Benefits of accelerated surgery in patients with hip fracture

Accelerated time to surgery—within an average of 6 hours after a hip fracture diagnosis—resulted in a lower risk of delirium and urinary tract infections, moderate to severe pain, faster mobilization, and a shorter length of hospital stay compared to standard care (when surgery occurred an average of 24 hours after a hip fracture diagnosis).

The HIP Fracture Accelerated Surgical Treatment and Care Track (HIP ATTACK) Trial, published in The Lancet, was led by researchers of the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences (HHS) in Hamilton. HIP ATTACK involved 2970 people at 69 sites in 17 countries.

Ten years ago, Dr P.J. Devereaux, principal investigator of the HIP ATTACK trial, as well as senior scientific lead of PHRI’s perioperative and surgery program, professor of medicine at McMaster, and cardiologist with HHS, was consulted to manage a 73-year-old female with a hip fracture who also had elevated troponin, demonstrating heart injury. The referring doctor told Dr Devereaux the patient’s heart issue had to be treated before surgery for her hip fracture could occur. Despite the best of intentions, with the medical treatment Dr Devereaux provided based on current practice at that time, the patient died before she was able to undergo surgery for her hip fracture.

Dr Devereaux wondered if the prevailing dogma regarding the need to medically optimize patients before hip fracture surgery was the wrong approach. He contacted Dr Mohit Bhandari, co-principal investigator of HIP ATTACK and an orthopaedic surgeon in Hamilton, to get his perspective on the case. Dr Bhandari told Dr Devereaux that observational studies suggested that shorter time to surgery may prevent death and major complications in patients with a hip fracture. Based on this evidence, they initiated a large randomized controlled trial to understand the effects of accelerated surgery in patients with a hip fracture.

Accelerated surgery did not result in a reduction in death or a collection of major complications; however, patients randomized to accelerated surgery had a lower risk of delirium, urinary tract infection, moderate to severe pain, and were faster to stand, mobilize, and go home compared to patients randomized to standard care. Among patients who had elevated troponin when they presented to the hospital with their hip fracture, accelerated surgery lowered the risk of death compared to standard care.