Periprosthetic Femoral Fracture — Vancouver Classification & Management

The problem. A periprosthetic femoral fracture around a hip stem is a fracture in bone that already carries an implant, so the operation must respect BOTH the broken bone AND the stem that sits in it. The Vancouver classification (Duncan and Masri) is the universally adopted framework precisely because it is treatment-directing: it combines three factors — the site of the fracture, the stability of the stem, and the quality of the bone stock — and each combination maps to a defined operation. The whole game is one question. Once a fracture is localised to the stem-tip region (Type B), the only thing that matters is whether the stem is well-fixed (B1) or loose (B2/B3) — because that single distinction decides whether you plate the bone and leave the stem, or revise the stem. Everything below serves that decision. Assessing stem stability — the crux. Interrogate stability BEFORE you choose an implant: - History: pre-injury thigh pain or start-up pain is the classic clue to a pre-existing loose stem — it can reclassify an apparent B1 to a B2.

• Radiographs: full-length femur films (AP and lateral) including the joint above (hip) and below (knee). Signs of loosening are subsidence/migration, complete radiolucent lines at the bone-cement or bone-implant interface, cement-mantle fracture, debonding, pedestal formation and varus tilt. Compare with the immediate post-operative film for migration.
• Intra-operative test: when stability is still uncertain after history and imaging, expose and test the stem directly. If it is loose, convert to a revision (B2/B3). Plating a stem that is in fact loose is the principal avoidable error.

Pre-operative preparation (all types). - Work-up: full-length femur radiographs (hip and knee included); CT if intra-articular extension, bone-loss assessment or stem-tip detail is needed. Identify the implant (stem make and taper, cemented vs uncemented, head size) and obtain the previous operation note if revision is possible.

• Exclude infection: a periprosthetic fracture can be the presentation of an infected loose stem — check CRP/ESR and aspirate if indicated before any reconstruction.
• Medical optimisation: orthogeriatric review, anticoagulation management, group-and-save/crossmatch (revision can be high-blood-loss), anaesthetic assessment. Aim for early surgery on a planned list with the right implants and revision trays available. The frailty lens. Because mortality approaches that of a native hip fracture, the construct should ideally permit early weight-bearing. A megaprosthesis or a stable long-stem revision allows this; a tenuous plate fixation in poor bone that demands prolonged restricted weight-bearing is often the wrong answer in a frail patient even when it is technically possible.

The goal: classify the fracture, expose the femur through an approach that gives controlled access to the canal, confirm stem stability on the table, then execute the operation dictated by the Vancouver type — ORIF around a well-fixed stem, or revision with a stem that bypasses the fracture. The exposure is the heart of the case and is laid out as the first operative steps below.

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Rehabilitation — the goal is early, safe weight-bearing. Prolonged non-weight-bearing is poorly tolerated and dangerous in the elderly, so the construct should ideally allow it: - Revision to a stable long stem and a proximal/distal femoral replacement generally permit early or immediate weight-bearing.

• ORIF weight-bearing depends on fracture pattern, bone quality and construct strength — progress under radiographic guidance. A tenuous fixation in poor bone is a reason to reconsider the strategy, not to impose long restriction. Multidisciplinary pathway. - Orthogeriatric co-management throughout admission; VTE prophylaxis; delirium prevention; nutrition and bone-health optimisation (treat the underlying osteoporosis).
• Physiotherapy from day 1; occupational therapy and discharge planning early.
• Follow-up: serial radiographs to confirm union/stability and exclude implant migration or inter-implant refracture; monitor for late infection and instability after revision. A periprosthetic fragility fracture is a sentinel event — refer to a bone-health clinic and address falls prevention, because many of these patients fall again.

Epidemiology. Periprosthetic femoral fracture is a recognised and growing problem, driven by increasing arthroplasty volume and an ageing population (Lindahl, Swedish registry-based epidemiology). National joint registries (NJR UK, AOANJRR Australia, AJRR US, Swedish/Nordic registries) document a rising absolute number of these fractures, and periprosthetic fracture is now a recognised and growing indication for revision. Registry data also informs implant- and fixation-related fracture risk — for example, some collarless polished tapered cemented stems are associated with a recognised periprosthetic fracture pattern. The Vancouver classification in full (Duncan and Masri). Its strength is that it is comprehensive yet treatment-directing, with good inter- and intra-observer reliability and validity.

Type A — trochanteric. AG = greater trochanter, AL = lesser trochanter. Usually low-energy, frequently associated with osteolysis from polyethylene wear particles that weakens the bone. Most are stable and managed non-operatively with protected weight-bearing. Fix a displaced AG fragment that destabilises the abductor mechanism (tension-band wiring, claw/hook plate, cables); a significant AL avulsion may be a marker of underlying osteolysis and impending stem compromise — investigate the stem. Type B — the decisive zone (around or just distal to the stem tip). Once a fracture is localised here, the only question that matters is whether the stem is well-fixed. B1 = well-fixed (fracture problem, fix it and keep the stem). B2 = loose with good bone (implant failure, revise). B3 = loose with deficient bone (reconstruct or replace). Type C — well distal to the stem tip. Treated as an ordinary distal/diaphyseal femoral fracture; the stem's fixation status is irrelevant to the fracture itself, but the construct must overlap the plate proximally with the stem to avoid an unsupported inter-implant segment. Outcomes. Well-classified and well-executed B1 ORIF and B2/B3 revisions achieve high union and stability rates; the major determinant of failure is misclassification (plating a loose stem) and inadequate constructs (short plates, inter-implant gaps). Cortical strut allografts incorporate over time and can augment fixation in poor bone. Periprosthetic distal femur (around a TKA) — brief account. - Classification: Su (based on level relative to the femoral component) and Lewis-Rorabeck (incorporates displacement and component fixation).

• Retrograde intramedullary nail: suitable when the femoral component has an open box that admits the nail and the component is well-fixed; gives load-sharing fixation.
• Distal femoral locking plate: versatile, especially for very distal fractures or a closed-box component; biological/bridging application.
• Distal femoral replacement: for a loose femoral component, very distal/comminuted unreconstructable fractures, or the frail elderly needing immediate weight-bearing.
• Beware the inter-implant zone: if a hip stem is also present (or a long plate is used), avoid leaving an unsupported segment between the two implants.