The second hip fracture--an analysis of 84 elderly patients.

To the Editor: We read with interest the paper by Shabat, et al, (J Orthop Trauma 2003; 17:613–617). The authors noticed a tendency for a second hip fracture (HF) to be the same type as the previous one. This observation is in agreement with previous reports. The authors found an incidence of a second HF of 9.5% which corresponds with some published data (8.3% – 11.8%) but higher than others (5.5%–6.6%). They also correctly concluded that with the growing elderly population the rates of second HF would increase. In older persons with a HF, the risk of a second HF is 6 to 10 times higher, occurring with a rate of 1.5% to 2.9% per year. For this reason it is important to identify potential precursors of a second HF, to determine its outcomes and implement adequate preventive strategies. Because these issues received little attention, we would like to add to this discussion by reporting our observations. We performed a retrospective analysis of 321 patients (60 years of age and older) who presented with an osteoporotic HF over a 3-year period (2000– 2003) to The Canberra Hospital (a 450bed tertiary care academic institution). A second HF occurred in 30 (9.3%) patients including 8.9% of all women and 10.5% of men. Twenty-six (9%) additional subjects had a known prior vertebrae (5.5%) or arm fracture (3.4%). All patients had operative fracture treatment. A comparison between the patients with second HF and first HF was performed by an unpaired t test. This revealed no significant differences with regard to the mean age (82.3 vs 87.6 years), gender (F:M ratio 2.3:1 vs 2.8:1), type of fracture (cervical 63.3% vs 56.7%, trochanteric 36.7% vs 43.3%), mean total length of hospital stay (23.1 vs 24.8 days), in-hospital mortality (7.1% vs 6.9%), co-morbid conditions including cognitive impairment (26.7% vs 32.6%), hypertension (50% vs 39.2%), coronary artery disease (23.3% vs 21.6%), chronic obstructive pulmonary disease (13.3% vs 26.8%), cerebrovascular diseases (6.7% vs 8.6%), renal impairment (30% vs 37.6%) or smoking history (10% vs 17.8%). There was no difference in the frequency of anaemia (haemoglobin less than 115 g/L in women and less than 135 g/L in men, 36.7% vs 38.1%), hypoalbuminaemia (less than 33 g/L, 23.3% vs 37.5%) or lymphopaenia (less than 1.2.10 g/L, 46.7% vs 59.3%). Similar proportions of patients with the first and second HF presented from home (50% vs 57%) or institutions (39.3% vs 32.9%), and required institutional care (14.3% vs 17%). Patients affected by recurrent HF compared to subjects suffering from the first HF more often were using a walking aid (50% vs 33.3%; P < 0.02). These data together with the published literature, indicate that (1) older people with a first HF have an increased prevalence of a second HF; (2) risk factors for subsequent HF are similar to those of the first HF; and (3) having a second HF does not significantly influence the outcome except for using a walking aid more often. The most important difference between the two groups was vitamin D status. In patients with a second HF, the incidence of low-serum concentration of 25(OH) vitamin D (less than 39 nmol/L) was significantly higher than in persons with the first HF (76.7% vs 62.8%; P < 0.05), and vitamin D deficiency [25(OH) vitamin D less than 25 nmol/L] was 1.6 times more common (66.6% vs 42.3%; P < 0.01). Moreover, only 5 (16.7%) of 30 patients who sustained a second HF were taking calcitriol and none was receiving antiresorptive agents (bisphosphonates). In other words, the majority of these highrisk subjects did not receive antiosteoporotic treatment, and none received adequate treatment. Our data confirm that a second HF occurs in 1 in 10 patients but is not predictive of increased risk of poor outcome compared to first HF, although half need a walking aid. Low vitamin D status and inadequate antiosteoporotic treatment after the first HF are important predisposing factors in development of a second HF. Current practice for treatment of osteoporosis in subjects who sustain a HF is inadequate, and greater education of orthopaedic surgeons, general physicians and the public, is urgently required.