Summary Periprosthetic fractures involving hip hemiarthroplasty are rare fractures that occur near or around femoral stems, often caused by low energy trauma, leading to possible implant instability, pain, and immobility. These fractures typically occur in geriatric patients with underlying osteoporosis. Treatment usually involves open reduction and internal fixation or revision hip arthroplasty, although certain fractures can be treated nonoperatively. Epidemiology Incidence approximately 1 to 4% of all hip hemiarthroplasties 1 to 7.4% of uncemented hemiarthroplasties 0.2 to 1.3% of cemented hemiarthroplasties Risk factors demographics increasing age female gender medical osteoporosis surgical use of an uncemented stem; demonstrated by multiple RCTs and registry studies undersized femoral components use of a slip-taper stem if performing cemented arthroplasty Etiology Pathophysiology mechanism of injury typically caused by a ground level fall Associated conditions medical osteoporosis orthopaedic stress-shielding and peri-implant osteopenia infection osteolysis subsidence Classification Vancouver Classification & Treatment Type Description Treatment AG Greater trochanteric fracture ORIF for fractures with >2cm displacement (to prevent abductor escape) AL Lesser trochanteric fracture Nonoperative B1 Fracture around stem, well fixed ORIF B2 Fracture around stem, loose Revision hemiarthroplasty ORIF + revision hemiarthroplasty B3 Fracture around stem, loose with poor bone stock Revision proximal femoral replacement C Fracture distal to stem ORIF Presentation History ground level fall history of startup pain may indicate antecedent loosening progressive pain, constitutional symptoms, or wound complications should raise concern for prosthetic joint infection Symptoms pain inability to bear weight Physical exam shortened, externally rotated limb pain with log roll a thorough examination of prior scars for surgical planning Imaging Radiographs recommended views AP and lateral femoral radiographs to evaluate the fracture pattern, displacement, and implant position. AP pelvis if planning revision of the component CT indications evaluate implant stability and detailed fracture morphology. better fidelity in evaluating the integrity of the cement mantle Treatment Nonoperative protected weightbearing with restricted abduction indications Vancouver AG fractures (<2 cm displacement) Vancouver AL fractures techniques protected weight bearing consider early weightbearing with walker support in the elderly restriction of active hip abduction x 6-12 weeks for Vancouver AG fractures Operative open reduction internal fixation (ORIF) greater trochanter indications Vancouver AG (>2 cm displacement) approaches lateral approach to the proximal femur techniques use of claw plates, cables, or tension band wiring if performing revision (see below) with certain modular stems, can use a trochanteric bolt or attachment open reduction internal fixation (ORIF) femoral diaphysis/metaphysis indications Vancouver B1 fractures Vancouver C fractures Vancouver B2 fractures (controversial) Favorable outcomes in select B2 fractures, particularly in elderly, lower demand patients favorable factors simple fracture pattern anatomic reduction no prior stem loosening intact bone-cement interface timing performed as soon as medically optimized approaches lateral approach (subvastus) MIPO techniques polyaxial locking plates proximal fixation with combination cables, cerclage, or screws drilling into cement results in increased pullout strength but may compromise cement mantle minimally invasive techniques with submuscular plating cable allograft struts (controversial) outcomes 15% complication rate revision arthroplasty (hemiarthroplasty or conversion to total hip arthroplasty) indications Vancouver B2 fractures timing performed as soon as medically optimized techniques revision to uncemented diaphyseal-engaging stem that bypasses fracture site by two cortical diameters +/- ORIF monoblock cylindrical stems modular fluted tapered stems +/- the addition of plate/cable/screw/bolt fixation of proximal fragments (greater trochanter) revision to long cemented stem +/- ORIF (controversial) cement may become trapped in fracture site and compromise healing cement-in-cement revision may have similar outcomes to uncemented tapered stems in select patients ORIF + revision arthroplasty with metaphyseal-engaging components controversial to use metaphyseal engaging components in the setting of fracture restore the proximal femoral geometry cemented or uncemented proximal metaphyseal filling stem outcomes up to 25% complication rate with both revision total hip arthroplasty and isolated ORIF for Vancouver B2 increased blood loss with revision arthroplasty than open reduction internal fixation proximal femoral replacement (PFR) indications Vancouver B3 fractures techniques complete resection of fracture cemented or uncemented proximal femoral replacement trochanteric fixation with suture, cable, or wires to implant Complications Infection Dislocation Refracture Stem subsidence Implant Failure Trochanteric Escape Prognosis Mortality approximately 25% mortality at 1 year, up to 50% at 2 years Morbidity high complication rate patients who receive hemiarthroplasty for femoral neck fracture are generally older and more comorbid may see a rise in mortality rates with hip hemiarthroplasty periprosthetic fractures Prognostic variable early mobilization is critical in preventing medical complications surgical delay associated with increased mortality