Management of infected periprosthetic fracture of hip and knee: a systematic review of the literature

Purpose: The coexistence of periprosthetic joint infection (PJI) and periprosthetic fracture (PPFx) is one of the most challenging complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Evidence regarding the management and outcomes of concomitant PJI and PPFx remains limited. This systematic review aimed to evaluate treatment strategies for infected PPFx in order to optimise infection eradication, fracture healing, implant survival, and limb function. Methods: A systematic review was conducted according to PRISMA and Cochrane guidelines and registered in the PROSPERO database (CRD420251051853). Studies of level II-V evidence reporting on the management of infected PPFx following THA or TKA were included. Extracted data comprised patient demographics, fracture classification, pathogens, treatment strategies, complications, infection control, and fracture healing outcomes. Results: Thirteen studies involving 210 patients were included, with a percentage of hip fractures of 81.9%. The most frequently isolated pathogens were Staphylococcus epidermidis, Staphylococcus aureus, and Cutibacterium acnes. Treatment strategies varied and included revision arthroplasty, plating, intramedullary fixation, distally locked stems, and staged reconstruction with antibiotic-loaded cement or spacers. Fracture union rates ranged from 58 to 100%, while reinfection or recurrence occurred in 6-28% of cases. Stable fixation was associated with improved outcomes, particularly in Vancouver B1 fractures, whereas B2 and B3 fractures showed higher mechanical complication rates. Mortality was reported up to 22% predominately in frail populations. Conclusion: Infected periprosthetic fractures remain rare but involve severe complications. Staged protocols combining infection eradication with stable fixation provide the most consistent outcomes, although treatment should be individualised.