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Background: Although total hip arthroplasty (THA) performed through the direct anterior (DA) approach is frequently marketed as superior to other approaches, there are concerns about increased risks of intraoperative and early postoperative femoral fracture. Purpose: We sought to assess patient-specific and radiographic risk factors for intraoperative and early postoperative (90-day) periprosthetic femoral fracture (PPFx) following DA approach THA. Methods: We retrospectively reviewed 1107 consecutive, primary, non-cemented DA THAs, performed between April 2009 and January 2015, for intraoperative and early postoperative PPFx. Patients lost to follow-up before 90 days (63), cemented or hybrid THA (52), or early femoral failure for another indication (3) were excluded, yielding 989 hips for analysis. Demographic variables and patient comorbidities were analyzed as risk factors for PPFx. Continuous variables were initially compared with 1-way analysis of variance (ANOVA) and categorical variables with chi-square test. A demographic matched-paired radiographic analysis was performed for femoral stem canal fill and compared using univariate logistic regression. Results: The incidence of perioperative PPFx was 2.02%, including 10 intraoperative and 10 early postoperative fractures. Sustaining a postoperative PPFx was associated with being 70 years old or older with a body mass index (BMI) of less than 25, or with having either osteoporosis or Parkinson disease. Radiographs demonstrated that intraoperative PPFx was associated with stems that filled greater proximally rather than distally. Conclusion: Our cohort study found older age, age over 70 with BMI of less than 25, osteoporosis, and Parkinson disease were associated with increased risk for early postoperative PPFx following DA approach THA. Intraoperative fractures may occur with disproportionate proximal femoral canal fill. Further study can evaluate whether cemented femoral components may mitigate risk in these patient populations.

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