Accelerated versus standard care in hip fracture patients: does speed save lives?

Each year, millions of adults worldwide suffer a hip fracture [1,2]. Hip fractures primarily occur in the elderly and have devastating consequences. A hip fracture initiates inflammatory, hypercoagulable, stress and catabolic states that can cause medical complications (e.g., myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke and life-threatening and major bleeding) [3,4]. These complications can result in severe disability and death. After a hip fracture, the 30-day mortality rate is 7–10% [5–8]. Patients who survive to 30 days are at substantial risk of disability: 11% are bed-ridden [9], 16% are in a long-term care facility and 80% are using a walking aid at 1 year [10]. Despite the magnitude of this problem, little progress has occurred in improving the prognosis of patients suffering a hip fracture. Without strong supporting evidence to the contrary, some physicians believe that delaying surgery in elderly patients with hip fracture and multiple comorbid conditions provides the opportunity to optimize patients’ medical status, thereby decreasing the risk of perioperative complications. Several observational studies have, however, demonstrated an association between delay in hip fracture surgery and poor outcomes [11–15]. Furthermore, there exists a biological rationale for how accelerated surgical treatment of a hip fracture may lower a patient’s risk of a major complication, improve their functional outcome and reduce their length of hospital stay. These postulated benefits could accrue from reducing the patient’s exposure to the inflammatory, hypercoagulable, stress and catabolic states induced by a hip fracture and accelerating their time to first mobilization.