Introduction

Femoral fractures are recognized as a serious, debilitating problem worldwide, especially concerning the geriatric population. As this issue continues to rise, with an annual estimate of 1.6 million patients with a hip fracture hospitalized [1], the number of hip fracture surgeries simultaneously expands alongside their associated complications, like postoperative pneumonia. It has been estimated that the total annual incidence of geriatric hip fractures in the Middle East in general is between 60 and 150 per 100,000 [2,3,4,5]. There is a scarcity of research examining the incidence and complications of hip fractures among the Jordanian population. According to recent research in Jordan, it was estimated that the annual incidence of hip fracture patients above the age of 55 in 2021 was approximately 96 cases per 100,000 individuals [6].

Factors such as advanced age, anemia, diabetes, prior stroke, the number of comorbidities, an American society of anesthesiologists (ASA) score ≥ III, general anesthesia, and delay in surgery were positively correlated to acquiring pneumonia after surgery [7, 8]. On the other hand, many elements, regardless of pneumonia, were found to affect the length-of-stay (LOS) following a hip fracture surgery. These included advanced age, higher ASA physical status scores, comorbid burden, with the addition of female gender, severe obesity with a body mass index (BMI) exceeding 40, the use of a cemented implant in the total hip replacement, previous hip fractures, acute renal failure, diabetes, cerebrovascular disease, smokers, and others [9,10,11]. Others were linked with death after these surgeries. For instance, longer LOS, age over 80, poor mobility prior to the surgery, inability to return to baseline mobility, the presence of 3 or more comorbidities, an ASA over III or IV, chest infection, and heart failure [10, 12, 13]. In the management of hip fractures, particularly among elderly patients, postoperative complications significantly influence outcomes and mortality rates [14,45]. This further confirms our findings of increased POP and LOS in patients with cardiovascular diseases on univariate analysis. Preoperative cardiac evaluation guidelines set out by the American College of Cardiology/American Heart Association (ACC/AHA) categorize any orthopedic procedure, including femoral fracture repair, as “intermediate risk.” [46]. Specifically, heart failure has been previously found to increase LOS following hip fracture surgeries, which goes hand in hand with our findings [47].

A Danish study in 2019 confirmed our findings regarding postoperative pneumonia. It suggested that a delay of 12 h was associated with an increased risk of pneumonia in patients with no comorbidities, a delay of 24 h was associated with an increased risk of pneumonia in patients with a medium level of comorbidity, and a delay of 48 h was associated with an increased risk of reoperation due to infection in patients with a high level of comorbidity. In conclusion, a delay in surgery was associated with an increased risk of hospital-treated pneumonia and reoperations due to infection within 30 days of surgery [48]. Many articles have confirmed that a delay in surgery over 48 h is concurrent with worsening outcomes, hence increased LOS, reasoning that a delay in the performance of surgery is linked to major medical complications, minor medical complications, and pressure sores [49, 50]. Furthermore, prior research involving polytrauma patients has demonstrated that early stabilization of femur fractures is linked to a reduced risk of acute respiratory distress syndrome and mortality [51]. Interestingly, a retrospective review conducted in 2018 revealed that increasing time to surgery was associated with longer postoperative lengths of stay but not with adverse outcomes of surgery [52].

The retrospective study investigating the impact of pneumonia on the length of hospital stay and mortality in elderly femoral fracture patients exhibits several notable strengths. The study addressed a clinically significant issue by investigating the impact of pneumonia, specifically in femoral fracture patients. In addition, understanding the interplay between these two conditions can inform healthcare strategies and improve patient care. Furthermore, a larger sample increases the likelihood of detecting true associations, strengthens the study’s external validity, and utilizes multivariate analysis controlled for potential confounding variables. However, certain limitations warrant consideration. The study’s retrospective design is inherently limited by its reliance on existing medical records, which may lack some critical information. Moreover, conducting the study at a single healthcare center may limit the generalizability of the findings. Also, failure to account for nosocomial cases could underestimate the true impact of hospital-acquired infections on the studied outcomes. Future studies could benefit from incorporating ASA grades and utilizing the CURB-65 scoring system, which could potentially enrich the analysis and provide deeper insights into the prognostic factors influencing postoperative outcomes.

Conclusion

In light of our findings, this study underscores the significant impact of postoperative pneumonia on the outcomes of patients undergoing femur fracture surgery. With a notable incidence of 10.8%, postoperative pneumonia was associated with older age, prolonged hospital stay, and intensive care unit (ICU) admissions, though it did not significantly affect mortality rates. In addition, prolonged hospital stay was associated with surgery not being performed within 48 h of admission, lower hemoglobin levels upon admission, and ICU admission. For clinicians, our study emphasizes the importance of early identification and management of risk factors for postoperative pneumonia. Implementing targeted interventions, such as preoperative optimization, timely surgical intervention, and enhanced postoperative care protocols, could mitigate the risk of develo** pneumonia, improve overall outcomes, and lower the incidence of postoperative pneumonia in patients with femur fractures.