Proximal femoral periprosthetic fractures: A review of current concepts

Periprosthetic femoral fractures (PFFs) are a serious complication of total hip arthroplasty (THA) and are expected to become more frequent as older patients live longer with osteoporotic bone and well-fixed implants. This review summarizes recent evidence to support rational prevention and management. A narrative review of contemporary clinical, registry, and biomechanical studies on proximal femoral PFFs was performed, focusing on epidemiology and risk factors, femoral stem design and biomechanics, classification, treatment of Vancouver B fractures, and peri-operative optimization. Registry and cohort studies show that PFFs occur mainly in frail older patients, with 1 year mortality similar to that after fragility hip fracture. Early post-operative fracture risk is consistently higher after uncemented than cemented THA, while composite beam cemented stems and collared cementless stems appear to reduce risk compared with polished taper slip and collarless designs. Short stems and hip resurfacing have theoretical advantages for proximal load transfer but have not shown consistent protection against PFF. Conventional Vancouver and Unified Classification System schemes are less reliable around polished taper slip stems; interface based concepts that focus on cement–bone integrity may better guide management. For selected Vancouver B2 and B3 fractures, especially in physiologically high-risk patients, open reduction and internal fixation can achieve outcomes comparable with revision when the cement–bone interface is intact. Early surgery in orthogeriatric pathways appears important. A design-specific, physiology-led approach combining implant selection, interface-based classification, selective fixation, and peri-operative optimization is central to improving outcomes in PFF. • Design-specific stem risks summarized, beyond cemented versus uncemented. • Interface-based classification proposed for polished taper slip fractures. • Evidence supports ORIF as alternative to revision in selected B2/B3 periprosthetic femoral fractures. • Peri-operative optimization and hip fracture style pathways emphasized. • Short stems and resurfacing critically appraised for fracture risk.