LETTERS TO THE EDITOR 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 ten- dency for a second hip fracture (HF) to be the same type as the previous one. This observation is in agreement with previ- ous reports. 1–4 The authors found an in- cidence of a second HF of 9.5% which corresponds with some published data (8.3% – 11.8%) 5–8 but higher than others (5.5%–6.6%). 2–4 They also correctly con- cluded 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. 2,8,9 For this reason it is important to identify potential precursors of a second HF, to determine its out- comes and implement adequate preven- tive strategies. Because these issues re- ceived 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 osteo- porotic HF over a 3-year period (2000– 2003) to The Canberra Hospital (a 450- bed 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 sub- jects had a known prior vertebrae (5.5%) or arm fracture (3.4%). All patients had operative fracture treatment. A compari- son between the patients with second HF and first HF was performed by an un- paired 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 mor- tality (7.1% vs 6.9%), co-morbid condi- tions including cognitive impairment (26.7% vs 32.6%), hypertension (50% vs 39.2%), coronary artery disease (23.3% vs 21.6%), chronic obstructive pulmo- nary disease (13.3% vs 26.8%), cerebro- vascular 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 fre- quency of anaemia (haemoglobin less than 115 g/L in women and less than 135 g/L in men, 36.7% vs 38.1%), hypoalbu- minaemia (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, 6–8 indicate that (1) older people with a first HF have an increased prevalence of a second HF; (2) risk factors for subse- quent HF are similar to those of the first HF; and (3) having a second HF does not significantly influence the outcome ex- cept 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 sig- nificantly 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 antire- sorptive agents (bisphosphonates). In other words, the majority of these high- risk subjects did not receive antiosteopo- rotic treatment, and none received ad- equate 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 treat- ment of osteoporosis in subjects who sus- tain a HF is inadequate, and greater edu- cation of orthopaedic surgeons, general physicians and the public, is urgently re- quired. Alexander A. Fisher, MD, FRACP, PhD Michael W. Davis, MBBS, FRACP Department of Geriatric Medicine The Canberra Hospital Woden, ACT, Australia Shyan Goh, MBBS Paul N. Smith, MBBS, FRCS Department of Orthopaedic Surgery The Canberra Hospital Woden, ACT, Australia REFERENCES 1. Finsen V, Benum P. The second hip fracture. An epidemiologic study. Acta Orthop Scand. 1986;57:431–433. 2. Schroder HM, Petersen KK, Erlandsen M. Oc- currence and incidence of the second hip frac- ture. Clin Orthop. 1993:166–9. 3. Dretakis KE, Dretakis EK, Papakitsou EF, Psa- rakis S, Steriopoulos K. Possible predisposing factors for the second hip fracture. Calcif Tis- sue Int. 1998;62:366–369. 4. Kaper BP, Mayor MB. Incidence of bilateral proximal femoral fractures in a tertiary care center. Orthopedics. 2001;24:571–574. 5. Boston DA. Bilateral fractures of the femoral neck. Injury. 1982;14:207–210. 6. Di Monaco M, Di Monaco R, Manca M, Ca- vanna A. Functional recovery and length of stay after recurrent hip fracture. Am J Phys Med Rehabil. 2002;81:86–89. 7. Dinah AF. Sequential hip fractures in elderly patients. Injury. 2002;33:393–394. 8. Chapurlat RD, Bauer DC, Nevitt M, Stone K, Cummings SR. Incidence and risk factors for a second hip fracture in elderly women. The Study of Osteoporotic Fractures. Osteoporos Int. 2003;14:130–136. 9. Wolinsky FD, Fitzgerald JF. Subsequent hip fracture among older adults. Am J Public Health. 1994;84:1316–1318. In Response: The prevalence of elderly in our society is increasing. About 13% of the population in the United States are older than 65 years today, and this rate is ex- 256 J Orthop Trauma • Volume 18, Number 4, April 2004