**4. Hip fracture consequences**

Hip fractures are associated with significant morbidity, mortality, loss of independence, and financial burden [3, 9, 25, 42, 51–53]. It has been reported that approximately 20% of hip fracture patients died within 1 year of the fracture [54]. Generally, the first year after hip fracture appears to be the most critical time. A recent meta-analysis revealed that women sustaining a hip fracture had a fivefold increase and men almost an eightfold increase in relative likelihood of death within the first 3 months compared with age- and sex-matched controls [29]. The relative death risk decreases substantially over the second year but still much higher than that of the controls [55]. Many lose their ability to walk mainly due to the pain caused by the hip fracture. In fact, only 40–79% of patients regain their previous ambulatory function a year after the fracture, and less than half return to their pre-fracture status of daily activities [56].

In addition to functional impairments, hip fracture can have a negative impact on self-esteem, body image, and mood [57], which may lead to psychological problems [58]. Individuals who suffer fractures may be immobilized by a fear of falling again and suffering more fractures. They may feel isolated and helpless. The National Osteoporosis Foundation conducted a survey [59] among 1000 women with osteoporotic fracture in the United States to investigate the psychological effects of the fracture on the patients. Eighty-nine percent of said they feared breaking another bone; 80% were afraid that they would be less able to perform their daily activities and lose their independence; 73% worried that they would have to reduce activities with family and friends; and 68% were concerned that another fracture would result in their having to enter a nursing home [59]. If not addressed, fear about the future and a sense of helplessness can produce significant anxiety and depression. These problems may be compounded by an inability to fulfill occupational, domestic, or social duties, thus leading to further social isolation.

The disability, reduced functional status, and poor mental health caused by hip fracture can have a profound impact on the quality of the individual's life. Survivors of hip fracture reported a 52% reduction in the quality of life in the first 12 months and a 21% reduction after 2 years [60].

Also, hip fracture is a major cause of the need for long-term nursing home care and a major contributor to healthcare costs [30, 61, 62]. There are approximately 23,000 cases of hip fracture every year in Canada with associated treatment costs of about \$1 billion [63]. In the United States, 310,000 hip fractures occurred in 2003, and the total Medicare cost was estimated between \$10.3 and \$15.2 billion, including acute medical care and nursing home services [53, 64, 65]. As the population of the elderly is still continuously increasing, the number of hip fractures is expected to rise dramatically, and it will put more burdens on the community healthcare system [2, 66].
