summary THA Periprosthetic Fractures are a complication of a total hip prosthesis with increasing incidence as a result of increased arthroplasty procedures and high-demands of elderly patients. Diagnosis can be made with plain radiographs of the affected hip and ipsilateral femur. Treatment may be nonoperative or operative based on location of fracture, implant stability and bone stock available. Epidemiology Incidence intraoperative fractures 3.5% of primary uncemented hip replacements 0.4% of cemented arthroplasties postoperative fractures 0.1% most common at stem tip Etiology Classification intraoperative fractures femur acetabulum postoperative fractures femur acetabulum Prevention preoperative templating reduces risk of intraoperative fractures adequate surgical exposure special care when using cementless prosthesis in poor bone (RA, osteoporosis) Intraoperative Acetabular Fractures Introduction incidence cemented acetabular components login to view 1 more bullet cementless acetabular components login to view 1 more bullet mechanism typically occurs during acetabular component impaction risk factors underreaming >2mm elliptical modular cups osteoporosis cementless acetabular components dysplasia radiation Evaluation must determine stability of implant Treatment observation alone indications login to view 1 more bullet postoperative care login to view 1 more bullet acetabular revision with screws vs. ORIF indications login to view 1 more bullet technique login to view 5 more bullets postoperative care login to view 1 more bullet Intraoperative Femur Fractures Introduction incidence primary THA login to view 1 more bullet revision THA login to view 1 more bullet mechanism proximal fractures login to view 2 more bullets middle-region fractures login to view 1 more bullet distal fractures login to view 1 more bullet risk factors impaction bone grafting female gender technical errors cementless implants osteoporosis revision minimally invasive techniques (controversial) Presentation change in resistance while inserting stem should raise suspicion for fracture Classification Vancouver classification (intraoperative) considerations login to view 3 more bullets types login to view 3 more bullets subtypes login to view 3 more bullets Imaging intraoperative radiographs are required when there is a concern for fracture Treatment stem removal, cabling, and reinsertion indications login to view 1 more bullet trochanteric fixation with wires, cables, or claw-plate indications login to view 1 more bullet removal of implant, insertion of longer stem prosthesis indications login to view 1 more bullet technique login to view 2 more bullets removal of implant, internal fixation with plate, reinsertion of prosthesis indications login to view 1 more bullet Vancouver Classification & Treatment - Intraoperative Periprosthetic Fracture Type Description Treatment A1 Proximal metaphysis, cortical perforation Bone graft alone (e.g. from acetabular reaming) A2 Proximal metaphysis, nondisplaced crack Cerclage wire before inserting stem (to prevent crack propagation) Ignore the fracture if fully porous coated stem is used (provided there is no distal propagation) A3 Proximal metaphysis, displaced unstable fracture Fully porous coated stem, or tapered fluted stem Wires/cables/claw plate for isolated GT fractures B1 Diaphyseal, cortical perforation (usually during cement removal) Fully porous coated stem (bypass by 2 cortical diameters) ± strut allograft B2 Diaphyseal, nondisplaced crack (from increased hoop stress during broaching or implant placement) Cerclage wire (if implant stable) Fully porous coated stem to bypass defect (if implant unstable) ± strut allograft PWB and observation (if detected postop) B3 Diaphyseal, displaced unstable fracture (usually during hip dislocation, cement removal, stem insertion) Fully porous coated stem to bypass defect ± strut allograft C1 Distal to stem tip, cortical perforation (during cement removal) Morcellized bone graft, fully porous coated stem to bypass defect, strut allograft C2 Distal to stem tip, nondisplaced fracture Cerclage wire, strut allograft C3 Distal to stem tip, displaced unstable fracture ORIF Postoperative Femur fracture Introduction incidence 0.1-3% for primary cementless total hip arthroplasties etiology early postoperative fractures login to view 4 more bullets late postoperative fractures login to view 2 more bullets risk factors poor bone quality cementless prostheses compromised bone stock revision procedures Collarless stems Classification Vancouver classification (postoperative) considerations login to view 3 more bullets pros login to view 2 more bullets cons login to view 1 more bullet Vancouver Classification & Treatment - Postoperative Periprosthetic Fracture Type Description Treatment AG Fracture in greater trochanteric region. Commonly associated with osteolysis. AG (greater trochanter) fractures caused by retraction, broaching, actual implant insertion, previous hip screws. Often requires treatment that addresses the osteolysis. AG fractures with < 2cm displacement, treat nonoperatively with partial WB and allow fibrous union. AG fractures >2cm needs ORIF (loss of abductor function leads to instability) with trochanteric claw/cables AL Fracture in lesser trochanteric region. AL fractures are commonly treated non-operatively B1 Fracture around stem or just below it, with a well fixed stem ORIF using cerclage cables and locking plates B2 Fracture around stem or just below it, with a loose stem but good proximal bone stock Revision of the femoral component to a long porous-coated cementless stems and fixation of the fracture fragment. Revision of the acetabular component if indicated B3 Fracture around stem or just below it, with proximal bone that is poor quality or severely comminuted Femoral component revision with proximal femoral allograft (APC) or proximal femoral replacement (PFR) C Fracture occurs well below the prosthesis ORIF with plate (leave the hip and acetabular prosthesis alone) Presentation often result after low-energy trauma Treatment nonoperative treatment with protected weight-bearing indications login to view 2 more bullets technique login to view 1 more bullet ORIF greater trochanter with wires, cables, or claw-plate indications login to view 1 more bullet technique login to view 1 more bullet ORIF femoral shaft with locking plate and cerclage wires indications login to view 2 more bullets technique login to view 3 more bullets femoral component revision with long-stem prosthesis indications login to view 2 more bullets femoral component revision with proximal femoral allograft indications login to view 1 more bullet femoral component revision with proximal femoral replacement indications login to view 1 more bullet