Research Impact Report - Project 540

Epidemiology of peri-prosthetic hip fractures in the UK

Principal Investigator Jonathan Evans

Stream Post-Doc

Duration 24 Months

Cost £46,812

Lay summary


For most patients, hip and knee replacements are incredibly successful in improving their quality of life for many years. Unfortunately, on occasion, complications can happen that result in pain and disability and can require further surgery and recovery time. One of these complications is when the bone supporting the hip or knee replacement breaks and the patient ends up unable to walk and is admitted to hospital as an emergency.

As surgeons, we frequently see these patients admitted, requiring urgent surgery to get them back on their feet again. Although the feeling amongst surgeons is that we are treating more of these injuries now than ever before, there are no records of how many patients suffer this every year and how big the problem is.

We are using information collected on every patient that comes into hospital to work out how many of these injuries are happening. We are also trying to find out what features are similar between patients, so that we can try and predict which patients are at higher risk of this happening to them. After that, we want to work out more about what happens to the patients after the injury; how long they are in hospital, how many of them require even more surgery and how many of them die in the months after the injury. The hospital information also allows us to work out how much NHS money is spent treating these injuries.

So far, we have shown that we may be underestimating the number of people breaking bones around hip and knee replacements by as much as half. The fact that twice as many people are having this injury than we thought before is incredibly valuable. It will allow us to argue that enough time and money should be spent trying to improve care for these patients and ensure they recover as well as possible. We are also able to be the first team to describe the different ways these patients are treated and how much this costs the NHS.

In the future, this information will allow us to better plan services to improve the care of patients suffering this life changing injury. It will also let us better explain to patients what to expect when they suffer this injury. The support from ORUK has allowed us to be the first people to look at this injury using such a big national information source. This will help us to light the way into research around these injuries and hopefully improve the care of these vulnerable patients.

Impact statement

Whilst hip and knee replacements are generally effective, sometimes the bone supporting the implant can break. This results in sudden pain and loss of function as well as emergency admission to hospital. Most patients who sustain these injuries will need surgery of some kind to enable them to walk again and even with this, may not recover the same level of function again afterwards. This surgery could take the form of re-do (revision) joint replacement or surgery to fix the bone around the joint replacement without changing the original implants.

At present, we are unaware of how many of these injuries happen in the UK, which patients suffer them and how they are treated. The main source of information on people who have joint replacement surgery in England and Wales is the National Joint Registry (NJR), whilst the NJR will tell us who has had their joint replacement changed, it does not tell us who has had other operations such as fixation of the bone without changing the implant.

We are using routinely collected data (hospital records collected for other reasons) to estimate how many of these injuries happen every year, describe the type of person they happen to and estimate what the impact is on the patients and the NHS. This information will help us better understand how to provide the best care for patients who sustain these life changing injuries.

Fundamental problem trying to address


Aims & Objectives

  1. Determine the incidence of peri-prosthetic fracture and how this has changed over the last 10 years.
  2. Use information from Objective 1 to predict future incidence of peri-prosthetic fracture.
  3. Investigate risk factors (predictors) for peri-prosthetic fractures using co-morbidity information held within HES and explore whether the impact of these predictors is the same in all patient groups.
  4. Establish the average length of hospital stay and mortality following peri-prosthetic fracture, how these outcomes change over time and what factors may predict increased risk of death or extended hospital stays.
  5. Assess the health economic implications of peri-prosthetic fractures including the cost implications of different management strategies and projections of future costs and economic burden of peri-prosthetic fractures given the findings of objective 2.

Intellectual property

At this stage, this work will not be leading to development of any products.

Team members & other funders


Two manuscripts are in draft form and shortly to be submitted for consideration of publication in journals. These focus on:

  • The reasons why estimating the incidence of PPFF using routine data is challenging, and ultimately may not be possible.
  • A description of who sustains these fractures and how they are treated.

I have presented initial findings of this work at the British Orthopaedic Association Congress 2021 and at Bristol Hip 2021.

Based on the findings of this work, I am chairing a peri-prosthetic fracture break out session at the British Hip Society Congress in Bournemouth in March 2022.

We also expect to submit abstracts based on this work to the International Society of Arthroplasty Registers congress as well as the British Orthopaedic Association annual congress.

Despite the data issues with the availability of the HES dataset as well as the challenges of correctly identifying patients who have suffered PPFF, we have now made clear progress and are optimistic about the final and most important steps of this study. We feel we will be adding the clearest and most important information regarding PPFF to the current knowledge base and that this will form the basis of future research. We are very grateful to ORUK and all of its donors and contributors for their support. Jonathan Evans

Tell us your thoughts

Your email address will not be published. Required fields are marked *