Abstract
Aims
Periprosthetic femoral fractures (PFFs) have emerged as the leading cause of reoperation following total hip arthroplasty (THA). This study aimed to evaluate patient-reported outcomes following operative management of PFFs with either fixation or revision arthroplasty around Exeter femoral components.
Methods
From a trauma database, 112 patients with operatively managed postoperative PFFs involving Exeter femoral componentss were identified from 2017 to 2023 (minimum one year follow-up). Patients who responded (89/112, 79%: mean age 73.3 years (SD 10.1; 44 to 92; 35/89 female) completed validated patient-reported outcome measures (PROMs), including the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), Oxford Hip Score (OHS), and Lower Extremity Functional Scale (LEFS), to assess both recalled prefracture and follow-up status.
Results
Fractures had been treated with fixation in 65/89 (73%) or revision THA (RTHA) in 24/89 (27%). There were no differences in patient demographic details between fixation and RTHA groups. Compared to recalled prefracture status, patients displayed significant postoperative declines across all PROMs (p < 0.001). The median EQ-5D declined by 0.106 following fixation and by 0.204 following RTHA, with no difference between groups (p = 0.500). Median OHS and LEFs declined by 3 and 2.5 points, respectively, in patients treated with fixation and by 5 and 8 points after RTHA. Overall, clinically meaningful declines in OHS of > 8 points were experienced by 34.8% (31/89) of patients and 62% of patients expressed satisfaction, with no significant differences between operative strategies (p = 0.621).
Conclusion
Health-related quality of life and joint-specific function declined significantly following Exeter femoral component associated postoperative periprosthetic fractures with comparable outcomes following RTHA or fixation of appropriately selected cases. Despite functional declines, most patients were satisfied with their outcome.
Cite this article: Bone Jt Open 2026;7(2):275–282.
Keywords: Patient reported outcome measures, Periprosthetic femoral fractures, Revision, Fixation, femoral components, patient-reported outcome measures (PROMs), taper slip, periprosthetic femoral fractures, revision arthroplasty, Oxford Hip Score (OHS), EQ-5D scores, reoperation, EQ-5D-3L, Lower Extremity Functional Scale
Introduction
Periprosthetic femoral fractures (PFFs) are now recognized as the leading cause of reoperation following total hip arthroplasty (THA).1-3 There is currently much interest in the effect of femoral component design (cementless, cemented taper slip, and cemented composite beam) and collars on the incidence of intraoperative and postoperative PFFs.1-3 The surgical management of these biomechanically complex fractures poses significant challenges. The Unified Classification System (UCS)4-6 provides surgeons with guidance on optimal treatment strategies for these complex injuries. However, recent evidence has begun to challenge how these established guidelines apply to fractures involving cemented collarless polished taper slip (PTS) femoral components.5,7-9 Specifically, there is growing evidence that fixation may be favourable to revision THA (RTHA) for UCS B2 fractures (stem loose) involving PTS femoral components.7-9 With studies reporting less perioperative morbidity and reoperation than revision arthroplasty provided the bone cement interface is intact, the fracture reduction is anatomical, and the fixation is adequate.7-9
Current studies on the management of these fractures have primarily examined reoperation rates, patient morbidity, and mortality.7-11 However, the frail elderly population who typically sustain PFFs, may be considered unfit for non-emergent reoperation, thus biasing this as a metric of success or failure. Concern remains that fixation of B2 to B3, may be associated with late femoral component subsidence and therefore pain resulting in poorer outcomes compared to revision arthroplasty. There is currently a lack of data on patient-reported outcome measures (PROMs) following PFFs internationally.
The aim of this study was to report PROMs following operatively managed Exeter femoral component associated PFFs treated with fixation or revision arthroplasty in the early to midterm. The primary outcome measure was health-related quality of life (HRQol) measured using the EuroQol five-dimenation three-level questionnaire (EQ-5D-3L).12 Secondary outcome measures included the Oxford Hip Score (OHS)13 and the Lower Extremity Functional Scale (LEFS).14
Methods
Ethical approval for this retrospective cohort patient-reported feedback study was obtained from the Scotland (A) Research Ethics Committee (reference number 20/SS/0125). From May 2007 to May 2022, 396 consecutive patients with periprosthetic fractures involving proximal femoral components were admitted to the study institution for operative management and were identified from a prospectively collected trauma database (Figure 1). The majority of patients presenting to the centre have a THA involving a cemented Exeter PTS femoral component. Overall, six patients with PFFs had other femoral component types and were excluded from the study, as were those who sustanined their fracture six or more years prior to the study.
Fig. 1.
Summary of patients (pts) included in the study. Figure represents patient exclusions for: mortality, femoral component type, contact details, cognitive ability, failure to respond, and appropriate follow up. PROMs, patient-reported outcome measures.
Patient characteristics
The study population included 89 operatively managed PFFs around Exeter PTS femoral components at one to six years post fracture (Table I). The mean patient age at fracture was 73.3 (10.1; 44 to 92) and 35/89 were female. Five fractures occurred around hemiarthroplasties and the remainder involved THAs.
Table I.
Patient characteristics of responders.
| Variable | ORIF (n = 65) | Revision (n = 24) | p-value |
|---|---|---|---|
| Mean age, yrs (SD) | 74.5 (10.2) | 69.7 (9.23) | 0.047* |
| Female sex, n (%) | 28 (43) | 7 (29) | 0.233† |
| SIMD, n (%) | |||
| 1 | 4 (6) | 4 (17) | 0.294† |
| 2 | 11 (17) | 3 (13) | |
| 3 | 13 (20) | 4 (17) | |
| 4 | 11 (17) | 8 (33) | |
| 5 | 23 (35) | 5 (8) | |
| ASA grade, n (%) | 0.656† | ||
| 1 | 5 (8) | 1 (4) | |
| 2 | 30 (46) | 12 (50) | |
| 3 | 26 (40) | 11 (46) | |
| 4 | 3 (5) | 0 | |
| Median NHFS (IQR) | 4 (3 to 5) | 4 (3 to 6) | 0.271 |
| Median CFS (IQR) | 3 (1 to 6) | 3 (2 to 6) | 0.681 |
| UCS grade, n (%) | |||
| B1 | 24 (37) | 1 (4) | < 0.001 |
| B2 | 31 (48) | 12 (50) | |
| B3 | 1 (2) | 11 (46) | |
| C | 7 (11) | 0 | |
| D | 2 (3) | 0 | |
| Median follow up, yrs (IQR) | 3.9 (1.2 to 5.6) | 3.2 (1 to 5) | 0.221 |
| Reoperated, n (%) | 8 (12) | 1 (4) | 0.243† |
Unpaired Student’s t-test.
Chi squared test.
ASA, American Society of Anesthesiologists; FU, follow-up; NHFS, Nottingham Hip Fracture Score; ORIF, open reduction and internal fixation; SIMD, Scottish Index of Multiple Deprivation; UCS, Unified Classification System.
Electronic patient records were reviewed to confirm the diagnosis and identify patients who were now deceased. Radiographs were examined by two authors (MP-B, CS). Fractures were classified according to the UCS classification,3 and the surgical management with fixation or revision was confirmed. All patients with periprostheic fractures are initially managed via our trauma unit where fixation is considered. As per Scott et al,5 contraindications to fixation of B2/3 fractures include: bone/cement interface loosening; comminuted metaphyseal split patterns; irreducible fractures (femoral component subsided into centralizer); and fractures where the calcar fragment cannot be reduced/captured. Where there is uncertainty about whether fixation will be possible, these fractures are managed by traumaplasty surgeons experienced in both revision THA and fixation, or revision arthroplasty surgeons where revision is definitely required. Patients who were still alive and who had undergone open reduction and internal fixation (ORIF) or revision for a PFF involving an Exeter cemented femoral component periprosthetic fracture were identified for the study (n = 196). Patients who had sustained their fracture less than one year or more than six years prior to January 2024 were excluded (Figure 1). In January 2024, all those meeting the inclusion criteria were contacted and asked to complete a postal questionnaire. Patients were asked to complete PROM scores for both the current status and their recalled pre-fracture status.15 Patients who did not respond to the questionnaire were contacted by telephone. Patients who were uncontactable (n = 10, 5%), who could not complete PROMs due to a change in cognitive status (n = 44, 23.7%), and those who declined to be included in the study were excluded (n = 13, 7.0%). This gave a study population of 89 PFFs involving Exeter PTS femoral components with a minimum of one year follow-up (Figure 1).
Questionnaires included validated PROMs: EQ-5D-3L;12 the OHS;13 and LEFS.14 The EQ-5D is a validated and widely used five-dimension (mobility (MO), self-care (SC), usual activities (UA), pain and discomfort (PD), and anxiety and depression (AD)) multi-attribute general health questionnaire that defines an overall health index (from -0.594 to 1). In the 3L version, each question has three possible levels indicating the degree of impairment (‘none’ = 1, ‘some’ = 2, ‘extreme’ = 3), giving 243 potential health states. The minimal important change (MIC) for the EQ-5D-3L in patients with knee osteoarthritis is reported as 0.105.16 No MIC specific to hip fracture or hip osteoarthritis patients has been calculated, but a minimal clinically important difference (MCID) of 0.075 has been used to power hip fracture studies previously.16,17 The OHS is a validated hip-specific outcome measure where 12 questions (five possible answers) give scores from 0 to 48 (higher scores = better function).13 A MIC in OHS was defined as 8 points.18 The LEFS is a validated lower limb specific score consisting of 20 questions (four possible answers), giving a score of 0 to 80 where higher scores reflect better function. It is both responsive and reliable with a MIC of 9 points.13 Satisfaction with the affected hip was measured using a five-point Likert scale from ‘very dissatisfied’ to ‘very satisfied’.19 There is no validated questionnaire for patients with PFFs. This study opted to utilize recognized and validated questionnaires often used for patients with hip pathology and lower limb fractures.
Patient demographic details were recorded from electronic patient records. The Scottish Index of Multiple Deprivation (SIMD) was calculated according to postcode.20
Outcomes
The primary outcome of interest was HRQoL (measured using the EQ-5D-3L) after the operative management of PFF with ORIF or revision arthroplasty. Secondary outcomes included joint/limb specific functional outcomes measures (OHS and LEFS), and patient satisfaction following PFF managed by ORIF and revision arthroplasty.
Statistical analysis
Data handling and statistical analysis was undertaken using SPSS v. 25 (IBM, USA). The distribution of continuous variables was plotted to assess appropriateness of parametric or non-parametric tests of differences. Patients who had undergone ORIF were compared to those who had undergone revision arthroplasty. Differences between non-parametric variables were compared using unpaired Mann-Whitney U test, and parametric variables with an independent-samples t-test. Differences in categorical variables between cohorts were measured using the chi-squared test of Fisher’s exact. Differences between pre and post fracture PROMs were compared using Wilcoxon signed rank. A p-value < 0.05 was considered statistically significant.
Results
The primary management was fixation in 65/89 (73%) and revision THA in 24/89 (27%) of patients. UCS fracture types included: B1 n = 25 (28.1%); B2 n = 43 (48.1%); B3 n = 12 (13.5%); C n = seven (7.9%); and D n = two (2.2%). Patient characteristics according to surgical treatment strategy are shown in Table I. There were no differences in patient demographic details between the groups, with comparable Nottingham Hip Fracture Score (NHFS),21 American Society of Anesthesiologists (ASA) grade,22 Clinical Frailty Scale (CFS),23 and deprivation levels (SIMD).20
Primary outcome measure
Prior to the PFF, the median EQ-5D was 0.848 (IQR 0.691 to 1.00), which declined significantly to 0.61 at a median follow-up of 4.0 years (p < 0.001, Wilcoxon signed rank, Figure 2). The decline was by a median of -0.106 following ORIF and -0.204 after revision, and this difference was not significant (p = 0.500, Mann-Whitney U test) (Figure 3).
Fig. 2.
Patient-reported outcome measures before (recalled) and after (one to six years) periprosthetic femoral fracture. a) EuroQol five-dimension three-level questionnaire (EQ-5D-3L); b) Oxford Hip Score (OHS); and c) Lower Extremity Functional Scale (LEFS).
Fig. 3.
Change in patient-reported outcome measures from recalled pre-fracture levels to one to six years after periprosthetic femoral fracture for patients managed with open reduction and internal fixation (ORIF) or revision total hip arthroplasty (RTHA). EuroQol five-dimension three-level questionnaire (EQ-5D-3L); b) Oxford Hip Score (OHS); and c) Lower Extremity Functional Scale (LEFS).
Secondary outcome measures
Across the cohort, the median OHS prior to the PFF was 40.5 (IQR 27 to 47), and at a median follow-up of 4.0 years after operatively managed PFF was 33.0 (IQR 24 to 40). Following PFF, the OHS declined significantly from pre-fracture levels (p < 0.001, Wilcoxon signed rank): by a median of 3 points after fixation and 5 points after revision (Figure 2 and Figure 3). A decline in OHS after PFF exceeding the OHS MIC of 8 was experienced by 34.8% (31/89) of the cohort overall: 21/64 after ORIF and 10/24 after revision arthroplasty (p = 0.439, chi-squared). Prior to the PFF, the median LEFS was 58. This declined significantly following PFF (p < 0.001, Wilcoxon signed rank): by a median of -2.5 following ORIF and -8.0 after revision. No significant differences in PROMs were found between ORIF and revision THA across the entire cohort (Table II) or when limited to B2 fractures only (Table III).
Table II.
Patient-reported outcomes following fixation or revision of taper slip associated periprosthetic femoral fracture.
| Variable | ORIF (n = 65) | Revision (n = 24) | p-value |
|---|---|---|---|
| Pre-fracture | |||
| EQ-5D | 0.815 | 0.883 | 0.462* |
| OHS | 40.5 | 44 | 0.546* |
| LEFS | 56.5 | 68.0 | 0.598* |
| Follow-up | |||
| EQ-5D | 0.604 | 0.620 | 0.919* |
| OHS | 35.5 | 32 | 0.936* |
| LEFS | 44 | 48 | 0.908* |
| Change | |||
| EQ-5D | -0.106 | -0.204 | 0.500* |
| Mean OHS (SD) | -5.3 (11.7) | -6.04 (7.8) | 0.773† |
| LEFS | -2.5 | -8.0 | 0.145* |
| Satisfaction, n (%) | 0.083‡ | ||
| Very satisfied | 22 (34) | 9 (38) | |
| Satisfied | 19 (29) | 5 (21) | |
| Neither | 18 (28) | 3 (13) | |
| Dissatisfied | 4 (6) | 6 (26) | |
| Very dissatisfied | 1 (2) | 1 (4) |
Mann-Whitney U test.
Unpaired t-test.
Chi squared.
EQ-5D, EuroQol five-dimension questionnaire; LEFS, Lower Extremity Functional Scale; OHS, Oxford Hip Score; ORIF, open reduction and internal fixation.
Table III.
Patient characteristics and outcomes of those with B2 fractures involving Exeter femoral components only.
| Variable | ORIF (n = 31) | Revision (n = 12) | p-value |
|---|---|---|---|
| Mean age, yrs (SD) | 72.1 (9.3) | 68.3 (10.2) | 0.659* |
| Female sex, n (%) | 10 (32) | 5 (42) | 0.692† |
| SIMD, n (%) | 0.272† | ||
| 1 | 2 (6) | 4 (33) | |
| 2 | 8 (26) | 1 (8) | |
| 3 | 5 (16) | 2 (16) | |
| 4 | 5 (16) | 3 (25) | |
| 5 | 10 (32) | 3 (25) | |
| ASA grade, n (%) | 0.615† | ||
| 1 | 1 (3) | 1 (8) | |
| 2 | 17 (55) | 5 (42) | |
| 3 | 12 (39) | 6 (50) | |
| 4 | 1 (3) | 0 | |
| NHFS, n | 4 | 4 | 0.690* |
| CFS, n | 4 | 4 | 0.093* |
| Pre-fracture | |||
| EQ-5D | 0.883 | 0.883 | 0.914* |
| OHS | 41 | 44.5 | 0.764* |
| LEFS | 57 | 64.5 | 0.979* |
| Follow-up | |||
| EQ-5D | 0.691 | 0.620 | 0.767* |
| OHS | 35 | 31.5 | 0.907* |
| LEFS | 44 | 45 | 1.00 |
| Change | |||
| EQ-5D | -0.165 | -0.268 | 0.832* |
| OHS | -5 | -3 | 0.865‡ |
| LEFS | -3 | -7 | 0.328* |
| Reoperated, n | 8 | 1 | 0.173† |
Mann-Whitney U test.
Chi-squared test.
Unpaired t-test.
ASA, American Society of Anesthesiologists; CFS, Clinical Frailty Scale; EQ-5D, EuroQol five-dimension questionnaire; LEFS, Lower Extremity Functional Scale; NHFS, Nottingham Hip Fracture Scale; OHS, Oxford Hip Score; ORIF, open reduction and internal fixation; SIMD, Scottish Index of Multiple Deprivation.
Following operative management of PFF, 62% (55/89) of patients were satisfied or very satisfied with their outcome. There was no difference in satisfaction rates between those who underwent ORIF (41/65, 63%) and those who had undergone revision arthroplasty (14/24, 58%, p = 0.621, chi-squared). Following operative management of PFF, nine patients (10%) had negative EQ-5D scores termed ‘worse than death’. There was no significant difference between those managed with ORIF (6/65) compared with revision arthroplasty (3/24) (p = 0.703, Fisher’s exact test).
Discussion
Recent shifts in PFF management have questioned traditional practices, especially regarding the surgical management of UCS B2 and B3 fractures around Exeter PTS femoral components. This study has shown that patients experience significant declines in both HRQoL and hip specific function after sustaining a periprosthetic femoral fracture whether it is managed using fixation or revision THA, with less than two-thirds satisfied with their outcomes. Importantly, fixation was not associated with worse PROMs than revision THA, though bias may exist in patient selection with more complex fractures/patients undergoing revision arthroplasty. Even if this is the case, it is relevant that fixation was not associated with inferior PROMs that may reflect a failing construct in the absence of reoperation. In appropriately selected patients therefore, fixation of PFFs around Exeter PTS femoral components yields comparable PROMs to revision arthroplasty at one to six years, with no statistically or clinically significant differences in health-related quality of life, joint-specific function, or patient satisfaction postoperatively.
Patient-reported outcome measures are fundamental to measuring treatment success. The PROMs used were not developed specifically for us in PFF patients. However, EQ-5D is the recommended outcomes measure following hip fracture,24 LEFS for lower limb fracture,25 and OHS is the UK standard score for THA including revision THA. There is much debate around clinically important thresholds and differences and how these are used to investigate different treatment options. Where MID or MCID are used, these values should be specific to the patient population in question. However, there is no agreed-upon MID or MCID for PROMs as they apply to patients will PFFs. However, using thresholds for a THA population, a third of patients with PFF had a drop in OHS exceeding the MIC of 8 points,18 and the median decline in EQ-5D scores exceeded the MIC used in hip fracture and knee osteoarthritis populations.18,26,27 Overall, it appears that PFFs precipitate a reduction in both joint-specific function and HRQoL regardless of the surgical management. Despite this the population questioned in the study were overall satisfied with their outcome (62%).
To our knowledge, this study represents the greatest number of PROMs following PFF involving an Exeter PTS femoral component using a range of both joint-specific and HRQoL validated questionnaires with a minimum follow-up of 12 months. Quantifying and comparing PROMs for these treatment methods is important. For there are concerns within the clinical community that cases treated with ORIF may be unhappy with symptomatic loose femoral components, but may not be reoperated upon due to frailty or comorbidity, thus providing false reassurance in this technique. While numerous studies have documented the surgical outcomes of PFF around THA, these focus on variables such as the type of surgical intervention, fracture classification, cementless implants, and patient morbidity and mortality.5-8,28-31 PFF patients are often compared to the hip fracture population. It has been recognized that to evaluate patient outcomes following hip fracture, patients should be assessed on the following: mortality, pain, activities of daily living, mobility, and health-related quality of life (HRQL).32,33 This study design was built with this evidence in mind, in the hope of highlighting the impact of the PFF on the patient.
This study has limitations. It was performed from a single institution, with a modest sample size (n = 89) that could lead to type 2 errors. Some of the methods could introduce recall bias as pre-fracture status was self-reported, and the follow-up period (one to six years) may not capture longer-term complications of late femoral component subsidence. It focuses on a patient cohort who are elderly with comorbidities and a predictably high mortality rate post injury, and therefore survivorship bias limits responders to those with fewer comorbidities and less frailty. Excluding patients with cognitive impairment who cannot complete PROMs, and others medically unable to respond, may have biased outcomes towards more favourable results. Additionally, while validated PROMs were used, these may not fully capture the specific impacts of PFFs on quality of life and function. However, three separate validated questionnaires were selected with the hope to maximize patient perspective and to really understand the impact of PFF on the patient.
The evidence produced from this study further supports that ORIF is a safe treatment for the management of Exeter femoral component associated PFF. When compared to revision arthroplasty, ORIF is associated with lower reoperation rates, lower perioperative morbidity, good long-term construct survivorship6-8 with PROMs similar to revision arthroplasty.
In conclusion, Vancouver (UCS) B and C type postoperative PFFs around Exeter PTS femoral components lead to functional and quality-of-life decline irrespective of treatment. When fixation is well performed with anatomical reduction, patients managed with fixation achieve comparable PROMs to those managed with revision THA. This provides further evidence for the efficacy of fixation in this challenging patient group.
Take home message
- Periprosthetic femoral fractures around Exeter stems influence patient-reported outcome measures, regardless of the treatment.
Author contributions
M. F. R. Powell-Bowns: Conceptualization, Validation, Visualization, Writing – original draft
J. T. Super: Investigation, Validation, Visualization
D. H. Martin: Investigation, Validation, Visualization
K. Milne: Investigation, Validation, Visualization
N. D. Clement: Formal analysis, Writing – original draft, Writing – review & editing
C. E. H. Scott: Formal analysis, Writing – original draft, Writing – review & editing
Funding statement
The author(s) received no financial or material support for the research, authorship, and/or publication of this article.
ICMJE COI statement
C. E. H. Scott has an institutional grant and is paid for teaching courses from Stryker, consulting fees from Stryker, Smith & Nephew, and Osstec, is on the advisory board for Osstec and Smith & Nephew and on the data safety monitoring board for the PASHION study, and is the Editor-in-Chief for Bone & Joint Research. N. D. Clement is the chief investigator and grant holder for Stryker for studies unrelated to this manuscript, and is on the editorial board for The Bone & Joint Journal and Bone & Joint Research.
Data sharing
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
© 2026 Powell-Bowns et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Data Availability
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.