Clin Orthop Surg.  2014 Jun;6(2):138-145. 10.4055/cios.2014.6.2.138.

Treatment Results of a Periprosthetic Femoral Fracture Case Series: Treatment Method for Vancouver Type B2 Fractures Can Be Customized

• Niikura T
• Lee SY
• Sakai Y
• Nishida K
• Kuroda R
• Kurosaka M

• KMID: 1784658
• DOI: http://doi.org/10.4055/cios.2014.6.2.138

Abstract

BACKGROUND
Currently, an algorithmic approach for deciding treatment options according to the Vancouver classification is widely used for treatment of periprosthetic femoral fractures after hip arthroplasty. However, this treatment algorithm based on the Vancouver classification lacks consideration of patient physiology and surgeon's experience (judgment), which are also important for deciding treatment options. The purpose of this study was to assess the treatment results and discuss the treatment options using a case series.
METHODS
Eighteen consecutive cases with periprosthetic femoral fractures after total hip arthroplasty and hemiarthroplasty were retrospectively reviewed. A locking compression plate system was used for osteosynthesis during the study period. The fracture type was determined by the Vancouver classification. The treatment algorithm based on the Vancouver classification was generally applied, but was modified in some cases according to the surgeon's judgment. The reasons for modification of the treatment algorithm were investigated. Mobility status, ambulatory status, and social status were assessed before the fracture and at the latest follow-up. Radiological results including bony union and stem stability were also evaluated.
RESULTS
Thirteen cases were treated by osteosynthesis, two by revision arthroplasty and three by conservative treatment. Four cases of type B2 fractures with a loose stem, in which revision arthroplasty is recommended according to the Vancouver classification, were treated by other options. Of these, three were treated by osteosynthesis and one was treated conservatively. The reasons why the three cases were treated by osteosynthesis were technical difficulty associated with performance of revision arthroplasty owing to severe central migration of an Austin-Moore implant in one case and subsequent severe hip contracture and low activity in two cases. The reasons for the conservative treatment in the remaining case were low activity, low-grade pain, previous wiring around the fracture and light weight. All patients obtained primary bony union and almost fully regained their prior activities.
CONCLUSIONS
We suggest reaching a decision regarding treatment methods of periprosthetic femoral fractures by following the algorithmic approach of the Vancouver classification in addition to the assessment of each patient's hip joint pathology, physical status and activity, especially for type B2 fractures. The customized treatments demonstrated favorable overall results.

Keyword

Femur; Periprosthetic fracture; Hip arthroplasty; Vancouver classification

MeSH Terms

Aged
Aged, 80 and over
Algorithms
Arthroplasty, Replacement, Hip/*adverse effects
Female
Femoral Fractures/classification/etiology/radiography/*surgery
Hemiarthroplasty/adverse effects
Humans
Male
Middle Aged
Periprosthetic Fractures/classification/etiology/radiography/*surgery
Retrospective Studies

Figure

• 

  Fig. 1 Case 3: An 80-year-old woman. (A) Substantial sinking of an Austin-Moore stem was observed and the fracture was judged to be Vancouver type B2. (B) This patient was treated by an osteosynthesis using a locking plate instead of revision arthroplasty because of technical difficulty of performing revision arthroplasty owing to severe central migration of an Austin-Moore implant and subsequent severe hip contracture. (C) Sixteen months after the osteosynthesis. Bony union was obtained and her previous walking ability was recovered.

• 

  Fig. 2 Case 14: A 73-year-old woman. (A) The patient had undergone a cementless total hip arthroplasty on her left hip for treatment of osteoarthritis. (B) A fracture occurred after a fall. Sinking of the stem was observed and the fracture was judged to be Vancouver type B2. (C) Three years after the revision arthroplasty. Wiring and stem revision was performed, and her previous walking ability was recovered.

• 

  Fig. 3 Case 17: A 91-year-old woman. (A) Cementless bipolar hemiarthroplasty was performed for treatment of a femoral neck fracture. Wiring was performed at the surgery. (B) A fracture occurred after a fall. Sinking of the stem was observed and the fracture was judged to be Vancouver type B2. (C) Four months after the fracture. Conservative treatment was carried out owing to low activity, low-grade pain, previous wiring around the fracture, and light weight. The previous walking ability was recovered at 1 month after the fracture. Bony union was obtained and the stem sinking never progressed.

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