A Fracture Around a Hip Implant: Does the Femoral Stem Need to Be Replaced?
Vancouver B1, B2 and B3 periprosthetic femoral fractures: how stem stability, bone stock and patient factors guide ORIF versus revision, and how to select a revision femoral stem.
A fall, a broken femur and an old hip replacement
A 77-year-old woman is admitted to hospital after falling in her kitchen.
She had a right total hip replacement nine years earlier. Before the fall, she lived independently, managed her own shopping and walked short distances without assistance.
Now she has severe pain in her thigh and cannot bear weight on the right leg.
Radiographs show a fracture around the femoral stem of her hip replacement.
Her daughter asks whether the surgeon can repair the broken bone with a plate or whether the artificial hip must be replaced as well.
It is a reasonable question, but the answer is not immediately obvious.
The fracture is visible on the radiographs. What is less certain is whether the existing femoral stem remains securely fixed.
That distinction matters. A fracture around a well-fixed implant may be treated differently from a fracture involving a loose stem.
In this illustrative case, the patient has hypertension, controlled type 2 diabetes and reduced bone density. Her original hip replacement was performed for osteoarthritis.
The orthopedic team must consider her general health and pre-injury mobility alongside the fracture and existing implant.
Clinical scenario: The patient is an illustrative composite. Her age, medical history and circumstances are hypothetical and do not describe a verified AK Medical patient or treatment outcome.
Does a fracture around a hip replacement always require stem revision?
No. Treatment depends primarily on the fracture pattern, femoral stem stability, remaining bone stock and the patient's condition.
A fracture around a well-fixed stem may be treated with internal fixation while retaining the implant. A loose stem often requires consideration of revision arthroplasty, although selected fractures may be managed without stem exchange.
The Vancouver classification helps distinguish these situations. It is particularly useful for understanding B1, B2 and B3 fractures.
The key question is whether the planned treatment will provide a stable reconstruction of both the femur and its existing implant.
Why surgeons look beyond the fracture line
A periprosthetic femoral fracture occurs around or near an implanted femoral prosthesis.
It can occur after a fall, but the circumstances vary. Bone quality, implant fixation, previous surgery and mechanical conditions may all influence the injury.
The first radiographs help identify where the bone has broken.
They may not establish whether the stem was stable before the fracture or remains stable afterward.
The surgeon therefore looks for other information.
Previous radiographs can sometimes reveal migration or changes around the implant.
The patient's history may also help. Persistent thigh pain before the fall could raise concern about an existing implant-related problem.
Neither imaging nor symptoms should be interpreted in isolation.
Where uncertainty remains, further assessment or intraoperative evaluation may be necessary.
Why stem stability changes the operation
A well-fixed femoral component may provide a stable foundation around which the fracture can be reconstructed.
In this situation, removing the stem is not necessarily required.
A loose stem presents a different problem.
Fixing the fracture fragments without adequately addressing implant instability may leave the reconstruction mechanically compromised.
On the other hand, removing a well-fixed stem can make surgery more extensive.
The decision therefore begins with a careful assessment of the existing implant.
Vancouver B1, B2 and B3: similar fracture locations, different treatment needs
The Vancouver classification considers the location of the fracture, the stability of the femoral stem and the remaining bone stock.
Type B fractures occur around or just below the femoral stem.
Within this group, the distinction between B1, B2 and B3 is particularly important.
| Vancouver type | Femoral stem | Remaining bone | Common treatment consideration |
|---|---|---|---|
| B1 | Well fixed | Generally sufficient for appropriate fracture fixation | Internal fixation while retaining the stem |
| B2 | Loose | Relatively adequate bone stock | Stem revision is commonly considered; fixation alone may be suitable in selected cases |
| B3 | Loose | Poor bone stock | More complex reconstruction is often required |
The table describes the classification, not a mandatory treatment protocol.
For example, a patient with a B2 fracture may have a particular cemented stem design or fracture configuration that influences whether retention is mechanically reasonable.
A B3 fracture can present a much more difficult reconstruction because bone deficiency limits the available fixation options.
The B1–B2 distinction can be difficult
In the woman's case, the fracture lies around the distal portion of the existing stem.
The surgeon reviews the available imaging and implant history.
The principal question is whether the femoral component remains fixed or has become loose.
A B1 fracture mistakenly classified as stable when the stem is actually loose may lead to an inadequate treatment plan.
Preoperative imaging is important, but stem stability is not always certain until surgery.
The team should therefore be prepared to reassess the reconstruction if the intraoperative findings differ from the original plan.
If the stem is loose, must it be replaced?
For many years, revision of a loose femoral stem has been a common approach to Vancouver B2 and B3 fractures.
The reasoning is mechanical.
A revision construct can be planned to address the unstable implant while allowing the surgeon to stabilize the fracture.
However, the decision is not identical for every patient.
Some B2 fractures may be treated with open reduction and internal fixation (ORIF) without exchanging the stem.
The suitability of this approach depends on the existing implant design, fracture configuration, available bone and whether a mechanically appropriate construct can be achieved.
The distinction between cemented and cementless stems may be relevant.
Certain cemented stem and cement-mantle configurations can present different fixation considerations from a loose cementless stem.
The surgeon must assess the actual construct rather than relying on the fracture classification alone.
Why the patient's general condition matters
The woman in our example is 77 years old and has several chronic medical conditions.
Revision arthroplasty may involve substantial operative demands, including blood loss and longer surgical time.
In selected circumstances, fixation without stem exchange may reduce some perioperative burdens.
That does not automatically make it the better operation.
If the retained implant cannot provide an appropriate mechanical foundation, the patient may face further complications or another procedure.
The treatment decision must balance surgical burden with the need for stable reconstruction.
Clinical evidence: what was reported in the earlier B2 and B3 literature?
A 2017 systematic review in The Bone & Joint Journal examined published treatment outcomes for Vancouver B2 and B3 periprosthetic femoral fractures.
It included 22 studies and reported fracture-specific treatment and reoperation outcomes.
Clinical Evidence 1 — Vancouver B2 and B3 Fracture Management
Study: Khan et al., 2017
Journal: The Bone & Joint Journal
DOI: 10.1302/0301-620X.99B4.BJJ-2016-1311.R1
PMID: 28363890
| Reported measure | Vancouver B2 | Vancouver B3 |
|---|---|---|
| Fractures included | 343 | 167 |
| Treated with stem revision, with or without additional fixation | 298 | 160 |
| Treated with fixation without stem revision | 45 | 7–8 reported |
| Reoperations following revision | 37/298 (12.4%) | 23/160 (14.4%) |
| Reoperations following fixation without revision | 6/45 (13.3%) | 2 cases (28.6% using denominator 7) |
Included studies: 22
Reported mean follow-up range across studies: 32–74 months.
Original research:
Evidence note: The published abstract reports eight B3 cases treated without stem revision, while the article's treatment table reports seven. The 28.6% reoperation figure corresponds to two of seven cases. The discrepancy is retained transparently rather than treating either number as an unquestioned exact total.
The review showed that stem revision was the predominant reported approach for both B2 and B3 fractures.
It also documented a proportion of B2 fractures managed with fixation alone.
The observed B2 reoperation proportions were 12.4% after revision and 13.3% after fixation without revision.
These figures should not be treated as evidence of equivalent treatment effectiveness.
The studies were observational, and treatment selection may have reflected differences in patient health, fracture characteristics and implant designs.
For B3 fractures, the small number of fixation-only cases makes the observed reoperation proportion particularly uncertain.
The review supports careful fracture classification and treatment selection. It does not provide a universal rule for every patient.
Nor does it establish the outcomes of a specific AK Medical, Stryker or DePuy Synthes implant system.
More recent evidence: can ORIF be appropriate for selected B2 and B3 fractures?
A systematic review and meta-analysis published in 2024 examined the outcomes of stem revision and ORIF for Vancouver B2 and B3 fractures.
The investigators analyzed 15 studies involving 1,629 patients.
Clinical Evidence 2 — ORIF Versus Stem Revision
Study: Di Martino et al., 2024
Journal: Archives of Orthopaedic and Trauma Surgery
DOI: 10.1007/s00402-024-05469-1
PMID: 39105834
| Study measure | Reported result |
|---|---|
| Included studies | 15 |
| Total patients | 1,629 |
| Treated with ORIF | 564 |
| Treated with stem revision | 1,065 |
| Pooled reoperation effect estimate | 0.87 (95% CI 0.39–1.96) |
| Pooled complication effect estimate | 1.01 (95% CI 0.45–2.27) |
| Reoperation heterogeneity | I² = 78% |
| Complication heterogeneity | I² = 85% |
Original research:
Statistical note: The numerical values are the pooled effect estimates reported by the authors, not implant revision percentages or product-specific complication rates. Their interpretation is limited by substantial variation among the included studies.
The investigators did not find a clear pooled difference in reoperation or complication outcomes between the two approaches.
ORIF was associated with less blood loss, shorter operating time and shorter hospital stay in certain analyses.
For older patients with significant comorbidities, these findings may be relevant to the treatment discussion.
They do not prove that ORIF and stem revision are interchangeable.
The studies included different patient populations, fracture configurations and implant systems.
The high heterogeneity also limits how confidently the pooled findings can be applied to any individual patient.
For a surgeon treating a loose stem, the essential question remains whether retention of the existing implant can provide a sound mechanical reconstruction.
The evidence supports selective clinical judgment rather than routine fixation of every loose-stem fracture.
Applying the evidence to the patient's situation
The orthopedic team now has several decisions to make.
The patient was independently mobile before the fall. Her existing hip implant is nine years old, and the fracture lies around the stem.
The team reviews her medical condition, prior imaging and implant documentation.
If the stem is well fixed, fracture fixation may be appropriate.
If it is loose and adequate bone remains, revision is commonly considered, although selected stem and fracture configurations may allow an alternative approach.
If the stem is loose and bone stock is poor, the reconstruction becomes more demanding.
The team may need to plan fixation beyond the compromised region and consider additional structural support.
What should be established before the operation?
| Clinical question | Why it matters |
|---|---|
| Where is the fracture? | Determines the anatomical fracture category |
| Is the stem stable? | Influences whether it may be retained |
| What implant is already present? | Helps assess the existing fixation mechanism and available options |
| How much suitable bone remains? | Determines where fixation may be obtained |
| What is the fracture configuration? | Influences the method of stabilization |
| Is there a cement mantle? | May affect reconstruction options for selected cemented designs |
| Was the patient mobile before the fracture? | Helps establish appropriate functional goals |
| What medical conditions are present? | Influences operative and rehabilitation considerations |
The Vancouver classification organizes the discussion, but the complete treatment plan depends on the patient's actual findings.
Selecting a revision femoral stem when distal fixation is required
If revision is necessary, the surgeon must select a femoral component capable of obtaining appropriate fixation in the remaining bone.
Proximal fixation may be compromised by the fracture, previous implant bed or associated bone deficiency.
A revision stem designed for distal fixation may be considered when suitable distal bone is available.
The selected stem must be evaluated for its geometry, intended fixation mechanism, size range and compatibility with the proposed reconstruction.
Stem length and fixation requirements are especially important when a fracture or cortical defect must be bypassed.
The manufacturer's surgical technique and instructions for use should guide the assessment of the selected system.
How do AK Medical, Stryker and DePuy Synthes approach femoral revision design?
Hospitals evaluating revision femoral stems may consider products from multiple manufacturers.
Among the available examples are:
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AK Medical AK-SL Femoral Stem.
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Stryker Restoration Modular Revision Hip System.
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DePuy Synthes RECLAIM Modular Revision Hip System.
These products are relevant to femoral revision, but they use different design architectures.
The distinction matters because a modular reconstruction system and a nonmodular tapered revision stem do not necessarily offer the same adjustment options or component configurations.
International femoral revision systems: documented design comparison
| Evaluation area | AK Medical — AK-SL | Stryker — Restoration Modular | DePuy Synthes — RECLAIM Modular |
|---|---|---|---|
| Product category | Cementless revision femoral stem | Cementless modular revision femoral system | Cementless modular revision femoral system |
| Stem architecture | Nonmodular tapered stem | Separate distal and proximal modular components | Separate distal and proximal modular components |
| Manufacturer-described taper | 2° | Depends on component configuration; check current technical documentation | 2.5° bi-planar taper |
| Distal fixation features | Circular tapered profile with eight longitudinal ribs | Distal fixation components designed for revision reconstruction | Wagner-style tapered distal stem with fixation geometry described by the manufacturer |
| Proximal reconstruction options | Determined by selected stem and compatible head configuration | Modular proximal body configurations | Modular proximal body configurations |
| Separate proximal-body/distal-stem junction | No | Yes | Yes |
| Primary evaluation question | Can the monobloc stem obtain adequate fixation in suitable remaining femoral bone? | Do the modular components meet distal fixation and proximal reconstruction requirements? | Do distal fixation and modular proximal reconstruction meet the intended requirements? |
| Essential documents | Current AK-SL IFU, surgical technique, sizing and relevant evidence | Current Restoration Modular IFU, technical documentation and evidence | Current RECLAIM Modular IFU, technical documentation and evidence |
Sources: Official AK Medical product catalogue and surgical technique; Stryker Restoration Modular official product information; DePuy Synthes RECLAIM Modular official product information. [3–5]
What the comparison means
AK-SL follows a nonmodular tapered-stem design.
AK Medical describes a 2° taper, circular cross-section and eight longitudinal ribs intended to engage suitable femoral bone and contribute to rotational stability.
Stryker Restoration Modular uses separate proximal and distal components, allowing selected reconstruction options within the system's documented configurations.
DePuy Synthes RECLAIM Modular also uses separate proximal and distal components. Its manufacturer describes a Wagner-style 2.5° bi-planar taper and additional engineering features associated with its modular junction.
These are genuine design differences.
They do not establish which system will have the lowest complication rate or the longest implant survivorship.
A modular system may offer useful adjustment options in some revisions.
A nonmodular system avoids an additional proximal-body/distal-stem junction.
Neither fact, taken alone, establishes superiority.
For the patient in this article, the surgeon would need to determine which fixation concept and implant configuration are appropriate for the actual fracture and remaining bone.
What distinguishes AK-SL as a product for evaluation?
AK Medical's AK-SL is a cementless tapered revision stem intended for selected femoral revision situations requiring distal fixation.
The company's surgical technique emphasizes assessment of femoral bone loss, stem sizing, available distal fixation, leg length and offset.
These considerations are relevant when proximal femoral support is compromised.
However, the studies discussed earlier in this article do not provide AK-SL-specific results.
No conclusion can be drawn from those studies about AK-SL's comparative survivorship, fracture union rates or revision risk relative to Restoration Modular or RECLAIM Modular.
Hospitals should request device-specific evidence before making such comparisons.
Why hospitals should compare the complete systems
A revision stem is not selected from a catalogue in isolation.
The surgeon may need associated instruments, trial components, supplementary fixation options and a range of implant sizes.
For complex periprosthetic fractures, product availability and surgical preparation can be particularly important.
Hospitals comparing international suppliers should evaluate the actual systems offered for their market, including documented compatibility, instrumentation, clinical evidence and regulatory status.
Request AK-SL technical documentation
Orthopedic trauma surgeons, revision arthroplasty specialists, hospitals and international distributors may contact AK Medical to request available information about AK-SL.
Relevant materials may include:
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Available stem lengths and diameters.
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Surgical technique and instrumentation.
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Intended use and contraindications.
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Fixation requirements.
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Compatible components.
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Available product-specific clinical evidence.
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Applicable market authorization and supply information.
AK Medical International Sales: sales@ak-medical.net
Product information: https://www.ak-medical.net/en/product.html
Official contact page: https://www.ak-medical.net/en/contact.html
Any patient-identifiable imaging or medical information should be transferred only through an appropriately approved and secure process.
What should the patient and her family expect?
The patient's daughter still wants a clear answer.
Will the surgeon repair the broken femur, or replace the stem?
The team explains that the decision depends on whether the existing implant is stable and what reconstruction will provide the most appropriate support.
If the stem is well fixed, it may be possible to treat the fracture while retaining the implant.
If the stem is loose, revision is often considered, but the final plan depends on the implant design, fracture pattern, remaining bone and patient's condition.
The team also discusses the possibility that the operative findings may require a change from the initial plan.
Recovery will depend on the reconstruction, the patient's general health and the postoperative rehabilitation strategy.
At 77, her ability to regain safe mobility is an important concern.
The family should understand the recommended procedure, the reasons for retaining or replacing the stem, and the expected course of rehabilitation.
An appropriate operation must address both the injury and the mechanical condition of the existing implant.
Frequently Asked Questions
Does a fracture around a hip replacement mean the implant has failed?
Not necessarily. The femoral stem may remain well fixed despite a fracture. Implant stability must be assessed before determining the appropriate treatment.
What is the difference between Vancouver B1 and B2 fractures?
B1 describes a fracture around a well-fixed femoral stem. B2 describes a fracture around a loose stem with relatively adequate remaining bone stock.
What is a Vancouver B3 fracture?
A B3 fracture involves a loose femoral stem and poor bone stock. This often makes reconstruction more complex.
Can a Vancouver B2 fracture be treated without replacing the stem?
In selected situations, yes. The decision depends on the existing implant, fracture characteristics, mechanical stability and patient factors.
Does the evidence show that ORIF is better than stem revision?
No universal conclusion is supported. Some studies report comparable outcomes in selected patient populations, but treatment selection and study heterogeneity limit direct comparisons.
Why might surgeons use a long revision stem after a periprosthetic fracture?
A revision stem may be selected to obtain fixation in suitable bone beyond a compromised region. The required fixation and stem geometry depend on the implant system and the patient's anatomy.
What is the difference between AK-SL and Stryker Restoration Modular?
AK-SL is a nonmodular tapered revision stem. Restoration Modular uses separate proximal and distal modular components. This distinction affects available reconstruction options but does not establish which product is clinically superior.
How does AK-SL compare with DePuy Synthes RECLAIM Modular?
Both are intended for selected femoral revision applications, but AK-SL is nonmodular while RECLAIM Modular incorporates separate proximal and distal components. Their suitability must be assessed using product-specific technical and clinical information.
Can hospitals compare AK Medical with Stryker and DePuy Synthes?
Yes. Hospitals may evaluate relevant systems using consistent clinical, technical, regulatory and commercial criteria.
Conclusion: A fracture around a hip replacement requires two assessments
When a patient fractures the femur around an existing hip replacement, the surgeon must assess the broken bone and the stability of the implanted stem.
That distinction is central to the Vancouver classification.
A well-fixed stem may be retained during fracture fixation. A loose stem often requires consideration of revision, although selected patients may be managed differently.
Published clinical evidence supports individualized treatment decisions rather than a universal preference for either fixation or revision.
Where revision is required, the implant must provide appropriate fixation in the remaining bone while allowing the surgeon to reconstruct the femur and stabilize the fracture.
AK Medical's AK-SL, Stryker's Restoration Modular and DePuy Synthes' RECLAIM Modular represent different femoral revision design approaches.
Their technical characteristics can inform professional evaluation, but clinical outcomes and cost advantages cannot be inferred from design features alone.
The aim is not simply to repair the fracture or exchange the implant. It is to restore a stable femoral reconstruction that meets the patient's clinical needs.
Contact AK Medical | Femoral Revision & Complex Hip Reconstruction
AK Medical welcomes professional inquiries from orthopedic trauma surgeons, revision arthroplasty specialists, hospitals, procurement teams and international distributors.
Request AK-SL Femoral Revision Technical Documentation
International Sales Email: sales@ak-medical.net
Official Contact Page: https://www.ak-medical.net/en/contact.html
AK Medical Hip Portfolio: https://www.ak-medical.net/en/product.html
International Product Catalogue: https://www.ak-medical-global.com/products
Please include your country or region, organization, professional role and the product information or technical documentation required.
Product availability, indications, component compatibility, clinical documentation and regulatory authorization vary by jurisdiction.
References
1. Khan T, Grindlay D, Ollivere BJ, Scammell BE, Manktelow ARJ, Pearson RG.
A systematic review of Vancouver B2 and B3 periprosthetic femoral fractures.
The Bone & Joint Journal. 2017;99-B(4 Suppl B):17–25.
DOI: 10.1302/0301-620X.99B4.BJJ-2016-1311.R1.
PMID: 28363890.
https://pubmed.ncbi.nlm.nih.gov/28363890/
2. Di Martino A, Brunello M, Villari E, et al.
Stem revision vs. internal fixation in Vancouver B2/B3 periprosthetic hip fractures: systematic review and metanalysis.
Archives of Orthopaedic and Trauma Surgery. 2024;144:3787–3796.
DOI: 10.1007/s00402-024-05469-1.
PMID: 39105834.
https://pubmed.ncbi.nlm.nih.gov/39105834/
3. AK Medical.
AK-SL Femoral Stem Surgical Technique. Manufacturer technical documentation.
Official product catalogue:
https://www.ak-medical.net/upload/file/2026/05/08/220c37878ce298cbf900070f7f66d03d.pdf
4. Stryker.
Restoration Modular Revision Hip System. Official product information.
https://www.stryker.com/us/en/joint-replacement/products/restoration-modular.html
5. DePuy Synthes, Johnson & Johnson MedTech.
RECLAIM Modular Revision Hip System. Official product information.
https://www.jnjmedtech.com/en-US/product/reclaim-modular-revision-hip-system
6. Stoffel K, Blauth M, Joeris A, Blumenthal A, Rometsch E.
Fracture fixation versus revision arthroplasty in Vancouver type B2 and B3 periprosthetic femoral fractures: a systematic review.
Archives of Orthopaedic and Trauma Surgery. 2020.
DOI: 10.1007/s00402-020-03332-7.
https://pubmed.ncbi.nlm.nih.gov/32086558/
Medical Information & Evidence Disclaimer
This article provides general medical education and professional information. It does not diagnose an individual patient or recommend a specific treatment or implant.
The patient scenario is illustrative and does not represent a verified AK Medical clinical case.
The independent clinical studies cited above are not product-specific comparative outcome studies of AK Medical, Stryker or DePuy Synthes unless expressly identified as such.
The manufacturer comparison addresses documented design characteristics and professional evaluation considerations. It does not establish clinical superiority, equivalence, market ranking or cost advantages.
The management of periprosthetic femoral fractures depends on fracture characteristics, implant stability, remaining bone, patient condition and the treating surgeon's clinical judgment.
Product indications, available configurations and regulatory authorization vary by jurisdiction.
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