Frank Stinchfield Award: Creation of a Patient-Specific Total Hip Arthroplasty Periprosthetic Fracture Risk Calculator

J Arthroplasty. 2023 Jul;38(7S):S2-S10. doi: 10.1016/j.arth.2023.03.031. Epub 2023 Mar 17.


Background: Many risk factors have been described for periprosthetic femur fracture (PPFFx) following total hip arthroplasty (THA), yet a patient-specific risk assessment tool remains elusive. The purpose of this study was to develop a high-dimensional, patient-specific risk-stratification nomogram that allows dynamic risk modification based on operative decisions.

Methods: We evaluated 16,696 primary nononcologic THAs performed between 1998 and 2018. During a mean 6-year follow-up, 558 patients (3.3%) sustained a PPFFx. Patients were characterized by individual natural language processing-assisted chart review on nonmodifiable factors (demographics, THA indication, and comorbidities), and modifiable operative decisions (femoral fixation [cemented/uncemented], surgical approach [direct anterior, lateral, and posterior], and implant type [collared/collarless]). Multivariable Cox regression models and nomograms were developed with PPFFx as a binary outcome at 90 days, 1 year, and 5 years, postoperatively.

Results: Patient-specific PPFFx risk based on comorbid profile was wide-ranging from 0.4-18% at 90 days, 0.4%-20% at 1 year, and 0.5%-25% at 5 years. Among 18 evaluated patient factors, 7 were retained in multivariable analyses. The 4 significant nonmodifiable factors included the following: women (hazard ratio (HR) = 1.6), older age (HR = 1.2 per 10 years), diagnosis of osteoporosis or use of osteoporosis medications (HR = 1.7), and indication for surgery other than osteoarthritis (HR = 2.2 for fracture, HR = 1.8 for inflammatory arthritis, HR = 1.7 for osteonecrosis). The 3 modifiable surgical factors were included as follows: uncemented femoral fixation (HR = 2.5), collarless femoral implants (HR = 1.3), and surgical approach other than direct anterior (lateral HR = 2.9, posterior HR = 1.9).

Conclusion: This patient-specific PPFFx risk calculator demonstrated a wide-ranging risk based on comorbid profile and enables surgeons to quantify risk mitigation based on operative decisions.

Level of evidence: Level III, Prognostic.

Keywords: patient-specific; periprosthetic femur fracture; prognosis; risk calculator; risk modification; total hip arthroplasty.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, N.I.H., Extramural

MeSH terms

  • Arthroplasty, Replacement, Hip* / adverse effects
  • Arthroplasty, Replacement, Hip* / methods
  • Awards and Prizes*
  • Female
  • Femoral Fractures* / epidemiology
  • Femoral Fractures* / etiology
  • Femoral Fractures* / surgery
  • Hip Prosthesis* / adverse effects
  • Humans
  • Periprosthetic Fractures* / epidemiology
  • Periprosthetic Fractures* / etiology
  • Periprosthetic Fractures* / surgery
  • Reoperation
  • Retrospective Studies
  • Risk Factors