Early Periprosthetic Femoral Fracture After THA: High Rates of Complications in New Study

Dr. Matt Schmitz, Senior Editor of Pediatrics and Social Media, spotlights a new study comparing outcomes of patients who sustained periprosthetic femoral fracture within 30 days following primary total hip arthroplasty versus later time points.

Periprosthetic femoral fracture (PFF) after total hip arthroplasty (THA) is a harbinger of adverse outcomes. How does early fracture (≤30 days postoperatively) compare with PFF at later time points? That question was examined by Acuña et al. in the Nov 4, 2026 issue of The Journal. They found that patients who sustained PFF within 30 days following primary THA were at significantly greater risk of complications. Read the study at JBJS.org:

Alarmingly High Rates of Complications and Refracture Among Patients with Early Periprosthetic Femoral Fracture Within 30 Days After THA

The authors used the PearlDiver all-payer database to identify patients who had undergone primary, elective THA for osteoarthritis from 2010 to 2022; intraoperative fractures were excluded, and a claims record active for at least 6 months before and 2 years after the index surgery was required.

Patients who sustained PFF ≤30 days postoperatively were propensity-matched 1:1 (on the basis of age, sex, Elixhauser Comorbidity Index, and selected comorbidities) to 3 groups based on fracture timing: fracture at 31 to 90 days (n = 1,725), fracture at 91 days to 1 year (n = 1,887), and no fracture within 1 year (n = 4,465). Outcomes were assessed with multivariable logistic regression and survivorship analyses utilizing death as a competing end-point.

Study Findings

Patients with early PFF had greater rates of complications within 90 days than the comparison cohorts, including higher transfusion rates and—versus the group with fracture at 91 days to 1 year—markedly higher readmission (47.8% vs. 11.7%) and overall complications (69.5% vs. 42.2%).

At 2 years, refracture was more frequent after early PFF than after fracture at 31 to 90 days (45.0% vs. 35.9%) or 91 days to 1 year (47.1% vs. 17.8%), as was reoperation. Most refractures occurred within 100 days of initial fracture management.

Compared with patients without fracture, those with early PFF had substantially lower 2-year survivorship free of infection (87.8% vs. 97.7%), refracture (57.4% vs. 99.5%), and reoperation (48.5% vs. 97.6%).

Obesity, congestive heart failure, and comorbidity burden were predictors of periprosthetic joint infection following the initial PFF. The authors theorize that infection risk may be related in part to reviolation of a poorly vascularized soft-tissue envelope and suggest excising the prior incision at early reoperation, extensive irrigation, and considering extended oral antibiotics or vacuum-assisted closure.

The authors note that the high rates of refracture and reoperation underscore the importance of preventing PFF and reducing refracture incidence among high-risk patients. They suggest considering the use of cemented or triple-taper, collared stems in at-risk patients, diaphyseal-engaging revision stems, and osteoporosis evaluation and treatment.

Limitations noted include unknown type of PFF, the inability to control for the index treatment strategy, differences in utilized implants and surgical approaches, and possible survivorship bias if some patients with early mortality or loss of insurance were excluded.

Although there are limitations to database studies, I commend the authors for reviewing over 16,000 patients to examine the effect of early PFF on outcomes following THA. The chicken-or-egg conundrum comes into play: are the worse outcomes following early PFF driven by patients’ underlying comorbidities or by PFF itself? The answer is likely a combination of both.

Data from the study can help inform our conversations with patients and our efforts to reduce complications following THA, including those associated with PFF.

The full study and related video abstract can be found at JBJS.org: Alarmingly High Rates of Complications and Refracture Among Patients with Early Periprosthetic Femoral Fracture Within 30 Days After THA

Additional perspective on this study is provided by Philip Linke, MD, MBA in a commentary article: Early Periprosthetic Femoral Fracture After Total Hip Arthroplasty Is Not a Complication; It Is a Crisis

Matthew R. Schmitz, MD   