Treatment Results of a Periprosthetic Femoral Fracture Case Series: Treatment Method for Vancouver Type B2 Fractures Can Be Customized

Abstract

BackgroundCurrently, an algorithmic approach for deciding treatment options according to the Vancouver classification is widely used for treatment of periprosthetic femoral fractures after hip arthroplasty. However, this treatment algorithm based on the Vancouver classification lacks consideration of patient physiology and surgeon's experience (judgment), which are also important for deciding treatment options. The purpose of this study was to assess the treatment results and discuss the treatment options using a case series.MethodsEighteen consecutive cases with periprosthetic femoral fractures after total hip arthroplasty and hemiarthroplasty were retrospectively reviewed. A locking compression plate system was used for osteosynthesis during the study period. The fracture type was determined by the Vancouver classification. The treatment algorithm based on the Vancouver classification was generally applied, but was modified in some cases according to the surgeon's judgment. The reasons for modification of the treatment algorithm were investigated. Mobility status, ambulatory status, and social status were assessed before the fracture and at the latest follow-up. Radiological results including bony union and stem stability were also evaluated.ResultsThirteen cases were treated by osteosynthesis, two by revision arthroplasty and three by conservative treatment. Four cases of type B2 fractures with a loose stem, in which revision arthroplasty is recommended according to the Vancouver classification, were treated by other options. Of these, three were treated by osteosynthesis and one was treated conservatively. The reasons why the three cases were treated by osteosynthesis were technical difficulty associated with performance of revision arthroplasty owing to severe central migration of an Austin-Moore implant in one case and subsequent severe hip contracture and low activity in two cases. The reasons for the conservative treatment in the remaining case were low activity, low-grade pain, previous wiring around the fracture and light weight. All patients obtained primary bony union and almost fully regained their prior activities.ConclusionsWe suggest reaching a decision regarding treatment methods of periprosthetic femoral fractures by following the algorithmic approach of the Vancouver classification in addition to the assessment of each patient's hip joint pathology, physical status and activity, especially for type B2 fractures. The customized treatments demonstrated favorable overall results.

Radiologic outcomes of open reduction and internal fixation for cementless stems in Vancouver B2 periprosthetic fractures

“…Treatment options include traction, open reduction, and internal fixation of the fracture while leaving the stem in situ, and femoral revision with or without adjunctive internal fixation 2, 17, 18, 19, 20. Because of the advantages of early mobilization and more favorable results in terms of disunion and stem loosening, surgical management of PFF is generally preferable in patients who are medically stable 12, 21, 22. About 86% of all PFF cases are Vancouver type B fractures (type B2 or B3), and 70% of type B fractures that occur are associated with a loose stem (type B2) following primary THA 17 .…”

“…One of the challenges for ORIF of PFF is to achieve sufficient fixation in the proximal fragment around the zone of the femoral prosthesis 32 . Cables are typically supplemented with screws in the trochanteric region or with unicortical locked screws in the zone of the prosthesis 12, 33, 34, 35. Relying on unicortical locked screws without cables should be avoided, as these constructs result in inadequate rotational control 1 .…”

Case report: A 10 years follow-up of periprosthetic femoral fracture after total hip arthroplasty in osteopetrosis

“…It can be partially attributed to surgeon's misinterpretation of the stability of the stem and a mistaken classification of type B2 fractures as type B1 fractures, under which condition, a plate fixation without revision was taken by surgeons. Meanwhile, some alternative treatments for B2 fractures are reported recently 16, 18, 19. Joestl et al 18 reported good results of ORIF for B2 fractures.…”

“…Joestl et al 18 reported good results of ORIF for B2 fractures. Niikura et al 19 treated one B2 fracture conservatively and gained a satisfying outcome. Therefore a customized treatment of B2 fracture seems to be valid.…”

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

“…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].…”