Conservative Treatment for Minimally Displaced Type B Periprosthetic Femoral Fractures

Outcomes of non-operatively managed Vancouver Type B1 periprosthetic femur fractures: a multi-center retrospective cohort study

BACKGROUND

This retrospective case series evaluated mortality outcomes in patients with Vancouver B1 periprosthetic fractures (PPFs) managed non-operatively using a matched cohort approach. We hypothesize that mortality rates will not significantly differ between operative and non-operative management of Vancouver B1 PPFs, as treatment decisions are likely driven by fracture complexity and patient comorbidities rather than a direct survival benefit of surgical intervention.

METHODS

Thirty patients with Vancouver B1 PPFs managed non-operatively between 2011 and 2017 across five major Australian trauma centers were identified. Patients were propensity-matched to 60 operatively managed patients, matched by age, ASA score, length of stay, follow-up duration, and fracture sub-type (B1). Mortality rates at 30 days, 1 and 5 years were compared between the non-operative and operatively managed groups. For the non-operative group alone, the impact of weight-bearing status on mortality was assessed.

RESULTS

There was no significant difference in mortality rates between the non-operative and operative cohorts at 30-day (3.3%; 1.7%; P = 1.00), 1 year (20.0%; 3.3%; P = 0.09) and 5 years (33.3%; 30.0%; P = 0.78). For the non-operative group alone, there was no significant difference in mortality rates between WBAT and non-WBAT groups at 30 days (7.7%; 0.0%; P = 0.400), 1 year (15.4%; 17.6%; P = 0.839) and 5 years (30.8%; 35.3%; P = 0.781), CONCLUSION: Comparable 5-year mortality rates were identified between non-operatively and operatively managed Vancouver Type B1 periprosthetic femoral fractures. Despite differences in age and comorbidities, non-operative management may be a viable option for selected patients, underscoring the need for further research to refine treatment guidelines.

CLINICAL TRIAL NUMBER

Not applicable.

Usefulness of non-surgical treatment without weight bearing restriction versus surgical treatment for maintaining activities of daily living in patients with peri-prosthetic femoral fractures

PURPOSE

Non-surgical treatment without weight-bearing restriction, even in the early post-injury phase, may have a favourable effect on the activities of daily living (ADLs) in elderly patients with peri-prosthetic femoral fractures (PFFs). This study aimed to assess the effectiveness of surgical and non-surgical treatments for PFFs in terms of ADL maintenance and clinical safety.

METHODS

This retrospective cohort study included 44 patients with PFFs proximal to the stem fixation site without stem loosening. Rehabilitation with weight bearing was initiated after internal fixation of the fracture site in the surgical group (n = 12) and immediately after the injury in the non-surgical group (n = 32). Clinical and radiological outcomes, including time until the first weight-bearing exercise, time until independent walking, ADL deterioration, and bone union rate, were compared between groups. Independent risk factors for ADL deterioration were also evaluated.

RESULTS

The time until first weight-bearing exercise was shorter and the ADL deterioration rate was smaller in the non-surgical group than in the surgical group (8.8 ± 9.2 vs. 21 ± 13 days, P = 0.004; 6.2% vs. 12.5%, P = 0.04, respectively). Bone union rates were similar between groups (91% vs. 83%, P = 0.42), and aseptic loosening of the stem was not observed. Time until first weight-bearing exercise was identified as an independent risk factor for ADL deterioration (odds ratio, 1.13; 95% confidence interval, 1.01-1.26; P = 0.03).

CONCLUSION

Non-surgical treatment of PFFs proximal to the stem fixation site without stem loosening, which does not restrict early weight-bearing exercise after injury, is an effective and safe treatment procedure that maintains ADL performance in elderly patients.

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.

Outcomes of Nonoperatively Treated Vancouver B1 Fractures: Is Failure Common?

BACKGROUND

Periprosthetic fractures (PPFx) are a severe complication of total hip and hemiarthroplasty. Surgical treatment is typically performed but can result in major morbidity. Nonoperative PPFx management may provide a successful treatment alternative in select patients.

METHODS

Vancouver B1 PPFx patients treated over a 10-year period were identified. Patient demographic data were retrospectively recorded. Injury and postoperative radiographs were reviewed. There were 48 patients who met the study criteria. Patients were divided into operative and nonoperative comparative cohorts. Outcome comparisons between the 2 cohorts included 1-year mortality, unplanned surgery within 24 months of injury, fracture union rate, and return to preinjury ambulation status.

RESULTS

There was no difference in 1-year mortality between the nonoperative and operative cohorts (17 versus 8%; P = .32). We found no significant difference in unplanned surgery between the nonoperative and operative groups (8.7 versus 12%; P = .71), fracture union (100 versus 96%, P = .34), or return to ambulation status (86 versus 91%; P = .86). Nonoperative fractures were minimally displaced and within the metaphyseal region of the proximal femur without stem subsidence. Nonoperative fractures with subsequent treatment failure had initial fracture extension closer to the tip of the stem compared to successfully treated nonoperative fractures (5.5 versus 10.2 centimeters; P = .02).

CONCLUSION

Select nonoperatively treated patients had infrequent need for unplanned surgery, high union rate, and return to their preinjury ambulation status. Nonoperative management is not appropriate for all Vancouver B1 PPFx, but those patients who have minimally displaced meta-diaphyseal fractures and partial remaining distal fixation can be successfully treated.

A cost analysis of treating postoperative periprosthetic femoral fractures following hip replacement surgery in a UK tertiary referral centre

AIM

This study aims to evaluate costs associated with periprosthetic femoral fracture (PFF) treatment at a UK tertiary referral centre.

METHODS

This study included 128 consecutive PFFs admitted from 02/04/2014-19/05/2020. Financial data were provided by Patient Level Information and Costing Systems. Primary outcomes were median cost and margin. Secondary outcomes were length of stay, blood transfusion, critical care, 30-day readmission, 2-year local complication, 2-year systemic complication, 2-year reoperation and 30-day mortality rates. Statistical comparisons were made between treatment type. Statistical significance was set at p<0.05.

RESULTS

Across the cohort, median cost was £15,644.00 (IQR £11,031.00-£22,255.00) and median loss was £3757.50 (£599.20-£8296.20). The highest costs were ward stay (£3994.00, IQR £1,765.00-£7,013.00), theatre utilisation (£2962.00, IQR £0.00-£4,286.00) and overheads (£1705.10, IQR £896.70-£2432.20). Cost (£17,455.00 [IQR, £13,194.00-£23,308.00] versus £7697.00 [IQR £3871.00-£10,847.00], p<0.001) and loss (£4890.00 [IQR £1308.00-£10,009.00] versus £1882.00 [IQR £313.00-£3851.00], p = 0.02) were greater in the operative versus the nonoperative group. There was no difference in cost (£17,634.00 [IQR £12,965.00-£22,958.00] versus £17,399.00 [IQR £13,394.00-£23,404.00], p = 0.98) or loss (£5374.00 [IQR £1950.00-£10,143.00] versus £3860.00 [IQR -£95.50-£7601.00], p = 0.21) between the open reduction and internal fixation (ORIF) and revision groups. More patients required blood transfusion in the operative versus the nonoperative group (17 [17.9%] versus 0 [0.0%], p = 0.009). There was no difference in any clinical outcome between the ORIF and revision groups (p>0.05).

CONCLUSION

PFF treatment costs are high with inadequate reimbursement from NHS tariff. Work is needed to address this disparity and reduce hospital costs. Cost should not be used to decide between ORIF and revision surgery.

Treatment Algorithm of Periprosthetic Femoral Fracturens

Introduction. The ever-expanding indications for total hip arthroplasty are leading to more implants being placed in younger as well as in older patients with high functional demand. Also, prolonged life expectancy is contributing to an overall increment of periprosthetic femoral fractures. The Vancouver classification has been the most used for guiding the surgeon choice since its proposal in 1995. Fractures occurring over a hip femoral implant can be divided into intra-operative and post-operative PFFs, and their treatment depends on factors that may severely affect the outcome: level of fracture, implant stability, quality of bone stock, patients' functional demand, age and comorbidities, and surgeon expertise. There are many different treatment techniques available which include osteosynthesis and revision surgery or a combination of both. The goals of surgical treatment are patients' early mobilization, restoration of anatomical alignment and length with a stable prosthesis and maintenance of bone stock. Significance. The aim of this review is to describe the state-of-the-art treatment and outcomes in the management of PFFs. We performed a systematic literature review of studies reporting on the management of PFFs around hip stems and inter-prosthetic fractures identifying 45 manuscripts eligible for the analysis. Conclusions. PFFs present peculiar characteristic that must be considered and special features that must be addressed. Their management is complex due to the extreme variability of stem designs, the possibility of having cemented or uncemented stems, the difficulty in identifying the "real" level of the fracture and the actual stability of the stem. As a result, the definition of a standardized treatment is unlikely, thereby high expertise is fundamental for the surgical management of PPFs, so this kind of fractures should be treated only in specialized centres with both high volume of revision joint arthroplasty and trauma surgery.

The race for the classification of proximal periprosthetic femoral fractures : Vancouver vs Unified Classification System (UCS) - a systematic review

Background

Periprosthetic femoral fractures (PFFs) represent a major cause for surgical revision after hip arthroplasty with detrimental consequences for patients. The Vancouver classification has been traditionally used since its introduction in 1995. The Unified Classification System (UCS) was described in 2014, to widen the spectrum by aiming for a more comprehensive approach. The UCS also aimed to replace the Vancouver classification by expanding the idea of the Vancouver classification to the whole musculoskeletal apparatus. After introduction of the UCS, the question was raised, whether the UCS found its place in the field of analysing PFFs. Therefore, this systematic review was performed to investigate, the use of the UCS compared to the established Vancouver classification.

Methods

Medline was searched for reports published between 1 January 2016 and 31 November 2020, without language restriction. Included were original articles, irrespective of the level of evidence and case reports reporting on a PFF and using either the Vancouver or the UCS to classify the fractures. Excluded were reviews and systematic reviews.

Results

One hundred forty-six studies were included in the analysis. UCS has not been used in a single registry study, giving a pooled cohort size of 3299 patients, compared to 59,178 patients in studies using the Vancouver classification. Since 2016, one study using UCS was published in a top journal, compared to 37 studies using the Vancouver classification (p=0.29). During the study period, the number of yearly publications remained stagnant (p=0.899).

Conclusions

Despite valuable improvement and expansion of the latter UCS, to date, the Vancouver system clearly leads the field of classifying PFFs in the sense of the common use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05240-w.

Periprosthetic fragility fracture of the femur after primary cementless total hip arthroplasty

OBJECTIVES

Periprosthetic bone fragility due to stress shielding (SS) can be a risk factor of periprosthetic fracture after cementless total hip arthroplasty (THA). We aimed to obtain epidemiological information on periprosthetic fragility fracture of the femur (PPFF) after THA.

METHODS

We retrospectively reviewed the medical records of 1062 hips that had undergone cementless THA. We evaluated the epidemiological data as well as the features of PPFFs.

RESULTS

Of the 1062 hips, 8 (0.8%) were diagnosed with PPFFs. The survival rates, with the occurrence of PPFF as the end point, were 99.2% and 97.6% at 10 and 16 years postoperatively, respectively. When patients were classified as having either mild or severe SS on radiographs 5 years postoperatively, there was no significant difference in the survival rate, with PPFF as the end point.

CONCLUSIONS

In our cases, the incidence of PPFF after cementless THA was 0.8%.

Nonoperative Treatment of a Fractured Uncemented Extensively Coated Femoral Stem: A Case Report with 2-Year Follow-up

CASE

A 62-year-old man who underwent total hip arthroplasty (THA) 17 years earlier presented with a fractured uncemented extensively coated diaphyseal engaging femoral stem. Treatment options, including revision surgery, were discussed, and the patient elected for nonoperative treatment. At 2 years of follow-up, the patient is asymptomatic, radiographs are stable, and he lives an active lifestyle without restrictions.

CONCLUSION

Fractures of well-fixed femoral prostheses are rare complications of THA and almost universally require revision surgery. Nonoperative treatment without activity restrictions may be a viable treatment option in select patients to preserve function and maintain quality of life.

Molecular enhancement of fracture healing - Is there a role for Bone Morphogenetic Protein-2, parathyroid hormone, statins, or sclerostin-antibodies?

Enhancement of fracture healing has been a hot topic over the last two decades. This narrative review article is aimed to provide an update on current clinical use and evidence on four clinically available agents in the treatment of fracture healing: bone morphogenetic proteins-2 (BMP-2), parathyroid hormone, statins and sclerostin-antibodies. After first promising results from animal and clinical studies in the early 2000s, BMP-2 was studied mainly in open tibia shaft fractures treated with intramedullary nailing. There are conflicting results from different randomized clinical trials (RCTs) regarding fracture healing time and complications compared to BMP-2 free control treatment in open tibia fractures, as BMP-2 could not show significant differences in patients treated with reamed nails compared to BMP-2 free control treatment with reamed nailing only. Given that fact, its official use was limited in Europe to open tibia shaft fractures treated with unreamed tibial nailing by the European Medical Agency (EMA). Another more recent RCT failed to show equivalence of BMP- 2 together with allograft versus autograft for the treatment of tibia fractures with critical size defects. Recombinant human parathyroid hormone has proven anabolic effects on bone metabolism and is commonly used in treatment of severe osteoporosis. Different animal trials suggested an enhancement effect in fracture healing by PTH. In several clinical trials, PTH seems to have a stimulative effect for lower limb fractures. Statins, commonly used in treatment of dyslipidemia, could also enhance fracture healing in animal trials, especially when they were applied locally at the fracture site. For statins, there is only one RCT that failed to show significant effects for the oral administration of statins in undisplaced distal radius fractures. The role of sclerostin in fracture healing has more and more been understood. Application of sclerostin antibodies has been shown to be beneficial for fracture healing in animal trials. However, no RCTs on the effect of sclerostin antibodies on fracture healing have been performed yet. In conclusion, the "magic bullet" for molecular enhancement of fracture healing has not been identified yet, at least not with its optimal dosage and delivery method.

Periprosthetic hip fractures: an update into their management and clinical outcomes

The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors.

Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.

Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.

Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.

Less invasive osteosynthesis, balanced plate–bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing.

Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050

Postoperative periprosthetic femoral fracture around total hip replacements: current concepts and clinical outcomes

The rising incidence of postoperative periprosthetic femoral fracture (PFF) presents a significant clinical and economic burden.

A detailed understanding of risk factors is required in order to guide preventative strategies.

Different femoral stems have unique characteristics and management strategies must be tailored appropriately.

Consensus regarding treatment of PFFs around well-fixed stems is lacking, but revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems.

Future research should focus on implant-related risk factors, treatment of concurrent metabolic bone disease and the use of large endoprostheses.

Cite this article: EFORT Open Rev 2020;5:558-567. DOI: 10.1302/2058-5241.5.200003

Treatment and outcomes of Vancouver type B periprosthetic femoral fractures

Aims

Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.

Methods

A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications.

Results

In surgically treated patients, all fractures united and nine complications were identified. The mean postoperative Visual Analogue Scale (VAS) for pain was 1.5 (SD 1.3), mean Parker Mobility Score (PMS) was 6.5 (SD 2.4), and mean Harris Hip Score (HHS) was 79.4 (SD 16.2). Among type B2 and type B3 fractures, patients treated with internal fixation had significantly lower PMS (p = 0.032) and required a longer time to heal (p = 0.012). In conservatively treated patients, one-year mortality rate was 36.4% (4/11), and two patients ultimately progressed to surgery. Young age (p = 0.039) was found to be the only risk factor for complications.

Conclusion

The overall clinical outcome among Vancouver type B PFF was satisfactory. However, treatment with internal fixation in type B2 and B3 fractures had a significantly longer time to heal and lower mobility than revision cases. Conservative treatment was associated with high rates of early mortality and, in survivors, nonunion. This probably reflects our selection bias in undertaking surgical intervention. In our whole cohort, younger patient age was a risk factor for postoperative complications in Vancouver type B PFF. Cite this article: Bone Joint J 2020;102-B(3):293–300

The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence

BACKGROUND

The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures.

METHODS

A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide".

RESULTS

The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old.

CONCLUSIONS

General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.

Reliability and Validity of the Vancouver Classification in Periprosthetic Fractures Around Cementless Femoral Stems

BACKGROUND

The Vancouver classification of periprosthetic femur fractures divides B1 and B2 subtypes based on the stability of the femoral stem. However, this classification was described and validated with cemented femoral stems. We sought to assess reliability and validity of the Vancouver classification in patients with cementless femoral stems.

METHODS

This is a blinded radiographic study which included patients treated for Vancouver B cementless periprosthetic femur fractures between February 2007 and December 2017. Adult reconstruction-trained and trauma fellowship-trained orthopedic surgeons graded all preoperative radiographs using the Vancouver classification on 3 separate occasions. Interobserver and intraobserver reliability was assessed via the Fleiss' kappa statistic. Validity was assessed via accuracy between radiographic and intraoperative assessments. The Landis and Koch criteria were used to interpret the kappa values.

RESULTS

Fifty-three patients with Vancouver B fractures (B1, 8; B2, 45) around a cementless femoral stem were included in the study. Five reconstruction-trained and 5 trauma-trained orthopedic surgeons graded all radiographs. The interobserver reliability kappa value was 0.45 (moderate agreement), with all raters agreeing on only 43% of radiographs. Validity analysis showed demonstrated 79% agreement. Overall, 20% (range, 14%-24%) of unstable B2 fractures were misread as B1 fractures. Intraobserver reliability was 0.71 between readings.

CONCLUSION

The reliability of the Vancouver classification for cementless total hip arthroplasty is lower than previously described in cemented femoral stems. Radiographic assessment alone may be inadequate for determination of stability of cementless stems in periprosthetic femur fractures.

LEVEL OF EVIDENCE

Level III therapeutic study: retrospective comparative study.