Accelerated surgery tied to lower mortality risk than standard care among hip fracture patients: study

Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture.

The study by Flavia K. Borges et al aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival.

The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture (median of 6 hours from orthopaedic diagnosis) was superior to standard care (median of 24 hours from orthopaedic diagnosis) in reducing death or major complications. This sub study is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization.

Key findings of the study were:

• Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group.

• Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72]).

The authors opined - ‘In conclusion, 1 in 5 patients with a hip fracture present with myocardial injury. Mortality is 3-fold higher in this population compared with the patients with a hip fracture who do not have a myocardial injury. Accelerated surgery has the potential to improve mortality rates and major cardiovascular outcomes compared with standard care. These findings must be confirmed in additional trials.’

Further reading:

Myocardial Injury in Patients with Hip Fracture A HIP ATTACK Randomized Trial Substudy Flavia K. Borges et al Level of Evidence: Therapeutic Level I. J Bone Joint Surg Am. 2024;106:2303-12 http://dx.doi.org/10.2106/JBJS.23.01459