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

Abstract

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.

Mortality, Risk Factors and Risk Assessment after Periprosthetic Femoral Fractures—A Retrospective Cohort Study

“…The treatment algorithm for periprosthetic femoral fractures has been continuously developed in recent years and is largely standardized [ 4 , 14 , 15 ]. The challenging task in the coming years will be to adequately provide care for the ever-increasing number of patients [ 16 ].…”

Current evidence and new challenges in periprosthetic hip and knee fractures

“…Among fractures of types B2, B3, and C, 94.2% of cases were treated with THA revision 2,28 . In cases of type B2 and B3 fractures, the most recent studies show that ORIF and the prosthetic revision are comparable in terms of results 27 . It should be noted that a prosthetic replacement of the proximal femur, with massive bone loss, brings about an infection rate of around 2% and a percentage of instability close to 19% 29 .…”

Treatment of Vancouver B1 periprosthetic femoral fractures using Intrauma Iron Lady® locking plate: A retrospective study on 32 patients

“…Inclusion criteria were: Vancouver B1 femoral fractures treated with Intrauma Iron Lady Conical Coupling Locking Plate with or without cerclages, clinical and radiographic follow-up greater than 6 months or until healed. Exclusion criteria were: Vancouver A periprosthetic femoral fractures (that are often treated nonoperatively or using plates with a trochanteric grip) [11] , Vancouver B2 and B3 femoral fractures (that often require also the femoral stem replacement, even if this statement is still debated) [19][20][21][22] , trasverse or short oblique fractures occurring at the tip of femoral stem (that often require femoral stem replacement, even if Vancouver B1 fractures) [23] , any other reason for femoral stem replacement in addition to the locking plate for the PFF treatment, pathologic fractures (malignancy or infection), non-surgical fractures, additional bone grafting, insufficient follow-up data, intraoperative femoral fractures during THA total hip arthroplasty [24] .…”