This is an excellent and really a very interesting question Prof Tanchev. Thank you. Its a very tricky scenario. The variables that i would be interested in are the age of the patient, co-morbidities, activity level, site of the fracture, fracture pattern (spiral or transverse), cemented polished taper stem or uncemented HA coated stem and the quality of the residual bone stock.

As the stem is fractured, i would assume this to be unstable and loose. If its uncemented and a spiral fracture, i would use the fracture as my osteotomy, remove the stem and revise it to an uncemented modular distal bearing plasma coated or fluted stem, with supplement cables and an allograft strut, if additional stability is needed. I would go atleast two cortical lengths past the fracture site. If its a transverse fracture, i will have a lower threshold to use a strut for added stability. 

If its a cemented stem and the patient is fit enough for a lengthy procedure, i would go down the same route after removing all the cement mantle. If not, and if the cement mantle is reasonable and if it is a polished stem, i will consider stem removal and a cement in cement revision, with an additional cable plate or allograft strut for stability.

If its a comminuted high fracture, one of the options could be a proximal femoral endoprosthetic replacement. This might warrant some additional stability in the form of a constrained acetabular liner or a complete acetabular component revision.

I hope you find this answer useful. Thank you   

Dear Dr. Prasad, thank you for your exhaustive answer. There is a lot of logics in it. 

Some 18 years ago we had a unique case and published it in International Orthopaedics (1996). We  have not had  a similar case since that time and never read of similar icase in the pertinent literature. We proposed by the way this injury to be enclosed in the current classifications of periprosthetic fractures (Bethea et al., Cooke and Newman, etc). It is not done yet. 

Please. see below.

Simultaneous fracture of the femur and the femoral stem following total hip replacement. A case report.

P I Tanchev et al.

University Hospital of Orthopaedics Gorna Banja, Sofia, Bulgaria.

International Orthopaedics (Impact Factor: 2.02). 02/1996; 20(3):182-4.

Source: PubMed

Thank you Prof Tanchev for a very interesting case report. The fact that it has not been included in the classification of periprosthetic fractures, so far, shows how uncommon it is. You propose a unique, valid treatment option. However, the most common practice in North America and Canada would be to use an uncemented stem with distal fixation.

Dear Dr. Prasad, do not forget that the case reported dated some 18-19 years ago. At that time we used to apply uncemented prosthesis and in this case the compressive plate with transcortical screws gave good results. The fractures were transverse and at one and the same level. Of course today I would use a long uncemented stem with distal fixation as you mention too. 

Yes, I realise the case report was a number of years ago. I fully agree with all your points. 

Please send me the anonymised ( ie with no identifiable data) to my hospital email address [email protected] 

i have a special interest in periprosthetic fractures and would be interested to see the images and give an opinion for what it's worth!

Dear Dr. Kane, 

I just sent  to your email address the title of my publication "Simultaneous fracture of the femur and the femoral stem following total hi replacement"" in Int. Orthop. (1996) . 

Hope it will be useful for your work on periprosthetic fractures. 

Kind regards

Prof. Panayot Tanchev

P.S. Anyway, you may find full-text and pictures in the database of Resarchgate.net (s. my publications)

first remove stem (and cement)

second : 

if transverse diaphysis fatigue fracture , new long stem cementless, like a nailing of the femur;

if the same in metaphysal area plate and wires and cemented stem

if spiral or oblique, osteosynthèsis with plate and (or) wires , and new cemented stem