McMaster University

McMaster University

An injured elderly man lies fallen on the foor; a hip x-ray demonstrating a fractured hip is superimposed.

Fragility Fractures in the Elderly

Principal Investigators

A photo link to the bio of Dr. Mohit Bhandari

Dr. Mohit Bhandari

A photo link to the bio of Dr. Gerard Slobogean

Dr. Gerard Slobogean

Current Research Initiatives


FAITH logo

FAITH is a large multi-centre randomized controlled trial comparing sliding hip screw and cancellous screw fixation in femoral neck fracture patients. The study outcomes are revision surgery rates and quality of life up to 24 months post initial hip surgery.



HEALTH is a large multi-centre randomized controlled trial comparing total hip arthroplasty with hemi-arthroplasty in patients with femoral neck fractures. The primary outcome is revision surgery rates at 24 months post initial surgery and the secondary outcome is quality of life up to 24 months post initial hip surgery.

Shoulder (Proximal Humerus) Fragility Fracture Scoping Review

Our scoping review will identify the available literature guiding the management of shoulder (proximal humerus) fractures and any deficiencies in the current literature. This review will inform research priorities on improving patient care for these challenging injuries.


Fragility fractures are common problems in Canada and have a significant economic impact on the healthcare system.  It is estimated that at least one in three women and one in five men will suffer a fragility fracture in their lifetime and the cost of treating osteoporotic fractures in Canada is more than $1.3 billion dollars per year. Two common types of fragility fractures are hip fractures and shoulder fractures.

Hip fractures occur in 280,000 Americans and 36,000 Canadians annually. Thus, on a yearly basis, one in 1000 Canadians will fracture a hip. Over half of these are femoral neck fractures, two thirds of which are typically treated by replacing the hip ball and/or socket with a prosthesis, known as hip replacement or hip arthroplasty. The remaining fractures are fixed with internal fixation (plates and/or screws).  As the population ages, the number of hip fractures will increase, and by 2040, the estimated annual health care costs associated with hip fractures will reach $9.8 billion in the US and $650 million in Canada.  Hip fractures are associated with a 30% mortality rate at one year and profound temporary and often permanent impairment of independence and quality of life.  The optimal surgical method for managing fragility hip fractures in the elderly remains unknown.

Proximal humerus fractures, also known as shoulder fractures, comprise a large proportion of all fragility fractures and typically occur in elderly adults from minimal trauma. Unlike geriatric hip fractures, more than 90% of proximal humerus fracture patients live at home and over 80% perform their own shopping and housework. The significance of these injuries in an independent, elderly population is further highlighted by the disappointing functional outcomes seen by many patients with displaced fractures. A recent clinical trial enrolling patients with 3-part proximal humerus fractures reported significant residual shoulder pain, limitations in shoulder motion, and decreased quality of life. The post-fracture deterioration in patient reported quality of life was so significant that it was of comparable magnitude to patients that sustain an unstable hip fracture. These unsatisfactory results have been observed in several other studies of three and four-part fractures, regardless of the treatment employed. Despite these detrimental outcomes for patients and high costs to the health care system, there is little literature to guide the management of these injuries.

The specific objectives of our research theme in fragility fractures in the elderly are:

  • To determine the optimal method of joint replacement (total hip replacement versus hemi-arthroplasty) in patients with hip fracture (femoral neck fractures).
  • To determine the optimal method of internal fixation (multiple screws versus sliding hip screws) in patients with hip fracture (femoral neck fractures).
  • To determine the optimal management strategy for shoulder fractures (proximal humerus fractures).

Recent Publications

  • Osteoperos Int. 2013 Sep 27. [Epub ahead of print]

    FAITH trial investigators. The societal costs of femoral neck fracture patients treated with internal fixation

  • Journal Name

    The radiographic union score for hip (RUSH): The use of a checklist to evaluate hip fracture healing improves agreement between radiologists and orthopaedic surgeons.

  • Orthop Clin North Am. 2013 Apr;44(2):153-62.

    Cognitive dysfunction in hip fracture patients.

  • Arch Orthop Trauma Surg. 2013 Apr;133(4):487-94.

    Absorbable and non-absorbable cement augmentation in fixation of intertrochanteric femur fractures: systematic review of the literature

  • J Orthop Trauma. 2013 Apr;27(4):183-8.

    When should we operate on elderly patients with a hip fracture? It's about time!

  • Int Orthop. 2012 Aug;36(8):1549-60.

    Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials.

  • Acta Orthop. 2012 Aug;83(4):328-33.

    Uneven global distribution of randomized trials in hip fracture surgery.

  • J Bone Joint Surg Am. 2012 Jul 18;94 Suppl 1:65-9.

    Use and interpretation of composite end points in orthopaedic trials.

  • Trials. 2012 Jan 8;13:5.

    FAITH trial investigators. Central coordination as an alternative for local coordination in a multicenter randomized controlled trial: the FAITH trial experience.

  • BMC Musculoskelet Disord. 2011 Dec 23;12:289.

    Surgical preferences of patients at risk of hip fractures: hemiarthroplasty versus total hip arthroplasty.

  • CMAJ. 2010 Oct 19; 182(15):1609-16.

    Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis.

  • Orthopedics. 2013 Jul 1;36(7):e849-58.

    FAITH Trial Investigators. Femoral neck shortening after internal fixation of a femoral neck fracture.

  • JBMC Musculoskelet Disord. 2011 Dec 23;12(1):289

    Surgical preferences of patients at risk of hip fractures; Hemiarthroplasty vs total hip arthroplasty.

  • J Arthroplasty. 2012 Apr;27(4):569-74.

    Variability in the approach to total hip arthroplasty in patients with displaced femoral neck fractures

  • Acta Orthopaedics

    Plate fixation or intramedullary fixation of humeral shaft fractures – an update

  • Acta Orthopaedics

    Uneven global distribution of randomized trials in hip fracture surgery

  • JBJS

    Denosumab treatment in postmenopausal women with osteoporosis does not interfere with fracture-healing: results from the FREEDOM trial

  • Indian Journal of Orthopaedics

    The development of a decision aid to elicit treatment preferences for displaced femoral neck fractures

  • Journal of Orthopaedic Trauma

    Assessment of Radiographic Fracture Healing in Patients With Operatively Treated Femoral Neck Fractures

  • BMC Musculoskeletal Surgery

    Radiographic union score for hip substantially improves agreement between surgeons and radiologists

  • Orthopaedics

    Use of a calcium sulfate-calcium phosphate synthetic bone graft composite in the surgical management of primary bone tumors

  • Journal of Orthopaedic Trauma

    Managing the burden of osteoporosis: is there a standard of care

  • Journal of Orthopaedic Trauma

    The need to standardize functional outcome in randomized trials of hip fracture: a review using the ICF framework

  • Archives of Orthopaedic and Trauma Surgery

    Outcome assessment in hip fracture: evaluation of the practicality of commonly-used outcomes in hip fracture studies

  • Journal of Orthopaedic Trauma

    Use of osteobiologics in the management of osteoporotic fractures

  • Journal of Orthopaedic Science

    Tip to apex distance in femoral intertrochanteric fractures: a systematic review

  • JBJS

    Poor citation of prior evidence in hip fracture trials

  • BMC Musculoskeletal Disorders

    The effect of regular physical activity on bone mineral density in post-menopausal women aged 75 and over: a retrospective analysis from the Canadian multicentre osteoperosis study

  • Clinical Orthopaedics and Related Research

    Cochrane in CORR ®: Arthroplasties (With and Without Bone Cement) For Proximal Femoral Fractures in Adults

  • Journal of Orthopaedic Trauma

    Systematic Review of the Treatment of Periprosthetic Distal Femur Fractures

  • CMAJ

    Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial

  • Acta Orthopaedica

    Similar mortality rates in hip fracture patients over the past 31 years

  • Journal of Orthopaedic Trauma

    Functional outcome after successful internal fixation versus salvage arthroplasty of patients with a femoral neck fracture

  • Journal Cover

    Hip fracture evaluation with alternatives of total hip arthroplasty versus hemiarthroplasty (HEALTH): protocol for a multicentre randomised trial

  • Journal Cover

    ixation using alternative implants for the treatment of hip fractures (FAITH): design and rationale for a multi-centre randomized trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures

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