Surgical timing beyond the 48-h guideline in elderly hip fractures: a retrospective evaluation of clinical and functional outcomes in 314 cases.

To evaluate the impact of surgical timing on mortality and functional outcomes in elderly patients with proximal femoral fractures (PFFs), specifically investigating whether a 72-h threshold provides a more sensitive clinical discriminator than the traditional 48-h guideline. A retrospective cohort study was conducted on 314 patients aged ≥ 65 years surgically treated for low-energy PFF (AO/OTA 31-A and B) between January 2018 and December 2019. Patients were initially dichotomized by a 48-h threshold (Group A ≤ 48 h, n = 139; Group B > 48 h, n = 175) and subsequently analyzed using a 72-h cutoff. Primary endpoints were 3-month and 1-year mortality. Multivariate logistic regression was performed to adjust for age, sex, and Charlson Comorbidity Index (CCI). Secondary outcomes included postoperative length of stay (LOS), transfusion requirements, and functional recovery assessed via the Barthel Index. No statistically significant difference in 3-month mortality was observed using the 48-h cutoff (Group A: 11.6% vs. Group B: 12.3%; p > 0.05). Conversely, the 72-h threshold emerged as a significant independent predictor of mortality (p < 0.05). Mortality rates for patients operated beyond 72 h were significantly higher at both 3 months (21.2% vs. 9.2%; p < 0.05) and 1 year (25.6% vs. 19.4%). Multivariate analysis confirmed surgical delay > 72 h as an independent risk factor (OR 2.1; 95% CI 1.3-3.4). The highest risk was observed in males aged > 85 years with extracapsular fractures operated beyond 72 h (1-year mortality: 37.5%). Mean LOS was significantly shorter in the early surgery group (7.6 ± 2.1 vs. 8.4 ± 2.8 days; p = 0.044). No significant differences were found in 3-month functional recovery between groups. In a real-world clinical setting, the 72-h threshold represents a critical "red line" for survival in elderly hip fracture patients. While striving for stabilization within 48 h remains ideal, maximum priority should be shifted toward preventing organizational delays that push vulnerable patients, particularly elderly males with extracapsular patterns, beyond the third day.Level of evidence: Level III (Retrospective cohort study).