doi:10.1186/s10195-025-00886-3engMoreta, JesúsAguado, Héctor J.Castillón-Bernal, PabloMuñoz-Vives, Josep M.Camacho, PilarJornet-Gibert, MontsantTeixidor, JordiPereda-Manso, AdelRoche-Albero, AdriánInternal fixation versus revision arthroplasty for Vancouver B2–B3 fractures: mortality and functional outcomes in frail patients. Insights from the PIPPAS study of 485 patientsART-2025-147770Background: Periprosthetic femoral fractures following hip arthroplasty (FH-PPF) represent a severe complication, especially in elderly patients with compromised health. Traditionally, revision arthroplasty is recommended for B2-B3 FH-PPF, yet internal fixation has emerged as a debated alternative in select patients. The hypothesis was that fixation, in selected patients with B2-B3 FH-PPF, decreases mortality and surgical complication rates with the same functional outcomes as revision arthroplasty. Materials and methods: PIPPAS is a multicenter prospective observational study. This cohort substudy includes 485 patients across 57 hospitals with B2-B3 FH-PPF between January 2021 and May 2023. Management strategy, revision or fixation, was at the attending surgeon's discretion. Propensity score matching, controlled for age, age-adjusted Charlson Comorbidity Index (a-CCI), prefracture mobility, Pfeiffer scale, and ASA score, was done. Mortality risk factors were assessed using univariate and multivariate analysis. Results: Out of 485 patients, 164 received fixation, and 321 underwent revision. Fixation patients were older (88 versus 82 years, p < 0.001) and frailer. Fixation was associated with shorter hospital stay (13 versus 15 days, p = 0.003) but higher 1-year mortality (25% versus 14.3%, p = 0.04). There were no differences in medical or surgical complications (p = 0.83 and p = 0.36) at any time, but dislocation rate was higher in the revision group (p = 0.001). The 1-year mortality rate in patients with no weight-bearing restrictions was higher for the revision group (p = 0.01). The propensity score matching showed higher 1-year mortality rate in the fixation group but no differences in functional outcomes, complications, or up to 6-months mortality. In the multivariate analysis a-CCI, cognitive impairment, B3 fractures, and prefracture independent walking impairment were independent mortality risk factors. Conclusions: Revision arthroplasty showed less 1-year mortality rate and weight-bearing restrictions than fixation. However, frail patients with B2-B3 FH-PPF managed with fixation allowing full weight-bearing showed a lower 1-year mortality rate. Fixation in B2-B3 FH-PPF is a treatment option in frail patients, while aiming for stable constructions allowing full weight-bearing. Level of evidence ii: prospective cohort study. Trial registration: ClinicalTrials.gov (NCT04663893). Keywords: Fixation; Frailty; Mortality; Orthogeriatrics; Periprosthetic fracture; Revision; Total hip arthroplasty; Vancouver B2 fracture; Vancouver B3; Weight-bearing.2025http://zaguan.unizar.es/record/16826710.1186/s10195-025-00886-3http://zaguan.unizar.es/record/168267oai:zaguan.unizar.es:168267JOURNAL OF ORTHOPAEDICS AND TRAUMATOLOGY 26, 1 (2025), [18 pp.]by-nc-ndhttps://creativecommons.org/licenses/by-nc-nd/4.0/deed.esinfo:eu-repo/semantics/openAccess