Early results of starting a fracture liaison service for fragility hip fractures in a regional South African hospital

Authors

  • S P Oosthuizen Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Orthopaedic Surgery, Tygerberg Hospital, Cape Town, South Africa https://orcid.org/0000-0001-5689-5366
  • J D Jordaan Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Orthopaedic Surgery, Tygerberg Hospital, Cape Town, South Africa https://orcid.org/0000-0002-6150-9463
  • M C Burger Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa https://orcid.org/0000-0003-2831-4960

DOI:

https://doi.org/10.7196/SAMJ.2025.v115i9.2998

Keywords:

Fragility Hip Fracture (FFH), Osteoporosis, Fracture Liaison Service, Bisphosphonates

Abstract

Background. Fragility hip fracture is a rising pandemic, with the burden currently shifting to developing countries. A fracture liaison service (FLS) was implemented in September 2021 in a regional South African (SA) hospital.

Objective. To describe two groups of patients with surgically treated fragility hip fractures – those before and after implementation of the FLS – in terms of early mortality, refracture and readmission rates.

Methods. Patients aged >50 years who sustained hip fractures between January 2020 and June 2022 were considered; those with high-energy injuries, pathological and periprosthetic fractures were excluded. Associations between treatment group and mortality, readmission and refracture rates within the first year after surgery were investigated. Subgroup analyses were also conducted for specific risk factors.

Results. A total of 299 patients (mean (standard deviation) age of 74.5 (11.0) years, 68.2% female) were included, of whom 32.8% (n=98) received bisphosphonates. The overall 30-day, 90-day and 1-year mortality rates were 9.4% (n=28), 17.4% (n=52) and 29.8% (n=89), respectively, while 24.1% (n=72) of patients had unplanned readmissions to hospital, and 2.7% (n=8) refractured within the first year after surgery. No statistical difference in 30-day, 90-day or 1-year mortality rate, refracture incidence or readmission incidence was observed between patient groups. Time to surgery was shorter after the implementation of the FLS (median (interquartile range (IQR)) 30.8 (22.3 - 48.9) hours v. before (median (IQR) 42.5 (23.1 - 70.8) hours, p=0.039).

Conclusion. An FLS was successfully implemented in a regional SA hospital. Early mortality, refractures and readmission rates were low or comparable with the existing literature, and not affected by treatment within the FLS nor by bisphosphonate initiation. Treatment within the FLS, however, resulted in a decrease in time to surgery.

Author Biographies

  • S P Oosthuizen, Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Orthopaedic Surgery, Tygerberg Hospital, Cape Town, South Africa

    Stefanus Petrus Oosthuizen

    Division of Orthopaedic Surgery, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa

    stefan.oosie@gmail.com

  • J D Jordaan, Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Orthopaedic Surgery, Tygerberg Hospital, Cape Town, South Africa

    Jacobus Daniel Jordaan

    Head of Arthroplasty unit

    Division of Orthopaedic Surgery, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa

    koosjor@sun.ac.za

  • M C Burger, Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

    Marilize C Burger

    Associate Professor

    Division of Orthopaedic Surgery, Stellenbosch University,  Cape Town, South Africa

    Stellenbosch University, Cape Town, South Africa

    mcburger@sun.ac.za

References

1. KautaN,HeldM,DlaminiS,etal.Themanagementoffragilityfracturesofthehip:Aqualityassessment project. S Afr Orthopaed J 2017;16(31-45). https://doi.org/10.17159/2309-8309/2017/v16n3a5

2. Paruk F, Tsabasvi M, Kalla AA. Osteoporosis in Africa – where are we now. Clin Rheumatol 2021;40(9)3419-3428. https://doi.org/10.1007/s10067-020-05335-6

3. Hawley S, Dela S, Burton A, et al. Incidence and number of fragility fractures of the hip in South Africa: Estimated projections from 2020 to 2050. Osteoporosis Int 2022;33(12):2575-2583. https://doi. org/10.1007/S00198-022-06525-5

4. Cooper C, Campion G, Melton LJ III. Hip fractures in the elderly: A world-wide projection. Osteoporosis Int 1992;2(6):285-289. https://doi.org/10.1007/BF01623184

5. Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporosis Int 1997;7(5):407-413. https://doi.org/10.1007/PL00004148

6. Dela SS, Paruk F, Brown SL, et al. Ethnic and gender-specific incidence rates for hip fractures in South Africa: A multi-centre study. Bone 2020;133:115253. https://doi.org/10.1016/j.bone.2020.115253

7. Johansson H, Dela SS, Cassim B, et al. FRAX-based fracture probabilities in South Africa. Arch Osteoporos 2021;16(1):51. https://doi.org/10.1007/s11657-021-00905-w

8. Kebaetse M, Nkhwa S, Mogodi M, et al. A country-specific FRAX model for Botswana. Arch Osteoporos 2021;16(1):90. https://doi.org/10.1007/S11657-021-00965-Y

9. McLellan AR, Gallacher SJ, Fraser M, McQuillian C. The fracture liaison service: Success of a program for the evaluation and management of patients with osteoporotic fractures. Osteoporosis Int 2003;14(12):1028-1034. https://doi.org/10.1007/S00198-003-1507-Z

10. Åkesson K, Marsh D, Mitchell PJ, et al. Capture the fracture: A best practice framework and global campaign to break the fragility fracture cycle. Osteoporosis Int 2013;24(8):2135-2152. https://doi. org/10.1007/S00198-013-2348-Z

11. Yan C, Chen Y, Cao J, et al. The effectiveness of fracture liaison services in patients with hip fractures: A systematic review and meta-analysis of randomised controlled trials. Heliyon 2023;9(10):E20838. https://doi.org/10.1016/J.HELIYON.2023.E20838

12. González-Quevedo D, Bautista-Enrique D, Pérez-del-Río V, et al. Fracture liaison service and mortality in elderly hip fracture patients: A prospective cohort study. Osteoporosis Int 2020;31(1):77-84. https:// doi.org/10.1007/s00198-019-05153-w

13. Wang CC, Liu HC, Lee MT, Huang WT. Effects of fracture liaison service on outcomes of patients with hip fracture in rural area of an Asian country. Geriatr Orthop Surg Rehabil 2023;14:21514593231204783. https://doi.org/10.1177/21514593231204783

14. Nakayama A, Major G, Holliday E, et al. Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporos Int 2016;27(3):873-879. https://doi.org/10.1007/S00198-015-3443-0

15. Lyles KW, Colón-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. New Engl J Med 2007;357(18):1799-1809. https://doi.org/10.1056/NEJMOA074941

16. Kim TY, Ha YC, Kang BJ, et al. Does early administration of bisphosphonate affect fracture healing in patients with intertrochanteric fractures? J Bone Joint Surg Br 2012;94(7):956-960. https://doi.

org/10.1302/0301-620X.94B7.29079

17. Cobden A, Cobden SB, Camurcu Y, et al. Effects of postoperative osteoporosis treatment on subsequent fracture and the 5-year survival rates after hemiarthroplasty for hip fracture. Arch Osteoporos 2019;14(1):100. https://doi.org/10.1007/s11657-019-0657-3

18. Wang P, Li Y, Zhuang H, et al. Anti-osteoporosis medications associated with decreased mortality after hip fracture. Orthop Surg 2019;11(5):777-783. https://doi.org/10.1111/OS.12517

19. Cengiz Ö, Polat G, Karademir G, et al. Effects of zoledronate on mortality and morbidity after surgical treatment of hip fractures. Adv Orthop 2016;2016(1):3703482. https://doi.org/10.1155/2016/3703482

20. BeaupreLA,MorrishDW,HanleyDA,etal.Oralbisphosphonatesareassociatedwithreducedmortality

after hip fracture. Osteoporos Int 2011;22(3):983-991. https://doi.org/10.1007/S00198-010-1411-2

21. Bolland MJ, Grey AB, Gamble GD, Reid IR. Effect of osteoporosis treatment on mortality: A meta-

analysis. J Clin Endocrinol Metab 2010;95(3):1174-1181. https://doi.org/10.1210/JC.2009-0852

22. Compston JE, McClung MR, Leslie WD. Osteoporosis. Lancet 2019;393(10169):364-376. https://doi. org/10.1016/S0140-6736(18)32112-3

23. Roberts KC, Brox WT, Jevsevar DS, Sevarino K. Management of hip fractures in the elderly. J Am Acad Orthopaed Surg 2015;23(2):131-137. https://doi.org/10.5435/jaaos-d-14-00432

24. National Institute for Health and Care Excellence. Hip fracture: Management. London: NICE, 2011. https://www.nice.org.uk/guidance/cg124 (accessed 21 August 2025).

25. Compston J, Cooper A, Cooper C, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017;12(1):43. https://doi.org/10.1007/S11657-017-0324-5

26. Cassim B, Lipschitz S, Paruk F, Tipping B. Recommendations for the acute and long-term medical management of low-trauma hip fractures. J Endocrinol Metab Diabetes S Afr 2013;18(1):21-32. https://doi.org/10.1080/22201009.2013.10872302

27. Hough S, Ascott-Evans BH, Brown SL, et al. NOFSA Guideline for the Diagnosis and Management of Osteoporosis. J Endocrinol Metab Diabetes S Afr 2010;15(3):107-108. https://doi.org/10.1080/22 201009.2010.10872239

28. Dell AJ, Gray S, Fraser R, et al. Orthopaedic surgeon density in South Africa. World J Surg 2018;42(12):3849-3855. https://doi.org/10.1007/S00268-018-4709-4

29. Weil YA, Bernstein BP, Maqungo S, et al. Hip fracture care and national systems in Israel and South Africa. OTA Internat 2020;3(1):e065. https://doi.org/10.1097/oi9.0000000000000065

30. Dela SS, Paruk F, Conradie M, et al. Access to care for low trauma hip fractures in South Africa. Arch Osteoporos 2022;17(1):15. https://doi.org/10.1007/S11657-022-01057-1

31. Kim SC, Kim MS, Sanfélix-Gimeno G, et al. Use of osteoporosis medications after hospitalisation for hip fracture: A cross-national study. Am J Med 2015;128(5):519-526. https://doi.org/10.1016/j. amjmed.2015.01.014

32. Solomon DH, Johnston SS, Boytsov NN, et al. Osteoporosis medication uses after hip fracture in US patients between 2002 and 2011. J Bone Min Res 2014;29(9):1929-1937. https://doi.org/10.1002/ jbmr.2202

33. Johansen A, Sahota O, Dockery F, et al. Call to action: A five nations consensus on the use of intravenous zoledronate after hip fracture. Age Ageing 2023;52(9):afad172. https://doi.org/10.1093/ AGEING/AFAD172

34. Ross BJ, Lee OC, Harris MB, et al. Rates of osteoporosis management and secondary preventative treatment after primary fragility fractures. JBJS Open Access 2021;6(2):e20. https://doi.org/10.2106/ JBJS.OA.20.00142

35. Paruk F, Matthews G, Gregson CL, Cassim B. Hip fractures in South Africa: Mortality outcomes over 12 months post-fracture. Arch Osteoporos 2020;15(1):76. https://doi.org/10.1007/s11657-020-00741-4 36. Essa S, Venter S, Jordaan JD. The effect of a post-anaesthesia high-care unit (PAHCU) admission on mobilisation, length of stay and in-hospital mortality post-surgery in low energy neck of femur fracture patients. Eur J Orthopaed Surg Traumatol 2024;34(3):1389-1396. https://doi.org/10.1007/

s00590-023-03799-1

37. HaleemS,LutchmanL,MayahiR,etal.Mortalityfollowinghipfracture:Trendsandgeographicalvariations over the last 40 years. Injury 2002;39(10):1157-1163. https://doi.org/10.1016/J.INJURY.2008.03.022

38. Mundi S, Pindiprolu B, Simunovic N, Bhandari M. Similar mortality rates in hip fracture patients over the past 31 years. Acta Orthop 2014;85(1):54-59. https://doi.org/10.3109/17453674.2013.878831 39. Downey C, Kelly M, Quinlan JF. Changing trends in the mortality rate at 1-year post hip fracture –

a systematic review. World J Orthop 2019;10(3):166-175. https://doi.org/10.5312/WJO.V10.I3.166

40. Jordaan JD, Burger MC, Jakoet S, et al. Mortality rates in femoral neck fractures treated with arthroplasty in South Africa. Geriatr Orthop Surg Rehabil 2022;13: 21514593221117309. https://doi.

org/10.1177/21514593221117309

41. Kates SL, Behrend C, Mendelson DA, et al. Hospital readmission after hip fracture. Arch Orthop Trauma Surg 2015;135(3):329-337. https://doi.org/10.1007/s00402-014-2141-2

42. Okike K, Chan PH, Paxton EW. Effect of surgeon and hospital volume on morbidity and mortality after hip fracture. J Bone Joint Surg 2017;99(18):1547-1553. https://doi.org/10.2106/JBJS.16.01133

43. Meyer AC, Eklund H, Hedström M, Modig K. The ASA score predicts infections, cardiovascular complications, and hospital readmissions after hip fracture – a nationwide cohort study. Osteoporosis Int 2021;32(11):2185-2192. https://doi.org/10.1007/S00198-021-05956-W

44. Ding L, Wei J, Wang B. The impact of COVID-19 on the prevalence, mortality, and associated risk factors for mortality in patients with hip fractures: A meta-analysis. J Am Med Dir Assoc 2023;24(6):846-854. https://doi.org/10.1016/j.jamda.2023.03.011

45. Konda SR, Esper GW, Meltzer-Bruhn AT, et al. Hip fracture care during COVID-19: Evolution through the pandemic. Cureus 2023;15(7):e42696. https://doi.org/10.7759/cureus.42696

Downloads

Published

2025-10-02

Issue

Vol. 115 No. 9 (2025)

Section

Research

License

Copyright (c) 2025 S P Oosthuizen, J D Jordaan, M C Burger

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Licensing Information

The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited. 

Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository. 

Publishing Rights

Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.

 

How to Cite

1.
Oosthuizen SP, Jordaan JD, Burger MC. Early results of starting a fracture liaison service for fragility hip fractures in a regional South African hospital. S Afr Med J [Internet]. 2025 Oct. 2 [cited 2025 Oct. 30];115(9):e2998. Available from: https://samajournals.co.za/index.php/samj/article/view/2998