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Yao Z, Fan S, Zhao W, Huang J. The History of Classification Systems for Periprosthetic Femoral Fractures: A Literature Review. Orthop Surg 2024; 16:1816-1831. [PMID: 38946014 PMCID: PMC11293929 DOI: 10.1111/os.14149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/02/2024] [Accepted: 06/11/2024] [Indexed: 07/02/2024] Open
Abstract
Periprosthetic femoral fractures (PPFFs) following total hip arthroplasty (THA) present a significant clinical challenge due to their increasing incidence with an aging population and evolving surgical practices. Historically, classifications were primarily based on anatomical fracture location, the stability of the implant, and bone quality surrounding the implant. We critically analyzed 25 classification systems, highlighting the emergence and adaptations of key systems such as the Vancouver classification system (VCS) and the Unified classification system (UCS), which are lauded for their simplicity and effectiveness yet require further refinement. VCS, developed in 1995, categorizes fractures based on the site, implant stability, and bone quality, and remains widely used due to its robust applicability across different clinical settings. Introduced in 2014, UCS expands the VCS to encompass all periprosthetic fractures with additional fracture types, aiming for a universal application. Despite their widespread adoption, these systems exhibit shortcomings, including the incomplete inclusion of all PPFF types and the imprecise assessment of implant stability and surrounding bone loss. These gaps can result in misclassification and suboptimal treatment outcomes. This paper suggests the necessity for ongoing improvements in classification systems to include emerging fracture types and refined diagnostic criteria, ensuring that they remain relevant to contemporary orthopedic practices and continue to facilitate the precise tailoring of treatment to patient-specific circumstances. This comprehensive historical review serves as a foundation for future innovations in classification systems, ultimately aiming to standardize PPFF treatment and improve patient prognosis.
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Affiliation(s)
- Zhi‐Yuan Yao
- Department of Orthopaedics & TraumatologyThe First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine)HangzhouChina
- The First Clinical Medical CollegeZhejiang Chinese Medical UniversityHangzhouChina
| | - Shu‐Yao Fan
- The First Clinical Medical CollegeZhejiang Chinese Medical UniversityHangzhouChina
- Department of Breast SurgeryThe First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine)HangzhouChina
| | - Wei‐Qiang Zhao
- Department of Orthopaedics & TraumatologyThe First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine)HangzhouChina
- The First Clinical Medical CollegeZhejiang Chinese Medical UniversityHangzhouChina
| | - Jie‐Feng Huang
- Department of Orthopaedics & TraumatologyThe First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine)HangzhouChina
- The First Clinical Medical CollegeZhejiang Chinese Medical UniversityHangzhouChina
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Kastner P, Zderic I, Gueorguiev B, Pastor T, Luger M, Gotterbarm T, Schopper C. The Effect of Cerclage Banding Distally to a Clamshell Fracture Pattern in Total Hip Arthroplasty-A Biomechanical Study. Bioengineering (Basel) 2023; 10:1397. [PMID: 38135988 PMCID: PMC10741217 DOI: 10.3390/bioengineering10121397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/21/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVES As currently there is no existing biomechanical work on the topic of interest, the aim of the current study was to investigate the effect of cerclage banding distally to an intraoperatively occurring proximal periprosthetic femoral clamshell fracture versus a non-fractured femur after total hip arthroplasty. METHODS A diaphyseal anchoring stem was implanted in twenty paired human cadaveric femora, assigned to a treatment and a control group. In the treatment group, each specimen was fitted with a cerclage band placed 3 mm distally to a clamshell fracture, created with an extent of 40% of the anchoring length of the stem. The resulting fragment was not treated further. The contralateral specimens were left with the stems without further fracture creation or treatment. All constructs were tested under progressively increasing cyclic axial loading until failure. Relative bone-implant movements were monitored by motion tracking. RESULTS Number of cycles and the corresponding load at stem loosening, defined as 1 mm displacement of the stem along the shaft axis, were 31,417 ± 8870 and 3641.7 ± 887 N in the control group, and 26,944 ± 11,706 and 3194.4 ± 1170.6 N in the treatment group, respectively, with no significant differences between them, p = 0.106. CONCLUSION From a biomechanical perspective, cerclage banding distally to an intraoperative clamshell fracture with an extent of 40% of the anchoring length of the stem demonstrated comparable resistance against hip stem loosening versus a non-fractured femur. It may therefore represent a valid treatment option to restore the full axial stability of a diaphyseal anchoring stem. In addition, it may be considered to keep the medial wall fragment unfixed, thus saving operative time and minimizing associated risks.
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Affiliation(s)
- Philipp Kastner
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland; (I.Z.); (B.G.); (T.P.)
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria; (M.L.); (T.G.); (C.S.)
| | - Ivan Zderic
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland; (I.Z.); (B.G.); (T.P.)
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland; (I.Z.); (B.G.); (T.P.)
| | - Torsten Pastor
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland; (I.Z.); (B.G.); (T.P.)
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
| | - Matthias Luger
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria; (M.L.); (T.G.); (C.S.)
| | - Tobias Gotterbarm
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria; (M.L.); (T.G.); (C.S.)
| | - Clemens Schopper
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria; (M.L.); (T.G.); (C.S.)
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Schopper C, Luger M, Hipmair G, Schauer B, Gotterbarm T, Klasan A. The race for the classification of proximal periprosthetic femoral fractures : Vancouver vs Unified Classification System (UCS) - a systematic review. BMC Musculoskelet Disord 2022; 23:280. [PMID: 35321671 PMCID: PMC8944079 DOI: 10.1186/s12891-022-05240-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Periprosthetic femoral fractures (PFFs) represent a major cause for surgical revision after hip arthroplasty with detrimental consequences for patients. The Vancouver classification has been traditionally used since its introduction in 1995. The Unified Classification System (UCS) was described in 2014, to widen the spectrum by aiming for a more comprehensive approach. The UCS also aimed to replace the Vancouver classification by expanding the idea of the Vancouver classification to the whole musculoskeletal apparatus. After introduction of the UCS, the question was raised, whether the UCS found its place in the field of analysing PFFs. Therefore, this systematic review was performed to investigate, the use of the UCS compared to the established Vancouver classification. Methods Medline was searched for reports published between 1 January 2016 and 31 November 2020, without language restriction. Included were original articles, irrespective of the level of evidence and case reports reporting on a PFF and using either the Vancouver or the UCS to classify the fractures. Excluded were reviews and systematic reviews. Results One hundred forty-six studies were included in the analysis. UCS has not been used in a single registry study, giving a pooled cohort size of 3299 patients, compared to 59,178 patients in studies using the Vancouver classification. Since 2016, one study using UCS was published in a top journal, compared to 37 studies using the Vancouver classification (p=0.29). During the study period, the number of yearly publications remained stagnant (p=0.899). Conclusions Despite valuable improvement and expansion of the latter UCS, to date, the Vancouver system clearly leads the field of classifying PFFs in the sense of the common use. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05240-w.
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Affiliation(s)
- Clemens Schopper
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz and Altenberger Strasse 69, 4040, Linz, Austria
| | - Matthias Luger
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz and Altenberger Strasse 69, 4040, Linz, Austria.
| | - Günter Hipmair
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz and Altenberger Strasse 69, 4040, Linz, Austria
| | - Bernhard Schauer
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz and Altenberger Strasse 69, 4040, Linz, Austria
| | - Tobias Gotterbarm
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz and Altenberger Strasse 69, 4040, Linz, Austria
| | - Antonio Klasan
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz and Altenberger Strasse 69, 4040, Linz, Austria
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Fan MQ, Fan XH, Chen XL, Shen JJ, Jiang XJ, Li XS, Huang JF. The reliability and validity of the modified Unified Classification System for periprosthetic femoral fractures after hip arthroplasty. J Orthop Sci 2021; 26:385-388. [PMID: 32229162 DOI: 10.1016/j.jos.2020.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 11/21/2019] [Accepted: 03/12/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study assessed the reliability and validity of the modified Unified Classification System for femur fractures after hip arthroplasty. METHODS Four hundred and two cases were evaluated by 6 observers, 3 experts and 3 trainee surgeons. Each observer read the radiographs on 2 separate occasions and classified each case as to its type. Reliability was assessed by looking at the intraobserver and interobserver agreement using the Kappa statistic. Validity was assessed within the B group by looking at the agreement between the radiographic classification and the intraoperative findings. Interobserver and intraobserver agreement and validity were analyzed, using weighted kappa statistics. RESULTS The mean k value for interobserver agreement was found to be 0.882 (0.833-0.929) for consultants (almost perfect agreement) and 0.776 (0.706-0.836) for the trainees (substantial agreement). Intraobserver k values ranged from 0.701 to 0.972, showing substantial to almost perfect agreement. Validity analysis of 299 type B cases revealed 89.854% agreement with a mean k value of 0.849 (0.770-0.946) (almost perfect agreement). CONCLUSIONS This study has shown that the modified Unified Classification System is reliable and valid. We believe it is useful to improve the judgment of the implant stability, and establish the therapeutic strategy for periprosthetic femoral fracture.
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Affiliation(s)
- Meng-Qiang Fan
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China; The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310006, Zhejiang, China
| | - Xiao-Hong Fan
- Department of Orthopaedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiao-Lei Chen
- Basic Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Jian-Jian Shen
- Department of Orthopaedics, Affiliated Cixi Hospital of Wenzhou Medical University, Cixi, China
| | - Xian-Jun Jiang
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China; The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310006, Zhejiang, China
| | - Xu-Song Li
- Department of Orthopaedics & Traumatology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, 528401, Guangdong, China
| | - Jie-Feng Huang
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China; The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310006, Zhejiang, China.
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Fenelon C, Murphy EP, Baig MN, Kearns SR, Murphy CG, Curtin W. Breaking Bad: A Comparative Descriptive Analysis of Periprosthetic Fractures Around Cemented and Uncemented Femoral Stems. J Arthroplasty 2019; 34:1783-1786. [PMID: 31027856 DOI: 10.1016/j.arth.2019.03.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/11/2019] [Accepted: 03/15/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periprosthetic fractures are most commonly classified according to the Vancouver classification system and more recently the Unified Classification System. The aim of this study is to provide a descriptive analysis of fracture patterns in femoral periprosthetic fractures (PPFs) by femoral stem fixation. METHODS A retrospective observational study of all femoral PPFs over a 10-year period at our institution was conducted. Presenting radiographs were examined to assess the fracture pattern. RESULTS Over the 10-year period, 138 femoral PPFs that underwent operative treatment were examined. Mean age of patients was 78 years with 45.7% male and median American Society of Anaesthesiologists grade 3. The femoral stem fixation was cemented in 83 patients and uncemented in 55 patients. Uncemented femoral stems most commonly caused a simple oblique fracture pattern (69.1%) with a more comminuted pattern seen in cemented fixation (59%). CONCLUSION Fracture patterns differ according to femoral stem fixation. A simple "sickle-like" oblique fracture pattern was more commonly seen in uncemented stems while cemented tapered stems resulted in a comminuted "axe splitting" pattern.
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Affiliation(s)
- Christopher Fenelon
- Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Evelyn P Murphy
- Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Muhammad N Baig
- Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Stephen R Kearns
- Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Colin G Murphy
- Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - William Curtin
- Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
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Huang JF, Jiang XJ, Shen JJ, Zhong Y, Tong PJ, Fan XH. Modification of the Unified Classification System for periprosthetic femoral fractures after hip arthroplasty. J Orthop Sci 2018; 23:982-986. [PMID: 30104103 DOI: 10.1016/j.jos.2018.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/09/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Unified Classification System (UCS) for Periprosthetic femoral fractures (PPFF) still has some limitations. METHODS We retrieved 18 previous classifications for PPFF based on systematic review of the literature, and also retrospectively analyzed 402 cases with PPFF. 46 cases (11.4%) were identified as beyond the classification scope of the original UCS. RESULTS We modified the UCS as follows: (1) add two new B2 subtypes: B2PALT/B2PAGT (i.e., the pseudo ALT/AGT: Fracture in trochanter region including a segment of the proximal medial/lateral femoral cortex); (2) add a new FS category to encompass stem fracture alone or accompanied by PPFF, with FSO designating this fracture with stem fracture alone, FS1 designating this fracture with the proximal portion of the fractured femoral prosthesis being stable, FS2 designating this fracture with the proximal portion of the fractured femoral prosthesis being loose and the surrounding bone quality being good, and FS3 designating this fracture with the proximal portion of the fractured femoral prosthesis being loose and the bone bed being of poor quality; and (3) delete Type F which does not apply to the femur. Thus, using our modification of the UCS, among the 46 cases, we found thirty-five B2PALT, two B2PAGT, three FSO, one FS1, two FS2 and three SF3. CONCLUSIONS Compared to the original UCS, our modified version is more comprehensive. We believe it is useful to improve the judgment of the implant stability, and establish the therapeutic strategy for PPFF.
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Affiliation(s)
- Jie-Feng Huang
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Xian-Jun Jiang
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Jian-Jian Shen
- Department of Orthopaedics, Affiliated Cixi Hospital of Wenzhou Medical College, Cixi, China
| | - Ying Zhong
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Pei-Jian Tong
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China.
| | - Xiao-Hong Fan
- Department of Orthopaedics, Affiliated Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
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Benelli G, Maritato M, Cerulli Mariani P, Sasso F. Revision of ASR hip arthroplasty: analysis of two hundred and ninety six recalled patients at seven years. INTERNATIONAL ORTHOPAEDICS 2018; 43:97-101. [PMID: 30194652 DOI: 10.1007/s00264-018-4128-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/21/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study is to present an algorithm for the evaluation of both symptomatic and asymptomatic patients. METHODS From November 2004 to May 2010, there were performed 296 operations: 245 total hip arthroplasty and 51 resurfacing arthroplasty with the ASR DePuy system. In April 2010, there was the first Medical Device Alert regarding all MoM hip replacements in the UK and in August 2010, DePuy recall started worldwide. In March 2012, we started our recall. All patients were invited to undergo clinical investigation, X-ray evaluations, and blood chrome and cobalt level determination. For a short period of time, there were performed second level exams and subsequently, we carried out MARS MRI hip study to all symptomatic patients and there was evidence of ALVAL lesions. RESULTS To the patients with ALVAL lesions were proposed surgical hip revision while the others frequent follow-up controls. One hundred patients underwent hip surgical revision. CONCLUSIONS We recommend constant MoM THA patients monitoring and early revision if necessary.
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Affiliation(s)
- Giovanni Benelli
- Orthopaedic and Traumatology Department, Santo Stefano Hospital, Azienda USL Toscana Centro, Prato, Italy
| | - Merildo Maritato
- Orthopaedic and Traumatology Department, Santo Stefano Hospital, Azienda USL Toscana Centro, Prato, Italy
| | - Pierpaolo Cerulli Mariani
- Orthopaedic and Traumatology Department, Santo Stefano Hospital, Azienda USL Toscana Centro, Prato, Italy.
| | - Francesco Sasso
- Orthopaedic and Traumatology Department, Santo Stefano Hospital, Azienda USL Toscana Centro, Prato, Italy
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Hamadouche M, Stern LLD. Periprosthetic fractures and complicated arthroplasties. INTERNATIONAL ORTHOPAEDICS 2015; 39:1671-2. [PMID: 26278676 DOI: 10.1007/s00264-015-2977-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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