Periprosthetic Femoral Fractures After Hip Replacement

Definition

  • Fracture of the femur around or below a hip replacement stem
  • Occurs during surgery or later, mostly after a low energy fall

Epidemiology

  • 0.1 to 2.1% after total hip replacement, and rising
  • Vancouver B fractures are the most common
  • Risk factors. Uncemented stems, older age, female sex, osteoporosis, revision surgery, loosening and osteolysis

Classification

Vancouver classification (Duncan and Masri, 1995)

TypeDescription
AGGreater trochanter
ALLesser trochanter
B1Around or just below the stem, stem well fixed
B2Around the stem, stem loose, good bone stock
B3Around the stem, stem loose, poor bone stock
CWell below the stem tip
  • The Unified Classification System (Duncan and Haddad, 2014) applies the same principles to any bone and joint

Investigations

  • AP and lateral radiographs of the whole femur, compared with earlier films
  • Signs of a loose stem. Subsidence, cement mantle fracture and progressive radiolucent lines
  • CT when stem stability is unclear
  • Infection markers when loosening predates the fall
  • Test stem stability at surgery, as a loose stem missed on radiographs leads to failed fixation

Management

  • AG minimally displaced. Protected weight bearing
  • AG displaced with abductor weakness or instability. Fixation with a claw plate or cables
  • AL. Non-operative unless calcar loss destabilises the stem
  • B1. Locking plate and cables spanning the stem
  • B2. Revision to a long, distally fixed stem with fixation of the fragments
  • B2 around a polished taper cemented stem with an intact bone cement interface. Fixation is an option in frail patients
  • B3. Proximal femoral replacement in older patients, allograft prosthesis composite in younger patients
  • C. Fixation independent of the stem, overlapping it to avoid a stress riser

Prognosis

  • Tapered fluted modular stems for B2 and B3 fractures had 96% survival at a mean of 54 months
  • B2 around polished taper stems. Fixation had lower 2-year reoperation than revision (OR 0.28), with no difference in 5-year implant survival or 1-year mortality
  • Complications. Nonunion, fixation failure, dislocation, infection and refracture

References

  1. Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect. 1995, 44, 293-304. PubMed
  2. Duncan CP, Haddad FS. The Unified Classification System (UCS). Improving our understanding of periprosthetic fractures. Bone Joint J. 2014, 96-B(6), 713-6. PubMed
  3. Bulatović N, Kezunović M, Vučetić Č, Abdić N, Benčić I, Čengić T. Treatment of periprosthetic femoral fractures after total hip arthroplasty Vancouver type B. Acta Clin Croat. 2017, 56(3), 536-543. PubMed
  4. Munro JT, Masri BA, Garbuz DS, Duncan CP. Tapered fluted modular titanium stems in the management of Vancouver B2 and B3 peri-prosthetic fractures. Bone Joint J. 2013, 95-B(11 Suppl A), 17-20. PubMed
  5. Choudhary Z, Singal S, Selim A, Ibrahim A, Nam RHK, Rafi AB, Govilkar S, Thomas G. Fixation vs. revision of Vancouver B2 periprosthetic fractures around polished tapered cemented femoral stems. A meta-analysis of outcomes. JBJS Rev. 2025, 13(12). PubMed
  6. González-Martín D, Hernández-Castillejo LE, Herrera-Pérez M, Pais-Brito JL, González-Casamayor S, Garrido-Miguel M. Osteosynthesis versus revision arthroplasty in Vancouver B2 periprosthetic hip fractures. A systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2023, 49(1), 87-106. PubMed

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 15 October 2026.