This narrative review covers the classification, causes, and management of periprosthetic femoral fractures around total hip arthroplasty. It synthesizes registry data, case series, and biomechanical studies to provide a treatment algorithm organized around the Vancouver classification. The central question is how to match surgical strategy to implant stability and bone stock.
Periprosthetic femoral fractures are the third most common reason for revision THA, and the instinct to simply plate the fracture has a documented 34% failure rate when stem stability is not confirmed first.
When you see a fracture at the femoral stem tip, do not rely on radiographs alone to call the stem stable. Open the hip, perform an intraoperative stability test, and be prepared to revise. Missing a loose stem and plating over it is the single most preventable cause of failure in this population.
For confirmed loose-stem fractures (B2/B3), plan for uncemented extensively porous-coated long-stem revision as the primary strategy. Add cortical strut grafts liberally — they restore bone stock, add mechanical stability, and achieve reliable union. Cement-in-cement revision is a reasonable option in elderly patients with a well-fixed cement mantle when prolonged operative time is undesirable.
Do not discharge these patients without addressing osteoporosis. One-year mortality after periprosthetic fracture reaches 9–10%, and 70% of fractures occur around a loose stem. Routine THA follow-up with early identification of osteolysis is likely more cost-effective than treating the acute fracture.
This narrative review covers the classification, causes, and management of periprosthetic femoral fractures around total hip arthroplasty. It synthesizes registry data, case series, and biomechanical studies to provide a treatment algorithm organized around the Vancouver classification. The central question is how to match surgical strategy to implant stability and bone stock.
Periprosthetic femoral fractures are the third most common reason for revision THA, and the instinct to simply plate the fracture has a documented 34% failure rate when stem stability is not confirmed first.
When you see a fracture at the femoral stem tip, do not rely on radiographs alone to call the stem stable. Open the hip, perform an intraoperative stability test, and be prepared to revise. Missing a loose stem and plating over it is the single most preventable cause of failure in this population.
For confirmed loose-stem fractures (B2/B3), plan for uncemented extensively porous-coated long-stem revision as the primary strategy. Add cortical strut grafts liberally — they restore bone stock, add mechanical stability, and achieve reliable union. Cement-in-cement revision is a reasonable option in elderly patients with a well-fixed cement mantle when prolonged operative time is undesirable.
Do not discharge these patients without addressing osteoporosis. One-year mortality after periprosthetic fracture reaches 9–10%, and 70% of fractures occur around a loose stem. Routine THA follow-up with early identification of osteolysis is likely more cost-effective than treating the acute fracture.