Revision hip arthroplasty in Vancouver B2/B3 fractures—best practice in a nutshell

 

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Although there are some recent literature suggesting that under certain special conditions, Vancouver type B2 fractures may be managed with osteosynthesis alone, it is general practice that periprosthetic femoral fractures (PPFF) with loose stems (ie, Vancouver types B2 and B3 fractures) and with either adequate or poor bone stock, should be treated with revision to achieve a better outcome and rapid recovery of the patient. 

 

Aims of PPFF management for Vancouver types B2 and B3 fractures

Surgical revision due to PPFF is a demanding treatment for both patients and surgeons. Revision surgery can be long and strenuous for patients who are oftentimes elderly, with high comorbidity, and have inadequate bone stock. Luigi Zagra, Head of the Hip Department, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy and Past President of the European and Italian Hip Societies, shares with us, "In revision surgery for Vancouver types B2 and B3 fractures, the management goals are, 1) to achieve safe early mobilization, 2) a pain-free hip, 3) stable fixation of the prosthesis and fracture healing in near-anatomical alignment so as to restore hip biomechanics and function, and 4) durable implant." In this article, Luigi Zagra will demonstrate how optimal revision hip arthroplasty should be performed.

Luigi Zagra

IRCCS Galeazzi Orthopaedic Institute Milan
Milan, Italy

Assessing the stem

As has been discussed in Part 2 of this series, one essential diagnosis in treating PPFF is to determine whether a stem is loose. This question often translates into, "Is the fracture Vancouver type B1 or type B2/B3?" To achieve a reasonably accurate diagnosis, it is essential to take high-quality x-rays in at least two planes at the pelvis level to determine if the stem is loose or stable. Radiolucent lines detected around the prosthesis or cement is an indication of osteolysis, stem loosening, or stem subsidence [1]. A computed tomographic (CT) scan is helpful in showing fracture pattern, extension of osteolysis, and even implant fixation. If the imaging does not offer a conclusive diagnosis of a stable stem, and during surgery implant stability is still doubtful, then a stem revision should be carried out.

 

Open reduction and internal fixation or revision?

There are a few recent studies suggesting that open reduction and internal fixation (ORIF) alone should be considered and in some circumstances may be more beneficial than stem revision in treating Vancouver type B2 and B3 fractures [1–3]. The justifications for this suggestion are that patients would benefit from a shorter operation, shorter anesthesia time, fewer complications, reduced operative risks, and maintain bone stock for future revisions. In addition, the operation would be less costly and technically less difficult. However, since these studies were all small and have high risk of a biased result, as well as lacking information on prognostic factors, additional supportive data will be necessary to confidently recommend ORIF over stem revision [4].

Recently, a systematic literature review of 22 studies (343 B2 and 167 B3 fractures, mean follow-up time of 32 months) showed that in Vancouver type B2 fractures, internal fixation alone is associated with a higher reoperation rate, although the increased relative risk did not reach statistical significance. In Vancouver type B3 fractures treated with internal fixation alone, two out of seven (28.6%) patients required reoperation, in comparison to 23 out of 160 (14.4%) patients that were treated with revision [5]. Summarizing the situation, Spina and Scalvi concluded that in general, revision is still the preferred method of treatment in PPFF with a loose stem. Of course, in some circumstances, such as extremely frail patients with low functional expectations or fractures of specific patterns, Vancouver B2 and B3 fractures around a loose stem could be fixed by osteosynthesis, assuming the bone stock is adequate in supporting weight bearing and that anatomical reduction can be achieved [4, 6].

Luigi Zagra advises, "When in doubt or the patient has poor bone quality, treat it as if the stem is loose and revise! One-shot surgery is advisable for these patients, moreover treatment of loose stems after plate fixation for PPFF can be extremely demanding. There is a high risk of infection due to repeated surgeries and recurrence of loosening due to devascularized bone after previous exposures and plate fixation. Dislocations due to subsidence and malunions with poor functional outcome are also frequent in such situations when the femur is fixed while the stem is loose." In addition to assisting in the assessment of stem stability, CT scans help determine the location and the extent of the fracture, the number of fragments, and the extent of osteolysis. This is information that will help the preoperative planning and determine the surgical exposure.
Figure 1. A CT scan can help determine the location and extent of the fracture. AP x-ray (left); cross sections of CT scans at different levels, with accompanying graphs showing the respective levels of the scans (panel right).
Figure 2. A CT scan can help determine the location and extent of the fracture. AP x-ray (left); cross sections of CT scans at different levels, with accompanying graphs showing the respective levels of the scans (panel right).

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  • Planning PPFF surgery
  • Watch out for infection
  • Timing of surgery
  • Choosing the correct stem
  • To cement or not to cement?
  • Cementless stems
  • Modular versus nonmodular stems
  • Take tribology into consideration when choosing the hip prosthesis
  • Fractures involving cemented stems
  • Loose stem removal and provisional reduction
  • Reaming
  • Long-stem prosthesis
  • Limb length, offset, and orientation
  • Reapproximate femur proximally
  • Conclusion: Revision hip arthroplasty

Part 1 | Risk factors in treatment of periprosthetic fractures

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Part 2 | Osteosynthesis in periprosthetic fractures: Indications, tips, and tricks

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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Baochao Ji

First Affiliated Hospital of Xinjiang Medical University
Urumqi, China

Cao Li

First Affiliated Hospital of Xinjiang Medical University
Urumqi, China

Karl Stoffel

University Hospital Basel
Basel, Switzerland

Luigi Zagra

IRCCS Galeazzi Orthopaedic Institute Milan
Milan, Italy

This issue was written by Maio Chen, AO Innovation Translation Center, Clinical Science, Switzerland.

 

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