Skip to content
evident
Original paper
2020LancetSurgery/Perioperative

HIP ATTACK

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

RCTHip fracture

On this page

Overview

In hip fracture, a goal of surgery within 6 hours of diagnosis did not significantly lower 90-day death or major complications versus standard care.

Clinical takeaway

HIP ATTACK did not show that accelerating surgery to a 6-hour goal reduces 90-day death or the coprimary major-complication composite compared with standard care.

Key result

Among 2970 randomized patients, 90-day death was 9% with accelerated surgery vs 10% with standard care (HR 0.91, 95% CI 0.72-1.14; P=0.40). Major complications were 22% in both groups (HR 0.97, 95% CI 0.83-1.13; P=0.71).

Practice impact

A 6-hour surgery goal did not significantly reduce 90-day death or major complications; do not cite HIP ATTACK as proof that acceleration saves lives.

Evidence

Study design

International randomized controlled trial at 69 hospitals in 17 countries, with 1:1 allocation, intention-to-treat analysis, open treatment assignment, and masked outcome adjudication.

Enrollment

2,970

Follow-up

90 days after randomization.

Geography

17 countries

Clinical question

Does accelerated surgery, with a goal of operating within 6 hours of diagnosis, reduce 90-day mortality or a composite of major complications compared with standard care in hip fracture?

Population

  • Adults 45 years or older with a hip fracture that required surgery.

Intervention

Accelerated surgery, with a goal of surgery within 6 hours of diagnosis (median time from diagnosis to surgery 6 hours; IQR 4-9).

Comparator

Standard care (median time from diagnosis to surgery 24 hours; IQR 10-42).

Primary outcome

Coprimary outcomes of mortality and a composite of major complications (mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomization.

Accelerated surgery did not significantly lower 90-day mortality or the coprimary major-complication composite compared with standard care.

Hazard ratio / 0.91 / 95% CI 0.72-1.14 / p=0.40

Key results

  • Of 27,701 patients screened, 7780 were eligible and 2970 were enrolled and randomly assigned (1487 accelerated surgery, 1483 standard care).
  • Median time from diagnosis to surgery was 6 hours (IQR 4-9) with accelerated surgery vs 24 hours (IQR 10-42) with standard care (P<0.0001).
  • Death by 90 days occurred in 140 of 1487 (9%) assigned to accelerated surgery vs 154 of 1483 (10%) assigned to standard care; HR 0.91 (95% CI 0.72-1.14); absolute risk reduction 1% (-1 to 3); P=0.40.
  • Major complications occurred in 321 (22%) vs 331 (22%); HR 0.97 (95% CI 0.83-1.13); absolute risk reduction 1% (-2 to 4); P=0.71.

Harms

  • The major-complication composite included life-threatening bleeding and major bleeding and did not differ between groups (22% vs 22%).

Clinical Use

Practice impact

  • Do not tell families that a 6-hour surgery goal has been shown to reduce 90-day death or major complications; both coprimary comparisons included no effect.
  • The trial did separate timing (median 6 hours vs 24 hours) without a significant outcome difference on the coprimary end points.

Applicability

  • Most applicable to adults 45 years or older with a hip fracture that requires surgery, treated at hospitals able to pursue a 6-hour diagnosis-to-surgery goal.

Limitations

  • Patients, clinicians, and study staff knew treatment assignment; outcome adjudicators were masked.
  • Only 2970 of 7780 eligible patients were enrolled.
  • Both coprimary confidence intervals included no effect, so this is not evidence of benefit or harm on those end points.

Common misinterpretations

  • HIP ATTACK does not show that earlier surgery is harmful; it shows no significant reduction in 90-day death or major complications.
  • Standard care was not multi-day delay as a protocol. Median time to surgery in that arm was 24 hours.

Related evidence

FOCUS - Same Disease

Citation

HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet. 2020;395(10225):698-708. doi:10.1016/S0140-6736(20)30058-1

Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.