Hip Fracture Time-to-Surgery

Hip fractures in the elderly were historically treated on a semi-urgent basis, often waiting days for an available operating theater. Early observational studies began to suggest that prolonged surgical delay was associated with increased mortality, pneumonia, pressure ulcers, and delirium. Retrospective analyses of administrative databases and registry data consistently showed a dose-response relationship between time to surgery and adverse outcomes. A landmark meta-analysis by Shiga and colleagues (2008) of 257,367 patients from 16 observational studies demonstrated that surgical delay beyond 48 hours was associated with a 41% increase in 30-day mortality and a 32% increase in 1-year mortality. These observational signals drove international interest in establishing surgical timing targets, but the lack of RCT evidence left uncertainty about whether the association was causal or confounded by patient comorbidity.

The HIP ATTACK trial (Hip Fracture Accelerated Surgical Treatment and Care Track), published in the Lancet in 2020, was the definitive international RCT addressing this question. This trial randomized 2,970 patients with hip fracture across 69 hospitals in 17 countries to accelerated surgery (target within 6 hours of diagnosis) versus standard care. The accelerated group achieved a median time to surgery of 6 hours versus 24 hours in the standard care group. The primary outcome of mortality or major complication at 90 days showed no significant difference between groups (30% accelerated vs 30% standard care). However, accelerated surgery significantly reduced several secondary outcomes including delirium, urinary tract infections, and time to mobilization. The trial clarified that while very early surgery (within 6 hours) did not reduce the primary composite endpoint, it confirmed the safety and secondary benefits of expedited surgical pathways.

Post-HIP ATTACK, the field has nuanced its understanding of surgical timing. While ultra-early surgery (within 6 hours) did not show a primary outcome benefit, comprehensive registry analyses from the UK National Hip Fracture Database, the Australian and New Zealand Hip Fracture Registry, and Scandinavian registries consistently demonstrate that surgery within 24-36 hours is associated with the best outcomes. The focus has shifted to identifying and rapidly optimizing medical conditions that commonly cause surgical delays (anticoagulation reversal, cardiac assessment, volume resuscitation) rather than operating before patients are medically stable. Orthogeriatric co-management models — with shared care between orthopedic surgeons and geriatricians — have demonstrated significant mortality reductions in multiple before-and-after studies and are now standard at many centers.

NICE guidelines (2023 update) recommend hip fracture surgery on the day of admission or the following day (ideally within 36 hours), with expedited medical optimization. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Hip Fracture Standard recommends surgery within 24 hours where medically feasible. The Australian and New Zealand Hip Fracture Registry targets surgery within 48 hours as a benchmark, with within 24 hours as the aspirational target. All guidelines emphasize concurrent medical optimization rather than delay for optimization, and recommend orthogeriatric co-management as the standard model of care.

Hip fracture care has been transformed by national audit and quality improvement programs that track time-to-surgery as a key performance indicator. Most high-income countries have established surgical timing targets (24-48 hours) supported by dedicated hip fracture pathways, ring-fenced theater time, and orthogeriatric co-management. While HIP ATTACK showed that ultra-early surgery (6 hours) does not improve the primary composite outcome compared to standard care, the overall evidence supports that surgery within 24-36 hours, combined with comprehensive geriatric assessment and optimization, produces the best outcomes. Ongoing research focuses on optimizing anticoagulation reversal protocols, regional anesthesia vs general anesthesia (the REGAIN trial), enhanced recovery after surgery (ERAS) protocols for hip fracture, and addressing the persistent 30-day mortality rate of approximately 7-10% that remains stubbornly high despite pathway improvements.