Association Between Operative Duration and Adverse Outcomes After Hip Fracture Surgery: A NSQIP Matched Cohort Study

Background Prolonged operative duration is an independent risk factor for surgical complications in numerous subspecialties. However, associations between adverse events and operative duration of hip fracture fixation in older adults have not been well-quantified. This study aims to determine if prolonged operative duration of hip fracture surgery is related to adverse outcomes. We hypothesized that patients with high operative durations experience greater rates of 30-day complications. Methods The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify older adults (55 years and above) who underwent hip fracture fixation between 2015-2019. Prolonged operative duration was defined as >75th percentile, and cases were matched using propensity scores based on demographic, surgical, and comorbidity factors. Univariate differences in adverse events (including readmission, reoperation, mortality, and organ-system complications) were analyzed. Multivariable mixed-effects logistic regression analyses were completed for statistically significant events. Results A total of 8,827 case-control pairs were identified for comparison. Rates of superficial surgical site infection (SSI) (p = 0.022), any SSI (p = 0.032), and any complication (p<0.001) were elevated in those with prolonged surgical duration in univariate analyses. In multivariable models, prolonged operative time was associated with superficial SSI (OR 1.50, p = 0.019), any SSI (OR 1.35; p = 0.029) and any complication (OR 1.58; p<0.001). In subgroup analyses, all findings persisted for IMN with operative time associated with superficial SSI (OR 1.98, p = 0.012), any SSI (OR 1.71; p = 0.019), and any complication (OR 1.84; p<0.001). Operative time was associated only with any complication for hemiarthroplasty/internal fixation and sliding hip screw (OR 1.27 and 1.89, respectively; p<0.001). Conclusion Our study demonstrates that duration of surgery is an independent risk factor for superficial SSI, any SSI, and any complication. Notably, our findings suggest that high operative durations may be most concerning for SSIs in IMN fixation, which is currently the most common choice for hip fracture fixation in the US. However, the rate of any complication is significantly elevated when surgical duration is prolonged, regardless of surgery type.