Periprosthetic Hip Fracture: Specialist Treatment in Birmingham
A periprosthetic fracture is a broken bone occurring around a hip replacement implant. Often triggered by a fall, these fractures are more common in older patients or those with reduced bone density. The treatment depends entirely on whether the hip implant stem remains firmly fixed in the bone, and on the location and pattern of the fracture using the Vancouver classification. Mr Shakir Hussain, Consultant Orthopaedic Surgeon at the Royal Orthopaedic Hospital Birmingham, manages periprosthetic hip fractures with both fixation and revision surgery depending on the clinical picture.
What is a periprosthetic hip fracture?
A periprosthetic fracture is a fracture that occurs at, around, or just below the components of a hip replacement. The femur (thighbone) is by far the most commonly affected bone. These fractures require specialist management because the presence of the implant complicates both fixation and revision surgery, and because determining whether the femoral stem remains well-fixed is the single most important decision in treatment planning.
Periprosthetic hip fractures are becoming more common as the number of patients living with hip replacements increases and as the population ages. The annual incidence in the UK is estimated at 1 to 3 per cent of all hip replacements over a ten-year period, and the number of cases is rising year on year. Management requires specialist experience in both fracture fixation and complex revision hip surgery.
The Vancouver classification is the universally adopted system for categorising these fractures by location and stem stability. Understanding this classification is essential because it directly determines treatment:
| Type | Location | Stem fixation | Typical treatment |
|---|---|---|---|
| AG | Greater trochanter | Well-fixed | Often non-operative if minimally displaced; fixation with cables/wires if displaced |
| AL | Lesser trochanter | Well-fixed | Fixation; rare and usually low consequence |
| B1 | Around or just below the stem | Well-fixed | Open reduction and internal fixation (ORIF) with locking plate and cerclage cables |
| B2 | Around or just below the stem | Loose; adequate bone stock | Revision hip replacement with long bypass femoral stem |
| B3 | Around or just below the stem | Loose; poor bone stock | Complex revision; may require proximal femoral replacement |
| C | Below the tip of the stem | N/A (fracture distal to stem) | Standard femoral shaft fixation; hip implant usually preserved |
The critical distinction that drives treatment is whether the femoral stem is well-fixed (B1) or loose (B2/B3). A well-fixed stem can be preserved and the fracture managed with fixation around it. A loose stem must be revised with a longer component that bypasses the fracture zone entirely to achieve fixation in healthy bone below. Getting this distinction wrong leads to fixation failure or persistent stem instability.
What are the signs of a fracture around a hip replacement?
Most periprosthetic hip fractures present after a fall with sudden severe hip or thigh pain and immediate inability to weight bear. The leg may appear shortened and rotated. Swelling and bruising develop over hours to days along the thigh. Some patients report a period of increasing thigh pain before the fracture occurs, indicating the stem was already loosening.
Sudden severe hip or thigh pain
Typically follows a fall or low-energy injury. The pain is immediate and severe, located in the hip, groin, or along the thigh depending on fracture location. All weight bearing becomes impossible.
Inability to weight bear
Patients cannot stand or walk after a periprosthetic fracture. Any attempt at weight bearing produces immediate severe pain and possible further displacement of the fracture fragments.
Leg shortening and rotation
The fractured leg appears shorter and rotated outward or inward, depending on the fracture pattern and whether the hip implant has also dislocated at the time of the fracture.
Swelling and bruising along the thigh
As the fracture haematoma develops over hours to days, swelling and bruising extend along the femoral shaft. The thigh may appear visibly deformed and feel tense to the touch.
Crepitus on movement
A grating or crunching sensation is felt and sometimes heard if the limb is moved during assessment. This indicates bone fragment movement at the fracture site and is an important clinical sign.
Pre-existing thigh pain before the fracture
Some patients report weeks or months of increasing thigh pain before the acute fracture event, particularly in B2 fractures where the femoral stem was already loosening. This history is clinically important and guides surgical planning.
What causes a fracture around a hip replacement?
Most periprosthetic fractures result from a fall in elderly patients with osteoporosis. The bone around a hip replacement is mechanically different from normal bone: stress concentrates at the tip of the femoral stem, making that region particularly vulnerable to fracture even in low-energy injuries such as a simple trip and fall.
Several factors increase the risk of periprosthetic fracture beyond the background population risk:
- Osteoporosis. Reduced bone mineral density is the most important systemic risk factor. The cortical bone around the femoral stem must absorb the stress concentrations created by the implant. When bone density is low, this stress concentrates to a fracture-inducing level even in low-energy falls.
- Stress concentration at the stem tip. The stiffness mismatch between the metal femoral stem and the surrounding bone means that stress is concentrated at the point where the stem ends. This region, just below the tip of the stem, is where the majority of B-type fractures occur.
- Osteolysis around the implant. Wear debris from the bearing surfaces stimulates bone resorption (osteolysis) around the implant, creating areas of weak, thinned cortical bone that are susceptible to fracture. This is the mechanism that links bearing wear to periprosthetic fracture risk.
- Prior cortical perforation or stress riser. If the cortex was perforated or scratched during the original hip replacement surgery (for example, during broaching or cement removal), the resulting notch acts as a stress riser that dramatically reduces the force required to propagate a fracture.
- Long-term corticosteroid use. Systemic corticosteroids suppress bone turnover and reduce bone mineral density, compounding the risk already present from ageing and reduced mobility.
- Uncemented press-fit stems. While modern uncemented stems achieve excellent long-term fixation, the cortical strains generated during initial press-fit implantation can produce intra-operative fractures or, when there is inadequate cortical support, early post-operative fractures before bone on-growth is established.
How is a periprosthetic hip fracture investigated?
AP pelvis and full-length femur X-rays are mandatory for every periprosthetic hip fracture. CT of the hip is often required for complex fracture patterns or where stem stability is uncertain. Critically, pre-fracture imaging is reviewed where available to assess whether the stem was already showing signs of loosening before the injury.
Accurate imaging is essential not only to characterise the fracture but to determine whether the stem is well-fixed. This is the decision that drives the entire surgical strategy:
- AP pelvis and full-length femur X-rays. The AP pelvis confirms the fracture pattern around the cup and proximal femur. A full-length femur X-ray is essential to show the complete extent of the fracture, the position of the stem tip relative to the fracture, and any fracture line extending below the stem tip (indicating Type C).
- CT with 3D reconstruction. Provides precise fracture mapping, particularly for complex B-type fractures where the fracture pattern extends around the stem. CT is also essential for planning hardware positioning in ORIF, identifying the most stable cortical segments for cable placement, and assessing bone stock for revision stem selection.
- Review of pre-injury imaging. Where available, pre-fracture X-rays are reviewed for radiolucent lines at the stem-cement or cement-bone interface, progressive stem subsidence, or cortical thickening (a sign of adaptive remodelling that indicates stem stability). These features are critical in classifying B1 (stable stem) versus B2 (unstable stem) fractures.
- Nuclear medicine bone scan (selected cases). In equivocal cases where stem fixation status cannot be determined from plain films and CT alone, a nuclear medicine bone scan can identify areas of increased metabolic activity around the stem that indicate loosening.
How is a periprosthetic hip fracture treated?
Treatment is determined by the Vancouver classification. Type B1 fractures with a well-fixed stem are treated with open reduction and internal fixation (ORIF) using locking plates and cerclage cables around the preserved implant. Type B2 and B3 fractures require revision hip replacement with a long femoral stem that bypasses the fracture zone and achieves fixation in healthy bone below.
Selecting the correct surgical approach for the correct fracture type is the central challenge in periprosthetic fracture management. Attempting to fix a fracture around a loose stem with plates and cables alone will fail, as there is no stable base for the fixation to resist weight-bearing forces. Conversely, revising a stem that is actually well-fixed exposes the patient to unnecessary surgical risk and bone loss.
Open Reduction and Internal Fixation (ORIF)
For B1 fractures where the stem is confirmed well-fixed on pre-operative imaging, the surgical strategy is to fix the fracture while leaving the stem entirely undisturbed. Locking plates that grip the outer cortex of the femur are combined with cerclage cables (wire or titanium bands that encircle the femur) to hold the fracture fragments around the implant. Bone graft or synthetic bone substitute may be added at the fracture site. Partial weight bearing is typically permitted from the first few post-operative days, progressing to full weight bearing over six to twelve weeks as the fracture heals.
- Femoral stem preserved undisturbed within the bone
- Locking plate applied to outer cortex for angular stability
- Cerclage cables encircle the femur to grip without disturbing stem fixation
- Bone graft at fracture site where cortical contact is inadequate
- Partial weight bearing from day one to two post-operatively
Revision Hip Replacement with Long Bypass Stem
For B2 and B3 fractures where the stem is loose, revision hip replacement is required. A long revision femoral stem is selected that passes through the fracture zone and extends well below it, achieving fixation by press-fit or cementation in the healthy cortical bone of the distal femur below the fracture. The fracture is simultaneously reduced and held with cerclage cables while the stem provides the mechanical support. For B3 fractures with severe bone loss, a proximal femoral replacement (a modular mega-prosthesis) may be necessary to reconstruct the proximal femur.
- Long revision stem bypasses the fracture zone entirely
- Fixation achieved in healthy bone below the fracture
- Cerclage cables hold fracture reduced around the long stem
- Proximal femoral replacement for catastrophic B3 bone loss
- Weight bearing protocol tailored to bone reconstruction achieved
Type AG fractures (greater trochanter) are managed individually based on the degree of displacement. Minimally displaced fractures in elderly patients are often managed non-operatively with protected weight bearing, as the functional consequences of greater trochanter non-union are usually acceptable. Displaced fractures causing significant abductor weakness may be fixed with tension band wiring or cable-plate systems.
Mr Hussain performs complex revision hip replacement at the Royal Orthopaedic Hospital Birmingham, with access to the full range of long revision stems, cerclage systems, and proximal femoral replacement components required for all fracture types. For more information, see the dedicated revision surgery page.
What are the outcomes after surgery for a periprosthetic hip fracture?
Outcomes after periprosthetic hip fracture surgery are good in specialist hands when the correct Vancouver classification is made pre-operatively. ORIF for B1 fractures achieves union in 85 to 90 per cent of cases. Revision surgery for B2 and B3 fractures achieves satisfactory functional outcomes in over 80 per cent of patients managed at specialist centres.
The key determinants of outcome are accurate fracture classification, correct identification of stem fixation status, and the availability of the full range of revision implant systems at a specialist centre. Cases managed at hospitals without access to long revision stems or proximal femoral replacement components are at substantially higher risk of fixation failure and reoperation.
Periprosthetic fractures in elderly patients carry risks beyond the orthopaedic surgery itself. Pre-operative medical optimisation, venous thromboembolism prophylaxis, and careful post-operative rehabilitation are as important as the surgical technique. The Royal Orthopaedic Hospital Birmingham provides comprehensive peri-operative care for complex revision cases, including specialist physiotherapy and access to the wider multi-disciplinary team.
Specialist expertise in periprosthetic hip fracture in Birmingham
Consultant at the Royal Orthopaedic Hospital
Mr Hussain practises at the Royal Orthopaedic Hospital Birmingham, with full access to complex revision implant systems including long revision stems, proximal femoral replacements, and specialist fracture fixation equipment.
3,000+ arthroplasty cases from 5,000+ procedures
A high operative volume including complex primary and revision hip cases. Read more about Mr Hussain's training and background.
British Hip Society Travelling Fellowship at ENDO-Klinik Hamburg
Specific experience in complex revision hip surgery including management of bone loss and fracture around implants, under Professor Thorsten Gehrke and Professor Mustafa Citak.
Complex revision surgery expertise
Mr Hussain performs revision hip replacement for the full spectrum of failure modes including fracture, loosening, and infection. See the revision surgery page for full details.
Doctify Outstanding Patient Experience 2024, 2025, and 2026
Awarded in three consecutive years, recognising consistently high patient-reported outcomes and communication throughout the surgical journey.
4.98 out of 5 from verified reviews on Doctify. Outstanding Patient Experience Award 2024, 2025, and 2026.
Frequently asked questions about periprosthetic hip fracture
For more questions about surgery, recovery, fees, and what to expect, see the full frequently asked questions page or read recent patient testimonials.