Title: Periprosthetic femoral fractures: data, management and outcomes
Funder: Department of Health and Social Care

Abstract: Research question What variations exist around periprosthetic femoral fracture (PPFF) treatment and outcomes, why do those variations exist, and what should be done to improve the situation? Background Hip and knee joint replacements are common operations and, due to an ageing and increasingly frail population, are forecast to grow greatly in the coming years. With this will come a rise in PPFFs, a known complication, when the bone around the prosthesis breaks. Costs are high, and outcomes can be poor. There is a lack of reliable data on the extent of variations in management and outcomes and the reasons for them. Other than our team’s initial work, existing data have been little analysed. There is also uncertainty over which service model(s) is considered best by staff and patients. We aim to fill these key gaps through a mixed-methods study of three work packages (WPs). Aims and objectives 1. Assess the variation between hospitals in England in how these patients are managed and their outcomes 2. Obtain healthcare professionals’ views on how patients should be managed, collecting new qualitative data from case study hospitals 3. Obtain patients’, family members’ and carers’ views on what they want from care during and after the fracture has been treated, including, for instance, on whether they would be willing to travel to a specialised centre 4. Define measures of quality of care to assess future improvement efforts, also exploring the best way to collect any necessary additional data Methods WP1 (Objective 1) will use Hospital Episodes Statistics (HES), the National Hip Fracture Database (NHFD), Trauma Audit and Research Network (TARN) and the National Joint Registry (NJR), each telling us part of the picture. Predictors of outcomes and variations in processes and outcomes between hospitals and service models will be estimated through multilevel models and funnel plots. Models will include a volume-outcome analysis. WP2 (Objectives 2 and 3): 4-6 case study sites, identified from HES data in WP1 and purposively sampled for ‘maximum variation’ of geographical and demographic variations, access to specialised services, and service models (referral centre, referring centre and self-sufficient centre). Case studies will follow an instrumental approach, involving in-person visits, interviews with staff, patients and carers, and review of protocols, guidelines and policies. WP3 (Objective 4): Delphi study to agree on quality-of-care measures, risk-adjustment and the process for collecting new data. This will use a three-step process, with the initial measure set drawn from WP1 findings, the literature and team expertise. We will also co-produce resources for patients and families on what to expect from PPFF treatment and recovery. Timelines M1-6: set-up, ethics and data applications, early HES analysis to identify case study sites M7-24: WP1 analysis for HES, NHFD and TARN and write-up; WP2 data collection and analysis M25-30: WP1 analysis for NJR; WP2 write-up; WP3 M31-36: remaining WP1 analysis and write-up; report to funder Anticipated impact and dissemination Our findings will inform clinical guidelines and service redesign decisions. We will disseminate through our networks, professional bodies, NHS England, NICE, charities, and through blogs and academic routes. Hospital-level feedback and reporting of performance measured through our indicators will be possible in the future via the NJR’s and NHFD’s existing web portals.

Lay abstract: BACKGROUND Hip and knee joint replacements (prostheses) are a very common, hugely successful way of treating bones damaged by fractures or arthritis. However, they present a number of challenges if the patient later fractures their thigh bone (femur), causing a periprosthetic femoral fracture (PPFF). As people live longer, more will have joints replaced and be at risk of PPFF. The number of PPFFs is steadily growing by 13% each year in England; in 2019-20 there were 7,430 hospital admissions with PPFF. Patients with PPFFs are difficult to manage surgically, require prolonged rehabilitation, are costly to treat (averaging over £30,000 for hospital stay alone), and can have poor outcomes, with pain and reduced independence and 1 in 30 patients dying within 30 days. We have little reliable data on patients with PPFFs. We know treatment varies widely between hospitals, but not how this affects patients’ experience and outcomes, or what health professionals, patients and their families think should be done to improve care. STUDY AIMS We will combine existing data with new information, to understand how patients with PPFF are cared for and how this can be improved, by: 1. measuring how PPFF care and outcomes vary between hospitals 2. exploring health professionals’ views on care 3. understanding patients’ and their families’ priorities for care during and after treatment 4. developing quality-of-care measures and exploring the best way to collect such data 5. creating patient resources about PPFF treatment and recovery 6. making national recommendations about improving care quality PLAN Firstly, we will analyse data from four existing English national databases of fractures and joint replacements. This will tell us how many patients with PPFF are treated by individual surgeons and hospitals, and how the fractures are managed and patient outcomes vary between these. Next, we will visit four to six English hospitals that represent the different ways of providing PFF care, and analyse their approaches, using face-to-face interviews to understand what patients and their families, and health professionals believe should be the priorities of providing care. Finally, we will use a structured process to build consensus out of patients’ and their family members experience and health professionals’ expertise to create a set of quality-of-care measures and develop resources to help patients and their families understand PPFF treatment and recovery. DISSEMINATION, IMPACT AND TEAM We will share our findings widely through standard outlets: professional bodies (such as the British Orthopaedic Association) and networks, charities, medical journals and conferences, and online. Our findings should inform future NICE clinical guidelines on the care of people with PPFF and make care better and more equal between hospitals in England. Our team includes people who lead NHS fracture and joint replacement databases and who have a special hospital or research interest in improving care for people with PPFF. We are therefore well-placed to successfully complete the work and make these changes happen.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MUSCULOSKELETAL