Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

Abstract

Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods:We randomised 2970 patients from 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were ≥45 years of age were eligible. Patients were randomly assigned to accelerated surgery (goal of surgery within 6 hours of diagnosis; 1487 patients) or standard care (1483 patients). The co-primary outcomes were 1.) mortality, and 2.) a composite of major complications (i.e., mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Outcome adjudicators were masked to treatment allocation, and patients were analysed according to the intention-to-treat principle; ClinicalTrials.gov, NCT02027896. Findings:The median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] 4-9) in the accelerated-surgery group and 24 hours (IQR 10-42) in the standard-care group, p<0.0001. Death occurred in 140 patients (9%) assigned to accelerated surgery and 154 patients (10%) assigned to standard care; hazard ratio (HR) 0.91, 95% CI 0.72-1.14; absolute risk reduction (ARR) 1%, 95% CI -1-3%; p=0.40. The primary composite outcome occurred in 321 patients (22%) randomised to accelerated surgery and 331 patients (22%) randomised to standard care; HR 0.97, 95% CI 0.83-1.13; ARR 1%, 95% CI -2-3%; p=0.71.Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared to standard care.

Prolonged social lockdown during COVID-19 pandemic and hip fracture epidemiology

“…new clinical pathway with PCR testing) had a disadvantageous effect on the ability to provide timely hip fracture care. Although accelerated surgery (< 6 h) has not proved to help decrease morbi-mortality rate, hip fractures should not wait for more than 24-48 hours to undergo surgery [29]. Whether the delay is higher than 48 hours, the risk of three day and one year mortality is significantly increased [30].…”

Periprosthetic Hip Fractures Outside the Initial Postoperative Period: Does Time from Diagnosis to Surgery Matter?

“…There may also be a time point beyond which no further gains are achieved. For instance, a randomized controlled trial of patients with native hip fractures found that attempting surgery within 6 hours of diagnosis was not associated with improved outcomes compared with routine care which was 24 hours in this trial [17]. Unfortunately, given the limitations of small sizes and heterogeneity within patients with periprosthetic hip fractures, using retrospective data to identify an inflection point or obtaining prospective data to test an intervention may not be feasible.…”

Prospective cohort protocol examining the perioperative indicators for complications and early mortality following hip fracture surgery in the frail patient

“…In the recent publication of the randomised controlled trial of the HIP ATTACK investigators there was no benefit in accelerated surgery within 6 hours after diagnosis compared with 24 hours (standard care group 10-42 hours). 30 We want to measure and validate the optimal time to surgery within the 48 hours before the risk of postoperative complications increases. Moreover, we wish to study whether the time to surgery should be strictly within 24 hours on admission or can be extended to 48 hours.…”