Periprosthetic Fractures Around Total Hip Arthroplasty

High Yield Overview

THA PERIPROSTHETIC FRACTURES

Post-Arthroplasty Femoral Fracture | Vancouver Classification | Revision Arthroplasty

0.4-1.1%10-year incidence

7.2%of all revisions

91%Union rate (B1)

10%1-year mortality

Vancouver Classification

Type A

PatternTrochanteric (AG greater, AL lesser)

TreatmentConservative vs ORIF

Type B

PatternAround stem (B1 stable, B2/B3 loose)

TreatmentB1 ORIF vs B2/B3 Revision

Type C

PatternWell below stem

TreatmentDistal femoral ORIF

Critical Must-Knows

Stem stability assessment is THE critical decision driver
B1 = Stable Stem → ORIF (Preserve stem)
B2/B3 = Loose Stem → Revision Arthroplasty
Obtain full-length femur radiographs (MANDATORY)
Always screen for infection (ESR/CRP) preoperatively

Examiner's Pearls

"
Most common error: Attempting ORIF on a loose stem (guaranteed failure)
"
Intraoperative fracture: STOP, assess, and stabilize immediately
"
Risk factors: Elderly female, osteoporosis, uncemented stems
"
Don't forget the acetabulum (associated loosening or fractures)

Clinical Imaging

Imaging Gallery

2-panel Vancouver B periprosthetic fracture with revision: (left) pre-op AP showing spiral fracture around cemented femoral stem, (right) post-op with long modular revision stem extending beyond fract — 2-panel Vancouver B periprosthetic fracture with revision: (left) pre-op AP showing spiral fracture around cemented femoral stem, (right) post-op withCredit: Cankaya D et al. - J Orthop Case Rep via Open-i (NIH) - PMC4845399 (CC-BY 4.0)

2-panel (A-B) Vancouver B1 periprosthetic fracture treated with ORIF: (A) pre-op AP showing oblique periprosthetic fracture with well-fixed stem, (B) post-op with lateral locking plate and multiple ce — 2-panel (A-B) Vancouver B1 periprosthetic fracture treated with ORIF: (A) pre-op AP showing oblique periprosthetic fracture with well-fixed stem, (B) Credit: Open-i/NIH via Open-i (NIH) - PMC4972891 (CC-BY 4.0)

Single AP pelvis X-ray showing Vancouver Type C periprosthetic fracture - fracture located well below the tip of the femoral stem, not involving the prosthesis. — Single AP pelvis X-ray showing Vancouver Type C periprosthetic fracture - fracture located well below the tip of the femoral stem, not involving the pCredit: Niikura T et al. - J Med Case Rep via Open-i (NIH) - PMC4427957 (CC-BY 4.0)

Vancouver B periprosthetic fracture around THA with revision stem fixation — Two-panel radiograph demonstrating Vancouver B periprosthetic fracture management. Left: Pre-operative view showing displaced fracture around the femoral stem with visible displacement. Right: Post-operative view after revision to a long cemented/uncemented stem with cerclage cables - the stem bypasses the fracture site providing stable fixation while cables maintain reduction during healing.Credit: PMC - CC BY 4.0

Critical Exam Points

Stem Stability

The Single Most Important Assessment. Differentiating B1 (stable) from B2 (loose) dictates treatment. Getting this wrong is an automatic fail.

Infection Screen

Mandatory Pre-op Check. Always rule out septic loosening presenting as fracture. Missed infection leads to catastrophic failure of fixation.

Imaging Protocol

Full-Length Femur Views. Essential to see distal extent of fracture and plan bypass fixation length (2 cortical diameters).

Risk Factors

Prevention is Key. Recognize high-risk patients (osteoporotic females, revision cases) and use prophylactic cables or gentle technique.

Quick Decision Guide

Scenario	Classification	Stem Status	Treatment
Trochanteric fracture, stable hip	Vancouver A	Stable	Conservative (unless displaced/unstable)
Fracture around stem, stem WELL FIXED	Vancouver B1	Stable	ORIF (Plate + Cables)
Fracture around stem, stem LOOSE, good bone	Vancouver B2	Loose	Revision THA (Long Uncemented Stem)
Fracture around stem, stem LOOSE, POOR bone	Vancouver B3	Loose	Revision (Impaction Graft or Megaprosthesis)
Fracture well below stem tip	Vancouver C	Stable	ORIF (Distal Femur Plate)

Mnemonic

IMPLANTAssessing Stem Stability (B1 vs B2/B3)

Interface

Lucent lines greater than 2mm suggest loosening

Movement

Pain with weight bearing suggests loosening

Position

Subsidence or migration on serial films

Lysis

Periprosthetic osteolysis around stem

Alignment

Change in stem version or varus/valgus tilt

New bone

Pedestal formation at stem tip (sign of loosening)

Testing

Intraoperative direct assessment if uncertain

Memory Hook:Check the IMPLANT before you plan your fixation strategy.

Overview and Epidemiology

Rising Burden

AOANJRR 2023 Report: Periprosthetic fracture is the 4th most common reason for THA revision. Incidence is increasing with the aging Australian population and high volume of primary THAs.

Intraoperative Risk Factors

Technical Factors:

Revision surgery (4-7% risk)
Uncemented stem insertion (press-fit)
Undersized canal preparation
Excessive impaction force

Patient Factors:

Rheumatoid arthritis
Severe osteoporosis
Anterior femoral cortical defects

Postoperative Risk Factors

Implant-Related:

Aseptic loosening with osteolysis
Stress shielding (cortical thinning)
Retained cement mantle

Patient-Related:

Age over 70 years
Female sex (2.5x higher risk)
Frequent falls

Epidemiology of Periprosthetic Fractures

Abdel et al. • JBJS 2016

Key Findings:

Overall incidence: 0.93% at mean 6.2 years
Vancouver B fractures most common (70%)
Female sex independent risk factor (OR 2.1)
Uncemented stems higher risk than cemented in elderly (greater than 70)
Most fractures (60%) occur greater than 5 years post-THA

Clinical Implication: Consider cemented stems in osteoporotic elderly females. Long-term surveillance for late fractures is essential.

Anatomy and Biomechanics

Stress Shielding

Pathophysiology: Rigid metallic stems transfer load distally, bypassing the proximal femur. This leads to adaptive bone resorption (Wolff's Law), causing cortical thinning and osteopenia in the proximal femur, significantly increasing fracture risk from minor trauma.

Bone Quality

Osteolysis: Wear debris induces cytokine-mediated bone loss
Cortical Thinning: less than 4mm cortex increases fracture risk exponentially
Bone Density: Osteopenia common in THA population

Danger Zones

Anterior Cortex: At femoral bow apex (common perforation site)
Proximal Lateral Cortex: Aggressive broaching risk
Calcar: Varus stem malposition

Classification Systems

Vancouver Classification

Duncan & Masri (1995) - The universal Gold Standard based on: Location, Stability, and Bone Stock.

Type	Location	Stem Status	Bone Stock	Management
AG	Greater Trochanter	Stable	Variable	Conservative vs ORIF
AL	Lesser Trochanter	Stable	Variable	Conservative
B1	Around Stem	STABLE	Good	ORIF (preserve stem)
B2	Around Stem	LOOSE	Good	Revision (Long Stem)
B3	Around Stem	LOOSE	Poor	Revision (Impaction/Megaprosthesis)
C	Below Stem	Stable	Variable	ORIF (Plate/Nail)

Vancouver Type C periprosthetic fracture below THA stem tip — AP pelvis radiograph demonstrating a Vancouver Type C periprosthetic fracture - note the fracture location is well below the tip of the femoral stem. The THA components appear stable. Type C fractures are essentially treated as standard femoral shaft fractures with ORIF (plate or nail), as the prosthesis is typically uninvolved in the fracture pattern.Credit: PMC - CC BY 4.0

Classification Reliability

Brady et al. • JBJS 2000

Key Findings:

Overall inter-observer reliability: Kappa 0.66
B1 vs B2 distinction is most challenging (Kappa 0.52)
Recommendation: Determine stability intraoperatively if radiographs equivocal
Correct classification guides successful treatment in 89% of cases

Clinical Implication: When B1 vs B2 is unclear radiographically, assess stem stability intraoperatively before deciding treatment.

Clinical Assessment

Mnemonic

NO PASSRed Flags (NO PASS)

Neurovascular

Sciatic nerve palsy?

Open fracture

Rare but critical

Pain

Out of proportion (Compartment Syndrome)

Acetabulum

Don't miss pelvic discontinuity

Sepsis

Infected arthroplasty?

Skin

Compromised soft tissue envelope

Memory Hook:If you see these, do NO PASS go - call senior immediately.

History

Mechanism: Low energy fall vs trauma
Pain: Prodromal thigh/groin pain (suggests loosening)
Pre-injury Function: Independent vs bedbound
Comorbidities: Osteoporosis, RA, steroids

Examination

Inspection: Shortening, rotation, swelling
Palpation: Tenderness, crepitus
Neurovascular: Sciatic/Femoral nerve check MANDATORY
Systemic: Signs of infection/sepsis

Red Flags

Immediate Orthopaedic Review Required:

Open Fracture: Rare but critical
Neurovascular Compromise: Sciatic nerve palsy
Compartment Syndrome: High index of suspicion
Septic Loosening: Red, hot, swollen joint with fracture

Investigations

Imaging Protocol

EssentialPlain Radiographs

Full-Length Femur (AP/Lat): Mandatory to plan fixation length. AP Pelvis: Assess cup and contralateral side. Hip Views: Detailed fracture pattern.

ComplexCT Scan (MARS)

Indicated for B3 fractures (bone stock), acetabular involvement, or uncertain comminution. Use Metal Artifact Reduction Sequence.

ScreeningInfection Labs

ESR & CRP: Mandatory in ALL cases to rule out septic loosening. Aspiration if elevated.

Exam Warning

NEVER proceed without Full-Length Femur Films. Missed distal extension leads to inadequate plate length, stress risers, and rapid fixation failure.

Management Algorithm

Clinical Algorithm

Loading flowchart...

Non-Operative Management

Indications: Undisplaced Type A, stable Type C in non-ambulatory patients, medically unfit for surgery. Protocol: Protected weight bearing 6-12 weeks, serial x-rays. Failure: Progressive displacement greater than 5mm or intractable pain requires surgery.

Surgical Technique

Vancouver B1: Fixation (Stem Preserving)

Prerequisite: You MUST be certain the stem is STABLE. If in doubt, treat as loose (revision).

Steps

ApproachExtended Lateral

Incision centered on trochanter, split fascia lata. Elevate vastus lateralis anteriorly. Preserve perforators.

ReductionAnatomic

Gentle traction and bone clamps. Verify stem alignment fluoroscopically.

FixationPlate and Cables

Proximal: Cables/screws around stem (unicortical or cable-plate). Distal: Bicortical locking screws (min 4-6). Bypass: Plate must extend 2 cortical diameters (10-15cm) distal to fracture.

AugmentStrut Grafts

Consider concomitant strut allografts for medial comminution or osteopenia.

Mnemonic

FIXATIONB1 Fixation Principles

Fracture reduction

Anatomic alignment

Implant preservation

Keep stable stem

eXtended fixation

Bypass by 2 diameters

Augmentation

Strut grafts if needed

Tension band

Lateral plate positioning

Immediate stability

Rigid construct

Osteogenic

Preserve soft tissue

No weight bearing

Protected rehab

Memory Hook:Good FIXATION saves the stem.

Vancouver B1 periprosthetic fracture treated with cable plate ORIF — Two-panel radiograph series (A, B) demonstrating Vancouver B1 periprosthetic fracture management. (A) Pre-operative view showing fracture around a stable THA stem with good bone stock. (B) Post-operative AP showing successful ORIF with lateral locking plate and cerclage cables - the cables encircle the femur proximally where the stem prevents bicortical screw placement, while locking screws provide distal fixation. This technique preserves a well-fixed stem.Credit: PMC - CC BY 4.0

Complications

Early

Infection: 3-8% (higher than primary)
Dislocation: 20-40% in revisions (use dual mobility/constrained liners)
DVT/PE: 1-2% symptomatic VTE
Nerve Injury: Sciatic (cable passage)

Late

Nonunion: 5-20% (poor biology/stability)
Loosening: Subsequent aseptic loosening
Refracture: At plate tip (stress riser)
Hardware Failure: Plate breakage

Complications Profile

Moreta et al. • Injury 2021

Key Findings:

Total complication rate: 36% at 2 years
Re-revision rate: 18%
Nonunion: 12% overall (higher in B2/B3)
Significant reduction in PROMs compared to primary THA

Clinical Implication: Counsel patients that functional outcome will likely be lower than pre-fracture level. One-third experience complications.

Postoperative Care

Rehabilitation Protocol

0-6 WeeksProtection

Toe-touch or restricted (20kg) weight bearing. Hip precautions (prevent dislocation). DVT prophylaxis (35 days).

6-12 WeeksProgression

Progress weight bearing as callus appears. Abductor strengthening. Transition to cane.

3-6 MonthsConsolidation

Full weight bearing once united. Return to baseline function. Osteoporosis management (Bisphosphonates).

Bone Health

ANZBMS Guidelines: All fragility fracture patients require:

Vitamin D (target greater than 50 nmol/L)
Calcium (1000mg/day)
Anti-resorptive therapy (Bisphosphonate/Denosumab) once healing established.

Outcomes and Prognosis

Type	Union Rate	Revision Rate (5y)	Functional Return
B1 (ORIF)	90-95%	5-10%	60-70% baseline
B2 (Revision)	85-90%	15-25%	40-60% baseline
B3 (Salvage)	N/A	20-30%	30-50% baseline
C (ORIF)	greater than 90%	5%	70-80% baseline

Important

Expectation Management: Recovery takes 6-12 months. Many patients will require long-term walking aids and will not return to pre-fracture mobility.

Evidence Base

Outcomes of Periprosthetic Fractures

Kang et al. • Hip Pelvis 2018

Key Findings:

5-year survivorship: 82% overall
B1: 91% survivorship with ORIF
B3: 74% survivorship (highest failure)
Patient satisfaction lower than primary THA
65% of patients have reduced mobility compared to baseline

Clinical Implication: B1 fractures have excellent outcomes with ORIF. B3 represents the most challenging scenario with highest failure rates.

AOANJRR Annual Report

Australian Orthopaedic Association • AOANJRR 2023

Key Findings:

Periprosthetic fracture is the 4th most common reason for revision (7.2%)
Risk is cumulative and increases with time
Uncemented stems have higher fracture rates than cemented in patients over 75
Revision of revision has even higher fracture risk

Clinical Implication: Australian registry data supports cemented fixation in elderly patients to reduce periprosthetic fracture risk.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: B1 vs B2 Assessment

EXAMINER

"78F falls at home. Primary THA 8 years ago. X-ray shows fracture around stem."

EXCEPTIONAL ANSWER

This is a Vancouver Type B periprosthetic fracture. My critical priority is to determine STEM STABILITY. I would assess this clinically (pre-injury pain, function) and radiographically (Implant mnemonic: interface lucency, migration, pedestal). If the stem is stable (B1), I will perform ORIF. If loose (B2), I must revise to a long stem. Treating a loose stem with ORIF inevitably leads to failure.

KEY POINTS TO SCORE

Stability dictates treatment

B1 = ORIF, B2 = Revision

IMPLANT mnemonic for loosening

Full length femur X-rays mandatory

COMMON TRAPS

✗Committing to ORIF without assessing stability

✗Missing subtle loosening signs

✗Using too short a plate (must bypass by 2 diameters)

LIKELY FOLLOW-UPS

"How do you fix a B1 fracture?"

"What if you acturally find the stem is loose intra-op?"

VIVA SCENARIOStandard

Scenario 2: Surgical Technique B1

EXAMINER

"You decide a patient has a B1 fracture (stable stem). Describe your fixation."

EXCEPTIONAL ANSWER

My goal is rigid fixation while preserving the stem. I use a lateral approach. I achieve anatomic reduction with clamps. My construct uses cables proximally around the stem (avoiding sciatic nerve posteriorly) and bicortical locking screws distally. Critical principles are: 1) Bypass fracture by 2 cortical bone diameters (10-15cm), 2) Augment with strut allografts if bone stock is poor, 3) Protected weight bearing post-op.

KEY POINTS TO SCORE

Lateral approach

Cable-plate construct

Bypass principle (2 diameters)

Strut graft indication

COMMON TRAPS

✗Inadequate plate length (stress riser)

✗Sciatic nerve injury with cables

✗Invading cement mantle with screws

LIKELY FOLLOW-UPS

"What if the bone is osteoporotic?"

"When can they mobilize?"

VIVA SCENARIOAdvanced

Scenario 3: B3 Salvage Decision

EXAMINER

"82F with B3 fracture (loose stem, severe bone loss). Medically frail."

EXCEPTIONAL ANSWER

This is a salvage situation. Options are Impaction Bone Grafting (IBG) or Proximal Femoral Replacement (Megaprosthesis). In an 82F frail patient, I favour Megaprosthesis because it allows immediate stability and weight bearing, unlike IBG which requires restricted weight bearing. Dislocation risk is high, so I would use a constrained liner or dual mobility cup. Goals are pain relief and basic transfers, not high function.

KEY POINTS TO SCORE

B3 = Loose + Poor Bone

Megaprosthesis vs Impaction Grafting

Patient factors drive choice (Frailty favors Megaprosthesis)

Dislocation management

COMMON TRAPS

✗Choosing complex reconstruction in frail patient

✗Ignoring high dislocation risk

✗Ignoring mortality risk

LIKELY FOLLOW-UPS

"Complications of megaprosthesis?"

"What about non-operative care?"

MCQ Practice Points

B1 vs B2

Q: What is the most significant predictor of failure after ORIF of periprosthetic fractures? A: Loose stem (Misdiagnosis of B2 as B1). Fixation of a loose stem leads to cantilever failure of the plate or nonunion.

Fixation Length

Q: What is the minimum recommended distal fixation length beyond the fracture? A: 2 cortical diameters (typically 10-15cm). Short plates create stress risers and lead to refracture.

Mortality

Q: What is the approximate 1-year mortality after periprosthetic hip fracture? A: 10-15%. This reflects the frailty and comorbidities of the population, similar to native hip fractures.

Cable vs Screw

Q: When do you use cables versus screws in periprosthetic fracture fixation? A: Cables proximally (where the stem occupies the canal), screws distally (where biocortical purchase is possible). This "cable-plate" construct provides optimal fixation.

Strut Graft

Q: What is the indication for cortical strut grafts? A: Significant bone loss or cortical defects (B2/B3). Strut grafts provide biological healing scaffold and mechanical support. Can be allograft or autograft.

Australian Context

Registry Data

AOANJRR 2023: Periprosthetic fracture is increasing as a cause for revision. Uncemented stems in older females have higher fracture rates.

Guidelines

ANZBMS: Mandatory osteoporosis assessment and treatment initiation. eTG: Antibiotic and VTE prophylaxis protocols.

Periprosthetic Fractures Essentials

High-Yield Exam Summary

Classification (Vancouver)

•Type A: Trochanteric (Stable)
•Type B1: Around stem, Stable to ORIF
•Type B2: Around stem, Loose to Revision (Long Stem)
•Type B3: Around stem, Loose, Poor bone to Salvage
•Type C: Below stem to ORIF

Key Assessment

•Stem Stability is the #1 Factor
•Full length femur X-ray Mandatory
•Pre-op Infection Screen Mandatory
•IMPLANT mnemonic for loosening signs

Surgical Principles

•Bypass fracture by 2 cortical diameters
•Cables proximally, Screws distally
•Strut grafts for poor bone
•Revision stems must achieve distal fixation

Complications

•Infection (3-8%)
•Dislocation (High risk in revisions)
•Nonunion/Refracture
•1-year mortality 10-15%

Periprosthetic Fractures Around Total Hip Arthroplasty

High Yield Overview

THA PERIPROSTHETIC FRACTURES

Post-Arthroplasty Femoral Fracture | Vancouver Classification | Revision Arthroplasty

0.4-1.1%10-year incidence

7.2%of all revisions

91%Union rate (B1)

10%1-year mortality

Vancouver Classification

Type A

PatternTrochanteric (AG greater, AL lesser)

TreatmentConservative vs ORIF

Type B

PatternAround stem (B1 stable, B2/B3 loose)

TreatmentB1 ORIF vs B2/B3 Revision

Type C

PatternWell below stem

TreatmentDistal femoral ORIF

Critical Must-Knows

Stem stability assessment is THE critical decision driver
B1 = Stable Stem → ORIF (Preserve stem)
B2/B3 = Loose Stem → Revision Arthroplasty
Obtain full-length femur radiographs (MANDATORY)
Always screen for infection (ESR/CRP) preoperatively

Examiner's Pearls

"
Most common error: Attempting ORIF on a loose stem (guaranteed failure)
"
Intraoperative fracture: STOP, assess, and stabilize immediately
"
Risk factors: Elderly female, osteoporosis, uncemented stems
"
Don't forget the acetabulum (associated loosening or fractures)

Clinical Imaging

Imaging Gallery

Critical Exam Points

Stem Stability

The Single Most Important Assessment. Differentiating B1 (stable) from B2 (loose) dictates treatment. Getting this wrong is an automatic fail.

Infection Screen

Mandatory Pre-op Check. Always rule out septic loosening presenting as fracture. Missed infection leads to catastrophic failure of fixation.

Imaging Protocol

Full-Length Femur Views. Essential to see distal extent of fracture and plan bypass fixation length (2 cortical diameters).

Risk Factors

Prevention is Key. Recognize high-risk patients (osteoporotic females, revision cases) and use prophylactic cables or gentle technique.

Quick Decision Guide

Scenario	Classification	Stem Status	Treatment
Trochanteric fracture, stable hip	Vancouver A	Stable	Conservative (unless displaced/unstable)
Fracture around stem, stem WELL FIXED	Vancouver B1	Stable	ORIF (Plate + Cables)
Fracture around stem, stem LOOSE, good bone	Vancouver B2	Loose	Revision THA (Long Uncemented Stem)
Fracture around stem, stem LOOSE, POOR bone	Vancouver B3	Loose	Revision (Impaction Graft or Megaprosthesis)
Fracture well below stem tip	Vancouver C	Stable	ORIF (Distal Femur Plate)

Mnemonic

IMPLANTAssessing Stem Stability (B1 vs B2/B3)

Interface

Lucent lines greater than 2mm suggest loosening

Movement

Pain with weight bearing suggests loosening

Position

Subsidence or migration on serial films

Lysis

Periprosthetic osteolysis around stem

Alignment

Change in stem version or varus/valgus tilt

New bone

Pedestal formation at stem tip (sign of loosening)

Testing

Intraoperative direct assessment if uncertain

Memory Hook:Check the IMPLANT before you plan your fixation strategy.

Overview and Epidemiology

Rising Burden

AOANJRR 2023 Report: Periprosthetic fracture is the 4th most common reason for THA revision. Incidence is increasing with the aging Australian population and high volume of primary THAs.

Intraoperative Risk Factors

Technical Factors:

Revision surgery (4-7% risk)
Uncemented stem insertion (press-fit)
Undersized canal preparation
Excessive impaction force

Patient Factors:

Rheumatoid arthritis
Severe osteoporosis
Anterior femoral cortical defects

Postoperative Risk Factors

Implant-Related:

Aseptic loosening with osteolysis
Stress shielding (cortical thinning)
Retained cement mantle

Patient-Related:

Age over 70 years
Female sex (2.5x higher risk)
Frequent falls

Epidemiology of Periprosthetic Fractures

Abdel et al. • JBJS 2016

Key Findings:

Overall incidence: 0.93% at mean 6.2 years
Vancouver B fractures most common (70%)
Female sex independent risk factor (OR 2.1)
Uncemented stems higher risk than cemented in elderly (greater than 70)
Most fractures (60%) occur greater than 5 years post-THA

Clinical Implication: Consider cemented stems in osteoporotic elderly females. Long-term surveillance for late fractures is essential.

Anatomy and Biomechanics

Stress Shielding

Bone Quality

Osteolysis: Wear debris induces cytokine-mediated bone loss
Cortical Thinning: less than 4mm cortex increases fracture risk exponentially
Bone Density: Osteopenia common in THA population

Danger Zones

Anterior Cortex: At femoral bow apex (common perforation site)
Proximal Lateral Cortex: Aggressive broaching risk
Calcar: Varus stem malposition

Classification Systems

Vancouver Classification

Duncan & Masri (1995) - The universal Gold Standard based on: Location, Stability, and Bone Stock.

Type	Location	Stem Status	Bone Stock	Management
AG	Greater Trochanter	Stable	Variable	Conservative vs ORIF
AL	Lesser Trochanter	Stable	Variable	Conservative
B1	Around Stem	STABLE	Good	ORIF (preserve stem)
B2	Around Stem	LOOSE	Good	Revision (Long Stem)
B3	Around Stem	LOOSE	Poor	Revision (Impaction/Megaprosthesis)
C	Below Stem	Stable	Variable	ORIF (Plate/Nail)

Classification Reliability

Brady et al. • JBJS 2000

Key Findings:

Overall inter-observer reliability: Kappa 0.66
B1 vs B2 distinction is most challenging (Kappa 0.52)
Recommendation: Determine stability intraoperatively if radiographs equivocal
Correct classification guides successful treatment in 89% of cases

Clinical Implication: When B1 vs B2 is unclear radiographically, assess stem stability intraoperatively before deciding treatment.

Clinical Assessment

Mnemonic

NO PASSRed Flags (NO PASS)

Neurovascular

Sciatic nerve palsy?

Open fracture

Rare but critical

Pain

Out of proportion (Compartment Syndrome)

Acetabulum

Don't miss pelvic discontinuity

Sepsis

Infected arthroplasty?

Skin

Compromised soft tissue envelope

Memory Hook:If you see these, do NO PASS go - call senior immediately.

History

Mechanism: Low energy fall vs trauma
Pain: Prodromal thigh/groin pain (suggests loosening)
Pre-injury Function: Independent vs bedbound
Comorbidities: Osteoporosis, RA, steroids

Examination

Inspection: Shortening, rotation, swelling
Palpation: Tenderness, crepitus
Neurovascular: Sciatic/Femoral nerve check MANDATORY
Systemic: Signs of infection/sepsis

Red Flags

Immediate Orthopaedic Review Required:

Open Fracture: Rare but critical
Neurovascular Compromise: Sciatic nerve palsy
Compartment Syndrome: High index of suspicion
Septic Loosening: Red, hot, swollen joint with fracture

Investigations

Imaging Protocol

EssentialPlain Radiographs

Full-Length Femur (AP/Lat): Mandatory to plan fixation length. AP Pelvis: Assess cup and contralateral side. Hip Views: Detailed fracture pattern.

ComplexCT Scan (MARS)

Indicated for B3 fractures (bone stock), acetabular involvement, or uncertain comminution. Use Metal Artifact Reduction Sequence.

ScreeningInfection Labs

ESR & CRP: Mandatory in ALL cases to rule out septic loosening. Aspiration if elevated.

Exam Warning

NEVER proceed without Full-Length Femur Films. Missed distal extension leads to inadequate plate length, stress risers, and rapid fixation failure.

Management Algorithm

Clinical Algorithm

Loading flowchart...

Non-Operative Management

Surgical Technique

Vancouver B1: Fixation (Stem Preserving)

Prerequisite: You MUST be certain the stem is STABLE. If in doubt, treat as loose (revision).

Steps

ApproachExtended Lateral

Incision centered on trochanter, split fascia lata. Elevate vastus lateralis anteriorly. Preserve perforators.

ReductionAnatomic

Gentle traction and bone clamps. Verify stem alignment fluoroscopically.

FixationPlate and Cables

AugmentStrut Grafts

Consider concomitant strut allografts for medial comminution or osteopenia.

Mnemonic

FIXATIONB1 Fixation Principles

Fracture reduction

Anatomic alignment

Implant preservation

Keep stable stem

eXtended fixation

Bypass by 2 diameters

Augmentation

Strut grafts if needed

Tension band

Lateral plate positioning

Immediate stability

Rigid construct

Osteogenic

Preserve soft tissue

No weight bearing

Protected rehab

Memory Hook:Good FIXATION saves the stem.

Complications

Early

Infection: 3-8% (higher than primary)
Dislocation: 20-40% in revisions (use dual mobility/constrained liners)
DVT/PE: 1-2% symptomatic VTE
Nerve Injury: Sciatic (cable passage)

Late

Nonunion: 5-20% (poor biology/stability)
Loosening: Subsequent aseptic loosening
Refracture: At plate tip (stress riser)
Hardware Failure: Plate breakage

Complications Profile

Moreta et al. • Injury 2021

Key Findings:

Total complication rate: 36% at 2 years
Re-revision rate: 18%
Nonunion: 12% overall (higher in B2/B3)
Significant reduction in PROMs compared to primary THA

Clinical Implication: Counsel patients that functional outcome will likely be lower than pre-fracture level. One-third experience complications.

Postoperative Care

Rehabilitation Protocol

0-6 WeeksProtection

Toe-touch or restricted (20kg) weight bearing. Hip precautions (prevent dislocation). DVT prophylaxis (35 days).

6-12 WeeksProgression

Progress weight bearing as callus appears. Abductor strengthening. Transition to cane.

3-6 MonthsConsolidation

Full weight bearing once united. Return to baseline function. Osteoporosis management (Bisphosphonates).

Bone Health

ANZBMS Guidelines: All fragility fracture patients require:

Vitamin D (target greater than 50 nmol/L)
Calcium (1000mg/day)
Anti-resorptive therapy (Bisphosphonate/Denosumab) once healing established.

Outcomes and Prognosis

Type	Union Rate	Revision Rate (5y)	Functional Return
B1 (ORIF)	90-95%	5-10%	60-70% baseline
B2 (Revision)	85-90%	15-25%	40-60% baseline
B3 (Salvage)	N/A	20-30%	30-50% baseline
C (ORIF)	greater than 90%	5%	70-80% baseline

Important

Expectation Management: Recovery takes 6-12 months. Many patients will require long-term walking aids and will not return to pre-fracture mobility.

Evidence Base

Outcomes of Periprosthetic Fractures

Kang et al. • Hip Pelvis 2018

Key Findings:

5-year survivorship: 82% overall
B1: 91% survivorship with ORIF
B3: 74% survivorship (highest failure)
Patient satisfaction lower than primary THA
65% of patients have reduced mobility compared to baseline

Clinical Implication: B1 fractures have excellent outcomes with ORIF. B3 represents the most challenging scenario with highest failure rates.

AOANJRR Annual Report

Australian Orthopaedic Association • AOANJRR 2023

Key Findings:

Periprosthetic fracture is the 4th most common reason for revision (7.2%)
Risk is cumulative and increases with time
Uncemented stems have higher fracture rates than cemented in patients over 75
Revision of revision has even higher fracture risk

Clinical Implication: Australian registry data supports cemented fixation in elderly patients to reduce periprosthetic fracture risk.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: B1 vs B2 Assessment

EXAMINER

"78F falls at home. Primary THA 8 years ago. X-ray shows fracture around stem."

EXCEPTIONAL ANSWER

KEY POINTS TO SCORE

Stability dictates treatment

B1 = ORIF, B2 = Revision

IMPLANT mnemonic for loosening

Full length femur X-rays mandatory

COMMON TRAPS

✗Committing to ORIF without assessing stability

✗Missing subtle loosening signs

✗Using too short a plate (must bypass by 2 diameters)

LIKELY FOLLOW-UPS

"How do you fix a B1 fracture?"

"What if you acturally find the stem is loose intra-op?"

VIVA SCENARIOStandard

Scenario 2: Surgical Technique B1

EXAMINER

"You decide a patient has a B1 fracture (stable stem). Describe your fixation."

EXCEPTIONAL ANSWER

KEY POINTS TO SCORE

Lateral approach

Cable-plate construct

Bypass principle (2 diameters)

Strut graft indication

COMMON TRAPS

✗Inadequate plate length (stress riser)

✗Sciatic nerve injury with cables

✗Invading cement mantle with screws

LIKELY FOLLOW-UPS

"What if the bone is osteoporotic?"

"When can they mobilize?"

VIVA SCENARIOAdvanced

Scenario 3: B3 Salvage Decision

EXAMINER

"82F with B3 fracture (loose stem, severe bone loss). Medically frail."

EXCEPTIONAL ANSWER

KEY POINTS TO SCORE

B3 = Loose + Poor Bone

Megaprosthesis vs Impaction Grafting

Patient factors drive choice (Frailty favors Megaprosthesis)

Dislocation management

COMMON TRAPS

✗Choosing complex reconstruction in frail patient

✗Ignoring high dislocation risk

✗Ignoring mortality risk

LIKELY FOLLOW-UPS

"Complications of megaprosthesis?"

"What about non-operative care?"

MCQ Practice Points

B1 vs B2

Fixation Length

Q: What is the minimum recommended distal fixation length beyond the fracture? A: 2 cortical diameters (typically 10-15cm). Short plates create stress risers and lead to refracture.

Mortality

Q: What is the approximate 1-year mortality after periprosthetic hip fracture? A: 10-15%. This reflects the frailty and comorbidities of the population, similar to native hip fractures.

Cable vs Screw

Strut Graft

Australian Context

Registry Data

AOANJRR 2023: Periprosthetic fracture is increasing as a cause for revision. Uncemented stems in older females have higher fracture rates.

Guidelines

ANZBMS: Mandatory osteoporosis assessment and treatment initiation. eTG: Antibiotic and VTE prophylaxis protocols.

Periprosthetic Fractures Essentials

High-Yield Exam Summary

Classification (Vancouver)

•Type A: Trochanteric (Stable)
•Type B1: Around stem, Stable to ORIF
•Type B2: Around stem, Loose to Revision (Long Stem)
•Type B3: Around stem, Loose, Poor bone to Salvage
•Type C: Below stem to ORIF

Key Assessment

•Stem Stability is the #1 Factor
•Full length femur X-ray Mandatory
•Pre-op Infection Screen Mandatory
•IMPLANT mnemonic for loosening signs

Surgical Principles

•Bypass fracture by 2 cortical diameters
•Cables proximally, Screws distally
•Strut grafts for poor bone
•Revision stems must achieve distal fixation

Complications

•Infection (3-8%)
•Dislocation (High risk in revisions)
•Nonunion/Refracture
•1-year mortality 10-15%

Type	Description	Cup Status	Management
Type I	Intraoperative	Stable	Screws/Plate + Cup
Type II	Postoperative	Stable	Conservative (if min displaced)
Type III	Postoperative	Unstable	Revision (Cage/Triflange)

Type	Description	Cup Status	Management
Type I	Intraoperative	Stable	Screws/Plate + Cup
Type II	Postoperative	Stable	Conservative (if min displaced)
Type III	Postoperative	Unstable	Revision (Cage/Triflange)