Abstract
Prevention: Many periprosthetic femur fractures may be prevented by: good patient follow-up; timely reoperation of lytic lesions if radiographs suggest fracture risk; prophylactic use of longer stemmed implants or strut grafts to bypass cortical defects at revision surgery.
Treatment: Periprosthetic fractures can be treated using an algorithmic approach based on the Vancouver classification system.
Fractures of greater or lesser trochanter (Type A): nonoperative treatment if displacement acceptable and if not associated with lysis; operative treatment if displacement unacceptable or associated with progressive lysis.
Fractures of distal femur well distal to implant (Type C): treat as any other femur fracture, usually operatively; fixation options: plate/retrograde nails.
Fractures around the implant or at its tip (Type B): these fractures almost always require surgery. Nonoperative treatment is associated with high rate of malunion, nonunion, poor results. Treatment is according to fixation status of implant and bone quality.
Well-fixed stem (Type B1): ORIF with cable plate and/or strut grafts; or with locking plate and minimally invasive biologic technique.
Loose stem (Type B2 and Type B3): revise implant to long stem; usually use uncemented distally-fixed implant; occasionally long cemented stem (avoid cement extrusion). In most cases we favor use of a modular fluted tapered stem which provides axial and rotational stability by fixation distal to the fracture.
Principles: obtain fracture stability, implant stability, and optimise conditions for bone healing (use bone grafts, don't strip periosteum)
