Optimizing periprosthetic fracture management and in-hospital outcome: insights from the PIPPAS multicentric study of 1387 cases in Spain

Abstract

Background: The incidence of all periprosthetic fractures (PPF), which require complex surgical treatment associated with high morbidity and mortality, is predicted to increase. The evolving surgical management has created a knowledge gap regarding its impact on immediate outcomes. This study aimed to describe current management strategies for PPF and their repercussions for in-hospital outcomes as well as to evaluate their implications for the community.

Methods: PIPPAS (Peri-Implant PeriProsthetic Survival Analysis) was a prospective multicentre observational study of 1387 PPF performed during 2021. Descriptive statistics summarized the epidemiology, fracture characteristics, management, and immediate outcomes. A mixed-effects logistic regression model was employed to evaluate potential predictors of in-hospital mortality, complications, discharge status, and weight-bearing restrictions.

Results: The study encompassed 32 (2.3%) shoulder, 4 (0.3%) elbow, 751 (54.1%) hip, 590 (42.5%) knee, and 10 (0.7%) ankle PPF. Patients were older (median 84 years, IQR 77-89), frail [median clinical frailty scale (CFS) 5, IQR 3-6], presented at least one comorbidity [median Charlson comorbidity index (CCI) 5, IQR 4-7], were community dwelling (81.8%), and had outdoor ambulation ability (65.6%). Femoral knee PPF were most frequently associated with uncemented femoral components, while femoral hip PPF occurred equally in cemented and uncemented stems. Patients were managed surgically (82%), with co-management (73.9%), through open approaches (85.9%) after almost 4 days (IQR, 51.9-153.6 h), with prosthesis revision performed in 33.8% of femoral hip PPF and 6.5% of femoral knee PPF. For half of the patients, the discharge instructions mandated weight-bearing restrictions. In-hospital mortality rates were 5.2% for all PPF and 6.2% for femoral hip PPF. Frailty, age > 84 years, mild cognitive impairment, CFS > 3, CCI > 3, and non-geriatric involvement were candidate predictors for in-hospital mortality, medical complications, and discharge to a nursing care facility. Management involving revision arthroplasty by experienced surgeons favoured full weight-bearing, while an open surgical approach favoured weight-bearing restrictions.

Conclusions: Current arthroplasty fixation check and revision rates deviate from established guidelines, yet full weight-bearing is favoured. A surgical delay of over 100 h and a lack of geriatric co-management were related to in-hospital mortality and medical complications. This study recommends judicious hypoaggressive approaches. Addressing complications and individualizing the surgical strategy can lead to enhanced functional outcomes, alleviating the economic and social burdens upon hospital discharge. Level of Evidence Level IV case series.

Trial registration: registered at ClinicalTrials.gov (NCT04663893), protocol ID: PI 20-2041.

Keywords: Epidemiology; Fracture fixation; Frailty; Geriatric co-management; Incidence; Management; Mortality; Outcome; Periprosthetic fracture; Replacement.

Fig. 1

Distribution and types of PPF. The number and percentage (with respect to the total number of PPF) of fractures of each type according to the Unified Classification System (UCS) are shown. The size of each circle is proportional to the number of fractures

Fig. 2

Incidence rates of shoulder PPF, elbow PPF, hip PPF, knee PPF, and ankle PPF in the Spanish population. HSA hemishoulderarthroplasty, TSA total shoulder arthroplasty, RSA reverse shoulder arthroplasty, THA total hip arthroplasty, PHA partial hip arthroplasty, TKA total knee arthroplasty, TAA total ankle arthroplasty.

Fig. 3

Candidate predictors of in-hospital mortality in patients with a periprosthetic fracture (PPF): alive at hospital discharge vs dies in hospital before hospital discharge. The reference category for each variable is the first value. The size of the box is proportional to the number of patients in the category. CI confidence interval, OR odds ratio, CFS clinical frailty scale, CCI Charlson comorbidity index, MIS minimally invasive surgery, PC percutaneous, MIPO minimally invasive plating osteosynthesis

Fig. 4

Candidate predictors of medical complications during hospital stay in patients with a periprosthetic fracture (PPF): complication vs no complications. The reference category for each variable is the first value. The size of the box is proportional to the number of patients in the category. CI confidence interval, OR odds ratio, CFS clinical frailty scale, CCI Charlson comorbidity index, MIS minimally invasive surgery, PC percutaneous, MIPO minimally invasive plating osteosynthesis

Fig. 5

Candidate predictors of destination at hospital discharge in patients with a periprosthetic fracture (PPF): own home vs nursing care. The reference category for each variable is the first value. The size of the box is proportional to the number of patients in the category. CI confidence interval, OR odds ratio, CFS clinical frailty scale, CCI Charlson comorbidity index, MIS minimally invasive surgery, PC percutaneous, MIPO minimally invasive plating osteosynthesis

Fig. 6

Candidate predictors of weight-bearing restrictions in patients with a lower limb [i.e. hip (pelvis and femur), knee (femur and tibia), and ankle (tibia)] periprosthetic fracture (PPF): full weight-bearing vs restrictions. The reference category for each variable is the first value. The size of the box is proportional to the number of patients in the category. CI confidence interval, OR odds ratio, CFS clinical frailty scale, CCI Charlson comorbidity index, MIS minimally invasive surgery, PC percutaneous, MIPO minimally invasive plating osteosynthesis