Vancouver B2 Peri-Prosthetic Fractures in Cemented Femoral Implants can be Treated With Open Reduction and Internal Fixation Alone Without Revision

Smitham, Peter; Carbone, Tania A.; Bolam, Scott M.; Kim, Young S.; Callary, Stuart A.; Costi, Kerry; Howie, Donald W.; Munro, Jacob T.; Solomon, Lucian B.

doi:10.1016/j.arth.2019.03.003

Cited by 46 publications

(28 citation statements)

References 29 publications

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“…In a small series of 12 B2 fractures involving PTC stems all united with stable stems within their original cement mantles at a median of 5 years following ORIF [22]. In a larger study of 52 B2 fractures around PTC stems treated with ORIF Smitham et al [23] reported no revision surgery or stem loosening, though similar to the present study 7/52 (13%) required reoperation for non-union or refracture. Goudie et al [15] reported that Vancouver B fractures involving Exeter stems can be fixed with non-locking plates with or without cables provided anatomic reduction is achieved without bone loss: failure to anatomically reduce predisposes to stem loosening and subsidence [15].…”

Section: Discussionsupporting

confidence: 77%

Vancouver B periprosthetic fractures involving the Exeter cemented stem

Powell-Bowns

Oag

et al. 2021

The Bone & Joint Journal

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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.

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Section: Discussionsupporting

confidence: 77%

Vancouver B periprosthetic fractures involving the Exeter cemented stem

Powell-Bowns

Oag

et al. 2021

The Bone & Joint Journal

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“…Several articles have shown good results in V-B2 fractures around cemented polished tapered stems treated by osteosynthesis [4,5,23]. In the present study, all the implant complications occurred around uncemented straight stems, but this difference was not significant when compared to anatomical or cemented stems.…”

Section: Discussioncontrasting

confidence: 50%

Is Stem Revision Necessary for Vancouver B2 Periprosthetic Hip Fractures? Analysis of Osteosynthesis Results from 39 Cases

González-Martín

González-Casamayor

Herrera-Pérez

et al. 2021

JCM

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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.

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“…Each fracture pattern, including the reverse clamshell, is approached with similar principles and centred on implant stability. Although revision arthroplasty is conventionally indicated where the stem is loose, there is an increasing weight of evidence to support fixation alone in B2 fractures [25,26].…”

Section: Discussionmentioning

confidence: 99%

Periprosthetic proximal femoral fractures in cemented and uncemented stems according to Vancouver classification: observation of a new fracture pattern

et al. 2020

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Background: Periprosthetic fractures are increasingly encountered in hip arthroplasty. The Vancouver classification system is widely used. Little knowledge exists regarding the association of the Vancouver classification with either cemented or uncemented stems. The aim was to analyse a series of fractures and determine associations. Methods: A series of consecutive patients over 8 years was identified including only post-operative fractures of primary hip arthroplasties. Baseline and radiographic characteristics were recorded including the type of stem fixation (cemented or uncemented) and Vancouver classification. Statistical analysis was performed to determine the association of the Vancouver classification between cemented and uncemented stems. Results: A total of 172 patients were identified (84 cemented stems, 88 uncemented stems). There were 30 Vancouver A fractures (12 cemented vs.18 uncemented, p > 0.05), 125 Vancouver B fractures (63 cemented vs. 62 uncemented, p > 0.05) and 17 Vancouver C fractures (9 cemented vs. 8 uncemented, p > 0.05). The Vancouver B2 fracture occurred most frequently (N = 95; 44 cemented vs. 51 uncemented, p > 0.05) and consists of four distinct fracture patterns: the previously described comminuted 'burst', clamshell and spiral patterns and the newly observed 'reverse' clamshell. The burst and spiral fracture patterns are significantly associated with cemented stems, and the clamshell pattern is significantly associated with uncemented stems. Conclusions: Vancouver A, B and C fractures occur equally in cemented and uncemented stems. Awareness of four distinct Vancouver B2 fracture patterns, including the newly observed reverse clamshell, will aid surgeons in predicting stem instability.

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Vancouver B2 Peri-Prosthetic Fractures in Cemented Femoral Implants can be Treated With Open Reduction and Internal Fixation Alone Without Revision

Cited by 46 publications

References 29 publications

Vancouver B periprosthetic fractures involving the Exeter cemented stem

Vancouver B periprosthetic fractures involving the Exeter cemented stem

Is Stem Revision Necessary for Vancouver B2 Periprosthetic Hip Fractures? Analysis of Osteosynthesis Results from 39 Cases

Periprosthetic proximal femoral fractures in cemented and uncemented stems according to Vancouver classification: observation of a new fracture pattern

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