Distal fixation with Wagner revision stem in treating Vancouver type B2 periprosthetic femur fractures in geriatric patients

A Consecutive Series of Vancouver B2 Periprosthetic Femur Fractures Treated With Contemporary Monoblock Versus Modular Revision Stems: Clinical and Radiographic Outcomes

BACKGROUND

Tapered fluted titanium (TFT) stems are the implant design of choice for managing Vancouver B2 periprosthetic femur fractures (PFFs), producing reliable results over the past few decades. The aim of this study was to compare the radiographic and clinical outcomes of Vancouver B2 PFFs treated with contemporary monoblock versus modular TFTs.

METHODS

A consecutive series of 113 patients (72 women, 64%, mean age 70 years [range, 26 to 96]) who had a B2 PFF were treated with either a monoblock (n = 42) or modular (n = 71) TFT stem between 2008 and 2021. The mean body mass index was 30 ± 7. The mean follow-up was 2.9 years. A radiographic review was performed to assess leg length and offset restoration, endosteal cortical contact length, and stem subsidence. Kaplan-Meier analyses were used to determine survivorship without revision, reoperation, or dislocation.

RESULTS

There was no difference in the restoration of leg length (0.3 ± 8.0 mm) or offset (2.8 ± 8.2 mm) between the monoblock and modular cohorts (P > .05). Mean endosteal cortical contact length (47.2 ± 26.6 versus 46.7 ± 2 6.4 mm, P = .89) and stem subsidence (2.7 ± 3.5 versus 2.4 ± 3.2 mm, P = .66) did not differ. No difference in patient-reported outcome measures (Hip Disability and Osteoarthritis Outcome Score-Joint Replacement; Veterans RAND 12 Item Health Survey Physical and Mental; visual analog score; and Lower Extremity Activity Scale) between the groups was observed. Survivorship at 2 years free from reoperation, revision, and dislocation was 90.4, 90.3, and 97.6%, respectively, for the monoblock cohort; and 84.0, 86.9, and 90.0%, respectively, for the modular cohort.

CONCLUSIONS

No significant differences in radiographic or clinical outcomes were observed between patients treated with monoblock or modular TFTs in this large series of B2 PFFs.

In-silico modelling of multi-strike insertion and torsional resistance of tapered revision hip stems: Insight into spline design philosophy

Despite the clinical success of tapered splined titanium stems, a knowledge gap still exists between spline design and its primary mechanical stability, which is critical to the long-term success of revision hip arthroplasty. Additionally, almost all published pre-clinical studies relied on resource-intensive benchtop and cadaveric testing. Hence, the present study developed a novel computational model to investigate effects of spline geometry and configuration on axial and torsional stability of tapered stem. Dynamic explicit Finite Element Analysis coupled with a state-of-the-art adaptive meshing technique was used to simulate the highly non-linear contacts and large bony material deformations. Hybridising primary straight splines with secondary angled splines results in 41% and 10% increases of peak insertion force and post-seating moment than the predicate device for the same seating position. The primary straight splines cut at multiple circumferential bony locations, enhancing torsional stability; while the alternatively placed secondary angled splines form wedges with the bone, providing reliable seating and additional torsional resistance. To the best knowledge of the author, this is the first in-silico investigation of its kind to simulate multi-strike seating and torsional resistance of revision hip stems, offering an effective and efficient platform for future multi-factorial parametric study and uncertainty quantification.

Outcomes of fixation of Vancouver B periprosthetic fractures around cemented versus uncemented stems

BACKGROUND

The incidence of periprosthetic femur fracture (PPFF) in the setting of total hip arthroplasty (THA) is steadily increasing. We seek to address whether there is a difference in outcomes between Vancouver B fracture types managed with ORIF when the original stem was a press-fit stem versus a cemented stem.

METHODS

In this retrospective cohort study at a level 1 trauma center, we identified 136 patients over 65 years-of-age with Vancouver B-type fractures sustained between 2005 and 2019. Patients were treated by ORIF and had either cemented or press-fit stems prior to their injury. Outcomes were subsidence of the femoral implant, time to full weight bearing, rate of the hip implant revision, estimated blood loss (EBL), postoperative complications, and the one-year mortality rate.

RESULTS

A total of 103 (75.7%) press-fit and 33 (24.3%) cemented patients were reviewed. Patient baseline characteristics, Vancouver fracture sub-types, and implant characteristics were not found to be significantly different between groups. The difference in subsidence rates, postoperative complications, and time to weight bearing were not significantly different between groups. EBL and one-year mortality rate were significantly higher in the cemented group.

CONCLUSIONS

In geriatric patients with Vancouver B type periprosthetic fractures managed with ORIF, patients with an originally press fit stem may have lower mortality, lower estimated blood loss, and similar subsidence and hospital length of stays when compared to those with a cemented stem.

Management of Vancouver B2 Periprosthetic Femoral Fractures, Revision Total Hip Arthroplasty Versus Open Reduction and Internal Fixation: A Systematic Review and Meta-Analysis

OBJECTIVE

To identify and analyze the current evidence for the use of open reduction and internal fixation (ORIF) constructs compared with conventional revision total hip arthroplasty (rTHA) for the management of Vancouver B2 periprosthetic femoral fractures (PFFs).

DATA SOURCES

A systematic literature search of the MEDLINE, CINAHL, and EMBASE databases was conducted. Prospective and retrospective studies were eligible. No limitation was placed on publication date, with only articles printed in English eligible.

STUDY SELECTION

Included studies were retrospective studies comparing ORIF and rTHA for the management of Vancouver B2 PFFs.

DATA EXTRACTION

The primary outcome was the overall complication rate. Other outcomes included as rate of dislocation, revision operation, refracture, infection, nonunion, and subsidence/loosening. Twenty-four studies were included totaling 1621 patients, of which 331 were treated with ORIF and 1280 with rTHA.

CONCLUSION

The 1621 patients included comprised a mixture of different fracture patterns, prostheses, and patient comorbidities. The overall complication rate for ORIF was 24% versus 18% for rTHA (P = 0.13). The results demonstrate that rTHA has a similar revision rate to ORIF in PFFs with a loose femoral component and adequate bone stock. ORIF was superior to rTHA in prevention of postoperative dislocation; however, there was no difference between other complications. This review suggests a potential role of both ORIF and rTHA in the management of Vancouver B2 PFFs.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Contribution of the remaining attachment index in the management of Vancouver B1 periprosthetic hip fracture

INTRODUCTION

Implant fixation assessment following Vancouver B1 periprosthetic hip fracture is a major decision factor for internal fixation and/or implant revision. The main aim of the present study was to assess the correlation between radiographic Remaining Attachment Index (RAI) and risk of implant loosening at last follow-up following internal fixation of Vancouver B1 periprosthetic hip fracture.

MATERIAL AND METHOD

A multicentre retrospective study included 50 patients with Vancouver B1 periprosthetic hip fracture with uncemented femoral stem between 2013 and 2019. Preoperative radiographs were analysed independently by 2 senior orthopedic surgeons, distinguishing 2 groups: RAI>2/3 versus<2/3. Postoperative and last follow-up radiographs were then screened for signs of complete femoral component loosening.

RESULTS

Median age was 89 years (range: 36-99 years). Two RAI>2/3 patients showed implant loosening (8%) versus 9 RAI<2/3 patients (36%), disclosing a significant correlation between early loosening and RAI<2/3 (p=0.005). Interobserver agreement for both radiographic RAI and radiographic loosening assessment at last follow-up was 98% with kappa correlation coefficient 0.96 [range: 0.88-1].

CONCLUSION

Remaining Attachment Index<2/3 in Vancouver B1 periprosthetic hip fracture was a risk factor for early implant loosening after isolated internal fixation. In these often frail elderly patients, first-line implant exchange is to be considered in the light of the risk/benefit ratio. The present results confirm the need for rigorous preoperative radiographic work-up of the remaining attachment area in Vancouver B1 fracture.

LEVEL OF EVIDENCE

IV.

Periprosthetic femoral fractures after total hip arthroplasty: An algorithm of treatment

BACKGROUND

Periprosthetic femoral fractures (PFFs) following total hip arthroplasty are becoming more prevalent and management of these fractures is often demanding. The surgeon has to assess in detail implant loosening, bone loss and type of fracture. The aim of the study is to identify the suitability of a treatment algorithm, based on the Vancouver classification that takes into account the activity and comorbidity of each patient.

PATIENTS AND METHODS

This study retrospectively assessed 38 patients who were surgically treated for a PFF around total hip arthroplasty between 2010 and 2014. All fractures were classified according to the Vancouver classification. There were 14 type B1, 8 type B2, 10 type B3 and 6 type C fractures. The data examined were age, sex, mechanism of injury, type of fracture, ASA score, type of surgery and complications. Radiographic evaluations were performed at 1, 3, 6 months and every 12 months thereafter. Clinical results were measured using the Merle-d'Aubigné-Postel score. Treatment options included an ORIF in 22 patients and a stem revision in 16 patients, with or without plates or supplemental cortical strut grafting when required.

RESULTS

The mean duration of follow-up was 3.1 years, mean age was 71.2 years and six patients (15.7%) died. Union was obtained in all patients in a mean of 16 weeks. Three patients required a surgical revision: one for stem loosening and two for re-fracture after a new fall. One patient had varus malunion of the femur. The mean postoperative Merle-d'Aubigné-Postel score was 13.2. Thirteen patients showed excellent results, 14 had a good result, three had a fair outcome and two had a poor result. Twenty patients returned to their baseline mobility status, while 12 patients had either a decline in their ambulatory status or a need for additional assistive devices.

CONCLUSIONS

PFF remains a serious complication of hip arthroplasty that is accompanied by high morbidity and mortality rates. This study shows how patients' comorbidities and functional demand can direct the proper treatment. This is a suitable algorithm for the treatment of PFF, which can provide satisfactory results in terms of pain and function.

Diagnosis and management of periprosthetic femoral fractures after hip arthroplasty

INTRODUCTION

Periprosthetic femoral fracture represent a severe complication, at present the third cause of revision surgery, with an estimated incidence from 0,1 to 2,1%. The number of these fracture can be expect to increase in line with the aging of population and amount of THA implants also in younger high demanding patients.

MATERIALS AND METHODS

The aim of this study is analyze the diagnostic and therapeutic decision making processes performed in 64 patients with periprosthetic fractures treated surgically from January 2012 and October 2016 in our center. We analysed instrumental exams and surgical reports focusing on type of procedure, surgical access, operative time and type of fixation.

RESULTS

Average age was 809 years and a mean follow-up 231 months. According to Vancouver system and after X-rays, CT scan and intraoperative evaluation, 26 fractures were classified as type B1, 31 as type B2, 3 type B3 and 4 type C. Follow up results were divided on the basis of the surgical treatment: in ORIF group (23 type B1 fractures and 4 type C fracture) fracture union was obtained in 16 cases (593%) and the final HHS mean value was 6161; in Revision group (3 type B1, 31 type B2 and 3 type B3) bone healing was reported in 26 cases (703%) with mean HHS score of 7194.

CONCLUSIONS

In this surgery the objectives are provide an adequate bone healing and return to previous functional status as soon as possible. Many reasons make these goals challenging, in particular advanced age, osteoporosis, co-morbidity and weakness that lead to low energy trauma, the most frequent cause of these injuries. In our opinion a crucial aspect is the evaluation of stem stability, considering an implant mobilized until the opposite is clearly evident. Reduction of surgical time and early mobilization are goals of this surgery, often associated with several complications and high mortality rate.

Management of Vancouver Type-B2 and B3 Periprosthetic Femoral Fractures: Restoring Femoral Length via Preoperative Planning and Surgical Execution Using a Cementless, Tapered, Fluted Stem

Introduction

Periprosthetic femoral fractures, which are likely to increase as the population ages and total hip arthroplasty becomes more prevalent¹, can be effectively managed by restoring femoral length via preoperative planning and surgical execution using a cementless, tapered, fluted stem.

Indications & Contraindications

Step 1 Preoperative Plan

Template the contralateral, uninjured side.

Step 2 Template the Fractured Side

Identify the ideal COR on the injured side and template the femoral stem.

Step 3 Establish Depth of Reaming

Use stem templates to establish a reference point on the reamer for use intraoperatively, and identify the distance from that point to an identifiable distal landmark.

Results

We report on 14 (12 Vancouver type-B2 and 2 Vancouver type-B3) periprosthetic femoral fractures treated with the described method¹⁵.

Pitfalls & Challenges

Hip revision arthroplasty for failed osteosynthesis in periprosthetic Vancouver type B1 fractures using a cementless, modular, tapered revision stem

Aims

To evaluate the hypothesis that failed osteosynthesis of periprosthetic Vancouver type B1 fractures can be treated successfully with stem revision using a transfemoral approach and a cementless, modular, tapered revision stem with reproducible rates of fracture healing, stability of the revision stem, and clinically good results.

Patients and Methods

A total of 14 patients (11 women, three men) with a mean age of 72.4 years (65 to 90) undergoing revision hip arthroplasty after failed osteosynthesis of periprosthetic fractures of Vancouver type B1 were treated using a transfemoral approach to remove the well-fixed stem before insertion of a modular, fluted titanium stem which obtained distal fixation. These patients were clinically and radiologically followed up for a mean 52.2 months (24 to 144).

Results

After a mean of 15.5 weeks (standard deviation (sd) 5.7) all fractures had healed. No stems subsided and bony-ingrowth fixation had occurred according to the classification of Engh et al. The mean Harris Hip Score increased from a pre-operative score of 22.2 points (sd 9.7) to 81.5 points (sd 16.8) 24 months post-operatively. All hips had obtained an excellent result according to the classification of Beals and Tower.

Conclusions

The technique described here for stem revision provides reproducibly good results in the treatment of failed osteosynthesis for Vancouver types B1 periprosthetic fractures of the hip. Cite this article: Bone Joint J 2017;99-B(4 Supple B):11–16.

A systematic review of Vancouver B2 and B3 periprosthetic femoral fractures

Aims

The aim of this study was to investigate the outcomes of Vancouver type B2 and B3 fractures by performing a systematic review of the methods of surgical treatment which have been reported.

Materials and Methods

A systematic search was performed in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. For inclusion, studies required a minimum of ten patients with a Vancouver type B2 and/or ten patients with a Vancouver type B3 fracture, a minimum mean follow-up of two years and outcomes which were matched to the type of fracture. Studies were also required to report the rate of re-operation as an outcome measure. The protocol was registered in the PROSPERO database.

Results

A total of 22 studies were included based on the eligibility criteria, including 343 B2 fractures and 167 B3 fractures. The mean follow-up ranged from 32 months to 74 months. Of 343 Vancouver B2 fractures, the treatment in 298 (86.8%) involved revision arthroplasty and 45 (12.6%) were treated with internal fixation alone. A total of 37 patients (12.4%) treated with revision arthroplasty and six (13.3%) treated by internal fixation only underwent further re-operation. Of 167 Vancouver B3 fractures, the treatment in 160 (95.8%) involved revision arthroplasty and eight (4.8%) were treated with internal fixation without revision. A total of 23 patients (14.4%) treated with revision arthroplasty and two (28.6%) treated only with internal fixation required re-operation.

Conclusion

A significant proportion, particularly of B2 fractures, were treated without revision of the stem. These were associated with a higher rate of re-operation. The treatment of B3 fractures without revision of the stem resulted in a high rate of re-operation. This demonstrates the importance of careful evaluation and accurate characterisation of the fracture at the time of presentation to ensure the correct management. There is a need for improvement in the reporting of data in case series recording the outcome of the surgical treatment of periprosthetic fractures. We have suggested a minimum dataset to improve the quality of data in studies dealing with these fractures. Cite this article: Bone Joint J 2017;99-B(4 Supple B):17–25.

Modular tapered titanium stems in revision arthroplasty of the hip: The Risk and Causes of Stem Fracture

Tapered fluted titanium stems are increasingly used for femoral revision arthroplasty. They are available in modular and non-modular forms. Modularity has advantages when the bone loss is severe, the proximal femur is mis shapen or the surgeon is unfamiliar with the implant, but it introduces the risk of fracture of the stem at the junction between it and the proximal body segment. For that reason, and while awaiting intermediate-term results of more recently introduced designs of this junction, non-modularity has attracted attention, at least for straightforward revision cases. We review the risks and causes of fracture of tapered titanium modular revision stems and present an argument in favour of the more selective use of modular designs.

REVISION TOTAL HIP ARTHROPLASTY USING A MODULAR CEMENTLESS DISTAL FIXATION PROSTHESIS: THE ZMR(®) HIP SYSTEM. CLINICAL AND RADIOGRAPHIC ANALYSIS OF 30 CASES

Objective: To evaluate the clinical and radiographic results from 30 cases of revision of total hip arthroplasty using a modular cementless distal fixation prosthesis: the ZMR^® Hip System. Method: Between July 2005 and December 2008, 30 operations were performed, on 14 men and 14 women. Two male patients had bilateral surgery. The mean age was 59.2 years (29-81 years), with a mean follow-up of 24 months. The Paprosky classification was used for periprosthetic bone loss, and the Harris Hip Score (HHS) was used to evaluate clinical results. On radiographs, distal migration of the femoral stem was defined in accordance with Sporer. Proximal bone remodeling was classified using the Callaghan criteria. Results: The mean preoperative HHS was 39, and there was a significant increase to 93 points in the final evaluation, which indicated excellent clinical results. No femoral stem migration greater than 5 mm (Sporer) was observed on radiographs, thus suggesting that all the femoral prostheses presented osseointegration and remained stable from the time of the surgery until the final evaluation. The proximal femoral remodeling was either type B or type C in 29 hips, according to Callaghan. Seven patients had complications, but without interfering with osseointegration of the femoral components. Conclusion: Our results from revision of total hip arthroplasty using the ZMR^® Hip System were extremely encouraging, and all the components became osseointegrated and remained fixed at the time of the final evaluation.

Periprosthetic Fractures About the Hip: A Case-Matched Retrospective Analysis of Functional Outcomes Postrehabilitation

Introduction:

Little research has examined postrehabilitation functional outcomes of periprosthetic hip fractures. Predicted functional deficits and acceptable rehabilitation outcomes for these patients are not established. This study aimed to compare functional outcomes of periprosthetic fractures to matched patients with total hip arthroplasty (THA).

Materials and Methods:

Cases with periprosthetic fracture (PPF) were matched for age, gender, and surgeon to primary THA cases. Only patients who had completed at least 1 year of rehabilitation were included. Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were calculated for all surviving cases with PPF and primary THA. Secondary outcomes included length of stay and mortality. Statistical analysis was performed using Microsoft Excel and the 2-tailed Wilcoxon signed rank test. A P value of <.05 was accepted as indicative of statistical significance.

Results:

We identified 25 patients with PPF. Three patients were unsuitable for functional assessment. Of the cases with PPF suitable for functional assessment, 14 (14/22) were male. The median age of the PPF and the THA groups was 71 years and 68 years respectively. The median WOMAC score for the PPF group was 26 (interquartile range [IQR] 5.5-49.5) compared to that of the primary THA group, 3 (IQR 2.0-24.5; P < .05). In the PPF group, there were 7 deaths and 3 of the surviving patients had significant complications. The median length of stay in the PPF group was 13 days (IQR 10.5-35) compared to the matched group of 5 days (IQR 5-8.5; P < .05).

Conclusion:

Patients with PPF have markedly poorer functional outcomes than age-, gender-, and surgeon-matched patients with THA as well as prolonged length of stay. Future research should target the identification of factors that may improve functional outcomes in this growing cohort.

Revision arthroplasty for periprosthetic femoral fracture using an uncemented modular tapered conical stem

Periprosthetic femoral fracture (PFF) is a potentially devastating complication after total hip arthroplasty, with historically high rates of complication and failure because of the technical challenges of surgery, as well as the prevalence of advanced age and comorbidity in the patients at risk.

This study describes the short-term outcome after revision arthroplasty using a modular, titanium, tapered, conical stem for PFF in a series of 38 fractures in 37 patients.

The mean age of the cohort was 77 years (47 to 96). A total of 27 patients had an American Society of Anesthesiologists grade of at least 3. At a mean follow-up of 35 months (4 to 66) the mean Oxford Hip Score (OHS) was 35 (15 to 48) and comorbidity was significantly associated with a poorer OHS. All fractures united and no stem needed to be revised. Three hips in three patients required further surgery for infection, recurrent PFF and recurrent dislocation and three other patients required closed manipulation for a single dislocation. One stem subsided more than 5 mm but then stabilised and required no further intervention.

In this series, a modular, tapered, conical stem provided a versatile reconstruction solution with a low rate of complications.

Cite this article: Bone Joint J 2015;97-B:1031–7.

Mid-Term Results of 121 Periprosthetic Femoral Fractures: Increased Failure and Mortality Within but not After One Postoperative Year

Periprosthetic femoral fractures are associated with high failure rates and mortality, particularly within one postoperative year. However, mid-term results related to this issue are lacking. Thus, we performed a retrospective follow-up evaluation. Between 2007 and 2012, we treated a total of 121 consecutive patients for periprosthetic femoral fractures. After a mean of 57.2 postoperative months, we documented a total surgical revision rate of 16.5% within the first year, and the one-year mortality rate was 13.2%. Between one year and up to 7.3 postoperative years, only one surgical revision was necessary, and the mortality rate also decreased. No significant factors related to surgical revisions were detected. However, the initial hip fracture, older age, higher ASA score and dementia were associated with a higher mortality rate.

Non-modular tapered fluted titanium stems in hip revision surgery

Non-modular tapered fluted, titanium stems are available for use in femoral revision. The combination of taper and flutes on the stem provides axial and rotational stability, respectively. The material and surface properties of the stem promotes bone on-growth. If the surgeon is confident and reasonably experienced in the surgical use of this sort of design and the case is relatively straightforward, a non-modular design is effective. It also potentially reduces implant inventory, and circumvents the potential problems of taper junction corrosion and fatigue fracture. There are reports of excellent survival, good clinical and functional results and evidence of subsequent increase in proximal bone stock.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):56–9.

Increase of cortical bone after a cementless long stem in periprosthetic fractures

BACKGROUND

Healing and functional recovery have been reported using an extensively porous-coated stem in Vancouver B2 and B3 periprosthetic fractures; however, loss of cortical bone has been observed when using these stems in revision surgery for aseptic loosening. However, it is unclear whether this bone loss influences subsequent loosening.

QUESTION/PURPOSES

We analyze the healing fracture rate and whether the radiographic changes observed around and extensively porous-coated stem used for periprosthetic fractures affect function or loosening.

METHODS

We retrospectively reviewed 35 patients with periprosthetic fractures (20 Vancouver B2 and 15 Vancouver B3). Patients' mean age at surgery was 80 years (range, 51-86 years). No cortical struts were used in this series. We evaluated radiographs for signs of loosening or subsidence. The cortical index and the femoral cortical width were measured at different levels on the immediate pre- and postoperative radiographs and at different periods of followup. The minimum followup was 3 years (mean, 8.3 years; range, 3-17 years).

RESULTS

All fractures had healed, and all stems were clinically and radiographically stable at the end of followup. Nineteen hips showed nonprogressive radiographic subsidence during the first 3 postoperative months without clinical consequences. The cortical index and the lateral and medial cortical thickness increased over time. Increase of femoral cortex thicknesses was greater in cases with moderate preoperative osteoporosis and in cases with stems less than 16 mm in thickness.

CONCLUSIONS

Our data suggest an extensively porous-coated stem for Vancouver B2 and B3 periprosthetic fractures leads to a high rate of union and stable fixation. Cortical index and lateral cortex thickness increased in these patients with periprosthetic fractures. Patients with moderate osteoporosis and those using thin stems showed a major increase in femoral cortex thickness over time.

Usefulness of histology for predicting infection at the time of hip revision for the treatment of Vancouver B2 periprosthetic fractures

When facing a Vancouver B2 periprosthetic fracture, the most recommended treatment is the prosthesis replacement. Current tests do not provide enough reliability to identify whether the fracture has been produced on a septic or an aseptic loosened prosthesis. Our aim was to evaluate the usefulness of the histology for the diagnosis of infection in these cases. A total of 11 hip revision procedures were performed (mean age: 78.1 years, 8 women and 3 men). Sensitivity, specificity, positive predictive value and negative predictive value of the histology were 100%, 55.5%, 33.3% and 100% respectively. Of the six patients presenting with a positive histology, four of them had negative cultures (66.6% of false positives). Our results suggest that periprosthetic fractures are a cause of false-positive histology results for the diagnosis of infection during revision of a hip prosthesis for the treatment of Vancouver B2 periprosthetic fractures.

Management of Vancouver B2 and B3 femoral periprosthetic fractures using a modular cementless stem without allografting

PURPOSE

We reviewed our experience with the management of B2 and B3 femoral periprosthetic fractures using a distally fixed modular femoral stem in 55 patients.

METHODS

All periprosthetic fractures were managed immediately after injury without using allograft; 53 hips were available for a mean follow up of 67 months.

RESULTS

All fractures united, and the mean Harris hip score at the last follow up was 72. Subsidence was noted in two patients (4%) within six months postoperatively and required revision surgery. One patient developed peroneal nerve palsy. Two hips dislocated and were managed by closed reduction.

CONCLUSION

In these severe cases of periprosthetic fracture, the technique reviewed here proved to be reliable.

Hip revision arthroplasty in periprosthetic fractures of vancouver type B2 and B3

OBJECTIVES

The purpose of the study was to test the hypothesis that stem revision in Vancouver Type B2 and B3 periprosthetic fractures using a transfemoral surgical approach and a modular, noncemented, tapered and fluted revision stem led to reproducibly good results with respect to fracture healing, stability of the prosthesis stem, dislocation, intraoperative fracture, and clinical outcome.

DESIGN

Prospective study.

SETTING

Orthopaedic specialized clinic and center for joint replacement.

PATIENTS

Twenty-two patients with periprosthetic fractures of Vancouver Type B2 and 10 of Type B3 were followed of at least 24 months.

MAIN OUTCOME MEASURE

Fracture healing, stability of the prosthesis stem, complications, and clinical outcome.

RESULTS

All fractures healed with a mean time of 14.5 ± 5.2 weeks. No cases of subsidence of the stem were observed and, according to the classification of Engh et al concerning the biologic fixation of the stem, there was bony ingrowth fixation in 28 cases and stable fibrous fixation in four cases. One dislocation occurred and there were no cases of intraoperative fracture. The Harris hip score rose continually after the operations; from a score 3-months postoperatively of 59.2 ± 14.6 points, it rose to 81.6 ± 16.5 points after 24 months. According to the classification of Beals and Tower, all results were rated as excellent.

CONCLUSIONS

The methods described here for stem revision lead to reproducibly good results in the treatment of periprosthetic hip fractures of Vancouver Types B2 and B3.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Stem subsidence after total hip revision: 183 cases at 5.9 years follow-up

INTRODUCTION

Secondary subsidence of a revision femoral stem is often a negative predictive sign for successful osseointegration and perfect long-term stability.

MATERIALS AND METHODS

We performed a retrospective study in a series of 183 revision total hip replacements between 1996 and 2000 to evaluate the importance and risk factors of secondary subsidence with a cementless press-fit design femoral stem as well as this subsidence's consequences to osseointegration.

RESULTS

Secondary subsidence did not occur in 80 cases (53%), was between 0 and 4mm in 41 cases (27%); between 5 and 10mm in 17 cases (12%) and was greater than 10mm in 12 cases (8%). Mean subsidence of all patients was 3mm (0-30). There was a statistically significant negative correlation between subsidence and the quality of osseointegration (P=0.03). There was no significant relationship between component diameter and stem subsidence (P=0.9). The presence of preoperative bone deficiencies did not increase the risk of secondary subsidence (P=0.2).

CONCLUSION

In the case of revision with press-fit stems, the importance of secondary subsidence should not be overestimated, because it usually does not negatively affect satisfactory osseointegration.

Polyaxial Locked Implants in the Treatment of Type Vancouver B1 Periprosthetic Fractures of the Femur: Retrospective Clinical Examination in 58 Cases with Review of the Literature

We concluded a retrospective study of the outcomes of a consecutive series of Vancouver B1 and C femoral injuries using two specific locked implants. The study center is a dedicated trauma hospital with a large catchment area. Over a five-year period we treated 58 patients with a periprosthetic fracture of the femur with an angular stable plate, defined as the index procedure. The mean age at the index procedure was 72.4 years; 40 patients were female (69%). In 32 cases (55.2%) we saw a hip endoprosthesis, in 21 cases (36.2%) a knee endoprosthesis, and in five cases both (8.6%). Outcome measures were intra- and postoperative complications, bony union, degree of mobility and social status with comparison to the preoperative status, Barthel index, and timed ''up and go'' test. Union occurred in 56 cases (96.5%) after the index procedure. Three patients were bedridden before the injury; the remainder regained full weight-bearing status. The mean duration until full weight-bearing status in these patients was 8.6 weeks (4-13). Early implant failure with proximal dislocation of the screws occurred in two cases (3.5% revision rate). At follow up, 78% had maintained the same social status as before the injury. Fifty-two patients (89%) had regained their previous level of mobility. The mean Barthel index was 85 points (70-100) out of a possible 100, and improved from a mean of 35 points at the start of rehabilitation. It decreased on average by ten points compared to the preoperative status. The mean ''up and go'' time was measured as 21.4 s. In conclusion, polyaxial plates can achieve excellent surgical results. On the other hand, patients with this type of injury exhibit a clear deterioration in their social status, especially regarding lower limb motor function and self-independence.

[Thirty-four years follow-up of a bilateral Mac Kee-Farrar arthroplasty without loosening or osteolysis]

We report the case of a 93-year-old patient with bilateral Mac Kee-Farrar hip arthroplasties implanted 34 years ago. The patient was seen in 2005 for a type B1 periprosthetic fracture on the right prosthesis implanted in 1973. There was no loosening and the fracture was treated by plate fixation. Before the fracture, the Postel-Merle d'Aubigné (PMA) score was 16 on both sides, with a Devane activity score grade 2. At last follow-up, the PMA score was 13 for both hips, with a Devane activity score grade 1. Serum cobalt level was 1.36 microg/L (normal <1 microg/L). This exceptional case is to our knowledge the longest observed with this implant without clinical or radiographic signs of loosening. The serum cobalt level, rarely assayed after more than 30 years, was within the limits accepted for a metal-on-metal hip bilateral arthroplasty. We discuss the causes of failure and success of the Mac Kee-Farrar implant as reported in the literature and remark that long survival of the metal-on-metal bearing can occasionally be observed without signs of wear. Recent works on the metal-on-metal bearing merit attention.

Periprosthetic fractures of the femur after hip arthroplasty: an analysis of 99 patients

The medical records and radiographs of 99 patients treated for a periprosthetic femur fracture after total hip arthroplasty over a 17-year period at a single institution were prospectively reviewed. Fractures were classified according to the Vancouver system and stratified as to treatment method. Sixty-six patients had complete records available and a minimum of 12 months follow-up. Overall, 86% of the patients achieved fracture union. The success rate of cemented revision in the B2 and B3 groups was 84%, whereas cement-less revision was 86% successful. The complication rate of surgical treatment was 29%. Fracture union with a stable implant was possible in the majority of cases. Our results support the use of the Vancouver classification as a treatment algorithm.

Radiographic bone regeneration and clinical outcome with the Wagner SL revision stem: a 5-year to 12-year follow-up study

We used 79 Wagner SL stems (Sulzer Orthopedics, Baar, Switzerland) in femoral revisions with a minimum 5-year follow-up. There were 11 dislocations. A limb length discrepancy and limp were frequent. One loosened stem was rerevised. The cumulative probability of not having a stem revision for any reason was 92.3% in the best case scenario. Stem subsidence was associated with poor femoral canal filling. Definite proximal new bone regeneration (50 hips) was associated with an absence of major bone defects (P = .01). Lateral and medial femoral cortex and the outside femoral diameter had increased at the end of follow-up (P < .001). Wagner SL femoral revision stems can solve difficult cases with major proximal bone defects or periprosthetic fractures. Radiographic bone fixation and bone regeneration were frequent. Dislocations and stem subsidence were also frequent.

Treatment for unstable intertrochanteric fractures in elderly patients: internal fixation versus cone hemiarthroplasty

PURPOSE

To evaluate the effectiveness of internal fixation versus cone hemiarthroplasty for the treatment of unstable intertrochanteric fractures in elderly patients.

METHODS

The choice of treatment was based on the year of admission: between 2001 and 2003, 42 patients (mean age, 73 years) underwent cone hemiarthroplasty using a cementless press fit through a posterior approach, whereas between 1999 and 2001, 45 patients (mean age, 75 years) underwent internal fixation using a dynamic hip screw through a lateral approach in a supine position. Patients with stable fractures with intact lesser trochanter, immobility before injury, age younger than 60 years, or with associated injuries (such as another fracture) were excluded. Patients were encouraged active rehabilitation in bed. Bony union was determined by clinical and radiological examinations. Patients were followed up at 6-week intervals in the first sixth months and every 3 months thereafter until bony union was achieved. In the final follow-up, 32 cone hemiarthroplasty patients and 38 internal fixation patients were available for evaluation according to Merle d'Aubigne and Postel criteria.

RESULTS

There were no significant differences between the 2 groups in terms of sex, age, fracture type, Singh index, follow-up period, hospital stay, operating time, and receipt of blood transfusions. Clinical results of both groups were similar. Hemiarthroplasty patients were allowed full weight bearing significantly earlier than the internal fixation patients.

CONCLUSION

Cone hemiarthroplasty can be an alternative treatment for unstable intertrochanteric fractures in elderly patients so as to achieve earlier mobilisation.

Periprosthetic fractures in total hip arthroplasty

Periprosthetic fractures can be discussed in many formats. In this article, epidemiology, classification, and treatment are divided into the following three categories of periprosthetic fracture: intraoperative fractures detected at the time of surgery; intraoperative fractures undetected at the time of surgery, but detected postoperatively; and postoperative fractures occurring late after the arthroplasty procedure.