Re-fractures after periprosthetic femoral fracture: A difficult to treat growing evidence Filippo Randelli a , Fabrizio Pace a, *, Daniele Priano a , Alessio Giai Via a , Pietro Randelli b a Hip Department – Orthopedic and Trauma V, I.R.C.C.S. Policlinico San Donato, 20097, San Donato Milanese, Milan, Italy b Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, 1  Clinica Ortopedica, Milan, Italy A R T I C L E I N F O Article history: Received 25 June 2018 Accepted 25 September 2018 Keywords: Hip arthroplasty Periprosthetic fracture Revision surgery A B S T R A C T Introduction: Periprosthetic fractures are increasing. The treatment is mostly surgical, but it has a high complication rate. Re-fracture and non-union with implant failure are the more frequent complications. Those complications are difficult to treat and can lead to severe disability. The purpose of this study is to determine the clinical results of periprosthetic femoral re-fracture treatment. Materials and methods: Twenty patients were treated for femoral re-fractures (17 women, 3 men). The mean age and follow-up are 75.7 years (46–95) and 6.15 years (0.4–15) respectively. The diagnosis of new periprosthetic fracture according to Vancouver classification were: 3 type A, 5 type B1, 1 type B2, 2 B3, 8 type C; 1 Lewis-Rorabeck type II. Patients were followed-up clinically, with a Harris Hip Score, and radiologically at 2, 4, 6, 12 months, and then annually. Results: All patients healed except for two cases in which an infection occurred. Two cases, treated with plate osteosynthesis, had a malunion in varus. Six patients died for unrelated reasons after fracture healing. One patient was excluded because of a follow-up shorter than 12 months. In 16 cases (84%) a Trendelenburg gait or the use of aids for walking has been necessary. At final follow-up the mean HHS was 65 (range 45–82). Fractures treatment differed depending on the type of the fracture, prosthesis stability and bone loss. Tension band wiring, long plate fixation, revision with a long stem with cables or a sandwich technique (two plates or one plate plus one strut graft) have been performed according to fracture type. Conclusions: Re-fractures and non-union with implant failure are common after periprosthetic fracture treatment. Infection and malunion are the main complications of their treatment. Residual limping with the necessity of aids even after fracture healing is often present. The choice of a correct surgical strategy is essential to minimize the risk of new complications and ensure the highest possibility to heal. The most important factor is to achieve a good stability, a reasonable vital environment and don’t leave new areas of lower resistance uncovered. Poor functional outcome has to be expected especially in refracture after a revision surgery. © 2018 Elsevier Ltd. All rights reserved. Introduction Recent studies reported an incidenceof periprosthesic fractures of 1–3% after Total Hip Arthroplasty (THA), and up to 8% after revision THA [1]. According to the Swedish National Hip Arthroplasty Register, periprosthesic fractures are the third cause of revision surgery [2]. The treatment of periprosthetic fractures is associated to a high rate of failure due to non-union with implant failure and re- fracture. A 10-years survival-rate of 70% has been reported [2]. Few experiences about periprosthetic re-fractures have been published in literature and each of these cases is usually treated individually, according to the features of the patients, the personality of the fracture and the experience of the surgeon. Many surgical techniques have been described, as cables, plate or double fixation in a sandwich technique and revision surgery with long stem with or without fixation [3]. In some cases, biological augmentation as bone graft, bone morphogenetic proteins (BMPs) or large allografts in conjunction with plate fixation have been suggested [4]. The extremely complex topic associated with the paucity of reports makes particularly difficult the decision making. In this article, we report our experience on the treatment of peripros- thetic femur re-fractures. * Corresponding author. E-mail address: fabriziopacemd@gmail.com (F. Pace). https://doi.org/10.1016/j.injury.2018.09.045 0020-1383/© 2018 Elsevier Ltd. All rights reserved. Injury, Int. J. Care Injured 49S3 (2018) S43–S47 Contents lists available at ScienceDirect Injury journal homepa ge: www.elsev ier.com/locate /injury