Periprosthetic Hip Fractures With a Loose Stem: Open Reduction and Internal Fixation Versus Stem Revision

Periprosthetic fractures around cemented hip hemiarthroplasty: Are SOFCOT-Vancouver recommendations mandatory? A comparative study with propensity score matching

INTRODUCTION

Periprosthetic hip fracture is a serious complication associated with increased mortality and impaired autonomy. When the implant is loosened, the standard treatment involves prosthetic revision. However, recent studies suggest that these cases can be successfully treated with fixation without prosthetic exchange. This strategy seems relevant for elderly and frail patients with fractures around hemiarthroplasties but it has not yet been investigated in France. Therefore we did a retrospective comparative investigation aiming to compare postoperative complications (i.e., death within one month or reintervention) between osteosynthesis and prosthetic revision in elderly patients with Vancouver B fractures around polished tapered stem hemiarthroplasties.

HYPOTHESIS

We hypothesized that there would be no significant difference between osteosynthesis and prosthetic revision.

MATERIALS AND METHODS

In a single-university-center, all patients treated between 2005 and 2024 for periprosthetic fractures after cemented hemiarthroplasty were included in a retrospective observational study. A total of 92 patients were included, with an average age of 88.7 years (range, 77-107), mostly institutionalized (58%) and with multiple comorbidities, as indicated by a mean ASA score of 2.75 (range: 2-4) and a mean Charlson Comorbidity Index of 6.4 (range: 4-10); the average time between HHA and PPF occurrence was 2.1 years (range: 7-5679 days). The primary outcome was a composite criterion including the occurrence of a complication requiring reintervention or death within one month postoperatively. Group comparability was established using a propensity score.

RESULTS

The mean follow-up was 665 days, with the longest follow-up reaching 5704 days. No significant difference was observed in the primary outcome between the osteosynthesis group (n = 19/39 patients, (48.71%)) and the revision group (n = 16/39 patients, (41.02%)) (p = 0.637). Osteosynthesis demonstrated significantly shorter operative time (96 min vs. 167 min, p < 0.001), reduced blood loss (428 mL vs. 874 mL, p < 0.001), shorter hospital stays (9.17 days vs. 13.39 days, p < 0.001), and better autonomy preservation (loss of 1.09 Parker score points vs. 1.97 points, p < 0.001) compared to revision surgery. The 1-year mortality rate was 29,3% (27/92). The reintervention rate was 27.2% (25/92). The main causes of reintervention were dislocations, accounting for 13% (12/92) of cases, (occurring in 9.4% (5/53) of patients in the osteosynthesis group and 17.9% (7/39) in the revision group. The second most common reintervention cause was infection, which accounted for 11% (10/92) of cases, (occurring in 7.5% (4/53) of patients in the osteosynthesis group and 15.4% (6/39) in the revision group).

DISCUSSION

This result supports the idea that, for HHA's PPF, the Vancouver-SOFCOT recommendations can be adapted. For all type B fractures, if the fracture can be reduced and the cement mantle is well-fixed to the bone and of good quality, osteosynthesis is also a reliable option.

LEVEL OF EVIDENCE

III; Retrospective comparative study.

Open reduction and internal fixation offers lower hip-related complications compared to stem revision in Vancouver B2 fractures around cemented polished tapered femoral stems

Purpose

Periprosthetic femoral fractures (PFFs) after total hip arthroplasty (THA) are increasing, particularly Vancouver B2 fractures around cemented polished tapered femoral stems. Open reduction and internal fixation (ORIF) are more frequently used in comparison to the traditional stem revision to deal with these complex fractures. This observational study aims to compare the outcomes of ORIF versus stem revision in the treatment of Vancouver B2.

Methods

A retrospective cohort study was conducted at Danderyd Hospital, Stockholm, from 2008 to 2022, including 157 patients (mean age 83.4 ± 7.0 years, 59% females) with a surgically treated Vancouver B2 fractures with an intact bone-cement interface. The study assessed the immediate and long-term outcomes of ORIF versus stem revision, examining post-operative complications, reoperation rates, and implant survivorship.

Results

Among the 157 patients, 37 were treated with ORIF and 120 with stem revision. The ORIF group, which consisted of older patients and had a higher prevalence of cognitive dysfunction, experienced no hip-related adverse events. In contrast, the revision group had a 17.8% incidence of adverse events. Mortality within 90 days was significantly higher in the ORIF group (24%) compared to the revision group (4%) (p = 0.0007). One-year mortality was also higher in the ORIF group (32%) than in the revision group (15%) (p = 0.03).

Conclusions

ORIF presents as a viable option for managing Vancouver B2 fractures in the proximity of a polished tapered stem when anatomical reduction is possible. The less invasive surgery provides potential advantages in patient outcomes and resource utilization. Further research is warranted to aid in the development of treatment guidelines.

Level of Evidence

III.

Indications and clinical results of Non-Operative management of periprosthetic hip fractures in elderly patients

BACKGROUND

The increase in life expectancy in the general population has led to a rise in the use of hip arthroplasties and consequently, to an increase in the incidence of periprosthetic hip fractures (PPHF). The impact of this type of fracture on patients necessitates a personalized approach to treatment, whether surgical or non-operative, taking into account the trajectory and associated comorbidities.

METHODS

We performed a retrospective study of 80 patients over the age of 70 diagnosed with a periprosthetic hip fracture between 2011 and 2018. These cases were reviewed after a minimum follow-up of 5 years. We included demographic data, comorbidities including Charlson comorbidity index (CCI), primary prosthesis characteristics, fracture type according to the Vancouver classification, treatment received and mortality among others. Radiographs were analyzed during follow-up and Merle D'Aubigné and visual analog scales were performed.

RESULTS

Fifty-two of the 80 fractures analyzed involved total hip arthroplasties, 26 were hemiartroplasties and only 2 were revision prostheses. A total of 77.5 % had cementless stems and 88.8 % of the patients had significant comorbidities. There were 29 B1 (36.3 %) and 30 B2 (37.5 %) fractures which compromised most of the study cohort. Fifty-three patients underwent surgery compared to 27 patients (34 %) treated non-operatively; most of the latter had short, oblique undisplaced B1 fractures. 28 fractures (35 %) required reduction and fixation (ORIF) while 25 patients (31.3 %) underwent a revision arthroplasty (RA). The mean score at 3 months for the VAS scale was 2.9 points and for Merle D'Aubigné scale, the scores were 4.3 points for pain, 4.1 for mobility and 3.8 for ambulation. Seven patients who underwent surgery died in the first 2 months compared to 2 in the non-operative group. Revision arthroplasty had the highest prevalence of mortality (p=0.032) as did those with a CCI ≥ 6 (p=0.038).

CONCLUSIONS

In some low functional demand elderly patients with significant comorbidities non-operative treatment can be considered, especially in fractures with short transverse and oblique patterns where it provides similar clinical and radiographic results to surgical treatment whilst avoiding additional risks in these fragile and vulnerable patients.

LEVEL OF EVIDENCE

Therapeutic Level IV (Case Series).

What's New in Periprosthetic Femur Fractures?

BACKGROUND

Periprosthetic femur fracture (PFF) is one of the most common indications for reoperation following total hip arthroplasty.

METHODS/RESULTS

This article provides a review of a symposium on PFF that was presented at the American Association of Hip and Knee Surgeons 2023 annual meeting, including an overview of the Vancouver classification and its implications on treatment and subsequent complications, an updated approach to the management of intraoperative fractures, and finally, contemporary strategies for both osteosynthesis as well as revision arthroplasty for PFFs.

CONCLUSION

As the incidence of PPF continues to increase, arthroplasty and trauma surgeons must be prepared to address this challenging complication with a contemporary understanding of the treatment options and their outcomes.

Stem revision vs. internal fixation in Vancouver B2/B3 periprosthetic hip fractures: systematic review and metanalysis

INTRODUCTION

Vancouver B2 and B3 periprosthetic fractures (PFF) are associated with stem instability and often require a demanding stem implant revision (SR) or internal fixation (ORIF). This latter surgery is increasingly performed in the last few years instead of SR, but it is unclear which is the best treatment to manage PFF patients. The aim of this study is the compare the outcomes of B2/B3 PFF managed by either ORIF or SR, by performing a systematic review and meta-analysis of current literature.

MATERIALS AND METHODS

Cochrane Database, PubMed, Google Scholar and MEDLINE were examined to find out relevant publications dealing with the different outcomes of SR vs. ORIF in B2/B3 PFF of the hip. The effect model (EM) was calculated using Cohen´s d index.

RESULTS

Fifteen studies were included, reporting on a total of 1629 patients (564 ORIF and 1065 SR). The pooled random EM estimates for reoperation was 0.87 (95% CI, 0.39-1.96; I2 = 78%) in favor of ORIF surgery; EM for complications was 1.01 (95% CI, 0.45-2.27; I2 = 85%) without difference among procedures. The EM for transfusion was 0.72 (95% CI, 0.46-1.12; I2 = 62%) in favor of fixation.

CONCLUSION

ORIF and SR were both suitable and effective options in PFF patients, being associated to similar complications rates. Our results show that ORIF performance in PFF patients is associated to significantly less in blood loss, surgical time and in-hospital stay. These advantages are particularly appealing in patients with multiple comorbidities.

Comparative outcomes of uncemented and cemented stem revision in managing periprosthetic femoral fractures: a retrospective cohort study

INTRODUCTION

Periprosthetic femoral fractures (PFFs) following hip arthroplasty, especially Vancouver B2 and B3 fractures, present a challenge due to the association with a loose femoral stem, necessitating either open reduction and internal fixation or stem revision. This study aims to compare outcomes between uncemented and cemented stem revisions in managing Vancouver B2 and B3 fractures, considering factors such as hip-related complications, reoperations, and clinical outcome.

METHODS

A retrospective cohort study was conducted at Danderyd Hospital, Sweden, from 2008 to 2022, encompassing operatively treated Vancouver B2 and B3 fractures. Patients were categorized into uncemented and cemented stem revision groups, with data collected on complications, revision surgeries, fracture healing times, and clinical outcomes.

RESULTS

A total of 241 patients were identified. Significant differences were observed between the two groups in patient demographics, with the cemented group comprising older patients and more females. Follow up ranged from 1 to 15 years. Average follow up time was 3.9 years for the cemented group and 5.5 years for the uncemented group. The cemented stems demonstrated lower rates of dislocation (8.9% versus 22.5%, P = 0.004) and stem loosening (0.6% versus 9.3%, P = 0.004) than the uncemented method. Moreover, the cemented group exhibited shorter fracture healing times (11.4 weeks versus 16.7 weeks, P = 0.034). There was no difference in clinical outcome between groups. Mortality was higher in the cemented group.

CONCLUSIONS

This retrospective study indicates that cemented stem revision for Vancouver B2-3 fractures is correlated with lower dislocation and stem loosening rates, necessitating fewer reoperations and shorter fracture healing times compared with the uncemented approach. The cemented group had a notably higher mortality rate, urging caution in its clinical interpretation.

LEVEL OF EVIDENCE III

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.

Rectangular Taper Stem Designs Are Associated With a Higher Risk for Periprosthstic Femoral Fractures After Cementless Total Hip Arthroplasty

BACKGROUND

Periprosthetic femoral fractures (PFFs) remain a major concern following cementless total hip arthroplasty (THA). This study aimed to evaluate the association between different types of cementless tapered stems and the risk of postoperative PFF.

METHODS

A retrospective review of primary THAs performed at a single center from January 2011 to December 2018 included 3,315 hips (2,326 patients). Cementless stems were classified according to their design. The incidence of PFF was compared between flat taper porous-coated stems (type A), rectangular taper grit-blasted stems (type B1), and quadrangular taper hydroxyapatite-coated stems (type B2). Multivariate regression analyses were performed to identify independent factors related to PFF. The mean follow-up duration was 61 months (range, 12 to 139). Overall, 45 (1.4%) postoperative PFFs occurred.

RESULTS

The incidence of PFF was significantly higher in type B1 stems than in type A and type B2 stems (1.8 versus 0.7 versus 0.7%; P = .022). Additionally, more surgical treatments (1.7 versus 0.5 versus 0.7%; P = .013) and femoral revisions (1.2 versus 0.2 versus 0%; P = .004) were required for PFF in type B1 stems. After controlling for confounding variables, older age, diagnosis of hip fracture, and use of type B1 stems were significant factors associated with PFF.

CONCLUSION

Type B1 rectangular taper stems were found to have higher risks for postoperative PFF and PFF requiring surgical management than type A and type B2 stems in THA. Femoral stem geometry should be considered when planning for cementless THA in elderly patients who have compromised bone quality.

Operative treatment of periprosthetic fractures of the proximal femur with a contralateral, upside-down LISS plate in elderly patients

BACKGROUND

Increasing expectancy of life and levels of activity in the growing geriatric population lead to a rising number of prosthetic implants of the hip and consequently the incidence of periprosthetic fractures of the femur increase. The fracture pattern and the possible instability of the stem are a challenge to the orthopaedic surgeon. Treatment options are complete replacement of the implant or a solitary osteosynthesis. The goal of this study was to analyse the feasibility of the operative intervention using a contralateral reversed anatomic distal femoral LISS® locking plate and the radiological and functional outcome in a geriatric cohort.

METHODS

We included all patients older than 75 years of age with a Vancouver type B fracture, which have been treated by osteosynthesis using a LISS® (contralateral reversed) plate in our institution in an interdisciplinary ortho-geriatric setting between 7/2013 and 12/2021. Perioperative morbidities, clinical and radiological outcome during follow-up were retrospectively analysed.

RESULTS

During the observed time period, 83 patients (mean age: 88 years (range: 76-103), male/female: 26/57) were treated. Most fractures were Vancouver type B2 (n = 45, 54%) followed by B1 (n = 20, 24%) and B3 (n = 18, 22%). The most prevalent postoperative surgical complication was anaemia (n = 73, 88%) followed by infections (n = 12, 14%, urinary infections, pneumonia) and cardiovascular decompensation (n = 8, 10%). Clinical and radiological follow up 6-8 weeks postoperative was possible for 59 patients (70%). The majority of them did not describe pain (n = 50, 85%) and had a good or excellent radiological outcome. Three cases needed revision surgery due to infection and another three due to non-union, loosening of the stem or an additional fracture. 1-year mortality was 30%.

CONCLUSION

We are convinced that the reversed contralateral LISS-plate is an easy-to-use implant with a small complication rate but a very successful and high healing rate in a geriatric, polymorbid cohort.

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

PURPOSE

Several studies comparing osteosynthesis and stem revision in Vancouver B2 (VB2) periprosthetic hip fractures (PPHF) have been published. This work aims to be the first systematic review and meta-analysis to include only studies involving statistical comparison between the two techniques.

METHODS

MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were systematically searched from inception to October 2021 for studies involving a comparison between VB2 treated by osteosynthesis versus revision arthroplasty. The effect size (ES) was calculated using Cohen´s d index.

RESULTS

From 17 published studies selected, a total of 856 patients were recruited (363 osteosynthesis / 493 revision arthroplasty). The pooled ES estimates for the Parker mobility score were 1.03 (95% CI, 0.22-1.84; I2 = 87.7%) for ORIF surgery, and 0.54 (95% CI, - 0.10-1.17; I2 = 83%) for revision surgery. The pooled ES estimates for the operative time, reintervention, complications, hospital stay and needing for blood transfusion were significant lower in ORIF than in revision surgery. There were no differences in first-year mortality between groups. There was a higher proportion of ASA > 3 patients in the ORIF group.

CONCLUSION

Osteosynthesis versus revision arthroplasty has a shorter operative time, less need for blood transfusion, fewer complications and reoperation rate and shorter hospital stay. Nonetheless, similar results were found for functional tests and first-year mortality. These results support the use of osteosynthesis in selected patients (low functional demand, multiple comorbidities, and high anesthetic risk).

LEVEL OF EVIDENCE

III.

Treatment algorithm in Vancouver B2 periprosthetic hip fractures: osteosynthesis vs revision arthroplasty

There is currently a debate on whether all Vancouver B2 periprosthetic hip fractures should be revised.

The aim of our work was to establish a decision-making algorithm that helps to decide whether open reduction and internal fixation (ORIF) or revision arthroplasty (RA) should be performed in these patients.

Relative indications in favour of ORIF are low-medium functional demand (Parker mobility score (PMS) <5), high anaesthetic risk (American Society of Anesthesiologists score (ASA) ≥ 3), many comorbidities (Charlson Comorbidity Index (CCI) ≥ 5), 1 zone fractured (VB2.1), anatomical reconstruction possible, and no prior loosening (hip pain).

Relative indications in favour of RA are high functional demand (PMS ≥6), low anaesthetic risk (ASA< 3), few comorbidities (CCI<5), fracture ≥ 2 zones (VB2.2), comminuted fractures, and prior loosening (hip pain).

In cemented stems, those fractures with fully intact cement–bone interface, no stem subsidence into the cementraliser, cement mantle anatomically reducible, and some partial stem-cement attachment can be safely treated with ORIF.

Ethical Dilemmas with Regard to Elderly Patients with Hip Fracture: The Problem of Nonagenarians and Centenarians

Hip fracture is the most feared complication of osteoporosis, producing up to 30% mortality at the first year. With the aging of society, it is increasingly common to deal with ethical dilemmas that involve decision making in the elderly patient with a hip fracture. The objectives of the present work are to describe the main bioethical dilemmas in this group of patients and their relationship with surgical delay. We conducted a retrospective descriptive study that studied an elderly population admitted to a University Hospital with a diagnosis of hip fracture. In total, 415 patients were analyzed. The majority received surgical treatment, a correct application of the principles of justice, non-maleficence and beneficence is verified, but a possible violation of the principle of autonomy is confirmed. Based on the results of this study, the elderly population may somehow lose their principle of autonomy when they enter a hospital due to a hip fracture. On the other hand, the so-called ageism due to ignorance can influence the surgical delay and therefore the mortality of these patients.

Is Stem Revision Necessary for Vancouver B2 Periprosthetic Hip Fractures? Analysis of Osteosynthesis Results from 39 Cases

Although stem revision is recommended for Vancouver B2 periprosthetic hip fractures (PPHFs), there has recently been a debate whether, under certain conditions, they could be treated by osteosynthesis alone. This study aimed to describe the medium-term clinical and radiological results of several patients with V-B2 fractures treated via osteosynthesis. A retrospective study of patients with V-B2 PPHF treated by osteosynthesis without stem revision, operated on between 2009 and 2019, was performed. The type of arthroplasty, type of stem, ASA, Charlson Comorbidity Index (CCI), medical and implant complications, reoperation rate, first-year mortality, radiological results (consolidation time), and functional results were analyzed. Thirty-nine patients were included. Their average age was 78.82 years. Most of the patients presented ASA ≥ 3 (35/39) and CCI ≥ 5 (32/39). Radiological consolidation was achieved in 93.5% of patients, with an average consolidation time of 92.93 days. The average Parker test score before admission was 5.84 while the current one was 4.92 (5.16 years follow-up). Osteosynthesis without stem revision is a valid surgical alternative in certain types of patients with V-B2 PPHF, depending on previous mobility, fracture pattern (anatomical reconstruction possible), anesthetic risk, comorbidities, and previous hip pain.