Periprosthetic hip fractures: an update into their management and clinical outcomes

Overview

This review updates the management of fractures around total hip replacements and proposes a treatment algorithm. As more people live longer with hip replacements, these fractures are becoming more common. Most follow a simple fall in older patients with weak bone. Treating them well requires combined trauma and joint-replacement expertise.

Assessment

Earlier symptoms such as thigh or groin pain may point to a loosening implant. Infection must always be ruled out, and blood inflammatory markers are unreliable for this. Full-length radiographs, previous images and often CT help define the fracture, bone stock and cement mantle. Whether the stem is loose is often misjudged before surgery and is best confirmed during the operation. The Vancouver classification, based on fracture location, stem stability and bone quality, remains the standard, but frailty, stem type and signs of infection should also be weighed.

Treatment

Non-operative treatment generally gives poor results, except in patients too ill for surgery. Fractures of the greater or lesser trochanter are usually managed conservatively unless underlying bone loss or an unstable implant requires surgery. Fractures around a stable stem are mostly fixed with plates, cables and sometimes bone struts. Simple short fractures exactly at the stem tip may do better with revision to a longer stem. Fractures around a loose stem usually need revision with a long stem. Fixation alone can suit selected frail patients, or fractures around cemented polished tapered stems with good bone and an intact cement mantle. When bone stock is poor, reconstruction with allograft composites or proximal femoral replacement may be needed. Fractures below the stem are fixed with a long plate that overlaps the implant and protects the whole femur. Good fixation depends on restoring length, axis and rotation, using minimally invasive locking bridge plates, and the longest plate possible.

Other fractures and outcomes

The review also covers fractures between hip and knee replacements and fractures of the acetabulum, both uncommon but increasing. Early mortality is similar to that of ordinary hip fractures, and many patients do not regain their previous walking ability. Delayed surgery and cognitive impairment worsen outcomes. Because costs and complication rates are high, the authors favour specialised centres with both trauma and arthroplasty skills.