Each year, about 3–4,000 hip fractures occur in New Zealand,1 and the death rate (over 12 months) worldwide following hip fracture injury has been reported at between 20% and 35%.2–4

In New Zealand, very little published data on mortality and morbidity following neck of femur fractures exists to date. In this issue of the Journal, the article by William Young et al (Audit of morbidity and mortality following neck of femur fracture using the POSSUM scoring system. URL: http://www.nzma.org.nz/journal/119-1234/1986) is very timely as it highlights this life-changing and sometimes life-ending event amongst elderly New Zealanders.

A report by the New Zealand Health Information Service,1 analysing hospital discharge data for the 1999/2000 period, showed an alarming mortality rate of 27% within 1 year following a neck of femur fracture. With an expected number of deaths of around 10%, the actual hip fracture related mortality was 17%.

With a rapidly ageing New Zealand population, the burden caused by hip fractures on the healthcare system is increasing rapidly. Sixteen percent of the population is currently aged over 60, but by 2050 this will double to just over 30%.5 The biggest increase will be in the 85-and-over age group. As this group contributes almost exclusively to this fracture type, we can therefore expect an epidemic of hip fractures over the next 50 years in New Zealand.

The incidence of neck of femur fractures has increased in the last decade by 40% in men and 50% in women according to in a study carried out in New South Wales, Australia.6 This trend is likely to continue in the future.

Young et al look at the value of a clinical severity score (POSSUM)7 in assessing mortality and morbidity following hip fractures over a period of 6 months. They report a morbidity of 58% in these elderly patients on the basis of age and comorbidities. The mortality was 12% at 30 days and 32% at 1 year (six-fold increase over predicted mortality).

The POSSUM system sorts patients into risk categories which is useful for comparing hip fracture mortality between hospitals. Unfortunately this scoring system cannot be used as a preoperative predictor of postoperative outcomes in individual patients, however.

A medical condition with such high mortality and morbidity (affecting the very frail of our community in a rapidly rising manner) must deserve more attention from our healthcare system. The causes of hip fracture mortality are well known and include age, severity of comorbid conditions, mental status, and delay in time to surgery. The only factor which we can really influence is the time to surgery.

A recent multicentre study in the United Kingdom8 reported that 40% of procedures were performed more than 24 hours after admission. Delay was associated with an increase in hospital mortality even after adjustment for comorbidity. The authors recommended that hip fracture patients be operated on within 24 hours of admission if at all possible. Similar delays in access to surgery occur in New Zealand hospitals.

Another issue which needs to be addressed is the perioperative management of these patients which is often left to the most junior members of the clinical teams. Shared care between geriatricians and orthopaedic surgeons has been suggested as a way of improving the outcome in hip fracture patients, and a recent paper from Christchurch9 reported a significant reduction in inpatient mortality as a result of such a model. However it remains unclear at this stage whether this will translate into a reduced mortality at 1 year.

I believe that it is time now to develop a National Hip Fracture Strategy which will guide the future prevention and treatment of hip fractures in this country. Such a strategy should aim at reducing the incidence of hip fractures by developing a national osteoporosis and falls prevention programme as well as improving postoperative outcomes and long-term quality of life by setting up dedicated multidisciplinary hip fracture teams in our hospitals with strong rehabilitation and community links.

Hip fractures disable and kill: let’s act now to control this silent epidemic!

Author information: Jean-Claude Theis, Associate Professor and Head of Section, Department of Orthopaedic Surgery, Dunedin School of Medicine, University of Otago, Dunedin

Correspondence: Associate Professor Jean-Claude Theis, Department of Orthopaedic Surgery, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin. Fax: (03) 474 7617; email: jean-claude.theis@stonebow.otago.ac.nz