- Design
- Target trial emulation using a national administrative database
- Population
- 4564 patients with periprosthetic hip fracture in Japan, mean age 84
- Primary outcome
- 30- and 90-day mortality, surgery within 2 days vs days 3–10
- Effect
- 90-day mortality 2.35% vs 2.31%; RR 1.01 (95% CI 0.59 to 1.68)
This study used a Japanese hospital database (2014 to 2024) to emulate a randomised trial in 4564 patients admitted with periprosthetic hip fracture, mean age 84 and 80% women. Using a clone-censor-weight design to remove immortal time bias, it compared a strategy of surgery within two days of admission with surgery on days 3 to 10. It was published in October.
Thirty-day mortality was 1.72% with early surgery and 0.83% with delayed surgery (risk difference 0.89%, 95% CI −0.32% to 1.72%; RR 2.06, 0.64 to 3.73). At 90 days the risks were almost identical: 2.35% versus 2.31% (RR 1.01, 0.59 to 1.68). Subgroups by age and sex were imprecise.
The 48-hour target for native hip fractures is well established, and it is often applied to periprosthetic fractures too. These are different operations: revision arthroplasty or complex fixation often needs implant information, specific kit and an experienced surgeon. This analysis suggests that taking a few days to stabilise the patient and plan the operation does not raise short-term mortality. It did not examine complications, pressure injury, delirium or function, so it does not justify delay for its own sake.
- Consider allowing time for medical optimisation and operative planning in periprosthetic hip fracture rather than forcing a 48-hour deadline.
- Obtain previous operation notes and implant details early, since planning time is better spent than lost.
- Arrange transfer to a surgeon experienced in revision or periprosthetic fixation when needed.
- Continue orthogeriatric care, pressure area care and delirium prevention during any wait.
- Avoid delays caused by theatre or staffing availability alone, which this study did not support.
Why it matters
It challenges the reflex to apply the native hip fracture 48-hour rule to a different and more complex operation.
Don't overread it
This observational analysis looked only at mortality and cannot show that delay is safe for complications or recovery.
The statistics, in plain English
The 30-day risk ratio of 2.06 looks like a doubling with early surgery, but the interval runs from 0.64 to 3.73, so the data are compatible with no difference or even benefit. At 90 days the estimates are near identical. Emulating a trial reduces some biases but cannot remove confounding from factors the database did not record, such as fracture complexity.
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