Outcome Of Periprosthetic Fractures Research Articles

A Quality Improvement Project to Improve Periprosthetic Fracture Management at District General Hospitals.

Introduction The incidence of periprosthetic femoral fractures (PPF) is expected to rise by 4.6% every decade over the next 30 years. The risk of mortality for patients who sustained a PPF was found to be similar to the mortality rate after a native hip fracture, and so The National Institute for Health and Care Excellence (NICE) guidelines advocate the timely management and mobilisation for patients with PPFs. Patient outcomes following these complex surgeries can be highly variable owing to the variability in regional practice and service delivery. This study aimed to review the management trend and outcomes of periprosthetic fractures (PPFs) involving hip and knee prostheses at a busy district general hospital in order to improve the overall efficacy in managing these complex fractures. Methods This retrospective study included 67 patients who presented to a single district general hospital during a two-year period. Data was collected on demographic profile, further onward referral to a tertiary centre, management (operative versus conservative), timing of surgery, complications, length of stay, implant survivorship, 30-day, one-year, and two-year mortality rate. Results Out of the total of 67 PPFs, 51 (76%) were managed operatively, and 16 (24%) were managed conservatively. Of the operatively managed PPFs, 49 (96%) were managed locally at the district general hospital, and two (4%) were managed at the tertiary centre. Eighteen patients (37%) underwent both revision and fixation, whilst 31 (63%) underwent fixation alone. The mortality rates at 30 days, one year, and two years were 10.4%, 20.9%, and 25.4%, respectively. For PPF patients managed operatively, the mean time taken from presentation to operation was 89.2 hours. The overall mean length of hospital stay for all patients was 23.6 days. Eight patients suffered complications. The implant survivorship at two years was 98%. Conclusion This study adds objective support for the successful operative management of PPFs at district general hospitals. However, improvement is required in service delivery and the efficacy of management. This could be achieved by a national database for PPFs, improved resource allocation, and prompt logistical support.

Managing periprosthetic fractures – a review of the hub and spoke model

Introduction: Periprosthetic fractures are associated with significant morbidity and mortality. The “hub and spoke model” consists of a central organisation (the hub) and a series of secondary units (the spokes). This study reviews the presentation, management, and outcomes of periprosthetic fractures at a large general district hospital, the Royal Blackburn Hospital. Methods: A retrospective data analysis for patients presenting with periprosthetic fractures from a single general district hospital between January 2011 and December 2020. Details recorded were patient demographics, primary arthroplasty procedure, fracture management, ASA grade, morbidity and mortality, and Unified Classification System for Periprosthetic Fractures (UCSPF). Results: With 229 periprosthetic fractures, the number tripled in 2020 that admitted in 2011. The mean age was 78.6 years (range 33–100), 151 were females. Seventy-five percent of the fractures were managed locally, while 25% a referral to the higher specialist centre was sort. Of the 57 referrals, 50 were transferred to the hub, 5 were operated on locally, and 2 were managed non-operatively. Higher-level care transfer resulted in a delayed definitive treatment (4.8 versus 12 days, p = 0.001). About 94.4% of patients treated locally had a favourable outcome versus 92% of patients treated at the hub hospital. Cumulative mortality rates for the two sites were comparable. Discussion: Most of the patients presenting to the local spoke hospital with periprosthetic fractures were managed in house. For this practice to be preserved, there is a need for future planning, such as maintaining an appropriate skill mix at spoke units. Discussion between specialists at the hub and spoke hospitals reduced patient transfer by 14%.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study

BackgroundPeriprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy.Materials and methodsData were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien–Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included.ResultsMedian age was 81 years (range 70–96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1–4), median VAS score on admission was 3 (range, 0–6), median CFS was 4 (range, 1–8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1–5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1–5). The median LOS was 12.8 days (range 2–36 days), and 21 patients (55.3%) were discharged home.ConclusionsThe incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future.Level of evidenceIV.

Management, outcome, and novel classification system of periprosthetic fractures in patients with transcutaneous osseointegrated prosthetic systems (TOPS)—a retrospective cohort analysis

IntroductionTranscutaneous osseointegrated prosthetic systems (TOPS) are anchored prosthetic systems for major limb loss. Sometimes TOPS patients suffer from periprosthetic fractures. The aim of this study was to analyze the management and outcomes of periprosthetic fractures in patients with TOPS and to introduce a novel classification system for this entity.Material/methodsSince 2010, 140 patients were treated with TOPS after transfemoral amputation in two centers in Germany. Fifteen patients sustained periprosthetic fractures, with five intra- and ten postoperative fractures. The outcome was analyzed by Prosthesis Mobility Questionnaire (PMQ), K-level and prosthesis wear time per day. A subgroup analysis for the body mass index (BMI) was performed.ResultsAll postoperative fractures were treated with implant-retaining osteosynthesis. Fourteen fractures healed without complications after a mean of 3 months. One postoperative fracture developed a clinically asymptomatic firm non-union. No Endo-Fixstem had to be removed. For the fracture and control group, a significant increase of the PMQ (p < 0.001) and K-level (p < 0.001) was observed after TOPS treatment compared to the preoperative baseline. Furthermore, the subgroup analysis showed a significant increase of the PMQ and K-level for both normal weight (p = 0.002) and overweight patients (p < 0.001). Of interest, overweight patients even showed a significantly higher increase in scores compared to normal weight patients, regardless of periprosthetic fracture.ConclusionPeriprosthetic fractures do not necessarily worsen outcomes of TOPS treatment. Proper classification and standardized appropriate treatment strategies according to fracture morphology are paramount for reliably good outcomes. We recommend to not remove or exchange the implant (Endo-Fixstem) even if it is assembly. Higher BMI did not have an impact onto rehabilitation success after TOPS to major limb loss of the lower extremity.

Management and Outcome of Periprosthetic Fractures After Total Knee Arthroplasty

The incidence of periprosthetic fractures after total knee arthroplasty is continuously rising because of an increasing number of knee joint replacements and an enhanced survivorship of the elderly population after knee arthroplasty. The purpose of this study was to analyze the practicability and effectiveness of the various treatment methods for management of periprosthetic fractures after total knee arthroplasty, and to determine the clinical and radiographic long-term results of patients following surgical and nonoperative treatment of these injuries. We reviewed the clinical and radiographic records of 41 patients (31 women and 10 men; average age, 78.6 years) with periprosthetic fractures after total knee arthroplasty between 1992 and 2008. Thirty-seven patients showed a periprosthetic fracture of the distal femur, and four patients had a periprosthetic proximal tibial fracture. Thirty-six patients underwent operative stabilization by plate fixation (n = 18), intramedullary nailing (n = 15) or revision arthroplasty (n = 3), and five patients were treated nonoperatively by long-term cast immobilization. Twenty-eight patients returned to their preinjury activity level and were satisfied with their clinical outcome. In 10 patients, we saw a relevant decrease of knee function and severe limitations in gait and activities of daily living. Three patients died related to surgery. Successful fracture healing within 6 months was achieved in 33 (87%) of 38 patients. Failures of reduction or fixation occurred in 8 (21%) of 38 patients. Reoperation due to technical failures was necessary in three patients. Compared with current data in literature, we had a satisfactory outcome in following individualized treatment of periprosthetic fractures after knee joint replacement. Referring to the wide field of treatment options and high rates of complications, periprosthetic femoral fractures around the knee commonly constitute a challenging problem for the treating surgeons and require an adequate analysis of fracture etiology and a corresponding transfer into an individual treatment concept.