Bethea et al classified proximal femoral fractures in patients who have had a total hip arthroplasty on the same side. The authors are from the Atlanta VA Hospital, Emory University and two community practices in Atlanta and San Francisco.

Location of Fracture


distal to stem tip (in femoral diaphysis)


spiral around stem in the proximal femur


comminuted about the stem



Risk factors for fracture:

(1) trauma

(2) longitudinal fractures associated with placement of the prosthesis or recurrent dislocations of the prosthesis

(3) underlying bone disease (osteoporosis, Gaucher's disease)

(4) previous surgical revisions

(5) loosening of the prosthesis


Many patients had signs or symptoms prior to the fracture. These patients may be candidates for preventive interventions.



Management Issues


may require revision with a long stem prosthesis or internal fixation; nonunion may occur with conservative therapy if multiple previous operations done on femur, poor bone stock, and/or improper alignment


loosening of hip prosthesis may occur if treated conservatively


immediate fixation recommended for early mobilization; usually require revision with a long stem prosthesis


For patients undergoing revision surgery, attention should be paid to:

(1) proper apposition of fracture fragments

(2) good cement technique at the proximal femur

(3) bone grafting


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