Periprosthetic femoral fractures in total hip arthoplasty

Khan, Tanvir (2019) Periprosthetic femoral fractures in total hip arthoplasty. PhD thesis, University of Nottingham.

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Periprosthetic Femoral Fractures (PFF)are a complication of Total Hip Arthroplasty (THA) which are technically challenging to treat and associated with significant morbidity. There is a lack of epidemiological evidence relating to these common fractures, which are thought to be an increasing problem in orthopaedic practice. This thesis aims to assess the temporal trends, the risk and risk factors as well as the outcome of treatment of PFF in THA.


This thesis used a combination of systematic review of existing evidence and analysis of the National Joint Registry(NJR), the world’s largest arthroplasty registry.Temporal trends of revision arthroplasty for PFF were assessed using NJR data to calculate“revision burden” and incidence of first revision in terms of implant-years at risk, by year. The risk and risk factors for PFF were assessed using a systematic review of high volume observational studies followed by analysis of NJR data of primary THAs performed in England and Wales. A novel flexible parametric approach was used to assess risk factors and estimate ‘real-life’ probabilities of revision for PFF in the presence of multiple competing risks (death and revision for indications other than PFF). A systematic review of treatment of PFF in the presence of a loose femoral stem (Vancouver B2 and B3 fractures) was performed to compare outcomes based on treatment modality including implants used and fracture type.

Finally, outcomes of first revision surgery for PFF were analysed based on NJR data using flexible parametric competing risk models to determine risk factors for failure and estimate the risk of further revision and death.

Thesis Findings

The results of the temporal trends study indicated that both revision burden and incidence of first revision for PFF have demonstrated an increase in England and Wales despite showing decreases for other indications for revision. For intra-operative fracture, increasing age, female gender and cementless stem fixation were associated with a higher risk of PFF based on systematic review and NJR data. For post-operative fractures, the NJR data indicated that increasing age, male gender and primary THA for neck of femur fracture were associated with a higher risk of revision for PFF. Implant factors were complex with significant difference in risk between stem designs as well as implant-brand specific differences. The results provide “real-life” estimates of probability of PFF revision for patient-implant groups.

The systematic review of treatment of Vancouver B2 and B3 fractures demonstrated overall poor outcomes particularly when revision arthroplasty was not used. A suggested minimum dataset for studies reporting outcomes of periprosthetic fracture was devised to improve comparisons between institutional studies. Analysis of NJR data relating to first revisions for PFF, suggested higher overall mortality compared with other common indications for revision. Risk of further revision was significantly higher after first revision for PFF compared to revision for aseptic loosening.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Ollivere, Benjamin
Scammell, Brigitte
Keywords: Periprosthetic Femoral Fractures; Total hip Arthroplasty; Epidemiology; Risk factors; Treatment outcome
Subjects: W Medicine and related subjects (NLM Classification) > WE Muscoskeletal system
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 57001
Depositing User: Khan, Tanvir
Date Deposited: 08 Apr 2020 12:38
Last Modified: 06 May 2020 09:02

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