In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function.

Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck.

Between 1999 and 2005, 10 264 patients who had undergone total hip replacement (THR) for subcapital fracture of the hip were compared with 76 520 in whom THR had been performed for other reasons. All the cases were identified through the Swedish Hip Arthroplasty Register. The THRs performed as primary treatment for fracture were also compared with those done after failure of internal fixation.

After seven years the rate of revision was higher in THR after fracture (4.4% vs 2.9%). Dislocation and periprosthetic fracture were the most common causes of revision. The risk was higher in men than in women. The type of femoral component and the surgical approach influenced the risk. After correction for gender, type of component and the surgical approach the revision rates were similar in the primary and secondary fracture THR groups.

Total hip replacement is therefore a safe method for both the primary and secondary management of fracture of the hip.

We invited 1604 randomly selected women, all 75 years of age, to participate in a study on the risk factors for fracture. The women were divided into three groups consisting of 1044 (65%) who attended the complete study, 308 (19%) respondents to the study questionnaire only and 252 (16%) who did not respond. The occurrence of the life-time fracture was ascertained from radiological records in all groups and by questionnaires from the attendees and respondents.

According to the radiological records, fewer of the questionnaire respondents (88 of 308, 28.6%) and non-respondents (68 of 252, 27%) had sustained at least one fracture when compared with the attendees (435 of 1044, 41.7%; chi-squared test, p < 0.001). According to the questionnaire, fewer of the respondents (96 of 308, 31.1%) had sustained at least one previous fracture when compared with the attendees (457 of 1044, 43.7%; chi-squared test, p < 0.001).

Any study concerning the risk of fracture may attract those with experience of a fracture which explains the higher previous life-time incidence among the attendees. This factor may cause bias in epidemiological studies.

The number of people suffering from pain or limitation of daily activities as a result of conditions related to the musculoskeletal system is increasing in Europe and worldwide. It is therefore essential to develop strategies to prevent both the occurrence of these conditions and the impact of these conditions.

Most musculoskeletal conditions occur in the elderly and as the elderly population will reach above 20% within the next 20 years this will further augment the problem within Europe, particularly as these conditions also increase with advancing age. It must be recognized that at most levels within the health care systems or within society, the impact of these conditions today and for the future is underestimated, both regarding number and regarding consequences; disability, handicap, social implications and costs. The major challenge is, however, not to make recommendations for preventive strategies but to implement them in order to secure a change, leading to improved care and improved quality of life for patient, regardless of age.

The first step in order to make a change is to define the size of the problem – the burden of musculoskeletal conditions. With respect to the incidence and prevalence the size of the problem is relatively well known. The size of the problem when it comes to the impact on the individual is less well known, as is the burden in terms of economic and societal costs. For many conditions the risk factors are identified and common to many conditions.

The second step involves evidence – evidence for the effectiveness of the interventions available today. When evaluating evidence it is useful to define population in terms of the normal or healthy population, those at risk, those at early or moderate stage and those at late stage of the condition since this will translate into preventive strategies appropriate for each level.

The final step is implementation and this is the major challenge at all levels, from policies trying to influence the entire population to adopt a healthier life style, to change the management of the individual patient in the doctor’s office. Based on knowledge of size and evidence, it is possible to transform recommendations into an actual action plan at national, regional and local levels. The principles for successful implementations are to a large extent similar for all levels.

The tools for success need to be identified and they may include financial or economic mechanisms, regulatory mechanisms, and educational or organisational mechanisms. It is particularly important to identify barriers and facilitators that will influence the outcome of the proposed strategy.

Musculoskeletal conditions have many risk factors and interventions in common with other conditions that affect public health, such as diabetes and cardiovascular conditions. In primary prevention it is therefore key to collaborate not only within the musculoskeletal field but also with other fields in order to improve also musculoskeletal health.

With the increasing number of people suffering from pain or limitation of daily activities as a result of conditions related to the musculoskeletal system, it is essential to develop strategies to prevent both the occurrence of these conditions and the impact of these conditions.

The Bone and Joint Decade initiative was developed around the core issue of improving the health related quality of life for those afflicted with a musculoskeletal condition. It was recognised that at most levels within the health care system or within society, the impact of these conditions today and for the future were underestimated both regarding number and regarding consequences; disability, handicap, societal implications or costs. The increasing population of elderly, reaching above 20% within the next 20 year, will further augment the problem within Europe, as these conditions also increase with advancing age.

In order to make a change, strategies needs to be developed addressing a number of issues: what is the incidence and prevalence of these conditions today, what is burden in terms of economic and societal costs, what is the impact on the individual and what is the outcome for the individual with optimal care but also with sub-optimal care. From systematic reviews of evidence-based interventions and collation of guidelines, recommendations for strategies including multiprofessional approaches have been developed. The evidence for interventions is identified in terms of effectiveness in dealing with symptoms, tissue damage, activities and participation. Policies can than be based on what is achievable and what is needed after local adaptation.