COMPOSE

Full title

Characteristics, Outcomes and Management of Peri-prOsthetic fractures: Service Evaluation

Background

Periprosthetic fractures (fractures that occur around an implant) are rising due to the growing number of total primary replacement procedures being performed each year combined with the increasing life expectancy of this patient population.

Over 115,000 hip revision surgeries have been recorded on the National Joint Registry for England, Wales and Northern Ireland since it started collecting data in 2003. Approximately 11% of these revisions were performed due to a periprosthetic fracture.

Over the same period, there were 75,000 knee revision surgeries performed with just over 4% of these due to periprosthetic fractures.

While the number of shoulder and elbow revisions are comparatively smaller the number of these procedures performed each year is also increasing.

The management of periprosthetic fractures is complicated due to the increasing age and co-morbidities that characterise the majority of these patients, especially given that non-operative management is rarely indicated. Revision surgery is often technically difficult due to a lack of sufficient or healthy bone stock, and distorted anatomy which contributes to the increased risk of complications in these patients.

What we did

This was a multi-centre, retrospective service evaluation that aimed to collect a substantial body of information relating to adult patients that sustain periprosthetic fractures, the current treatment strategies used in the management of periprosthetic fractures related to hip, knee, ankle, shoulder, elbow and wrist arthroplasty, and to describe the outcome of these treatment approaches.

The evaluation included 539 adult patients who presented to 27 NHS hospitals with periprosthetic fractures between 1 January 2018 and 31 December 2018.

Data collected included: management strategy (i.e., operative and nonoperative), length of stay, discharge destination, and details of post-treatment outcomes (e.g., reoperation, readmission, and 30-day and 12-month mortality).

What we found

77% of fractures were managed operatively and 23% conservatively.

The median time to surgery was four days.

Of those undergoing surgery, 59% underwent revision and/or fixation and 41% fixation alone.

The median length of hospital stay was 15 days.

The 12-month reoperation rate was 5.6%, and 30-day readmission rate was 8.4%.

The 30-day and 12-month mortality rates were 5.2% and 21.0%. Significant predictors of 12-month mortality included: non-operative treatment, older age, male sex, admission from residential or nursing care, and sustaining the periprosthetic fracture around a revision prosthesis.