Characteristics and Risk Factors of Atypical Periprosthetic Femoral Fractures Following Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

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Background Atypical periprosthetic femoral fractures (APFFs) are a challenging, albeit uncommon, complication after total hip arthroplasty (THA). This systematic review will evaluate the characteristics and risk factors associated with APFFs following THA. Methods A systematic search of EMBASE, MEDLINE, CENTRAL, and CINAHL was performed from inception to October 6, 2025, for studies reporting APFFs after THA. Patient, surgical, and radiographic data were extracted. Random-effects meta-analyses pooled proportions and odds ratios (ORs). Results Eight studies comprising 1072 THA patients with periprosthetic fractures were included. APFFs accounted for 120/1072 fractures (11.2%), with a pooled proportion of 11% (95% confidence interval [CI], 7%-18%; I 2 = 90.2%). Patients with APFFs were predominantly female (91.1%), with a mean age of 76.5 years. Bisphosphonate exposure was common (88%; 95% CI, 71%-96%; I 2 = 0%) and more likely in APFFs than typical periprosthetic fractures (OR, 6.7; 95% CI, 3.1-14.4; I 2 = 2.1%). The mean interval from THA to APFF was 8.4 years. Where reported, most APFFs were Vancouver B (85.3%). Fixation was common (67.9%), with a mean union of 8.8 months. APFFs had higher complication odds after initial management than typical periprosthetic fractures (OR, 6.5; 95% CI, 2.2-19.2; I 2 = 0%). Conclusions Long-term bisphosphonate use may increase APFF risk after THA. These fractures typically occur late and have characteristic clinical and radiographic features. APFFs represent a high-risk subtype of periprosthetic fracture that requires careful surveillance and thoughtful surgical management. As THA volumes rise, prospective studies and standardized diagnostic criteria are needed to clarify incidence and inform prevention. Level of Evidence Level III, Systematic review.

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