Skip to main content
  • Systematic review
  • Open access
  • Published:

Factors affecting the incidence of postoperative periprosthetic fractures following primary and revision hip arthroplasty: a systematic review and meta-analysis



The increasing number of hip arthroplasties (HA), due to the growing elderly population, is associated with the risk of femoral periprosthetic fractures (FPFs). The purpose of this study was to identify potential risk factors for the development of FPFs after HA.


A systematic review was conducted in five data bases (Medline, Embase, Cochrane, Cinahl, ICTRP) according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines up to May 2019, using the key words “risk factor,” “periprosthetic fracture,” and “hip replacement or arthroplasty.” Meta-analysis of the clinical outcomes of HA and subgroup analysis based on the factors that were implicated in FPFs was performed.


Sixteen studies were included (sample size: 599,551 HA patients, 4253 FPFs, incidence 0.71%). Risk factors statistically associated with increased incidence of FPFs were female gender (+ 40%), previous revision arthroplasty surgery (× 3 times), and the presence of rheumatoid arthritis (× 2.1 times), while osteoarthritis (− 57%), cement application (− 59%), and insertion of Biomet (− 68%) or Thompson’s prosthesis (− 75%) were correlated with low prevalence of FPFs. Obesity, cardiac diseases, advanced age, bad general health (ASA grade ≥ 3), and use of Exeter or Lubinus prosthesis were not linked to the appearance of FPFs.


This meta-analysis suggested that female gender, rheumatoid arthritis, and revision arthroplasty are major risk factors for the development of FPFs after a HA. In those patients, frequent follow-ups should be planned. Further prospective studies are necessary to clarify all the risk factors contributing to the appearance of FPFs after HA.


Femoral periprosthetic fractures (FPFs) after total hip arthroplasty (THA) were first described by Horwitz and Lenobel in 1954 [1]. FPFs constitute a devastating complication that often results in poor clinical outcome. Diagnosis of FPFs is typically made by the combination of clinical appearance, history of injury, and conventional radiographic examination. The widely used Vancouver classification provides a reliable evaluation of FPFs based on the femoral anatomic location of the fracture and the presence of a well-fixed or loose component [1]. The incidence of FPFs after hip arthroplasties (HA) has been reported between 0.045 and 4.1% [2,3,4]. The increasing prevalence of FPFs is directly associated with the increasing frequency of primary or revision HAs [5].

Although FPFs were not correlated with a specific implantation procedure, it was reported that they occurred more frequently after the application of cementless HA [6]. Factors that also contributed to the development of FPFs were the (a) low preoperative quality of patients’ bone stock like osteolytic or osteoporotic defects, (b) accompanied reduced mechanical properties of the implant surrounding tissue, (c) absence of stability of the implanted prosthesis, and (d) presence of pericapsular pathological changes [5]. Furthermore, patients with increased age, poor American Society of Anaesthesiologists (ASA) score, dementia, limited mobilization, partial weight bearing, and substantive functional limitations during postoperative period appeared to have a much higher risk for FPFs, implant failure, and mortality [6]. FPFs after primary HA resulted following spontaneous or low-energy injury corresponding to 8% or 75%, respectively [7, 8]. Treatment and postoperative rehabilitation of these fractures are complicated and expensive and correlate to increased morbidity and mortality. Specifically, the mortality rate after FPFs was remarkably increased in patients who had undergone primary joint replacement corresponding to 11% during the first year post-operatively. We must highlight the fact that a delay greater than 2 days from admission to the time of surgery also increased the mortality rate at one year [9].

Therefore, it is crucial to determine the potential risk factors that are associated with FPFs after total HA and hemiarthroplasty. Identification of risk factors for FPFs not only bridges the gap between clinical and basic or translational science but also improves the surgical practice in operating room as surgeons may incorporate novel concepts in their surgical techniques [10, 11]. Furthermore, in complex surgical problems, like FPFs, it is deemed necessary to understand the disease process and to integrate new scientific findings [12]. However, literature regarding the qualitative analysis of the identification of such risk factors is limited and does not provide adequate evaluation of their impact on clinical practice. Moreover, the majority of the studies included qualitative synthesis of limited sample size and/or number of surveys [13, 14] and/or potential risk factors [15].

Despite the fact that multiple identified risk factors for FPF have been described in the international literature including older age, female sex, bone fragility disorders, and systematic diseases [5, 6], there is a lack of a comprehensive study with generalized statistics analyzing the association between FPF and risk factors in both primary and revision HA. The aim of our systematic review and meta-analysis was to provide an up-to-date summary of the incidence and odds ratio of FPFs after performing primary and revision HA and to establish the contribution of potential risk factors in the development of FPFs.

Materials and methods

This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [16]. PRISMA checklist was used for reporting of relevant items for this meta-analysis and was provided in the supplementary document (Supplementary Table 1) [16].

Literature search

A systematic computer-based literature review search with predefined criteria was attained on 08 May 2019 in the following databases: PubMed (1947 to present), Cochrane Database of Systematic Reviews (1992 to present), Embase (1974 to present), Cinahl, and WHO International Clinical Trials Registry platform (ICTRP). Research methodology was based on the combination of the following terms: “factors [All Fields],” “risk [All Fields],” “periprosthetic fractures [All Fields],” and “hip replacement, hemiarthroplasty or arthroplasty [All Fields].” The entire electronic literature search was conducted independently by two authors (CB and ODS) and an experienced clinical librarian. Moreover, the two senior authors (CB and ODS) screened the titles and abstracts independently in order to identify studies examining the clinical outcomes after the application of HA. If there was a disagreement between them, the final decision was made by the senior author.

Study eligibility

Studies that examined the risk factors, the outcome, and the incidence of post-operative FPFs after performing HA were identified. HA was defined as the replacement of all or part of the hip joint by a prosthetic implant [17]. FPFs were defined as the femoral fractures that took place above, below, or close to an implanted prosthesis stem [18]. Only full-text articles were eligible for inclusion. The inclusion criteria were (a) studies written in English language, (b) comparative studies assessing the application of primary and revision hip arthroplasties, (c) surveys concerning HA that were performed in human subjects, and (d) data on the risk factors for FPFs and the outcome should have been clearly given for each patient. No publication date limitations there were set.

Studies that examined primary or metastatic hip cancers treated with HA, or surveys without comparative results, or being written in a language other than English were excluded. Case reports, reviews, letters to the editor, expert opinions articles, studies concerning PFs of acetabulum, research with insufficient details about the type of intervention, the clinical outcome, and surveys without obtainable data, were excluded.

Data extraction

All data of each study was assembled in a Microsoft Excel spreadsheet, classified per intervention and type of periprosthetic fracture. Characteristics extracted from clinical studies included authorship, publication year, study design (cohort or randomized control trial), single or multicenter status, enrolled sample number, population gender and age, and risk factors in both control and treatment groups, HA procedure, outcomes regarding the frequency of periprosthetic fracture development, and the type of HA. Data from each study are summarized in Table 1.

Table 1 Clinical characteristics of studies included in the meta-analysis

Two reviewers (CB and ODS) examined all the identified surveys and extracting data by using a predetermined form. The presence of duplicate studies was examined using Endnote software (Clarivate Analytics, Philadelphia, Pennsylvania, USA).

Study selection and quality assessment

The methodology of each study was assessed independently by the two senior authors (CB and ODS) using the Newcastle–Ottawa quality assessment scale [35]. Included studies were graded according to a three-category scale. Surveys that appeared a total score of 0–3, 4–6, and 7–9 were classified to be of a poor, fair, or good quality, respectively (Table 2a). Modified Jadad scale for clinical trials was also used to evaluate the quality of included trials [36]. Jadad score greater than 4 was considered to be of high quality (Table 3). There were not exclusion criteria for age, population, diagnosis, or quality of the studies. Funnel plots were built in order to determine the aspect of publication bias that may affect the conclusions of our analysis.

Table 2 Study quality of the included studies based on the Newcastle–Ottawa scale
Table 3 Study quality of the included studies based on the modified Jadad scale

Statistical analysis

This meta-analysis was conducted in line with the recommendations from Cochrane and PRISMA statement [16]. Statistical analysis was performed with the STATA Statistical software, version 11.0 (Stata Corp LLC, College Station, TX, USA). The incidence of FPFs after the application of HAs, the correlated risk factors and the odds ratios (ORs), and the associated 95% confidence intervals (95% CI) were calculated. Heterogeneity between the trials was calculated by using Cochrane Q and the inconsistency (I2) test. The degree of heterogeneity was graded as low (I2 < 25%), moderate (I2 from 25 to 75%), and high (I2 > 75%). A random effect model was used to calculate pooled ORs in the case of significant heterogeneity, while the fixed effect model was used in the studies with low heterogeneity. This was undertaken because in sensitivity analysis the presentation of both models provides comprehensive evaluation of how differences in datasets affected the observed outcomes [37]. Egger’s test and graphical exploration with funnel plots were used to evaluate the risk of publication bias. The level of statistical significance was defined as p < 0.05.


Study characteristics

In the initial search, a total of 126 relevant trials were detected. After the initial evaluation of the studies based on the abstract and title, 103 publications were included. The further analysis of the remaining papers resulted in the exclusion of 104 surveys. Twenty-eight studies were excluded due to inadequate methodology, while 49 studies were declined being statistically unsatisfactory. Moreover, 13 studies examined acetabular PFs, 3 were written in other language than English and 11 surveys were not original studies and were analyzed in the flowchart of Fig. 1.

Fig. 1
figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flowchart for the screening and identification of included studies

Finally, sixteen studies published between 2003 and 2018 met our inclusion criteria for the analysis of potential risk factors for the development of FPFs after THA [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34]. The grade of the agreement among the reviewers that evaluated the scientific quality of the included studies was strong. The main characteristics of the included participants are displayed in the Table 1.

Quality assessment

In Tables 2 and 3, the methodological quality of the enrolled studies is summarized. According to the Newcastle–Ottawa scale and the modified Jadad score, all the enrolled trials were considered being of good and high quality and, therefore, were judged to be at a low risk of bias.

Furthermore, funnel plots were created to evaluate publication bias. After this evaluation, all studies were found to lie within a 95% CI as represented by the inverted funnel, suggesting absence of publication bias.


In total, 599.677 HA were included in the meta-analysis. Fourteen studies were used to reveal the prevalence of FPFs [20, 22,23,24,25,26,27,28,29,30,31,32,33,34], as two of the studies were characterized as case–control surveys [19, 21] and were excluded of prevalence calculation. Finally, 599.551 HA and 4253 FPFs were reported, demonstrating prevalence of 0.71%. In specific, the reported cases between 2003 and 2013 corresponded to incidence of 2.4%, whereas the prevalence of FPFs between 2014 and 2018 was reduced to 0.27% (Fig. 2).

Fig. 2
figure 2

Diagram demonstrating the incidence of the collected reported femoral periprosthetic fractures after hip arthroplasty between 2003 and 2017

Epidemiological risk factors

Thirteen studies [20,21,22,23,24,25, 27,28,29, 31,32,33,34] analyzed gender as a risk factor for the development of femoral PFs after HA. Meta-analysis of these studies (Q = 27.4, I2 = 56.2%, P = 0.007) revealed that female gender was as much as 40% more likely to sustain FPFs (OR: 1.40, 95% CI: 1.15–1.64, p < 0.001) (Fig. 3).

Fig. 3
figure 3

a Forest plot demonstrating the female gender as a significant risk factor for femoral periprosthetic fractures after hip arthroplasty. b Funnel plot demonstrating the low risk of publication bias of the included studies

Five studies [20, 23, 27,28,29] and six studies [20, 23, 24, 27, 28, 32] reported age greater than 80 years and 70 years as a risk factor, respectively. Meta-analysis of these studies (Q = 18.4, I2 = 78.2%, P = 0.765, and Q = 59.1, I2 = 91.5%, P = 0.001, respectively) revealed that age (older than 80 and 70 years) was not a significant risk factor for the development of FPFs (OR: 1.36, 95% CI: 0.79–1.94, p = 0.249, and OR: 1.31, 95% CI: 0.82–1.81, p = 0.351, respectively).

Obesity was examined as a risk factor for FPF appearance in four surveys [27, 28, 32, 33]. Meta-analysis of these trials (Q = 0.17, I2 = 0.0%, p = 0.982) demonstrated that obesity was not an important risk factor associated with increased frequency of FPFs (OR: 0.90, 95% CI: 0.76–1.03, p = 0.164).

General medical condition risk factors

In three studies [21, 27, 28], general health status of the patients who underwent HA was evaluated with the ASA Physical Status Classification System. However, meta-analysis of these studies (Q = 11.3, I2 = 81.9%, p = 0.001) did not identify the ASA score ≥ 3 as statistically significant risk factor for FPF appearance (OR: 0.47, 95% CI: 0.43–1.31, p = 0.731).

Similarly, meta-analysis (Q = 4.56, I2 = 56.1%, p = 0.102) of three studies [21, 28, 29], which explored pre-existing cardiac disease as a risk factor for FPF development, showed that heart pathology was not associated with increased incidence of FPFs (OR: 1.00, 95% CI: 0.65–1.36, p = 0.289).

Joint diseases risk factors

Meta-analysis (Q = 2.0, I2 = 0.0%, p = 0.573) of four surveys [20,21,22, 28] that included the examination of rheumatoid arthritis (RA) as a risk factor for PFs demonstrated that RA is a remarkable risk factor contributing in FPF development. Specifically, patients with RA who underwent HA had 2.1 times greater risk to experience FPFs (OR: 2.1, 95% CI: 1.05–3.15, p = 0.009) (Fig. 4).

Fig. 4
figure 4

a Forest plot demonstrating rheumatoid arthritis as a significant risk factor for femoral periprosthetic fractures after hip replacement. b Funnel plot demonstrating the low risk of publication bias of the included studies

Meta-analysis (Q = 2.06, I2 = 2.09%, p = 0.357) of three studies [20, 22, 28] that reviewed osteoarthritis (OA) as potential factor implicated in FPF evolvement revealed that OA was negatively associated with the appearance of FPFs. Indeed, patients with OA had 57% reduced risk to experience FPFs (OR: 0.43, 95% CI: 0.32–0.54, p = 0.010) (Fig. 5).

Fig. 5
figure 5

a Forest plot demonstrating osteoarthritis as a significant protective factor for femoral periprosthetic fractures after hip arthroplasty. b Funnel plot demonstrating the low risk of publication bias of the included studies

Fixation and implant type risk factors

In five studies [21, 24, 26, 29, 31], the presence of a revision HA was reported. Meta-analysis (Q = 51.3, I2 = 91.2%, p < 0.001) of these studies identified that the risk of FPFs after revision HA is 3 times higher than primary HA (OR: 3.05, 95% CI: 1.27–4.82, p = 0.005) (Fig. 6).

Fig. 6
figure 6

a Forest plot demonstrating revision hip arthroplasty as a significant risk factor for femoral periprosthetic fractures. b Funnel plot demonstrating the low risk of publication bias of the included studies

In seven studies [19, 20, 22, 26, 28, 30, 33], the application of cemented prosthesis was presented. Meta-analysis of these surveys (Q = 286.4, I2 = 97.9%, p = 0.001) confirmed that the use of cemented femoral prosthesis was a significant protective factor, decreasing the possibility of FPFs (0.41, 95% CI: 0.19–0.62, p < 0.001) (Fig. 7).

Fig. 7
figure 7

a Forest plot demonstrating the insertion of cemented prosthesis as a significant protective factor for femoral periprosthetic fractures. b Funnel plot demonstrating the low risk of publication bias of the included studies

The impact of the implant type that was inserted during THA was also evaluated. Meta-analysis of four [19,20,21, 23], two [20, 21], three [19,20,21], and two [20, 21] studies regarding Exeter (Stryker, Kalamazoo, USA) (Q = 17.1, I2 = 82.5 %, p = 0.001), Thompson (Stryker UK Ltd., Newbury, UK) (Q = 0.18, I2 = 0.0%, p = 0.672), Lubinus (Waldemar Link GmbH & Co, Hamburg, Germany) (Q = 0.0, I2 = 0.0%, p > 0.999), and Biomet (Zimmer Biomet Holdings, Warsaw, USA) (Q = 0.0, I2 = 0.0%, p > 0.999) prosthesis, respectively, indicated that Thompson (OR: 0.25, 95% CI: 0.00–0.61, p = 0.010) (Fig. 8) and Biomet (OR: 0.32, 95% CI: 0.00–0.83, p = 0.021) (Fig. 9) prostheses were associated with reduced risk of FPFs. Conversely, Exeter (OR: 0.97, 95% CI: 0.03–1.91, p = 0.759) and Lubinus (OR: 1.02, 95% CI: 0.90–1.14, p = 0.869) implants did not favor the development of FPFs.

Fig. 8
figure 8

a Forest plot demonstrating the application of Thompson prosthesis as a significant protective factor for femoral periprosthetic fractures after hip arthroplasty. b Funnel plot demonstrating the low risk of publication bias of the included studies

Fig. 9
figure 9

a Forest plot demonstrating the application of Biomet prosthesis as a significant protective factor for femoral periprosthetic fractures after hip arthroplasty. b Funnel plot demonstrating the low risk of publication bias of the included studies


Femoral periprosthetic fractures after HA constitute a major complication and are usually associated with increased mortality rate and inadequate functional recovery [38]. However, the general and local risk factors that contribute in the development of FPFs remain relatively unclear. This meta-analysis focused on the examination of the incidence and the detection of possible predisposing factors leading to FPFs.

Our analysis indicated that the prevalence of FPFs after HA was 0.71%. Interestingly, during the last 4 years the frequency of FPFs was limited to 0.27%. The reported incidences range from 0.3 to 27.8% after primary HA and from 0.3 to 17.6% after revision HAs [3, 39, 40]. Despite the fact that a growing rate of HA was noted [39], the incidence of FPFs was reduced. The progressive identification of risk factors, the advancing orthopedic education in hip surgical techniques, and the ongoing surgical experience may explain the above finding.

The frequency of FPFs was higher after the insertion of uncemented HA ranging from 3 to 18% [14, 40, 41]. This is in line with our findings, where cemented prosthesis was a protective factor for FPFs. Our observations confirmed Berry’s report who observed an increased frequency of 20.9% for intra-operative fractures when using of uncemented fixation, compared with 3.6% for cemented femoral revisions [3]. Similarly, only a 3% of intra-operative FPFs were noted after the insertion of cemented implants [42], being three times less common compared with uncemented stems [43]. The above result may be explained by the fact that the insertion of cement into a weak osteoporotic femur stabilizes the bony structure and enhances the bone biomechanical properties [40]. Additionally, failure of the bone biological ingrowth or ongrowth process or occurrence of a femoral crack and microfracture during the insertion of a press-fit cementless prosthesis may lead to increased rate of FPFs even after low-energy trauma. Although the impact of implant type has been examined in many surveys, the results vary from study to study [22, 23]. Inadequate surgical familiarity with the uncemented technique and different methodological protocols (e.g., population samples or follow-up duration) could be correlated with these discrepancies.

Based on our results, revision HA was strongly associated with FPFs, a consistent result in many surveys [3, 14, 44, 45]. The insertion of a new femoral stem in a weak proximal femur due to excessive osteopenia or osteoporosis, accompanied by concurrent development of intra-operative stress shielding or cortical injuries during the removal process of the previous stem or cement and the application of longer or larger-diameter stems, especially using reaming procedure, may provide an explanation for the above findings [44, 45].

Little is known about the association between femoral implant design characteristics and the frequency of FPFs. Our results did not confirm the previously reported correlation of Exeter prosthesis to increased rate of FPFs [46]. Conversely, insertion of Exeter and Lubinus prostheses did not increase the prevalence of FPFs, whereas Thompson and Biomet implants significantly decreased the incidence of FPFs (by 75% and 68%, respectively). Sarvilinna et al. reported that in patients with hip fractures treated with HA, the polished wedge type of prosthesis was linked to an increased risk of FPFs [21]. Results from a large Norwegian Hip Fracture Register, which were undertaken in patients with a femoral neck fracture, demonstrated high re-operation ratio due to FPFs after the application of polished stems compared to anatomical and straight stems [47]. This is, also, consistent with a UK National Joint Registry study which investigated revision interventions for FPFs after THAs and found lower incidence of FPFs with a Charnley stem [48]. Finally, a large retrospective cohort study conducted by the UK National Joint registry after the analysis of 299,019 primary THAs reported that the high rate of FPFs after the insertion of polished hip cemented stems was, also, associated with cobalt-chromium stem material, the increased stem offset, the ovaloid and round diaphyseal cross-sectional stem shape, and the increased head size [49].

Our results showed that OA was a protective factor in FPF appearance, while RA was a significant risk factor being in line with previous studies [4, 14, 40, 44, 45]. Poor bone quality, multiple joint involvement and considerable comorbidity, may explain why the presence of RA was associated with a high risk of FPFs. Furthermore, the significant bone erosion, osteolytic defects, and the simultaneous induced expression of osteoclasts and inflammatory cytokines may result in the generation of FPFs [50]. Clinical studies also confirmed the close association between low Bone Mineral Density (BMD) and RA leading to increased bone loss and femoral frailty [51, 52]. It was suggested that prevention of late FPFs could be accomplished by the intra-operative recognition of locations of cortical defects and osteolytic lesions and the prophylactically application of cortical grafts to reinforce cortical weakness and other stress risers [15]. Contrariwise, the exact mechanism of OA-protective effects in the appearance of FPFs is largely unknown. Patients with OA are characterized by reduced level of activity due to localized arthralgia and limitation of joint movements, especially to those who were overweight. Furthermore, altered embiomechanical bony structure due to subchondral sclerosis and absence osteoporotic defects may provide an extra explanation of this finding in OA [53].

Based on our findings, female gender was an important epidemiological factor that increased the risk of FPFs by 40%. Although female gender has been suggested to be an independent risk factor, it is obviously confounded by osteoporosis [45]. Contrariwise, age older than 70 or 80 years, obesity, medical comorbidities such as cardiac disease, or physical condition with ASA score ≥ 3 were not related with high rate of FPFs, confirming the results of previous studies [14, 40].

Strengths and limitations

Strength of our analysis was that it included all the current international literature comprising a large number of prospective studies and a large population sample (8 times larger than in previous analyses) [14, 15]. However, the selected studies had the following limitations: First, the prevalence of FPFs was calculated by a pool that included both hemiarthroplasties and THAs patients. However, in the international literature, a large number of studies that examined the risk factors, the outcomes, and the frequency of FPFs have enrolled patients of both interventions [54, 55]. Moreover, the fact that the mean incident of complications, including FPFs, did not differ significantly between patients treated with hemiarthroplasty or THAs [4, 56] does not alter the credibility of our results. Another limitation may was the fact that only studies written in English were reviewed and thus some studies may be missing in the analysis. Nevertheless, the vast majority of critical reviews and meta-analyses on the international literature follow the same methodology. Additional drawbacks could be the heterogeneity of data population, the variability of diagnostic and treatment protocols, the different selection criteria and follow-up periods, and the absence of diseases severity classification (e.g., in OA). Finally, other limitation factors were the differences in methodological approaches and the conditions under which the studies were conducted or other confounding factors that were not taken into consideration.


This meta-analysis suggested that female gender, RA, and revision arthroplasty are major risk factors for the development of FPFs whereas OA, cement application, and insertion of Biomet or Thompson’s prosthesis were correlated with low prevalence of FPFs. Obesity, cardiac diseases, advanced age, poor general health (ASA grade ≥ 3), and use of Exeter or Lubinus prosthesis did not conduce to the appearance of FPFs. Based on the meta-analysis data, it could be recommended that (a) insertion of a femoral implant designed with anatomic characteristics can reduce the risk of re-operation in patients of similar age, sex, and bone quality; (b) intra-operative application of cortical grafts may prevent possible bone defects or stress risers in patients with known risk factors like RA or revision surgery [15]; (c) cement insertion for the fixation of the femoral implant is suggested to reduce the risk of FPFs; (d) systematic clinical and radiographic postoperative follow-ups are necessary to examine the stem stability and bone quality; and (e) the pre- and postoperative nutritional status and BMD level must be assessed and corrected, especially in patients suffering of RA. However, the risk of atypical femoral neck fractures after prolonged bisphosphonate therapy should be considered [57].

Future basic science and clinical prospective studies are warranted to establish stronger evidence regarding the mechanisms that alter bone strength and quality in female patients and in those suffering of rheumatic diseases resulting in FPFs, to strengthen the efficacy of insertion of Biomet or Thompson’s prostheses though cemented procedure in the prevention of FPFs and to produce more robust results for the clarification of the potential risk factors contributing to the development of FPFs after HAs.

Availability of data and materials

Datasets are available through the corresponding author upon reasonable request



American Society of Anaesthesiologists

95% CI:

95% confidence intervals


Femoral periprosthetic fractures


Hip arthroplasties


International Clinical Trials Registry platform




Odds ratios


Preferred Reporting Items for Systematic Reviews and Meta-Analysis


Rheumatoid arthritis


Total hip arthroplasty


World Health Organization


  1. Rayan F, Haddad F. Periprosthetic femoral fractures in total hip arthroplasty - a review. Hip Int. 2010;20(4):418–26.

    Article  PubMed  Google Scholar 

  2. Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty. 2005;20(7):857–65.

    Article  PubMed  Google Scholar 

  3. Berry DJ. Epidemiology: hip and knee. Orthop Clin North Am. 1999;30(2):183–90.

    Article  CAS  PubMed  Google Scholar 

  4. Lindahl H. Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury. 2007;38(6):651–4.

    Article  PubMed  Google Scholar 

  5. Della Rocca GJ, Leung KS, Pape HC. Periprosthetic fractures: epidemiology and future projections. J Orthop Trauma. 2011;25(Suppl 2):S66–70.

    Article  PubMed  Google Scholar 

  6. Füchtmeier B, Galler M, Müller F. Mid-term results of 121 periprosthetic femoral fractures: increased failure and mortality within but not after one postoperative year. J Arthroplasty. 2015;30(4):669–74.

    Article  PubMed  Google Scholar 

  7. Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop Relat Res. 1996;327:238–46.

    Article  Google Scholar 

  8. Lindahl H, Garellick G, Regnér H, Herberts P, Malchau H. Three hundred and twenty-one periprosthetic femoral fractures. J Bone Joint Surg Am. 2006;88(6):1215–22.

    Article  PubMed  Google Scholar 

  9. Bhattacharyya T, Chang D, Meigs JB, Estok DM 2nd, Malchau H. Mortality after periprosthetic fracture of the femur. J Bone Joint Surg Am. 2007;89(12):2658–62.

    Article  PubMed  Google Scholar 

  10. Mediouni M. A new generation of orthopaedic surgeons: “T-model”. Curr Orthop Pract. 2019;30(5):444–5.

    Article  Google Scholar 

  11. Mediouni M, Madiouni R, Gardner M, Vaughan N. Translational medicine: challenges and new orthopaedic vision (Mediouni-Model). Curr Orthop Pract. 2020;31(2):196–200.

    Article  Google Scholar 

  12. Mediouni M, Schlatterer DR, Madry H, Cucchiarini M, Rai B. A review of translational medicine. The future paradigm: how can we connect the orthopaedic dots better? Curr Med Res Opin. 2018;34(7):1217–29.

    Article  PubMed  Google Scholar 

  13. Deng Y, Kieser D, Wyatt M, Stringer M, Frampton C, Hooper G. Risk factors for periprosthetic femoral fractures around total hip arthroplasty: a systematic review and meta-analysis. ANZ J Surg 2020;90(4):441–7.

  14. Zhu Y, Chen W, Sun T, Zhang X, Liu S, Zhang Y. Risk factors for the periprosthetic fracture after total hip arthroplasty: a systematic review and meta-analysis. Scand J Surg. 2015;104(3):139–45.

    Article  CAS  PubMed  Google Scholar 

  15. Franklin J, Malchau H. Risk factors for periprosthetic femoral fracture. Injury. 2007;38(6):655–60.

    Article  PubMed  Google Scholar 

  16. Moher D, Liberati A, Tetzlaff J. Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–41.

    Article  PubMed  Google Scholar 

  17. Merola M, Affatato S. Materials for hip prostheses: a review of wear and loading considerations. Materials (Basel). 2019;12(3):495.

    Article  CAS  PubMed Central  Google Scholar 

  18. Frenzel S, Vécsei V, Negrin L. Periprosthetic femoral fractures--incidence, classification problems and the proposal of a modified classification scheme. Int Orthop. 2015;39(10):1909–20.

    Article  PubMed  Google Scholar 

  19. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. 2011. Available from: (cited 15 October 2019).

  20. Sarvilinna R, Huhtala HS, Sovelius RT, Halonen PJ, Nevalainen JK, Pajamäki KJ. Factors predisposing to periprosthetic fracture after hip arthroplasty: a case (n = 31)-control study. Acta Orthop Scand. 2004;75(1):16–20.

    Article  PubMed  Google Scholar 

  21. Sarvilinna R, Huhtala H, Pajamäki J. Young age and wedge stem design are risk factors for periprosthetic fracture after arthroplasty due to hip fracture. A case-control study. Acta Orthop. 2005;76(1):56–60.

    Article  PubMed  Google Scholar 

  22. Berend ME, Smith A, Meding JB, Ritter MA, Lynch T, Davis K. Long-term outcome and risk factors of proximal femoral fracture in uncemented and cemented total hip arthroplasty in 2551 hips. J Arthroplasty. 2006;21(6 Suppl 2):53–9.

    Article  PubMed  Google Scholar 

  23. Cook RE, Jenkins PJ, Walmsley PJ, Patton JT, Robinson CM. Risk factors for periprosthetic fractures of the hip: a survivorship analysis. Clin Orthop Relat Res. 2008;466(7):1652–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93(1):96–101.

    Article  CAS  PubMed  Google Scholar 

  25. Zhang C. Analysis on relevant factors of around prosthesis fracture after total replacement. Mod Prev Med. 2012;39:3961–3.

    Google Scholar 

  26. Savin L, Barhăroşie C, Botez P. Periprosthetic femoral fractures--evaluation of risk factors. Rev Med Chir Soc Med Nat Iasi. 2012;116(3):846–52.

    PubMed  Google Scholar 

  27. Singh JA, Jensen MR, Lewallen DG. Patient factors predict periprosthetic fractures after revision total hip arthroplasty. J Arthroplasty. 2012;27(8):1507–12.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Singh JA, Jensen MR, Harmsen SW, Lewallen DG. Are gender, comorbidity, and obesity risk factors for postoperative periprosthetic fractures after primary total hip arthroplasty? J Arthroplasty. 2013; 28(1):126-131.e1-2.

  29. Katz JN, Wright EA, Polaris JJ, Harris MB, Losina E. Prevalence and risk factors for periprosthetic fracture in older recipients of total hip replacement: a cohort study. BMC Musculoskelet Disord. 2014;15:168.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Thien TM, Chatziagorou G, Garellick G, Furnes O, Havelin LI, Mäkelä K, Overgaard S, Pedersen A, Eskelinen A, Pulkkinen P, Kärrholm J. Periprosthetic femoral fracture within two years after total hip replacement: analysis of 437,629 operations in the nordic arthroplasty register association database. J Bone Joint Surg Am. 2014;96(19):e167.

    Article  PubMed  Google Scholar 

  31. Ricioli W Jr, Queiroz MC, Guimarães RP, Honda EK, Polesello G, Fucs PM. Prevalence and risk factors for intra-operative periprosthetic fractures in one thousand eight hundred and seventy two patients undergoing total hip arthroplasty: a cross-sectional study. Int Orthop. 2015;39(10):1939–43.

    Article  PubMed  Google Scholar 

  32. Gromov K, Bersang A, Nielsen CS, Kallemose T, Husted H, Troelsen A. Risk factors for post-operative periprosthetic fractures following primary total hip arthroplasty with a proximally coated double-tapered cementless femoral component. Bone Joint J. 2017;99-B(4):451–7.

    Article  CAS  PubMed  Google Scholar 

  33. Lindberg-Larsen M, Jørgensen CC, Solgaard S, Kjersgaard AG, Kehlet H. Increased risk of intraoperative and early postoperative periprosthetic femoral fracture with uncemented stems. Acta Orthop. 2017;88(4):390–4.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Tamaki T, Jonishi K, Miura Y, Oinuma K, Shiratsuchi H. Cementless tapered-wedge stem length affects the risk of periprosthetic femoral fractures in direct anterior total hip arthroplasty. J Arthroplasty. 2018;33(3):805–9.

    Article  PubMed  Google Scholar 

  35. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Ottawa Health Research Institute. 2000. (date last accessed 15 October 2019). Google Scholar.

  36. Oremus M, Wolfson C, Perrault A, Demers L, Momoli F, Moride Y. Interrater reliability of the modified Jadad quality scale for systematic reviews of Alzheimer's disease drug trials. Dement Geriatr Cogn Disord. 2001;12(3):232–6.

    Article  CAS  PubMed  Google Scholar 

  37. Bown MJ, Sutton AJ. Quality control in systematic reviews and meta-analyses. Eur J Vasc Endovasc Surg. 2010;40(5):669–77.

    Article  CAS  PubMed  Google Scholar 

  38. Lee SR, Bostrom MP. Periprosthetic fractures of the femur after total hip arthroplasty. Instr Course Lect. 2004;53:111–8.

    PubMed  Google Scholar 

  39. Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am. 2015;97(17):1386–97.

    Article  PubMed  Google Scholar 

  40. Sidler-Maier CC, Waddell JP. Incidence and predisposing factors of periprosthetic proximal femoral fractures: a literature review. Int Orthop. 2015;39(9):1673–82.

    Article  PubMed  Google Scholar 

  41. Foster AP, Thompson NW, Wong J, Charlwood AP. Periprosthetic femoral fractures--a comparison between cemented and uncemented hemiarthroplasties. Injury. 2005;36(3):424–9.

    Article  PubMed  Google Scholar 

  42. Morrey BF, Kavanagh BF. Complications with revision of the femoral component of total hip arthroplasty. Comparison between cemented and uncemented techniques. J Arthroplasty. 1992;7(1):71–9.

    Article  CAS  PubMed  Google Scholar 

  43. Abdel MP, Houdek MT, Watts CD, Lewallen DG, Berry DJ. Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties: a 40-year experience. Bone Joint J. 2016;98-B(4):468–74.

    Article  CAS  PubMed  Google Scholar 

  44. Davidson D, Pike J, Garbuz D, Duncan CP, Masri BA. Intraoperative periprosthetic fractures during total hip arthroplasty. Evaluation and management. J Bone Joint Surg Am. 2008;90(9):2000–12.

    Article  PubMed  Google Scholar 

  45. Mayle RE, Della Valle CJ. Intra-operative fractures during THA: see it before it sees us. J Bone Joint Surg Br. 2012;94(11 Suppl A):26–31.

    Article  CAS  PubMed  Google Scholar 

  46. Garellick G, Malchau H, Regnér H, Herberts P. The Charnley versus the Spectron hip prosthesis: radiographic evaluation of a randomized, prospective study of 2 different hip implants. J Arthroplasty. 1999;14(4):414–25.

    Article  CAS  PubMed  Google Scholar 

  47. Kristensen TB, Dybvik E, Furnes O, Engesæter LB, Gjertsen JE. More reoperations for periprosthetic fracture after cemented hemiarthroplasty with polished taper-slip stems than after anatomical and straight stems in the treatment of hip fractures: a study from the Norwegian Hip Fracture Register 2005 to 2016. Bone Joint J. 2018;100-B(12):1565–71.

    Article  CAS  PubMed  Google Scholar 

  48. Palan J, Smith MC, Gregg P, Mellon S, Kulkarni A, Tucker K, Blom AW, Murray DW, Pandit H. The influence of cemented femoral stem choice on the incidence of revision for periprosthetic fracture after primary total hip arthroplasty: an analysis of national joint registry data. Bone Joint J. 2016;98-B(10):1347–54.

    Article  CAS  PubMed  Google Scholar 

  49. Lamb JN, Jain S, King SW, West RM, Pandit HG. Risk factors for revision of polished taper-slip cemented stems for periprosthetic femoral fracture after primary total hip replacement: a registry-based cohort study from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. J Bone Joint Surg Am. 2020;102(18):1600–8.

    Article  CAS  PubMed  Google Scholar 

  50. Wei S, Siegal GP. Mechanisms modulating inflammatory osteolysis: a review with insights into therapeutic targets. Pathol Res Pract. 2008;204(10):695–706.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Hu Z, Xu S, Lin H, Ni W, Yang Q, Qi J, Du K, Gu J, Lin Z. Prevalence and risk factors for bone loss in Southern Chinese with rheumatic diseases. BMC Musculoskelet Disord. 2020;21(1):416.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Wysham KD, Shoback DM, Andrews JS, Katz PP. Sex differences in frailty and its association with low bone mineral density in rheumatoid arthritis. Bone Rep. 2020;12:100284.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Mann T, Eisler T, Bodén H, Muren O, Stark A, Salemyr M, Sköldenberg O. Larger femoral periprosthetic bone mineral density decrease following total hip arthroplasty for femoral neck fracture than for osteoarthritis: a prospective, observational cohort study. J Orthop Res. 2015;33(4):504–12.

    Article  PubMed  Google Scholar 

  54. Naqvi GA, Baig SA, Awan N. Interobserver and intraobserver reliability and validity of the Vancouver classification system of periprosthetic femoral fractures after hip arthroplasty. J Arthroplasty. 2012;27(6):1047–50.

    Article  PubMed  Google Scholar 

  55. Moreta J, Aguirre U, de Ugarte OS, Jáuregui I, Mozos JL. Functional and radiological outcome of periprosthetic femoral fractures after hip arthroplasty. Injury. 2015;46(2):292–8.

    Article  PubMed  Google Scholar 

  56. McGraw IW, Spence SC, Baird EJ, Eckhardt SM, Ayana GE. Incidence of periprosthetic fractures after hip hemiarthroplasty: are uncemented prostheses unsafe? Injury. 2013;44(12):1945–8.

    Article  PubMed  Google Scholar 

  57. Kim KK, Park YW, Kim TH, Seo KD. Atypical femoral neck fracture after prolonged bisphosphonate therapy. J Pathol Transl Med. 2020;12:100284.

    Google Scholar 

Download references


Not applicable


Not applicable

Author information

Authors and Affiliations



CB conceived the idea; performed the study design, data collection, data analysis; and wrote the manuscript. AK performed the data analysis and wrote the manuscript. AK performed the data collection and data analysis and edited the manuscript. KP performed the data analysis and edited the manuscript. NN performed the data collection and data analysis and edited the manuscript. KB performed the data analysis and edited the manuscript. PJP performed the data analysis and edited the manuscript. ODS performed the data collection and data analysis and edited the manuscript. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Christos Bissias.

Ethics declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no conflicts of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bissias, C., Kaspiris, A., Kalogeropoulos, A. et al. Factors affecting the incidence of postoperative periprosthetic fractures following primary and revision hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 16, 15 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: