Summary Periprosthetic fractures about hemiarthroplasty are rare fractures that occur near or around femoral stems, often caused by 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 incidence approximately 2% of hip hemiarthroplasties Risk factors demographics increasing age female gender medical osteoporosis inflammatory arthropathy surgical multiple randomized control trials demonstrate that uncemented stems have a higher risk of fracture undersized femoral components controversial but some evidence that polished slip-taper stems have a higher risk of fracture than composite-beam stems this risk may be mitigated with line-to-line cementing (French paradox) 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 low energy trauma ground level fall history of startup pain may indicate antecedent loosening history of wound complication, recurrent swelling, pain, or systemic signs of infection may warrant a workup 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 Laboratory Studies Infection workup labs serum ESR, CRP joint aspiration lower specificity in serum and synovial markers using the MSIS guidelines in the setting of concomitant fracture Treatment Nonoperative protected weightbearing with restricted abduction indications Vancouver AG fractures (<2cm displacement) Vancouver AL fractures techniques protected weight bearing with a walker recommend restriction of active hip abduction for 6-12 weeks Operative open reduction internal fixation (ORIF) greater trochanter indications Vancouver AG (>2cm 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) similar overall complication and revision rate with revision total hip arthroplasty in B2 fractures lower risk of postoperative dislocation with ORIF timing performed as soon as medically cleared approaches typically lateral approach (subvastus) utilize caudal extent of hip arthroplasty incision if available can use percutaneous or submuscular plating techniques techniques variable angle locking plates proximal fixation with combination cables, cerclage, or screws drilling into the cement mantle results in extremely high pullout strength but can compromise the cement mantle minimally invasive techniques with submuscular plating cable allograft struts (controversial) outcomes 15% complication rate approximately 10% revision rate revision arthroplasty (hemiarthroplasty or total hip arthroplasty) indications Vancouver B2 fractures timing performed as soon as medically cleared techniques revision arthroplasty with diaphyseal engaging stems to bypass the fracture monoblock cylindrical stems modular fluted tapered stems +/- the addition of plate/cable/screw/bolt fixation of proximal fragments (greater trochanter) ORIF of proximal femur with revision arthroplasty utilizing standard metaphyseal engaging components 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 and risk of dislocation 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