When an artificial hip becomes chronically infected and the femur around it then breaks, orthopaedic surgeons face one of the most punishing combinations in modern joint surgery. Two of the most feared complications of total hip replacement, periprosthetic joint infection and periprosthetic fracture, rarely strike together, and when they do, there has been no standardized playbook. A new case series published in the Journal of Bone and Joint Infection by Georges F. Vles of University Hospitals Leuven and colleagues across Belgium, the Netherlands, and Switzerland now offers a pragmatic answer: a carefully sequenced two-stage treatment framework that, in all three patients reported, cleared the infection, healed the fracture, and restored function.
The scale of the underlying problem is set to grow. The annual number of total hip arthroplasties is projected to rise substantially over the coming decades, driven by population growth and increasing utilization. Although revision rates per implant have gradually declined thanks to better bearing surfaces and fixation, the absolute number of revision procedures continues to climb. Meanwhile, the true incidence of both major complications is likely underestimated. Joint registries capture only fractures requiring stem revision, yet more than half of periprosthetic femoral fractures are treated without stem revision, yielding an estimated true incidence of 0.92 per 1000 prosthesis years. Infection figures suffer from incomplete reporting and failure to update preoperative diagnoses with intraoperative culture results. With an ageing, increasingly comorbid population living longer with prosthetic joints, the absolute burden of both complications is expected to increase sharply.
The coexistence of the two conditions is rarer still, and the authors stress a crucial distinction: a fracture occurring around a chronically infected implant is fundamentally different from an acute infection developing after fracture-fixation surgery. Chronic infection involves a mature biofilm on the implant surface, a microbial fortress that antibiotics alone cannot penetrate, and typically arises in the setting of longstanding infection and septic loosening. Because implant loosening is a well-established risk factor for periprosthetic fracture, septic loosening may further increase fracture susceptibility, although robust data on this relationship remain limited. Existing evidence-based guidelines cover fractures, joint infection, and fracture-related infection separately, but integrating fracture stabilization, infection eradication, and definitive reconstruction in often frail patients has remained an unsolved challenge.
The first patient, a 74-year-old woman with multiple comorbidities, had undergone hip replacement in 2019 for a femoral neck fracture, followed by an Escherichia coli joint infection treated with repeated surgeries, and then presented in 2022 after a low-energy fall. Imaging showed a Vancouver type C fracture around a loosened cemented stem. Fluoroscopy-guided hip aspiration revealed a synovial white blood cell count of 15,880 cells per microliter with 97 percent neutrophils and a positive alpha-defensin test, meeting European Bone and Joint Infection Society criteria for infection; cultures confirmed methicillin-resistant Staphylococcus epidermidis. After multidisciplinary discussion and shared decision-making, the team proceeded with a two-stage revision.
The first stage follows a disciplined dirty-then-clean logic. In the dirty phase, surgeons explant the prosthesis through an extensile approach, perform thorough debridement and lavage, and remove infected tissue and foreign material. In the clean phase, the fracture is stabilized, here with cerclage wiring and a plate-screw construct, and a custom-made antibiotic-loaded cement spacer is implanted to bridge the fracture and deliver high local antibiotic concentrations. For this patient, the spacer was lengthened from a prefabricated device and loaded with meropenem because of her history of ESBL-producing E. coli. Targeted antibiotics were de-escalated to oral minocycline, wounds healed uneventfully, and C-reactive protein normalized. Ten weeks later, the second stage removed the spacer and hardware, confirmed healthy tissues and fracture healing, applied fresh plate fixation to reinforce the femur, and implanted a definitive cemented stem with a dual mobility cup. Three and a half years on, imaging showed complete healing, infection markers stayed normal, and the patient reported better mobility than before her fall.
The second case illustrates how unpredictable these scenarios become. A 56-year-old man with a history of hip resurfacing, early infection, and a two-stage revision for Staphylococcus aureus and Pseudomonas aeruginosa sustained a fracture whose plate fixation failed through non-union. At referral, his synovial fluid showed 59,800 white cells per microliter with 99 percent neutrophils, though cultures were negative, likely suppressed by ongoing antibiotics from the referring hospital. During the first stage, surgeons encountered frank pus along the plate and in the joint; the stem was so well fixed that extraction required an extended trochanteric osteotomy, a controlled cut of the greater trochanter to gain access. Cultures grew P. aeruginosa, treated with eight weeks of oral levofloxacin. At the second stage, with the fracture and osteotomy not yet healed, a new plate construct and a modular revision stem were implanted, but six samples unexpectedly grew Candida albicans, prompting six months of fluconazole alongside the antibacterial course. Two years later, radiographs and CT showed complete healing and normalized inflammatory markers, although patient-reported outcome measures remained poor, a sobering reminder that eradication does not guarantee subjective recovery in complex, comorbid patients.
The third patient, a 76-year-old woman, presented with a draining skin fistula over her anterior incision and a Vancouver B2 fracture after a fall. The fistula was traced and excised down to the implant, the prosthesis was explanted, and the fracture stabilized with a plate extending to the trochanter plus a long antibiotic spacer. Cultures identified Cutibacterium avidum, a slow-growing skin bacterium, treated with oral amoxicillin. Eight weeks after the first stage, all second-stage cultures were negative, a new plate and an uncemented dual mobility cup with a modular fluted titanium revision stem were implanted, and the patient completed twelve weeks of total antibiotic therapy. Seven months after reimplantation she reported no problems, and her patient-reported scores were essentially perfect across pain, symptoms, activities, functioning, and quality of life.
Beyond the outcomes, the paper distills hard-won technical lessons. Diagnosing infection amid a fracture is treacherous: hemarthrosis and local inflammation can produce false-positive synovial white cell counts, especially when the fracture extends into the joint, so the authors reserve the first milliliter of aspirate for cell analysis to minimize blood contamination, and note that molecular diagnostics can add value. Timing matters too: recent studies found no clear correlation between the interval from trauma to definitive surgery and outcomes, including mortality, so postponing surgery until an experienced revision and septic-surgery team is available appears safe. Fracture-related infection principles demand stable fixation that preserves bone biology, and the authors advise leaving spare screw holes or using the shortest adequate plate at the first stage to preserve options for reconstruction. Surgeons must also consider adjacent prosthetic joints, since metachronous infection of a same-side knee replacement has been reported in up to 20 percent of cases.
The interval between stages must be individualized, balancing the risk of septic failure against premature reimplantation compromising fracture healing. The team generally targets a window of roughly six weeks without an antibiotic-free interval, extended when fracture healing needs more time, and weighs wound status, C-reactive protein trends, spacer tolerance, and acetabular erosion. Conceptually, they treat the second stage as a single-stage exchange of the spacer, replacing all components including the first-stage plate, reasoning that organisms introduced during the long first procedure may not have been covered by targeted therapy, and that plate exchange is straightforward once the fracture is reduced and partially healed. The authors acknowledge the limits of their evidence: three heterogeneous patients, no control group, and a framework grounded in expert opinion. They call on large musculoskeletal infection centers to build prospective databases and on international societies to forge consensus algorithms. For now, their framework offers surgeons confronting this rare collision of broken bone and entrenched biofilm a tested, reproducible path through it.
Subject of Research: Two-stage surgical management of periprosthetic femoral fractures around chronically infected total hip arthroplasties
Article Title: Periprosthetic fractures around chronically infected total hip arthroplasties: a case series and pragmatic two-stage treatment framework
Article References: Vles, G. F., Metsemakers, W.-J., Aerden, L., Geurts, J., Borens, O., & Ghijselings, S. (2026). Periprosthetic fractures around chronically infected total hip arthroplasties: a case series and pragmatic two-stage treatment framework. Journal of Bone and Joint Infection, 11(4), 547-554. https://doi.org/10.5194/jbji-11-547-2026
Image Credits: AI Generated
Keywords: periprosthetic fracture, periprosthetic joint infection, total hip arthroplasty, two-stage revision, antibiotic-loaded cement spacer, biofilm, fracture-related infection, septic loosening, revision stem, orthopaedic surgery, case series, debridement
News Source: Ophelia Keating. (October 9, 2026). Two-Step Surgery Beats Broken Bones and Hidden Infections Around Artificial Hips. Scienmag.
