Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods:We randomised 2970 patients from 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were ≥45 years of age were eligible. Patients were randomly assigned to accelerated surgery (goal of surgery within 6 hours of diagnosis; 1487 patients) or standard care (1483 patients). The co-primary outcomes were 1.) mortality, and 2.) a composite of major complications (i.e., mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Outcome adjudicators were masked to treatment allocation, and patients were analysed according to the intention-to-treat principle; ClinicalTrials.gov, NCT02027896. Findings:The median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] 4-9) in the accelerated-surgery group and 24 hours (IQR 10-42) in the standard-care group, p<0.0001. Death occurred in 140 patients (9%) assigned to accelerated surgery and 154 patients (10%) assigned to standard care; hazard ratio (HR) 0.91, 95% CI 0.72-1.14; absolute risk reduction (ARR) 1%, 95% CI -1-3%; p=0.40. The primary composite outcome occurred in 321 patients (22%) randomised to accelerated surgery and 331 patients (22%) randomised to standard care; HR 0.97, 95% CI 0.83-1.13; ARR 1%, 95% CI -2-3%; p=0.71.Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared to standard care.

Objectives: Obesity is a documented comorbidity that is prevalent in the elderly population and a known predictor for surgical site infection (SSI). Body mass index is a convenient method to classify obesity, but it fails to account for fat distribution. The objective of our study was to evaluate the association between surgical site infection and a subcutaneous radiographic measurement (SRM) in elderly hip fracture patients.Materials and Methods: A retrospective case-control study was conducted to compare SRMs at the hip in patients diagnosed with surgical site infection after hip fracture surgery with patients that were not diagnosed with surgical site infection. Each case was matched to two controls. An SRM was defined as the distance from the tip of the greater trochanter to the skin following a perpendicular line to the femoral diaphysis in anteroposterior hip radiographs. Clinical diagnosis of acute surgical site infection was based on Tsukayama criteria.Results: Patients with an SRM greater than 6.27cm had a 7-fold increase in the odds of surgical site infection (OR=7.42, 95% Confidence Interval (CI)=3.01-18.28, p<0.001) compared to those with smaller measurements. The odds ratio (OR) for infection of patients with an ASA score of 3 was 15.82(95% CI=5.11-48.9, p-value<0.001)A statistically significant difference between cases and controls was also found when SRM at the hip was analyzed as a continuous variable. Patients with an infection had a 2.24cm (95% CI=1.59 - 2.90; p<0.001) greater mean SRM.Conclusion: Results of our study suggest an association between the SRM at the hip and the risk of SSI in elderly patients with surgically treated hip fractures. SRM may be a helpful tool for evaluating the risk of SSI in elderly hip fracture patients.

BACKGROUND The usefulness of a mandatory joint aspiration before re-implantation in patients with a cement spacer already in place is unclear. AIM To evaluate the role of culturing synovial fluid obtained by joint aspiration before re-implantation in patients who underwent a two-stage septic revision. METHODS A retrospective observational study was conducted, including patients that underwent a two-stage septic revision (hip or knee) from 2010 to 2017. After the first stage revision and according to intraoperative culture results, all patients were treated with an antibiotic protocol for 6-8 wk. Following 2 wk without antibiotics, a culture of synovial fluid was obtained. The results of these cultures were recorded and compared with cultures obtained during re-implantation surgery. RESULTS Forty-one patients (20 hip and 21 knee spacers) were included in the final analysis. In 39 cases, the culture of synovial fluid was negative, while in the remaining 2 cases (knee spacers) no analysis was possible due to dry tap. In 5 of the patients, two or more intraoperative cultures taken during the re-implantation surgery were positive. CONCLUSION We found no evidence to support mandatory joint aspiration before re-implantation in patients with a cement spacer in place.

Background: Multimodal analgesia regimes including local infiltration analgesia (LIA) have been successfully applied in fast-track hip arthroplasty programmes. LIA’s contribution to the analgesic effect in hip arthroplasty has been questioned. Our study sought to determine the analgesic efficacy of LIA in THA surgery in a fast-track programme. Methods: Patients diagnosed with hip osteoarthritis scheduled for arthroplasty were randomised to receive LIA (120 ml ropivacaine 0.2% plus epinephrine 0.5 µ/ml) or saline as a part of a multimodal analgesia regime. The surgical team, the nursing staff, and patients were all blinded regarding patient allocation throughout the study. The primary outcome was pain assessed as a continuous variable using the visual analogue scale (VAS) at 4, 8, 24 and 48 hours postoperatively. Secondary outcomes included the amount of analgesic rescue consumption, complications and length of hospital stay. Results: A total of 63 patients were interviewed and agreed to participate in the study. No statistically significant differences were found between groups for pain measurements at 4, 8, 12, 24 and 48 hours after surgery. There were also no differences in rescue medication consumption, complications, or length of stay. Conclusions: Our results suggest LIA (ropivacaine plus epinephrine, single shot) has no effect in pain management and has not shown benefits for early ambulation in primary THA surgery. Further research is needed to establish the optimal multimodal analgesia regime for THA fast-track programmes. Clinical trial registration: Clinicaltrials.gov (NCT03513276).

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