Expedited surgery for hip fracture?
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* Flavia Kessler Borges
* Mohit Bhandari
* P.J. Devereaux

We are responding to an commentary by Gandhi and Perruccio1 who stated, “some advocates are now calling for surgical intervention within 12 hours, and even within 6 hours, after hospital admission.”

We believe they were referring to the HIP ATTACK pilot study.2 To clarify, we have not called for surgery within six hours of a hip fracture; however, we have called for, and are currently conducting, a large international trial to determine the effects of rapid surgery compared with standard care. The authors are concerned about feasibility of early surgery: “We doubt that delivering surgical intervention for all patients with hip fracture within six hours after admission will be feasible …” We use the example of cardiology to show that the seeming challenges with acute percutaneous coronary intervention for ST elevation myocardial infarction were overcome when high quality evidence showed benefit. Moreover, it is also possible that accelerated hip fracture surgery results in a substantial cost savings to the health care system.

The authors argue, “Expedited surgery within six hours after hospital admission for frail patients may affect the opportunity to optimize their medical conditions before surgery …”; however, it is possible that this group has the most to benefit from accelerated surgery because they are at highest risk of a poor outcome.3,4

Large randomized control data offer the most informed way to address these issues. We thank the authors for referencing our ongoing trial and look forward to using HIP ATTACK to provide an evidence-based rationale for the timing of hip fracture surgery.

## References

1.  Gandhi R, Perruccio AV. Reducing mortality and morbidity following hip fracture: Is expedited surgery the way to go? CMAJ 2016;188:E277–8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTg4LzEyL0UyNzciO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTg5LzQvRTE3MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Hip Fracture Accelerated Surgical Treatment and Care Track (HIP ATTACK) Investigators. Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial. CMAJ 2014;186:E52–60.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODYvMS9FNTIiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTg5LzQvRTE3MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

3.  Le Manach Y, Collins G, Bhandari M, et al. Outcomes after hip fracture surgery compared with elective total hip replacement. JAMA 2015;314: 1159–66.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/jama.2015.10842&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=26372585&link_type=MED&atom=%2Fcmaj%2F189%2F4%2FE171.atom) 

4.  Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ 2010;182:1609–16.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTgyLzE1LzE2MDkiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTg5LzQvRTE3MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)