Periprosthetic fractures at the site of a total hip replacement may occur intraoperatively or postoperatively and may involve the femur, the acetabulum, or both. The present review concerns only postoperative femoral fractures, with a brief overview of the evidence supporting the treatment of these injuries. It is not feasible to present an exhaustive description of all of the relevant studies regarding this topic, but we have searched widely to determine the levels of evidence to support our treatment recommendations. As will be seen, there is a paucity of Level-I and II research regarding periprosthetic femoral fractures, and additional study is required regarding almost every aspect of their treatment. It is difficult to assess the true prevalence of periprosthetic femoral fractures following total hip arthroplasty. Most joint registries only record cases in which the fracture pattern necessitates revision surgery. The Swedish Hip Arthroplasty Register is designed to record all periprosthetic fractures and includes codes for internal fixation as well as revision arthroplasty. A review of Swedish registry data from 1979 to 2000 demonstrated that the cumulative prevalence of periprosthetic fracture was 0.4% after primary arthroplasty and 2.1% after revision arthroplasty1. The Vancouver classification system2 is the most widely accepted system for categorizing postoperative fractures of the femur occurring around a hip prosthesis (Fig. 1). Studies have demonstrated the reliability and validity of this system when used by both experienced surgeons and junior staff alike3-5. The Vancouver classification system takes into account three relevant surgical factors: …