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 login to view 2 more bullets techniques login to view 3 more bullets Operative open reduction internal fixation (ORIF) greater trochanter indications login to view 1 more bullet approaches login to view 1 more bullet techniques login to view 2 more bullets open reduction internal fixation (ORIF) femoral diaphysis/metaphysis indications login to view 9 more bullets timing login to view 1 more bullet approaches login to view 2 more bullets techniques login to view 5 more bullets outcomes login to view 1 more bullet revision arthroplasty (hemiarthroplasty or conversion to total hip arthroplasty) indications login to view 1 more bullet timing login to view 1 more bullet techniques login to view 11 more bullets outcomes login to view 2 more bullets proximal femoral replacement (PFR) indications login to view 1 more bullet techniques login to view 3 more bullets 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