The data available suggest that hip fracture is a condition associated with a high social cost, particularly for expenses needed for hospitalisation and rehabilitation. Expenditures are rising very quickly and are a source of concern in many countries [3]. In a prospective study lasting 1 year in Belgium, a group of 159 older women totalled a mean cost of the initial hospitalisation of $9,534 and the total direct costs during the year after discharge were $13,470. These costs were almost triple that of a group of age- and sex-matched older subjects without hip fracture [46].

It is estimated that the expenditure needed for hip fracture exceeds that for breast and gynaecological cancers combined, but not those for cardiovascular disease in USA [47]. The comparison of costs between hip fracture and cardiovascular diseases is intriguing. In Switzerland, for example, osteoporotic hip fractures account for more hospital bed days than myocardial infarction and stroke and consequently lead to higher costs [48], while in Italy the costs due to hip fractures are comparable to those of acute myocardial infarction [44].

Hospital costs include costs associated with surgery (implant and theatre costs), laboratory and radiological investigations and length of hospitalisation in an acute ward [49].

The mean duration of hospitalisation is highly variable. In the United Kingdom, a study reported that, in people with a mean age over 80 years, the duration of hospitalisation was 23 days, without including the days due to rehabilitation [49]. In Italy, another study in people over 45 years of age found the mean duration of hospitalisation was about 15 days, again not considering rehabilitation [44]. In the United States, on the contrary, during the period from 1990 to 2003, the mean length of stay in the hospital for hip fractures declined by about half, leading to an average hospital stay of 6.5 days [50]. It should be noted that these huge differences probably depend on the different health systems and the relative costs for each day of hospitalisation. In the United States, for example, every day in hospital costs $1,791 in for-profit hospitals, $1,878 in state/local government hospitals and $2,289 in non-profit hospitals [50], while in the United Kingdom 1 day costs $600 [51]. It should be noted that shorter lengths of stay have been associated with higher 30-day mortality in patients experiencing a hip fracture in Sweden [52]. By contrast, a recent study in USA demonstrated that decreased length of stay was associated with reduced rates of early mortality [53]. This difference might be related to the fact that increased time to surgery is associated with longer hospital stay and we know that time to surgery (more than 24/48 h after the fracture) is a key factor in predicting early mortality [54].

Rehabilitation is a mandatory step for people having experienced a hip fracture [55]. However, the advanced age and the co-morbidities affecting hip fracture patients often dictate that the completion of the rehabilitation programme takes place in a long-term care (LTC) facility or in a nursing home [56]. The percentage of people requiring a LTC facility or similar institution is estimated at between 6 and 60 % of people with a hip fracture, with a cost ranging from $19,000 to $66,000 [56]. The costs needed for a LTC seem to be almost double those required by a rehabilitation institute [57].

However, the roles of these organisations for rehabilitation of older patients are still debated. In a well-known study on this topic, hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in their return to the community or in disability rate [58]. Moreover, costs were significantly greater for rehabilitation hospital patients than for nursing home patients and the evidence about the value of these organisations in the elderly is conflicting [58–60].

Hip fracture is associated with several negative outcomes. For example, reports of permanent disability in those surviving initial hospitalisation after a hip fracture ranged from 32 to 80 % [56].

The most common and important consequence of hip fracture is, however, increased mortality. It is estimated that about 20 % of the subjects die within the first 3–6 months of their injury [61]. Moreover, as for cardiovascular diseases, the likelihood of having any subsequent hospital episodes increased by 231 %, any subsequent incident increased future incident episodes by 9.4 %, the total number of hospital days by 21.3 % and the total charges by 16.3 % [62].

Other consequences may be loss of muscle strength, increased postural sway and decline in walking speed that can lead to loss of functional muscle mass, sarcopenia and finally to disability [61]. The impact on disability is striking: 1 year after fracturing a hip, 40 % of patients are still unable to walk independently, 60 % have difficulty with at least one essential activity of daily living, and 80 % are restricted in instrumental activities of daily living, such as driving and grocery shopping [63].

Finally, hip fracture seems to be associated with the onset of other co-morbidities with a high cost for society. Recent research has highlighted that people experiencing a hip fracture have a greater incidence of depression [64] and consequently a higher use of anti-depressant medications [65]. Another field of interest is the possible relationship between hip fracture and the onset of cardiovascular diseases. Hip fracture, in fact, seems to increase the risk of coronary heart disease, particularly during the first year after the event [66]. Since cardiovascular diseases are among the most expensive medical conditions [67], the impact of hip fracture in contributing to a huge increase in medical and social costs is highly relevant.