Cable plating with a single strut allograft in the treatment of periprosthetic fractures of the femur

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.

The race for the classification of proximal periprosthetic femoral fractures : Vancouver vs Unified Classification System (UCS) - a systematic review

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.

Atypical periprosthetic femoral fractures of the hip: characterisation of three cases

INTRODUCTION

Long-term use of bisphosphonates (BPs) has been associated with a specific type of tensile side femoral stress fracture known as Atypical Femoral Fracture (AFF). Theoretically periprosthetic femoral fractures (PFF) should be excluded from the diagnosis of AFF. However, emerging evidence correlates prolonged BPs use with the occurrence of a type of PFF with an atypical pattern (atypical PFF, APFF). The aim of the present study is to report 3 cases of APFF treated at a single centre.

METHODS

Clinical and radiographic records of PFF that occurred between January 2016 and August 2018 were retrospectively reviewed. All patients meeting the American Society for Bone and Mineral Research (ASBMR) criteria for definition of PFF were included. Management strategies for APFF and patient outcomes, including fracture healing and hip function (assessed by the Oxford Hip Score [OHS]) were collected.

RESULTS

3 patients in the study period were identified as APFF (1 incomplete, 2 complete). All patients were females with a mean age of 83.3 years. All patients were treated with lateral plating. The application of a contralateral strut allograft resulted in fracture healing in cases of complete fractures. Mean OHS at final follow-up was 34.3.

CONCLUSIONS

Despite occurring around a hip stem like PFF, APFF had peculiar clinical and radiographic features, making them more similar to AFF. Therefore, the orthopaedic surgeon should also consider the natural history and healing problems associated with AFF prior in order to choose the most appropriate management for APFF.

Incidence, Classification, and Risk Factors for Intraoperative Periprosthetic Femoral Fractures in Patients Undergoing Total Hip Arthroplasty With a Single Stem: A Retrospective Study

BACKGROUND

The collum femoris preserving (CFP) stem was a specially designed femoral neck preserving component. The incidence, classification, and risk factors for intraoperative periprosthetic femoral fractures with this special stem remain unclear.

METHODS

This was a retrospective study. We analyzed the clinical and radiological data of all patients who underwent primary hip arthroplasty with a CFP stem in our hospital between January 2006 and November 2018. Demographic characteristics and radiological features were obtained from the medical records and the Picture Archiving and Communication System, respectively. The incidence, Vancouver classification, and risk factors for intraoperative periprosthetic femoral fractures were identified.

RESULTS

A total of 1633 hips were included. The incidence rate of periprosthetic femoral fractures in patients undergoing total hip arthroplasty with a CFP stem was 3.2%. According to the Vancouver classification, there were 24 patients (45.3%) with Vancouver type A fractures, 27 patients (50.9%) with Vancouver type B fractures, and 2 patients (3.8%) with Vancouver type C fractures. Five independent risk (protective) factors were found, including surgical history (odds ratio [OR] = 3.275, 95% confidence interval [CI] = 1.192-8.997), neck-shaft angle (OR = 1.104, 95% CI = 1.058-1.152), neck length preserved (OR = 0.913, 95% CI = 0.850-0.980), canal flare index (OR = 0.636, 95% CI = 0.413-0.980), and bone mineral density (OR = 0.083, 95% CI = 0.016-0.417).

CONCLUSION

The detailed characteristics of intraoperative periprosthetic femoral fractures in patients who received a CFP stem were identified in this study. Cracks of the femoral neck and fractures on the front side of the proximal femur were more common in patients with CFP stems. As a kind of a femoral neck preserving stem, the anatomical features (eg, neck-shaft angle, preserving length) of the remaining femoral neck might influence the incidence and characteristics of intraoperative periprosthetic femoral fractures in patients with CFP stems.