68 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78
Total Hip Arthroplasty Periprosthetic Femoral
Fractures
A Review of Classification and Current Treatment
Ran Schwarzkopf, M.D., M.Sc., Julius K. Oni, M.D., and Scott E. Marwin, M.D.
Abstract
Periprosthetic fractures of the femur after total hip replace-
ment can present some unique challenges to the treating
reconstructive orthopedic surgeon. Treatment may differ
depending on fracture location, bone condition, implant
stability, patient characteristics, and surgeon experience.
It is imperative that adequate and sufficient mechanical
fixation be achieved in the treatment of these patients. It is
crucial that the treating orthopaedic surgeon have a clear
and effective treatment plan to manage these complex cases.
The patient’s final outcome is dependent on fracture union,
implant stability, early functional recovery, and return to
pre-injury independence. This review presents an overview
of the current diagnostic and treatment approaches, with the
goal of providing a template for optimal decision-making
when dealing with these complex injuries.
T
otal hip arthroplasty (THA) has been an extremely
effective procedure in relieving pain and dysfunction
for patients with hip arthritis of varying etiologies.
However, after many decades of successful total hip re-
placements, there has also been a substantial increase in the
incidence of periprosthetic fractures following THA. This
increase in fracture prevalence is attributed to the substantial
increase in the number of primary and revision THAs being
performed annually, the growing number of patients with a
THA in place for more than 20 years, the aging population
of THA patients (with increasing life expectancy, poorer
Ran Schwarzkopf, M.D., M.Sc., Julius K. Oni, M.D., and Scott
E. Marwin, M.D., are in the Department of Orthopaedic Surgery,
NYU Hospital for Joint Diseases, New York, New York.
Correspondence: Scott E. Marwin, M.D., Department of Ortho-
paedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th
Street, Suite 1402, New York, New York 10003; scott.marwin@
nyumc.org.
Schwarzkopf R, Oni JK, Marwin, SE. Total hip arthroplasty periprosthetic femoral fractures: a review of classification and current treatment. Bull Hosp
Jt Dis. 2013;71(1):68-78.
bone quality, and high fall risk), and broader indications
for THA that allow younger, more active, and consequently
high-energy trauma prone patients to undergo the surgery.
Periprosthetic femur fractures are divided into intraopera-
tive and postoperative fractures. Intraoperative fractures oc-
cur during the course of surgery and postoperative fractures,
the main focus of this review, usually occur within days to
several years after the procedure. In a Swedish National
Hip Arthroplasty registry study, the mean time from THA
to fracture was 7.4 years for primary THA and 3.9 years for
revision THA.1 Also, in a Mayo Clinic Total Joint Registry
study, average time between primary THA and fracture was
8.1 years.2
Periprosthetic femoral fractures may present many
challenges to the reconstructive orthopedic surgeon. Such
fractures can range from minor injuries, with minimal effect
on the patient’s outcome to being catastrophic and possibly
creating a non-reconstructable problem with a detrimental
effect on the patient’s function. The economic impact and
disabilities associated with femoral periprosthetic fractures
can therefore be substantial. Thus, having a clear and effec-
tive treatment plan to manage these injuries is crucial for
the treating physician.
Prevalence
The prevalence of postoperative periprosthetic femoral
fractures ranges from 0.1% to 4% depending on the series
reviewed, with higher rates after revision surgery.3-6 In a
Mayo Clinic retrospective study of total hip arthroplas-
ties performed between 1969 and 1990, the postoperative
femoral fracture prevalence after 19,657 primary THAs was
0.6%. The postoperative fracture prevalence for cemented
primary arthroplasties was 0.6% of the 17,579 cemented
primary arthroplasties and 0.4% of the 2,078 uncemented
primary arthroplasties. In the revision arthroplasty group, the
overall prevalence of postoperative periprosthetic fracture
 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78 69

was higher at 2.4% of the 4,397 procedures performed, with and the condition of the acetabular component should be
2.8% of fractures occurring in the 3,265 cemented revision assessed as well, and if revision is warranted, it should be
cases and 1.5% of the 1,132 uncemented revision cases.2 addressed appropriately. Routine use of CT or MRI is usu-
ally not warranted.
Etiology
The main risk factor for sustaining a periprosthetic femur Classification
fracture is osteolysis associated with implant loosening.7 Several classification systems of periprosthetic fractures
In both the Mayo clinic and Swedish registry studies, 94% have been developed over the years.5,9-11 Most are descriptive
and 70% of patients respectively had a loose stem prior to and provide information about the location of the fracture
fracture.1,8 However, any pathologic process that weakens but have no significant value with regard to aiding the for-
bone may contribute to these fractures. Examples include os- mulation of a treatment strategy.
teoporosis and other conditions with pathologic bone such as The Vancouver classification system proposed by Duncan
rheumatoid arthritis, Paget’s disease, and polyneuropathies. and Masri is the most widely used system for classification of
Tumors, cortical defects, trauma, revision surgery, extruded total hip periprosthetic femoral fractures, although initially
cement, stress risers, and varus stem position are all also developed for THAs with cemented femoral components.5
significant risk factors for periprosthetic femoral fractures. The Vancouver classification takes into account the three
Age, sex, and body mass index have not been shown in any most important factors in management of these injuries: the
large study to be a significant risk factor. The most frequent site of the fracture, the stability of the femoral component,
mechanism for sustaining these fractures is a low energy and the quality of the surrounding femoral bone stock (Fig.
fall from sitting or standing, accounting for 75% of primary 1). In addition to being simple and reproducible, it is useful
THA and 56% of revision THA periprosthetic fractures.8 for devising a treatment strategy based on easily identifiable
characteristics. In particular, the Vancouver classification
Exam and Imaging helps the surgeon differentiate between a stable fracture and
A detailed assessment of the patient prior to treatment is es- an unstable fracture, which requires osteosynthesis, as well
sential in order to maximize the chances of a good outcome.
As previously stated, many periprosthetic femur fractures
occur from low-energy trauma such as a fall from standing
height. The treating physician must elicit from the patient’s
history any signs and symptoms that may suggest implant
loosening prior to the injury, such as thigh pain and start up
pain, usually reported as pain while rising from a chair or
at initiation of ambulation. A complete physical examina-
tion with an emphasis on the injured limb’s neurovascular
status should be carefully documented. Physical examination
may reveal inability to ambulate, tenderness to palpation
of the fracture site, and pain with range of motion of the
affected extremity. Preoperative planning should include
identification of previous surgical scars and soft tissue con-
dition, review of previous operative reports, especially for
identification of the currently implanted prosthesis and any
unusual intraoperative events, and appropriate workup if
septic loosening is suspected. Patients with fractures around
asymptomatic, well-fixed implants usually do not require an
infectious workup. High-quality standard anteroposterior
(AP) and lateral radiographs of the affected hip and femur
together with an AP radiograph of the pelvis should be ob-
tained. Images should be reviewed thoroughly to ascertain
the type of fracture and the stability of the implant.
Signs of a loose femoral stem include continuous lucency
at the cement-bone and cement-stem interfaces, as well as
cement mantle fractures prior to incurring the periprosthetic
fracture. Post-injury cement mantle fracture is not a sign
Figure 1 The Vancouver classification of periprosthetic femur
of stem loosening by itself. Failure to identify an unstable fractures around total hip arthroplasty. The classification is based
implant is likely to lead to treatment failure if osteosynthesis on the location of the fracture, stability of the femoral implant,
rather than revision arthroplasty is performed. The stability and quality of the surrounding bone stock.
70 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78
Figure 2 Radiograph of a Vancouver type ALT periprosthetic
femur fracture. The lesser trochanter is fractured along with the
medial cortex.
as a stable implant from an unstable implant, which requires
revision. The Vancouver classification has been validated in
several studies.12
Vancouver Classification
Type A fractures include those involving the lesser tro-
chanter (ALT) (Fig. 2) or the greater trochanter (AGT). These
fractures are most commonly associated with osteopenia of
the proximal femur.
Type B fractures occur around or just distal to the femoral
stem. Type B fractures are further divided into subtypes:
B1-adjacent to a well-fixed stem, B2-adjacent to a loose
stem but with adequate bone stock, and B3-adjacent to
a loose stem and associated with marked osteopenia and
loss of bone stock. This sub-classification is critical to the
decision making process of the treating physician because
a fracture accompanied by a loose implant requires revision
arthroplasty compared to osteosynthesis for fractures associ-
ated with a stable implant.
Type C fractures are far distal to the femoral stem, such
that their treatment is independent of the total hip arthro-
plasty.
Treatment
Treatment of total hip periprosthetic femoral fractures is
dependent on a few fracture characteristics such as fracture
location, femoral bone stock, implant stability, patient’s
characteristics like age and medical co-morbidities, and
surgeon experience.
Historically, non-operative treatment was the mainstay
for periprosthetic femoral fractures.13 With advances in
surgical techniques and instrumentation, the balance has
shifted in favor of surgical management, thus avoiding
the recognized complications associated with prolonged
recumbency such as thromboembolism, pneumonia, pres-
sure ulceration and knee joint contractures. Nevertheless,
non-operative treatment is still recommended for a subset
of patients with otherwise operative fractures who are un-
able to tolerate a prolonged surgical procedure for medical
reasons, especially if they are non-ambulatory and have low
levels of physical function. There is no consensus regarding
the use of skeletal or cutaneous traction preoperatively for
periprosthetic femur fractures. The goals of surgery should
be fracture union, prosthetic stability, anatomical alignment,
rotation, and length, as well as return to pre-injury function.
In cases of severe osteopenia, osteosynthesis with relative
stability techniques, such as bridging of comminuted seg-
ments, should be employed. In cases where revision total hip
arthroplasty is being contemplated as the treatment option,
the possibility of infection should be considered and ruled
out. Unfortunately, laboratory studies, such as white blood
cell count, erythrocyte sedimentation rate, and C-reactive
protein, are not as useful in the presence of a periprosthetic
fracture compared to failed total hip arthroplasty without a
fracture.14 A hip aspiration culture may, however, be helpful
when septic loosening prior to fracture is suspected.
Many different treatment options have been described
in the literature, and no single treatment has been shown
to be the gold standard. The following is a presentation of
common treatment options for each fracture type.
Vancouver Type ALT
Type ALT fractures are rare, and usually non-operative
treatment is required, unless the fracture compromises the
stability of the implant by involving a large portion of the
calcar region with loss of the medial buttress (Fig. 3). In this
case, treatment may include cerclage wiring and revision if
the implant is deemed unstable.
Vancouver Type AGT
Type AGT fractures are usually stable, due to the composite
tendons of the vasti and glutei muscles, and treatment for
non-displaced fractures is non-operative, with protected
weight bearing for 6 to 12 weeks and avoidance of hip abduc-
tion until fracture union is achieved.15 Displaced fractures
may require fixation, either with a hook cable plate con-
struct or cerclage fixation, in order to restore the functional
leverage arm of the glutei muscles. Often, osteolysis of the
proximal femur is associated with these type A fractures.
In these cases, operative treatment is warranted and should
include bone grafting of the osteolytic lesion, trochanteric
fixation, and acetabular liner revision to address the underly-
 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78 71

Type A

AGT ALT

Displaced Minimal Stable Displaced

or no medial
displacement cortex

No Osteolysis Osteolysis No No Cerclage

Osteolysis Osteolysis Treatment wire

Fixation with Fixation with Protected

cerclage wire or cerclage wire or weightbearing
trochanteric claw trochanteric claw
plate system plate system with
bone grafting
Figure 3 Treatment algorithm for Vancouver type A periprosthetic femur fractures.

ing cause of osteolysis. In a study of with mean follow-up
of 11years, Hsieh and associates16 reported an incidence of
greater trochanteric periprosthetic fractures as 2.6%. They
also reported that these fractures all occurred in the pres-
ence of an osteolytic lesion 4 to 11 years postoperatively.
Fifteen of 17 patients treated non-operatively for minimally
displaced fractures healed clinically and radiographically
by 6 to 8 weeks, but all fractures eventually healed without
further displacement, as did all four patients that underwent
operative treatment. Pritchett and coworkers15 showed that
trochanteric fractures that have migrated less than 2 cm could
be treated successfully non-operatively, and internal fixa-
tion should be considered in cases of displacement greater
than 2.5 cm or when trochanteric nonunion results in pain,
instability, or abduction weakness.
Vancouver Type B
Type B fractures represent approximately 80% of all cases.
Sub-classification and treatment options depend on the mor-
phology of the fracture, the stability of the femoral compo-
nent, and the quality of the proximal femoral bone (Fig. 4).
At the time of surgery, the surgeon should be familiar
and feel comfortable with the extensile approaches to the
hip and femur. The surgeon should try to minimize soft tis-
sue trauma when feasible and preserve blood supply to the
fracture fragments by limiting surgical dissection. When
using plate fixation, it is important to bypass the distal limit
of the fracture by at least two femur widths. Biomechanical
studies by Larson and colleagues showed that perforation
of the femur led to a 44% reduction in the original strength
of the femur and osteosynthesis with a plate that bridged
the fracture area by two femur widths re-established the
stability of the bone to 84% of its original strength.17 Intra-
operative stability testing can be done without an arthrotomy,
if the distal stem is exposed in the fracture site. However, if
there is any doubt about the implant stability, intraoperative
stability testing utilizing hip arthrotomy and dislocation is
recommended.
Vancouver Type B1
Controversy still exists regarding the preferred fracture
fixation technique for type B1 fractures, given the high
stress location of these fractures and the femoral implant.
In general, type B1 fractures should be treated with open
reduction and internal fixation with or without cortical
strut allograft based on the bone quality observed intra-
operatively (Fig. 5). There are several options for internal
fixation, most of which have shown good to excellent
outcomes. Historically, these fractures were treated with
stainless steel cerclage wires and open reduction and in-
ternal fixation with rigid dynamic compression plates.9,18-20
However, many studies have reported that cerclage wir-
ing alone has a high failure rate, and proximal unicortical
screws in dynamic compression plates, while more stable
72 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78

Type B

Minimal Displaced fracture

displacement and
stable implant

May treat Stable impant B1 Loose

with protected Implant
weightbearing

Surgical Poor bone Good bone

Fixation with stock B3 stock B2
osteosynthesis
and strut graft
Young Elderly Long stem
patient patient revision

Revision with a long Proximal femoral

stem implant and replacement
bone graft
Consider allograft
prosthesis composite

Figure 4 Treatment algorithm for Vancouver type B periprosthetic femur fractures.

than cerclage wiring alone, are also inadequate.21-26 Also,
when standard plates and screws are used, they tend to
violate the cement mantle. Additionally, if a canal-filling
uncemented stem is present, it may be difficult to insert
screws around the implant, thereby compromising fixa-
tion strength. Therefore, as an alternative, plates that can
accommodate cables and screws have been designed and
are available from most implant manufacturers. The first of
these cable-plate constructs was the Ogden plate, (Zimmer,
Warsaw, IN) introduced in 1976, and best described as a
metallic bone side plate that was secured to the proximal
fragment by Parham bands and to the distal fragment by
screws.27 The relative ease, minimal morbidity, and stabil-
ity of this technique made it popular, but its disadvantages
included the potential for stress risers as a result of the
transcortical screws, fractures below the plate, prosthetic
loosening, and nonunion.27 Therefore, many modifications
on the same treatment modality have been developed since
the introduction of this technique, as evident in the mod-
ern day cable plating systems. These plates can be used
in isolation or may be augmented with cortical allograft
struts, and they provide the surgeon with many options for
securing the plate to the femur without interfering with the
femoral implant or the cement mantle.
Some studies have shown that a trochanteric plate with
proximal unicortical and distal bicortical screws or a plate
with proximal unicortical screws combined with cerclage
wires and distal bicortical screws are a sufficiently strong
mechanical construct.21,28 Tadross and coworkers reported
on seven periprosthetic femoral fractures treated with cable
plates, of which three achieved union, two failed to unite,
and two malunited in varus.29 In the Swedish Registry study,
Lindahl and associates found the revision rate after internal
fixation of Vancouver B1 periprosthetic fractures to be 59%.
They reported that the strongest negative prognostic factor
was the use of a single non-locked plate for fixation.1
The use of cortical strut grafts is, therefore, a good alter-
native or adjunct fixation method. Strut grafts, in the case of
stable implants (type B1), may be used as the only means
of stabilization with either a single strut or as a double strut
 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78
A B
complex in a 90° or 180° to each other or in combination
with osteosynthesis (Fig. 6). Strut grafts have an advantage
of being a biological and osteoconductive osteosynthesis
technique, providing reduced stress shielding due to similar
modulus of elasticity as the native bone, and augmenting
host bone stock and strength after union.12,21,30-32 Placing
two strut grafts with three fixation points above and below
the fracture have been shown to yield good outcomes.33,34
Emerson and colleagues reported a 96.6% incorporation rate
in 63 cases were strut grafts were used, with a high rate of
fracture healing.35
In a multicenter study of 40 type B1 periprosthetic
fractures, Haddad and coworkers treated 19 patients with
cortical strut onlay grafts alone, while 21 patients were
managed by a plate and one or two cortical struts. Union
occurred in 98% of the fractures. There were four mal-
Figure 6 Clinical photograph of a periprosthetic femur fracture
with a fixation construct utilizing a strut allograft and plate fixation
with locked screws and cerclage wires.
73
Figure 5 A, A radiograph of a
Vancouver type B1 femur frac-
ture, with a fracture at the level
of the tip of the stem with a stable
implant. B, This fracture was
treated with open reduction and
internal fixation with a locked
plate construct using unicortical
screws proximally and bicortical
screws distally.
unions, but all had less than 10º of malalignment, and the
investigators suggested that cortical strut grafts should
be routinely used in the treatment of these periprosthetic
fractures. They also suggested that combined plating
with proximal cable fixation augmented with an anterior
or medial strut graft may provide better fixation than an
allograft strut alone.30 Biomechanical studies by Dennis
and associates demonstrated that plates with proximal uni-
cortical screws or unicortical screws and cerclage, as well
as distal bicortical screws, achieved a significantly more
stable osteosynthesis than plates with cerclage alone, plates
with just proximal cerclage and distal bicortical screws
(Ogden construct) or two strut grafts (SGs) with cerclage
alone.22 The disadvantages of strut grafts are their high
cost, limited availability, increased danger of infection, and
potential for transmitting disease. In addition, remodeling
occurs subsequent to the initial incorporation of the strut
graft, and this leads, in turn, to biomechanical weakness
during the first 4 to 6 months following grafting.
The recent introduction of locking plates has provided
another excellent alternative for fixation of these fractures.
These plates use screws that lock into the plate allowing
multiple points of unicortical or bicortical fixation. These
plates have the advantage of increased axial and angular
stability, indirect fracture reduction, less soft tissue dissec-
tion, preservation of periosteal blood supply, strong fixation
in bone of poor quality, and less damage to cement mantle
or stable implant due to possibility of multiple proximal
unicortical fixation points. In a biomechanical study com-
paring the locking plate and Ogden construct, Fulkerson
and coworkers reported locking plates to be stiffer than the
Ogden construct in pre- and post-cyclic axial loading and
torsion.36 The investigators concluded that locked plating is
not mechanically superior compared to conventional plating
although it does offer the advantages of minimally invasive
74 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78
fixation techniques. Another biomechanical study by Choi
and colleagues compared the strength of three constructs
for treating comminuted type B1 fractures and found that a
double anterior and lateral locked plates construct is stronger
than the lateral plate and anterior strut allograft construct,
which in turn was stronger than a single lateral locking plate
construct.37 A few studies have shown excellent outcomes
with use of locking plates either in isolation or augmented
with cerclage wires and strut allografts.38-40 In summary, it
would, therefore, seem logical to combine a plate, locked or
non-locked, with distal bicortical screw fixation and proxi-
mal unicortical screw fixation supplemented with an onlay
cortical strut allograft fixed by cables. Locking screws may,
however, be preferred in patients with poor bone quality.
Vancouver Type B2
Revision arthroplasty is the treatment of choice when the
prosthesis is loose or fractured. Duncan and Masri reported
that 82% of type B fractures occurred in the presence of a
loose implant.5 Bethea and coworkers reported that 75%
of all postoperative femoral fractures are related to loose
implants.9 Therefore, a majority of all periprosthetic femur
fractures are either type B2 or B3. When considering type B2
fractures, some questions that need to be addressed include
how long the femoral prosthesis should be, cemented versus
non cemented stem, cerclage wires or plates for fracture
reduction, and if strut allograft will be used to augment
the fixation. The most commonly recommended fixation
for type B2 fractures is revision with a long femoral stem,
effectively bypassing the fracture by a minimal distance
of two femoral diameters with at least 5 cm of diaphyseal
fit.2,5,17 The disadvantage of a cemented implant is the pos-
sible excursion of the cement into the fracture site, which
can impede fracture union and healing.
A B
Cementless implants with distal fixation have an advan-
tage of bypassing the fracture site and having their point of
fixation outside the area of injury. This allows the fracture to
be fixed around the stem, with cables, struts, and plates (Fig.
7). Fracture fragments should be separated to enable canal
debridement and reaming to provide adequate implant fit in
patients treated with long stem bypass fixation. If rotational
stability, soft tissue tensioning, or restoration of limb length
are concerns, then a fluted modular noncemented stem may
be considered. Strut allograft may be needed for preliminary
stability of the construct in select cases, such as that of a
rotationally unstable transverse fracture.
Sledge and associates proposed an algorithm for treatment
of Vancouver type B2 fractures.41 They recommended that
fracture fragments should first be reduced to reconstitute the
proximal tube of the femur and held together with doubled
18 gauge cerclage wires. Once the new stem is in position,
it is then stabilized by the addition of the allograft struts as
needed.41
In cases where there is significant proximal bone de-
ficiency in revision total hip arthroplasty, distally fixed
porous-coated stems are used to gain intramedullary fixa-
tion for complex periprosthetic fractures. MacDonald and
colleagues reported on 14 cases of postoperative fracture
treated with extensively coated cementless stems, and all
14 fractures healed with no deformity at an average of 8.4
years status post-surgery.42
Tower and Beals studied 102 revisions for periprosthetic
fracture of the femur from 30 surgeons and reported a 62%
rate of complications for cemented revisions, with 38%
loosening and 24% of other complications, such as infec-
tion, dislocation, or trochanteric nonunion.43 Cementless
revisions were reported to have a 34% complication rate,
with 18% rate of subsidence (some of which stabilized), 7%
Figure 7 A, Radiograph of a
Vancouver type B2 periprosthetic
femur fracture, with a fracture
at the level of the stem with an
unstable implant. B, Cerclage
wires were used to reduce the
fracture and revision arthroplasty
was performed with a long stem
to gain distal fixation.
 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78
A B
rate of loosening, and 9% dislocation, trochanteric nonunion,
or infection.43 Given the higher rates of complication with
cemented techniques, changing to a cemented stem is gener-
ally only recommended for older patients with osteoporotic
bones or patients with irradiated bone, in whom cementless
fixation would be more challenging. When the patient is frail
and elderly and could benefit from a quicker procedure, the
cement-in-cement technique may be considered. The tech-
nique is indicated for non-comminuted fractures with well-
fixed, good-quality cement mantles. The approach is faster
and technically less demanding, resulting in theoretically less
blood loss and lower risk of iatrogenic bone fragmentation
during cement removal.44 The use of the cement-in-cement
technique for femoral component revision has excellent
clinical outcomes and long-term results, with survivorship
of 98% to 100% at 5 to 15 years.44
Another alternative for treating type B2 fractures is the
use of cementless revision stems with distal interlocking
screws. Mertl and coworkers retrospectively reviewed the
use of interlocking stems in 725 patients with an average
follow up of 4.5 years.45 The main advantages of these
interlocking stems are initial axial and rotational stability
and consistent bony in-growth due to the hydroxyapatite
coating.45 In a study of 118 type B2 and type B3 fractures,
different uncemented stems (a proximally porous coated
uncemented stem, an extensively porous-coated stem, or
an allograft prosthetic composite/tumor prosthesis) were
implanted in different patients, Springer and coworkers
found that the uncemented extensively porous coated im-
plants had the most stable fixation and were not associated
with any nonunions.6 In another study, Ko and colleagues
followed 12 patients with type B2 fractures treated with the
Wagner revision stem for an average of 58.5 months.46 All
12 patients were found to have stable prostheses and solid
75
Figure 8 A, Radiograph of a
Vancouver type B3 periprosthetic
femur fracture. The fracture is at
the level of the stem, with a loose
implant, and poor bone quality.
B, In this elderly, low demand
patient, a proximal femoral re-
placement was used.
fracture union. In summary, type B2 fractures are complex
procedures needing both stabilization of the fracture while
also revising the femoral component.
Vancouver Type B3
Revision arthroplasty is the treatment of choice for type
B3 fracture patterns. There are no major series of type B3
fractures in the literature. However, these are challenging
cases with a high rate of complications. It is essential that
the implant obtain adequate distal fixation to provide axial
and rotational stability, as the proximal bone does not usu-
ally give sufficient support. In young patients, restoration
of bone stock is a priority; therefore, an allograft-prosthesis
composite is an attractive option.47 Wong and associates
reported their experience with 15 type B3 fractures treated
with an allograft-prosthesis composite, with a rate of heal-
ing of 93.3%.32
In older and low functional demand patients, a proximal
femoral replacement or “megaprosthesis” may be used (Fig.
8). In contrast to an allograft composite, this option allows
immediate weightbearing after surgery, which is an essential
component of care for this population group.21 Because of
soft tissue deficiency, a constrained acetabular liner may be
needed to prevent instability. There are only scarce reports
of treatment outcomes for Vancouver type B3 periprosthetic
fractures. Proximal femoral replacement for these fractures
has been shown to be effective with a 64% survivorship at
12 years.48
Impaction grafting and cemented stem fixation should
be considered for select cases of femoral periprosthetic
fractures, with significant comminution at or below the level
of the femoral isthmus that can prevent achieving axial and
rotational stability of a traditional long cementless porous-
coated femoral stems. The advantages of long-stem cement-
76 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78
Type C
Adequate Poor
bone stock bone stock
Plate Plate and
fixation strut graft
fixation
Figure 9 Treatment algorithm for Vancouver type C periprosthetic
femur fractures.
ed femoral fixation augmented with impaction bone grafting
include intramedullary fixation of the implant, presence of
osteoconductive agents at the fracture site, immediate stabil-
ity provided by the use of cement, and potentially reliable
long-term prosthetic fixation and restoration of bone stock.49
An alternative to impaction grafting is the use of modular
long-stemmed fluted cementless femoral components, as
these stems do not require as much femoral diaphysis for
fixation compared with the traditionally fully porous-coated
implants and they provide three-point fixation to anchor
the prosthesis distally. Berry and coworkers reported the
outcomes of seven patients with type B3 fractures treated
with fluted, tapered stems and followed for an average of
2 years.50 All fractures healed, and all implants were stable
as of the most recent follow-up. In a study of 24 patients
A B
with type B2 and B3 fractures treated with cementless, ta-
pered, fluted and distally fixed stems, Mulay and colleagues
reported that 91% of fractures healed although there were
five dislocations and two nonunions.51
Vancouver Type C
Surgical fixation is the treatment of choice for this pattern
of fractures (Fig. 9). There are numerous types of fixation
devices available to address these fractures including locking
plates, screw and cable hybrid plates, and intramedullary
devices. Our recommended implant of choice is a hybrid
plate with unicortical screws and cable fixation proximally
around the femoral stem and bicortical screws distal to the
femoral stem (Fig. 10). Occasionally, a strut allograft may
be used to provide a more stable construct. Care should be
taken to avoid leaving a segment of weak, unprotected bone,
between the intramedullary implant and the proximal end
of the plate. Adequate overlap should be achieved to avoid
such stress risers that may lead to a recurrent fracture.
The main concern with intramedullary nail fixation relates
to the possibility of creating a stress riser between the tip of
the nail and the femoral component. Fractures close to the
tip of the stem may be treated with the same techniques as
type B1 fractures.
Outcomes
Outcomes of periprosthetic femur fractures have been
reported on by many investigators. Young and coworkers
compared 232 periprosthetic femur fracture patients with
matched patients who underwent total hip revision; they
found a higher 6 month mortality rate (7.3% vs. 0.9%, p
< 0.001) and higher likelihood of re-revision (7.3% vs.
Figure 10 A, Radiograph of a
Vancouver type C periprosthetic
femur fracture, occurring distal
to the stem of the total hip arthro-
plasty. This patient also had an
ipsilateral total knee arthroplasty.
Both implants were determined to
be stable. B, A locked plate con-
struct was used with unicortical
screws proximally and bicortical
screws distally, with retention of
both the total hip and total knee
prostheses.
 Bulletin of the Hospital for Joint Diseases 2013;71(1):68-78
2.6%, p = 0.06) in the periprosthetic fracture patients. The
most common indications for re-revision were dislocation
and re-fracture.52 Bhattacharyya and associates reported a
1 year mortality rate of 11% in patients treated operatively
for periprosthetic femur fractures compared with 2.9% in
patients who underwent primary joint replacement, and 16%
among hip fracture patients.53 Revision arthroplasty for the
treatment of type B periprosthetic fractures was associated
with a one-year mortality rate that was three-fold less than
that after surgical treatment with open reduction and inter-
nal fixation. Therefore, the investigators suggested that in
instances when either treatment option is feasible, revision
arthroplasty should be the preferred option.
Summary
The surgical advances achieved in the past years in femoral
periprosthetic fracture care have significantly improved
patient outcomes. The current standard treatment for most
periprosthetic femoral fractures is surgical with osteosyn-
thesis or revision arthroplasty. Consequently, it is essential
to correctly classify the type of fracture and the stability of
the prosthesis as failure to identify an unstable implant is
likely to lead to treatment failure if osteosynthesis rather
than revision surgery is performed.
Poor cortical bone quality is a common finding among
patients presenting with total hip periprosthetic femoral
fractures, thus it is imperative that adequate and sufficient
mechanical fixation be achieved in the treatment of these
patients. The patient’s final outcome is dependent on early
functional recovery and return to pre-injury independence.
Routine radiological follow-up of high-risk patients may
help to identify loose implants and enable early intervention
prior to fracture occurrence. With an expected rise in the
prevalence of periprosthetic fractures, further advancements
in surgical management of these complex patients are war-
ranted.
Disclosure Statement
None of the authors have a financial or proprietary interest
in the subject matter or materials discussed, including, but
not limited to, employment, consultancies, stock ownership,
honoraria, and paid expert testimony.
Acknowledgments
The authors would like to thank Dr. Kenneth Egol and Dr.
Nirmal Tejwani for providing some of the images used in
this manuscript.
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