Periprosthetic fractures are among the most challenging complications facing modern joint replacement surgeons. As more patients receive hip and knee replacements and remain active with them for longer, surgeons increasingly encounter fractures around existing implants that require expertise in both fracture fixation and revision arthroplasty. Contemporary management can range from internal fixation to complex revision reconstruction depending on implant stability, remaining bone stock, fracture pattern, and the individual patient.
In Episode 40 of The Joint Replacement Podcast, I sit down with Elizabeth Gausden, MD, MPH, an orthopedic surgeon at Hospital for Special Surgery (HSS), to explore this intersection of orthopedic trauma and joint replacement: an emerging area often referred to as “traumaplasty.”
Dr. Gausden has an unusual background that makes her particularly well suited to this discussion. After completing orthopedic surgery residency at HSS, she pursued two fellowships: orthopedic trauma at UTHealth Houston and hip and knee arthroplasty at Mayo Clinic. She now specializes in primary and revision hip and knee replacement, periprosthetic fractures, post-traumatic arthritis, and complex reconstruction at HSS. Her official HSS profile similarly highlights her dual expertise in adult lower-extremity reconstruction and orthopedic trauma.
Why Train in Both Trauma and Joint Replacement?
Dr. Gausden originally planned to pursue orthopedic trauma. During her joint replacement rotation as a senior resident, however, mentors encouraged her to consider adult reconstruction as well. The eventual goal was a practice centered on the difficult cases where the two specialties overlap, particularly periprosthetic fractures.
She ultimately completed trauma fellowship first and arthroplasty fellowship second. Interestingly, she does not recommend two fellowships for everyone. Her message to trainees is that additional training should serve a specific career goal rather than simply prolonging training for its own sake.
That combination has positioned her to tackle a question increasingly relevant to orthopedic surgeons: When a patient fractures around a joint replacement, should we fix the fracture, revise the replacement, or do both?
Periprosthetic Fractures: Fix or Revise?
There is no single operation for a periprosthetic fracture. Around a total hip replacement, one of the fundamental considerations is whether the femoral stem remains well fixed. In general, fractures around a stable stem can often be treated with fixation, while a loose stem typically requires revision arthroplasty.
Around the knee, the decision can become even more nuanced.
One of Dr. Gausden’s central messages is to preserve the patient’s native bone whenever reliable fixation is possible. Modern plates, intramedullary nails, and combined constructs have expanded the range of fractures that can be reconstructed without immediately proceeding to a distal femoral replacement.
She frequently favors robust constructs such as a nail plus plate when necessary. While adding a second implant increases operative time, the goal is to create enough stability that the patient can mobilize confidently rather than relying on a construct that may only barely survive until fracture union.
This has also changed the traditional argument for distal femoral replacement in elderly patients. Historically, surgeons sometimes favored replacement because older patients could not reliably maintain restricted weight bearing after fracture fixation. Dr. Gausden argues that increasingly robust fixation can allow immediate weight bearing while preserving bone and avoiding a much larger reconstruction.
When Is a Distal Femoral Replacement Necessary?
There are still circumstances where reconstruction is the better option.
Dr. Gausden describes massive osteolysis, extremely poor remaining bone, severe fracture comminution, or loss of the condyles and ligamentous support as situations where fixation may no longer provide a useful knee. In selected patients, large cones and hinged components may preserve more bone than a full distal femoral replacement. In others, distal femoral replacement becomes necessary.
The key question is not simply whether a fracture can be made to heal. It is whether healing that fracture will leave the patient with a stable and functional joint.
The Changing Landscape of Periprosthetic Hip Fractures
Another fascinating part of our conversation involves changes in femoral stem design.
Dr. Gausden has become a strong advocate for triple-taper collared cementless stems in primary total hip arthroplasty. She describes a dramatic decline in the number of certain postoperative periprosthetic hip fractures she encounters as surgeons at her institution have transitioned toward these designs.
She still uses cemented fixation selectively, including certain femoral neck fractures, unusually capacious canals, and some dysplastic hips where controlling femoral version may be advantageous. But compared with earlier in her career, she now cements substantially fewer primary hips.
At the same time, she is beginning to see a different fracture problem around cementless total knee replacements. She discusses technical risks such as femoral notching and fractures associated with preparation or impaction of certain cementless components. These remain uncommon but represent an evolving issue as cementless knee replacement becomes more widespread.
Why She Became “Addicted” to Robotic Hip Replacement
Dr. Gausden also discusses her evolution toward robotic-assisted joint replacement.
Her initial experience was not with a routine hip, but a technically difficult patient with a BMI of 43. She found that robotic assistance made it substantially easier to reproduce her planned acetabular position despite the challenging exposure. That experience changed her practice.
Today, she reports using robotic assistance for approximately 99% of her primary hip and knee replacements. Interestingly, she believes the argument for robotics may currently be stronger in the hip than in the knee because of the ability to objectively execute component position, leg length, and reconstruction while potentially influencing instability.
Evidence continues to evolve. A 2024 study of 11,740 primary total hip replacements reported raw dislocation rates of 1.2% with conventional techniques versus 0.4% with robotic assistance, although surgical approach, fluoroscopy, dual mobility, and other variables are important when interpreting these observational data. A 2026 systematic review and meta-analysis of 15 studies involving 2,485 procedures found more accurate component positioning, fewer safe-zone outliers, and a lower rate of early dislocation with robotic-assisted THA compared with manual THA.
These findings do not mean that every patient necessarily experiences a measurable improvement in how the hip feels. As we discuss in the episode, total hip replacement already produces excellent patient-reported outcomes, creating a ceiling effect that can make incremental improvements difficult to demonstrate.
Direct Anterior Hip Replacement and Revision Surgery
Dr. Gausden’s surgical approach has also evolved considerably.
She began practice performing predominantly posterior hip replacements. After gradually progressing through the learning curve of the direct anterior approach, she now performs more than 90% of her hips anteriorly, including selected revision procedures.
She emphasizes, however, that this should not become an anterior-versus-posterior dogma. Surgeons graduating today should be comfortable with both approaches because some complex reconstructions are simply better addressed posteriorly.
For patients, she describes much of the potential recovery advantage of the anterior approach as occurring during the first several weeks. By approximately six weeks, she believes many of the differences between approaches become much smaller.
The “Quiet Knee” After Total Knee Replacement
We also discuss a very different evolution in joint replacement: doing less during the earliest stage of knee replacement recovery.
Dr. Gausden has incorporated elements of the “Quiet Knee” philosophy into her practice. Instead of aggressively pushing range of motion and activity immediately after surgery, the strategy emphasizes keeping swelling under control and avoiding the cycle in which patients feel better, dramatically increase activity, develop substantial swelling, and then struggle with pain and motion.
One of the biggest challenges is cultural. Patients and therapists have spent decades hearing that knee replacement rehabilitation must be pushed aggressively from the beginning. As Dr. Gausden puts it, sometimes it actually requires more explanation to convince patients to do less.
For patients who develop concerning stiffness later in recovery, however, the strategy changes. She discusses closer surveillance and, in selected appropriate patients, the evolving use of postoperative corticosteroids as part of strategies to control inflammation and reduce stiffness.
Complex Reconstruction and Heterotopic Ossification
Some of Dr. Gausden’s most difficult cases involve severe heterotopic ossification, or abnormal bone formation within soft tissues around a joint.
Severe cases can occur after major trauma or prolonged critical illness. When soft tissues around the hip essentially become bone, patients may develop profound contractures and loss of mobility. Surgical treatment can require extensive excision and reconstruction around major nerves and blood vessels, sometimes with vascular surgeons involved in the operation.
These cases illustrate one of the themes running through the entire conversation: complex reconstruction requires understanding far more than how to implant a hip or knee replacement. Surgeons need strategies for fracture fixation, bone loss, soft-tissue deficiency, instability, vascular anatomy, revision implants, and sometimes several of these problems simultaneously.
That is the essence of traumaplasty.
The 2026 IOEN Traumaplasty Course
Dr. Gausden is co-chairing the inaugural IOEN Traumaplasty Course, taking place October 2–3, 2026, in Orlando, Florida.
The cadaver-based program is designed specifically for the intersection between orthopedic trauma and arthroplasty. Faculty from both disciplines will teach practical techniques for periprosthetic fracture fixation, revision reconstruction, surgical approaches, modular revision stems, and other technical problems that can be difficult to master through lectures alone.
As Dr. Gausden explains in the episode, a trauma surgeon may be extremely comfortable reconstructing a femur but less comfortable implanting a revision stem. An arthroplasty surgeon may be highly experienced with revision components but have less exposure to complex fracture fixation. Traumaplasty brings those skill sets together.
Residents and fellows can register for FREE using code: TRAUMA100.
Learn more and register for the 2026 IOEN Traumaplasty Course
Listen to Episode 40
This conversation with Dr. Elizabeth Gausden covers far more than periprosthetic fractures. It is a look at how trauma, revision arthroplasty, robotics, implant design, surgical approach, and postoperative recovery are converging to change the way we think about modern hip and knee replacement.
Listen to Episode 40 of The Joint Replacement Podcast: “Trauma Meets Joint Replacement: Periprosthetic Fractures, Robotics & the Future of Traumaplasty” on YouTube, Spotify, Apple Podcasts, or wherever you listen to podcasts.
References
- Gausden EB. Hospital for Special Surgery physician profile. Hospital for Special Surgery.
- Kumar GA, Sharma G, Ali AFU, et al. Robotic-assisted versus conventional manual total hip arthroplasty: a systematic review and meta-analysis of component position accuracy, Lewinnek zone outliers, and early dislocation rates. Journal of Robotic Surgery. 2026;20(1):717. doi:10.1007/s11701-026-03678-x.
- Fewer Dislocations After Total Hip Arthroplasty With Robotic Assistance or Fluoroscopic Guidance. Journal of Arthroplasty. 2024;39(9 Suppl 2):S359-S366.
- Liporace FA, Kubiak EN, Levine B, Yoon RS. Periprosthetic fractures about the hip and knee: contemporary techniques for internal fixation and revision. Instructional Course Lectures. 2018;67:223-239.
- Management of periprosthetic femoral fractures following total hip arthroplasty: a review. Orthopedic literature review. Treatment is guided by fracture characteristics, bone quality, and implant stability.
- AO Foundation. Periprosthetic fractures: management of the hip and knee. 2024.