In-hospital mortality in hip fracture patients undergoing surgery later than 24 hours post admission might rather reflect the impact of comorbidities and treatment limitations than additional risks imposed by the mere timely delay itself.

purposeEarly surgery for proximal femoral fractures is widely recommended, but the association between surgical delay and short-term mortality remains uncertain because observational studies are vulnerable to confounding by patient characteristics and treatment limitation.

methodsWe retrospectively studied adults with operatively treated proximal femoral fractures at a DGU-certified regional trauma center in Germany (2022-2025). Time to surgery was measured from emergency department registration to operative start. Delays > 24 h were classified as medical or non-medical where sufficiently documented. The primary outcome was in-hospital mortality. Adjusted analyses included age, sex, ASA category, fracture type, concomitant orthopaedic injury, and treatment limitation (DNR/DNI; not time-anchored to surgery) and used Firth penalized logistic regression.

resultsAmong 927 patients, 871 (94.0%) underwent surgery within 24 h; 53 (5.7%) died in hospital. Crude mortality was 5.6% after surgery within 24 h and 7.1% after surgery > 24 h. After adjustment, no clear independent association between surgery > 24 h and mortality was detected (aOR 1.03, 95% CI 0.29-2.92). Higher age, male sex, advanced ASA class, and treatment limitation were associated with mortality. In exploratory analyses, mortality was 19.0% among medically delayed patients and 0% among patients with non-medical delay, but adjusted estimates were highly imprecise.

conclusionNo clear association between surgery beyond 24 h and in-hospital mortality was detected after adjustment for measured patient characteristics and treatment-limitation status. The estimate was imprecise and compatible with clinically relevant benefit or harm; these findings do not establish the absence of an effect of surgical delay.