Osteosynthesis versus revision arthroplasty in Vancouver B2 periprosthetic hip fractures: a systematic review and meta-analysis

Vancouver B2 Periprosthetic femoral fractures around cemented polished taper-slip stems - how should we treat these? A systematic scoping review and algorithm for management

BACKGROUND

Periprosthetic femoral fractures (PFF) are a challenging complication of hip arthroplasty surgery, posing a high risk of morbidity, mortality and reoperation. The Vancouver Classification describes a B2 PFF around a loose stem with sufficient bone stock. In recent years, the number of B2 PFFs and cementation of femoral stems have increased substantially.

HYPOTHESIS

This systematic scoping review aimed to review the options available to surgeons in managing Vancouver B2 PFFs around cemented polished taper-slip (PTS) stems and establish an algorithm of management to treat varying fracture presentations.

PATIENTS AND METHODS

This study reviewed articles reporting on Vancouver B2 PFFs around cemented femoral stems between 2012 and 2022. Data extracted included: patient demographics, index prosthesis, surgical intervention and decision for treatment, operation time, transfusion requirement, length of hospital stay, post-operative rehabilitation protocol, mobility outcomes, radiological outcomes, complications, reoperations, mortality rates and follow-up.

RESULTS

In total, fourteen studies met all inclusion criteria including 552 cases. Mean patient age was 76.8 years with a male:female ratio 1:1.83 and median follow-up 49.2 months. Treatment options included open reduction and internal fixation (ORIF), revision arthroplasty using cementless modular and monoblock long-stems ± distal locking, cement-in-cement revision and cemented long-stem revision ± impaction bone grafting.

CONCLUSIONS

Management of B2 PFFs around cemented PTS stems is complex and aims to obtain stable fracture and stem fixation. Options include ORIF, cement-in-cement and cementless revision. The optimal choice depends on a combination of patient, fracture and surgeon factors. This review has proposed an algorithm to aid in decision making.

LEVEL OF EVIDENCE

III; systematic scoping review.

Open Reduction and Internal Fixation Is a Feasible Alternative to Femoral Revision Arthroplasty in Geriatric Patients with Vancouver B2/3 Type Periprosthetic Fractures: A Study Analyzing In-Hospital Outcomes

Purpose: The surgical management of periprosthetic femoral fractures is particularly challenging in geriatric patients due to physiological limitations. The choice between open reduction and internal fixation (ORIF) and hip revision arthroplasty for treating Vancouver B2 and B3 fractures remains controversial. This study aims to contribute further evidence by analyzing the in-hospital outcomes in geriatric patients with Vancouver B2/3 fractures. Methods: This retrospective study analyzed 133 patients treated for Vancouver B2/3 fractures at a level I trauma center from 2017 to 2023. Data were collected on preclinical characteristics, comorbidities, Vancouver classification, surgery-related parameters, and postoperative outcomes for an age- and gender-matched analysis. A subgroup analysis was also conducted on patients classified as American Society of Anesthesiologists (ASA) class 3 and 4. Results: Among the 133 patients, 85 suffered Vancouver B2 fractures and 48 Vancouver B3 fractures. Age-and-gender-matched analysis revealed that ORIF was more commonly performed in patients with higher ASA grades. A subgroup analysis of ASA 3 and 4 patients and an age-and-gender-matched analysis showed that ORIF resulted in shorter operation times and less blood loss. No significant differences were found in mortality or complication rates. Conclusions: ORIF is associated with shorter operation times, less bleeding, and comparable in-hospital outcomes in treating Vancouver B2/3 fractures in higher-risk geriatric patients compared to revision arthroplasty. The retrospective design and small sample size in the ORIF group are limitations of the study. Further studies with functional evaluation are still required.

Who Is Treating Periprosthetic Femur Fractures? An Analysis of the Periprosthetic Research Consortium

Background

Periprosthetic femur fractures (PPFFs) following total hip arthroplasty (THA) have increased in the past decade as the demand for primary surgery continues to grow. Although there is now more evidence to describe the treatment of Vancouver B fractures, there is still limited knowledge regarding factors that cause surgeons to perform either an open reduction and internal fixation (ORIF) or revision THA (rTHA). The purpose of this study was to determine what type of surgeons treat Vancouver B PPFFs at 11 major academic institutions and if there are trends in treatment decision-making regarding the use of ORIF or rTHA based on surgical training or patient factors.

Methods

This multicenter retrospective study evaluated patients surgically treated for Vancouver B PPFF after THA between 2014 and 2019. Patients from 11 academic centers located in the United States were included in this study. Surgical outcomes and patient demographics were evaluated based on surgeon training, surgical treatment type, and institution.

Results

Presence of Vancouver B2 (odds ratio [OR]: 0.02, P < .001) or B3 (OR: 0.04, P < .001) fractures were independent risk factors for treatment with rTHA. Treatment by a trauma (OR: 12.49, P < .001) or other-specified surgeon (OR: 13.63, P < .001) were independent risk factors for ORIF repair of Vancouver B fractures. There were no differences in outcomes based on surgeon subspecialty training.

Conclusions

This study showed the trends in surgeons who surgically manage Vancouver B fractures at 11 major academic institutions and highlighted that regardless of surgical training or surgical treatment type, postoperative outcomes following management of PPFF were similar.

Do All Postoperative Vancouver B2 Fractures Require Revision Arthroplasty With Cementless Stems?

Background

Management of periprosthetic fractures has been guided by the Vancouver classification, which recommends revision for fractures around a loose femoral implant (B2). New studies have challenged this approach, demonstrating acceptable outcomes with internal fixation. This study evaluates our experience with Vancouver B2 fractures, comparing internal fixation to femoral revision. We hypothesized that in select cases with cementless stems, internal fixation would provide acceptable results with reduced morbidity.

Methods

A retrospective review was performed of periprosthetic hip fractures treated at our institution between 1 January 2012 and 4 November 2022. We excluded patients who did not have prior radiographs and evidence of stem subsidence, suggestive of a Vancouver B2 fracture. Thirteen patients were included in the analysis.

Results

Four patients (31%) underwent revision of the femoral component, 4 patients (31%) underwent plating, and 5 patients (38%) underwent internal fixation with cerclage cabling. The average operative duration was 158 minutes, 203 minutes, and 62 minutes for the revision, plating, and cabling cohorts, respectively (P = .009). Blood loss was 463 cc, 510 cc, and 90 cc for the revision, plating, and cabling cohorts, respectively (P = .036). Three patients in both the revision and plating cohorts each received a transfusion (75%), whereas no patients in the cabling cohort required a transfusion (P = .033). All patients demonstrated fracture healing on the postoperative radiographs. No patients required additional surgery during the follow-up period.

Conclusions

We have demonstrated that Vancouver B2 periprosthetic fractures with intact lateral cortices may be treated with internal fixation with cerclage cabling with excellent results.

Stem revision vs. internal fixation in Vancouver B2/B3 periprosthetic hip fractures: systematic review and metanalysis

INTRODUCTION

Vancouver B2 and B3 periprosthetic fractures (PFF) are associated with stem instability and often require a demanding stem implant revision (SR) or internal fixation (ORIF). This latter surgery is increasingly performed in the last few years instead of SR, but it is unclear which is the best treatment to manage PFF patients. The aim of this study is the compare the outcomes of B2/B3 PFF managed by either ORIF or SR, by performing a systematic review and meta-analysis of current literature.

MATERIALS AND METHODS

Cochrane Database, PubMed, Google Scholar and MEDLINE were examined to find out relevant publications dealing with the different outcomes of SR vs. ORIF in B2/B3 PFF of the hip. The effect model (EM) was calculated using Cohen´s d index.

RESULTS

Fifteen studies were included, reporting on a total of 1629 patients (564 ORIF and 1065 SR). The pooled random EM estimates for reoperation was 0.87 (95% CI, 0.39-1.96; I2 = 78%) in favor of ORIF surgery; EM for complications was 1.01 (95% CI, 0.45-2.27; I2 = 85%) without difference among procedures. The EM for transfusion was 0.72 (95% CI, 0.46-1.12; I2 = 62%) in favor of fixation.

CONCLUSION

ORIF and SR were both suitable and effective options in PFF patients, being associated to similar complications rates. Our results show that ORIF performance in PFF patients is associated to significantly less in blood loss, surgical time and in-hospital stay. These advantages are particularly appealing in patients with multiple comorbidities.

Periprosthetic Femoral Fractures-Beyond B2

The proliferation of hip arthroplasty has seen concomitant increases in periprosthetic femoral fractures (PFFs). The most common pattern involves fracture at the level of a loose prosthesis (B2). B2 PFFs have a unique mechanopathogenesis linked to the tendency of polished taper-slip cemented stems to subside in the cement. Such stems carry a much higher PFF risk than other cemented designs. Mega-data, consistent across national registries, suggest that increasing application of the taper-slip principle has resulted in the emergence of highly polished, very low friction cemented prostheses. These have the propensity to migrate within the cement, increasing B2 PFF risk. This would explain the strong association between cobalt-chromium stems and PFF. Is PFF the mode of failure of polished taper-slip stems rather than aseptic loosening? Established wisdom teaches that B2 PFFs should be managed with revision surgery. There is a large body of new evidence that, in certain instances, fixation results in outcomes at least equivalent to revision arthroplasty, with shorter surgical time, decreased transfusion requirements, and lower dislocation risk. This is so in B2 PFFs around cemented polished taper-slip stems with an intact bone-cement interface. We outline advances in understanding of B2 PFF with special reference to mechanopathogenesis and indications for fixation.

[Concept for the treatment of periprosthetic proximal femoral fractures]

Due to demographic changes and increased survival rates of total hip arthroplasties, the incidence of periprosthetic proximal femoral fractures is increasing. The current treatment concept requires accurate preoperative planning. Besides patient-related risk factors, fracture type, prosthesis stability, and bone quality influence whether osteosynthesis or a revision arthroplasty is required.

Periprosthetic Hip Fractures around the Stem: Can the Stem Design Affect Fracture Features?

Background: Total hip arthroplasty is one of the most successful orthopedic surgeries; nevertheless, many of these surgeries are the causes of failure, and among them, periprosthetic fractures are one of the major causes of revision. Our study focuses on periprosthetic hip fractures with two different stem designs. The aim of the study was to analyze the obtained results, focusing on the features of periprosthetic stem fractures observed. Methods: We retrospectively reviewed periprosthetic fractures occurring between 2010 and 2023, involving Alloclassic® or CLS® uncemented femoral stems. We analyzed demographic data, proximal femur morphology, and the fracture type. Results: We identified 97 patients. Considering the proximal femur morphology, we found that there was statistically significant prevalence of Dorr A proximal femur morphology in the CLS® group and of Dorr C in the Alloclassic® group. Considering the distribution of the fracture pattern, we reported a non-statistically significant prevalence of the fracture pattern with stable stems in the CLS® group. Conclusions: The choice of the prosthetic design of the femoral stem is a crucial element when planning total hip arthroplasty. However, we found a non-statistically significant difference between the two stems considered, raising questions about the real role of stem design as a primary determinant of periprosthetic hip fractures.

Analysis of complications in 97 periprosthetic Vancouver B2 fractures treated either by internal fixation or revision arthroplasty

INTRODUCTION

The treatment of Vancouver B2 periprosthetic fractures after hip arthroplasty is still a matter of debate. Revision Arthroplasty (RA) was long thought to be the treatment of choice, however several recent papers suggested that Open Reduction and Internal Fixation (ORIF) is a viable option for selected B2 fractures. Complication rates of 14-26% have been reported following surgical treatment of B2 fractures. No significant difference between RA and ORIF in the complication rates nor in the functional outcome was observed.

METHOD

We conducted a retrospective analysis of 97 consecutive Vancouver B2 fractures treated according to the algorithm at our institution from 2007 to 2020 and recorded complications and patient specific data.

RESULT

From the 97 patient, 45 fractures were treated with RA while 52 fractures were treated with ORIF. Thirteen patients in the RA group had a complication that needed revision (28%) and 11 patients in the ORIF group needed revision (21%). There was no significant difference between complication rates. The reason for failure in the 13 RA patients were infection (n = 4), stem subsidence (n = 1), refracture after a new fall (n = 3), secondary dislocation of the greater trochanter (n = 1) and dislocation (n = 4). The reason for failure in the 11 ORIF patients that were revised were infection (n = 5), persistent symptomatic stem loosening (n = 3) and refracture (n = 3) after a new fall.

CONCLUSION

ORIF can be used to revise cemented and non-cemented shafts in more than half of Vancouver B2 fractures with no difference in complication rates when compared to RA. A periprosthetic fracture around the hip has a 21-28% risk of a re-operation after revision surgery with infection and re-fracture after a new fall being the most frequent cause of re-operation.

Open Reduction and Internal Fixation for Vancouver B1 and B2 Periprosthetic Femoral Fractures: A Proportional Meta-Analysis

Purpose

Periprosthetic femoral fracture (PFF) is a common complication after total hip arthroplasty, and open reduction and internal fixation (ORIF) is a common surgical treatment. We conducted a meta-analysis to compare the outcomes of ORIF in patients with different fracture patterns (Vancouver B1 and B2).

Materials and Methods

We conducted a systematic search of PubMed, Embase, Cochrane Library and KoreaMed from inception to August 2022. We conducted a pair-wise meta-analysis (with a fixed-effects model) on the 10 comparative studies and a proportional meta-analysis on the data from the 39 articles to determine a consensus. The outcomes were the incidence of reoperations that included osteosynthesis, irrigation/debridement and revision arthroplasty.

Results

The pair-wise meta-analysis showed similar outcomes between two groups; the risk of reoperation (odds ratio [OR]=0.82, confidence interval [CI] 0.43-1.55, P=0.542), nonunion (OR=0.49; CI 0.22-1.10, P=0.085) and deep infection (OR=1.89, CI 0.48-7.46, P=0.361). In proportion meta-analysis, pooled prevalence of reoperation was 9% (95% CI, 6-12) in B1 and 8% (95% CI, 2-15) in B2 (heterogeneity between two groups (Q), P=0.772). The pooled prevalence of nonunion was same as of 4% in B1 and B2 (Q, P=0.678), and deep infection was 2% (95% CI, 1-3) in B1 and 4% (95% CI, 2-7) in B2 (Q, P=0.130).

Conclusion

ORIF is a feasible treatment for B1 and B2 periprosthetic femoral fractures, with acceptable outcomes in terms of, nonunion and infection. The results of this study would help clinicians and provide baseline data for further studies validating PFF.

Surgeon-Stratified Periprosthetic Fracture Risk in a Single-Hospital Cohort of 1531 Uncemented ABG-II Femoral Stems at Primary Total Hip Arthroplasty

Purpose

Late periprosthetic fracture risk with uncemented ABG-II femoral stems at primary total hip arthroplasty (THA) has been reported before, but single-hospital surgeon-stratified reports of this implant have never been published. We asked whether periprosthetic fracture rates of ABG-II femoral stems implanted at a single tertiary hospital depended on patients' age, gender and the operating surgeon.

Methods

The study included 1531 consecutive primary ABG-II femoral stems implanted at a single tertiary hospital between January 1, 2012 and December 31, 2018. The Kaplan-Meier and Cox regression analyses were performed after 3.6-10.6 years of follow-up.

Results

In the cohort, we recorded 8 intraoperative, 22 early postoperative (within 90 days of implantation) and 26 late periprosthetic fractures (over 90 days postoperatively). The revision rate of ABG-II femoral stems was 5.1/100 component-years for early and 0.3/100 component-years for late periprosthetic fractures. The Kaplan-Meier cumulative probability of periprosthetic fracture was 2.1% at one, 2.3% at 2, 3.2% at 5, and 6.5% at 10 years after the implantation. Higher patient's age at operation was an independent risk factor of subsequent periprosthetic fracture (hazard ratio 1.07, 95% confidence interval 1.03-1.10; p < 0.01), regardless of the operating surgeon. Most of the fractured femora were Dorr type C (stovepipe).

Conclusion

The study presents the largest published ABG-II femoral stem cohort from a single hospital so far with 9291 component-years of observation. Periprosthetic fracture risk of ABG-II increased with patients' age, had no variability between different surgeons, and was considerably higher from other uncemented femoral stems used at the same hospital.

Level of Evidence

III.