Osteosynthesis versus revision arthroplasty in Vancouver B2 periprosthetic hip fractures: a systematic review and meta-analysis

Do All Postoperative Vancouver B2 Fractures Require Revision Arthroplasty With Cementless Stems?

Background

Management of periprosthetic fractures has been guided by the Vancouver classification, which recommends revision for fractures around a loose femoral implant (B2). New studies have challenged this approach, demonstrating acceptable outcomes with internal fixation. This study evaluates our experience with Vancouver B2 fractures, comparing internal fixation to femoral revision. We hypothesized that in select cases with cementless stems, internal fixation would provide acceptable results with reduced morbidity.

Methods

A retrospective review was performed of periprosthetic hip fractures treated at our institution between 1 January 2012 and 4 November 2022. We excluded patients who did not have prior radiographs and evidence of stem subsidence, suggestive of a Vancouver B2 fracture. Thirteen patients were included in the analysis.

Results

Four patients (31%) underwent revision of the femoral component, 4 patients (31%) underwent plating, and 5 patients (38%) underwent internal fixation with cerclage cabling. The average operative duration was 158 minutes, 203 minutes, and 62 minutes for the revision, plating, and cabling cohorts, respectively (P = .009). Blood loss was 463 cc, 510 cc, and 90 cc for the revision, plating, and cabling cohorts, respectively (P = .036). Three patients in both the revision and plating cohorts each received a transfusion (75%), whereas no patients in the cabling cohort required a transfusion (P = .033). All patients demonstrated fracture healing on the postoperative radiographs. No patients required additional surgery during the follow-up period.

Conclusions

We have demonstrated that Vancouver B2 periprosthetic fractures with intact lateral cortices may be treated with internal fixation with cerclage cabling with excellent results.

[Concept for the treatment of periprosthetic proximal femoral fractures]

Due to demographic changes and increased survival rates of total hip arthroplasties, the incidence of periprosthetic proximal femoral fractures is increasing. The current treatment concept requires accurate preoperative planning. Besides patient-related risk factors, fracture type, prosthesis stability, and bone quality influence whether osteosynthesis or a revision arthroplasty is required.

Periprosthetic Hip Fractures around the Stem: Can the Stem Design Affect Fracture Features?

Background: Total hip arthroplasty is one of the most successful orthopedic surgeries; nevertheless, many of these surgeries are the causes of failure, and among them, periprosthetic fractures are one of the major causes of revision. Our study focuses on periprosthetic hip fractures with two different stem designs. The aim of the study was to analyze the obtained results, focusing on the features of periprosthetic stem fractures observed. Methods: We retrospectively reviewed periprosthetic fractures occurring between 2010 and 2023, involving Alloclassic® or CLS® uncemented femoral stems. We analyzed demographic data, proximal femur morphology, and the fracture type. Results: We identified 97 patients. Considering the proximal femur morphology, we found that there was statistically significant prevalence of Dorr A proximal femur morphology in the CLS® group and of Dorr C in the Alloclassic® group. Considering the distribution of the fracture pattern, we reported a non-statistically significant prevalence of the fracture pattern with stable stems in the CLS® group. Conclusions: The choice of the prosthetic design of the femoral stem is a crucial element when planning total hip arthroplasty. However, we found a non-statistically significant difference between the two stems considered, raising questions about the real role of stem design as a primary determinant of periprosthetic hip fractures.

Analysis of complications in 97 periprosthetic Vancouver B2 fractures treated either by internal fixation or revision arthroplasty

INTRODUCTION

The treatment of Vancouver B2 periprosthetic fractures after hip arthroplasty is still a matter of debate. Revision Arthroplasty (RA) was long thought to be the treatment of choice, however several recent papers suggested that Open Reduction and Internal Fixation (ORIF) is a viable option for selected B2 fractures. Complication rates of 14-26% have been reported following surgical treatment of B2 fractures. No significant difference between RA and ORIF in the complication rates nor in the functional outcome was observed.

METHOD

We conducted a retrospective analysis of 97 consecutive Vancouver B2 fractures treated according to the algorithm at our institution from 2007 to 2020 and recorded complications and patient specific data.

RESULT

From the 97 patient, 45 fractures were treated with RA while 52 fractures were treated with ORIF. Thirteen patients in the RA group had a complication that needed revision (28%) and 11 patients in the ORIF group needed revision (21%). There was no significant difference between complication rates. The reason for failure in the 13 RA patients were infection (n = 4), stem subsidence (n = 1), refracture after a new fall (n = 3), secondary dislocation of the greater trochanter (n = 1) and dislocation (n = 4). The reason for failure in the 11 ORIF patients that were revised were infection (n = 5), persistent symptomatic stem loosening (n = 3) and refracture (n = 3) after a new fall.

CONCLUSION

ORIF can be used to revise cemented and non-cemented shafts in more than half of Vancouver B2 fractures with no difference in complication rates when compared to RA. A periprosthetic fracture around the hip has a 21-28% risk of a re-operation after revision surgery with infection and re-fracture after a new fall being the most frequent cause of re-operation.

Open Reduction and Internal Fixation for Vancouver B1 and B2 Periprosthetic Femoral Fractures: A Proportional Meta-Analysis

Purpose

Periprosthetic femoral fracture (PFF) is a common complication after total hip arthroplasty, and open reduction and internal fixation (ORIF) is a common surgical treatment. We conducted a meta-analysis to compare the outcomes of ORIF in patients with different fracture patterns (Vancouver B1 and B2).

Materials and Methods

We conducted a systematic search of PubMed, Embase, Cochrane Library and KoreaMed from inception to August 2022. We conducted a pair-wise meta-analysis (with a fixed-effects model) on the 10 comparative studies and a proportional meta-analysis on the data from the 39 articles to determine a consensus. The outcomes were the incidence of reoperations that included osteosynthesis, irrigation/debridement and revision arthroplasty.

Results

The pair-wise meta-analysis showed similar outcomes between two groups; the risk of reoperation (odds ratio [OR]=0.82, confidence interval [CI] 0.43-1.55, P=0.542), nonunion (OR=0.49; CI 0.22-1.10, P=0.085) and deep infection (OR=1.89, CI 0.48-7.46, P=0.361). In proportion meta-analysis, pooled prevalence of reoperation was 9% (95% CI, 6-12) in B1 and 8% (95% CI, 2-15) in B2 (heterogeneity between two groups (Q), P=0.772). The pooled prevalence of nonunion was same as of 4% in B1 and B2 (Q, P=0.678), and deep infection was 2% (95% CI, 1-3) in B1 and 4% (95% CI, 2-7) in B2 (Q, P=0.130).

Conclusion

ORIF is a feasible treatment for B1 and B2 periprosthetic femoral fractures, with acceptable outcomes in terms of, nonunion and infection. The results of this study would help clinicians and provide baseline data for further studies validating PFF.

Surgeon-Stratified Periprosthetic Fracture Risk in a Single-Hospital Cohort of 1531 Uncemented ABG-II Femoral Stems at Primary Total Hip Arthroplasty

Purpose

Late periprosthetic fracture risk with uncemented ABG-II femoral stems at primary total hip arthroplasty (THA) has been reported before, but single-hospital surgeon-stratified reports of this implant have never been published. We asked whether periprosthetic fracture rates of ABG-II femoral stems implanted at a single tertiary hospital depended on patients' age, gender and the operating surgeon.

Methods

The study included 1531 consecutive primary ABG-II femoral stems implanted at a single tertiary hospital between January 1, 2012 and December 31, 2018. The Kaplan-Meier and Cox regression analyses were performed after 3.6-10.6 years of follow-up.

Results

In the cohort, we recorded 8 intraoperative, 22 early postoperative (within 90 days of implantation) and 26 late periprosthetic fractures (over 90 days postoperatively). The revision rate of ABG-II femoral stems was 5.1/100 component-years for early and 0.3/100 component-years for late periprosthetic fractures. The Kaplan-Meier cumulative probability of periprosthetic fracture was 2.1% at one, 2.3% at 2, 3.2% at 5, and 6.5% at 10 years after the implantation. Higher patient's age at operation was an independent risk factor of subsequent periprosthetic fracture (hazard ratio 1.07, 95% confidence interval 1.03-1.10; p < 0.01), regardless of the operating surgeon. Most of the fractured femora were Dorr type C (stovepipe).

Conclusion

The study presents the largest published ABG-II femoral stem cohort from a single hospital so far with 9291 component-years of observation. Periprosthetic fracture risk of ABG-II increased with patients' age, had no variability between different surgeons, and was considerably higher from other uncemented femoral stems used at the same hospital.

Level of Evidence

III.