Fracture after Total Hip Replacement

A periprosthetic fracture refers to a break in the bone surrounding a hip replacement implant. These fractures can occur during the initial surgery or years later as the bone or implant weakens. As more people undergo hip replacement surgery and live active lives into older age, these types of fractures have become more common. They are significant because they can lead to pain, instability, and difficulty walking, often requiring additional surgery for repair.

How Common It Is and Who Gets It? (Epidemiology)

Periprosthetic fractures are relatively uncommon but increasing as hip replacement surgeries become more frequent. They occur more often in older adults, particularly those with osteoporosis or other conditions that weaken bone strength. Women and individuals with prior hip surgeries are also at higher risk. Many fractures happen years after the original hip replacement due to natural wear and tear or loosening of the implant.

Why It Happens – Causes (Etiology and Pathophysiology)

Periprosthetic fractures can occur during or after hip replacement surgery. During surgery, they may result from the use of excessive force, improper implant fit, or weakened bone from osteoporosis or radiation therapy. After surgery, fractures may develop from falls, trauma, or gradual weakening of the bone due to implant loosening or increased physical activity. Cementless hip implants are more prone to early postoperative fractures, while cemented implants tend to fracture later.

X-ray showing a total hip replacement surgery.

How the Body Part Normally Works? (Relevant Anatomy)

The hip joint is a ball-and-socket joint formed by the femoral head (ball) and the acetabulum (socket) in the pelvis. A total hip replacement replaces these parts with artificial components that restore movement and relieve pain. Surrounding muscles, tendons, and ligaments stabilize the joint, while strong thigh and pelvic bones bear the body’s weight. When a fracture occurs near the implant, it disrupts this balance and may affect the stability of the artificial joint.

What You Might Feel – Symptoms (Clinical Presentation)

Patients with a periprosthetic fracture typically experience sudden, severe hip or thigh pain and an inability to bear weight on the affected leg. The leg may appear shortened, rotated, or abnormally positioned. Swelling, bruising, and deformity around the hip may also occur. These symptoms often require urgent medical attention.

How Doctors Find the Problem? (Diagnosis and Imaging)

Doctors diagnose periprosthetic fractures using a physical exam and imaging studies. X-rays are usually the first step and show the location and extent of the fracture. In complex cases, a CT scan may help evaluate the stability of the implant and the condition of surrounding bone. The surgeon will determine whether the implant remains secure or if revision surgery is needed.

Classification

Periprosthetic fractures are commonly classified based on their location and whether the implant is stable. The Vancouver classification system is widely used:

• Type A: Fracture near the greater or lesser trochanter.

• Type B: Fracture around or just below the stem of the implant, with subtypes depending on implant stability.

• Type C: Fracture well below the implant.
  This system helps guide treatment decisions.

Other Problems That Can Feel Similar (Differential Diagnosis)

Other conditions that may cause similar symptoms include hip dislocation, implant loosening without fracture, stress fractures, infection around the implant, or new hip arthritis in nearby joints. Imaging and examination help distinguish these conditions.

Treatment Options

• Non-Surgical Care – Small, stable fractures—especially those involving the greater or lesser trochanter—may be managed without surgery. Treatment includes rest, protected weight-bearing, and physical therapy.
• Surgical Care – Most periprosthetic fractures require surgery. Procedures may include fixation with plates, screws, or cables, and in some cases, revision of the hip implant using a longer stem or specialized implant. Bone grafts may be added if there is bone loss. The goal is to restore stability, alignment, and allow healing.

Intraoperative acetabulum fractures

Intraoperative fractures occur during the surgery. Cementless fixation, not removing enough bone (under-reaming) before the impaction, metabolic bone disease such as osteoporosis, mal-formation of the acetabulum socket, any history of prior radiation therapy are all risk factors for intraoperative acetabulum fractures.

The fractures are evaluated intraoperative and if found to be stable, only observation is done along with protected weight-bearing. In case the fracture is found to be unstable, an acetabular component revision is done which may involve the use of jumbo cups or additional screws. In cases, where there is bone loss or extensive fracture, additional fixation may be necessary for the form of plates and screws along with bone graft.

Intraoperative femur fractures

Intraoperative femur fractures occur more often during revision total hip replacement rather than primary hip replacement. The fractures occur often during bone preparation of the femur for implant insertion. May occur as a result of a wrong technique, implants or instrument mismatch, or use of excessive force.

Patients with underlying bone metabolic disorders such as osteoporosis are also at an increased risk of intraoperative fractures. The management depends upon the level of fracture and the extent of the fracture. Usually, cables, wires, plates may be used to fix the fracture which is followed by re-insertion of the same implant or an implant with a longer stem.

Postoperative femur fractures

The fractures around the prosthetic joint occurring after the surgery are known as postoperative fractures. The postoperative fracture may occur in the early postoperative period or may occur years after the initial surgery.

Cementless hip arthroplasties are prone to fracture in the first 6 months of the surgery. Similar to intraoperative fractures, patients with diseases such as osteoporosis are at an increased risk of fracture. Compared to cementless fixation, cemented hip arthroplasties often fracture years after the surgery.

The postoperative fracture in the early postoperative period occurs as a result of stressors arising in the area of bone preparation for the implants. The fracture may be located near the upper part of the prosthesis. Cemented hip replacement often fractures below the lower end of the prosthesis.

The periprosthetic fractures occurring years after the initial surgery often occur as a result of aseptic loosening, or due to increased activity level of the patient.

The management of postoperative femur periprosthetic fracture depends upon the type and the extent of the fracture. Fractures of the greater and the lesser trochanter may be managed with the nonoperative treatment in the form of protected weight-bearing.

Displaced fractures may require the use of plates, wires, and screws. The implants may need to be revised along with fixation with other implants. The revised implants may have a longer stem or may be modified to accommodate the screws and plates.

Various revision hip replacement implants.

Recovery and What to Expect After Treatment
Recovery varies based on the type of fracture and the surgical procedure. Patients typically remain in the hospital for several days, followed by physical therapy. Weight-bearing may be limited for several weeks. Full recovery can take several months, and rehabilitation is usually longer than after the initial hip replacement.

Possible Risks or Side Effects (Complications)
Complications may include infection, blood loss, blood clots (deep vein thrombosis), nerve injury, nonunion (failure of the bone to heal), re-fracture, or leg length differences. The risk of these complications is higher than with primary hip replacement surgery due to the complexity of revision procedures.

Long-Term Outlook (Prognosis)
Most patients regain mobility and pain relief after proper treatment, though recovery may take time. The success of surgery depends on the stability of the new implant, bone quality, and adherence to rehabilitation. With appropriate care, patients can return to walking and daily activities, although high-impact activities are often discouraged.

Out-of-Pocket Costs

Medicare

CPT Codes 27236 / 27244 – ORIF of Periprosthetic Hip Fracture (Fixation Using Plates, Screws, or Cables): $282.31 / $290.61

CPT Code 27134 – Revision THA (Both Components, Femoral and Acetabular Replacement): $448.00

CPT Code 27137 – Revision THA (Femoral Component Only): $345.69

CPT Code 27138 – Revision THA (Acetabular Component Only): $359.01

CPT Code 20902 – Bone Grafting (Harvest and Placement of Bone Graft): $63.66

Medicare Part B typically covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover that remaining 20%, significantly reducing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans coordinate with Medicare to fill the coverage gap and reduce the patient’s financial responsibility.

If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans typically cover any remaining coinsurance or small deductibles, which generally range from $100 to $300, depending on your plan and provider network.

Workers’ Compensation

If your periprosthetic hip fracture or need for revision total hip arthroplasty is related to a work injury, Workers’ Compensation will cover all associated medical expenses, including surgery, bone grafting, rehabilitation, and postoperative care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly pays for all approved treatments.

No-Fault Insurance

If your hip fracture or implant failure is linked to an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including fixation, revision surgery, and recovery. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your policy.

Example

James Carter sustained a periprosthetic hip fracture after a previous hip replacement and underwent revision THA (CPT 27134) with an estimated Medicare out-of-pocket cost of $448.00. Since James had supplemental insurance through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the surgery.

Frequently Asked Questions (FAQ)

Q. Is a periprosthetic fracture an emergency?
A. Yes. Severe pain, inability to walk, or visible deformity after hip replacement requires immediate medical evaluation.

Q. Can these fractures heal without surgery?
A. Some minor fractures can heal with rest and limited movement, but most require surgical fixation or implant revision.

Q. How can I reduce my risk?
A. Maintain bone health through diet and medication for osteoporosis, avoid falls, and follow your surgeon’s postoperative instructions.

Summary and Takeaway

A periprosthetic hip fracture is a serious but treatable condition. It typically occurs around a hip implant due to weakened bone or trauma. Most cases require surgery to restore stability and mobility. With careful treatment and rehabilitation, patients can achieve excellent functional recovery and pain relief.

Clinical Insight & Recent Findings

A recent study aimed to predict periprosthetic femoral fractures (PFF) after total hip arthroplasty (THA) by constructing a nomogram model. This model incorporated six key risk factors: age, sex, hip revision, non-cemented prosthesis, trauma history, and osteoporosis.

The study involved 2,528 patients and used logistic regression analysis to identify high-risk populations. The nomogram showed strong predictive accuracy across multiple cohorts and has been externally validated.

The findings emphasize the importance of individualized risk assessments and proactive management strategies for patients undergoing THA to reduce the risk of PFF. (“Study on predicting hip fractures after total hip replacement surgery – see PubMed.“)

Who Performs This Treatment? (Specialists and Team Involved)

Periprosthetic fracture management is performed by orthopedic surgeons with expertise in joint reconstruction and revision surgery. The surgical team may include an anesthesiologist, physician assistants, physical therapists, and nursing staff specializing in postoperative care.

When to See a Specialist?

If you experience persistent hip pain, instability, or difficulty walking after a hip replacement, schedule an evaluation with an orthopedic specialist. Early diagnosis helps prevent more serious complications.

When to Go to the Emergency Room?

Seek emergency care if you experience sudden severe pain, inability to move the leg, visible deformity, or signs of infection such as fever, redness, or drainage from the surgical site.

What Recovery Really Looks Like?

Recovery can be demanding, involving hospital stay, pain management, and structured rehabilitation. Patients may initially require walking aids and gradual return to normal movement. Full recovery and return to daily activities typically take several months.

What Happens If You Ignore It?

Untreated periprosthetic fractures can lead to worsening pain, implant failure, deformity, and loss of mobility. Delay in treatment increases the risk of permanent disability and more complex surgery later.

How to Prevent It?

Prevention focuses on strengthening bones through calcium and vitamin D, managing osteoporosis, avoiding high-impact activities, and fall-proofing the home. Regular follow-up with your surgeon helps detect implant loosening early.

Nutrition and Bone or Joint Health

A diet rich in calcium, vitamin D, and protein supports strong bones and healing. Foods such as dairy, leafy greens, and fish are beneficial. Staying hydrated and maintaining a healthy weight also promote recovery.

Activity and Lifestyle Modifications

After recovery, patients should focus on safe physical activity like walking or swimming. Avoid high-impact sports or heavy lifting. Using supportive footwear, maintaining balance, and continuing exercises recommended by a physical therapist can help preserve joint and bone health.

Do you have more questions?