Clinicians › Hip

Periprosthetic fracture (hip)

105 citationsUpdated Sep 2026

Overview

Periprosthetic femoral fractures following total hip arthroplasty are complex, clinically challenging events accompanied by a perceptible decline in function and remarkably high complication rates [1, 5]. These injuries demonstrate similar mortality rates to native hip fractures but carry higher rates of major and minor complications [2]. Early periprosthetic femoral fracture represents a distinct clinical phenotype defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity [3]. Patients sustaining a fracture within 30 days of primary total hip arthroplasty face significantly greater complication risks than those fracturing at later time points [12]. The treatment of these fractures is associated with a high complication rate and a large number of re-operations [16]. Delaying surgery has a deleterious impact on mortality and other important patient outcomes [4]. By 20 years, nearly 12% of surviving patients will have experienced a post-operative periprosthetic fracture of the femur after revision total hip arthroplasty [7]. Periprosthetic fractures will continue to increase in prevalence and compromise successful surgery [48], representing a troublesome epidemic requiring a focus on avoidance, understanding existing data, and evolving surgical planning to deliver safe and effective surgery with a low risk of complications [67].

Most periprosthetic fractures following total hip arthroplasty are fragility fractures that qualify patients for osteoporosis diagnoses [6]. There remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment for these injuries [6]. The key to prevention is routine follow-up with radiographic studies [17]. The choice of treatment modality depends on fracture, implant, and bone characteristics [18]. Revision total hip arthroplasty for the treatment of a periprosthetic fracture around the stem of the femoral implant successfully restored function for most patients [8]. Hospital charges for periprosthetic fractures about total hip arthroplasty are increasing independently of consistent treatment trends [75].

Periprosthetic acetabular fractures are associated with a poor prognosis regarding the survival of the acetabular component, though it is possible to achieve union and salvage a functional prosthesis [46]. Periprosthetic fracture fixation can be performed as part of a standardised less invasive strategy, and the minimally invasive technique should be the preferred treatment for periprosthetic fracture fixation [47]. Avoiding the use of long-stem implants during periprosthetic fracture fixation can benefit young patients who may require further revisions in the future [68]. Locking plates offer a viable treatment option for periprosthetic femoral fractures around well-fixed hip and knee implants [70]. Endoprosthetic replacement of the femur is a reasonable salvage option for patients with periprosthetic fracture and bone loss, with good clinical results [76].

Anatomy & Pathophysiology

Bony Anatomy

The hemipelvis comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [81]. The acetabulum consists of an articular crescent-moon–shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [81]. The femoral head forms two-thirds of a sphere, featuring a small central depression from which the ligamentum teres extends to connect to the acetabular notch [81]. The femoral neck-shaft angle averages 125° [81], while normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [81]. At the junction of the neck and shaft, the greater and lesser trochanters are connected by the intertrochanteric line anteriorly and the intertrochanteric crest posteriorly [81]. The subtrochanteric portion of the femur contends with the highest compressive and tensile forces in the human skeleton [93].

The proximal femur contains two prime trabecular groups: the principal tensile group and the principal compressive group [87]. The weakest area in the femoral neck is located in the Ward triangle [87]. The calcar femorale, a medial area of dense trabecular bone, transfers stress from the femoral shaft to the inferior portion of the femoral neck [87]. In adults, the mean femoral neck-shaft angle is 130° ± 7° and the mean anteversion of the neck is 10° ± 7° [87].

Ligaments and Capsule

The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck [81]. The capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum [82]. The basicervical region of the femoral neck and the intertrochanteric region of the femur are not intracapsular [82].

Three main ligaments support the hip joint: * Iliofemoral ligament: The thickest and strongest ligament, it limits external rotation, while its lateral arm limits extension of the joint [81]. * Ischiofemoral ligament: Provides support posteriorly and restricts internal rotation motion [81]. * Pubofemoral ligament: Acts to limit abduction of the joint [81].

Deep fibers from the iliofemoral, ischiofemoral, and pubofemoral ligaments merge to form the zona orbicularis, which circumvents the femoral neck [81].

Vascular Anatomy

The medial femoral circumflex artery is the main blood supply to the femoral head [87]. In adulthood, the major blood supply to the femoral head is from the medial femoral circumflex and lateral epiphyseal arteries [90]. The lateral femoral circumflex artery gives rise to the anterior aspect of the extracapsular arterial ring [87]. The ascending cervical arteries originate from this ring and are divided into four distinct groups: lateral, medial, posterior, and anterior [87]. The lateral group of ascending branches constitutes the main blood supply to the femoral head [87]. Fractures that disrupt the ascending blood flow to the lateral epiphyseal vessel carry an increased risk of osteonecrosis [87]. The artery of the ligamentum teres does not provide sufficient blood supply to maintain the viability of the femoral head [87].

Muscular Anatomy and Biomechanics

The primary hip flexor muscles are the iliopsoas, rectus femoris, and sartorius muscles [85]. The gluteus maximus and hamstring muscles are the most important hip joint extensors [85]. The abductors of the hip are predominantly the gluteus medius and minimus muscles, which function together to maintain and abduct the femur during the stance phase of gait [85].

In subtrochanteric fractures, significant displacement of the proximal segment occurs secondary to the pull of the iliopsoas, gluteus medius, and short external rotators [93]. The unopposed pull of the adductors on the distal segment often leads to femoral shortening in these injuries [93].

Pathophysiology of Periprosthetic Fractures

Periprosthetic fracture (PFF) remains a serious complication of hip arthroplasty accompanied by high morbidity and mortality rates [23]. Most periprosthetic fractures are divided into those with a well-fixed prosthesis ('happy hips') and those with prosthetic loosening ('unhappy hips') [24]. Implant-related fractures following hip fracture surgery are more common than previously appreciated [25]. Intraoperative mechanical injury of the femoral neck or malpositioning of the femoral component may lead to changes in loading patterns, resulting in acute and chronic biomechanical femoral neck fractures [115].

Femoral Fracture Incidence and Risk Factors: * Incidence: The incidence of intraoperative periprosthetic femoral fracture is 0.1% to 5.4% in primary THA and 3.0% to 20.9% in revision THA [29]. * Causes: Trauma is the most commonly cited cause of periprosthetic fractures of the femur [29]. * Surgical Risks: Revision surgery carries a higher risk than primary THA [29]. Noncemented press-fit technique is a risk factor compared to cemented technique [29]. Impaction grafting technique is also a risk factor [29]. * Bone Quality: Compromised bone stock, such as osteolytic defect or osteoporosis, is a risk factor [29]. * Approach-Specific Risks: The risk of Vancouver B periprosthetic femoral fractures associated with the direct anterior approach to THA is increased in patients with unfavorable proximal femoral geometry, coronal stem malalignment, advanced age, increased comorbidities, and right-sided procedures [42]. * Protective Factors: Hip osteoarthritis, male sex, and age 41 to 50 years were protective factors against periprosthetic fractures in patients younger than 50 years [148]. Collared stems seemed to offer a protective effect in torsional loading in a biomechanical model comparing matched femora [157]. * Morphology: The morphology of the proximal femur and the pelvis do not differ in several radiological parameters in patients sustaining a PFF between cementless short stem and straight stem THA [141].

Acetabular Fracture Incidence and Risk Factors: * Incidence: The incidence of periprosthetic fracture of the acetabulum during primary total hip arthroplasty is 0.2% with cemented components and 0.4% with noncemented components [29]. * Intraoperative Risks: Intraoperative acetabular fractures typically occur during cup impaction, especially in older patients or those with poor bone quality [29]. Risk factors include noncemented acetabular components (press-fit) [29], underreaming by more than 2 mm [29], elliptical monoblock components [29], osteopenia or osteoporosis [29], Paget disease [29], and removal of acetabular components at revision [29]. * Postoperative Risks: Trauma and osteolysis are postoperative risk factors for periprosthetic acetabular fracture [29].

Preoperative identification of risk factors, in particular femur shape, is crucial and should be incorporated into the decision-making process for intraoperative periprosthetic fractures [151].

Classification

Vancouver Classification (Femoral)

The Vancouver classification is the current standard for assessing and reporting periprosthetic femoral shaft fractures about hip arthroplasty stems [57]. It remains the most widely used classification system in the orthopaedic community [118] and has been validated for use in the United States and Europe [111]. The system’s reliability and validity have been confirmed [57], although its reliability for cementless total hip arthroplasty is lower than previously described for cemented femoral stems [74]. The classification considers the location of the fracture relative to the stem, the stability of the implant, and associated bone loss [57]. It is most useful for directing communication about and treatment of periprosthetic femoral shaft fractures [57]. The system separates fracture patterns by location [71] and stratifies fractures about the stem by implant stability and available bone stock [71].

Type A fractures are located in the trochanteric region [57]. These are subdivided into fractures of the greater trochanter (AG) and fractures about the lesser trochanter (AL) [57]. Type B fractures involve the area of the stem [57] and occur about the distal tip of the stem [71]. Type B1 fractures are associated with a stable implant [57]. Type B2 fractures are associated with a loose implant [57]. Type B3 fractures are associated with bone loss and usually a loose implant [57]. Type C fractures are distal to the tip of the stem [57]. Vancouver type B fractures generally require surgical management [71]. Definitive classification of stem stability in Vancouver type B fractures is usually made intraoperatively [71]. The ability to distinguish a well-fixed from a loose implant may be difficult [57]; therefore, intraoperative testing of implant stability and preparation for dealing with a loose stem are prudent [57]. Most periprosthetic fractures can be divided into those with a well-fixed prosthesis and those with prosthetic loosening [24].

The original Vancouver classification was developed to describe postoperative fractures but has been expanded to address intraoperative periprosthetic femur fractures [57]. The intraoperative Vancouver classification divides fractures into three zones: type A (proximal metaphysis), type B (diaphyseal about the tip of the stem), and type C (distal to the stem) [57]. In this intraoperative system, subtype I represents a simple cortical perforation [57]. Subtype II is a nondisplaced linear cortical crack [57]. Subtype III is a displaced or otherwise unstable fracture [57].

The Vancouver classification is used to classify periprosthetic fractures in hemiarthroplasty patients [34], interprosthetic femoral fracture studies [58], osteosynthesis studies [45], finite element analysis studies [69], surgical treatment studies [64], revision arthroplasty studies [111], locking plate studies [119], delay-to-surgery studies [124], functional outcome studies [128], less invasive stabilisation system studies [140], surgical approach studies [143], mortality and complication studies [2], early fracture studies [3], revision total hip arthroplasty studies [8], treatment algorithm studies [23], mortality predictor studies [13], economic impact studies [22], implant fracture studies [30], loose femoral component studies [31], infected fracture studies [33], histology studies [36], interprosthetic fracture validation studies [52], greater trochanter fracture studies [53], Vancouver B2 treatment studies [55], interprosthetic fracture management studies [58], institutional experience studies [64], interprosthetic fracture classification studies [120], and failed osteosynthesis studies [123]. It is also used to sort periprosthetic femoral fractures in clinical datasets [58].

Paprosky Classification (Acetabular)

The Paprosky classification of periprosthetic fractures of the acetabulum associated with total hip arthroplasty is used to summarize recommendations based on fracture displacement and available bone stock [29]. It also summarizes recommendations based on implant stability, fracture displacement, and available bone stock [35]. The classification is used to address periprosthetic acetabular fractures based on implant stability [71] and to determine treatment for both intraoperative and postoperative fractures about the acetabular cup [71].

The Paprosky classification includes types for intraoperative fractures during implant insertion (A, B, C) [71]. Type IA is an acetabular wall fracture recognized intraoperatively that is nondisplaced and has a stable component [29]. Type IB is a fracture recognized intraoperatively that is displaced [29]. Type IC is a fracture not recognized intraoperatively [29]. The classification includes types for intraoperative fractures during implant removal (A, B) [71]. Type II is an intraoperative fracture secondary to acetabular implant removal [29].

The Paprosky classification includes types for traumatic fractures (A, B) [71]. Type III is a traumatic fracture [29]. Type IIIA is a traumatic fracture with a stable component [29]. Type IIIB is a traumatic fracture with an unstable component [29]. The classification includes types for spontaneous fractures (A, B) [71]. Type IV is a spontaneous fracture [29]. Type IVA is associated with a loss of less than 50% of acetabular bone stock [29]. Type IVB is associated with a loss of greater than 50% of acetabular bone stock [29].

The Paprosky classification includes types for pelvic discontinuity (A, B, C) [71]. Type V is pelvic discontinuity [29]. Type VA is associated with a loss of less than 50% of acetabular bone stock [29]. Type VB is associated with a loss of greater than 50% of acetabular bone stock [29]. Type VC is associated with prior pelvic radiation [29].

Other Classification Systems

The Unified Classification System proposes a rational approach to treatment regardless of the bone broken or joint involved [107]. It aims to improve understanding and consistency in reporting periprosthetic fractures [107] and is considered a suitable tool to aid in treatment fracture classification and treatment planning [128]. The Vancouver classification is used to classify periprosthetic fractures in the context of the Unified Classification System [128]. However, the Unified Classification System is unsatisfactory for the classification of periprosthetic femoral fractures around polished taper-slip stems [112]. It demonstrates considerably lower reliability and validity for polished taper-slip stems than previously described for other stem types [112].

A new classification system for interprosthetic femoral fractures showed adequate inter-observer reproducibility [52]. A proposed new classification system and treatment algorithm are potentially valuable tools for the treatment of interprosthetic femoral fracture [120]. An extended version of the Vancouver classification has been proposed to include periprosthetic fractures associated with endoprostheses anchored in the epiphysis or metaphysis, as well as interprosthetic fractures [109]. A modified classification scheme for periprosthetic fractures has been proposed as an alternative to published classifications for all joints with an arthroplasty [133]. A new classification system for isolated greater trochanter fractures associated with total hip arthroplasty has been proposed based on fracture location relative to insertional anatomy [53].

Clinical Presentation

Periprosthetic hip fractures present in elderly, comorbid patients and are associated with high mortality rates of up to 34.7% [19, 41]. These injuries carry higher rates of major and minor complications compared to native hip fractures [2] and place a significant burden on healthcare systems, particularly among females over 75 years [22]. The rising incidence of postoperative periprosthetic femoral fracture presents a significant clinical and economic burden [63]. Risk factors for perioperative Vancouver B periprosthetic femoral fractures include unfavorable proximal femoral geometry, coronal stem malalignment, advanced age, increased comorbidities, and right-sided procedures [42]. The periprosthetic fracture rate is greater than that related to cemented stems, necessitating consideration of morphological and clinical factors of bone weakness [27]. An increased incidence is anticipated in populations with significant co-morbidities [54].

Diagnostic Imaging and Workup

A minimum of two views (AP and lateral) are obtained to help identify the type and extent of periprosthetic femoral fractures [29]. For the acetabulum, postoperative fracture should be suspected if groin pain is present after trauma [29]. Plain radiographs may underestimate bone loss in periprosthetic acetabular fractures, and the fracture line may be obscured by metallic components [29]. Judet views (obturator and iliac oblique radiographs) may help identify an anterior or posterior column fracture in the acetabulum [29]. Bone scans may help identify late periprosthetic acetabular fractures not seen on plain radiographs, although they may show areas of increased uptake for 1 to 2 years postoperatively in the absence of fracture [29]. CT is seldom needed but may help visualize periprosthetic acetabular fractures not identified using other imaging methods [29].

Diagnostic Pitfalls and Comorbidities

The diagnostic utility of serum and synovial markers for diagnosing periprosthetic joint infection was lower in the setting of concomitant periprosthetic fracture compared to periprosthetic joint infection alone [56]. Periprosthetic fractures are a cause of false-positive histology results for the diagnosis of infection during revision of a hip prosthesis for the treatment of Vancouver B2 periprosthetic fractures [36]. Infected periprosthetic fractures remain rare but involve severe complications [33]. Atypical periprosthetic femoral fractures after hip arthroplasty are not rare with the wide use of bisphosphonates [37]. There remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment for osteoporosis among patients with periprosthetic fractures after total hip arthroplasty [6].

Prognosis and Complexity

Periprosthetic femoral fractures remain a serious complication of hip arthroplasty accompanied by high morbidity and mortality rates [23]. Periprosthetic acetabular fractures are a rare, but challenging complication of total hip arthroplasty with high complication rates [44]. In elderly patients, the surgical procedure for periprosthetic femoral fractures may be particularly complicated due to poor bone quality and higher prevalence of medical comorbidities [59]. Periprosthetic femoral fractures after hip arthroplasty are a severe complication and their treatment is a difficult challenge [59]. These fractures are difficult to treat and require a complex treatment approach according to risk assessment, fracture type, implant stability, bone stock and medical status of the patient [64].

Investigations

Plain radiography: Conventional radiographs remain critical in the initial imaging evaluation of the hip and can be used to diagnose fractures [50]. A complete hip series usually consists of an anterior-posterior (AP) pelvis, a centered AP hip, a lateral view (frog-leg, cross-table, Dunn 45° or 90°), and a false-profile (Lequesne) view [50]. Plain radiographs will identify the fracture in the majority of cases, with anteroposterior (AP) and lateral radiographs required [102]. Radiographs can serially assess hardware positioning and evaluate symptomatic hardware related to total hip arthroplasty [50]. An algorithmic approach to identifying loose stems around proximal femoral periprosthetic fractures takes patient history, stem design, and plain radiographs into consideration [178].

CT: CT scanning is helpful in fracture evaluation, particularly in the setting of negative radiographs or for further defining fracture morphology in patients requiring surgical reduction [83]. CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for use in surgical planning [95]. In cases where there is a suspected fracture but normal or equivocal plain radiographs, CT scanning is a more accurate investigation than technetium bone scan but exposes the patient to further radiation [102].

MRI: MRI is the modality of choice for patients suspected of soft tissue or intra-articular pathology, given its superior sensitivity and specificity [95]. Conventional MRI is effective at identifying osteochondral injuries, musculotendinous pathologies, and inflammation [95]. An MRI scan will demonstrate soft tissue problems that may be causing hip pain in the absence of a fracture [102]. Studies comparing CT and MRI for occult hip fractures have come out in favor of MRI scanning, which is more accurate in detecting occult hip fractures [102]. MRI is the current additional imaging modality recommended where there is uncertainty about the presence of an intracapsular fracture [102]. Magnetic resonance arthrography (MRA) is more appropriate than conventional MRI to determine injuries to the labrochondral structures and the ligamentum teres and to identify the presence of loose bodies and synovial chondromatosis [95]. In the accurate detection and staging of articular cartilage lesions, the utility of MRA is reduced, with sensitivity reported to be less than 50% compared with arthroscopic findings [95].

Ultrasonography: Ultrasonography can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions, such as bursitis [95]. Ultrasonography is also being increasingly used for targeted injections into muscles, tendons, or intra-articularly around the hip [95].

Other Considerations: Positron emission tomography/computed tomography (PET/CT) at 6 weeks could detect recovery of vascularity and could predict the risk of vascular necrosis [102]. Dynamic MRI–positive enhancement integral color mapping (PEICM) may be a useful addition in identifying a subgroup of patients at higher risk of complications if fixation is being considered [102].

Treatment

General Principles and Timing

Delaying surgery for periprosthetic fractures of the hip has a deleterious impact on mortality and other important patient outcomes [4]. The primary goal of contemporary surgical treatment is to allow for immediate, full weight bearing [35]. Because morbidity and mortality rates rival those of patients with hip fracture, early mobilization via early surgical intervention is prioritized [35]. Periprosthetic fractures sustained after the surgical treatment of extra capsular neck of femur fractures carry higher mortality rates than hip fractures themselves [154].

Classification and Decision Making

Definitive classification of stem stability in Vancouver type B fractures is usually made intraoperatively, requiring provisions for both fixation and implant revision [71]. Consensus surrounding the management of Vancouver B1 periprosthetic femoral fractures is lacking, with a perceived need for a large prospective randomized controlled trial to define optimal management [173]. The orthopaedic community should adopt a common language and limited fundamental treatment principles for periprosthetic fractures to avoid confusion and improve teaching, practice, and outcome measurement [61].

Non-Operative

A review of management strategies for periprosthetic fractures in the United Kingdom found that 23% of such injuries were managed without surgery [139]. Certain patients may be managed conservatively if their pre-morbid functional status makes postoperative mobilization unlikely or if medical comorbidities or frailty puts them at an excessive risk of mortality [139]. Vancouver AG and AL fractures that are minimally displaced and not associated with instability may be managed conservatively with a period of limited weight-bearing and bracing [139]. Conservative treatment is feasible for cases of type B1 minimally displaced periprosthetic fractures [174] and may be considered as an alternative option for type B2 minimally displaced periprosthetic fractures [174]. Furthermore, conservative treatment is recommended as an alternative option in failed periprosthetic fracture fixation to preserve the biology around the fracture site instead of difficult and potentially traumatic revision surgery [160].

Operative

Indications: Surgery is indicated when conservative management is not feasible due to instability, displacement, or patient factors allowing for mobilization. For Vancouver type AG fractures, symptomatic treatment or open reduction and internal fixation (ORIF) with a claw plate is used to treat pain, weakness, or instability [57].

Surgical Approach / Technique: Periprosthetic fracture fixation can be performed as part of a standardised less invasive strategy, with the minimally invasive technique being the preferred treatment [47]. For Vancouver type B1 fractures, a lateral plate is applied with biologic fracture reduction techniques [57]. Intraoperative Vancouver type A1 and A2 fractures are treated with protected weight bearing or bone graft/cerclage cables [57]. Intraoperative Vancouver type B1 fractures are treated with a cortical strut with or without conversion to a long stem [57]. Intraoperative Vancouver type B2 and B3 fractures are treated with a lateral plate with conversion to a long stem if the implant is unstable [57].

Implant Selection: The availability of polyaxial locking implants widened the range of indications for plate fixation in femoral fractures [116]. The internal fixator was effective for the stabilisation of periprosthetic fractures, even in cases of poor bone quality, with good functional outcomes [144]. The modular design of plating systems may offer enhanced versatility and favorable early outcomes for fixation of periprosthetic femoral fractures around the hip [77]. Fixation components may be combined according to their individual advantages to achieve an optimal periprosthetic fracture fixation [129]. For Vancouver type C fractures, a distal femoral locking plate extending proximal to overlap the femoral stem is the preferred treatment option [57]. For Vancouver type B2 fractures, an uncemented revision long stem with or without a lateral plate is the preferred treatment option [57]. For Vancouver type B3 fractures, a long stem revision with allograft with or without a lateral plate or revision to a tumor prosthesis is the preferred treatment option [57]. The use of non–HA-coated, distally locked long femoral stems in combination with strict adherence to the principles of infection management can facilitate the management of infected periprosthetic fractures [150].

Acetabular Fractures: Addressing periprosthetic acetabular fractures depends mainly on implant stability, which is determined by fracture displacement and available bone stock [35]. Stable, minimally displaced acetabular fractures can usually be managed nonsurgically [35], whereas unstable components with displaced fractures require surgical intervention [35]. For unstable, intraoperative acetabular fractures, upsizing to a larger cup may provide a stable construct [71]. If cup stability is questionable even with screw fixation, an additional posterior column buttress should be provided via a reconstruction plate [71]. For periprosthetic fractures with an obviously loose cup, a thorough CT assessment should be performed to determine the amount of associated bone loss and location of fracture lines [71]. The surgeon should have a low threshold for revision to a jumbo cup and for the use of a cage construct to help re-create a stable acetabular side [71]. Periprosthetic acetabular fractures are associated with a poor prognosis regarding the survival of the acetabular component, but it is possible to achieve union and salvage a functional prosthesis [46].

Other Considerations: Most periprosthetic fractures following total hip arthroplasty are fragility fractures that qualify patients for osteoporosis diagnoses, yet there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment [6]. Patients receiving prophylactic bisphosphonate treatment appear to experience a similar rate of periprosthetic fractures as those receiving only calcium supplements [73]. However, osteoporosis treatment is associated with lower incidence of periprosthetic fractures following hip arthroplasty for femoral neck fractures [152]. It is ok to restart bisphosphonates 1 week postoperatively [121].

Complications

Periprosthetic fracture: Early periprosthetic femoral fracture following total hip arthroplasty is defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity [3]. Patients sustaining a fracture within 30 days of primary total hip arthroplasty face significantly greater complication risks than those fracturing at later time points [12]. These fractures are a severe complication associated with several serious post-operative issues [59]. In elderly patients, poor bone quality and higher prevalence of medical comorbidities complicate surgical procedures and worsen prognosis [59]. Periprosthetic acetabular fractures represent a rare but challenging complication with high complication rates [44].

Mortality: Delaying surgery in patients with periprosthetic fractures of the hip has a deleterious impact on mortality and other important patient outcomes [4]. Periprosthetic fractures generally carry a high risk of post-operative mortality [60].

Other Considerations: Periprosthetic lower extremity fractures place an unusual and significant burden on healthcare systems [22]. The rising incidence of postoperative periprosthetic femoral fracture presents a significant clinical and economic burden [63].

Recovery

Other Considerations: The epidemiological profile of periprosthetic fractures indicates a rising burden on healthcare systems. An increasing number of periprosthetic fractures were observed during the investigated period in the United States [28], and these injuries are anticipated to impose a substantial health-care burden in the coming decades [196]. Conversely, a nationwide analysis of lower extremity periprosthetic fractures found that the annual incidence remained relatively stable throughout the study period [62]. Specifically, a decade after primary total hip replacement, periprosthetic fractures occur annually in 26 per 10,000 persons [65]. These fractures are especially frequent in patients with prior total knee or revision total hip replacements [65]. Patients with a history of acetabular fractures undergoing acute, subacute, or delayed total hip arthroplasty have significantly increased rates of revision, periprosthetic fracture, and dislocation compared to primary total hip arthroplasty in those without a history of acetabular fractures [66].

Functional milestones: The short-term survivorship of conversion hip arthroplasty after surgical treatment of an intertrochanteric fracture is excellent regardless of the original fracture fixation method [72].

Rehabilitation protocol: Salvage procedures for periprosthetic femoral fractures with severe bone loss are challenging and depend on the severity of bone loss, patient age, activity level, and surgeon experience [194].

Other Considerations: Despite consistent treatment trends of periprosthetic fractures about total hip arthroplasty, hospital charges are increasing independently [75]. The early periprosthetic femoral fracture rate in a series of direct anterior primary total hip arthroplasty may warrant consideration of using a different design or different approach in elderly female patients [193].

Key Evidence

• [L4] Periprosthetic femoral fractures following total hip arthroplasty are accompanied by a perceptible decline in function and remarkably high complication rates. [1] (10.1007/s00264-015-2673-2)
• [L3] Periprosthetic hip fractures demonstrate similar mortality rates but higher rates of major and minor complications compared to native hip fractures. [2] (10.1016/j.arth.2018.01.046)
• [L5] Early periprosthetic femoral fracture after total hip arthroplasty is not simply the same fracture occurring sooner but represents a distinct clinical phenotype defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity. [3] (10.2106/jbjs.26.00128)
• [L1] 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. [4] (10.1007/s00402-020-03739-2)
• [L4] Periprosthetic femoral fractures after total hip arthroplasty are a complex and clinically challenging issue. [5] (10.1007/s00264-015-2979-0)
• [L3] Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. [6] (10.1016/j.arth.2024.06.002)
• [L3] By 20 years, nearly 12% of surviving patients will have experienced a post-operative periprosthetic fracture of the femur after revision THA. [7] (10.1302/0301-620x.98b4.37203)
• [L4] Revision total hip arthroplasty for the treatment of a periprosthetic fracture around the stem of the femoral implant successfully restored function for most patients. [8] (10.2106/00004623-200311000-00015)
• [L4] Periprosthetic fractures are difficult to manage and may have serious complications. [10] (10.1016/j.injury.2009.07.023)
• [L3] Patients who sustained early periprosthetic femoral fracture within 30 days following primary total hip arthroplasty were found to be at significantly greater risk for complications when compared with patients who sustained a fracture at later time points. [12] (10.2106/jbjs.25.01355)
• [L3] [13] (10.1016/j.injury.2018.10.032)
• [L3] The treatment of periprosthetic femoral fractures has a high complication rate and a large number of re-operations occur. [16] (10.1016/j.injury.2010.01.102)
• [L4] Recent evidence from large registries has shown that the key to prevention of periprosthetic femur fractures is routine follow-up with radiographic studies. [17] (10.1016/j.injury.2007.02.049)
• [L1] The choice of treatment modality for periprosthetic femoral fractures depends on fracture, implant, and bone characteristics. [18] (10.1007/s00402-020-03332-7)
• [L3] Periprosthetic femoral fractures affect elderly, comorbid patients and are associated with high mortality. [19] (10.1186/s13018-025-06446-z)
• [L3] Periprosthetic lower extremity fractures place an unusual and significant burden on healthcare systems, with patients at highest risk being females over 75 years. [22] (10.1016/j.arth.2022.03.012)
• [L4] PFF remains a serious complication of hip arthroplasty that is accompanied by high morbidity and mortality rates. [23] (10.1016/j.injury.2019.01.044)
• [L4] Most periprosthetic fractures can be divided into those with a well-fixed prosthesis ('happy hips') and those with prosthetic loosening ('unhappy hips'). [24] (10.1016/j.injury.2007.02.053)
• [L3] Implant-related fractures following hip fracture surgery are more common than has previously been appreciated. [25] (10.2106/00004623-200207000-00004)
• [L4] The periprosthetic fracture rate was greater than that related to cemented stems, requiring that morphological and clinical factors of bone weakness be taken into account. [27] (10.1016/j.otsr.2016.05.013)
• [L3] An increasing number of periprosthetic fractures were observed during the investigated period. [28] (10.1097/corr.0000000000002825)
• [L1] Implant fractures in total hip arthroplasty occur in a relevant number of patients. [30] (10.1007/s00264-013-2110-3)
• [L4] Surgeons must have a sound understanding of the diagnosis and treatment of periprosthetic femoral fractures. [31] (10.5435/jaaos-22-08-482)
• [L4] Infected periprosthetic fractures remain rare but involve severe complications. [33] (10.1530/eor-2025-0278)
• [Paper] [34] (10.1016/j.injury.2013.07.023)
• [L4] Periprosthetic fractures are a cause of false-positive histology results for the diagnosis of infection during revision of a hip prosthesis for the treatment of Vancouver B2 periprosthetic fractures. [36] (10.1016/j.arth.2012.12.016)
• [L3] Atypical periprosthetic femoral fractures after hip arthroplasty are not rare with the wide use of bisphosphonates. [37] (10.1016/j.injury.2018.09.014)
• [L3] Periprosthetic fractures are associated with a high mortality risk (34.7%). [41] (10.1007/s00402-018-3084-9)
• [L3] The risk is increased in patients with unfavorable proximal femoral geometry, coronal stem malalignment, advanced age, increased comorbidities, and right-sided procedures. [42] (10.1016/j.arth.2019.12.009)
• [L4] Periprosthetic acetabular fractures are a rare, but challenging complication of THA with high complication rates. [44] (10.1016/j.arth.2026.03.058)
• [L4] This study provided added validation of the current management of periprosthetic femoral fractures after total hip arthroplasty. [45] (10.1186/s42836-021-00089-1)
• [L4] Periprosthetic acetabular fractures are associated with a poor prognosis regarding the survival of the acetabular component, but it is possible to achieve union and salvage a functional prosthesis in patients who have sustained such a fracture. [46] (10.2106/00004623-199608000-00011)
• [L4] Periprosthetic fracture fixation can be performed as part of a standardised less invasive strategy, but the minimally invasive technique should be the preferred treatment. [47] (10.1016/j.injury.2012.10.035)
• [L5] Periprosthetic fractures will continue to increase in prevalence and compromise successful surgery, requiring concerted efforts to capture the totality of fractures in registries and optimize care pathways. [48] (10.1302/0301-620x.102b5.bjj-2020-0427)
• [L4] The new classification system for interprosthetic femoral fractures showed adequate inter-observer reproducibility. [52] (10.1016/j.injury.2017.04.008)
• [L5] This review outlines management strategies for isolated greater trochanter fractures associated with total hip arthroplasty, proposing a new classification system based on fracture location relative to insertional anatomy to inform treatment recommendations for intraoperative, postoperative, primary, and revision settings. [53] (10.5435/jaaos-d-23-00560)
• [Paper] Increased incidence of periprosthetic femoral fractures is anticipated in a population with significant co-morbidities. [54] (10.1016/j.injury.2014.08.034)
• [L5] All Vancouver type B2 and B3 femoral fractures mandate a revision arthroplasty. [55] (10.1007/s00264-015-2959-4)
• [L3] The diagnostic utility of serum and synovial markers for diagnosing periprosthetic joint infection was lower in the setting of concomitant periprosthetic fracture compared to PJI alone. [56] (10.1016/j.arth.2020.08.029)
• [L4] [58] (10.1016/j.injury.2010.08.020)
• [L4] [59] (10.1016/j.injury.2014.07.013)
• [L3] Periprosthetic fractures carry a high risk of post-operative mortality. [60] (10.1302/0301-620x.99b7.bjj-2016-0974.r1)
• [L5] The author argues that the orthopaedic community should adopt a common language and limited fundamental treatment principles for periprosthetic fractures to avoid confusion and improve teaching, practice, and outcome measurement. [61] (10.1302/0301-620x.96b6.34041)
• [L3] The annual incidence of periprosthetic fractures remained relatively stable throughout the study period. [62] (10.1016/j.arth.2020.07.050)
• [L5] The rising incidence of postoperative periprosthetic femoral fracture presents a significant clinical and economic burden requiring a detailed understanding of risk factors to guide preventative strategies. [63] (10.1302/2058-5241.5.200003)
• [Paper] Periprosthetic femoral fractures are difficult to treat and require a complex treatment approach according to risk assessment, fracture type, implant stability, bone stock and medical status of the patient. [64] (10.1016/j.injury.2015.06.017)
• [L3] A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements. [65] (10.1186/1471-2474-15-168)
• [L3] Patients who had a history of acetabular fractures undergoing acute, subacute, or delayed total hip arthroplasty have significantly increased rates of revision, periprosthetic fracture, and dislocation compared to primary total hip arthroplasty in those who did not have a history of acetabular fractures. [66] (10.1016/j.arth.2024.04.046)
• [L5] Periprosthetic fractures represent a troublesome epidemic requiring a focus on avoidance, understanding existing data, and evolving surgical planning and component choice to deliver safe and effective surgery with a low risk of complications. [67] (10.1302/0301-620x.98b4.38069)
• [L1] Avoiding the use of long-stem implants during periprosthetic fracture fixation can benefit young patients who may require further revisions in the future. [68] (10.1186/s12891-025-09052-6)
• [Paper] [69] (10.1016/j.injury.2012.01.015)
• [L4] Locking plates offer a viable treatment option for periprosthetic femoral fractures around well-fixed hip and knee implants. [70] (10.1016/j.arth.2010.07.002)
• [L3] The short-term survivorship of conversion hip arthroplasty after surgical treatment of an IT fracture is excellent regardless of original fracture fixation method. [72] (10.1016/j.arth.2017.06.032)
• [L1] Patients receiving prophylactic bisphosphonate treatment appear to experience a similar rate of periprosthetic fractures as those receiving only calcium supplements. [73] (10.1016/j.arth.2024.10.067)
• [L3] The reliability of the Vancouver classification for cementless total hip arthroplasty is lower than previously described in cemented femoral stems. [74] (10.1016/j.arth.2019.02.062)
• [L3] Despite consistent treatment trends of periprosthetic fractures about total hip arthroplasty, hospital charges are increasing independently. [75] (10.1016/j.arth.2016.01.062)
• [L4] Endoprosthetic replacement of the femur is a reasonable salvage option for patients with periprosthetic fracture and bone loss, with good clinical results. [76] (10.1016/j.injury.2012.03.024)
• [L4] The modular design may offer enhanced versatility and favorable early outcomes for fixation of periprosthetic femoral fractures around the hip. [77] (10.1016/j.arth.2026.05.059)
• [L5] The Unified Classification System proposes a rational approach to treatment regardless of the bone broken or joint involved, aiming to improve understanding and consistency in reporting periprosthetic fractures. [107] (10.1302/0301-620x.96b6.34040)
• [L4] The review proposes an extended version of the Vancouver classification to include periprosthetic fractures associated with endoprostheses anchored in the epiphysis or metaphysis, as well as interprosthetic fractures, to guide fracture-specific treatment concepts. [109] (10.1007/s00402-005-0828-0)
• [L4] [111] (10.1302/0301-620x.97b8.34431)
• [L4] The Unified Classification System (UCS) is unsatisfactory for the classification of periprosthetic femoral fractures around polished taper-slip stems, demonstrating considerably lower reliability and validity than previously described for other stem types. [112] (10.1302/0301-620x.103b8.bjj-2021-0021.r1)
• [L4] Intraoperative mechanical injury of the femoral neck or malpositioning of the femoral component may lead to changes in loading patterns resulting in acute and chronic biomechanical femoral neck fractures. [115] (10.2106/jbjs.h.01113)
• [L4] The availability of polyaxial locking implants widened the range of indications for plate fixation in femoral fractures. [116] (10.1016/j.otsr.2012.05.014)
• [L5] The Vancouver Classification System (VCS) remains the most widely used classification system in the orthopaedic community and is likely to continue as the dominant method in the 21st century. [118] (10.2106/jbjs.26.00115)
• [Paper] [119] (10.1016/j.injury.2019.10.029)
• [L4] The new classification proposal and treatment algorithm are potentially valuable tools for the treatment of interprosthetic femoral fracture. [120] (10.1016/s0020-1383(14)70012-9)
• [L4] The technique described for stem revision provides reproducibly good results in the treatment of failed osteosynthesis for Vancouver types B1 periprosthetic fractures of the hip. [123] (10.1302/0301-620x.99b4.bjj-2016-1201.r1)
• [L3] [124] (10.1016/j.injury.2015.11.013)
• [L4] [128] (10.1016/j.injury.2020.06.017)
• [L5] Fixation components may be combined according to their individual advantages to achieve an optimal periprosthetic fracture fixation. [129] (10.1016/j.clinbiomech.2013.09.005)
• [L4] [133] (10.1007/s00264-015-2967-4)
• [L4] [139] (10.1530/eor-2024-0205)
• [L4] This series suggests that the management of periprosthetic femoral fractures with the LIS-System results in a good mid-term functional outcome. [140] (10.1016/j.injury.2007.10.034)
• [L3] The morphology of the proximal femur and the pelvis do not differ in several radiological parameters in patients sustaining a PFF between cementless short stem and straight stem THA. [141] (10.1186/s13018-025-05502-y)
• [L5] The annotation describes approaches to the femur that can be used to facilitate the surgical management of peri- and interprosthetic fractures of the femur at all levels using either modern methods of fixation or revision arthroplasty. [143] (10.1302/0301-620x.105b6.bjj-2022-1202.r1)
• [L4] The internal fixator was effective for the stabilisation of periprosthetic fractures, even in cases of poor bone quality, with good functional outcomes. [144] (10.1007/s00402-005-0075-4)
• [L3] Hip osteoarthritis, male sex, and age 41 to 50 years were protective factors against periprosthetic fractures. [148] (10.1016/j.arth.2025.08.069)
• [L4] The use of non–HA-coated, distally locked long femoral stems in combination with strict adherence to the principles of infection management can facilitate the management of infected periprosthetic fractures. [150] (10.1016/j.arth.2010.11.021)
• [L3] The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process. [151] (10.1186/s13018-019-1494-1)
• [L3] The present study suggests that osteoporosis treatment is associated with lower incidence of periprosthetic fractures following hip arthroplasty for femoral neck fractures. [152] (10.1016/j.arth.2022.10.042)
• [L4] Periprosthetic fractures sustained after the surgical treatment of extra capsular neck of femur fractures have higher mortality rates than hip fractures themselves. [154] (10.1016/j.injury.2018.01.001)
• [L5] Collared stems seemed to offer a protective effect in torsional loading in this biomechanical model comparing matched femora. [157] (10.2106/jbjs.19.01125)
• [L4] The authors recommend conservative treatment as an alternative option in failed periprosthetic fracture fixation with preservation of the biology around the fracture site instead of difficult and potentially traumatic revision surgery. [160] (10.1007/s00402-015-2210-1)
• [L4] Consensus surrounding the management of Vancouver B1 periprosthetic femoral fractures is lacking, and there is a perceived need among orthopaedic surgeons for a large prospective randomized controlled trial in order to define the optimal management of these injuries. [173] (10.1016/j.injury.2017.10.034)
• [L4] Conservative treatment is feasible for the cases of type B1 minimally displaced periprosthetic fractures, and it may also be considered as an alternative option for type B2 minimally displaced periprosthetic fractures. [174] (10.1016/j.arth.2017.05.057)
• [L5] The article presents an algorithmic approach to identifying loose stems around proximal femoral periprosthetic fractures, taking patient history, stem design, and plain radiographs into consideration. [178] (10.1302/2058-5241.5.190086)
• [L3] The early periprosthetic femoral fracture rate in our series may warrant consideration of using a different design or different approach in elderly female patients. [193] (10.1016/j.arth.2016.03.007)
• [Paper] Salvage procedures for periprosthetic femoral fractures with severe bone loss are challenging and depend on the severity of bone loss, patient age, activity level, and surgeon experience. [194] (10.1016/j.injury.2007.02.047)
• [L3] Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. [196] (10.2106/jbjs.23.00868)

See Also

• Hip osteoarthritis
• Total hip replacement
• Intertrochanteric fracture

References

[1] Adequate surgical treatment of periprosthetic femoral fractures following hip arthroplasty does not correlate with functional outcome and quality of life. International Orthopaedics. 2015. DOI: 10.1007/s00264-015-2673-2

[2] Do Mortality and Complication Rates Differ Between Periprosthetic and Native Hip Fractures?. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.01.046

[3] Early Periprosthetic Femoral Fracture After Total Hip Arthroplasty Is Not a Complication; It Is a Crisis. Journal of Bone and Joint Surgery. 2026. DOI: 10.2106/jbjs.26.00128

[4] Does early surgery improve outcomes for periprosthetic fractures of the hip and knee? A systematic review and meta-analysis. Archives of Orthopaedic and Trauma Surgery. 2021. DOI: 10.1007/s00402-020-03739-2

[5] Management of periprosthetic femoral fractures following total hip arthroplasty: a review. International Orthopaedics. 2015. DOI: 10.1007/s00264-015-2979-0

[6] Systemic Osteoporosis and Osteopenia Among Periprosthetic Fractures After Total Hip Arthroplasty. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.06.002

[7] Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b4.37203

[8] TREATMENT OF PERIPROSTHETIC FEMORAL FRACTURES FOLLOWING TOTAL HIP ARTHROPLASTY WITH FEMORAL COMPONENT REVISION. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200311000-00015

[10] Periprosthetic femoral fracture after total hip arthroplasty: Our clinical experience. Injury. 2009. DOI: 10.1016/j.injury.2009.07.023

[12] Alarmingly High Rates of Complications and Refracture Among Patients with Early Periprosthetic Femoral Fracture Within 30 Days After THA. Journal of Bone and Joint Surgery. 2026. DOI: 10.2106/jbjs.25.01355

[13] Outcomes and predictors of mortality following periprosthethic proximal femoral fractures. Injury. 2019. DOI: 10.1016/j.injury.2018.10.032

[16] High incidence of complications and poor clinical outcome in the operative treatment of periprosthetic femoral fractures: An analysis of 71 cases. Injury. 2010. DOI: 10.1016/j.injury.2010.01.102

[17] Risk factors for periprosthetic femoral fracture. Injury. 2007. DOI: 10.1016/j.injury.2007.02.049

[18] Fracture fixation versus revision arthroplasty in Vancouver type B2 and B3 periprosthetic femoral fractures: a systematic review. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03332-7

[19] Impact of periprosthetic femoral fractures on frailty, mobility and outcomes in hip arthroplasty. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06446-z

[22] The Economic Impact of Lower Extremity Periprosthetic Fractures in a Large Hospital System. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.03.012

[23] Periprosthetic femoral fractures after total hip arthroplasty: An algorithm of treatment. Injury. 2019. DOI: 10.1016/j.injury.2019.01.044

[24] Classification of femoral periprosthetic fractures. Injury. 2007. DOI: 10.1016/j.injury.2007.02.053

[25] Implant-Related Fractures of the Femur Following Hip Fracture Surgery. The Journal of Bone & Joint Surgery. 2002. DOI: 10.2106/00004623-200207000-00004

[27] Periprosthetic fracture in the elderly with anatomic modular cementless hemiarthroplasty. Orthopaedics & Traumatology: Surgery & Research. 2016. DOI: 10.1016/j.otsr.2016.05.013

[28] What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002825

[29] Aaos Comprehensive Orthopaedic Review 3. Periprosthetic Fractures Associated With Total Hip and Knee Arthroplasty > I. Total Hip Arthroplasty.

[30] The incidence of implant fractures after total hip arthroplasty. International Orthopaedics. 2013. DOI: 10.1007/s00264-013-2110-3

[31] Periprosthetic Fractures Around Loose Femoral Components. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-08-482

[33] Management of infected periprosthetic fracture of hip and knee: a systematic review of the literature. EFORT Open Reviews. 2026. DOI: 10.1530/eor-2025-0278

[34] Incidence of periprosthetic fractures after hip hemiarthroplasty: Are uncemented prostheses unsafe?. Injury. 2013. DOI: 10.1016/j.injury.2013.07.023

[35] Chapter 51 Periprosthetic Fractures. 2021.

[36] Usefulness of Histology for Predicting Infection at the Time of Hip Revision for the Treatment of Vancouver B2 Periprosthetic Fractures. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.12.016

[37] Frequency and associated factor of atypical periprosthetic femoral fracture after hip arthroplasty. Injury. 2018. DOI: 10.1016/j.injury.2018.09.014

[41] Evaluating risk factors following surgery for periprosthetic fractures around hip and knee arthroplasties. Archives of Orthopaedic and Trauma Surgery. 2018. DOI: 10.1007/s00402-018-3084-9

[42] Predictors of Perioperative Vancouver B Periprosthetic Femoral Fractures Associated With the Direct Anterior Approach to Total Hip Arthroplasty. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2019.12.009

[44] Periprosthetic Fractures of the Acetabulum: A Rare, but Serious Complication of Total Hip Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.058

[45] Osteosynthesis and outcomes of traumatic periprosthetic femoral fractures after total hip arthroplasty. Arthroplasty. 2021. DOI: 10.1186/s42836-021-00089-1

[46] Periprosthetic Fracture of the Acetabulum after Total Hip Arthroplasty. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199608000-00011

[47] Less invasive polyaxial locking plate fixation in periprosthetic and peri-implant fractures of the femur—A prospective study of 41 patients. Injury. 2013. DOI: 10.1016/j.injury.2012.10.035

[48] Periprosthetic fractures: more challenges ahead. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b5.bjj-2020-0427

[50] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Radiography.

[52] Validation of a new classification system for interprosthetic femoral fractures. Injury. 2017. DOI: 10.1016/j.injury.2017.04.008

[53] Management of Isolated Greater Trochanter Fractures Associated With Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00560

[54] A Retrospective Review of the Dall-Miles Plate for Periprosthetic Femoral Fractures: Twenty-seven Cases and a Review of the Literature. Injury. 2014. DOI: 10.1016/j.injury.2014.08.034

[55] Treatment of Vancouver type B2 periprosthetic femoral fractures. International Orthopaedics. 2015. DOI: 10.1007/s00264-015-2959-4

[56] Concomitant Hip and Knee Periprosthetic Joint Infection in Periprosthetic Fracture: Diagnostic Utility of Serum and Synovial Fluid Markers. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.08.029

[57] Rockwood And Green S Fractures In Adults. Mechanisms of Injury for Distal Femur Fractures > Periprosthetic Femur Fractures About Hip Arthroplasty Prostheses > Classification of Periprosthetic Femur Fractures About Hip Arthroplasty Prostheses.

[58] Management and outcome of interprosthetic femoral fractures. Injury. 2011. DOI: 10.1016/j.injury.2010.08.020

[59] Functional and radiological outcome of periprosthetic femoral fractures after hip arthroplasty. Injury. 2015. DOI: 10.1016/j.injury.2014.07.013

[60] Cardiac disease and advanced age increase the mortality risk following surgery for periprosthetic femoral fractures. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b7.bjj-2016-0974.r1

[61] Periprosthetic fractures associated with joint replacement. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b6.34041

[62] Nationwide Analysis of Lower Extremity Periprosthetic Fractures. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.07.050

[63] Postoperative periprosthetic femoral fracture around total hip replacements: current concepts and clinical outcomes. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.200003

[64] Surgical treatment of periprosthetic femoral fractures following hip arthroplasty: Our institutional experience. Injury. 2015. DOI: 10.1016/j.injury.2015.06.017

[65] Prevalence and risk factors for periprosthetic fracture in older recipients of total hip replacement: a cohort study. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-168

[66] Acute Total Hip Arthroplasty Following Acetabular Fracture is Associated With a High Risk of Revision, Dislocation, and Periprosthetic Fracture. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.04.046

[67] Periprosthetic femoral fractures. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b4.38069

[68] Effectiveness of open reduction internal fixation versus revision arthroplasty around Vancouver type B2 periprosthetic femoral fractures: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09052-6

[69] Finite element analysis of different repair methods of Vancouver B1 periprosthetic fractures after total hip arthroplasty. Injury. 2012. DOI: 10.1016/j.injury.2012.01.015

[70] Locking Compression Plates for the Treatment of Periprosthetic Femoral Fractures Around Well-Fixed Total Hip and Knee Implants. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.07.002

[71] Orthopaedic Knowledge Update Trauma. Periprosthetic Fractures > Lower Extremity Periprosthetic Fractures > Hip Arthroplasty.

[72] Hip Arthroplasty After Surgical Treatment of Intertrochanteric Hip Fractures. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.06.032

[73] Should Patients Who Have Periprosthetic Fractures Around the Hip or Knee Be Screened and Treated for Osteoporosis?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.067

[74] Reliability and Validity of the Vancouver Classification in Periprosthetic Fractures Around Cementless Femoral Stems. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.02.062

[75] Frequency and Treatment Trends for Periprosthetic Fractures About Total Hip Arthroplasty in the United States. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.01.062

[76] Femoral replacement for salvage of periprosthetic fracture around a total hip replacement. Injury. 2012. DOI: 10.1016/j.injury.2012.03.024

[77] Results of a Novel Modular Plating System for Periprosthetic Fractures Around the Hip: A Multi-Center Experience. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.05.059

[81] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Osseous and Ligamentous Anatomy.

[82] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > IV. Hip Capsule and Ligaments.

[83] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Introduction.

[85] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > V. Hip Joint Muscles.

[87] Aaos Comprehensive Orthopaedic Review 3. Fractures of the Hip > I. General Considerations.

[90] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > VI. Neurovascular Structures Surrounding the Hip.

[93] Rockwood And Green S Fractures In Adults. 51: Hip Dislocations and Femoral Head Fractures > Pathoanatomy and Applied Anatomy Relating to Subtrochanteric Femur Fractures.

[95] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Imaging.

[102] Rockwood And Green S Fractures In Adults. 51: Hip Dislocations and Femoral Head Fractures > Imaging and Other Diagnostic Studies for Femoral Neck Fractures.

[107] The Unified Classification System (UCS): improving our understanding of periprosthetic fractures. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b6.34040

[109] Periprosthetic fractures of the femur associated with hip arthroplasty. Archives of Orthopaedic and Trauma Surgery. 2005. DOI: 10.1007/s00402-005-0828-0

[111] Revision arthroplasty for periprosthetic femoral fracture using an uncemented modular tapered conical stem. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b8.34431

[112] Reliability and validity of the Unified Classification System for postoperative periprosthetic femoral fractures around cemented polished taper-slip stems. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b8.bjj-2021-0021.r1

[115] Morphologic Analysis of Periprosthetic Fractures After Hip Resurfacing Arthroplasty. The Journal of Bone & Joint Surgery. 2010. DOI: 10.2106/jbjs.h.01113

[116] NCB-plating in the treatment of geriatric and periprosthetic femoral fractures. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2012.05.014

[118] Periprosthetic Femoral Fractures in 2026: Reaffirming the Vancouver Classification While Confronting Its Limits. Journal of Bone and Joint Surgery. 2026. DOI: 10.2106/jbjs.26.00115

[119] Lower reoperation rate with locking plates compared with conventional plates in Vancouver type C periprosthetic femoral fractures: A register study of 639 cases in Sweden. Injury. 2019. DOI: 10.1016/j.injury.2019.10.029

[120] Interprosthetic femoral fractures: proposed new classification system and treatment algorithm. Injury. 2014. DOI: 10.1016/s0020-1383(14)70012-9

[121] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > GERIATRIC HIP FRACTURES.

[123] Hip revision arthroplasty for failed osteosynthesis in periprosthetic Vancouver type B1 fractures using a cementless, modular, tapered revision stem. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b4.bjj-2016-1201.r1

[124] The effect of delay to surgery on morbidity, mortality and length of stay following periprosthetic fracture around the hip. Injury. 2016. DOI: 10.1016/j.injury.2015.11.013

[128] Functional outcome after lower limb periprosthetic fractures. Injury. 2021. DOI: 10.1016/j.injury.2020.06.017

[129] Mechanical behavior of fixation components for periprosthetic fracture surgery. Clinical Biomechanics. 2013. DOI: 10.1016/j.clinbiomech.2013.09.005

[133] Periprosthetic femoral fractures—incidence, classification problems and the proposal of a modified classification scheme. International Orthopaedics. 2015. DOI: 10.1007/s00264-015-2967-4

[139] Management of periprosthetic fractures around cemented femoral stems: osteosynthesis and revision strategies. EFORT Open Reviews. 2026. DOI: 10.1530/eor-2024-0205

[140] Less invasive stabilisation system (LISS) for the treatment of periprosthetic femoral fractures: A 3-year follow-up. Injury. 2008. DOI: 10.1016/j.injury.2007.10.034

[141] Periprosthetic femoral fractures in minimally-invasive anterolateral short stem versus transgluteal straight stem cementless total hip arthroplasty: What are the differences in the femoral and pelvic morphology?. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05502-y

[143] Surgical approaches to periprosthetic femoral fractures for plate fixation or revision arthroplasty. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b6.bjj-2022-1202.r1

[144] Stabilisation of periprosthetic fractures with angular stable internal fixation: a report of 13 cases. Archives of Orthopaedic and Trauma Surgery. 2005. DOI: 10.1007/s00402-005-0075-4

[148] Risk Factors for Periprosthetic Fractures Following Total Hip Arthroplasty in Patients Younger Than 50 Years. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.069

[150] The Use of Interlocking Prostheses for Both Temporary and Definitive Management of Infected Periprosthetic Femoral Fractures. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.11.021

[151] Risk analysis and clinical outcomes of intraoperative periprosthetic fractures: a retrospective study of 481 bipolar hemiarthroplasties. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1494-1

[152] The Association of Postoperative Osteoporosis Therapy With Periprosthetic Fracture Risk in Patients Undergoing Arthroplasty for Femoral Neck Fractures. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2022.10.042

[154] Mortality in patients sustaining a periprosthetic fracture following a previous extracapsular hip fracture fixation. Injury. 2018. DOI: 10.1016/j.injury.2018.01.001

[157] A Calcar Collar Is Protective Against Early Torsional/Spiral Periprosthetic Femoral Fracture. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01125

[160] Conservative treatment after failure of internal fixation for periprosthetic femoral fractures: a report of two cases. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-015-2210-1

[173] An international, cross-sectional survey of the management of Vancouver type B1 periprosthetic femoral fractures around total hip arthroplasties. Injury. 2018. DOI: 10.1016/j.injury.2017.10.034

[174] Conservative Treatment for Minimally Displaced Type B Periprosthetic Femoral Fractures. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.05.057

[178] Periprosthetic fractures of the proximal femur: beyond the Vancouver classification. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.190086

[193] Risk of Periprosthetic Fractures With Direct Anterior Primary Total Hip Arthroplasty. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.03.007

[194] Salvage procedures and implant selection for periprosthetic femoral fractures. Injury. 2007. DOI: 10.1016/j.injury.2007.02.047

[196] Fixation or Revision for Periprosthetic Fractures. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00868