Isolated greater trochanter fractures in THA: a narrative review| Lo Scalpello - Journal

Abstract

Isolated fractures of the greater trochanter (Vancouver type AG) in total hip arthroplasty (THA) are quite rare but can significantly affect outcomes. These fractures may occur intraoperatively or postoperatively, with pain and impaired function. Treatment remains controversial with debate on the choice of conservative management or surgical fixation.
Objective. This review summarizes the available evidence on incidence, risk factors, outcomes, and different kinds of surgical techniques.
Methods. A PRISMA-guided search across four databases identified 24 relevant studies
from an initial pool of 389.
Results. While nonoperative management yields good results for minimally displaced fractures, surgical fixation may be required for displaced or unstable cases, although complications and reoperations are not uncommon.
Conclusions. No technique has shown clear superiority. More high-quality studies are needed to guide treatment strategies for this uncommon but impactful complication.

Introduction

Isolated fractures of the greater trochanter following total hip arthroplasty (THA), or periprosthetic hip fractur) Vancouver classification type AG, are uncommon but their clinical impact is not irrelevant. These fractures can occur intraoperatively or postoperatively, leading to pain, impaired function, abductor weakness, and patient reduced satisfaction. Even if there is a relatively low incidence of these pattern fractures, the consequences can substantially affect rehabilitation and long-term outcomes, particularly in elderly or osteoporotic patients. The management of these fractures is controversial, ranging from conservative treatment to various surgical fixation techniques. Given the lack of consensus and variability in reported outcomes, this systematic review aims to summarize the current evidence on the incidence, risk factors, clinical outcomes, and optimal management strategies for isolated greater trochanter fractures in the context of THA.

Materials and methods

During June 2025 we performed searches of PubMed, EMBASE, Scopus and Cochrane systematic reviews using the search terms “greater trochanter”, “hip”, “fracture”, “THA”. We followed the 27-item checklist PRISMA Statement 2020 ¹ to plan and conduct our review to ensure the correct methodology of the study. The inclusion criteria were as follows: articles from January 2000, English-written articles in humans, full text available, both retrospective and prospective series, case report and articles describing treatment protocols of great trochanter fractures in THA. The exclusion criteria were as follows: studies describing fractures associated with other occult fractures of the hip including acetabulum, not written in English, and full-text not available. Case reports were included in our study and we did not limit the number of patients in each study or the minimum duration follow-up because of limited evidence available. The first search yielded a total of 389 articles which was reduced to 41 after applying the “English” and “from year 2000” filters. We began the study selection by screening titles and abstracts of articles retrieved from the search. For the articles identified to be potentially relevant, full text was reviewed. The full text was also reviewed if a decision could not be made from reading the title and abstract alone. By title and abstract reading of these 41 articles, 17 full-text articles were assessed for eligibility. In addition, we manually screened citations of relevant articles to identify additional studies and we identified 7 additional articles from the bibliography.

Results

Complete data were not available in some of the studies but information such as age, diagnosis, management of fracture and follow-up was identified in all reports (Tab. I).

Brun et al. found iatrogenic GT fractures in 26 of 911 THR (3%). Seven of the patients were treated with fixation of the fracture, using either Kirschner wires with cerclage or a claw plate. They saw no difference in the outcome irrespective of whether the fracture was fixed primarily, secondarily or not fixed at all. When dealing with isolated fractures of the greater trochanter in adults due to trauma they claimed that the recommendations are bed rest/crutches with protected weight bearing for 3-4 weeks and that often the fracture is incomplete and intact fibers of the gluteus medius prevent wide separation.

Hartford et al. showed that of the 31 hips with isolated GT fractures, 17 occurred intraoperatively and 14 postoperatively. The average time to functional healing was 11 weeks (range, 6 to 20) whether the fracture occurred intraoperatively or postoperatively. Fractures which occurred intraoperatively were treated without fixation in 13 hips and with cerclage fixation in 4 hips. The decision for fixation was made by the surgeon when the size of the fragment allowed for adequate fixation. The size of the fragments which underwent fixation involved 20% of the greater trochanter in 2 hips, a third of the trochanter in 1 hip, and the entire greater trochanter in 1 hip. One radiographic nonunion occurred in 1 trochanter which was treated with cerclage figure of eight wire. The fragment size was approximately 20%. None of the hips with postoperative fractures required return to the operating room for surgical treatment. All healed and the average displacement was 6 mm. All postoperative greater trochanter fractures in their series healed with nonoperative treatment which included protective weight bearing and discontinuation of hip abduction and flexion exercises. Once the patients became asymptomatic with radiographic evidence of healing, progressive weight bearing, hip abduction and hip flexion exercises were reinstituted. The treatment was successful for fractures which were displaced up to 15 mm ¹.

Inoue et al. had 30 perioperative greater trochanteric fractures (30/440, 6.8%) and of all joints, osteosynthesis was performed only in three cases ².

The authors stated that they 10 joints (10/209, 4.8%) were in perioperative GT fractures and osteosynthesis was performed in only one case because the bone fragments were significantly displaced proximally by the gluteus medius (1/209, 0.5%) ³.

Foissey et al. studied greater trochanter fractures in a direct anterior approach in 13 cases (2.4%) and none of the fractures was fixed during the surgical procedure or during follow-up ⁴.

Alexandra et al. reported on 9 cases of post-operative GT fractures induced by osteolysis in radiographic follow-up. Two patients were asymptomatic and did not receive immediate treatment for their fractures. Four symptomatic patients were treated with crutches and pain-limited weight bearing for 4 to 6 weeks. The three other symptomatic patients were not treated for fractures ⁵.

Iwata et al. reported that GT avulsion fractures of the greater trochanter occurred in 3 patients (9.7%) during the operation in the obese group which was 3 times higher than that of the non-obese group (one patient, 3.2%), and cases were treated conservatively in both groups ⁶.

Schafer et al. studied 76 patients treated with current-generation cable plate devices for GT fixation. They observed a nonunion rate of 23.7%, which is lower than that of multiple previously reported studies. Stewart et al. noticed a trend toward improved union rate with perfect or near-perfect bony apposition (< 3 mm gap), but this was not statistically significant ⁷. They chose to analyze the anatomic position of the plate and GT because the plate is designed to capture the fragment and stabilize it to the proximal femur: if the fragment or the plate is not in an optimal position, stability of the construct may be compromised, which will likely result in increased strain at the fracture site: of the 6 patients with unstable nonunions, 4 had nonanatomic positioning of the plate/GT construct. This could have clinical implications as it has been reported in the literature that displacement of the GT of greater than 2 cm can result in significant weakness of the abductors ⁸. They concluded that anatomic reduction, which may be difficult to achieve, and sufficient plate length and number of cables should improve the union rate and new plate designs with locking screws may improve the results ^9,10.

Sheth et al. affirmed that 9 of the 11 fractures in their patients were isolated GT fractures treated with ORIF including one treated with Mersilene tape only, one treated with two cerclage cables only and 9 treated with a trochanteric plate with supplemental cable fixation. Nine of the 11 GT fractures (82%) developed a nonunion of the GT. One (9%) patient that went onto trochanteric nonunion also developed a postoperative hematoma that required surgical evacuation and subsequently developed Brooker grade III heterotopic ossification ¹¹. This was quite different than that reported by Zarin et al. ¹² who retrospectively reviewed 31 patients treated with a claw plate for trochanteric fixation: osseous union was documented in 28 of 31 (90%) patients.

Zarin et al. focused on claw plate fixation of the GT performed for trochanteric nonunion in 16 patients. In all, 15 patients underwent plating of the trochanter for acute events including 7 patients for intraoperative trochanteric osteotomy, 5 for periprosthetic fractures, and 3 for intraoperative fractures. Four patients underwent placement of the trochanteric plate only. Twenty-five patients had oblique or vertical wires placed around the proximal trochanteric plate. Six patients did not have vertical wires, when additional fixation was felt to be necessary to increase plate stability and prevent trochanteric migration. Three patients developed a painful bursitis post-operatively requiring removal of the plate. They suggested improved union rates with the use of a claw plate that can grip the trochanteric fragment, with options for attachment below the lesser trochanter. Comparison of a cable plate to older techniques showed significant improvement in functional outcome scores, non-union rate, dislocation rate, limp, and need for assistive devices ¹³. The addition of vertical wires and improved plate-bone contact has been shown to increase osseous union as well ¹⁴ and monofilament wires were used to minimize complications associated with frayed multifilament cables. None of the patients with radiographic nonunion had clinical symptoms, suggesting either fibrous union or functional stability from the plate itself. Multivariate regression analysis identified the use of the short plate as an independent predictor of plate failure. They suggested that increased fixation to the femoral shaft with a longer plate may be necessary to resist torque and displacing forces at the trochanter ¹².

Baril et al. claimed that even for second generation trochanteric systems there are significant rates of nonunion (14.6%) andcable breakage (19%). The Y3 plate and SMA cables present advantages over Zimmer Cable-Ready^® GTR when compared in the laboratory: the Y3 reduces displacements generated by the hip abductors, especially in the flexed position. Greater stability may translate clinically to lower non-union rates and thus yield to better functional outcome for patients. SMA cables effectively reduced cable loosening ⁹.

Tetreault et al. studied the fixation of the greater trochanter (osteotomy, displaced or symptomatic fracture, or trochanteric nonunion); 29 of 32 trochanters (90.6%) achieved osseous union. There were 2 hips (6.2%) with stable fibrous nonunion and 1 hip with trochanteric nonunion and proximal migration (3.1%). For the 22 hips fixed with tibial locking plates, 19 healed with osseous union, for a fixation rate of 86.4%. All the 10 hips that were fixed with a specifically designed trochanteric locking plate achieved osseous union. In these 3 patients without bony healing, all demonstrated broken hardware on radiographic follow-up and 2 had subsequent hardware removal. Two of the 3 patients also reported trochanteric pain. Trochanteric pain occurred in 6 of 32 patients (18.8%). Overall, 5 patients had hardware complications: 2 with fractures of the distal-most screw, 1 had cable breakage, 1 had screw dissociation and a fifth had nonunion with proximal fragment migration and failure of distal fixation. Five patients (15.6%) had repeat surgery to remove hardware: 3 for pain alone and 2 for hardware removal because of breakage. Fixation of the greater trochanter in THA is imperative after osteotomy and also desirable in cases of displaced or symptomatic fracture or nonunion. Of these indications, nonunions are most difficult to treat because of bone loss, soft-tissue scarring and traction, and poor bone viability ¹⁵. They demonstrate in this cohort of patients that locking plates used for trochanteric fixation yield a high union rate with an acceptable rate of complications. They also claimed that allogeneic structural bone graft augmentation may be used in selected instances of severe trochanteric osteolysis ¹⁶. They placed a crescent of bulk allograft bone in the defect after debridement. The bulk allograft bone acted to engage the locking screws. They concluded that osseous union occurred in 30 (90.9%) of 33 hips and HHS was 91.6. Complications included broken hardware in 5 (15.2%) patients, of which 2 underwent subsequent hardware removal. Three additional patients elected hardware removal due to trochanteric pain ¹⁷.

Fan et al. declared that early cerclage cable fixation alone can successfully address in particular Vancouver Type A periprosthetic fracture despite reported destabilization of the femoral stem. Although the principles of treatment suggest use of longer stem revision and the fracture fixation, ORIF has the advantages of minimal invasion and rapid recovery for them ¹⁸.

Regis et al. studied a patient with spontaneous fracture of the greater trochanter through osteolytic lesion induced by polyethylene wear and claimed that while markedly displaced acute fractures of the greater trochanter require immediate wire fixation and allogeneic bone-grafting to fill osteolytic defects or plate osteosynthesis, lesions with minimal displacement can undergo nonoperative treatment successfully with an abduction orthosis and limited weight-bearing, leading to bone healing within three months. Osteolysis of the GT secondary to excessive PE wear ultimately requires surgical treatment to address the underlying problem of particulate debris generation promoting periprosthetic bone loss. They concluded that undisplaced lesions can be successfully treated with a two-stage approach, including conservative healing of the fracture and subsequent surgical replacement of the acetabular liner, thus addressing the underlying problem of wear ¹⁹.

Neitzke et al. reported on a series of trochanteric plates and cables for GT fractures. In 6 (14%) cases, they performed proximal impaction grafting with cancellous allograft bone chips at the discretion of the operating surgeon to restore the bone stock in the proximal femur. Their cumulative probability of any subsequent reoperation within 2 years following trochanteric plate fixation was 20%. They had 9 subsequent reoperations, including 5 for removal of the hardware for either hardware failure (plate/cable breakage or migration) or hardware irritation, 2 for joint debridement for periprosthetic joint infection, 1 for osteosynthesis for a subsequent supracondylar extension fracture, and 1 for revision to a constrained liner for recurrent dislocation. All 5 cases involving hardware removal had GT nonunion at the time of reoperation. Four of the cases of hardware removal involved failed hardware around a GT nonunion and in 1 case the removal was for intact hardware that was irritating the patient also around a GT nonunion. In both of their cases of debridement for periprosthetic joint infection after trochanteric plating, the arthroplasty was retained and the patients were managed with chronic oral antibiotic suppression. The GT fractures went on to nonunion in both of these cases. After reduction and trochanteric plating, the GT fracture went on to nonunion in 14 of 36 (39%) cases. Of their intraoperative and early postoperative (within 6 weeks) GT fractures, 8 of 12 went on to nonunion compared to 6 of 24 (25%) delayed GT fractures. Displacement of the GT prior to fixation with trochanteric plate was a predictor of subsequent nonunion as 9 of the 14 (64%) initially displaced fractures went on to nonunion compared to 5 of the 22 (23%) nondisplaced fractures. In addition, of the 6 patients who also received a trochanteric bolt, 1 patient had complete bolt dissociation, 3 patients had trochanteric bolt loosening, and 3 (50%) patients had trochanteric nonunion at final follow-up. Three patients experienced at least one dislocation following trochanteric plate fixation, and 2 of those patients underwent subsequent reoperation for instability ²⁰.

Fraval A et al. meticulously described the management of isolated greater trochanter fractures associated with THA. Nonsurgical management usually involves a period of protected weight-bearing while utilizing an assistive device for gait. The authors are of the view that due to the deforming forces that may be exerted on the greater trochanter in functional activities such as rising from sitting to standing, it is unlikely that restricting mobility would have a protective effect on fracture fragment migration. Given this, they provide patients with a gait aid to protect against falls but provide no other restrictions in the postoperative period ²¹.

Surgical management involves fixation of the greater trochanteric fracture. The fixation methods include cerclage cables, claw plates (either using cable fixation, screw fixation, or a combination of both), locking plates, tension bands, and suture fixation.

Based on the available intraoperative and postoperative classification schemes, fractures of the GT are not appropriately subclassified to predict their behavior based on the deforming forces of the anatomical attachments and they propose a new classification based on location of the fracture with respect to the GT insertional anatomy.

Applying the classification system proposed by the authors of this article to fractures seen postoperatively, they would recommend treating ‘type 1’ fractures nonsurgically as these fractures pose little potential for functional impairment. ‘Type 3’ fractures may have lower rates of migration due to the persistence of the vastus insertion to the proximal fragment and as such we would also recommend for nonsurgical management. ‘Type 2’ fractures have a high potential for migration due to the unbalanced muscle attachments of the proximal fragment and may be associated with functional impairment and ongoing pain ²¹.

Pritchett J ²² stated that the indications for operative treatment of GT fractures following THA are dislocation or instability of the prosthesis, severe limp or pain and widely displaced trochanter fracture > 2 cm. In cases of non-union with dislocation tension band fixation or a trochanteric claw plate can be effective ²³.

Discussion

The aging of the population as well as the improved quality of life are only two of the factors that led to the increased number of arthroplasties of major joint surgeries over the past decades ⁹.

As a result of the heightened prevalence of these procedures, there has been a noticeable rise in the incidence of their complications. Periprosthetic fractures are quite significant injuries, particularly femoral fractures around a hip arthroplasty. They represent the third most frequent reason to perform a THA revision surgery ¹⁸. The 2.5-fold increase in their incidence in the last few years is expected to grow exponentially in the future ²¹.

The most common and recognized classification of these types of fractures is the Vancouver classification. It considers the location of the fracture relative to the stem, the implant’s stability and the possible association with bone loss. In the context of periprosthetic hip fractures, a subset is represented by isolated fractures of the greater trochanter, which are identified by the Vancouver classification as type AG ^18,24.

Although these are not the most common periprosthetic hip fractures (3-7%) ⁹, they are not negligible as their consequences may affect postoperative recovery and long-term outcomes, especially in the elderly.

Isolated fractures of the greater trochanter can occur either intraoperatively (iatrogenic fractures) or after the surgery. Approximatively 5% of iatrogenic femoral fractures involve only the greater trochanter mainly after a trochanteric osteotomy ^15,23.

GT fractures can be a consequence of direct high energy postoperative trauma, but also caused by the fact that the greater trochanter is an attachment site for hip abductors and external rotators, whose forced contraction may cause the avulsion of the bone ².

Regarding perioperative greater trochanteric fractures, several studies aimed to describe their risk factors. The direct anterior or anterolateral approach, female sex, obesity (BMI ≥ 30 kg/m²), low bone density, advancing age, developmental hip dysplasia, and a certain type femoral geometry in three-dimensional preoperative planning seem to all be linked to high incidence of perioperative GT fracture ^1,3,4,6,11. Instead, according to the study of Foissey et al. (2021), the surgeon’s experience is not related to the rate of GT fractures.

The treatment is still controversial, as the surgical advances over the years led to the possibility of new operative fixation techniques. Vancouver AG fractures are generally stable and do not usually require additional treatment ²⁴.

Minimally displaced greater trochanter fractures are traditionally managed non-operatively with some days of bed rest and a period of 6-12 weeks of protected weight-bearing and restriction of active hip abduction. They usually successfully lead to reasonable radiographic and clinical results with bone healing within 3 months ^4,5,19. The assumption is that the fracture has limited initial displacement.

However, markedly displaced acute fractures may require operative treatment. This kind of surgery is associated with a relatively high reoperation rate and several complications ¹⁰ and still remains a challenge due to the forces being transmitted and also the poor bone quality that is often linked to these fractures ⁷.

The paper by Pritchett in 2001 identified the main indications to perform a surgical fixation of periprosthetic greater trochanter fractures, which are prosthesis instability or dislocation, severe pain or limp and displaced fractures > 2 cm ^22,23.

Displacement of the GT > 2 cm has in fact shown to result in significant weakness of the abductor muscles ⁸.

Fixation may be accomplished using several methods, including abductor slide, trochanteric claw plate (either using cable fixation, screw fixation, or a combination of both), Dalls-Miles cable grip system, and various wiring techniques ^13,15. None has proven superiority in the current literature.

Cable plate devices have been demonstrated to be biomechanically superior to cable or wires alone, but require anatomical reduction to better capture the fragment and stabilize it to the proximal femur in order to provide stability to the construct. Otherwise, the procedure can result in a strain at the fracture site with high nonunion rate and consequent long-term pain and functional status ^7,8.

Vertical wires may be used as additional fixation to prevent trochanteric migration and provide more plate stability. Not only the anatomical reduction but also a sufficient plate length and number of cables are necessary to improve the fracture union rate.

Cerclage cable fixation alone is another option that can successfully address Vancouver AG fractures. However, a certain rate of destabilization of the femoral system is reported ¹⁸.

Different techniques can also be managed together to fix the same fracture and allogeneic bone-grafting to fill bone-loss defects in case of severe trochanteric osteolysis may be necessary ²⁴.

Although nowadays there is an increasing interest in finding the best treatment for different types of greater trochanter fractures, it has not been clearly demonstrated that surgical fixation may be than nonsurgical management.

Conclusions

Currently, there is no acknowledged ideal treatment for greater trochanter fractures in THA. The aim of every method is to reduce pain and return the patient to baseline functional status. The noticeable trend is the nonoperative management in cases of non-displaced or minimally displaced fractures, while a surgical fixation is required when there is a remarkable displacement or a consequent instability of the prosthetic implant. A variety of surgical fixation techniques are available, including claw plate, cerclage, cable grip and different wiring systems. More comparative studies are required to clarify the criteria to perform the surgery and establish evidence-based guidelines for the best treatment of this rare but significant type of fracture.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

MS, ES, SG: conceptualisation and methodology; MS, ES: investigation and data curation; MS, ES: writing - original draft preparation; MS, ES: writing - review and editing; SG: supervision. All authors have read and agreed to the published version of the manuscript.

Ethical consideration

Not applicable.

History

Received: July 3, 2025

Accepted: September 7, 2025

Figures and tables

References

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