Cement-in-cement stem revision for Vancouver type B periprosthetic femoral fractures after total hip arthroplasty. A 3-year follow-up of 23 cases

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.

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.

Revision total hip arthroplasty for periprosthetic fracture: epidemiology, outcomes, and factors associated with success

The aging population and the increasing number of patients with primary total hip arthroplasties (THA) has equated to an increased incidence of periprosthetic fractures (PPF) of the hip. These injuries are a significant source of patient morbidity and mortality, placing a financial burden on healthcare systems worldwide. As the volume of PPF is expected to along with the growing volume of primary and revision THA, it is important to understand the outcomes and factors associated with treatment success. The choice of procedure is in large part guided by the help of the Vancouver Classification system, which is a valid and reproducible system that classifies fractures based on several factors including site of fracture, implant stability and bone stock. PPFs account for approximately 18% of revision THA (rTHA) procedures. rTHA for PPFs is commonly indicated in Vancouver B2 and B3 fractures, to bypass a lack of metaphyseal support with diaphyseal fixation. Such revisions are technically challenging and typically require urgent treatment, with inherent difficulties in patient optimization, leading to a notable rate of post-operative complications, re-revision and mortality. This article reviews epidemiology, health economics and risk factors for PPFs. It additionally reviews outcomes associated with rTHA for PPFs including peri-operative complications, indications for re-operation, rates of re-operation and rates of mortality. Finally, it aims to identify evidence-based factors that have been associated with successful management including modifiable patient-related factors, uncemented vs. cemented stems, stem design (porous coated stems vs. fluted tapered stems), modularity, dislocation and its impact on outcomes following rTHA and strategies for managing bone loss.

Open Reduction and Internal Fixation and Cement-In-Cement Revision for Selected Vancouver B Proximal Femur Periprosthetic Fractures

The incidence of periprosthetic proximal femoral fractures is increasing with the increase in arthroplasty being performed as well as aging populations. We describe an open reduction and internal fixation and cement-in-cement technique utilizing a well-fixed cement mantle. The advantages of this allow for a shorter operative time, reduction in risk of iatrogenic femoral fractures, and reduction in blood loss. This was a retrospective study reviewing 20 patients that underwent this technique for periprosthetic fractures. Thirty percent (n = 6) of patients underwent subsequent surgery. We had a 95% (n = 19) union rate with 1 case refracturing through the old fracture. This technique can allow for shorter operative times and a lower physiological insult in reducible periprosthetic proximal femur fractures with a stable cement mantle.

Periprosthetic Fracture around a Cemented Stem in Total Hip Arthroplasty

The increase in the number of primary total hip arthroplasties that will be performed over the next several decades will lead to an increase in the incidence of periprosthetic fractures around the femoral stem. A search of targeted articles was conducted using on-line databases of PubMed (National Library of Medicine) and articles were obtained from January 2008 to November 2021. Reliable prediction of treatment can be achieved using the Vancouver classification; internal fixation is indicated in fractures involving a stable implant and revision arthroplasty is indicated in those with unstable prostheses. To the best of our knowledge, relatively fewer studies regarding periprosthetic proximal femur fractures of cemented stems have been reported. The focus of this review is on the risk factors and strategies for treatment of these fractures for periprosthetic femoral fractures around a cemented hip arthroplasty.

Comparable outcomes of in-cement revision and uncemented modular stem revision for Vancouver B2 periprosthetic femoral fracture at 5 years

INTRODUCTION

Periprosthetic femoral fractures (PFF) are detrimental for patients. Vancouver B2 fractures about a cemented stem can be revised to a longer uncemented stem or using an in-cement revision, if the cement mantle is adequate. There are reports documenting the success of both techniques. The aim of this single centre study was to perform a direct comparison of these two procedures.

MATERIALS AND METHODS

A retrospective study of consecutive Vancouver B2 PFFs around a cemented stem during 16 years was performed. All study cases were treated either using an in-cement revision or with an uncemented stem revision. Preoperatively, the groups were compared based upon age, gender, ASA, BMI, and Charlson comorbidity score. The outcome measures were surgical time, complications, in-hospital stay, revisions, 1-year readmission rate, and survivorship.

RESULTS

After a median of 3.5 years, there were 70 patients in the uncemented and 31 in the in-cement group. There was no difference in any of the preoperative variables. Surgical time was shorter for in-cement revisions by a mean of 45 min (p < 0.001). There was no difference in in-hospital stay, surgical complications or readmissions. Implant survival at 5 years was 93.5% for the in-cement and 94.4% for the uncemented revision (p = 0.946). Patient survivorship at 5 years was 62.5% for the in-cement and 69.8% for the uncemented group (p = 0.094).

CONCLUSIONS

This study demonstrates that in-cement revision is a valid treatment option for Vancouver B2 fractures, comparable to uncemented stem revision, if certain criteria are met. There was no difference in revision rate, patient survivorship, complications, readmissions or in-hospital stay.

Cement-in-cement versus uncemented modular stem revision for Vancouver B2 periprosthetic fractures

Background

To compare outcomes of revision to a long uncemented stem with cement-in-cement revision for Vancouver B2 periprosthetic fracture (PPF).

Methods

Patients undergoing surgery for a Vancouver B2 PPF in a cemented stem from 2008 to 2018 were identified using our prospectively collated database.

Results

We identified 43 uncemented and 29 cement-in-cement revisions. Cement-in-cement revision had a shorter operative time, reduction in certain complications, no increased rate of non-union, lower degree of stem subsidence and no difference in re-revision rate.

Conclusion

With appropriate patient selection, both cement-in-cement and long uncemented stem revision represent appropriate treatment options for Vancouver B2 fractures.

Combined Surgical and Medical Treatment for Vancouver B1 and C Periprosthetic Femoral Fractures: A Proposal of a Therapeutic Algorithm While Retaining the Original Stable Stem

INTRODUCTION

There is lack of consensus regarding best operative fixation strategy for periprosthetic femoral fractures (PFFs) around a stable stem. Evidence exists that some patterns of fracture around a stable stem are better treated with revision surgery than with standard fixation. Anyway, a more aggressive surgical procedure together with medical treatment could allow for stem retention, and reduced risk of nonunion/hardware failure, even in these cases.

SIGNIFICANCE

This paper is placed in a broader context of lack of studies on the matter, and its aim is to shed some light on the management of PFFs around a stable stem, when peculiar mechanical and biological aspects are present.

RESULTS

Based on our casuistry in the treatment of nonunions after PFF successfully treated with original stem retention, and on review of Literature about risk factors for fixation failure, an algorithm is proposed that can guide in choosing the ideal surgical technique even for first-time PFFs with a stable stem, without resorting to revision. Mechanical (major and minor) and biological (local and systemic) factors that may influence fracture healing, leading to nonunion and hardware failure, and subsequent need for re-operation, are considered. The proposed surgical technique consists of rigid fixation with absolute stability (using a plate and structural allograft) plus local biological support (structural allograft and autologous bone marrow concentrate over a platelet-rich plasma-based scaffold) at fracture site. Systemic anabolic treatment (Teriparatide) is also administered in the post-operative period.

CONCLUSION

Mechanical factors are not the only issues to be considered when choosing the surgical approach to PFFs over a stable stem. Systemic and local biological conditions should be taken into account, as well. A therapeutic algorithm is proposed, given the prosthetic stem to be stable, considering mechanical and biological criteria.

A Comparison of Risks and Benefits Regarding Hip Arthroplasty Fixation

Since the field-changing invention of noncemented hip arthroplasty fixation in the 1980s, noncemented fixation has been progressively replacing cemented fixation. However, analyses of fixation frequencies reveal new patterns in cement versus noncemented preferences. Although cementation is again gaining ground in the United States, noncemented models remain the dominant fixation mode, seen in more than 90% of all hip arthroplasties. This stark preference is likely driven by concerns regarding implant durability and patient safety. Although advances in surgical techniques, intensive perioperative care, and improved instrument have evolved in both methods, data from large arthroplasty registries reveal shifting risks in contemporary hip arthroplasty, calling the use of noncemented fixation into question. Varying risk profiles regarding sex, age, or health comorbidities and morphological and functional differences necessitate personalized risk assessments. Furthermore, certain patient populations, based on the literature and data from large registries, have superior outcomes from cemented hip arthroplasty techniques. Therefore, we wanted to critically evaluate the method of arthroplasty fixation in primary hip arthroplasties for unique patient populations.

Midterm Results of Primary Exeter Cemented Stem in a Select Patient Population

BACKGROUND

Most North American surgeons predominantly use uncemented stems in primary total hip arthroplasties (THAs) and reserve cemented stems for selected older patients and those with poor bone quality. However, data on this "selective use" strategy for cemented stems in the population at risk for periprosthetic fracture and implant loosening are limited. The purpose of this study was to describe implant survivorship, complications, and radiographic results of a specific collarless, polished, tapered cemented stem (Exeter; Stryker) used selectively in a predominantly elderly population undergoing primary THA.

METHODS

We identified 386 patients who underwent a total of 423 primary THAs with selectively utilized Exeter stems for the treatment of osteoarthritis between 2006 and 2017. In the same time period, 11,010 primary THAs were performed with uncemented stems and 961 with non-Exeter cemented stems. The mean patient age was 77 years, 71% were female, and the mean body mass index was 29 kg/m2. Competing risk analysis accounting for death was utilized to determine cumulative incidences of revision and reoperation. The mean follow-up was 5 years (range, 2 to 12 years).

RESULTS

The 10-year cumulative incidence of any femoral component revision in this patient cohort was 4%, with 10 stems revised at the time of the latest follow-up. There were no intraoperative femoral fractures. The indications for revision were postoperative periprosthetic femoral fracture (n = 6), dislocation (n = 3), and infection (n = 1). There were no revisions for femoral loosening. The 10-year cumulative incidence of reoperation was 10%. The 10-year cumulative incidence of Vancouver B periprosthetic femoral fracture was 2%. Radiographically, there were no cases of aseptic loosening or osteolysis. There was a significant improvement in median Harris hip score, from 53 preoperatively to 92 at a mean follow-up of 5 years (p < 0.001).

CONCLUSIONS

The strategy of selectively utilizing a collarless, polished, tapered cemented stem produced a low (4%) cumulative incidence of stem revision at 10 years postoperatively and resulted in no cases of aseptic loosening. The use of the Exeter stem did not eliminate postoperative femoral fractures in this predominantly elderly, female patient population.

LEVEL OF EVIDENCE

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

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.

Cement-in-cement technique of the femoral component in aseptic total hip arthroplasty revision: A systematic review of the contemporary literature

Background

Clinical outcomes of cemented femoral stems revisions using the cement-in-cement technique in aseptic conditions after total hip arthroplasty have been widely described.

Methods

The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried.

Results

Twelve articles were included (620 revision THA). Revision rate for complications related to the femoral side was 1.4% at mid-term follow-up (5.4 years). Periprosthetic femoral fracture rate was 1.1%, aseptic loosening of the femoral component 0.3%.

Conclusions

Cement-in-cement revision technique of the femoral component is associated with a high mid-term success rates (98.6%) and is potentially less challenging than other revision techniques.

Vancouver B periprosthetic fractures involving the Exeter cemented stem

AIMS

The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter).

METHODS

This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan-Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality.

RESULTS

Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision.

CONCLUSION

When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309-320.

The cement-bone bond is weaker than cement-cement bond in cement-in-cement revision arthroplasty. A comparative biomechanical study

This study compares the strength of the native bone-cement bond and the old-new cement bond under cyclic loading, using third generation cementing technique, rasping and contamination of the surface of the old cement with biological tissue. The possible advantages of additional drilling of the cement surface is also taken into account. Femoral heads from 21 patients who underwent a total hip arthroplasty performed for hip arthritis were used to prepare bone-cement samples. The following groups of samples were prepared. A bone—cement sample and a composite sample of a 6 weeks old cement part attached to new cement were tested 24 hours after preparation to avoid bone decay. Additionally, a uniform cement sample was prepared as control (6 weeks polymerization time) and 2 groups of cement-cement samples with and without anchoring drill hole on its surface, where the old cement polymerized for 6 weeks before preparing composite samples and then another 6 weeks after preparation. The uniaxial cyclic tension-compression tests were carried out using the Zwick-Roell Z020 testing machine. The uniform cement sample had the highest ultimate force of all specimens (n = 15; R_m = 3149 N). The composite cement sample (n = 15; R_m = 902 N) had higher ultimate force as the bone-cement sample (n = 31; R_m = 284 N; p <0.001). There were no significant differences between composite samples with 24 hours (n = 15; R_m = 902 N) and 6 weeks polymerization periods (n = 22; R_m = 890 N; p = 0.93). The composite cement samples with drill hole (n = 16; R_m = 607 N) were weaker than those without it (n = 22; R_m = 890 N; p < 0.001). This study shows that the bond between the old and new cement was stronger than the bond between cement and bone. This suggests that it is better to leave the cement that is not loosened from the bone and perform cement in cement revision, than compromising bone stock by removal of the old cement with the resulting weaker cement-bone interface. The results support performing cement-in-cement revision arthroplasty The drill holes in the old cement mantle decrease cement binding strength and are not recommended in this type of surgery.

B2 or not B2? That is the question: a review of periprosthetic fractures around cemented taper-slip femoral components

AIMS

Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification.

METHODS

We reviewed 87 PPFs. Each was a first episode of fracture around a cemented femoral component, where surgical management consisted of revision surgery. Data regarding initial injury, intraoperative findings, and management were prospectively collected. Patient records and serial radiographs were reviewed to determine fracture classification, whether the bone cement was well fixed (B2W) or loose (B2L), and time to fracture union following treatment.

RESULTS

In total, 47 B2W fractures (54.0%) and one B3 fracture (1.1%) had cement that remained well-fixed at the cement-bone interface. These cases were treated with cement-in-cement (CinC) revision arthroplasty. Overall, 43 fractures with follow-up united, and two patients sustained further fractures secondary to nonunion and required further revision surgery. A total of 19 B2L fractures (21.8%) and 19 B3 fractures (21.8%) had cement that was loose at the cement-bone interface. These cases were managed by revision arthroplasty with either cemented or uncemented femoral components, or proximal femoral arthroplasty. One case could not be classified.

CONCLUSION

We endorse a modification of the original Vancouver system to include a subclassification of B2 fractures around cemented femoral prostheses to include B2W (where cement is well-fixed to bone) and B2L (where the cement is loose). Fractures around taper-slip design stems are more likely to fracture in a B2W pattern compared to fractures around composite beam design stems which are more likely to fracture in a B2L pattern. B2W fractures can reliably be managed with CinC revision. Cite this article: Bone Joint J 2021;103-B(1):71-78.

Fracture fixation versus revision arthroplasty in Vancouver type B2 and B3 periprosthetic femoral fractures: a systematic review

INTRODUCTION

Hip arthroplasty (HA) is commonly performed to treat various hip pathologies. Its volume is expected to rise further due to the increasing age of the population. Complication rates are low; however, periprosthetic femoral fractures (PFF) are a rare, albeit serious, complication with substantial economic impact. While current guidelines propose revision with long-stemmed prostheses for all Vancouver B2 and B3 PFF, some recent research papers suggest that open reduction with internal fixation (ORIF) could lead to an equivalent outcome. Our aim was to summarize the evidence, elucidating under which circumstances ORIF leads to a favorable outcome after B2 and B3 PFF compared with revision surgery.

MATERIALS AND METHODS

A systematic literature search was performed to identify studies on patients treated with ORIF and with stem revision after B2 and/or B3 fractures. Extracted information included initial pathology, stem fixation mechanism, bone quality and stem stability at the time of PFF, clinical outcomes, and mortality. Results of individual studies were summarized in a table in lieu of a quantitative data synthesis due to a lack of standardized information.

RESULTS

We identified 14 original research articles including both patients treated with ORIF and with stem revision after B2 and/or B3 PFF. Five studies included statistical comparisons, all were in favor of ORIF or indeterminate. The common lack of rigorous statistical analyses and significant methodological weaknesses made identification of outcome predictors impossible.

CONCLUSION

The choice of treatment modality for PFF depends on fracture, implant, and bone characteristics. Recent data show that successful outcome can be achieved without revising loose stems. ORIF may be a viable option if bone stock is adequate around uncemented or tapered polished stems with an intact cement mantle and the fracture geometry allows stable anatomic reconstruction. Conceptional considerations support this idea, but more data are needed to identify outcome predictors.

Surgical treatment of peri-prosthetic femur fractures with dedicated NCB plates: our experience

Background and aim of the work:

The incidence of periprostethic femur fractures has increased over the last years; the treatment includes an open reduction and internal fixation or revision implant. The treatment of these fractures can be complex, expensive and associated with risks of systemic and local complications.

Methods:

We evaluated clinical and radiological results in patients treated in our department for periprosthetic femoral fractures from 2011 to 2017. We included 52 cases of periprosthetic fractures regardless of their classification with a mean follow-up of 2 years. The analisys of the result was performed using Harris Hip Score and searching for radiographic signs of loosening, infections or mechanical failure of the implants.

Results:

There was no evidence of septic complications or mechanical failure in cases treated. The average HHS was equal to 92 points with a certificate pain relief and a sufficient independence in daily living activities.

Conclusions:

The treatment of periprosthetic fractures is complex: it depends on type of fracture, on stability of the stem and on the bone quality. A right classification of the fractures, a good experience of the surgeon in prosthetic and trauma surgery is the basis for the best treatment. (www.actabiomedica.it)

Cement-in-cement revision with the Exeter Short Revision Stem: A review of 50 consecutive hips

Revision of a well-fixed cemented femoral stem is technically challenging. The Exeter Short Revision Stem (SRS) was developed to facilitate cement-in-cement revision mitigating some of these challenges. We present the short to mid-term results of 50 cement-in-cement revisions performed with this implant. A retrospective review of all cement-in-cement revision with the Exeter SRS, at our institution, over a seven-year period between 2007 and 2014 was conducted. Records were assessed for radiological and clinical component loosening at greater than 12 months follow-up and for revision and complications at all time points. An Oxford Hip Score (OHS) and Numeric Rating Scale (NRS) for groin and thigh pain at rest and initial mobilisation were obtained. 50 implants in 46 patients were identified. Radiographic and clinical follow-up was available for 42 and 38 implants respectively at greater than 12 months. Mean radiographic follow-up was 5.1 years and clinical 4.9 years. There was no radiographic or clinical evidence of loosening. 3 revisions were performed, one for each of recurrent dislocation, infection and stem breakage. Median OHS was 39 (IQR 12) and mean NRS for groin pain at rest and initial mobilisation was 1.7 and 1.7 respectively and NRS for thigh pain at rest and initial mobilisation was 1.3 and 1.6 respectively with mean follow-up of 6.9 years. The Exeter SRS provides a viable option for cement-in-cement stem revision, with low revision, complication and loosening rates and good patient reported outcomes at short to mid-term follow up.

Difficulties associated with the variable geometry of different-offset Exeter long stems in cement-in-cement technique: A case report

Although the cement in cement technique is a simple method for exchanging cemented stems, it may be technical demanding. The different geometry of different-offset Exeter long stems can be a problem with this technique. We describe a case revision hip surgery as a consequence of neglected bipolar hemiarthroplasty dislocation in which a 44 mm offset long stem was exchanged by a shorter and smaller size 37.5 mm offset stem. The implications of the procedure and the surgical pitfalls are discussed.

Even "Cementless" Surgeons Use Cement

BACKGROUND

Patients presenting with hip arthritis have huge variability in anatomy, bone quality, and functional expectation. These can contribute to a varying degree of complexity on both the femoral and acetabular sides. Surgeons should be aware of all the various options in fixation, bearing surface, and surgical technique.

METHODS

In this article, based on a presentation given at the recent American Association of Hip and Knee Surgeons meeting in Dallas, we will discuss why and how cemented fixation can, and indeed should, be considered when making decisions regarding how a primary, complex primary, or revision hip arthroplasty should be performed.

RESULTS

We will review the evidence, surgical technique, and indications for cemented fixation in primary and complex primary surgery. In addition, we will discuss the potential benefits at revision of previous cemented fixation.

CONCLUSION

We hope to support the concept that even cementless surgeons should also use cement.

A systematic review of Vancouver B2 and B3 periprosthetic femoral fractures

Aims

The aim of this study was to investigate the outcomes of Vancouver type B2 and B3 fractures by performing a systematic review of the methods of surgical treatment which have been reported.

Materials and Methods

A systematic search was performed in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. For inclusion, studies required a minimum of ten patients with a Vancouver type B2 and/or ten patients with a Vancouver type B3 fracture, a minimum mean follow-up of two years and outcomes which were matched to the type of fracture. Studies were also required to report the rate of re-operation as an outcome measure. The protocol was registered in the PROSPERO database.

Results

A total of 22 studies were included based on the eligibility criteria, including 343 B2 fractures and 167 B3 fractures. The mean follow-up ranged from 32 months to 74 months. Of 343 Vancouver B2 fractures, the treatment in 298 (86.8%) involved revision arthroplasty and 45 (12.6%) were treated with internal fixation alone. A total of 37 patients (12.4%) treated with revision arthroplasty and six (13.3%) treated by internal fixation only underwent further re-operation. Of 167 Vancouver B3 fractures, the treatment in 160 (95.8%) involved revision arthroplasty and eight (4.8%) were treated with internal fixation without revision. A total of 23 patients (14.4%) treated with revision arthroplasty and two (28.6%) treated only with internal fixation required re-operation.

Conclusion

A significant proportion, particularly of B2 fractures, were treated without revision of the stem. These were associated with a higher rate of re-operation. The treatment of B3 fractures without revision of the stem resulted in a high rate of re-operation. This demonstrates the importance of careful evaluation and accurate characterisation of the fracture at the time of presentation to ensure the correct management. There is a need for improvement in the reporting of data in case series recording the outcome of the surgical treatment of periprosthetic fractures. We have suggested a minimum dataset to improve the quality of data in studies dealing with these fractures. Cite this article: Bone Joint J 2017;99-B(4 Supple B):17–25.

Management of Vancouver B2 and B3 Periprosthetic Proximal Femoral Fractures by Distal Locking Femoral Stem (Cannulok) in Patients 75 Years and Older

BACKGROUND

Periprosthetic fracture following total hip arthroplasty is a significant problem faced by hip surgeons, and its management in elderly patients remains a considerable challenge.

METHODS

We retrospectively reviewed 28 Vancouver B2 and B3 periprosthetic femoral fractures (PFF) treated with revision of the femoral stems by distally locked, hydroxyapatite-coated uncemented stems (Cannulok). Patients were aged 75 years or older at the time of surgery.

RESULTS

The mean follow-up was 44.6 months (range, 24-102). The mean postoperative Oxford hip score was 30.1 (range, 10-46). The rate of fracture union was 95.8%, and the survivorship of the stem was 100% at the end of follow-up.

CONCLUSION

The management of PFF in elderly is associated with increased postoperative morbidity and mortality. The use of a distally locked, hydroxyapatite-coated femoral stem is a valid option for the treatment of PFF to achieve fracture union with a low rate of revision.

Principles of managing Vancouver type B periprosthetic fractures around cemented polished tapered femoral stems

The management of periprosthetic fractures around total hip replacements is a complex and challenging problem. Getting it right first time is an important factor in reducing the morbidity, mortality and financial burden associated with these injuries. Understanding and applying the basic principles of fracture management helps increase the chance of successful treatment. Based on these principles, we suggest a treatment algorithm for managing periprosthetic fractures around polished tapered femoral stems.

The Outcome of 69 Recemented Hip Femoral Prostheses Performed by One Surgeon 22-40 Years Ago

BACKGROUND

There is a lack of long-term data on cement-in-cement technique in revision of failed hip femoral stem.

METHODS

We present the outcome of 69 consecutive recemented femoral prostheses, performed by one surgeon (GH) 22-40 years ago. Four patients (4 hips) were lost to follow-up. Sixty-three patients (65 hips) were followed for their lifetime or until the time of the preparation of the study. The study population consisted of 18 failed hemiarthroplasties and 47 failed total hip arthroplasties.

RESULTS

The 23-year probability of survival for the recemented femoral components, with re-revision for any reason and resection arthroplasty as the end point, was 73.6% (61.8%-85.4%) and, with re-revision for aseptic loosening as the end point, was 82.2% (71.4%-93%).

CONCLUSION

Our follow-up study at 22-40 years, after recemented hip femoral prostheses, shows that recementing works well in selected cases.

Revision of hemiarthroplasty to total hip arthroplasty using the cement-in-cement technique

Revision of a cemented hemiarthroplasty of the hip may be a hazardous procedure with high rates of intra-operative complications. Removing well-fixed cement is time consuming and risks damaging already weak bone or perforating the femoral shaft. The cement-in-cement method avoids removal of intact cement and has shown good results when used for revision total hip arthroplasty (THA). The use of this technique for the revision of a hemiarthroplasty to THA has not been previously reported.

A total of 28 consecutive hemiarthroplasties (in 28 patients) were revised to a THA using an Exeter stem and the cement-in-cement technique. There were four men and 24 women; their mean age was 80 years (35 to 93). Clinical and radiographic data, as well as operative notes, were collected prospectively and no patient was lost to follow-up.

Four patients died within two years of surgery. The mean follow up of the remainder was 70 months (25 to 124). Intra-operatively there was one proximal perforation, one crack of the femoral calcar and one acetabular fracture. No femoral components have required subsequent revision for aseptic loosening or are radiologically loose.

Four patients with late complications (14%) have since undergone surgery (two for a peri-prosthetic fracture, and one each for deep infection and recurrent dislocation) resulting in an overall major rate of complication of 35.7%.

The cement-in-cement technique provides reliable femoral fixation in this elderly population and may reduce operating time and rates of complication.

Cite this article: Bone Joint J 2015;97-B:1623–7.

A study of 44 patients with subtrochanteric fractures treated using long nail and cerclage cables

OBJECTIVE

This study aims to demonstrate that the use of long cephalomedullary nail and cerclage cables represents a good strategy in order to reduce the high risk of nonunion of the most displaced subtrochanteric fractures.

METHODS

This retrospective study examines 44 patients with average follow-up of 23 months, with subtrochanteric fracture type SH IIB, IIC, IIIA, IIIB treated by the same operator and with the same nail and cerclage cables. The clinical results which are derived from THRS have been reported.

RESULTS

Clinical and radiological consolidation occurred in all 44 cases, without re-intervention. The average evaluation derived from the THRS was 48 which corresponds to good, according to the scale.

CONCLUSIONS

Considering the anatomic reduction achieved in all patients and the clinical results, we can define the use of long cephalomedullary nail and cerclage cables as the most useful technique in the armamentarium of a trauma surgeon for the treatment of the subtrochanteric fractures.

Concepts and Potential Future Developments for Treatment of Periprosthetic Proximal Femoral Fractures

Periprosthetic proximal femoral fractures are a major challenge for the orthopaedic surgeon, with a continuously increasing incidence due to aging populations and concordantly increasing numbers of total hip replacements. Surgical decision-making mainly depends on the stability of the arthroplasty, and the quality of bone stock. As patients final outcomes mainly depend on early mobilization, a high primary stability of the construct is of particular relevance. Osteosynthetic procedures are usually applied for fractures with a stable arthroplasty, while fractures with a loosened endoprosthesis commonly require revision arthroplasty. Osteoporotic bone with insufficient anchoring substance for screws poses one major concern for cases with well-fixed arthroplasties. Complication rates and perioperative mortality have remained unacceptably high, emphasizing the need for new innovations in the treatment of periprosthetic fractures. Transprosthetic drilling of screws through the hip stem as the most solid and reliable part in the patient might represent a promising future approach, with auspicious results in recent biomechanical studies.

Stem compatibility for cement-in-cement femoral revision: an in vitro study

Cement-in-cement femoral component revision is a useful and commonly practised technique. Onerous and hazardous re-shaping of the original cement mantle is required if the new stem does not seat easily. Furthermore, without removing the entirety of the original cement mantle, the freedom to alter anteversion or leg length is difficult to predict preoperatively. We present data from in vitro experiments testing the compatibility of the top cemented stems according to UK registry figures (NJR 2013). This data augments preoperative planning by indicating which revision stems require minimal or no cement reshaping when being inserted into another stem's mantle. We also present the maximum shortening and anteversion that can be achieved without reshaping the original cement mantle.

The management of type B1 periprosthetic femoral fractures: when to fix and when to revise

The incidence of periprosthetic fractures around total hip arthroplasty is increasing as patient longevity rises and the number of patients with hip implants continues to grow. Type B1 periprosthetic femoral fractures are associated with a well-fixed stem and have traditionally been treated with internal fixation. However, there are a subset of these fractures which fare badly when internal fixation is undertaken, and revision of the femoral component to a long-stemmed implant may be more appropriate. We look at the traditional methods of fixation, and the evidence and indications for revision of these fractures.

Outcomes of post-operative periprosthetic femur fracture around total hip arthroplasty: a review

As the number of primary total hip arthroplasties increase over the next several decades so will the incidence of periprosthetic fractures around the femoral stem. Treatment can reliably be predicted using the Vancouver classification with internal fixation being indicated in fractures involving a stable implant and revision arthroplasty indicated in those with unstable prostheses. Non-displaced fractures involving the greater and lesser trochanter can generally be treated non-operatively. Extensively porous-coated stems and the use of modular uncemented revision stems to treat Vancouver B fractures have shown encouraging results. The treatment of Vancouver C periprosthetic fractures continues to follow basic AO fixation principles with an emphasis on eliminating stress risers with adequate implant overlap and length. This review will focus on the risk factors and classification of these fractures, as well as highlight the treatment options for post-operative periprosthetic femoral fractures around a total hip arthroplasty.

A review of periprosthetic femoral fractures associated with total hip arthroplasty

Periprosthetic fractures of the femur in association with total hip arthroplasty are increasingly common and often difficult to treat. Patients with periprosthetic fractures are typically elderly and frail and have osteoporosis. No clear consensus exists regarding the optimal management strategy because there is limited high-quality research. The Vancouver classification facilitates treatment decisions. In the presence of a stable prosthesis (type-B1 and -C fractures), most authors recommend surgical stabilization of the fracture with plates, strut grafts, or a combination thereof. In up to 20% of apparent Vancouver type-B1 fractures, the femoral stem is loose, which may explain the high failure rates associated with open reduction and internal fixation. Some authors recommend routine opening and dislocation of the hip to perform an intraoperative stem stability test to rule out a loose component. Advances in plating techniques and technology are improving the outcomes for these fractures. For fractures around a loose femoral prosthesis (types B2 and 3), revision using an extensively porous-coated uncemented long stem, with or without additional fracture fixation, appears to offer the most reliable outcome. Cement-in-cement revision using a long-stem prosthesis is feasible in elderly patients with a well-fixed cement mantle. It is essential to treat the osteoporosis to help fracture healing and to prevent further fractures. We provide an overview of the causes, classification, and management of periprosthetic femoral fractures around a total hip arthroplasty based on the current best available evidence.

Cement-in-cement revision for selected Vancouver Type B1 femoral periprosthetic fractures: a biomechanical analysis

The aim of this study was to perform a biomechanical analysis of the cement-in-cement (c-in-c) technique for fixation of selected Vancouver Type B1 femoral periprosthetic fractures and to assess the degree of cement interposition at the fracture site. Six embalmed cadaveric femora were implanted with a cemented femoral stem. Vancouver Type B1 fractures were created by applying a combined axial and rotational load to failure. The femora were repaired using the c-in-c technique and reloaded to failure. The mean primary fracture torque was 117 Nm (SD 16.6, range 89-133). The mean revision fracture torque was 50 Nm (SD 16.6, range 29-74), which is above the torque previously observed for activities of daily living. Cement interposition at the fracture site was found to be minimal.

Factors affecting flexural strength in cement within cement revisions

Cement within cement revisions provide substantial benefits for conventional revision yet remains uncommon possibly because of the perceived weakness of the cement-cement interface. This study investigated the flexural strength of beams composed of 2 different cements, exploring the factors of pore size, fracture location, viscosity, and the surface roughness of the interface. We found no significant difference when comparing combinations of different cements (P = .30), varying pore sizes (P = .13), or surface roughness (P = .39). Differences in fracture locations and viscosity combinations approached statistical significance (P = .08 and .05, respectively). Our findings suggest strong bonding between cements at the interface, with other factors being more important causes of weakness. Thus, we recommend that the strength of the cement-cement interface should not be a factor when considering such revisions.

Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: a review of 17 consecutive cases over 2 years

BACKGROUND

The conflict between the anatomist and biologist surgeons is exemplified by the debate about subtrochanteric hip fractures. Closed intramedullary nailing is biologically friendly but may result in prolonged procedures and malunion. By contrast, accurate anatomical open reduction may disturb the biological composition of the fracture environment.

METHODS

There were 17 patients at our institution over a 2-year period whose long oblique subtrochanteric fractures would not reduce perfectly in an anatomical fashion using closed methods. All these patients had their fractures treated identically using a new policy at our unit. This strategy involved reduction of the fracture through an open approach, and then employing cerclage cables to stabilise the fracture in an anatomical position before finally inserting a cephalomedullary nail. These patients were retrospectively reviewed at an average of 18 months postoperatively, to assess their progressive functional and radiological outcome up to that point.

RESULTS

One patient had nonunion and required a secondary procedure. One patient died 8 days postoperatively from a medical complication. The remaining 15 healed within 6 months and all returned to independent living.

CONCLUSIONS

The results demonstrate that judicious use of cerclage cables to augment fixation of subtrochanteric femur fractures does not have a deleterious effect on healing. One should endeavour, however, to minimise the number of cables used. The basic science literature underpinning our approach to these unstable fractures is also discussed.

A review of 202 periprosthetic fractures--stem revision and allograft improves outcome for type B fractures

We report a retrospective review of the outcome of treatment of 202 periprosthetic fractures around total hip arthroplasty (THA) from two specialised arthroplasty centres. Fractures were classified according to the Vancouver classification. The aim was to evaluate treatment methods with respect to stem revision and grafting. Transverse B1 fractures treated with stem revision compared to those treated with open reduction and internal fixation (ORIF) with a plate showed a trend towards improved overall union rate (OR=2, p=0.6, 95% CI:0.14-28.4) and shorter times to union (p=0.038, mean 12 months SD 6.573 for ORIF versus 4.48 months SD 0.757 for stem revision). B2 fractures undergoing stem revision and grafting were significantly more likely to unite compared to ORIF alone (OR=17.3, p=0.018 95%CI:1.63-184.4). B3 fractures presented with significant variation in fracture configuration and bone loss and therefore their treatment was individualised. When treated with stem revision and grafting healing was achieved in a mean time of 7 months (n=81). Periprosthetic fractures of the femur are highly complex and challenging. Stem revision for transverse B1 fractures is now considered as a viable treatment modality as this fracture configuration is difficult to control with single plating, and fixation with a long stem bypassing the distal fracture line is necessary to achieve axial stability and healing. Bone allografting, whether used as a cortical onlay or in morselised impacted form for B2 and B3 fractures enhances fracture healing.

Periprosthetic proximal femur fractures: current concepts

With the increase in demand for total hip and knee arthroplasty, the orthopaedic community has seen a dramatic increase in periprosthetic fractures. Given the high morbidity and mortality associated with these fractures, the orthopaedic surgeon needs to be prepared to deal with this difficult problem. The purpose of this article is to provide the surgeon with an algorithmic approach that allows for easy classification and treatment options for periprosthetic fractures of the proximal femur. Such an approach should prevent the mismanagement of these complications.

The effect of surface finish and interstitial fluid on the cement-in-cement interface in revision surgery of the hip

The mechanical performance of the cement-in-cement interface in revision surgery has not been fully investigated. The quantitative effect posed by interstitial fluids and roughening of the primary mantle remains unclear. We have analysed the strength of the bilaminar cement-bone interface after exposure of the surface of the primary mantle to roughening and fluid interference. The end surfaces of cylindrical blocks of cement were machined smooth (Ra = 200 nm) or rough (Ra = 5 μm) and exposed to either different volumes of water and carboxymethylcellulose (a bone-marrow equivalent) or left dry. Secondary blocks were cast against the modelled surface. Monoblocks of cement were used as a control group. The porosity of the samples was investigated using micro-CT. Samples were exposed to a single shearing force to failure.

The mean failure load of the monoblock control was 5.63 kN (95% confidence interval (CI) 5.17 to 6.08) with an estimated shear strength of 36 MPa. When small volumes of any fluid or large volumes were used, the respective values fell between 4.66 kN and 4.84 kN with no significant difference irrespective of roughening (p > 0.05). Large volumes of carboxymethylcellulose significantly weakened the interface. Roughening in this group significantly increased the strength with failure loads of 2.80 kN (95% CI 2.37 to 3.21) compared with 0.86 kN (95% CI 0.43 to 1.27) in the smooth variant. Roughening of the primary mantle may not therefore be as crucial as has been previously thought in clinically relevant circumstances.

Revision total hip arthroplasty: the femoral side using cemented implants

Advances in surgical technique and implant technology have improved the ten-year survival after primary total hip arthroplasty (THA). Despite this, the number of revision procedures has been increasing in recent years, a trend which is predicted to continue into the future. Revision THA is a technically demanding procedure often complicated by a loss of host bone stock which may be compounded by the need to remove primary implants. Both cemented and uncemented implant designs are commonly used in the United Kingdom for primary and revision THA and much controversy still exists as to the ideal method of stem fixation. In this article we discuss revision of the femur using cemented components during revision THA. We focus on three clinical scenarios including femoral cement-in-cement revision where the primary femoral cement-bone interface remains well fixed, femoral cement-in-cement revision for peri-prosthetic femoral fractures, and femoral impaction grafting. We discuss the clinical indications, surgical techniques and clinical outcomes for each of these procedures.