Hip fracture surgery within 24 hours: no association between time to surgery and mortality in a real-world cohort

Abstract Purpose Early surgery is recommended for hip fractures, and in Germany, operative treatment within 24 h has been mandatory since 2021. While delays beyond 24–48 h are associated with worse outcomes, it remains unclear whether further acceleration within a 24-hour timeframe improves survival. This study evaluated mortality and perioperative risk factors within a strictly implemented early-treatment pathway. Methods This retrospective single-centre cohort study included 1,051 consecutive patients with femoral neck and trochanteric fractures treated surgically within 24 h of admission (2016–2020). Time to surgery was grouped into < 6 h, 6–12 h, and > 12–24 h. The primary outcome was one-year mortality; secondary outcome was two-year mortality. Mortality data were obtained from the national citizen registry. Multivariable logistic and Cox proportional hazards regression analyses were performed for one-year mortality. Results Mean time to surgery was 10.2 ± 6.2 h. One-year mortality was 29.5% and increased to 40.1% at two years. Mortality did not differ significantly between time-to-surgery groups (< 6 h: 30.9%, 6–12 h: 26.4%, > 12–24 h: 31.5%; p = 0.258). This finding was consistent across all adjusted analyses. In contrast, non-surgical complications were the strongest independent predictors of mortality, particularly pneumonia (OR 2.1), renal failure (OR 5.2), and cardiac events (OR 5.1). Surgical complications and implant choice were not associated with mortality. Conclusion Within a 24-hour treatment pathway, further reduction of time to surgery was not associated with improved survival in this cohort. Mortality was strongly associated with perioperative medical complications. These findings support current early-surgery targets but suggest that optimisation of perioperative and orthogeriatric care may be at least as important for improving outcomes as further reductions in time to surgery.