Osteoporosis International

, Volume 27, Issue 10, pp 2945–2953 | Cite as

Hip fracture, mortality risk, and cause of death over two decades

  • M. von Friesendorff
  • F. E. McGuigan
  • A. Wizert
  • C. Rogmark
  • A. H. Holmberg
  • A. D. Woolf
  • K. AkessonEmail author
Original Article



Men and women with hip fracture have higher short-term mortality. This study investigated mortality risk over two decades post-fracture; excess mortality remained high in women up to 10 years and in men up to 20 years. Cardiovascular disease (CVD) and pneumonia were leading causes of death with a long-term doubling of risk.


Hip fractures are associated with increased mortality, particularly short term. In this study with a two-decade follow-up, we examined mortality and cause of death compared to the background population.


We followed 1013 hip fracture patients and 2026 matched community controls for 22 years. Mortality, excess mortality, and cause of death were analyzed and stratified for age and sex. Hazard ratio (HR) was estimated by Cox regression. A competing risk model was fitted to estimate HR for common causes of death (CVD, cancer, pneumonia) in the short and long term (>1 year).


For both sexes and at all ages, mortality was higher in hip fracture patients across the observation period with men losing most life years (p < 0.001). Mortality risk was higher for up to 15 years (women (risk ratio (RR) 1.9 [95 % confidence interval (CI) 1.7–2.1]); men (RR 2.8 [2.2–3.5])) and until end of follow-up ((RR 1.8 [1.6–2.0]); (RR 2.7 [2.1–3.3])). Excess mortality by time intervals, censored for the first year, was evident in women (<80 years, up to 10 years; >80 years, for 5 years) and in men <80 years throughout. CVD and pneumonia were predominant causes of death in men and women with an associated higher risk in all age groups. Pneumonia caused excess mortality in men over the entire observation period.


In a remaining lifetime perspective, all-cause and excess mortality after hip fracture was higher even over two decades of follow-up. CVD and pneumonia reduce life expectancy for the remaining lifetime and highlights the need to further improve post-fracture management.


Age Cause of death Hip fracture Mortality Sex 



This work was supported by grants from the Swedish Research Council (K2009-53X-14691-07-3, K2010-77PK-21362-01-2); FAS (Grant 2007–2125); Greta and Johan Kock Foundation; A Påhlsson Foundation; A Österlund Foundation; King Gustav V and Queen Victoria Foundation; Malmö University Hospital Research Foundation; Research and Development Council of Region Skåne, Sweden; and the Swedish Medical Society. We thank Professor Jonas Ranstam and Mr Jan-Åke Nilsson for statistical advice and Dr Jack Besjakov for access to radiography files.

Compliance with ethical standards

Conflicts of interest


Supplementary material

198_2016_3616_MOESM1_ESM.doc (76 kb)
Supplementary Table 1 (DOC 75 kb)
198_2016_3616_MOESM2_ESM.doc (123 kb)
Supplementary Table 2 (DOC 123 kb)


  1. 1.
    Borgstrom F, Johnell O, Kanis JA, Jonsson B, Rehnberg C (2006) At what hip fracture risk is it cost-effective to treat? International intervention thresholds for the treatment of osteoporosis. Osteoporos Int 17:1459–1471CrossRefPubMedGoogle Scholar
  2. 2.
    Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB (2009) Incidence and mortality of hip fractures in the United States. JAMA 302:1573–1579CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Leslie WD, O’Donnell S, Jean S, Lagace C, Walsh P et al (2009) Trends in hip fracture rates in Canada. JAMA 302:883–889CrossRefPubMedGoogle Scholar
  4. 4.
    Rogmark C, Sernbo I, Johnell O, Nilsson JA (1999) Incidence of hip fractures in Malmo, Sweden, 1992–1995. A trend-break. Acta Orthop Scand 70:19–22CrossRefPubMedGoogle Scholar
  5. 5.
    Ahlborg HG, Rosengren BE, Jarvinen TL, Rogmark C, Nilsson JA, Sernbo I, Karlsson MK (2010) Prevalence of osteoporosis and incidence of hip fracture in women—secular trends over 30 years. BMC Musculoskelet Disord 11:48CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Karampampa K, Ahlbom A, Michaelsson K, Andersson T, Drefahl S, Modig K (2015) Declining incidence trends for hip fractures have not been accompanied by improvements in lifetime risk or post-fracture survival—a nationwide study of the Swedish population 60 years and older. Bone 78:55–61CrossRefPubMedGoogle Scholar
  7. 7.
    Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a world-wide projection. Osteoporos Int 2:285–289CrossRefPubMedGoogle Scholar
  8. 8.
    Johnell O, Kanis JA (2004) An estimate of the worldwide prevalence, mortality and disability associated with hip fracture. Osteoporos Int 15:897–902CrossRefPubMedGoogle Scholar
  9. 9.
    Melton LJ 3rd (1993) Hip fractures: a worldwide problem today and tomorrow. Bone 14(Suppl 1):S1–S8CrossRefPubMedGoogle Scholar
  10. 10.
    Leonardsson O, Garellick G, Karrholm J, Akesson K, Rogmark C (2012) Changes in implant choice and surgical technique for hemiarthroplasty. 21,346 procedures from the Swedish Hip Arthroplasty Register 2005–2009. Acta Orthop 83:7–13CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Empana JP, Dargent-Molina P, Breart G (2004) Effect of hip fracture on mortality in elderly women: the EPIDOS prospective study. J Am Geriatr Soc 52:685–690CrossRefPubMedGoogle Scholar
  12. 12.
    Farahmand BY, Michaelsson K, Ahlbom A, Ljunghall S, Baron JA (2005) Survival after hip fracture. Osteoporos Int 16:1583–1590CrossRefPubMedGoogle Scholar
  13. 13.
    Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK (2003) The components of excess mortality after hip fracture. Bone 32:468–473CrossRefPubMedGoogle Scholar
  14. 14.
    Omsland TK, Emaus N, Tell GS, Magnus JH, Ahmed LA et al (2014) Mortality following the first hip fracture in Norwegian women and men (1999–2008). A NOREPOS study. Bone 63:81–86CrossRefPubMedGoogle Scholar
  15. 15.
    Johnell O, Kanis JA, Oden A, Sernbo I, Redlund-Johnell I et al (2004) Mortality after osteoporotic fractures. Osteoporos Int 15:38–42CrossRefPubMedGoogle Scholar
  16. 16.
    Pande I, Scott DL, O’Neill TW, Pritchard C, Woolf AD, Davis MJ (2006) Quality of life, morbidity, and mortality after low trauma hip fracture in men. Ann Rheum Dis 65:87–92CrossRefPubMedGoogle Scholar
  17. 17.
    Trombetti A, Herrmann F, Hoffmeyer P, Schurch MA, Bonjour JP, Rizzoli R (2002) Survival and potential years of life lost after hip fracture in men and age-matched women. Osteoporos Int 13:731–737CrossRefPubMedGoogle Scholar
  18. 18.
    Abrahamsen B, van Staa T, Ariely R, Olson M, Cooper C (2009) Excess mortality following hip fracture: a systematic epidemiological review. Osteoporos Int 20:1633–1650CrossRefPubMedGoogle Scholar
  19. 19.
    Koh GC, Tai BC, Ang LW, Heng D, Yuan JM, Koh WP (2013) All-cause and cause-specific mortality after hip fracture among Chinese women and men: the Singapore Chinese Health Study. Osteoporos Int 24:1981–1989CrossRefPubMedGoogle Scholar
  20. 20.
    Panula J, Pihlajamaki H, Mattila VM, Jaatinen P, Vahlberg T, Aarnio P, Kivela SL (2011) Mortality and cause of death in hip fracture patients aged 65 or older: a population-based study. BMC Musculoskelet Disord 12:105CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Forsen L, Sogaard AJ, Meyer HE, Edna T, Kopjar B (1999) Survival after hip fracture: short- and long-term excess mortality according to age and gender. Osteoporos Int 10:73–78CrossRefPubMedGoogle Scholar
  22. 22.
    Magaziner J, Lydick E, Hawkes W, Fox KM, Zimmerman SI, Epstein RS, Hebel JR (1997) Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health 87:1630–1636CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Luthje P, Helkamaa T, Kaukonen JP, Nurmi-Luthje I, Kataja M (2011) A long-term follow-up of 221 hip fracture patients in southeastern Finland: analysis of survival and prior or subsequent fractures. Arch Gerontol GeriatrGoogle Scholar
  24. 24.
    Gronskag AB, Romundstad P, Forsmo S, Langhammer A, Schei B (2011) Excess mortality after hip fracture among elderly women in Norway : the HUNT study. Osteoporos IntGoogle Scholar
  25. 25.
    Michaelsson K, Nordstrom P, Nordstrom A, Garmo H, Byberg L, Pedersen NL, Melhus H (2014) Impact of hip fracture on mortality: a cohort study in hip fracture discordant identical twins. J Bone Miner Res 29:424–431CrossRefPubMedGoogle Scholar
  26. 26.
    Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR (2009) Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 301:513–521CrossRefPubMedGoogle Scholar
  27. 27.
    Schroder HM, Erlandsen M (1993) Age and sex as determinants of mortality after hip fracture: 3,895 patients followed for 2.5-18.5 years. J Orthop Trauma 7:525–531CrossRefPubMedGoogle Scholar
  28. 28.
    Vestergaard P, Rejnmark L, Mosekilde L (2007) Increased mortality in patients with a hip fracture-effect of pre-morbid conditions and post-fracture complications. Osteoporos Int 18:1583–1593CrossRefPubMedGoogle Scholar
  29. 29.
    Kannegaard PN, van der Mark S, Eiken P, Abrahamsen B (2010) Excess mortality in men compared with women following a hip fracture. National analysis of comedications, comorbidity and survival. Age Ageing 39:203–209CrossRefPubMedGoogle Scholar
  30. 30.
    Frost SA, Nguyen ND, Center JR, Eisman JA, Nguyen TV (2013) Excess mortality attributable to hip-fracture: a relative survival analysis. Bone 56:23–29CrossRefPubMedGoogle Scholar
  31. 31.
    Ekstrom W, Samuelsson B, Ponzer S, Cederholm T, Thorngren KG, Hedstrom M (2015) Sex effects on short-term complications after hip fracture: a prospective cohort study. Clin Interv Aging 10:1259–1266CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Sennerby U, Melhus H, Gedeborg R, Byberg L, Garmo H et al (2009) Cardiovascular diseases and risk of hip fracture. JAMA 302:1666–1673CrossRefPubMedGoogle Scholar
  33. 33.
    Tosteson AN, Gottlieb DJ, Radley DC, Fisher ES, Melton LJ 3rd (2007) Excess mortality following hip fracture: the role of underlying health status. Osteoporos Int 18:1463–1472CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Wehren LE, Hawkes WG, Orwig DL, Hebel JR, Zimmerman SI, Magaziner J (2003) Gender differences in mortality after hip fracture: the role of infection. J Bone Miner Res 18:2231–2237CrossRefPubMedGoogle Scholar
  35. 35.
    von Friesendorff M, Besjakov J, Akesson K (2008) Long-term survival and fracture risk after hip fracture: a 22-year follow-up in women. J Bone Miner Res 23:1832–1841CrossRefGoogle Scholar
  36. 36.
    von Friesendorff M, McGuigan FE, Besjakov J, Akesson K (2011) Hip fracture in men-survival and subsequent fractures: a cohort study with 22-year follow-up. J Am Geriatr Soc 59:806–813CrossRefGoogle Scholar
  37. 37.
    Jonsson B, Gardsell P, Johnell O, Redlund-Johnell I, Sernbo I (1994) Remembering fractures: fracture registration and proband recall in southern Sweden. J Epidemiol Community Health 48:489–490CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    National Board of Health and Welfare E, Sweden (2006) Causes of death: the National Board of Health and Welfare, SwedenGoogle Scholar
  39. 39.
    Fine JP, Gray RJ (1999) A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 94:496–509CrossRefGoogle Scholar
  40. 40.
    Haentjens P, Johnell O, Kanis JA, Bouillon R, Cooper C et al (2004) Evidence from data searches and life-table analyses for gender-related differences in absolute risk of hip fracture after Colles’ or spine fracture: Colles’ fracture as an early and sensitive marker of skeletal fragility in white men. J Bone Miner Res 19:1933–1944CrossRefPubMedGoogle Scholar
  41. 41.
    Roche JJ, Wenn RT, Sahota O, Moran CG (2005) Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 331:1374CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Hofbauer LC, Brueck CC, Shanahan CM, Schoppet M, Dobnig H (2007) Vascular calcification and osteoporosis—from clinical observation towards molecular understanding. Osteoporos Int 18:251–259CrossRefPubMedGoogle Scholar
  43. 43.
    Persy V, D’Haese P (2009) Vascular calcification and bone disease: the calcification paradox. Trends Mol Med 15:405–416CrossRefPubMedGoogle Scholar
  44. 44.
    Rosvall M, Chaix B, Lynch J, Lindstrom M, Merlo J (2006) Similar support for three different life course socioeconomic models on predicting premature cardiovascular mortality and all-cause mortality. BMC Public Health 6:203CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2016

Authors and Affiliations

  • M. von Friesendorff
    • 1
    • 2
  • F. E. McGuigan
    • 1
    • 2
  • A. Wizert
    • 3
  • C. Rogmark
    • 1
    • 2
  • A. H. Holmberg
    • 1
    • 2
  • A. D. Woolf
    • 4
  • K. Akesson
    • 1
    • 2
    Email author
  1. 1.Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research UnitLund UniversityMalmöSweden
  2. 2.Department of Orthopedics MalmöSkåne University HospitalMalmöSweden
  3. 3.ERC Syd - Epidemiology and Register Centre SouthSkåne University HospitalLundSweden
  4. 4.Department of Rheumatology Royal Cornwall HospitalTruroUK

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