RESEARCH LETTER Restricted weight bearing after hip fracture surgery in the elderly: economic costs and health outcomes Jane Wu MBBS MPH RACP (FRARM), 1 Susan Kurrle MBBS Dip Ger Med PhD 1 and Ian D. Cameron MBBS RACP (FRARM) PhD 1,2 1 Staff Specialist in Aged Care and Rehabilitation, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia 2 Head, Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia Correspondence Dr Jane Wu Hornsby Ku-ring-gai Hospital Palmerston Road Hornsby NSW 2077 Australia E-mail: wujane2000@hotmail.com Accepted for publication: 15 August 2007 doi:10.1111/j.1365-2753.2008.00943.x To the Editor Hip fracture is a common fracture in older people and the vast majority (>95%) are managed surgically. Currently in Australia, there are 22 000 hip fracture surgeries (HFS) performed annually [1]. The cost of HFS will only escalate in the future as it is predicted that hip fractures will increase by 66% by the year 2021 and 190% by the year 2051 [2]. It is therefore imperative that to reduce economic costs associated with these fractures, we strive to tease out factors that increase the cost of rehabilitation management. The rationale for restriction in weight bearing following HFS appears to reflect concerns about the stability of the fracture and the belief that the incidence of complications is reduced with restricted weight bearing. However, there is very little clinical data to guide this decision. The latest Cochrane review states that the authors ‘could not identify any randomised trial that adequately addresses this issue’ [3]. The only trial identified which partially answers the question, was performed by Graham [4] in 1968 who compared weight bearing as tolerated (WBAT) at 2 weeks with 12 weeks after internal fixation of a displaced intracapsular fracture in 273 patients. The results were poorly presented and follow-up was incomplete, but there appeared to be no difference in the rate of failure of fixation (which was approximately 15%). There is a non-randomized study which has demonstrated in 569 elderly cognitively intact patients that it was safe to allow them to WBAT immediately after hip fractures [5]. Because of the lack of data to guide this decision, it is our empirical impression that the current practice of prescribing weight-bearing status after HFS is quite variable between different orthopaedic units. Despite the lack of literature existing on the adverse effects of restricted weight bearing on clinical outcomes, some rehabilitation units often have an unwritten policy of not accepting patients until they are allowed to fully weight bear, especially if they have concurrent issues with balance and/or cog- nitive impairment. To our knowledge, weight-bearing status has never been con- sidered in the orthopaedic or rehabilitation literature to be a factor influencing outcome. The aim of this audit is to demonstrate any difference in outcome for those with restricted weight bearing compared with those who are allowed to WBAT. Methods A total of 359 surgical procedures for hip fracture were performed at Hornsby Ku-ring-gai Hospital, a metropolitan hospital in north- ern Sydney, from July 2003 to December 2005. Excluded were 12 cases of hip fractures due to significant trauma, pathological fractures due to metastases or Paget’s disease, and hip fractures occurring during a hospital admission for an alternative reason. An additional four cases were excluded as their medical records could not be found. Of the 343 patients audited, 331 (96.4%) of all minimal trauma hip fractures occurred in those aged 65 years and over. It is this group that was selected for analysis. Patients’ case notes were retrospectively reviewed and data extracted by the lead author. Data were analysed using spss version 11.5 (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant. Results The mean age of patients undergoing HFS was 85 (6.6) years. Among those patients, 269 (80%) were female and 68 (20%) were male. Cognitive impairment was present in 62% (204/331) of the cases; 49% were admitted from home, 25% from hostel (low level care) and 26% from nursing homes (high level care). Eighty-six per cent of patients were mobile with or without an aid prior to Journal of Evaluation in Clinical Practice ISSN 1356-1294 © 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 217–219 217