Skip to main content
Download PDF
  • Research article
  • Open access
  • Published:

Delayed surgery after hip fracture affects the incidence of venous thromboembolism

Journal of Orthopaedic Surgery and Research volume 18, Article number: 630 (2023) Cite this article

Abstract

Background

Venous thromboembolism (VTE) is one of the most common complications of hip fracture surgeries, and it is unclear whether delayed surgery affects the incidence of VTE. This study aimed to examine the association between delayed surgery and VTE incidence by statistically adjusting for factors that may influence VTE incidence.

Methods

We included 862 patients ≥ 65 years with hip fractures who underwent surgery between October 2010 and December 2020. We examined the effect of surgical delay 48 h after injury on postoperative VTE. Patients with and without VTE were assigned to groups V and NV, respectively. Those with and without proximal deep venous thrombosis (DVT) were assigned to PD and NPD groups, respectively. Univariate analysis was performed to identify factors that might influence DVT development. Risk factors for developing VTE and proximal DVT were analyzed using logistic regression analysis to determine whether delayed surgery was a risk factor.

Results

VTE was observed in 436 patients (40%) and proximal DVT in 48 patients (5.6%). Univariate analysis showed significant differences in the time from trauma to surgery between the V and NV groups and between the PD and NPD groups. In multivariate analysis, surgery 48 h later was also a risk factor for developing VTE and proximal DVT.

Conclusion

A delay in surgery beyond 48 h after a hip fracture injury is a risk factor for developing VTE and proximal DVT.

Background

Hip fractures are common in older adults [1]. With increasing life expectancy, the incidence of hip fractures is increasing [2]. Therefore, it is important to not only treat fractures but also prevent patient complications [3]. Venous thromboembolism (VTE) is one of the most common complications of hip fracture surgery, and pulmonary embolism (PE) is the fourth leading cause of death in patients with hip fracture [4]. Deep venous thrombosis (DVT) is a major cause of PE; hence its prevention is very important [5]. Reports examining complications after hip fracture surgery found no association between the occurrence of DVT and delayed surgery [6, 7]. However, these studies were unclear on how to assess DVT, and the incidence of DVT was very low, ranging from 0.8 to 1.4%.

Recent studies have, however, reported that the incidence of DVT ranges from 11 to 57% [8,9,10,11]. The incidence of DVT from these studies differs significantly from that in studies denying the association.

DVT is often asymptomatic [12] and can occur outside the injured limb [13]. Studies reporting no association may have inaccurately assessed the occurrence of VTE [6, 7]. Additionally, many factors [14] influence the development of VTE, and it is unclear whether delayed surgery influences VTE incidence.

This study aimed to examine the association between delayed surgery and the incidence of VTE by statistically adjusting for factors that influence the incidence of VTE.

Methods

Study design

This single-center retrospective cohort study was conducted based on Strengthening the Reporting of Observational Studies in Epidemiology statement.

Our study was approved by the institution’s ethics committee, and the requirement for informed consent was waived due to the retrospective nature of the study.

We included 1119 cases of hip fractures treated between October 2010 and December 2020. The exclusion criteria were as follows: (1) patients ≤ 65 years of age; (2) no postoperative duplex ultrasonography; (3) no body mass index (BMI) data; and (4) simultaneous bilateral hip fractures.

Protocol for the prevention of VTE in hip fracture

Preoperative: Patients were encouraged to wear elastic stockings on both lower limbs. Automatic ankle joint movement was encouraged to the maximum extent possible.

Intraoperative: Intermittent pneumatic compression device worn on the healthy side.

Postoperative: Intermittent pneumatic compression device worn on both sides.

Patients without contraindications were treated with anticoagulants. On postoperative day 5, DVT of both the lower extremities was evaluated using duplex ultrasonography.

DVT definition and data collection

Distal DVT was defined as a thrombus in the tibial, peroneal, soleus, or gastrocnemius vein. Proximal DVT was defined as a thrombus in the popliteal vein or a vein proximal to the popliteal vein [15]. If distal and proximal DVT occurred together, we classified it as proximal DVT [16]. Based on medical records, we examined factors that might influence the development of DVT. Factors influencing DVT were age at injury, sex, BMI, fracture type, operative technique, time from injury to surgery, time from surgery to echo, and postoperative anticoagulation therapy, based on previous reports [17].

It has been reported that surgery within 48 h of admission improves outcomes [17]. However, there are cases where this time elapses between injury and hospitalization. We examined patients who underwent surgery within 48 h of injury and those who underwent surgery after this duration.

Patients with and without VTE were classified into the V and NV groups, respectively. Patients with and without proximal DVT were classified into the PD and NPD groups, respectively.

Statistical analysis

Factors that may influence the development of DVT were compared in univariate and multivariate analyses between the V and NV groups and between the PD and NPD groups.

In univariate analysis, the Mann–Whitney test was used for numerical data and Fisher's exact test for categorical data. Additionally, the risk factors for the development of VTE and proximal DVT were analyzed using logistic regression analysis to test whether the duration of the surgical waiting period was a risk factor.

All p values were two-sided, and results were considered statistically significant at p values < 0.05. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). It is a modified version of the R software focusing on statistical functions frequently used in biostatistics.

Results

The criteria were met in 862 cases (Fig. 1). VTE was observed in 436 patients (40%), proximal DVT in 48 patients (5.6%), and asymptomatic PE in two patients (0.2%). Symptomatic PE was not observed.

Fig. 1
figure 1

Patient selection flowchart. Overall, 41 cases of patients under 65 years old, 170 cases of no ultrasound performed, 41 cases of no data description of BMI, and five cases of bilateral fracture were excluded. BMI, body mass index

Full size image

Univariate analysis

Univariate analysis between the V and NV groups revealed significant differences in age, sex, surgical technique, and waiting period for surgery (p < 0.01, p < 0.01, p < 0.05, p < 0.01) (Table 1). There were also significant differences between the PD and NPD groups in terms of BMI and the waiting period for surgery (p < 0.01) (Table 2).

Table 1 Comparison between VTE and non-VTE groups
Full size table
Table 2 Comparison between proximal and non-proximal DVT groups
Full size table

Multivariate analysis

Multivariate analysis revealed that age, female sex, and surgery 48 h later (odds ratio [OR] = 1.04, 95% confidence interval [CI]: 1.02–1.06, p < 0.01; OR = 1.76, 95% CI 1.22–2.53, p < 0.01, and OR = 1.83, 95% CI 1.21–2.20, p < 0.01, respectively) were risk factors for VTE (Table 3). BMI and surgery 48 h later (OR = 0.90, 95% CI 0.82–0.99, p < 0.05 and OR = 2.17, 95% CI 1.15–4.08, p < 0.05, respectively) were risk factors for developing proximal DVT (Table 4).

Table 3 Risk factors for postoperative VTE using logistic regression analysis
Full size table
Table 4 Risk factors for postoperative proximal DVT
Full size table

Discussion

In this study, we screened for DVT using lower-extremity duplex ultrasonography after hip fracture surgery and statistically adjusted for factors that may influence the development of VTE, including the time from trauma to surgery.

The incidence of postoperative DVT was 40%. Delayed surgery is a risk factor for VTE development. Delayed surgery is also a risk factor for proximal DVT, which is associated with a high risk of developing PE.

Some reports with large surveys found no association between delayed surgery and VTE [5, 6]. These studies reported a DVT incidence of 0.8–1.9% and a PE incidence of 0.7–1.7%. Compared with the present study, the incidence of PE is comparable, but the incidence of DVT is very low, and the method of testing for DVT is unknown. Screening tests were not performed, and DVT was likely not diagnosed. Patients with symptomatic VTE present with swelling, pain, erythema, localized heat in the lower extremities, and dyspnea. Swelling and pain are often difficult to diagnose when symptoms overlap with those associated with proximal femoral fractures or asymptomatic VTE [18]. It can occur on the healthy and injured sides 10, and a screening examination of both lower extremities is necessary.

The present study included cases in which screening tests were performed on both lower extremities to diagnose symptomatic and asymptomatic DVT. Zhang et al. performed a multivariate analysis of 463 proximal femoral fractures that underwent ultrasonography at screening and reported that the duration of time waiting for surgery was a risk factor for the development of DVT [8]. However, the study did not distinguish between distal and proximal DVT. Proximal DVT is associated with a higher risk of developing PE than distal DVT [19,20,21], and its impact on proximal DVT is clinically significant. Therefore, we investigated the relationship between proximal DVT and surgical waiting time. The waiting time for surgery was also a risk factor for proximal DVT.

However, a recent study stated that distal DVT could progress to proximal DVT and PE [22]. It should be noted that distal DVT is associated with the same risk of developing PE as proximal DVT [23]. In the present study, we examined distal and proximal types of VTE and DVT and found that the duration of the delayed surgery was a risk factor for both types of VTE. Surgery within 48 h is important to prevent postoperative VTE.

The limitations of this study include the following:

  1. (1)

    This was a single-center retrospective study, which may have affected the accuracy and precision of data collection and introduced unavoidable selection bias.

  2. (2)

    Although there were reports of preoperative DVT, we performed surgery early in many cases and did not perform a preoperative thrombogenic evaluation.

  3. (3)

    We did not include all factors, such as history of hospitalization, postoperative mobilization, cancer, or presence of infection, involved in DVT.

Conclusions

Surgery for proximal femur fractures 48 h after an injury is a risk factor for developing VTE and proximal DVT. Surgery within 48 h is important to prevent postoperative VTE.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

VTE:

Venous thromboembolism

PE:

Pulmonary embolism

DVT:

Deep venous thrombosis

PD:

Patients with proximal DVT

NPD:

Patients without proximal DVT

V:

Patients with VTE

NV:

Patients without VTE

OR:

Odds ratio

CI:

Confidence interval

References

  1. Aletto C, Aicale R, Pezzuti G, Bruno F, Maffulli N. Impact of an orthogeriatrician on length of stay of elderly patient with hip fracture. Osteoporos Int. 2020;31:2161–6. https://doi.org/10.1007/s00198-020-05510-0.

    Article  CAS  PubMed  Google Scholar 

  2. Collin PG, D’Antoni AV, Loukas M, Oskouian RJ, Tubbs RS. Hip fractures in the elderly: a clinical anatomy review. Clin Anat. 2017;30:89–97. https://doi.org/10.1002/ca.22779.

    Article  PubMed  Google Scholar 

  3. Quaranta M, Miranda L, Oliva F, Migliorini F, Pezzuti G, Maffulli N. Haemoglobin and transfusions in elderly patients with hip fractures: the effect of a dedicated orthogeriatrician. J Orthop Surg Res. 2021;16:387. https://doi.org/10.1186/s13018-021-02524-0.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Perez JV, Warwick DJ, Case CP, Bannister GC. Death after proximal femoral fracture: an autopsy study. Injury. 1995;26:237–40. https://doi.org/10.1016/0020-1383(95)90008-l.

    Article  CAS  PubMed  Google Scholar 

  5. Giordano NJ, Jansson PS, Young MN, Hagan KA, Kabrhel C. Epidemiology, pathophysiology, stratification, and natural history of pulmonary embolism. Tech Vasc Interv Radiol. 2017;20:135–40. https://doi.org/10.1053/j.tvir.2017.07.002.

    Article  PubMed  Google Scholar 

  6. Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA. 2017;318:1994–2003. https://doi.org/10.1001/jama.2017.17606.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182:1609–16. https://doi.org/10.1503/cmaj.092220.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Zhang BF, Wei X, Huang H, Wang PF, Liu P, Qu SW, et al. Deep vein thrombosis in bilateral lower extremities after hip fracture: a retrospective study of 463 patients. Clin Interv Aging. 2018;13:681–9. https://doi.org/10.2147/CIA.S161191.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Shin WC, Woo SH, Lee SJ, Lee JS, Kim C, Suh KT. Preoperative prevalence of and risk factors for venous thromboembolism in patients with a hip fracture: an indirect multidetector CT venography study. J Bone Joint Surg Am. 2016;98:2089–95. https://doi.org/10.2106/JBJS.15.01329.

    Article  PubMed  Google Scholar 

  10. Song K, Yao Y, Rong Z, Shen Y, Zheng M, Jiang Q. The preoperative incidence of deep vein thrombosis (DVT) and its correlation with postoperative DVT in patients undergoing elective surgery for femoral neck fractures. Arch Orthop Trauma Surg. 2016;136:1459–64. https://doi.org/10.1007/s00402-016-2535-4.

    Article  PubMed  Google Scholar 

  11. Tang Y, Wang K, Shi Z, Yang P, Dang X. A RCT study of Rivaroxaban, low-molecular-weight heparin, and sequential medication regimens for the prevention of venous thrombosis after internal fixation of hip fracture. Biomed Pharmacother. 2017;92:982–8. https://doi.org/10.1016/j.biopha.2017.05.107.

    Article  CAS  PubMed  Google Scholar 

  12. Sun Y, Chen D, Xu Z, Shi D, Dai J, Qin J, et al. Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: a retrospective study with routinely applied venography. Arthroscopy. 2014;30:818–22. https://doi.org/10.1016/j.arthro.2014.02.043.

    Article  PubMed  Google Scholar 

  13. Decker S, Weaver MJ. Deep venous thrombosis following different isolated lower extremity fractures: what is known about prevalences, locations, risk factors and prophylaxis? Eur J Trauma Emerg Surg. 2013;39:591–8. https://doi.org/10.1007/s00068-013-0266-6.

    Article  CAS  PubMed  Google Scholar 

  14. Streiff MB, Agnelli G, Connors JM, Crowther M, Eichinger S, Lopes R, et al. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis. 2016;41:32–67. https://doi.org/10.1007/s11239-015-1317-0.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Niu S, Li J, Zhao Y, Ding D, Jiang G, Song Z. Preoperative deep venous thrombosis (DVT) after femoral neck fracture in the elderly, the incidence, timing, location and related risk factors. BMC Musculoskelet Disord. 2021;22:264. https://doi.org/10.1186/s12891-021-04145-4.

    Article  PubMed  PubMed Central  Google Scholar 

  16. MacDonald DRW, Neilly D, Schneider PS, Bzovsky S, Sprague S, Axelrod D, et al. Venous thromboembolism in hip fracture patients: a subanalysis of the FAITH and HEALTH trials. J Orthop Trauma. 2020;34(Suppl 3):S70–5. https://doi.org/10.1097/BOT.0000000000001939.

    Article  PubMed  Google Scholar 

  17. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40:692–7. https://doi.org/10.1016/j.injury.2009.01.010.

    Article  PubMed  Google Scholar 

  18. Shin WC, Lee SM, Suh KT. Recent updates of the diagnosis and prevention of venous thromboembolism in patients with a hip fracture. Hip Pelvis. 2017;29:159–67. https://doi.org/10.5371/hp.2017.29.3.159.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lagerstedt CI, Olsson CG, Fagher BO, Oqvist BW, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet. 1985;2:515–8. https://doi.org/10.1016/s0140-6736(85)90459-3.

    Article  CAS  PubMed  Google Scholar 

  20. Kakkar VV, Howe CT, Flanc C, Clarke MB. Natural history of postoperative deep-vein thrombosis. Lancet. 1969;2:230–2. https://doi.org/10.1016/s0140-6736(69)90002-6.

    Article  CAS  PubMed  Google Scholar 

  21. Huisman MV, Büller HR, ten Cate JW, Vreeken J. Serial impedance plethysmography for suspected deep venous thrombosis in outpatients: the Amsterdam general practitioner study. N Engl J Med. 1986;314:823–8. https://doi.org/10.1056/NEJM198603273141305.

    Article  CAS  PubMed  Google Scholar 

  22. Wilbur J, Shian B. Deep venous thrombosis and pulmonary embolism: current therapy. Am Fam Phys. 2017;95:295–302.

    Google Scholar 

  23. Olson EJ, Zander AL, Van Gent JM, Shackford SR, Badiee J, Sise CB, et al. Below-knee deep vein thrombosis: an opportunity to prevent pulmonary embolism? J Trauma Acute Care Surg. 2014;77:459–63. https://doi.org/10.1097/TA.0000000000000305.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

None.

Funding

None.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Kobe Red Cross Hospital, Kobe City, Hyogo, 651-0073, Japan

    Takuya Taoka, Takao Ohmori, Tomoko Kanazawa, Kazukiyo Toda, Takeshi Ishihara & Yasuo Ito

Authors
  1. Takuya Taoka
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Takao Ohmori
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tomoko Kanazawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kazukiyo Toda
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Takeshi Ishihara
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yasuo Ito
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization: TT, TO; methodology: TT, TO, TK, TI; formal analysis and investigation: TT, TO; writing—original draft preparation: TT; writing—review and editing: TO; resources: KT, YI; supervision: TT.

Corresponding author

Correspondence to Takuya Taoka.

Ethics declarations

Ethics approval and consent to participate

This study was approved by Kobe Red Cross Hospital’s Ethics Committee. The requirement for informed consent was waived due to the retrospective nature of the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Taoka, T., Ohmori, T., Kanazawa, T. et al. Delayed surgery after hip fracture affects the incidence of venous thromboembolism. J Orthop Surg Res 18, 630 (2023). https://doi.org/10.1186/s13018-023-04122-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13018-023-04122-8

Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X