Periprosthetic fractures of the femur after total hip replacement can present some unique challenges to the treating reconstructive orthopedic surgeon. Treatment may differ depending on fracture location, bone condition, implant stability, patient characteristics, and surgeon experience. It is imperative that adequate and sufficient mechanical fixation be achieved in the treatment of these patients. It is crucial that the treating orthopaedic surgeon have a clear and effective treatment plan to manage these complex cases. The patient's final outcome is dependent on fracture union, implant stability, early functional recovery, and return to pre-injury independence. This review presents an overview of the current diagnostic and treatment approaches, with the goal of providing a template for optimal decision-making when dealing with these complex injuries.