periprosthetic femoral fractures after primary total hip arthroplasty occur at an incidence of 1% , and show an increasing tendency of 4% following revision surgery . , among these occurrences , the time interval between primary total hip arthroplasty and fracture varies among different studies , ranging from 7.4 years ( swedish registry ) to 8.1 years ( mayo clinic total joint registry ) . furthermore , the swedish registry reported the time interval between revision surgery and fracture to average 3.9 years . , the respective treatment of periprosthetic femoral fractures is expensive and of complex nature , clinically showing relatively low harris - hip - scores and an elevated risk of mortality . adding to these facts , the effected patients are mostly of advanced age with accompanying comorbidities , therefore complicating post - revision rehabilitation and reducing clinical outcome . these facts , in addition to a high prevalence of poor bone quality , require specialized strategies for effective surgical treatment . currently , the vancouver classification is mostly utilized , including localization of the fracture , implant loosening , and bone quality to categorize fracture types . , surgical treatment of these fractures is being recommended . an exception can be made for special circumstances of vancouver type a fractures , showing beneficial results following conservative treatment . after deciding in favor of surgical treatment , different operating methods these options range from open reduction with internal fixation ( for instance wires , cerclage cables , struts ) , revision total hip arthroplasty using a long - stemmed femoral prosthesis , or utilization of fixed - angle plates in addition to minimally - invasive attachment of screws and cerclage cables to stabilize the fracture over enlarged distances . postoperative results vary depending on surgical institution and method utilized.- this study documents a series of consecutive patients with periprosthetic femoral fractures , with surgical treatment and follow - up occurring at the same orthopedic department . thirty - four consecutive patients ( 14 male , 20 female ; average age 81.28.5 years ) with acute periprosthetic femoral fracture , vancouver type a ( n=5 ) and type b ( n=29 ) , were enrolled to participate within this study at our orthopedic department . after evaluation of general operability according to comorbidities and following optimization of blood coagulation , surgical treatment occurred as soon as possible . the mean follow - up period was 43.2 months ( range 20 - 64 months ) , with none of the patients having been lost to follow - up . preoperatively , the american society of anesthesiologists ( asa ) physical status classification system was performed for proper risk evaluation . collected data also included the patients body - mass - index ( bmi ) , duration until surgery , and medical conditions . furthermore , patients underwent a physical examination , including patient history , and x - ray imaging of the injured hip for classification purposes . the radiological fracture classification was based on the vancouver classification , to estimate the optimal surgical strategy ( table 1 ) . the vancouver classification includes type and localization of the fracture , implant stability , as well as bone quality . however , every single operation was undertaken using the entire array of surgical instruments for femoral revision ( alloclassic sll , zimmer , inc . , warsaw , in , usa ) , modular long - stemmed prostheses ( mrp - titan , peter brehm gmbh , weisendorf , germany ) , surgical plates ( ncb distal femur plate , zimmer , inc . ; liss plate , synthes , inc . , west chester , pa , usa ) , as well as cerclage cables ( gundolf titanbandcerclage , implantec schweiz gmbh , baar , switzerland ) . the follow - up visit included x - ray images of the hip , clinical examination , harris - hip score , a quick neurological status , as well as documentation of complications or consecutive surgeries after revision surgery . the individually adjusted surgical procedure was performed as soon as possible following diagnosis , with 23 out of 34 patients receiving surgical treatment either immediately or within 24 h. delays were a result of patients insufficient preoperative conditions , where optimizing of blood coagulation and other preoperative preparations had to primarily be undertaken . a bmi between 25 and 29 kg / m was observed within 15 patients ( 44% ) , whereas 13 patients ( 38% ) showed a bmi lower than 25 kg / m , and 6 patients ( 18% ) were documented with bmi greater than 30 kg / m . only 1 patient ( 3% ) was categorized as asa grade 1 , 8 patients ( 24% ) asa grade 2 , 22 patients ( 64% ) asa grade 3 , and 3 patients ( 9% ) asa grade 4 . there were 15 well - fixed stems ( 43% ) ( = vancouver type a / b1 ) , the remaining 19 ( 57% ) were loose within bone ( = vancouver b2/b3 ) . concerning choice of surgical method , 19 patients ( 57% ) had an exchange of stem with application of cerclage cables , 10 patients ( 29% ) underwent open reduction and internal fixation also using cerclage cables , and 5 patients ( 14% ) were treated with fixed - angle plates ( figure 1 - 6 ) . for patients with exchange of stem , 13 out of 19 received a modular long - stemmed prosthesis ( mrp - titan , peter brehm gmbh ) , and 6 patients received a revision monoblock - stem ( zweimller sll , zimmer , inc . ) . postoperatively , 1 had a harris hip score of 89 points and showed patient showed a deep infection and was treat- normal clinical and radiological results . two ed using a two - stage revision protocol . at the multimorbid patients ( 5.8% ) died of cardiac follow - up visit after 21 months , this patient arrest shortly after surgery , both having been categorized asa 4 . one of these patients , aged 78 years , died one day postoperatively , and the other 86-year old patient deceased on the third day postoperatively . no further peri- or postoperative complications occurred , and the remaining 32 patients presented themselves in good health without any signs or symptoms of implant failure or recurrent bone fracture during follow - up visits . the patients maximally utilized two walking - sticks for locomotion , and the average harris hip score was 85 points ( range 60 - 95 points ) . within the last years , major advances have been achieved for treatment of periprosthetic femoral fractures . credit may be given to standardized classification systems , which allow for respective treatment algorithms . , , currently , internal fixation and revision total hip arthroplasty are viewed as gold standard , being utilized depending upon implant stability , bone rigidity , and type of fracture . the careful evaluation of these factors is crucial within the process of deciding upon the individually most efficient surgical procedure . many cases simply show a non - adequate minor trauma , which might be resulting from prior implant loosening . existing data document up to 70% of loose implants at occurrence of periprosthetic femoral fractures , which is often a result of poor or missing follow - up visits . elderly patients , frequently living in retirement homes , simply lack high - quality follow - up programs to screen for possible implant loosening prior to fracturing . a retrospective study by abdel and colleagues , evaluating 32,644 total hip arthroplasties over four decades , found a gradually rising cumulative probability of periprosthetic femoral fracture , with 0.4% after one year , 0.8% after 5 years , 1.6% after 10 years , and as many as 3.5% after 20 years . ideally , loosened femoral implants should be replaced before the occurrence of fracture . , precaution is advised for chronic progressive loosening as respective signs and symptoms are often missing , therefore regular clinical and radiological follow - ups are recommended . within current literature , surgical treatment of periprosthetic femoral fractures demonstrate an elevated rate of complications and mortality , generally showing a prevalence of approximately 10% . , for instance , a matched pair study from the new zealand registry , comparing postoperative functional outcome of femoral periprosthetic fracture and revision hip arthroplasty , documented an increased rate of mortality ( 7.3 vs. 0.9% ) and increased rates of re - revision ( 7.3 vs 2.6% ) after periprosthetic fracture , describing re - fracturing and luxation to be dominant causes for re - revision . another study , comparing periprosthetic femoral fractures to primary hip arthroplasty concerning mortality rates , also showed an elevation within the fracture group ( 11 vs 2.9% ) , with a three - fold decrease in mortality after stem revision compared to open reduction and internal fixation . the swedish registry evaluated 63,582 primary hip arthroplasties and 736 periprosthetic femoral fractures to show an increased rate of postoperative mortality for the latter , ranging from 2.1 to 10% , and documenting great variation among functional results with up to 60% of patients complaining of chronic pain . other studies also highlight this tendency of unexpected events after surgical treatment of periprosthetic femoral fractures , with complications in 14 out of 45 patients ( 31% ) , including 6 deep infections , 6 cases of pseudarthrosis , and 2 cases of loosening,12 or even larger rates of complications ranging from 26 to 43%.20,21 our consecutive series of patients demonstrated a mortality rate of 5.8% and one infection , but no other complications or re - revisions , showing a complication rate of 2.9% . although large rates of complications and mortality have been described within literature , our results support the recommendation of surgical treatment after periprosthetic femoral fractures within elderly multimorbid patients .
surgical treatment of periprosthetic femoral fractures has a high complication and mortality rate of more than 10% . 
 the aim of this study is to report the outcome of a consecutive single center patient group . 
 thirty - four consecutive patients ( mean age 81.2+/-8.5 years , 14 male , 20 female ) with a periprosthetic femoral fracture vancouver type a ( n=5 ) or type b ( n=29 ) were followed - up after 43.2 months , none of the patients were lost to follow - up . 
 nineteen of the patients were treated through change of the stem and cerclage fixation , five by plates and ten by cerclage cables . 
 one successfully treated infection was observed . 
 no further complications have been reported peri- or postoperatively , therefore resulting in 2.9% overall complication rate . 
 these results demonstrate that precisely selected revision surgery protocol following periprosthetic femoral fractures within elderly multimorbid patients may lead to beneficial outcomes at a low risk of complications .