We determined the age-specific incidence of a second fracture of the hip and compared it with that of a primary fracture in a study population drawn from 6331 patients admitted to Nottingham University Hospital with a primary fracture of the hip over a period of 8.5 years. The incidence of a second fracture was determined using survival analysis. The mean age-specific incidence rates of primary hip fracture were calculated using census data.

The overall incidence of a second fracture was 2.7% at one year and 7.8% at 8.5 years. That of a primary fracture was 50 per 100 000 in women aged 55 to 64 years rising to 3760 in those aged 84 years and over. The incidence of a second fracture in women aged 55 to 64 years was 2344 per 100 000. Patients of this age had a relative risk of 45 (95% confidence interval 13 to 155) for further fracture when compared with the population at risk of a first fracture. The incidence of a second fracture in women aged > 84 years was 2451 per 100 000 (relative risk 0.7, 95% confidence interval 0.5 to 0.9). A similar trend was seen in men.

Patients sustaining a primary fracture of the hip between the ages of 55 and 64 years have a much greater risk of further fracture than the normal population, whereas those over 84 years have a similar risk. These findings have important implications for the provision of fracture prevention services in primary and secondary care.

To assess the relationship between preoperative urea concentration and mortality in patients with hip fractures requiring surgery, we carried out a prospective observational study of 1230 consecutive patients admitted to a single trauma unit with a hip fracture, required surgery.

Results: The mean age was 80 years (range 17–101) and 931 (77%) were female. 669 patients (54%) had intracapsular fractures, 547 patients (45%) had extra-capsular fractures and 14 patients (1%) had periprosthetic fractures. 760 (62%) patients were admitted from their own homes, 178 (15%) from residential homes, 150 (12%) from nursing homes and 123 (10%) from warden-aided homes. 644 (53%) were independently mobile before injury, 311 (26%) used walking aids, 241 (20%) were mobile with the use of a frame and 24 (2%) were unable to walk. 371 (32%) patients had a mini mental test score of less than 7. 49 (4%) were known to have renal disease and 106 (9%) had diabetes.

The 30-day mortality was 9.8% and the 90-day mortality was 19.9%. The mortality at 1 year was 29.0% and at 2 years was 30.2%. There is a clear relationship between a raised admission urea concentration and mortality at 90 days, 1 year and 2 years. Abnormalities of serum sodium and potassium concentration did not influence mortality.

Conclusion: Mortality is high following hip fracture. Patients admitted with a raised serum urea and treated with operative methods are at increased risk of death at all the time intervals analysed, up to and including 2 years. This group of patients may require a separate care pathway that provides more intensive management of fluid and electrolyte balance.

The aim of this study was to determine the incidence of second hip fracture.

A prospective cohort study include 2682 patients aged 50 years or more admitted with a hip fracture over a 4 year period. Mortality data were available for all patients and survival analysis was performed to determine the incidence of second hip fracture. The mean age-specific incidence rates of primary hip fracture in the population were calculated to serve as a baseline.

95 patients (3.5%) sustained a sequential, contralateral hip fracture within the study period. The mean age at first hip fracture was 82 years and the mean interval between fractures was 316 days. Fracture morphology was similar on both sides in 69% of cases. Survival analysis demonstrated that the incidence of second hip fracture at 1 year was 2.8% (95% CI: 2.0–3.6), 2 years was 5.7% (95% CI: 4.3–7.1) and 3 years was 7.3% (95% CI: 5.4–9.2). The relative risk of hip fracture in patients who had already sustained one hip fracture was 2.4 times above that of matched controls. Assistance with activities of daily living was identified as a risk for second hip fracture (p=0.026, 95% CI: 1.058, 2.466). The odds ratio for sustaining a second hip fracture compared with the incidence of primary hip fracture in the normal population aged 55–64 years was 47.5 xs; 65–74 years was 15 xs; 75–84 years was 3.7x and 85+ years was 1x.

The risk of sustaining a second contralateral hip fracture is substantial. In younger patients preventative measures can be targeted at the individual who has sustained a fracture whereas in more elderly patients, preventative measures need to address the population as a whole.

Funding for the health service is limited and this inevitably leads to rationing. However, the allocation of funding to different specialities and clinical areas often has no rational basis. The aim of this study was to evaluate the health status of patients on the orthopaedic waiting list.

The SF-36 was used as a postal questionnaire and sent to all adult patients on the elective orthopaedic waiting list at our hospital. Demographic data was collected and patients were grouped by intended operation. The health domains of the SF-36 were adjusted for demographic variables and compared to population norms using non-parametric statistical methods.

The SF-36 was sent to 1586 patients and 1155 responded (73%). Analysis was undertaken for hip replacement (n=194), knee replacement (n=291), knee arthroscopy (n=232), foot and ankle (n=147) and cruciate ligament reconstruction (n=46). All diagnostic groups had significantly worse (p< 0.05) scores for all domains of health when compared to population norms. Patients awaiting joint replacement had worse disability (p< 0.001) than other groups, particularly for pain and physical function. Patients over 40 years awaiting arthroscopy had disability approaching these levels and those awaiting ACL reconstruction had poor physical function. In general, patients awaiting foot or ankle surgery had better health than other diagnostic groups but still had significant reductions when compared to normal. Health scores were not related to the Townsend index for social deprivation, indicating equity of access within the health service.

Patients awaiting hip and knee replacement have worse health than others on the waiting list. The SF-36 could be a useful tool if priority on waiting lists were to be determined by pain and disability rather than waiting time.

The New Zealand health score was developed by the New Zealand government to ensure that patients with the greatest needs were given priority. It allows explicit rationing of health care by clinical priority rather than waiting time (the current UK system). The scoring system has not been validated against an accepted measure of health status and the aim of this study was to compare the New Zealand score with the SF-36.

Patients on the orthopaedic waiting list for hip or knee replacement were sent postal questionnaires to collect demographic data and complete an SF-36 and New Zealand score.

581 patients were sent questionnaires. The response rate was 72% and data was available on 243 knee replacement and 168 hip replacement patients. For patients awaiting hip replacement there was good correlation between the NZ and all health domains of the SF-36 (correlation coefficient: 0.19 – 0.62). In contrast, there was poor correlation between the NZ score and the SF-36 for patients awaiting knee replacement with only physical function having a significant correlation (coefficient 0.25). Breakdown of the NZ score into pain and function components did not improve the correlation with SF-36 scores for these patients.

The New Zealand clinical priority scoring system correlates well with health status, as measured by the SF-36, for patients with hip arthritis awaiting hip replacement. However, the NZ score does not correlate with the SF-36 for patients awaiting knee replacement. This system is now being used by some centres in the UK for waiting list management but has been introduced without comparison to any well-established measures of health status. Its use for the prioritisation of patients who require knee replacement should be questioned.

The aim of this study was to evaluate the peri-operative (30-day) mortality following hip fracture and look at the variables which influence early mortality after this injury. A prospective audit of all patients admitted with hip fracture was undertaken over an 18-month period. An independent research assistant collected data on a standardised questionnaire. Data included basic demographics, comorbidities, mental test score, mobility and social status, All patients received prophylactic antibiotics and thromboprophylaxis and surgery was undertaken on dedicated trauma and hip fracture operating lists.

There were 1072 patients admitted with hip fracture: 829 females (77%) and 240 males (23%) with a mean age of 80 years (range 24–103 years). The basic fracture types were intracapsular (n=616; 58%); extracapsular (n=414; 38%); subtrochanteric (n=29; 3%) and periprosthetic (n=12; 1%). 69 patients (7%) had acute medical problems which delayed anaesthesia. Delays to surgery, because of a lack of theatre resources, were common and only 314 patients (29%) had their hip fracture fixed on the day of admission or the following day. There were 9 deep infections (0. 8%) and 69 patients (6%) died within 30 days of surgery. Linear regression analysis showed that the 30-day mortality was not associated with pre-injury mobility or mental test score (p=0. 224). Any delay to surgery (2 days or more) resulted in a significant increase in mortality (p=0. 0042) and the risk of death increased 21% for every day surgery was delayed. Subgroup analysis showed that acute medical comorbidity was the most important factor influencing mortality with an odds ratio for death of 4. 9 (p=0, 0007). Delay to surgery in medically fit patients (n= 633) gave an odds ratio for death of 1. 6. In this group, the risk of death increased 16% for every day surgery was delayed with an 85% probability (p=O. 125) that this trend was significant.

The peri-operative mortality for hip fractures is now quite low (6%). Acute medical comorbidities are the most important cause of early post-operative death. Delay to surgery may be a factor in medically fit patients and our data suggests that the ideal time for surgery is the day after admission.