Treatment of Periprosthetic Femoral Fractures Vancouver Type B2: Revision Arthroplasty Versus Open Reduction and Internal Fixation With Locking Compression Plate

Abstract

Introduction:The Vancouver algorithm recommends revision arthroplasty (RA) for Vancouver type B2 (VTB2) fractures. However, open reduction and internal fixation (ORIF) using locking compression plates (LCP) may be a valid and less invasive alternative treatment.Materials and Methods:Between January 2007 and March 2017, we retrospectively recruited all patients treated with either ORIF with LCP or RA for VTB2 fractures in our clinic. All of the following were reviewed: the length of hospital stay, the operating time, the need for blood transfusions during and/or after surgery, implant-related and patient-related complications, need for revision surgery, and the radiological outcome. Additionally, the functional outcome was investigated.Results:Fifty-nine patients were recruited. Thirty-five (59.3%) patients underwent RA, while 24 (40.7%) patients received ORIF with LCP. The median surgical time was 137.50 minutes in the LCP group compared to 160.00 minutes in the RA group ( P = .051). Three (12.5%) patients in the LCP group and 10 (28.6%) patients in the RA group experienced an implant-associated complication ( P = .131). Patient-related complications occurred in 3 (12.5%) patients in the LCP group versus 6 (17.1%) patients in the RA group ( P = .628). The mean preoperative Parker mobility score was 9 points in both groups and decreased in both groups to a mean of 5 points in the LCP and 7 points in the RA group.Discussion:Open reduction and internal fixation with LCP seems to be a less invasive procedure for VTB2 fractures in comparison to RA. It is a bone-sparing procedure that can be advantageous for further revision operations. Moreover, some fractures can only be anatomically reduced by ORIF with LCP, whereas for proximal fractures with a radiologically unambiguously loosened stem RA might be advantageous.Conclusion:In line with previously published studies, our data suggest that ORIF using LCP is a valid treatment option for VTB2 fractures.

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

“…Our systematic search identified 14 original studies that included patients treated with ORIF and patients treated with revision arthroplasty in the treatment of B2 and B3 PFF [5,16,[19][20][21][22][23][24][25][26][27][30][31][32]. The publications were mainly retrospective cohort studies which did not describe the treatment allocation, provided little information about potential predictive factors and presented diverse outcome parameters.…”

“…The conception that ORIF could be advantageous in PFF around certain loose stems is supported by several reports where ORIF was compared to stem revision in B2 and/or B3 fractures and resulted in equivalent, if not better, outcomes [5,16,[19][20][21][22][23][24][25][26][27].…”

“…In several other publications, which had not used statistical tests to compare the results of ORIF vs. stem revision in B2 or B3 fractures, there were trends which appeared to favor ORIF for various parameters [20,24,25]. Other publications also showed trends for better outcomes of revision arthroplasty [22,24].…”

Periprosthetic fractures of the proximal femur: beyond the Vancouver classification

“…For example, the one-year mortality after a periprosthetic fracture of the femur is 30%, therefore, conservative treatment should be considered in non-ambulatory patients and patients with severe morbidity and/or low life expectancy. 11 – 14 Some studies have documented that ORIF resulted in less intraoperative blood loss and shorter operation time than stem revision; 18 , 21 this could also be a reason for a surgeon to favour ORIF over stem revision in patients with poor health and low physical demands, despite stem revision being indicated. These considerations are patient specific and are not incorporated into our algorithm.…”

“… 16 , 17 In general, it is accepted that Vancouver B1 fractures can be treated with ORIF, and some newer studies on Vancouver B2 fractures have also found good clinical results following ORIF in selected cases. 18 – 21 However, most loose stems must be revised. Whether or not a revision is necessary, or whether ORIF alone is sufficient, is not a straightforward decision.…”