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Hip fractures occur in approximately 340,000 Americans annually, with the vast majority in individuals older than 65. As the US population continues to age, it is likely that the incidence of hip fractures will increase steadily in the coming years. This is cause for concern as 30-day, 90-day, and 1-year mortality rates after a hip fracture are significant at ~7%, 15% and 30% respectively. These statistics are driven by complications post hip surgery, including those of cardiovascular, venous thrombotic, infectious, and hematologic etiology. Additionally, studies suggest that delayed surgical treatment post hip fracture may also increase the risk of mortality. Patients with a hip fracture, as well as an acute heart injury, are particularly challenging for physicians who must make a choice between suboptimal options, either delaying surgery and accepting higher short-term mortality, or performing surgery before the extent of cardiac risk is fully defined.

A current study co-led by Gerard Slobogean, MD, MPH, Associate Professor and Director of Clinical Research in the Department of Orthopaedics at the University of Maryland School of Medicine, and Drs. Flavia Borges and PJ Devereaux at McMaster University in Hamilton, Ontario, investigates the potential benefits of accelerated surgery for patients who present with hip fractures. This research is anchored by findings from the impactful international multi-center HIP Fracture Accelerated Surgical Treatment and Care track (HIP ATTACK 1) trial which showed beneficial outcomes for patients who received accelerated surgery post hip fracture and suggested that elevated troponin levels could be leveraged as a biomarker for those who may benefit from expedited surgical care.

Recently, the team at University of Maryland conducted a retrospective cohort study including 299 patients older than 60 who presented with a hip fracture and had cardiac troponin levels measured at the time of admission. The objective was to outline the relationship between elevated troponin levels in patients and multiple critical outcomes including time to surgery, 90-day mortality rates and major complications within 90 days of the injury. The study showed that patients who presented with elevated troponin levels waited on average 21 hours longer for surgery (median time from admission to surgery 31 hours vs. 12 hours). Additionally, the 90-day mortality rate was 14% higher in the group of patients who had elevated troponin levels at presentation.

Study findings have significant implications for the clinical management of hip fractures worldwide. Slobogean’s team in Maryland, along with collaborators from the HIP ATTACK 1 Trial, plan on exploring this issue further with a proposed HIP ATTACK 2 Trial. The forthcoming 1,100-patient international, multi-center randomized controlled trial will compare accelerated surgery to standard care in hip fracture patients presenting with elevated troponin levels. Trial findings will generate more evidence to help evaluate the benefits of accelerated surgical care for hip fracture patients and have the potential to significantly change the paradigm of postponing hip fracture surgery in those with evidence of acute heart injury.

To refer a patient, call 410-448-6400. For Grand Rounds presentations or to set up a meet and greet with our Orthopaedics team, email diane.fisher@umm.edu.

References:

  1. HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomized, controlled trial. Lancet Lond Engl. 2020 Feb 29;395(10225):698–708.

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