It is well appreciated that thigh pain following recent arthroplasty surgery is likely to be due to prosthetic loosening or infection. Both these sequelae can lead to periprosthetic fracture presenting complex challenges to even experienced surgeons.

Revision arthroplasty patients are prone to both fatigue and insufficiency fractures as they may have reduced bone stock after previous surgery and reduced bone density secondary to medical and immobility reasons. The post operative painfree condition will frequently permit early load bearing leading to a relatively rapid increase in activity and load bearing.

Fatigue fractures occur in bone of normal quality subject to abnormal cyclical overloading, leading to resorption and eventual failure, before adequate time has passed to permit adaptive remodelling. Insufficiency fractures occur when normal physiological loads are applied to bone of abnormal quality.

Surprisingly few periprosthetic stress fractures are reported in the literature but a series notes lateral tensile stress fractures associated with varus prosthetic alignment. These all occurred near the tip of the prosthesis.

The case of an unusual Gruen Zone 2, Vancouver B1 stress fracture, 9 months following revision arthroplasty is reported. Initially loosening was suspected due to the development of load bearing thigh pain. Plain radiography revealed the development of a dreaded black line, consistent with a stress fracture. Bone scintigraphy revealed the typical appearance of a stress fracture in the absence of loosening or infection.

The unusual location of this stress fracture allowed consideration of conservative non weight bearing management which lead to the alleviation of symptoms rather than further revision surgery.

This report illustrates this unusual stress fracture and highlights the importance of careful loading practises to permit adequate remodelling following complex revision surgery.

Background: Fracture neck of the femur (NOF) is one of the indications for Total Hip Replacement (THR). However, the practice is not the same throughout the world.

Aim: We compared the use of THR in the management of the fracture NOF using the annual reports of the National Joint Registries from various countries.

Material and Methods: We used the latest available on line annual report of seven national arthroplasty registries to ascertain the rate of use of THR for fractures of the neck of the femur. The registries from Australia, Canada, Norway, Sweden, and the UK gave a detailed breakup of the indications for THR in their reports.

Results: 11.9% of the all the THRs performed in Norway since 1987 were for NOFs. · 11.39% of all the THRs performed in Sweden since 1992 were for NOFs.

6.0% of the THRs performed in Canada in 2002–2003 were for NOFs.

The registries from Finland and New Zealand had no detailed information on their websites regarding the indications for THA surgery.

Discussion: In the Scandinavian countries, THR is performed for the management of a NOF 6 times more often than in the UK, and 4 times more often than in Australia. It is unlikely that the prevalence of patients with previous osteoarthritis of hip who sustain a NOF is higher in the Scandinavian countries than in the UK. Women in Sweden have a higher lifetime risk of hip fracture and live longer, so a procedure providing a good long term results would be beneficial. Provision of health care may also influence surgical management options. The long waiting lists for elective THR in the UK may explain the low number of THRs performed for NOFs.