Aims. Current levels of hip fracture morbidity contribute greatly to the overall burden on health and social care services. Given the anticipated ageing of the population over the coming decade, there is potential for this burden to increase further, although the exact scale of impact has not been identified in contemporary literature. We therefore set out to predict the future incidence of hip fracture and help inform appropriate service provision to maintain an adequate standard of care. Methods. Historical data from the Scottish Hip Fracture Audit (2017 to 2021) were used to identify monthly incidence rates. Established time series forecasting techniques (Exponential Smoothing and Autoregressive Integrated Moving Average) were then used to predict the annual number of hip fractures from 2022 to 2029, including adjustment for predicted changes in national population demographics. Predicted differences in service-level outcomes (length of stay and discharge destination) were analyzed, including the associated financial cost of any changes. Results. Between 2017 and 2021, the number of annual hip fractures increased from 6,675 to 7,797 (15%), with a rise in incidence from 313 to 350 per 100,000 (11%) for the at-risk population. By 2029, a combined average projection forecast the annual number of hip fractures at 10,311, with an incidence rate of 463 per 100,000, representing a 32% increase from 2021. Based upon these projections, assuming discharge rates remain constant, the total overall length of hospital stay following hip fracture in Scotland will increase by 60,699 days per annum, incurring an additional cost of at least £25 million per year. Approximately five more acute hip fracture beds may be required per hospital to accommodate this increased activity. Conclusion. Projection modelling demonstrates that hip fracture burden and incidence will increase substantially by 2029, driven by an ageing population, with substantial implications for health and social care services. Cite this article: Bone Joint J 2024;106-B(1):62–68

Aims. The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients. Methods. Data on 35,206 hip fractures (2014 to 2018; 67.2% female) in the Norwegian Hip Fracture Register were linked to data from the Norwegian Patient Registry and Statistics Norway. PROMs data were collected using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) scoring instrument and living patients were invited to respond at four, 12, and 36 months post fracture. Multiple imputation procedures were performed as a model to substitute missing PROM data. Differences in response rates between categories of covariates were analyzed using chi-squared test statistics. The association between patient and socioeconomic characteristics and the reported EQ-5D-3L scores was analyzed using linear regression. Results. The median age was 83 years (interquartile range 76 to 90), and 3,561 (10%) lived in a healthcare facility. Observed mean pre-fracture EQ-5D-3L index score was 0.81 (95% confidence interval 0.803 to 0.810), which decreased to 0.66 at four months, to 0.70 at 12 months, and to 0.73 at 36 months. In the imputed datasets, the reduction from pre-fracture was similar (0.15 points) but an improvement up to 36 months was modest (0.01 to 0.03 points). Patients with higher age, male sex, severe comorbidity, cognitive impairment, lower income, lower education, and those in residential care facilities had a lower proportion of respondents, and systematically reported a lower health-related quality of life (HRQoL). The response pattern of patients influenced scores significantly, and the highest scores are found in patients reporting scores at all observation times. Conclusion. Hip fracture leads to a persistent reduction in measured HRQoL, up to 36 months. The patients’ health and socioeconomic status were associated with the proportion of patients returning PROM data for analysis, and affected the results reported. Observed EQ-5D-3L scores are affected by attrition and selection bias mechanisms and motivate the use of statistical modelling for adjustment. Cite this article: Bone Joint J 2024;106-B(4):394–400

Aims. Older adults with hip fractures are at high risk of experiencing complications after surgery, but estimates of the rate of specific complications vary by study design and follow-up period. The aim of this systematic review was to determine the prevalence of complications in older adults after hip fracture surgery. Methods. MEDLINE, Embase, CINAHL, and CENTRAL databases were searched from inception until 30 June 2023. Studies were included if they reported prevalence data of complications in an unselected, consecutive population of older adults (aged ≥ 60 years) undergoing hip fracture surgery. Results. A total of 95 studies representing 2,521,300 patients were included. For surgery-specific complications, the 30-day prevalence of reoperation was 2.31%, surgical site infection 1.69%, and deep surgical site infection 0.98%; the 365-day prevalence of prosthesis dislocation was 1.11%, fixation failure 1.77%, and periprosthetic or peri-implant fracture 2.23%. For general complications, the 30-day prevalence of acute kidney injury was 1.21%, blood transfusion 25.55%, cerebrovascular accident 0.79%, lower respiratory tract infection 4.08%, myocardial infarction 1.98%, urinary tract infection 7.01%, and venous thromboembolism 2.15%. Conclusion. Complications are prevalent in older adults who have had surgery for a hip fracture. Studies reporting complications after hip fracture surgery varied widely in terms of quality, and we advocate for the routine monitoring of complications in registries and clinical trials to improve the quality of evidence. Cite this article: Bone Joint J 2025;107-B(2):139–148

Hip fractures pose a major global health challenge, leading to high rates of morbidity and mortality, particularly among the elderly. With an ageing population, the incidence of these injuries is rising, exerting significant pressure on healthcare systems worldwide. Despite substantial research aimed at establishing best practice, several key areas remain the subject of ongoing debate. This article examines the latest evidence on the place of arthroplasty in the surgical treatment of hip fractures, with a particular focus on the choice of implant, the use of cemented versus uncemented fixation, and advances in perioperative care. Cite this article: Bone Joint J 2024;106-B(12):1372–1376

Aims. Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture. Methods. This retrospective cohort study used linked data from the Australian Hip Fracture Registry and the National Death Index. Descriptive analysis and Kaplan-Meier survival curves tested the unadjusted association of mortality between cemented and uncemented procedures. Multilevel logistic regression, adjusted for covariates, tested the association between cement use and 30-day mortality following arthroplasty. Given the known institutional variation in preference for cemented fixation, an instrumental variable analysis was also performed to minimize the effect of unknown confounders. Adjusted Cox modelling analyzed the association between cement use and mortality at 30 days and one year following surgery. Results. The 30-day mortality was 6.9% for cemented and 4.9% for uncemented groups (p = 0.003). Cement use was significantly associated with 30-day mortality in the Kaplan-Meier survival curve (p = 0.003). After adjusting for covariates, no significant association between cement use and 30-day mortality was shown in the adjusted multilevel logistic regression (odd rati0 (OR) 1.1, 95% confidence interval (CI) 0.9 to 1.5; p = 0.366), or in the instrumental variable analysis (OR 1.0, 95% CI 0.9 to 1.0, p=0.524). There was no significant between-group difference in mortality within 30days (hazard ratio (HR) 0.9, 95% CI 0.7to 1.1; p = 0.355) or one year (HR 0.9 95% CI 0.8 to 1.1; p = 0.328) in the Cox modelling. Conclusion. No statistically significant difference in patient mortality with cement use in arthroplasty was demonstrated in this population, once adjusted for covariates. This study concludes that cementing in arthroplasty for hip fracture is a safe means of surgical fixation. Cite this article: Bone Jt Open 2023;4(3):198–204

Aims. Surgery is often delayed in patients who sustain a hip fracture and are treated with a total hip arthroplasty (THA), in order to await appropriate surgical expertise. There are established links between delay and poorer outcomes in all patients with a hip fracture, but there is little information about the impact of delay in the less frail patients who undergo THA. The aim of this study was to investigate the influence of delayed surgery on outcomes in these patients. Methods. A retrospective cohort study was undertaken using data from the Scottish Hip Fracture Audit between May 2016 and December 2020. Only patients undergoing THA were included, with categorization according to surgical treatment within 36 hours of admission (≤ 36 hours = ‘acute group’ vs > 36 hours = ‘delayed’ group). Those with delays due to being “medically unfit” were excluded. The primary outcome measure was 30-day survival. Costs were estimated in relation to the differences in the lengths of stay. Results. A total of 1,375 patients underwent THA, with 397 (28.9%) having surgery delayed by > 36 hours. There were no significant differences in the age, sex, residence prior to admission, and Scottish Index of Multiple Deprivation for those with, and those without, delayed surgery. Both groups had statistically similar 30-day (99.7% vs 99.3%; p = 0.526) and 60-day (99.2% vs 99.0%; p = 0.876) survival. There was, however, a significantly longer length of stay for the delayed group (acute: 7.0 vs delayed: 8.9 days; p < 0.001; overall: 8.7 vs 10.2 days; p = 0.002). Delayed surgery did not significantly affect the rates of 30-day readmission (p = 0.085) or discharge destination (p = 0.884). The results were similar following adjustment for potential confounding factors. The estimated additional cost due to delayed surgery was £1,178 per patient. Conclusion. Delayed surgery does not appear to be associated with increased mortality in patients with an intracapsular hip fracture who undergo THA, compared with those who are treated with a hemiarthroplasty or internal fixation. Those with delayed surgery, however, have a longer length of stay, with financial consequences. Clinicians must balance ethical considerations, the local provision of orthopaedic services, and optimization of outcomes when determining the need to delay surgery in a patient with a hip fracture awaiting THA. Cite this article: Bone Joint J 2023;105-B(11):1201–1205

Aims. The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. Methods. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups. Results. The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group. Conclusion. Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted. Cite this article: Bone Joint J 2023;105-B(8):872–879

Aims. The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone. Methods. This nationwide retrospective cohort study used data from the Diagnosis Procedure Combination database. We included patients aged ≥ 18 years who underwent surgery for hip fractures and received acetaminophen combined with NSAIDs (combination group), NSAIDs alone (NSAIDs group), or acetaminophen alone (acetaminophen group) preoperatively, between April 2010 and March 2022. Primary outcomes were in-hospital mortality and complications. Secondary outcomes were opioid use postoperatively; readmission within 90 days, one year, and two years; and total hospitalization costs. We used propensity score overlap weighting models, with the acetaminophen group as the reference group. Results. We identified 93,018 eligible patients, including 13,068 in the combination group, 29,203 in the NSAIDs group, and 50,474 in the acetaminophen group. Propensity score overlap weighting successfully balanced patient characteristics among the three groups, with no significant difference in in-hospital mortality rates observed among the groups (combination group risk difference 0.0% (95% CI -0.5 to 0.4%); NSAIDs group risk difference -0.2% (95% CI -0.5 to 0.2%)). However, the combination group exhibited a significantly lower risk of in-hospital complications than the acetaminophen group (risk difference -1.9% (95% CI -3.2 to -0.6%)) as well as a significantly lower risk of deep vein thrombosis (risk difference -1.4% (95% CI -2.2 to -0.7%)). Furthermore, total hospitalization costs were higher in the NSAIDs group than in the acetaminophen group (difference USD $438 (95% CI 249 to 630); p < 0.001). No significant differences in other secondary outcomes were observed among the three groups. Conclusion. The combination of acetaminophen with NSAIDs appears to be safe and advantageous in terms of reducing in-hospital complications. Cite this article: Bone Joint J 2024;106-B(8):849–857

Aims. The aim of this study was to compare the cost-effectiveness of cemented hemiarthroplasty (HA) versus hydroxyapatite-coated uncemented HA for the treatment of displaced intracapsular hip fractures in older adults. Methods. A within-trial economic evaluation was conducted based on data collected from the World Hip Trauma Evaluation 5 (WHiTE 5) multicentre randomized controlled trial in the UK. Resource use was measured over 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from the NHS and personal social service perspective. Methodological uncertainty was addressed using sensitivity analysis, while decision uncertainty was represented graphically using confidence ellipses and cost-effectiveness acceptability curves. Results. The base-case analysis showed that cemented implants were cost-saving (mean cost difference -£961 (95% confidence interval (CI) -£2,292 to £370)) and increased QALYs (mean QALY difference 0.010 (95% CI 0.002 to 0.017)) when compared to uncemented implants. The probability of the cemented implant being cost-effective approximated between 95% and 97% at alternative cost-effectiveness thresholds held by decision-makers, and its net monetary benefit was positive. The findings remained robust against all the pre-planned sensitivity analyses. Conclusion. This study shows that cemented HA is cost-effective compared with hydroxyapatite-coated uncemented HA in older adults with displaced intracapsular hip fractures. Cite this article: Bone Joint J 2022;104-B(8):922–928

Aims. The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture. Methods. This retrospective study included hip fracture patients aged 50 years and older treated with Exeter (PTS) bipolar hemiarthroplasty between 2019 and 2022. Patient demographics, place of domicile, fracture type, delirium status, American Society of Anesthesiologists (ASA) grade, length of stay, and mortality were collected. Reoperation and mortality were recorded up to a median follow-up of 29.5 months (interquartile range 12 to 51.4). Cox regression was performed to evaluate independent risk factors associated with reoperation and mortality. Results. The cohort consisted of 1,619 patients with a mean age of 82.2 years (50 to 104), of whom 1,100 (67.9%) were female. In total, 29 patients (1.8%) underwent a reoperation; 12 patients (0.7%) sustained a PFF during the observation period (United Classification System (UCS)-A n = 2; UCS-B n = 5; UCS-C n = 5), of whom ten underwent surgical management. Perioperative delirium was independently associated with the occurrence of PFF (hazard ratio (HR) 5.92; p = 0.013) and surgery for UCS-B PFF (HR 21.7; p = 0.022). Neither all-cause reoperation nor PFF-related surgery was independently associated with mortality (HR 0.66; p = 0.217 and HR 0.38; p = 0.170, respectively). Perioperative delirium, male sex, older age, higher ASA grade, and pre-fracture residential status were independently associated with increased mortality risk following hemiarthroplasty (p < 0.001). Conclusion. The cumulative incidence of PFF at four years was 1.1% in elderly patients following cemented PTS hemiarthroplasty for a hip fracture. Perioperative delirium was independently associated with a PFF. However, reoperation for PPF was not independently associated with patient mortality after adjusting for patient-specific factors. Cite this article: Bone Jt Open 2024;5(4):269–276

Aims. This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods. We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results. In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion. This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment. Cite this article: Bone Joint J 2024;106-B(6):603–612

Aims. In UK there are around 76,000 hip fractures occur each year 10% to 15% of which are undisplaced intracapsular. There is considerable debate whether internal fixation is the most appropriate treatment for undisplaced fractures in older patients. This study describes cannulated hip screws survivorship analysis for patients aged ≥ 60 years with undisplaced intra-capsular fractures. Methods. This was a retrospective cohort study of consecutive patients aged ≥ 60 years who had cannulated screws fixation for Garden I and II fractures in a teaching hospital between March 2013 and March 2016. The primary outcome was further same-side hip surgery. Descriptive statistics were used and Kaplan-Meier estimates calculated for implant survival. Results. A total of 114 operations were performed on 112 patients with a mean age of 80.2 years (SD 8.9). The 30-day and one-year mortality were 1% (n = 1) and 13% (n = 15), respectively. Median follow-up was 6.6 years (interquartile range 6.0 to 7.3). Kaplan-Meier estimates showed a survivorship of 95% at one year and 90% at five years (95% confidence interval 84% to 95%) for cannulated screws. Nine patients underwent further hip surgery: four revision to total hip arthroplasty, one revision to hemiarthroplasty, three removals of screws, and one haematoma washout. Posterior tilt was assessable in 106 patients; subsequent surgery was required in two of the six patients identified with a posterior angle > 20° (p = 0.035 vs angle < 20°). Of the 100 patients with angle < 20°, five-year survivorship was 91%, with seven patients requiring further surgery. Conclusion. This study of cannulated hip screw fixation for undisplaced fractures in patients aged ≥ 60 years reveals a construct survivorship without further operation of 90% at five years. Cannulated screws can be considered a safe reliable treatment option for Garden I and II fractures. Caution should be taken if posterior tilt angle on lateral view exceeds 20°, due to a higher failure rate and reoperation, and considered for similar management to Garden III and IV injuries. Cite this article: Bone Jt Open 2022;3(3):182–188

The Nottingham Hip Fracture Score (NHFS) was developed in 2007 as a predictor of 30-day mortality after hip fracture surgery following a neck of femur fracture. The National Hip Fracture Database is the standard used which calculated their own score using national data. The NHF score for 30-day mortality was calculated for 50 patients presenting with a fractured neck femur injury between January 2020 to March 2020. A score <5 was classified as low risk and >/=5 as high risk. Aim was to assess the accuracy in calculating the Nottingham Hip Fracture Score against the National Hip Fracture Database. To explore whether it should it be routinely included during initial assessment to aid clinical management?. There was an increase in the number of mortalities observed in patients who belonged to the high-risk group (>=5) compared to the low risk group. COVID-19 positive patients had worse outcomes with average 30-day mortality of 6.78 compared to the average of 6.06. GEH NHF score per month showed significant accuracy against the NHFD scores. The identification of high-risk groups from their NHF score can allow for targeted optimisations and elucidation of risk factors easily gathered at the point of hospitalisation. The NHFS is a valuable tool and useful predictor to stratify the risk of 30-day mortality and 1-year mortality after hip fracture surgery. Inclusion of the score should be considered as mandatory Trust policy for neck of femur fracture patients to aid clinical management and improve patient safety overall

Aims. The aim of this study was to evaluate the suitability, against an accepted international standard, of a linked hip fracture registry and routinely collected administrative dataset in England to embed and deliver randomized controlled trials (RCTs). Methods. First, a bespoke cohort of individuals sustaining hip fractures between 2011 and 2016 was generated from the National Hip Fracture Database (NHFD) and linked to individual Hospital Episode Statistics (HES) records and mortality data. Second, in order to explore the availability and distribution of outcomes available in linked HES-Office of National Statistics (ONS) data, a more contemporary cohort with incident hip fracture was identified within HES between January 2014 and December 2018. Distributions of the outcomes within the HES-ONS dataset were reported using standard statistical summaries; descriptive characteristics of the NHFD and linked HES-ONS dataset were reported in line with the Clinical Trials Transformation Initiative recommendations for registry-enabled trials. Results. Case ascertainment of the NHFD likely exceeds 94%. The assessment of the robustness, relevance, and reliability of the datasets was favourable. Outcomes from the HES-ONS dataset were concordant with other contemporaneous prospective cohort studies with bespoke data collection frameworks. Conclusion. Our findings support the feasibility of the NHFD and HES-ONS to support a registry-embedded, data-enabled RCT. Cite this article: Bone Joint J 2025;107-B(2):229–238

Background. In a number of disciplines, positive correlations have been reported between volume and clinical outcome. This has helped drive the evolution of specialist centres to deal with complex or high risk medical conditions. Hip fractures are a common injury associated with high morbidity and mortality. Aim. To assess whether volume of hip fracture cases attended to by individual hospitals is associated with the quality of care provided and clinical outcomes. Methods. Utilising 19 quality of care measures espoused by NICE and available on the National Hip Fracture Database website, we examined whether there was a correlation between Volume of hip fractures per institution and each outcome measure for 2016 and 2018. Outcomes were assessed for normality of distribution and correlated using either Spearman rank or Pearson Correlation as appropriate. Results. Over 170 institutions were available for analysis. The average number of procedures per institution was 371 (sd 154) in 2016 and 378 (sd 158) in 2018. 9 units attended to in excess of 700 cases per annum. There was a positive correlation between volume of cases and a number of quality of care indices; notably survivorship, length of stay, ortho-geriatric consultation, pressure ulcer prevention, post-operative mobilisation, delirium prevention, bone health assessment and the proportion of patients satisfying the Best Practice Tariff (BPT) criteria. 5 of the measures had no correlation. The worst performances were observed for measures that were not financially incentivised. Discussion. Our analysis of a large synchronous national dataset show weak but favourable correlations with unit volume and important outcomes including mortality and length of stay. Our results do not invariably justify the centralisation of hip fracture services. Hip fracture care may be more convincingly improved by promoting compliance to the guidance that already exists via financial incentivisation or otherwise

The hip fracture burden on health and social care services in Scotland is anticipated to increase significantly, primarily driven by an ageing population. This study forecasts future hip fracture incidence and the annual number of hip fractures in Scotland until 2029. The monthly number of patients with hip fracture aged ≥ 50 admitted to a Scottish hospital between 01/01/2017 and 31/12/2021 was identified through data collected by the Scottish Hip Fracture Audit. This data was analysed using Exponential Smoothing and Auto Regressive Integrated Moving Average forecast modelling to project future hip fracture incidence and the annual number of hip fractures until 2029. Adjustments for population change were accounted for by integrating population projections published by National Records of Scotland. Between 2017 and 2021 the annual number of hip fractures in Scotland increased from 6675 to 7797, with a respective increase in hip fracture incidence from 313 to 350 per 100,000. By 2029, the averaged projected annual number of hip fractures is 10311, with an incidence rate of 463 per 100,000. The largest percentage increase in hip fracture occurs in the 70-79 age group (57%), with comparable increases in both sexes (30%). Based upon these projections, overall length of stay following hip fracture will increase from 142713 bed days per annum in 2021, to 203412 by 2029, incurring an additional cost of over £25 million. Forecast modelling demonstrates that the annual number of hip fractures in Scotland will rise substantially by 2029, with considerable implications for health and social care services

Aims. Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. Methods. We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England’s SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models. Results. Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days. Conclusion. COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival. Cite this article: Bone Joint J 2022;104-B(10):1156–1167

Aims. Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era. Methods. A multicentre observational study was carried out at 19 NHS Trusts in England. The study period for the data collection was 1 February 2021 until 28 February 2022, with mortality tracing until 28 March 2022. Data collection included demographic details, data points to calculate the Nottingham Hip Fracture Score, COVID-19 status, 30-day mortality, and vaccination status. Results. A total of 337 patients tested positive for COVID-19. The overall 30-day mortality in these patients was 7.7%: 5.5% in vaccinated patients and 21.7% in unvaccinated patients. There was no significant difference between post-vaccine mortality compared with pre-pandemic 2019 controls (7.7% vs 5.0%; p = 0.068). Independent risk factors for mortality included unvaccinated status, Abbreviated Mental Test Score ≤ 6, male sex, age > 80 years, and time to theatre > 36 hours, in decreasing order of effect size. Conclusion. The vaccination programme has reduced 30-day mortality rates in hip fracture patients with concomitant COVID-19 infection to a level similar to pre-pandemic. Mortality for unvaccinated patients remained high. Cite this article: Bone Joint J 2022;104-B(12):1362–1368

Aims. To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC). Methods. A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)’s Perioperative Special Interest Group and clinicians’ personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples t-tests and chi-squared tests. Results. A total of 406 respondents from 51 countries answered the questionnaire, of whom 225 came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median and mean estimated proportion of admitted patients with hip fracture undergoing surgery (median 96% (interquartile range (IQR) 95% to 99%); mean 94% (SD 8%)) than those from LMIC (median 85% (IQR 75% to 95%); mean 81% (SD 16%); p < 0.001). Global heterogeneity seems to exist regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making. Conclusion. This study represents the first international sampling of clinician perspectives regarding nonoperative hip fracture management. Several factors seemed to influence the clinician decision-making process. Further research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people. Cite this article: Bone Jt Open 2023;4(10):766–775

Aims. The aim of this study was to develop and evaluate a deep learning-based model for classification of hip fractures to enhance diagnostic accuracy. Methods. A retrospective study used 5,168 hip anteroposterior radiographs, with 4,493 radiographs from two institutes (internal dataset) for training and 675 radiographs from another institute for validation. A convolutional neural network (CNN)-based classification model was trained on four types of hip fractures (Displaced, Valgus-impacted, Stable, and Unstable), using DAMO-YOLO for data processing and augmentation. The model’s accuracy, sensitivity, specificity, Intersection over Union (IoU), and Dice coefficient were evaluated. Orthopaedic surgeons’ diagnoses served as the reference standard, with comparisons made before and after artificial intelligence assistance. Results. The accuracy, sensitivity, specificity, IoU, and Dice coefficients of the model for the four fracture categories in the internal dataset were as follows: Displaced (1.0, 0.79, 1.0, 0.70, 0.82), Valgus-impacted (1.0, 0.80, 1.0, 0.70, 0.82), Stable (0.99, 0.95, 0.99, 0.83, 0.89), and Unstable (1.0, 0.98, 0.99, 0.86, 0.92), respectively. For the external validation dataset, the sensitivity and specificity were as follows: Displaced (0.83, 0.94), Valgus-impacted (0.89, 0.90), Stable (0.88, 0.95), and Unstable (0.85, 0.99), respectively. The overall means (Micro AVG and Macro AVG) for the external dataset were Micro AVG (0.83 (SD 0.05), 0.96 (SD 0.01)) and Macro AVG (0.69 (SD 0.02), 0.95 (SD 0.02)), respectively. Conclusion. Compared to human diagnosis alone, our study demonstrates that the developed model significantly improves the accuracy of detecting and classifying hip fractures. Our model has shown great potential in assisting clinicians with the accurate diagnosis and classification of hip fractures. Cite this article: Bone Joint J 2025;107-B(2):213–220