Optimizing periprosthetic fracture management and in-hospital outcome: insights from the PIPPAS multicentric study of 1387 cases in Spain
Authors:   The PIPPAS Study Group, Aguado Héctor J. , Castillón-Bernal Pablo , Teixidor-Serra Jordi , García-Sánchez Yaiza , Muñoz-Vives Josep M. , Camacho-Carrasco Pilar , Jornet-Gibert Montsant , Ojeda-Thies Cristina , García-Portabella Pablo , Pereda-Manso Adela , Mateos-Álvarez Elvira , Manzano-Mozo Javier , Carrillo-Gómez Raquel , País-Ortega Sergio , García-Virto Virginia , Noriega-González David , Álvarez-Ramos Begoña Aránzazu , Ganso-Pérez Abel , Cervera-Díaz Carmen , Plata-García María , Ortega-Briones Alina , Berrocal-Cuadrado Juan , Criado del Rey-Machimbarrena Diego , Salvador Jordi , Rey Laura , Tomás-Hernández Jordi , Selga-Marsà Jordi , Andrés-Peiró José Vicente , Querolt-Coll Jordi , Triana Guillermo , Vives-Barquiel Marian , Renau-Cerrillo Marina , Campuzano-Bitterling Borja , Hernández José M , Ostilla Ricardo , Carreras-Castañer Anna , Torner Pere , Díaz-Suárez Rebeca , Fernández Eliam Ajuria , Olaya-González Carlos , Fernández-Villán María , García de Cortázar Unai , Arrieta Mirentxu , Escobar Daniel , Castrillo Estíbaliz , Balvis Patricia , Rodríguez-Arenas Mónica , García-Pérez Ángela , Moreta Jesús , Bidea Iñigo , Jiménez-Urrutia Xabier , Olías-López Beatriz , Boluda-Mengod Juan , González-Martín David , Bárcena-Goitiandia Leopoldo , López-Dorado Daniel , Borrás-Cebrián Juan Carlos , García-Aguilera David , Freile-Pazmiño Patricio Andrés , Suárez-Suárez Miguel Ángel , Lanuza-Lagunilla Lucía , García-Arias Antonio , Sánchez-Saz Jaime , García-Coiradas Javier , Valle-Cruz José , Mora-Fernández Jesús , Cano-Leira María Ángeles , Rieiro Guillermo , Benjumea-Carrasco Antonio , Priego-Sánchez Rodrigo Jesús , Sánchez-Pérez Coral , Guadilla-Arsuaga Jorge , Fernández-Juan Alexis , Sánchez Plácido , Ricón Javier , Fuentes-Díaz Alfonso , García-García Elena M. , Cuadrado-Abajo Francisco , García-Portal Gonzalo , del PozoManrique Pedro , Castillo del Pozo Virginia , Garcia-Navas Francisco Manuel , García-Paredero Ester , Beteta-Robles Teresa , Guijarro-Valtueña Ainhoa , Gutiérrez-Baiget Gonzalo , Alonso-García Noelia , Navas-Pernía Inés , Ariza-Herrera Diana , Vilanova Joan , Videla-Cés Miquel , Serra-Porta Teresa , Vázquez-García César , Carrasco-Becerra Carmen , Pena-Paz Silvia , Otero-Naveiro Víctor , Fernández-Billón-Castrillo Inés , Martínez-Menduiña Amaia , Hernández-Galera Carolina , Fernández-Dorado Fátima , Madrigal-López María , Murcia-Asensio Antonio , Galián-Muñoz Elena , Castro-Sauras Ángel , Espallargas-Doñate Teresa , Royo-Agustín María , Plaza-Salazar Nuria , Gámez-Asunción Carla , Muñoz-Vicente Adrián , Pareja-Sierra Teresa , Benito-Santamaría Jennifer , Cuenca-Copete Alejandro , Verdejo-González Ana , González-Montero Blas , Giraldo-Vegas Luis Alejandro , Alonso-Viana Laura , Díez-Pérez Eduardo José , Briso-Montiano Ricardo , Andrés Ana Isabel , Mingo-Robinet Juan , Naharro-Tobío María , Escudero-Martínez Emma , Serrano-Sanz Jorge , Peñalver-Matamoros J. M. , Fernàndez-Poch Núria , Martínez-Carreres Laia , Macho-Mier María , Martín-Hernández Carlos , Laclériga-Giménez Antonio Francisco , Saló-Cuenca José Carlos , Salamanca-Ontiveros César , Espona-Roselló Jordi , Altemir-Martínez Victoria , Criado-Albillos Guillermo , Cunchillos-Pascual Jorge , Millán-Cid Mercedes , Cabello-Benavides Hugo Gabriel , Martínez-Íñiguez-Blasco Jorge , Sevilla-Ortega Paloma , Cano Juan Ramón , Ramírez Alicia , Marqués-López Fernando , Martínez-Díaz Santos , Carabelli Guido S. , Slullitel Pablo A , Astore Ignacio , Boietti Bruno R. , Hernández-Pascual Carlos , Marín-Sánchez Javier , Córdova-Peralta Julio César , Dot-Pascuet Iván , Pereira-Mosquera Eduardo , Martín-Antúnez Javier , Pérez José María , Mandía-Martínez Alfonso , De Caso Julio , Martín-Marcuello Jordi , Benito-Mateo Miguel , Murillo-Vizuete A. David , Delgado Luis Gracia , dela Herrán Gaspar , Nunes Nahikari , Pérez-Coto Ivan , González-Panisello María Rosa , Iglesias-Fernández Susana , Ruete-Gil Gorka Luis , Ramos-García Sergio , Villarreal Juan Pablo 
Published: March 2024

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.

Graphical abstract