What are the consequences and treatment options for untreated osteoporosis of the hip?

Untreated Osteoporosis of the Hip: Consequences

Untreated osteoporosis of the hip leads to hip fractures, which are associated with devastating morbidity and mortality—particularly in the first year post-fracture—along with severe functional disability, loss of independence, and substantially increased risk of subsequent fractures. 1

Mortality Risk

• Postfracture mortality is highest in the first year following hip fracture, with rates nearly twice that seen at 2 years 1
• Men face substantially higher mortality risk than women: inpatient mortality following hip fracture is 10.2% in men compared with 4.7% in women, and 1-year mortality reaches 37.5% in men versus 28.2% in women 1
• This elevated mortality risk may persist for over 10 years after the initial fracture 1
• Hip fractures are associated with increased mortality rates, with untreated patients showing mortality rates of 21.8% compared to 4.3% in treated patients 2

Morbidity and Functional Consequences

• Hip fractures require surgical intervention with associated risks including anesthetic complications, postoperative pain, bleeding, infection, and thromboembolic complications 1
• Patients frequently do not return to their baseline mobility following hip fracture 1
• Hip fractures lead to significant disability and loss of independence, with substantial burden from absenteeism and loss of productivity in working patients 1
• Successful surgical outcomes depend on the bone's capacity to remodel and heal through callus formation and sustain new loads at bone-implant interfaces 1

Fracture Cascade and Recurrence

• Patients with prevalent fractures are at much higher risk for future fractures 1
• Hip fractures are associated with high recurrence rates 3
• From age 50 to 90, the risk of hip fracture in white women increases 50-fold 4
• 60% of osteoporotic fractures occur in patients with a T-score higher than -2.5, indicating that bone density alone underestimates fracture risk 1

Economic and Healthcare Burden

• More than 4 million fractures occur annually (nearly 10 per minute) with direct costs of almost €57 billion per year in Europe 1
• The burden and cost of fractures is similar to cardiovascular disease and greater than many cancers, although osteoporosis receives considerably less attention 1
• By 2050, 50% of the world's hip fractures are expected to occur in Asia as populations age 1

Treatment to Prevent These Consequences

High-Risk Patients (Primary Prevention)

• Bisphosphonates reduce hip fracture risk by 36% over 36-48 months (RR 0.64; 95% CI 0.50-0.82) 1
• Denosumab reduces hip fracture risk by 39% over 36 months (RR 0.61; 95% CI 0.37-0.98) 1
• Sequential romosozumab followed by alendronate reduces hip fracture risk by 38% over 24 months in females with high fracture risk (RR 0.62; 95% CI 0.42-0.91) 1

Very High-Risk Patients

• For females with very high fracture risk, use romosozumab or teriparatide followed by a bisphosphonate to reduce fracture risk 1
• Very high risk is defined as: prior osteoporotic fracture(s), BMD T-score ≤-3.5, FRAX 10-year risk of major osteoporotic fracture ≥30% or hip ≥4.5%, or high glucocorticoid doses 1

All Patients

• All patients should receive calcium (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) supplementation 1
• Weight-bearing exercise, smoking cessation, and alcohol moderation are essential 5
• Fall prevention strategies and balance training are integral to comprehensive management 3, 6

Common Pitfall

The most critical gap is that osteoporosis remains substantially underdiagnosed and undertreated—many patients with hip fractures never receive appropriate metabolic assessment or osteoporosis treatment, resulting in preventable subsequent fractures 2, 6. Only 40% of hip fracture patients receive metabolic follow-up even with structured protocols 2.