Femoral fractures occur more frequently in elderly people and have a high degree of mortality. The problem of a second fracture of the femur has not been emphasized enough in documents. The percentage of patients with fractures of contralateral femur has resulted in 4.4%, of which 83% were women and 17% men. The refracturing within a year, on 1183 fractured patients resulted in 2.4%. The average time between the two fractures is of 22 months and 55.7% (29 patients) refractured within 1 year while 90.3% within 5 years.
Berry et al. study in 2007 total amount of refractures is of 14.8% and 1–2.5% of the cases occur after a year from the first fracture while 8–8.2% after 5 years, (7
); Lönnroos et al. (2007) study 5,1% after a year and 8.1% after 2 years (9
). Ryg (2009) study instead was 16.5% of the patients suffer a second femoral fracture, of which 9% after a year and 20% after 5 years (11
); Nymark study (2006) second fracture occurs in 8.7%, of which 50% within 12–19 months (6
). According to Dretakis et al. to (1998) 50% of the subjects already refracture within 2 years and 75% within 4 years (10
). Angthong et al. (2009) reported a total amount of the second fracture is 5–10%, of which 78.6% occurs in the 12 months after the first fracture (8
). In general terms the other research carried out demonstrates that the frequency of refractures varies from 2 to 11% after the first fracture.
Our sample of new fractured patient had a mean age 83,4 years old (83 years old in women and 85,4 years in the man). Our data do not deviate from other literature available, in fact according to Shabat et al. (2003) average age is 82 years old (4
) and according to Nymark et al. (2006) it is over 85 years old (6
). From the answers to the questions of questionnaire EQ-5D carried out by patients it turns out that 4 patients (21.1%) have completely recovered the ability to walk and this group resulted in a better ability to recover probably due to the absence of significant comorbidity and their very good psychological state. 13 (68.4%) need aid such as crutches and walking sticks and 2 (10.5%) are bedridden. There was a minor recovery in the movement in the patients with lateral fractures in comparison those with medial fractures, the possible explanation could be due to the fact that, after the surgery, they are verticalized after 25–30 and this increases the risk of other complications, like thrombosis and wounds from decubitus, but above all the negative psychological state of the patient, after the traumatic event and hospital stay influences his total recovery.
Shabat et al. (2003) estimated that 60–70% of the subjects with refractures walk again (4
). The difficulty they are faced with in walking again and the daily activities is partially tied to general clinical problems. Must be kept in mind that many patients have senile dementia and find more difficulty taking part in rehabilitation programs. In our study 31.6% of the patients contacted again turn out to be confused or have Alzheimer’s, therefore the questionnaire has to be completed by relatives. Moreover we have noticed that recovery is better in younger patients, with medial hip fractures and significant absence of comorbidity.
Patients affected by femoral neck fracture are usually treated with arthroplasty, therefore they are able to walk after 2–3 days, while patients affected by perthrocanteric unstable fractures are usually treated with osteosynthesis.
Moreover we have found that in 69.2% of the cases (36 patients) the fracture of the contralateral femur was the same as the first fracture while in 30.8% of the cases (16 patients) fractures varied agreeing therefore with Shabat et al. (2003) and Yamanashi et al. (2005)(15
In our sample mortality is 26.9%, especially the first year has been of 23%. Of the deceased patients 78% died within 6 months (11 people), 85% within 12 months (12 people). Mortality rate is higher in men (66.7%) than in women (18.6%), in line with Berry study (2007) which indicates 24.1% mortality after a year from the refracture and 66.5% after 5 years (7
), and Ryg (2009) estimated 27% mortality in men after a year and 64% after 5 years, while in women 21% after a year and 58% after 5 years (11
). In both cases mortality is higher in men (7
). As far as the medical therapy against osteoporosis, 19 patients contacted again, 9 were taking medication, prescribed by our specialist or their family doctor while 10 patients did not. According to Edwards (2007) a reduction in refracture risk is estimated from 5 to 50% if medication for osteoporosis is taken and failing to take medication from the first fracture contributes to an increase of the incidence of a second fracture of the femur (17
). Chapurlat (2003)(18
) and Yamanashi (2005)(15
) also emphasize the importance of preventive therapy for osteoporosis, following the first fracture is important in order to prevent a second one (). Among disposable medical therapies, according the 2010 North American Menopause Society (NAMS) position statement (19
), bisphosphonates are considered the first line therapy in the treatment of osteoporosis and reduce vertebral fractures by 40 to 70% and non-vertebral fractures by 20 to 35%. Teriparatide is recommended for patients with severe osteoporosis and has been shown to reduce vertebral fractures 65% and non-vertebral fractures 53%. Calcitonin showed promise during early trials in 2000 with a 33% reduction in fractures but these results have not been replicated and this therapy is now relegated to a second line treatment. The newly approved monoclonal antibody for osteoporosis treatment in postmenopausal women, denosumab, leads to a 68 and 19% reduction of vertebral and non-vertebral fractures, respectively.