A systematic review of Vancouver B2 and B3 periprosthetic femoral fractures

Treatment strategy and clinical outcomes of surgically managed hip periprosthetic fractures: analysis from a high-volume centre

BACKGROUND

Hip periprosthetic fractures (PPF) after total hip arthroplasty (THA) are becoming increasingly prevalent. Their management is secondary to the fracture type and the stability of the implant. This study aimed to provide the outcomes of operatively managed PPF from a high-volume centre to help guide future decision making.

METHODS

This was a retrospective study of prospectively collected data from January 2008 to January 2021. Patient demographics, implant specific details, and fixation strategy were collected. Complications including infection, reoperation, re-fracture, re-revision, were collected. Short-term mortality was evaluated at 3 months and 1 year. P-values <0.05 were considered significant.

RESULTS

282 surgically managed PPF were identified. Vancouver B2 were predominant in 52% of the cases. Revision alone and revision with additional fixation were the most frequent strategies in 168 cases (60%). Complications requiring reoperation occurred in 20% of the cases, with infection as the most frequent (8.5%). Mortality rate was 7.8% at 3 months and 15.7% at 1 year, with significantly lower rates in B2 type. B2 fractures treated with cemented stems had a significantly lower 1-year mortality than distal fit revisions.

CONCLUSIONS

PPF is associated with a high complication rate. Revision alone and revision with additional fixation remain the preferred method in B2/B3 type fractures, however, cemented revision can yield similar outcomes with lower short-term mortality. Considering the high-risk elderly and frail category of patients, a multidisciplinary team is necessary to improve outcomes and reduce mortality.

Managing B2 periprosthetic femoral fractures: ORIF vs stem-revision

BACKGROUND

The gold-standard treatment for Vancouver type B2 and B3 fractures is revision arthroplasty. This procedure can be prolonged and complex, posing challenges for patients with severe medical comorbidities and reduced physical status. Recently, osteosynthesis has been proposed as an alternative treatment for B2 periprosthetic femoral fractures (PFF) in frail patients, though its efficacy compared to revision arthroplasty has not been studied in detail.

METHODS

A retrospective study was conducted from 2012 to 2022, comparing complications, mortality, length of stay, gait ability, hemoglobin decrease, and blood transfusion rates between 44 patients undergoing treatment for B2 or B3 PPF with either stem-revision arthroplasty (n = 28) or open reduction and internal fixation (ORIF) with plates and screws (n = 16).

RESULTS

The results showed no significant differences in mortality, complications, hemoglobin decrease, blood transfusion rate, or length of stay between the two groups. In the stem-revision group, 11 patients (60.7 %) experienced a medical complication, while 7 patients (43.8 %) in the ORIF group had complications (p = 0.778). The mortality rate within the first year post-surgery was 17.9 % (5 patients) in the stem-revision group compared to 18.8 % (3 patients) in the ORIF group (p = 0.943). Surgical complications occurred in 2 patients (7.1 %) in the stem-revision group and in 4 patients (25 %) in the ORIF group (p = 0.101). Blood transfusions were required in 17 patients (60.7 %) in the stem-revision group and in 8 patients (50 %) in the ORIF group (p = 0.829).

CONCLUSIONS

This study suggests that ORIF is an acceptable treatment option for patients with B2 or B3 PFF, especially for those with severe medical comorbidities and reduced physical status who may not tolerate revision arthroplasty. However, further research with larger sample sizes and longer follow-up periods is needed to confirm these findings.

LEVEL OF EVIDENCE

IV.

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

Cemented vs cementless stems for revision arthroplasties due to Vancouver B2 periprosthetic hip fracture

PURPOSE

According to Vancouver classification, B2 type fractures are most often treated with removal of the loose stem and implantation of a long stem that bypasses the fracture site. However, there is a controversy about the stem fixation that should be used: cemented or cementless. Hence, this study aims to compare cemented and cementless stems in prosthetic revision due to Vancouver B2 (VB2) periprosthetic hip fracture.

METHODS

A retrospective study was done including all the patients treated with stem exchange due to VB2 periprosthetic hip fracture in a tertiary hospital between 2015 and 2022. Patients were divided into two groups according to the stem fixation used: cemented or cementless. Functional outcomes, hospital stay, surgical time, complication rate, and mortality were compared between the two groups of patients.

RESULTS

Of the 30 included patients, 13 (43.4%) were treated with cementless stems and 17 (56.7%) with cemented stems. There were no statistically significant differences in age, gender, anesthesia risk scale (ASA) or functional capacity prior to the intervention. Patients treated with cementless stems had a higher complication and reintervention rate than those treated with cemented stems: 62 and 45% versus 34 and 6% (p = 0.035; p = 0.010), respectively. Furthermore, in the group of cementless stems a higher proportion of non-union was found (53.8% vs. 17.6%; p = 0.037). Also, the hospital stay (33 vs. 24 days; p = 0.037) and the time to full weight-bearing (21 days vs. 9 days; p < 0.001) were longer in the cementless stem group.

CONCLUSION

Cemented fixation in stem revision due to Vancouver B2 periprosthetic hip fracture could be an optimal option with faster recovery which could decrease the rate of complications and reintervention, without compromising the fracture healing and patient mortality. Thus, this option can be considered when an anatomical reduction can be obtained, especially in elderly patients with multiple comorbidities in which a less aggressive surgical option should be considered.

Health-related quality of life (EQ-5D) after revision arthroplasty following periprosthetic femoral fractures Vancouver B2 and B3 in geriatric trauma patients

INTRODUCTION

The aim of this study was to determine the outcome parameters of revision arthroplasties for periprosthetic femoral fractures (PPFF) with a particular attention to quality of life (QoL) and mobility.

MATERIALS AND METHODS

Retrospective single-center study of PPFF with loose implants that underwent revision arthroplasty. Depending on individual patient characteristics, either an uncemented or cemented revision stem was chosen. Data collection included demographics, complications, clinical course and outcome parameters. Follow-up took place at least one year postoperatively.

RESULTS

Between 2008 and 2016, 43 patients could be included. Most patients (63%) were able to walk independently or with a walking aid after one year and amongst the surveyed patients 77% were able to reside at home. Concerning the QoL assessment, a high index of 0.8 ± 0.1 has been reached after one year. Mortality pointed out to be 9% after one year and 28% in general.

CONCLUSION

The treatment of PPFF remains challenging. Although complication rates and mortality are high in this frail collective of geriatric patients, revision arthroplasty leads to good postoperative results regarding mobility and quality of life.

Health status after periprosthetic proximal femoral fractures

Aims

Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

Methods

A cohort of patients with PFF after THA was derived from the Brabant Injury Outcomes Surveillance (BIOS) study. The BIOS study, a prospective, observational, multicentre follow-up cohort study, was conducted to obtain data by questionnaires pre-injury and at one week, and one, three, six, 12, and 24 months after trauma. Primary outcome measures were the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the Health Utility Index 2 (HUI2), and the Health Utility Index 3 (HUI3). Secondary outcome measures were general measurements such as duration of hospital stay and mortality.

Results

A total of 70 patients with a PFF were included. EQ-5D utility scores were significantly lower on all timepoints except at six months' follow-up compared to pre-injury. EuroQol visual analogue scale (EQ-VAS) scores at one month's follow-up were significantly lower compared to pre-injury. The percentage of reported problems at two years was higher for all dimensions except anxiety/depression when compared to pre-injury. The mean EQ-5D utility score was 0.26 higher in males compared to females (95% confidence interval (CI) 0.01 to 0.42; p = 0.003). The mean EQ-VAS score for males was 8.9 points higher when compared to females over all timepoints (95% CI 1.2 to 16.7; p = 0.027). Mortality was 10% after two years' follow-up.

Conclusion

PFF patients are a frail population with substantial functional impairment at baseline. Post-injury, they have a significant and clinically relevant lower health status two years after trauma when compared to pre-injury. Health status improves the most between one and three months after injury. Two years after PFF, more patients experience problems in mobility, self-care, usual activities, and pain/discomfort than pre-injury.

Vancouver B2 periprosthetic hip fractures treatment: fix or replace? A retrospective study comparing both techniques

INTRODUCTION

Vancouver B2 periprosthetic hip fractures involve stem stability and they have been classically treated with revision surgery. Crucial factors such as age, clinical comorbidities and functional status are often neglected. The current study aims to compare clinical outcomes between patients treated with open reduction and internal fixation (ORIF) or femoral stem exchange.

METHODS

This is a retrospective study that includes all Vancouver B2 periprosthetic hip fractures in a tertiary referral hospital from 2016 to 2020. Patients were divided into two groups: Group 1. Patients treated with an ORIF and Group 2. Patients treated with stem replacement. The outcomes that were compared between groups included demographic data, functional capacity, complications and mortality.

RESULTS

29 periprosthetic Vancouver B2 fractures were finally analyzed. 11 (37.9%) were treated with ORIF (Group 1) and 18 (62.1%) by stem replacement (Group 2). Surgery time (143 vs. 160 min), hemoglobin drop (1.8 vs. 2.5 g/dL) and hospital stance (25.5 vs. 29.6 days) were shorter in Group 1. According to complications, 18.2% of patients in the ORIF group had orthopedic complications compared with 44.4% in the revision group. In the revision group, 3 cases needed a two-stage revision and one of these revisions ended up with a resection arthroplasty (Girdlestone). The first-year mortality rate was 27% in Group 1 and 11% in Group 2.

DISCUSSION

ORIF treatment seems to be a less aggressive and complex procedure which can lead to a faster general recovery. Revision surgery can imply a higher risk of orthopedic complications which can be severe and may require further aggressive solutions. The ORIF group mortality was similar to the proximal femur fracture rate (20-30%). In conclusion, ORIF treatment seems to be a good option especially in fragile patients with low functional demand when anatomical reduction is possible.

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.

Revision total hip arthroplasty using a modular fluted, tapered revision femoral component and interlocking screws in Vancouver B3 periprosthetic fractures with insufficient bone at the isthmus

Aims

Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients.

Methods

A total of 46 femoral components in patients with Vancouver B3 fractures (23 with Paprosky type IIIA, 19 with type IIIB, and four with type IV defects) in 46 patients were revised with a transfemoral approach using a modular, tapered, cementless revision Revitan curved femoral component with distal cone-in-cone fixation and prospectively followed for a mean of 48.8 months (SD 23.9; 24 to 112). The mean age of the patients was 80.4 years (66 to 100). Additional distal interlocking was also used in 23 fractures in which distal cone-in-cone fixation in the isthmus was < 3 cm.

Results

One patient (2.2%) died during the first postoperative year. After six months, 43 patients (93.5%) had osseous, and three had fibrous consolidation of the fracture and the bony flap, 42 (91.3%) had bony ingrowth and four had stable fibrous fixation of the stem. No patient had radiolucency around the interlocking screws and no screw broke. One patient had non-progressive subsidence and two had a dislocation. The mean Harris Hip Score increased from of 57.8 points (SD 7.9) three months postoperatively to 76.1 points (SD 10.7) 24 months postoperatively.

Conclusion

The 2° tapered, fluted revision femoral component with distal cone-in-cone-fixation, combined with additional distal interlocking in patients with bony deficiency at the isthmus, led to reproducibly good results in patients with a Vancouver B3 fracture and Paprosky type IIIA, IIIB, and IV defects with regard to union of the fracture, subsidence or loosening of the stem, and clinical outcomes.

Comparative outcomes after treatment of peri-implant, periprosthetic, and interprosthetic femur fractures: which factors increase mortality risk?

Objectives

To compare mortality rates between patients treated surgically for periprosthetic fractures (PPF) after total hip arthroplasty (THA), total knee arthroplasty (TKA), peri-implant (PI), and interprosthetic (IP) fractures while identifying risk factors associated with mortality following PPF.

Design

Retrospective.

Setting

Single, Level II Trauma Center.

Patients/Participants

A retrospective review was conducted of 129 consecutive patients treated surgically for fractures around a pre-existing prosthesis or implant from 2013 to 2020. Patients were separated into 4 comparison groups: THA, TKA, PI, and IP fractures.

Intervention

Revision implant or arthroplasty, open reduction and internal fixation (ORIF), intramedullary nailing (IMN), percutaneous screws, or a combination of techniques.

Main Outcome Measurements

Primary outcome measures include mortality rates of different types of PPF, PI, and IP fractures at 1-month, 3-month, 6-month, 1-year, and 2-year postoperative. We analyzed risk factors associated with mortality aimed to determine whether treatment type affects mortality.

Results

One hundred twenty-nine patients were included for final analysis. Average follow-up was similar between all groups. The overall 1-year mortality rate was 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%). There were no differences in mortality rates between each group at 30 days, 90 days, 6 months, 1 year, and 2 years (P-value = 0.86). A Kaplan-Meier survival curve demonstrated no difference in survivorship up to 2 years. Older than 65 years, history of hypothyroidism and dementia, and discharge to a skilled nursing facility (SNF) led to increased mortality. There was no survival benefit in treating patients with PPFs with either revision, ORIF, IMN, or a combination of techniques.

Conclusion

The overall mortality rates observed were 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%), and no differences were found between each group at all follow-up time points. Patients aged 65 and older with a history of hypothyroidism and/or dementia discharged to an SNF are at increased risk for mortality. From a mortality perspective, surgeons should not hesitate to choose the surgical treatment they feel most comfortable performing.

Level of Evidence

Level III.

Cemented femoral stem design and postoperative periprosthetic fracture risk following total hip arthroplasty

Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF.

Exploring Individualized Approaches to Managing Vancouver B Periprosthetic Femoral Fractures: Insights from a Comprehensive Case Series Analysis

The increasing prevalence of periprosthetic femoral fractures, specifically in the vicinity of the hip, has emerged as a significant issue in recent times. Consequently, there is a need for a thorough examination to enhance the effectiveness of management and treatment approaches. The findings of this study emphasize a significant disparity in the occurrence and characteristics of these fractures, and the multiple cases have highlighted the efficacy of various treatment strategies, such as open reduction and internal fixation, as well as the utilization of cortical strut allografts. Furthermore, the study has identified potential risk factors that have an impact on the characteristics of fractures, providing valuable insights that could be crucial in the development of preventive strategies. This study provides a thorough examination of periprosthetic femoral fractures, highlighting the importance of a cohesive treatment algorithm to improve the handling of such fractures. Moreover, it promotes the need for a collaborative endeavor in conducting research in this field, cultivating a more profound comprehension that has the potential to drive progress in therapeutic approaches, ultimately enhancing patient results over an extended period of time. It is crucial that forthcoming research endeavors persist in expanding upon these discoveries, striving towards a unified methodology in tackling this substantial clinical obstacle.

The Effect of Cerclage Banding Distally to a Clamshell Fracture Pattern in Total Hip Arthroplasty-A Biomechanical Study

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.

Biomechanics of PHILOS plates in Vancouver B1 periprosthetic femoral fracture

Objective: To investigate the clinical efficacy of PHILOS plates in the treatment of Vancouver B1 periprosthetic femoral fracture (PFF) and to validate its biomechanical reliability via finite element analysis and mechanical testing on the Synbone femoral models. Methods: Ten males and eight females with Vancouver B1 PFF who underwent PHILOS plate fixation between September 2017 and January 2022 were selected. The average age was 72.61 ± 8.19 years, with a range of 57-86 years old. X-ray films were taken to assess the fracture healing situation around the femoral prosthesis as well as the position of the PHILOS plates and femoral prosthesis. Two different plates (the PHILOS plate and the Cable GTR plate) were used for fixation, and the differences in biomechanical stability of the two fixation methods were compared using finite element analysis and mechanical testing on the Synbone femoral models to validate the biomechanical dependability of the PHILOS plate. Results: All 18 cases were followed for at least 1 year, as a result. The average period of follow-up was 17 months, ranging from 12 to 36 months. At the most recent follow-up, Harris scores for the hip joints of patients ranged from 82 to 89, with an average score of 86. The X-rays revealed that all fractures surrounding the femoral prosthesis had healed and that there was no looseness in the femoral prosthesis. None of the PHILOS license plates had expired. All patients were able to perform full-load walking, and pain and claudication in affected limbs were significantly reduced. Finite element analysis and mechanical testing of the Synbone femoral model revealed that the fixation effect of the PHILOS group was superior to that of the Cable group; consequently, PHILOS plates can be used to effectively fix fractures around the proximal femoral prosthesis. Conclusion: PHILOS plates are initially used in the treatment of Vancouver B1 PFF, which may be a good choice due to their simpler operation, lower medical costs, and satisfactory clinical efficacy.

Vancouver type B2 periprosthetic femoral fractures: clinical and radiological outcomes from a tertiary care center

INTRODUCTION

The purpose of this study was to report mid-term clinical and radiographic results after hip arthroplasty revision in Vancouver type B2 femoral periprosthetic fractures (PPFx). Specifical focus of the paper is as follows: (1) the description of a standardized and reproducible surgical technique, (2) functional outcomes presentation and (3) type and number of complications and implants' survival rate analysis.

METHODS

We retrospectively reviewed all patients treated for hip revision with non-modular tapered fluted titanium stem in patients with Vancouver type B2 femur PPFx at a single institution. At least 18 months' follow-up period was required. Harris Hip Scores and SF-12 were obtained, and radiographical follow-up was performed. Complications were reported and analyzed.

RESULTS

The authors included 114 patients (114 hips) with a mean follow-up of 62.8 ± 30.6 months. All patients were treated with Wagner SL revision hip stem (Zimmer-Biomet), metal cerclage wires ± trochanteric plate. The mean HHS and SF-12 score at the last follow-up evaluation were respectively 81.3 ± 9.7 and 32.5 ± 7.6. Seventeen (14.9%) complications occurred. We observed five cases of dislocations, two of periprosthetic joint infections and six cases of new PPFx. The stem-related revision rate for any cause at the final FU was 1.7%, due to PJI. No patients underwent stem revision surgery for aseptic loosening. Fracture healed in all the included patients with a union-rate of 100%. The re-operation rate for any cause was 9.6%, with an implant survival rate for overall failure of 96.5%.

CONCLUSION

The presented standard and reproducible surgical technique obtains optimal clinical and radiological results with limited complication rate at mid-term follow up. Preoperative planning as well as careful intraoperative surgical technique is of a paramount importance.

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.

Effect of Fracture Type, Treatment, and Surgeon Training on Reoperation After Vancouver B Periprosthetic Femur Fractures

BACKGROUND

The treatment of Vancouver B periprosthetic proximal femur fractures (PPFFs) is complex due to the overlap between arthroplasty and orthopedic trauma techniques. Our purpose was to assess the effects of fracture type, treatment difference, and surgeon training on the risk of reoperation in Vancouver B PPFF.

METHODS

A collaborative research consortium of 11 centers retrospectively reviewed PPFFs from 2014 to 2019 to determine the effects of variations in surgeon expertise, fracture type, and treatment on surgical reoperation. Surgeons were classified as per fellowship training, fractures using the Vancouver classification, and treatment as open reduction internal fixation (ORIF) or revision total hip arthroplasty with or without ORIF. Regression analyses were performed with reoperation as the primary outcome.

RESULTS

Fracture type (Vancouver B3 versus B1: odds ratio [OR]: 5.70) was an independent risk factor for reoperation. No differences were found in reoperation rates with treatment (ORIF versus revision: OR 0.92, P = .883). Treatment by a nonarthroplasty-trained surgeon versus an arthroplasty specialist led to higher odds of reoperation in all Vancouver B fracture (OR: 2.87, P = .023); however, no significant differences were seen in the Vancouver B2 group alone (OR: 2.61, P = .139). Age was a significant risk factor for reoperation in all Vancouver B fractures (OR: 0.97, P = .004) and in the B2 fractures alone (OR: 0.96, P = .007).

CONCLUSION

Our study suggests that age and fracture type affect reoperation rates. Treatment type did not affect reoperation rates and the effect of surgeon training is unclear.

Monoblock tapered stems in management of UCS B2 and B3 periprosthetic fractures in revision total hip arthroplasty

Aims

United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

Methods

A retrospective review was conducted of all patients who underwent revision THA (rTHA) for periprosthetic UCS B2 and B3 periprosthetic fracture who received a single design monoblock fluted tapered titanium stem at two large, tertiary care, academic hospitals. A total of 72 patients met inclusion and exclusion criteria (68 UCS B2, and four UCS B3 fractures). Primary outcomes of interest were radiological stem subsidence (> 5 mm), radiological osseointegration, and fracture union. Sub-analysis was also done for 46 patients with minimum one-year follow-up.

Results

For the total cohort, stem osseointegration, fracture union, and stem subsidence were 98.6%, 98.6%, and 6.9%, respectively, at latest follow-up (mean follow-up 27.0 months (SD 22.4)). For patients with minimum one-year of follow-up, stem osseointegration, fracture union, and stem subsidence were 97.8%, 97.8%, and 6.5%, respectively.

Conclusion

Monoblock fluted stems can be an acceptable modality for the management of UCS B2 periprosthetic fractures in rTHAs due to high rates of stem osseointegration and survival, and the low rates of stem subsidence, and revision. Further research on the use of this stem for UCS B3 periprosthetic fractures is warranted to determine if the same conclusion can be made for this fracture pattern.

Subsidence in Centraliser Sign: A Novel Tool to Help Predict Early Subsidence in Periprosthetic Femoral Fractures Around Polished Tapered Stems Treated With Internal Fixation

Background When treating periprosthetic femoral fractures (PPF) around polished taper slip stems (PTS), determining which patients can be successfully treated with internal fixation can be challenging. We have described the subsidence-in-centraliser (SINC) sign as a radiographic feature of PPF around PTS stems. We hypothesise that a positive SINC sign can help predict a poorer outcome for the fixation of these fractures. Patients and methods Retrospective identification of PPFs around cemented PTS with an appreciable centraliser on radiographs was conducted at a single centre. A positive SINC sign was defined as a post-injury radiograph demonstrating >50% reduction in the radiographic lucency representing the stem centraliser when compared to pre-injury films or complete obliteration of distal lucency when no pre-injury film was available. The primary outcome was the rate of subsequent stem subsidence on follow-up radiographs comparing SINC-positive and SINC-negative fractures, which were managed with open reduction and internal fixation (ORIF). Results Fifty-four patients were included in the analysis. The mean age was 76.8 years, and the mean follow-up for all patients was 12.7 months. Thirty-five fractures were deemed SINC-positive, and 19 were SINC-negative. 17/17 (100%) SINC-positive fractures managed with fixation underwent further subsidence (mean 5.4 mm, SD 2.8). A positive SINC sign demonstrated a sensitivity of 90.5% and specificity of 100% for subsequent stem subsidence in fractures treated without revision. SINC positive fractures underwent significantly more subsidence compared with SINC negative fractures when fixed (5.4 mm vs. 0.28 mm, U = 6.50, p<0.001) at a mean follow-up of 12.7 months. The SINC sign demonstrated strong inter- (k=0.96) and intra-rater (k=0.86) reliability. Conclusion The SINC sign can serve as a useful adjunct in the decision to fix or revise PPF around PTS. A positive SINC sign may represent a cement mantle that cannot be reconstituted anatomically, leading to subsidence after treatment with ORIF.

Treatment of Vancouver B2 Femur Fractures With Open Reduction Internal Fixation Versus Revision Arthroplasty

Background Vancouver B2 periprosthetic femur fractures have traditionally been treated with revision arthroplasty. However, there is increasing evidence that open reduction and internal fixation (ORIF) may be a valid alternative treatment strategy. The purpose of this study was to compare the outcomes of ORIF versus revision arthroplasty for the treatment of Vancouver B2 fractures and evaluate the influence of the treating surgeon's fellowship training on treatment selection. Methodology This was a retrospective cohort study of 31 patients treated for Vancouver B2 periprosthetic fractures (16 ORIF and 15 revision arthroplasty) at a single academic Level 1 trauma center. Outcome measures included one-year mortality, revision, reoperation, infection, and blood loss. Results There were no statistically significant differences in revision, reoperation, or infection at an average follow-up of 65 weeks. Median estimated blood loss was higher in the arthroplasty group (700 cc versus 400 cc; P = 0.04). There were five deaths in the ORIF group versus one in the revision group (P = 0.18). Cases treated by surgeons with fellowship training in arthroplasty were more likely to be treated with revision arthroplasty (10/11, 90.9%) than those treated by surgeons with fellowship training in trauma (5/15, 33.3%; P < 0.01). Conclusions There was no difference in outcomes between the two treatment strategies, but revision was associated with higher blood loss. The appropriate treatment method should be based on surgeon familiarity and patients' characteristics.

Outcomes of fixation of Vancouver B periprosthetic fractures around cemented versus uncemented stems

BACKGROUND

The incidence of periprosthetic femur fracture (PPFF) in the setting of total hip arthroplasty (THA) is steadily increasing. We seek to address whether there is a difference in outcomes between Vancouver B fracture types managed with ORIF when the original stem was a press-fit stem versus a cemented stem.

METHODS

In this retrospective cohort study at a level 1 trauma center, we identified 136 patients over 65 years-of-age with Vancouver B-type fractures sustained between 2005 and 2019. Patients were treated by ORIF and had either cemented or press-fit stems prior to their injury. Outcomes were subsidence of the femoral implant, time to full weight bearing, rate of the hip implant revision, estimated blood loss (EBL), postoperative complications, and the one-year mortality rate.

RESULTS

A total of 103 (75.7%) press-fit and 33 (24.3%) cemented patients were reviewed. Patient baseline characteristics, Vancouver fracture sub-types, and implant characteristics were not found to be significantly different between groups. The difference in subsidence rates, postoperative complications, and time to weight bearing were not significantly different between groups. EBL and one-year mortality rate were significantly higher in the cemented group.

CONCLUSIONS

In geriatric patients with Vancouver B type periprosthetic fractures managed with ORIF, patients with an originally press fit stem may have lower mortality, lower estimated blood loss, and similar subsidence and hospital length of stays when compared to those with a cemented stem.

The Stability of Fixation of Vancouver B2 Periprosthetic Femoral Fractures: Effect of Implantation Technique

INTRODUCTION

Due to increasing volume of total hip arthroplasties, periprosthetic femoral fractures have become a common complication with increased revision burden and perioperative morbidity. The objective of this study was to evaluate the fixation stability of Vancouver B2 fractures treated with two techniques.

METHODS

A common B2 fracture was created by reviewing 30 type B2 cases. The fracture was then reproduced in 7 pairs of cadaveric femora. The specimens were divided into two groups. In Group I ("reduce-first"), the fragments were reduced first, followed by implantation of a tapered fluted stem. In Group II ("ream-first"), the stem was implanted in the distal femur first, followed by fragment reduction and fixation. Each specimen was loaded in a multi-axial testing frame with 70% of peak load during walking. A motion analysis system was used to track the motion of the stem and fragments.

RESULTS

The average stem diameter in Group II was 16.1±0.4 millimeters (mm), versus 15.4 ±0.5mm in Group I. The fixation stability was not significantly different in the two groups. After the testing, the average stem subsidence was 0.36±0.31mm and 0.19±0.14mm (P=0.17), and the average rotation was 1.67±1.30° and 0.91±1.11° (P=0.16) in Group I and II, respectively. Compared to the stem, there was less motion of the fragments, and there was no difference between the two groups (P>0.05).

CONCLUSIONS

When tapered fluted stems were used in combination with cerclage cables for treatment of type B2 periprosthetic femoral fractures, both the "reduce-first" and "ream-first" technique showed adequate stem and fracture stability.

Factors associated with failure of fixation of Vancouver B fractures around a cemented polished tapered stem: A 5 to 14 year follow up study

AIMS

There is increasing evidence for fixation as opposed to revision for Vancouver B fractures around polished taper slip stems, however it is remains unclear whether fixation is associated with stem loosening in the longer term. This study aims to assess survival of plate-fixation of Vancouver-B-fractures around a polished-taper- slip cemented stem and identify factors associated with failure.

METHODS

Retrospective cohort study assessed 129 consecutive unilateral Vancouver-B-fractures around cemented Exeter stems at a minimum of 5 years following open-reduction-internal-fixation (ORIF) with unilateral non-locked unilateral plating+/-cerclage cables. The primary outcome measure was reoperation for any reason. Kaplan Meier survival analysis was performed.

RESULTS

Fractures (B1 n = 31 (24%); B2 n = 91 (71%); and B3 n = 7 (5%)) occurred at median of 6 years (IQR 1.2-9.2) after primary surgery. Mean patient age was 78.2 (SD10.56, range 46-96) and 54 (42.9%) were female. Mean follow up was 8.7 years (SD 2.48, 5.7 to 14.4). Symptomatic femoral stem loosening requiring revision occurred in two B2 fractures of metaphyseal split and short spiral patterns. The most common mode of failure was non-union (n = 7, 5%). Both fixation failure (n = 6/31 Vs n = 3/91 vs n = 0/7, p = 0.008) and reoperation (n = 8/31 vs n = 6/91 vs n = 0/7, p = 0.008) were significantly higher following fixation of B1 fractures compared to B2 and B3 fractures. Overall 5year survival free from reoperation was 88.8% (82.0-94.7 95%CI). B1 fracture types were associated with an increase risk of failure (endpoints fixation failure p = 0.010; and reoperation p = 0.016). Transverse fractures (B1) were associated with a relative risk of reoperation of 4.22 (1.63-10.9 95% CI, p = 0.008).

CONCLUSION

Fixation of Vancouver-B fractures around cemented Exeter stems, when the bone-cement interface is intact and the fracture is anatomically reducible, had an excellent 5-year survival. Only 2 (1.6%) cases of late femoral stem loosening occurred, however, B1 type transverse fractures were associated with a higher rate of reoperation.

Cementless femoral stem revision in total hip arthroplasty: The periprosthetic clamshell fracture. A biomechanical investigation

To biomechanically evaluate the stability of a diaphyseal anchored, cementless stem in presence of a proximal periprosthetic femoral medial wall defect compared to the stability of the same stem in an intact femur. Twenty-two paired human cadaveric femora were pairwise assigned either to a fracture group, featuring a proximal medial wall defect involving 40% of the stems medial anchorage distance, or a control group with native specimens. The specimens were tested under a monotonically increasing cyclic axial loading protocol. Load, cycles, and multiples of the respective body weight at implant loosening was measured. Mean initial stiffness was 2243.9 ± 467.9 N/mm for the intact group and 2190.1 ± 474.8 N/mm for the fracture group. Mean load to loosening in the intact group was 3210.5 ± 1073.2 N and 2543.6 ± 576.4 N in the fracture group, with statistical significance. Mean cycles to loosening in the intact group were 27104.9 ± 10731.7 and 20431.5 ± 5763.7 in the fracture group, with statistical significance. Mean multiples of the resulting body weight at loosening in the intact group was 548.3 ± 158.5% and 441.4 ± 104% in the fracture group, with statistical significance. A medial wall defect involving 40% of the medial anchorage distance significantly decreases the axial stability of a diaphyseal anchored stem. However, mechanical failure occurred beyond physiological stress. At loosening rates of about 4 multiples of the body weight in the fracture group, a "safe zone" remains of a 0.5-fold body weight for maximum loads and twofold body weights for average loads.

Periprosthetic fracture management of the proximal femur

The most common periprosthetic fractures occur around the hip. The most widely used classification is the Vancouver classification, and management requires careful planning and skill in both arthroplasty and fracture surgery. This article presents an overview of the diagnosis, classification, and management of periprosthetic fractures of the proximal femur. This work represents a summary review from Latin American Society Members of the International Orthopaedic Trauma Association.

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.

Mortality and clinical outcomes of Vancouver type B periprosthetic femoral fractures : a multicentre retrospective study

AIMS

The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures.

METHODS

A total of 126 Vancouver type B fractures were analyzed from 2010 to 2019 in 11 associated centres' database (named TRON). We divided the patients into two Vancouver type B subtypes according to implant stability. Patient demographics and functional scores were assessed in the Vancouver type B subtypes. We estimated the mortality according to various patient characteristics and clinical outcomes between the open reduction internal fixation (ORIF) and revision arthroplasty (revision) groups in patients with unstable subtype.

RESULTS

The one-year mortality rate of the stable and unstable subtype of Vancouver type B was 9.4% and 16.4%. Patient demographic factors, including residential status and pre-injury mobility were associated with mortality. There was no significant difference in mortality between patients treated with ORIF and Revision in either Vancouver B subtype. Patients treated with revision had significantly higher Parker Mobility Score (PMS) values (5.48 vs 3.43; p = 0.00461) and a significantly lower visual analogue scale (VAS) values (1.06 vs 1.94; p = 0.0399) for pain than ORIF in the unstable subtype.

CONCLUSION

Among patients with Vancouver type B fractures, frail patients, such as those with worse scores for residential status and pre-injury mobility, had a high mortality rate. There was no significant difference in mortality between patients treated with ORIF and those treated with revision. However, in the unstable subtype, the PMS and VAS values at the final follow-up examination were significantly better in patients who received revision. Based on postoperative activities of daily life, we therefore recommend evision in instances when either treatment option is feasible.Cite this article: Bone Jt Open 2023;4(1):38-46.

Treatment of periprosthetic femoral fractures following total hip arthroplasty: results of an online survey of the European Hip Society

BACKGROUND

Periprosthetic femoral fractures (PPF) are a devastating complication after total hip arthroplasty (THA). Both trauma and adult reconstruction surgeons or combined teams treat these fractures following management algorithms. The aim of this study is to investigate the current treatment of PPF by members of the European Hip Society (EHS).

METHODS

An online survey of the members of the European Hip Society (EHS) was conducted. 20 cases of periprosthetic fracture were presented and surgeons were asked to answer questions regarding classification, treatment and postoperative treatment protocol.

RESULTS

A total of 132 (130 male; 2 female) EHS members responded. Mean years in surgical practice was 18.8 (min. 1 year; max. 50 years). The preferred surgical method was combined open reduction and internal fixation (ORIF) (30.3%) for AG fractures, ORIF with cables (30.4%) for AL fractures, combined ORIF (cable and plate) for B1 fractures (49.2%), stem revision with cables for B2 fractures (73.1%), stem revision with cables for B3 (55.9%) fractures and combined ORIF (cable and plate: 55.5%) for C fractures. Surprisingly, 10.8% suggested various stem revision techniques for B1 and 17.4% for C fractures. Strong variations were observed regarding postoperative weight-bearing protocol.

CONCLUSIONS

A strong consensus was found for the choice of conservative or surgical treatment of the different PPF types according to the Vancouver Classification. Various stem revision techniques were the preferred surgical techniques for Vancouver B2 (91.2%) and B3 (88.6%) fractures. However, for postoperative weight-bearing, when the ORIF technique was used, a significant variation of protocols was found.

Clinical and Radiological Outcome of Vancouver B2 Fracture Treated With Open Reduction and Internal Fixation. A Multicenter Cohort Analysis

OBJECTIVES

To determine whether open reduction and internal fixation (ORIF) of periprosthetic Vancouver B2 fractures can lead to successful fracture healing in selected patients, when attention is given to the surgical exposure and the creation of a balanced extramedullary construct.

DESIGN

Retrospective.

SETTING

Two Level-1 trauma centers in Germany and United Kingdom.

METHODS

Patients with a B2 fracture receiving solely ORIF using a polyaxial locking plate were included for analysis. Patients with other fracture types, or treated with other methods, or with follow-up less than 12 months were excluded. Clinical characteristics, including the Charlson index, the American Society for Anesthesiologists score, and their preinjury functional levels, were recorded. Main outcome measures were 1-year mortality, revision rate, and radiological healing according to the Beals-Tower criteria.

RESULTS

A total of 32 patients (mean age ,79 ± 12 years) were enrolled. Six patients died within the first year (1-year mortality: 19%), and 5 were unavailable for follow-up studies. The remaining 21 patients had a mean follow-up of 30 months. Of 21, 20 had an excellent/good result using the criteria of Beals-Tower. One patient required revision surgery due to loosening and secondary subsidence of the stem.

CONCLUSION

ORIF can be offered to selected patients suffering from B2 fractures, especially if their functional demand is limited, and perioperative risk high for revision arthroplasty. In this challenging cohort of patients, ORIF was a safe and effective therapeutic option.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management and outcomes of femoral periprosthetic fractures at the hip : data from the characteristics, outcomes and management of periprosthetic fracture service evaluation (COMPOSE) cohort study

AIMS

The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population.

METHODS

This was a multicentre retrospective cohort study including adult patients who presented to 27 NHS hospitals with 539 new PPFs between 1 January 2018 and 31 December 2018. Data collected included: management strategy (operative and nonoperative), length of stay, discharge destination, and details of post-treatment outcomes (reoperation, readmission, and 30-day and 12-month mortality). Descriptive analysis by fracture type was performed, and predictors of PPF management and outcomes were assessed using mixed-effects logistic regression.

RESULTS

In all, 417 fractures (77%) were managed operatively and 122 (23%) conservatively. The median time to surgery was four days (interquartile range (IQR) 2 to 7). Of those undergoing surgery, 246 (59%) underwent revision and/or fixation and 169 (41%) fixation alone. The surgical strategy used differed by Unified Classification System for PPF type, with the highest rate of revision in B2/B3 fractures (both 77%, 176/228 and 24/31, respectively) and the highest rate of fixation alone in B1- (55/78; 71%) and C-type (49/65; 75%) fractures. Cemented stem fixation (odds ratio (OR) 2.66 (95% confidence interval (CI) 1.42 to 4.99); p = 0.002) and B2/B3 fracture type (OR 7.56 (95% CI 4.14 to 13.78); p < 0.001) were predictors of operative management. The median length of stay was 15 days (IQR 9 to 23), 12-month reoperation rate was 5.6% (n = 30), and 30-day readmission rate was 8.4% (n = 45). The 30-day and 12-month mortality rates were 5.2% (n = 28) and 21.0% (n = 113). Nonoperative treatment, older age, male sex, admission from residential or nursing care, and sustaining the PPF around a revision prosthesis were significant predictors of an increased 12-month mortality.

CONCLUSION

Femoral hip PPFs have mortality, reoperation, and readmission rates comparable with hip fracture patients. However, they have a longer wait for surgery, and surgical treatment is more complex. There is a need to create a national framework for data collection for this heterogeneous group of patients in order to understand the outcomes of different approaches to treatment. Cite this article: Bone Joint J 2022;104-B(8):997-1008 .

Epidemiology and characteristics of femoral periprosthetic fractures : data from the characteristics, outcomes and management of periprosthetic fracture service evaluation (COMPOSE) cohort study

AIMS

The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population.

METHODS

This is a multicentre retrospective cohort study including adult patients presenting to hospital with a new PPF between 1 January 2018 and 31 December 2018. Data collected included: patient characteristics, comorbidities, anticoagulant use, social circumstances, level of mobility, fracture characteristics, Unified Classification System (UCS) type, and details of the original implant. Descriptive analysis by fracture location was performed, and predictors of PPF type were assessed using mixed-effects logistic regression models.

RESULTS

In total, 720 femoral PPFs from 27 NHS sites were included. PPF patients were typically elderly (mean 79.9 years (SD 10.6)), female (n = 455; 63.2%), had at least one comorbidity (n = 670; 93.1%), and were reliant on walking aids or bed-/chair-bound prior to admission (n = 419; 61.7%). The study population included 539 (74.9%) hip PPFs, 151 (21.0%) knee PPFs, and 30 (4.2%) dividing type PPFs. For hip (n = 407; 75.5%) and knee (n = 88; 58.3%) arthroplasty UCS B type fractures were most common. Overall, 556 (86.2%) were treated in the presenting hospital and 89 (13.8%) required transfer for treatment. Female sex was the only significant predictor of fracture type (A/B1/C type versus B2/B3) for femoral hip PPFs (odds ratio 0.61 (95% confidence interval 0.41 to 0.91); p = 0.014). Sex, residence type, primary versus revision implant PPF, implant fixation, and time between arthroplasty and PPF were not found to predict fracture type for hip PPFs.

CONCLUSION

This multicentre analysis describes patient and injury factors for patients presenting with femoral PPFs to centres across the UK. These patients are generally elderly and frail, comparable to those sustaining a hip fracture. These data can be useful in planning future services and clinical trials. Cite this article: Bone Joint J 2022;104-B(8):987-996 .

Treatment Algorithm of Periprosthetic Femoral Fracturens

Introduction. The ever-expanding indications for total hip arthroplasty are leading to more implants being placed in younger as well as in older patients with high functional demand. Also, prolonged life expectancy is contributing to an overall increment of periprosthetic femoral fractures. The Vancouver classification has been the most used for guiding the surgeon choice since its proposal in 1995. Fractures occurring over a hip femoral implant can be divided into intra-operative and post-operative PFFs, and their treatment depends on factors that may severely affect the outcome: level of fracture, implant stability, quality of bone stock, patients' functional demand, age and comorbidities, and surgeon expertise. There are many different treatment techniques available which include osteosynthesis and revision surgery or a combination of both. The goals of surgical treatment are patients' early mobilization, restoration of anatomical alignment and length with a stable prosthesis and maintenance of bone stock. Significance. The aim of this review is to describe the state-of-the-art treatment and outcomes in the management of PFFs. We performed a systematic literature review of studies reporting on the management of PFFs around hip stems and inter-prosthetic fractures identifying 45 manuscripts eligible for the analysis. Conclusions. PFFs present peculiar characteristic that must be considered and special features that must be addressed. Their management is complex due to the extreme variability of stem designs, the possibility of having cemented or uncemented stems, the difficulty in identifying the "real" level of the fracture and the actual stability of the stem. As a result, the definition of a standardized treatment is unlikely, thereby high expertise is fundamental for the surgical management of PPFs, so this kind of fractures should be treated only in specialized centres with both high volume of revision joint arthroplasty and trauma surgery.

Outcomes After Operative Fixation of Vancouver B2 and B3 Type Periprosthetic Fractures

OBJECTIVES

The incidence of periprosthetic femur fracture in the setting of total hip arthroplasty is steadily increasing. Although the traditional dogma is that loose femoral components must be revised, we propose that in a frail geriatric population, anatomic reduction and fixation of Vancouver B2 and B3 periprosthetic fracture variants can restore stem stability and provide similar outcomes as revision arthroplasty.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center, tertiary academic medical center.

PATIENTS/PARTICIPANTS

We identified 94 patients over 65 years of age with Vancouver B2 and B3 fractures sustained between 2005 and 2019.

INTERVENTION

Patients were treated by either open reduction and internal fixation (ORIF) or revision arthroplasty (RA) with or without fixation.

MAIN OUTCOME MEASUREMENTS

Outcomes were mortality, time to full weight-bearing after surgery, intraoperative estimated blood loss, perioperative complications, reoperation, subsidence rate, and Patient-Reported Outcomes Measurement Information System pain and physical function scores.

RESULTS

A total of 75 (79.8%) ORIF and 19 (20.2%) RA patients were reviewed. One-year mortality for our cohort was 26.3%, and there was no significant difference between groups. Mean time to weight bear and surgical complication rates were similar between groups. The ORIF group had a significantly shorter time to surgery than the RA group. The RA group had greater incidence and amount of subsidence as well as estimated blood loss than the ORIF group.

CONCLUSIONS

In geriatric patients with Vancouver B2 and B3 type periprosthetic fractures with known loose stems, ORIF may offer a similarly safe method of treatment than revision arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cementless, modular, titanium stem in Vancouver B2 and B3 periprosthetic femoral fractures

INTRODUCTION

The periprosthetic femoral fracture (PFF) is a serious complication after primary total hip arthroplasty. We conducted a retrospective study to determine whether the PRIUS^® system presented similar survival to other existing implants for the treatment of Vancouver B2 or B3 PFFs. Bone consolidation rate, functional results and complications were analysed.

METHOD

This is a bi-centric retrospective study between 2012 and 2017 including 39 patients with (B2/B3) PFFs treated by senior surgeons using a PRIUS^® femoral implant. Implant survival, radiological outcome (fracture healing) and clinical scores (Oxford-OHS, Harris Hip Score-HHS, Postel Merle d'Aubigné-PMA, Devane and Charnley) were analysed. 10 patients had died before data collection and 5 patients were lost to follow-up. A total of 21 patients were able to undergo a clinical and radiological evaluation. The mean follow-up period was 3 years.

RESULTS

The 3-year PRIUS^® stem survival rate was 88.6% [95% CI, 77.2-100]. The consolidation rate was 81% (17/21). The rate of satisfied or very satisfied patients was 85.6% (18/21). Regarding the Devane score, activity level was maintained in 70.6% of cases (12/17) and decreased in 29.4% of cases (5/17), the Charnley score was stable in 94% of cases (16/17) and decreased in 6% of cases (1/17). The mean Oxford score was 28.8/48 (9.3; 16-48), the mean HHS was 67/100 (16.4; 46-91) and the mean PMA score was 12.6/18 (4.5; 2-18).

CONCLUSION

The results in terms of survival rate and bone consolidation are comparable to other literature series. The PRIUS® System can be added to the surgical arsenal in the treatment of (B2/B3) PFF, subject to confirmation of these results in the longer term.

Current Practice of Italian Association of Revision Surgery Members in the Treatment of Unified Classification System Type B Periprosthetic Femoral Fracture Around Hip Arthroplasty: A Cross-Sectional Survey

Introduction

Periprosthetic femoral fracture around hip arthroplasty are growing in the world, nevertheless management and treatment options for fractures “around the stem” are still debated due to lack of high-level studies.

Materials and method

A 85-item survey were fill out by 40 Italian Orthopedic Surgeon member of SIOT (Società Italiana di Ortopedia e Traumatologia) and AIR (Associazione Italiana Riprotesizzazione) to assess their current opinion in the management of type B periprosthetic femoral fractures. Responses were summarized using proportions, and further stratified by practice type, case volume, surgeon age, and fellowship training.

Results

Vancouver/UCS fracture classification showed a good interobserver agreement (k value = .76). ORIF were the treatment of choice for UCS type B1 fractures (100%), revision stem for B2 (85%) and B3 (100%). Locked plates were preferred to cable plate and cerclage without a plate for B1 fractures (50% vs 40% vs 10%); revision with modular stem was preferred to monoblock stem for B2 fractures (50% vs 35%) and B3 (75% vs 15%). Responders tended to postpone at 1-month weight-bearing in patients with B1 fractures. Regarding postoperative pharmacological treatment there was absolute lack of consensus.

Discussion

The primary finding of our survey confirmed the preference of ORIF for B1 fractures and stem revision for B2 and B3 fractures. However, there is no definitive operative technique for all UCS B fractures. Surgeons tended to favor locked plating over cable plating, although only slightly. This general lack of consensus coincides with the inconclusive evidence that currently exists in the literature, which demonstrates both favorable and unfavorable outcomes for both techniques

Conclusions

The absence of complete homogeneity among participants showed the need for prospective randomized studies to set up stronger guidelines for classification, management, surgical treatment, rehabilitation, and pharmacological support of periprosthetic femoral fractures.

Metallic versus Non-Metallic Cerclage Cables System in Periprosthetic Hip Fracture Treatment: Single-Institution Experience at a Minimum 1-Year Follow-Up

Metallic cerclage cables are reliable and cost-effective internal fixation devices, which are largely used in surgical practice for the treatment of periprosthetic fractures. Nevertheless, complications connected with their use have been described in the literature, including the following: third-body generation, failure and consequent migration, fraying, allergies, and injury to the surgical team. The development of new materials offers alternatives to traditional metallic cables. This study compares the outcomes between two groups of patients affected by periprosthetic hip fractures, treated with titanium cables or with ultra-high-molecular-weight polyethylene (UHMWPe) iso-elastic cables. Our retrospective study aims to compare the clinical and radiological outcomes of titanium cables and UHMWPe iso-elastic cables, isolated or associated with dedicated plates, for the surgical treatment of periprosthetic fractures with stable implants. Two groups of 30 (group A-metallic cables) and 24 (group B-UHMWPe iso-elastic cables) patients have been surgically treated in our institution for hip periprosthetic fractures, between September 2017 and June 2020. The mean age of the patients was 81 years in group A and 80 years in group B. In our study, we included fractures classified as B1 or C, according to the Vancouver postoperative fractures classification; the patients were evaluated retrospectively at 1 year postoperatively, regarding the following: surgery time, blood loss, partial weight-bearing time, radiographical healing time, Harris hip score, and postoperative complications. Comparable outcomes were observed in patients from both groups. Group A showed a higher complication rate compared to group B, at 1 year postoperatively. Non-metallic nylon fiber and ultra-high-molecular-weight polyethylene (UHMWPe) cerclage cables could represent a reliable fixation device, ensuring comparable healing and complication rates with traditional titanium cerclage cables.

New Sub-Classification of Vancouver B2 Periprosthetic Hip Fractures According to Fracture Pattern

INTRODUCTION

There is currently a debate on whether all Vancouver type B2 (V-B2) periprosthetic hip fractures (PPHF) should be revised. Vancouver classification takes into account fracture location, implant stability and bone stock, but it does not distinguish between fracture patterns. The aim of our work was to study the different fracture patterns of V-B2 PPHF and to analyze if there is any pattern that presents lower osteosynthesis failure rates.

MATERIAL AND METHODS

All patients with V-B2 PPHF treated by osteosynthesis between January 2009 and January 2019 were included in the study. Using the Gruen system the proximal femur was divided into 3 zones. The lateral zone (Gruen 1±2±3), medial zone (Gruen 5±6±7), and distal zone (Gruen 4±3±5) were analysed and it was determined whether each of the 3 zones was fractured.

RESULTS

56 patients were included in the study. Their mean age was 79 years (R 45 - 92). The chosen treatment was: 39 Open reduction and internal fixation (ORIF), 10 Stem revision and 7 nonoperatively treatment. In ORIF group, no implant complications (0/24) were found in patients with a single fractured zone, while 5 implant complications (5/15) were discovered in patients with two or more fractured areas; this difference was significant (p=0.0147). All patients treated by stem revision had a fracture that involved two or more zones. In the nonoperatively group, the fracture pattern did not influence the treatment because of all of them had a very precarious functional and medical situation.

CONCLUSIONS

V-B2 PPHF treated via ORIF affecting only one zone (medial, lateral, or distal) have a lower risk of complication than those affecting two or more zones. We propose a sub-classification of Vancouver B2 type fractures: B2.1 (1 fractured zone) and B2.2 (≥2 fractured zones).

LEVEL OF EVIDENCE

Historical cohorts. Level III.

Clinical and radiographical outcome after surgical treatment of periprosthetic type B proximal femur fractures: a retrospective study

PURPOSE

Periprosthetic fractures after hip prosthesis represent a constantly increasing clinical problem and a challenging complication to treat surgically. Among these, type B proximal femur fractures should be diagnosed correctly to be treated surgically. The aim of this study was to re-evaluate the type of surgical treatment of periprosthetic fractures.

METHODS

We examined the cases treated between January 2012 and February 2018, classifying them according to the U.C.S. AO/OTA. We evaluated the radiographic outcome according to the Beals and Tower criteria. Patients still alive were also re-evaluated according to the H.H.S. and the WOMAC score.

RESULTS

We treated 48 patients (12 men, 35 women, average age 81 years), divided into 24 type B1, 14 type B2 and 10 type B3 fractures. The overall consolidation rate was 95.4%, while the major complication (implant dislocation, pseudoarthrosis and deep infection) rate was 12.5%. Clinically, it was possible to reassess 34 patients with a mean follow-up of 38.4 months, an average HHS of 75.89 and a mean WOMAC score of 79.93.

CONCLUSIONS

Periprosthetic type B fractures are difficult to manage and require careful preoperative planning and appropriate intraoperative management. However, the overall clinical and radiographic result was satisfactory, although patients should still be aware of the risk of complications associated with this type of fracture.

Vancouver B and C periprosthetic fractures around the cemented Exeter Stem: sex is associate with fracture pattern

INTRODUCTION

The aim of this study was to identify factors associated with the level of periprosthetic fracture involving a cemented polished tapered stem: Vancouver B or Vancouver C.

METHODS

A retrospective cohort study of 181 unilateral periprosthetic fractures involving Exeter stems was assessed by three observers (mean age 78.5, range 39-103; mean BMI 27.1, 17-39; 97 (54%) male). Patient demographics, deprivation scores, BMI and time since primary prosthesis were recorded. Femoral diameter, femoral cortical thickness, Dorr classification and distal cement mantle length were measured from calibrated radiographs. Interobserver reliability was calculated using intraclass correlation coefficients (ICCs). Univariate and multivariate analysis was performed to identify associations with Vancouver B or C fractures.

RESULTS

160/181 (88%) Vancouver B and 21/181 (12%) Vancouver C-level fractures occurred at a mean of 5.9 ± 5.4 years (0.2-26.5) following primary surgery. Radiographic measurements demonstrated excellent agreement (ICC > 0.8, p < 0.001). Mortality was significantly higher following Vancouver C compared to B fractures: 90 day 14/160 Vs 5/21 (p = 0.05); 1 year 29/160 Vs 8/21 (p = 0.03). Univariate analysis demonstrated that Vancouver C fractures were associated with female sex, bisphosphonate use, cortical bone thickness, and distal cement mantle length (p < 0.05). On multivariate analysis, only female sex was an independent predictor of Vancouver C-level fractures (R² =0.354, p = 0.005).

CONCLUSION

Most PFFs involving the Exeter stem design are Vancouver B-type fractures and appear to be independent of osteoporosis. In contrast, Vancouver C periprosthetic fractures display typical fragility fracture characteristics and are associated with female sex, thinner femoral cortices, longer distal cement mantles and high mortality.

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.

The Outcomes of Cemented Femoral Revisions for Periprosthetic Femoral Fractures in the Elderly: Comparison with Cementless Stems

Introduction

The present study compares the outcome of the long cemented stem and the revision uncemented stem used in periprosthetic femoral fractures. We propose that the revision with a long stem cemented prosthesis does not compromise fracture healing.

Patients and Methods

A consecutive series of 37 patients, operated between 2010 and 2017, were enrolled in a retrospective analysis. A long cemented stem was implanted in 21 patients (study group; age at operation: 63 to 89 years). A distally tapered fluted uncemented stem was used in 16 patients (control group; age at operation: 35 to 77 years). The clinical outcome was evaluated with Merle d'Aubigné and Postel scoring system. Standard radiographs were taken before surgery, at 3, 6, and 12 months postoperatively, and last follow-up. Any and all complications during the follow-up period were recorded.

Results

Although a significant difference (P = 0.006) was observed in the post-operative Merle d´Aubigné score over the 12-month follow-up period, no significant difference (P = 0.066) was found in the post-operative pain score between the study and control groups. Periodic radiographic assessments showed the disappearance of radiolucent lines and the diaphyseal part of the fracture was healed in all 34 followed-up cases during the first annual follow-up. Early surgical complications were seen in both groups, the medical complications were observed only in the study group.

Conclusion

Based on our results, periprosthetic fractures of the femur after a total hip arthroplasty were associated with significant morbidity and increased mortality in elderly patients. Revision with a long-stem cemented prosthesis provided early pain-free weight-bearing without compromising the healing of femoral fractures in elderly patients with osteoporotic bone, altered mobility, poor balance, and reduced cognitive capacity.

Periprosthetic fractures of hip and knee-A morbidity and mortality analysis

BACKGROUND

Periprosthetic fractures (PPF) following total knee (TKA) and hip arthroplasty (THA) have become more common over the years. The aim of the present study was to assess morbidity and mortality following surgery for PPF of hip and knee.

PATIENTS AND METHODS

Altogether, 124 patients (mean age: 77 years; 77.4% female) with PPF of the hip (n=97) and knee (n=27), treated between 2005 and 2017 at a level-1 trauma centre, were retrospectively included. In order to assess risk factors for postoperative morbidity, Fine and Gray's model was used to compensate for death as the competing event. Risk factors for mortality were estimated with uni- and multivariate Cox-regression models.

RESULTS

Vancouver B2 fractures were most common (n=39; 42.4%), followed by B1 fractures (n=23; 25.0%). Lewis-Rorabeck Type I fractures (n=14; 51.9%) were most frequent in PPF of the knee. Overall complication rates were 44.0% and 29.9% for PPF of the knee and hip, respectively, with three patients having both early and late complications, 25 patients developing early complications and 19 patients undergoing surgery for implant-related, late complications. In the multivariate Fine and Gray model, advanced patient age (HR: 0.956; 95%CI: 0.922-0.991; p=0.014) and prosthesis exchange (vs. ORIF; HR: 0.242, 95%CI: 0.068-0.859; p=0.028) were associated with lower risk of implant-related complications, irrespective of gender (p=0.450) and a surgical delay > 2 days (p=0.411). One- and 5-year overall survival-rates were 97.9% and 93.1%, respectively. Gender, type of fixation (ORIF vs. prosthesis exchange), surgical delay > 2 days, BMI and age at surgery were neither in the univariate, nor multivariate Cox-regression model associated with an increased mortality rate.

CONCLUSION

Postoperative morbidity caused by implant-related complications is higher in younger patients and those receiving ORIF. With the statistical approach used, potential underestimation of actual complication rates may have been avoided, taking into account death as the competing event. Despite being based on a retrospective, heterogenous patient collective treated at a level-1 trauma centre, our results indicate that careful planning of the surgical procedure beyond 2 days, taking into consideration both patient's age and activity level, has no negative effect on patient outcome.

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

BACKGROUND

It is recommended revision for periprosthetic hip fractures (PPHF) with a loose stem. However, several authors have argued that under certain conditions, this fracture could be treated using osteosynthesis. The aim is to compare stem revision versus internal fixation in the treatment of PPHF with a loose stem.

METHODS

All patients with PPHF with a loose stem treated by osteosynthesis and stem revision between January 2009 and January 2019 were included. We assessed hospital stay, American Society of Anesthesiologists, Charlson comorbidity index, surgery time, blood transfusion, complications, reoperation rate, first-year mortality, radiological, and functional results.

RESULTS

A total of 57 patients were included (40 osteosyntheses and 17 stem revision), with an average follow-up time of 3.1 years. Their mean age was 78.47 years (R 45-92). In the osteosynthesis group, fewer patients required blood transfusion (32.5% vs. 70.6%), surgical times were shorter (108 minutes vs. 169 minutes), and the cost was lower, both in terms of total cost (€14,239.07 vs. €21,498.45 and operating room cost (€5014.63 vs. €8203.34). No significant differences were found between the groups in terms of complications, reoperation rate, or functional outcomes.

CONCLUSION

Compared with stem revision, osteosynthesis requires less surgery time, has a lower need for blood transfusions, and a reduced hospital cost. Stem revision remains the treatment of choice in PPHF with a loose stem, but in V-B2 fractures in elderly patients with low functional demand, high anesthetic risk (American Society of Anesthesiologists ≥3), and many comorbidities (Charlson comorbidity index ≥5) in whom anatomic reconstruction is possible, osteosynthesis can be a viable option.

EVIDENCE LEVEL

Historical cohorts. Level III.

Revision Arthroplasty Versus Open Reduction and Internal Fixation of Vancouver Type-B2 and B3 Periprosthetic Femoral Fractures

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Revision arthroplasty (RA) continues to be considered the gold standard in the surgical treatment of Vancouver type-B2 and B3 periprosthetic femoral fractures. However, open reduction and internal fixation (ORIF) has been associated with satisfactory outcomes. Thus, there is an ongoing discussion regarding the optimal surgical strategy for the treatment of these fractures.

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In this systematic review and meta-analysis, no significant differences in clinical and radiographic outcome were observed between ORIF and RA in the treatment of Vancouver type-B2 periprosthetic femoral fractures.

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ORIF of Vancouver type-B3 periprosthetic femoral fractures was associated with higher revision and reoperation rates than those after RA.

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Compared with RA, a significantly higher rate of subsidence was found in the ORIF group in Vancouver type-B2 periprosthetic femoral fractures whereas no significant difference in terms of loosening was observed.

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In the comparison of RA and ORIF for the treatment of Vancouver type-B2 and B3 fractures, the percentage of patients achieving full weight-bearing did not differ significantly.

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Mortality rates did not differ between RA and ORIF in the treatment of Vancouver type-B2 and B3 fractures.

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Overall complication rates did not differ between RA and ORIF in the treatment of Vancouver type-B2 and B3 fractures.

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We found a high heterogeneity in applied surgical and fixation techniques in the ORIF group.

Reliability and validity of the Unified Classification System for postoperative periprosthetic femoral fractures around cemented polished taper-slip stems

AIMS

This aim of this study was to assess the reliability and validity of the Unified Classification System (UCS) for postoperative periprosthetic femoral fractures (PFFs) around cemented polished taper-slip (PTS) stems.

METHODS

Radiographs of 71 patients with a PFF admitted consecutively at two centres between 25 February 2012 and 19 May 2020 were collated by an independent investigator. Six observers (three hip consultants and three trainees) were familiarized with the UCS. Each PFF was classified on two separate occasions, with a mean time between assessments of 22.7 days (16 to 29). Interobserver reliability for more than two observers was assessed using percentage agreement and Fleiss' kappa statistic. Intraobserver reliability between two observers was calculated with Cohen kappa statistic. Validity was tested on surgically managed UCS type B PFFs where stem stability was documented in operation notes (n = 50). Validity was assessed using percentage agreement and Cohen kappa statistic between radiological assessment and intraoperative findings. Kappa statistics were interpreted using Landis and Koch criteria. All six observers were blinded to operation notes and postoperative radiographs.

RESULTS

Interobserver reliability percentage agreement was 58.5% and the overall kappa value was 0.442 (moderate agreement). Lowest kappa values were seen for type B fractures (0.095 to 0.360). The mean intraobserver reliability kappa value was 0.672 (0.447 to 0.867), indicating substantial agreement. Validity percentage agreement was 65.7% and the mean kappa value was 0.300 (0.160 to 0.4400) indicating only fair agreement.

CONCLUSION

This study demonstrates that the UCS is unsatisfactory for the classification of PFFs around PTS stems, and that it has considerably lower reliability and validity than previously described for other stem types. Radiological PTS stem loosening in the presence of PFF is poorly defined and formal intraoperative testing of stem stability is recommended. Cite this article: Bone Joint J 2021;103-B(8):1339-1344.

Selected Vancouver B2 periprosthetic femoral fractures around cemented polished femoral components can be safely treated with osteosynthesis

AIMS

We aimed to compare the implant survival, complications, readmissions, and mortality of Vancouver B2 periprosthetic femoral fractures (PFFs) treated with internal fixation with that of B1 PFFs treated with internal fixation and B2 fractures treated with revision arthroplasty.

METHODS

We retrospectively reviewed the data of 112 PFFs, of which 47 (42%) B1 and 27 (24%) B2 PFFs were treated with internal fixation, whereas 38 (34%) B2 fractures underwent revision arthroplasty. Decision to perform internal fixation for B2 PFFs was based on specific radiological (polished femoral components, intact bone-cement interface) and clinical criteria (low-demand patient). Median follow-up was 36.4 months (24 to 60). Implant survival and mortality over time were estimated with the Kaplan-Meier method. Adverse events (measured with a modified Dindo-Clavien classification) and 90-day readmissions were additionally compared between groups.

RESULTS

In all, nine (8.01%) surgical failures were detected. All failures occurred within the first 24 months following surgery. The 24-month implant survival was 95.4% (95% confidence interval (CI) 89.13 to 100) for B1 fractures treated with internal fixation, 90% (95% CI 76.86 to 100) for B2 PFFs treated with osteosynthesis-only, and 85.8% (95% CI 74.24 to 97.36) for B2 fractures treated with revision THA, without significant differences between groups (p = 0.296). Readmissions and major adverse events including mortality were overall high, but similar between groups (p > 0.05). The two-year patient survival rate was 87.1% (95% CI 77.49 to 95.76), 66.7% (95% CI 48.86 to 84.53), and 84.2% (95% CI 72.63 to 95.76), for the B1 group, B2 osteosynthesis group, and B2 revision group, respectively (p = 0.102).

CONCLUSION

Implant survival in Vancouver B2 PFFs treated with internal fixation was similar to that of B1 fractures treated with the same method and to B2 PFFs treated with revision arthroplasty. Low-demand, elderly patients with B2 fractures around well-cemented polished femoral components with an intact bone-cement interface can be safely treated with internal fixation. Cite this article: Bone Joint J 2021;103-B(7):1222-1230.

Retrospective Population-Based Cohort Study of Incidence, Complications, and Survival of 202 Operatively Treated Periprosthetic Femoral Fractures

BACKGROUND

The aim of this study is to investigate the population and primary total hip arthroplasty (THA)-based incidences, fracture types, complications, and survival of operatively treated periprosthetic femoral fracture (PFF).

METHODS

This retrospective study reviewed 202 cases of operatively treated PFFs in a study period from January 2004 to December 2016. The Vancouver classification was used to classify PFFs.

RESULTS

The incidence of PFF related to 1000 primary THAs per year was 2.7 (standard deviation 1.0, range 0.9-4.5) at a defined hospital district area during the study period. The mean population-based incidence of operatively treated PFFs raised from 1.6 to 4.5 per 100,000 person-years during the study period. The B1-type fracture was the most common fracture type in 71 of 202 (35%) of these PFFs. The cumulative incidence of re-revision was 10.9% at 1 year and 15.6% at 15 years (95% confidence interval [CI] 10.9-21.0). The cumulative incidence for other major complications was 6.4% at 1 year and 9.9% at 15 years (95% CI 5.9-15.0). The cumulative incidence of death after PFF was 7.4% at 1 year and 56.3% at 15 years (95% CI 41.3-68.8) during the follow-up time from January 1, 2004 to December 31, 2019.

CONCLUSION

This country-specific study showed a 3-fold increasing trend in the incidence of operatively treated PFFs from 2004 to 2016 per 1000 THAs. The Vancouver type B1 fracture was the most common type. A high number of complications were associated with PFFs and 7.4% of the patients had died within 1 year after PFF surgery.