Dear Sir,

We read with great interest the article by Tay in the Singapore Medical Journal,(1) which compared operative and nonoperative management of hip fractures. We congratulate the author for a successful study that focused on an important issue.

However, we have a few remarks with regard to the study’s methodology. Firstly, Tay concluded that elderly patients with hip fractures should be managed operatively due to increased mortality risk when compared with nonoperative management. We believe that, in the context of this study, it is difficult to come to this conclusion, as the exact causes of mortality are not stated. Therefore, we question whether the mortality causes are indeed related to hip fractures/treatment methods. Secondly, there is a significant difference in mean age (78.8 years vs. 82.8 years; p < 0.05) between the groups. Therefore, higher mortality in the elderly (i.e. nonoperative) group is expected. Thirdly, the study did not include the patients’ demographical and clinical features, and comorbidities including diabetes mellitus, hypertension, chronic obstructive pulmonary diseases and heart failure. We believe that the aforementioned comorbidities are vital when examining mortality.(2)

Furthermore, Tay neglected to mention if patients underwent a rehabilitation programme during or after treatment, which might have decreased the overall mortality. Finally, the study only focused on mortality; functionality, performance, walking, activities of daily living and quality of life after the operative/nonoperative management were not covered in this study. We believe that apart from mortality, these are important factors when deciding on treatment methodology.

Yours sincerely,

Tay E. Hip fractures in the elderly:operative versus nonoperative management. Singapore Med J. 2016;57:178-81.
Marufu TC, Mannings A, Moppett IK. Risk scoring models for predicting peri-operative morbidity and mortality in people with fragility hip fractures:Qualitative systematic review. Injury. 2015;46:2325-34.