Periprosthetic Hip Fractures

Periprosthetic Hip Fractures

Prepared by Dr. Savas CAMUR

Vancouver B2 fractures—those with a loose stem but adequate bone stock—remain the most debated subtype in terms of optimal management, with recent meta-analyses redefining treatment algorithms.Periprosthetic femoral fractures (PPF) represent one of the most challenging complications after total hip arthroplasty (THA). Their incidence is rising sharply worldwide, driven by increasing THA volumes, aging populations, and poor bone health, particularly osteoporosis.

Periprosthetic Hip Fractures 

Epidemiology & Trends

• Incidence: PPFs occur in 0.1–3.5% of all THAs and are among the leading causes of revision surgerys
• Rising burden: U.S. data (2010–2019) demonstrate a +7% annual growth in 2-year PPF incidence, nearly doubling since 2010
• At-risk populations:
  Age < 50 years
  Osteoporosis
  Vitamin D deficiency
  Medicaid recipients
  These findings emphasize socioeconomic disparities and bone-quality-related vulnerability.

Pathophysiology & Biomechanics

Osteoporosis contributes directly to the pathogenesis of PPFs by altering both bone mineral density (BMD) and microarchitecture:

• Trabecular perforation and cortical thinning reduce load transfer capacity.
• Weakened osseointegration diminishes stem anchorage, increasing micromotion and loosening.
• This fragile biomechanical environment sets the stage for PPF even under low-energy trauma or routine postoperative stress.Animal and human models confirm that osteoporotic bone shows reduced periprosthetic bone formation and inferior implant fixation.

Risk Factors

CategorySpecific FactorsPatientOlder age, female sex, low BMI, vitamin D deficiency, chronic corticosteroid use, smoking, alcohol, rheumatoid arthritisImplant/BoneOsteoporotic bone, cementless stems (especially in Dorr C femurs), poor osseointegrationSurgicalUndersized stem, eccentric reaming, improper alignment, absence of cement in poor bone qualitySystemicChronic kidney disease, endocrine disorders (thyroid/parathyroid), malnutrition

Classification

The Vancouver Classification remains the standard:

• Type B1: Stable stem
• Type B2: Loose stem, adequate bone stock
• Type B3: Loose stem, poor bone stock

The Unified Classification System (UCS) expands this to periprosthetic fractures beyond the femur.

Treatment Options

1. Osteosynthesis (ORIF)

• Indications: Low-demand, frail patients (ASA ≥ 3), multiple comorbidities, acceptable bone stock.
• Advantages:
  Shorter operative time (≈120 min vs 173 min for revision)
  Lower blood transfusion rate (44% vs 53%)
  Fewer complications and reoperations
  Similar 1-year mortality (~13%)s00198-025-07583-1
• Techniques:
  Locking plate ± cables or cerclage
  Biological fixation with bridging constructs
  Avoid excessive stripping of periosteum
  Goal: achieve relative stability rather than perfect anatomic reduction

2. Revision Arthroplasty

• Indications: Younger, active patients; poor implant stability; severe osteolysis or bone loss.
• Approach:
  Long, diaphyseal-engaging revision stem (cementless or cemented)
  Extended trochanteric osteotomy if necessary
  Address offset, version, and limb length
• Drawbacks: Longer surgery, higher bleeding and infection risk, increased dislocation rates

3. Role of Cemented Fixation

• Hybrid THA (cemented stem + press-fit cup) yields significantly lower PPF rates in osteoporotic patients (hazard ratio 7.7 for uncemented vs cemented stems)
• Cemented constructs are particularly advantageous in elderly (> 65 years) and Dorr C femurs.

Clinical Decision Pearls

• Always confirm stem stability intraoperatively before deciding against revision.
• In osteoporotic bone, avoid under-reaming; consider cemented fixation.
• ORIF is viable for low-demand elderly or comorbid patients with adequate bone stock.
• Preoperative bone health optimization (vitamin D, calcium, bisphosphonates, denosumab) can reduce postoperative PPF risk.
• Functional outcomes (Parker Mobility, Harris Hip Score) show no significant difference between ORIF and revision.

Future Directions

• Pre-THA bone health screening using DXA or FRAX is underutilized and should be standardized.
• Augmented reality navigation and AI-assisted risk scoring may improve preoperative planning.
• Novel biologic bone enhancers (anabolic agents, PTH analogs, sclerostin inhibitors) show promise in reducing fragility-related complications.
• Registry-based big data analysis will continue refining patient-specific algorithms for PPF management.

Decision-Making Flowchart: Management of Vancouver B2 Periprosthetic Hip Fractures

Step 1: Confirm Diagnosis

• Imaging: X-ray + CT (for stem stability, bone stock, osteolysis)
• Exclude infection: ESR, CRP, joint aspiration
  → If infection positive → Two-stage revision (exclude from this algorithm)

Step 2: Assess Stem Stability

• Stable stem → → Vancouver B1 → Fixation (ORIF)
• Loose stem → → Vancouver B2 → Proceed below

Step 3: Evaluate Patient Factors

💡 Rule of thumb:

“Fix frail, revise fit.”
If patient unlikely to tolerate prolonged surgery or blood loss → choose osteosynthesis.

Step 4: Evaluate Bone and Implant Conditions

Step 5: Select Surgical Strategy 

If ORIF selected:

• Use locking plate ± cerclage; avoid excessive stripping.
• Achieve relative stability → biological fixation concept.
• Allow partial weight bearing at 6–8 weeks.
• Post-op early geriatric rehab essential.

If Revision selected:

• Long diaphyseal-engaging stem (cementless or cemented)
• Consider Extended Trochanteric Osteotomy (ETO) if necessary.
• Restore offset, limb length, and version.
• Consider dual-mobility or constrained liner for instability risk.

Step 6: Postoperative Protocol

• ORIF group: Gradual weight bearing; follow radiographs every 6–8 weeks.
• Revision group: Early protected mobilization; DVT prophylaxis mandatory.
• All patients: Evaluate bone health (vitamin D, calcium, antiresorptives).

Step 7: Expected Outcomes

References:

1. González-Martín D et al. Eur J Trauma Emerg Surg. 2023.
2. .Zhao A Y et al. Osteoporosis Int. 2025;36:1371–77s00198-025-07583-1
3. .Bauer J et al. Curr Osteoporos Rep. 2025;23:29s11914-025-00922-5
4. Stoffel K et al. Arch Orthop Trauma Surg. 2020.
5. Lewis DP et al. J Orthop Trauma. 2021.