 2011.
[26] HCQI, “Health Care Quality Indicators Project. Initial
Indicators Report,” 2012.
[27] M. P. Fantini, G. Fabbria, M. Lausb, E. Carrettaa, S. Mi-
mmia, G. Franchino, L. Faveroc and P. Rucci, “Determi-
nants of Surgical Delay for Hip Fracture,” The Surgeon,
Vol. 9, No. 3, 2011, pp. 130-134.