Article Text

Download PDFPDF
Extended report
Changes in hip fracture rate before and after total knee replacement due to osteoarthritis: a population-based cohort study
  1. Daniel Prieto-Alhambra1,2,3,
  2. M Kassim Javaid1,
  3. Joe Maskell1,4,
  4. Andrew Judge1,
  5. Michael Nevitt5,
  6. Cyrus Cooper1,4,
  7. Nigel K Arden1,4
  1. 1NIHR Oxford Biomedical Research Unit, University of Oxford, Oxford, UK
  2. 2Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
  3. 3IDIAP Jordi Gol i Gurina, Institut Catala de la Salut, Barcelona, Spain
  4. 4MRC Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Southampton, UK
  5. 5Department of Epidemiology, University of California, San Francisco, California, USA
  1. Correspondence to Professor Nigel Arden, The Botnar Research Centre Institute of Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD; nka{at}


Objectives Patients with knee osteoarthritis have an increase in bone mass but no corresponding decrease in risk of fracture. This study describes the rates of hip fracture in subjects with knee osteoarthritis before and after having a total knee replacement (TKR), compared with matched controls.

Methods A population-based prospective cohort study was conducted. The study population included, from the General Practice Research Database (UK), patients 40 years and older, undergoing TKR between 1986 and end-2006 for knee osteoarthritis as ‘cases’ (n=20 033). Five disease-free controls (n=100 165) were randomly selected, and matched for age, gender and practice. Hip fractures were ascertained using READ codes, and yearly rates of hip fracture and rate differences were calculated for the 5 years before and after surgery, using Poisson regression. Stratified analyses were performed by age and history of fracture.

Results Hip fracture rates were non-significantly reduced compared with controls before the operation. In the year after TKR, risk increased significantly (RR 1.58; 95% CI 1.14 to 2.19). Rates then declined to equal those of controls by 3 years, and continued decreasing until the end of follow-up; corresponding RR were not significant. The increased risk is greatest in younger ages and in those without previous fracture.

Conclusions The association between knee osteoarthritis and fractures is time-dependent, which may explain the current controversy in the literature. The association is also modified by TKR: subjects have a higher rate of hip fracture than matched controls after TKR, although the rates may eventually decrease.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding This study was funded by the NIHR programme grant for applied research funding scheme. This work represents the views and opinions of the authors and does not necessarily reflect those of the DH/NIHR. Support was also received from the NIHR Biomedical Research Unit into Musculoskeletal Disease, Nuffield Orthopaedic Centre and University of Oxford. Partial funding by: Institut Catala de la Salut--IDIAP Jordi Gol (grant for a research fellowship, 4th edition), Instituto de Salud Carlos III, Government of Spain (BAE grant 2009 expedient number BA09/90023), MSD, Novartis and Southampton Rheumatology Trust.

  • Competing interests None.

  • Ethics approval The GPRD group obtained ethical approval from a multicentre research ethics committee for all purely observational research using GPRD data, such as ours. This study obtained approval from the GPRD Independent Scientific Advisory Committee, responsible for reviewing protocols for scientific quality.