Periprosthetic Femoral Fracture in Hip Arthroplasty Using Cemented Stems: Toward a Construct-Level and Time-Dependent Perspective

Abstract

Periprosthetic femoral fracture (PFF) is an increasingly recognized complication following cemented total hip arthroplasty (THA); it is associated with substantial morbidity and mortality and often occurring several years after implantation. Although polished taper-slip (PTS) stems demonstrate favorable long-term survivorship, they have also been associated with a higher incidence of PFF, the biomechanical basis of which remains unclear. Existing studies have investigated a few key aspects of cemented THA, including implant migration, cement behavior, and fracture biomechanics. However, these factors are typically examined in isolation or under simplified conditions, and current construct-level models evaluate fracture without accounting for prior loading history. Pre-clinical testing standards relevant to fracture in cemented THA remain limited, with existing standards addressing individual components under simplified laboratory conditions rather than the integrated periprosthetic system under a physiologically relevant environment. As a result, how the implant–cement–bone construct evolves from implantation to eventual failure remains insufficiently characterized. In this study, we critically evaluate current experimental approaches and identify the absence of a time-resolved, construct-level framework as a key limitation. We outline a conceptual framework describing how implant migration, material response, and fracture behavior evolve with loading exposure. This framework may provide a foundation for both improving the mechanistic understanding of PFF and supporting the development of future pre-clinical testing strategies that can better reflect clinical loading conditions.