From the Research
The best approach for managing a periprosthetic greater trochanteric fracture typically involves conservative treatment for stable, non-displaced fractures and surgical intervention for displaced or unstable fractures. For most stable fractures, initial management includes protected weight-bearing with crutches or a walker for 6-8 weeks, pain management with NSAIDs (such as ibuprofen 400-600mg three times daily) or acetaminophen (1000mg three times daily), and physical therapy focusing on gentle range of motion exercises while avoiding abduction.
Key Considerations
- Fracture characteristics: displacement, comminution, and location relative to the implant
- Bone quality: osteoporosis, osteolysis, or other conditions affecting bone strength
- Patient activity level and comorbidities: influencing the choice between conservative and surgical management
- Implant stability: a crucial factor in determining the management strategy, as loose implants may require revision arthroplasty 1
Surgical Intervention
For displaced fractures greater than 1-2cm or those with persistent pain after conservative treatment, surgical fixation is recommended, typically using cable cerclage systems, trochanteric claw plates, or tension band wiring techniques. The choice of surgical technique depends on the fracture pattern, bone quality, and implant stability. Open reduction and internal fixation (ORIF) is often used for fractures associated with well-fixed implants, while revision arthroplasty may be necessary for loose implants 2, 3.
Post-Operative Rehabilitation
Post-operative rehabilitation involves protected weight-bearing for 6-12 weeks with gradual progression to full weight-bearing as healing progresses. Physical therapy should focus on maintaining range of motion, strengthening the surrounding muscles, and promoting functional recovery. The treatment approach must be individualized based on the patient's specific needs and circumstances.
Evidence-Based Practice
The management of periprosthetic greater trochanteric fractures is supported by various studies, including a retrospective review of 19 patients treated with internal fixation and allogeneic bone-grafting, which reported an average Harris hip score improvement from 32.5 to 91.2 points at follow-up 2. Another study evaluated the efficacy of an LC-DCP with trochanteric purchase in fixing Vancouver type B1 periprosthetic femoral fractures, reporting a mean Harris hip score of 85 at final follow-up 3. However, the most recent and highest quality study should be prioritized when making treatment decisions.