AAOS Registry Program Blog

AJRR Data Correlate Periprosthetic Femur Fractures with Fixation Method

Apr 2, 2019 12:00:00 PM

close up of conference meeting microphones and businessman writing


This blog is the final installment in a three-part series reporting on orthopaedic studies presented at the 2019 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting and utilizing American Joint Replacement Registry (AJRR) registry data. All presentations are reported by Terry Stanton, senior science writer for AAOS Now.

Paper 878, “Correlation of Perioperative Periprosthetic Femur Fractures with Fixation Method” was presented by Bryan D. Springer, MD, vice chair of AJRR, on Friday, March 15, 2019 at the AAOS Annual Meeting in Las Vegas, Nevada. The study evaluated data from the AJRR over a five-year period and analyzed the relationship between femoral stem fixation and perioperative periprosthetic femur fracture (PPFx) requiring early revision total hip arthroplasty (THA) surgery. Analyses determined that cementless femoral fixation accounted for 93 percent of stems with early PPF. Dr. Springer said that patients with cementless stems were 2.6 times more likely to undergo early revision for PPF than those with cemented fixation, although the number of cemented stems in the analyzed population was small, making that finding not statistically significant.

Over the course of the study, 734 participating institutions submitted THA procedural data to AJRR. Data submission was based on a monthly upload of all total joint replacement procedures conducted at that institution during the prior month. AJRR’s database was utilized to identify all primary THAs and hemiarthroplasties performed between 2012 and 2017. Subsequently, the authors sought to identify cases in which the AJRR included both the index arthroplasty and subsequent revision THA (linked revisions). Linkages of primary and revision procedures were confirmed by patient identifiers, including Social Security numbers, procedure site, and laterality.

“It is important to note that not all index procedures are linked to a revision THA, as the revision cases may be performed elsewhere in a hospital either not participating in the Registry or not regularly submitting data to AJRR,” the authors wrote. 

The researchers analyzed all early (three months or less from index arthroplasty) linked primary and revision hip arthroplasties to identify revisions that were performed with an accompanying International Classification of Diseases (ICD), Ninth Revision, Clinical Modification (ICD-9) or ICD, tenth revision (ICD-10) diagnosis code of PPF. The authors evaluated patient demographics (age and sex), ICD-9 or ICD-10 procedure code (hemiarthroplasty versus THA), and method of stem fixation (cemented versus cementless). Stem fixation was identified by submitted implant attributes.

There were 10,277 linked revisions reported to AJRR during the study. The most common reasons for failure requiring rTHA were instability/dislocation (13.0 percent) and infection (7.7 percent).

Early periprosthetic femur fracture requiring revision occurred in 628 patients (6.1 percent). Osteoarthritis was the ICD-9 or ICD-10 diagnosis code for the majority (82.4 percent) of the index arthroplasties studied, with femoral neck fracture as the diagnosis for 12.1 percent. Most of the index procedures performed (n = 529, 84.0 percent) were THA, with a small fraction (n = 99, 16.0 percent) being hemiarthroplasty. Fifty-eight percent of patients were aged 70 years and older, and 20 percent were aged 80 years and older. The preponderance of revisions for PPF was in women (70 percent).

Cementless femoral fixation was associated with 94.9 percent (n = 596 versus n = 32) of the periprosthetic fractures. Age, evaluated as a continuous variable, was close to statistical significance, whereas sex was statistically significant. Females were 1.86 times more likely to undergo early revision compared to males.

The authors concluded: “Cementless femoral stem fixation is strongly correlated with increased risk of early periprosthetic femur fracture, and this appears especially true in the female and older population. Despite this and many other reports showing increased risk of periprosthetic femur fracture, it remains the overwhelmingly dominant mode of fixation for hip arthroplasty in those centers reporting to the AJRR. Clearly defining risk factors and indications for cemented or cementless fixation should be a priority to reduce the incidence of this complication.”

Dr. Springer noted that this study and others deriving data from the AJRR demonstrate the value of the Academy-sustained registry. “Although in its infancy from a national registry standpoint, the AJRR is now the largest registry in the world by procedural volume,” he said. “Registry data give a representative sample of practices and trends across the country. In addition, as the Registry grows, we will be able to evaluate more granular data and determine best practice benchmarks.”


If you have any additional questions about the study, feel free to contact us at RegistryInfo@aaos.org


Dr. Springer’s coauthors of “Perioperative Periprosthetic Femur Fractures Are Strongly Correlated with Fixation Method: An Analysis from the American Joint Replacement Registry (AJRR)” are Caryn D. Etkin, PhD, MPH; Peter B. Shores, MPH; Terence J. Gioe, MD; David G. Lewallen, MD; and Kevin J. Bozic, MD, MBA.


For information about the AAOS RegistryInsights platform, speak with a Registry Engagement Associate at (847) 292-0530 or Request A Demo today!


Be sure to leave a comment in the form below!


Topics: Registry Findings

A Message for Our Readers

This blog was created by the American Joint Replacement Registry (AJRR), part of the American Academy of Orthopaedic Surgeons (AAOS) Registry Program. The blog is part of our commitment to improve orthopaedic care through the collection, analysis, and reporting of actionable hip and knee arthroplasty data. Our purpose is to communicate with others in the orthopaedic field who share the same commitment. Watch for weekly news alerts, quick tips, actionable checklists, best practices, and research findings posted to this blog. It will be information you can use each week!

The more interactive you are, the greater the value shared. Visit us at www.aaos.org/ajrr, speak with a Registry Engagement Associate at 847-292-0530, or follow us on Twitter.

Subscribe to the Blog Now!

Data Snapshot

Did you know? For the 2017 sample population, AJRR calculated a total hip arthroplasty (THA) revision burden of 4% and a total knee arthroplasty (TKA) revision burden of 5%. This revision burden for both THA and TKA is lower than in previous years (2012-2016) in AJRR. The 2017 AJRR results are also substantially lower than the results reported from the Australian Orthopaedic Association National Joint Replacement Registry where revision burden for THA was 8.9% and TKA burden was 7.4%. However, the AJRR results are likely multi-factorial and do not necessarily reflect a lower overall revision rate.

Read more in the AJRR 2018 Annual Report.

Table 6 from the AJRR 2018 Annual Report 


This Week's Blog

  • Tuesday, April 2, 2019 - AJRR Data Correlate Periprosthetic Femur Fractures with Fixation Method


This Week’s References

The American Academy of Orthopaedic Surgeons (AAOS) Registry Program

The mission of the AAOS Registry Program is to improve orthopaedic care through the collection, analysis, and reporting of actionable data. The Program's vision goes beyond hips and knees to include additional anatomic registries like the Shoulder & Elbow Registry (SER). Beginning with the American Joint Replacement Registry (AJRR), the AAOS Registry Program is managed by AAOS as a multi-stakeholder participation model. Stakeholders include representatives from the orthopaedic surgeon community, device manufacturers, hospitals, private payers, and the public.




AAOS RegistryInsights™

As a health care provider of orthopaedic services, you can access information about joining the AAOS Registry Program and RegistryInsights by visiting www.aaos.org/ajrr or speaking with a Registry Engagement Associate at (847) 292-0530.  New Call-to-action

Recent Posts

AAOS Registry Program Staff Writers

AAOS Registry Program Blog posts are researched and created by Registry Program staff writers: Karen Metropulos, Erik Michalesko, and Lori Boukas. If you would like to contact the writing staff, email us at RegistryInfo@aaos.org


This blog shares health care information from a variety of independent expert sources. Some sources offer opinions that may be of interest to other professionals facing similar challenges. Our approach helps ensure diverse, well-rounded presentation of important, often complex health care content. Shared content does not necessarily represent AAOS findings and practices. 

2018 MarCom Awards Gold Winner 

The AAOS Registry Program Blog won a Gold MarCom award in the digital media/writing/blog category. The MarCom Awards honor excellence in marketing and communication while recognizing the creativity, hard work, and generosity of industry professionals.

2018 MarCom Gold Award