Does early surgery improve outcomes for periprosthetic fractures of the hip and knee? A systematic review and meta-analysis

Abstract

Introduction Previous evidence has established that early surgery is beneficial to improve outcomes for individuals with native hip fractures in the elderly population. Patients who sustain a periprosthetic fracture have been demonstrated to have similar demographics and outcomes as those with native fractures around the hip and knee. We therefore set out to determine if there is a similar difference in perioperative outcomes between early and delayed surgery for periprosthetic fractures of the hip and knee through a systematic review and meta-analysis. Methods Literature search outputs were screened for studies meeting the inclusion criteria. The groups of early surgery and delayed surgery were defined by study authors. The primary outcome measure was 30 day mortality. Where there was sufficient study homogeneity, a random-effects meta-analysis was performed. Individual study risk of bias was assessed using the ROBINS-I criteria, with the GRADE criteria used for independent outcome evaluation. The review protocol was registered on PROSPERO prior to commencement (Registration number CRD42019149360). Results The inclusion criteria was met in 11 studies (n = 3006). Mean time to surgery from admission for reporting studies was 64 h. 59.6% patients underwent early surgery as defined by the study authors. We identified a significantly lower risk of 30 day mortality for those with early surgery versus delayed surgery (RR 0.21; 95% CI 0.05, 0.90; p = 0.04, n = 2022). There were also significantly better outcomes for early versus delayed surgery regarding: medical complications, length of stay, transfusion risk, and reoperation. The quality of evidence for all the individual outcomes was low or very low. Conclusions There is evidence that delaying surgery in those with periprosthetic fractures of the hip and knee has a deleterious impact on mortality and other important patient outcomes. There are, however, notable limitations to the existing available literature, with further appropriately designed large-scale studies required to confirm these findings.

Management and outcomes of femoral periprosthetic fractures at the hip

“…The longest waits were observed in hip B2/3 type PPFs, in which the majority of patients underwent revision. A recent systematic review by Farrow et al 15 reported a mean time to surgery of 2.7 days, and observed that delays in surgery were associated with higher mortality and poorer clinical outcomes, including greater risk of medical complications, longer length of stay, higher transfusion risk, and increased rates of reoperation. Griffiths et al 10 reported that a delay to surgery of greater than 72 hours led to increased risk of postoperative complications, whereas Bliemel et al 16 observed that early surgery had no effect on mortality and patient outcomes at 120 days, but did find that the risk of reoperation was significantly higher in patients whose surgery was delayed.…”

Early Surgery Does Not Improve Outcomes for Patients with Periprosthetic Femoral Fractures—Results from the Registry for Geriatric Trauma of the German Trauma Society

“…Other studies focusing on mortality in patients with PFF suggested different time intervals to separate early from delayed surgical treatment, e.g., 24 h [ 17 , 22 , 23 ] or 72 h [ 15 , 24 ]. A separate analysis of ATR-DGU using 24 and 72 h as cutoffs also failed to prove differences in regard to mortality (data not shown).…”

A multicentre comparative analysis of fixation versus revision surgery for periprosthetic femoral fractures following total hip arthroplasty with a cemented polished taper-slip femoral component

“…Surgical waiting times vary and there is some evidence that longer waiting times are associated with poorer outcomes, such as increased rates of transfusion, LOS, and mortality. 26,27 Revision surgery is more complex than ORIF and this explains the higher blood transfusion and critical care requirements observed in this group. The mean LOS was similar in the two groups, which was an unexpected finding as revision femoral components allow full weightbearing postoperatively whereas some surgeons may restrict weightbearing following ORIF.…”