Dear Sir,

I would like to thank Ekiz et al for taking the time to read my article and for their valuable comments.(1) I would like to respond to the issues raised by the authors.

It has been well established that hip fractures result in increased all-cause mortality in affected patients. There are few studies that examine cause-specific mortality rates among hip fracture patients. Common causes of death among the elderly following a hip fracture are cardiovascular and cerebrovascular events, cancer, infections involving the respiratory and urinary tracts, and dementia. Koh et al studied cause-specific mortality rates among 63,257 Singaporean Chinese with hip fractures and found that hip fracture patients were at higher risk of death for stroke, coronary heart disease, cancer, pneumonia and urinary tract infection compared with the general population.(2) A similar study of 31,495 British patients with hip fractures also found increased risk of death after hip fracture for all specific causes.(3) Further research could be performed to determine the difference in cause-specific mortality rates between hip fracture patients who are treated operatively and nonoperatively. A very large sample size would be required in order to detect significant differences for each cause of mortality between the two groups.

I agree that there is a significant difference (p < 0.05) in mean age between the two groups, which could be a contributing factor to the increased mortality rate in the nonoperative group. Nevertheless, as this paper is retrospective in nature, patient selection bias is an inherent limitation. Furthermore, older patients may have been less willing to undergo surgery for their hip fractures.

I also agree that comorbidities are a significant contributing factor to mortality. I chose to use the American Society of Anesthesiologists (ASA) classification system, which grades patients according to the severity of their comorbidities. When stratified according to ASA grade, there was no significant increase in mortality between the two groups at both one and two years after hip fracture. It is mentioned in my methods section that all patients in both groups underwent early mobilisation.

My study aimed to examine all-cause mortality so as to aid clinicians in the decision-making process and counsel patients with regard to management options. While I agree that further information on function and quality of life would have an impact on that decision, it was not within the scope of the article.

Yours sincerely,

Ekiz T, Pazarli AC, Yildiz D. Comment on:Should functionality and activities of daily living be considered aside from mortality in the management of hip fractures?. Singapore Med J. 2016;57:471.
Koh GC, Tai BC, Ang LW, et al. All-cause and cause-specific mortality after hip fracture among Chinese women and men:the Singapore Chinese Health Study. Osteoporos Int. 2013;24:1981-9.
Klop C, Welsing PM, Cooper C, et al. Mortality in British hip fracture patients 2000-2010: a population-based retrospective cohort study. Bone. 2014;66:171-7.