B2 Periprosthetic Femoral Fractures Research Articles

Long stem revision versus short stem revision with plate osteosynthesis for Vancouver type B2 periprosthetic femoral fracture: a comparative study of eighty five cases.

Periprosthetic femoral fractures (PPFs) around the hip are challenging complications in orthopaedic surgery, particularly Vancouver type B2 (VTB2) fractures. The surgical management of these fractures is crucial and depends on various factors. Cementless short taper stem with plate osteosynthesis is an alternative surgical technique. This study aims to compare the outcomes of this surgical technique with revision arthroplasty (RA) with long stem in the treatment of VTB2 PPFs. This retrospective study was conducted in a single medical institute from February 2010 to May 2019. Patients who had received either total hip arthroplasty or bipolar hemiarthroplasty and subsequently developed a VTB2 PPF were included; patients who sustained intra-operative fractures or received a cemented stem previously were excluded from the analysis. The patients were divided into two groups: group I received RA with cementless long stem, while group II underwent RA with cementless short taper stem with plate osteosynthesis. Demographic data, radiographic and functional outcomes, and complications were analyzed between the two groups. A total of 85 patients diagnosed with VTB2 PPFs were included in the study. There were no significant differences between the two groups in terms of demographic data, including age, gender, mean follow-up times, estimated blood loss, and operative times. The radiographic results showed that there was no significant difference in the incidence of subsidence and implant stability between the two groups. However, group II tended to have less subsidence and periprosthetic osteolysis. Patients in group II had significantly better functional scores (mean Harris hip score: post-operative: 60.2 in group I and 66.7 in group ii; last follow-up: 77.4 in group 1 and 83.2 in group II (both p < 0.05)). There were no significant differences in the overall complication rate, including infection, dislocation, re-fracture, and revision surgery, between the two groups. Both surgical techniques, cementless long stem and cementless short taper stem with plate osteosynthesis, are effective in the treatment of Vancouver B2 PPFs, with no significant differences in outcomes or complications. However, patients in cementless short taper stem with plate osteosynthesis had better functional scores at both post-operative and the last follow-up.

Unstable Vancouver B1 periprosthetic femoral fracture fixation: A biomechanical comparison between a novel C-shaped memory alloy implant and cerclage wiring.

To compare the biomechanical stability of a novel, C-shaped nickel-titanium shape memory alloy (SMA) implant (C-clip) with traditional cerclage wiring in the fixation of a Vancouver B1 (VB1) periprosthetic femoral fracture (PFF). In total, 18 synthetic femoral fracture models were constructed to obtain unstable VB1 fracture with an oblique fracture line 8 cm below the lesser trochanter. For each model, the distal portion was repaired using a 10-hole locking plate and four distal bi-cortical screws. The proximal portion was repaired using either three, threaded cerclage wirings or three, novel C-shaped implants. Specimens underwent biomechanical testing using axial compression, torsional and four-point bending tests. Each test was performed on three specimens. The C-clip was statistically significantly stronger (i.e., stiffer) than cerclage wiring in the three biomechanical tests. For axial compression, medians (ranges) were 39 (39-41) and 35 (35-35) N/mm, for the C-clip and cerclage wiring, respectively. For torsion, medians (ranges) were, 0.44 (0.44-0.45) and 0.30 (0.30-0.33) N/mm for the C-clip and cerclage wiring, respectively. For the four-point bending test, medians (ranges) were 39 (39-41) and 28 (28-31) N/mm; for the C-clip and cerclage wiring, respectively. Results from this small study show that the novel, C-shaped SMA appears to be biomechanically superior to traditional cerclage wiring in terms of stiffness, axial compression, torsion and four-point bending, and may be a valuable alternative in the repair of VB1 PFF. Further research is necessary to support these results.

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

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). 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. 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). 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.

Biomechanics of PHILOS plates in Vancouver B1 periprosthetic femoral fracture.

Objective: To investigate the clinical efficacy of PHILOS plates in the treatment of Vancouver B1 periprosthetic femoral fracture (PFF) and to validate its biomechanical reliability via finite element analysis and mechanical testing on the Synbone femoral models. Methods: Ten males and eight females with Vancouver B1 PFF who underwent PHILOS plate fixation between September 2017 and January 2022 were selected. The average age was 72.61 ± 8.19years, with a range of 57-86years old. X-ray films were taken to assess the fracture healing situation around the femoral prosthesis as well as the position of the PHILOS plates and femoral prosthesis. Two different plates (the PHILOS plate and the Cable GTR plate) were used for fixation, and the differences in biomechanical stability of the two fixation methods were compared using finite element analysis and mechanical testing on the Synbone femoral models to validate the biomechanical dependability of the PHILOS plate. Results: All 18 cases were followed for at least 1year, as a result. The average period of follow-up was 17months, ranging from 12 to 36months. At the most recent follow-up, Harris scores for the hip joints of patients ranged from 82 to 89, with an average score of 86. The X-rays revealed that all fractures surrounding the femoral prosthesis had healed and that there was no looseness in the femoral prosthesis. None of the PHILOS license plates had expired. All patients were able to perform full-load walking, and pain and claudication in affected limbs were significantly reduced. Finite element analysis and mechanical testing of the Synbone femoral model revealed that the fixation effect of the PHILOS group was superior to that of the Cable group; consequently, PHILOS plates can be used to effectively fix fractures around the proximal femoral prosthesis. Conclusion: PHILOS plates are initially used in the treatment of Vancouver B1 PFF, which may be a good choice due to their simpler operation, lower medical costs, and satisfactory clinical efficacy.

Vancouver type B2 periprosthetic femoral fractures: clinical and radiological outcomes from a tertiary care center

IntroductionThe purpose of this study was to report mid-term clinical and radiographic results after hip arthroplasty revision in Vancouver type B2 femoral periprosthetic fractures (PPFx). Specifical focus of the paper is as follows: (1) the description of a standardized and reproducible surgical technique, (2) functional outcomes presentation and (3) type and number of complications and implants’ survival rate analysis.MethodsWe retrospectively reviewed all patients treated for hip revision with non-modular tapered fluted titanium stem in patients with Vancouver type B2 femur PPFx at a single institution. At least 18 months’ follow-up period was required. Harris Hip Scores and SF-12 were obtained, and radiographical follow-up was performed. Complications were reported and analyzed.ResultsThe authors included 114 patients (114 hips) with a mean follow-up of 62.8 ± 30.6 months. All patients were treated with Wagner SL revision hip stem (Zimmer-Biomet), metal cerclage wires ± trochanteric plate. The mean HHS and SF-12 score at the last follow-up evaluation were respectively 81.3 ± 9.7 and 32.5 ± 7.6. Seventeen (14.9%) complications occurred. We observed five cases of dislocations, two of periprosthetic joint infections and six cases of new PPFx. The stem-related revision rate for any cause at the final FU was 1.7%, due to PJI. No patients underwent stem revision surgery for aseptic loosening. Fracture healed in all the included patients with a union-rate of 100%. The re-operation rate for any cause was 9.6%, with an implant survival rate for overall failure of 96.5%.ConclusionThe presented standard and reproducible surgical technique obtains optimal clinical and radiological results with limited complication rate at mid-term follow up. Preoperative planning as well as careful intraoperative surgical technique is of a paramount importance.

IS A TYPE 2B SHORT STEM ADEQUATE IN PATIENTS WITH PROXIMAL FEMORAL DEFORMITIES?

We sought to determine the short to medium-term clinical and radiographic outcomes using a short stem in young adults with a proximal femoral deformity (PFD).We prospectively studied 31 patients (35 hips) with PFDs treated with an uncemented primary THA using a short stem with cervicometaphyseal fixation between 2011–2018. There were 19 male (23 hips) and 12 female (12 hips) patients, with a mean BMI of 26.7±4.1 kg/m2. Twelve cases had a previous surgical procedure, and six of them were failed childhood osteotomies. Mean age of the series was 44±12 years, mean follow-up was 81±27 months and no patients were lost to follow-up. PFDs were categorized according to a modified Berry´s classification. Average preoperative leg-length discrepancy (LLD) was −16.3 mm (−50 to 2).At a mean time of 81 months of follow-up, survival rate was 97% taking revision of the stem for any reason and 100% for aseptic loosening as endpoints. No additional femoral osteotomy was required in any case. Average surgical time was 66 minutes (45 to 100). There was a significant improvement in the mHHS score when comparing preoperative and postoperative values (47.3±10.6 vs. 92.3±3.7, p=0.0001). Postoperative LLD was in average 1 mm (−9 to 18) (p=0.0001). According to Engh's criteria, all stems were classified as stable without signs of loosening. Postoperative complications included 1 pulmonary embolism, 1 neurogenic sciatic pain, 1 transient sciatic nerve palsy that recovered completely after six months, and 2 acute periprosthetic joint infections. One patient suffered a Vancouver B2 periprosthetic femoral fracture 45 days after surgery and was revised with a modular distally fixed uncemented fluted stem.A type 2B short stem evidenced promising outcomes at short to medium-term follow up in young adult patients with PFDs, avoiding the need for corrective osteotomies and a revision stem.

The Stability of Fixation of Vancouver B2 Periprosthetic Femoral Fractures: Effect of Implantation Technique

BackgroundDue to increasing volume of total hip arthroplasties, periprosthetic femoral fractures have become a common complication with increased revision burden and perioperative morbidity. The objective of this study was to evaluate the fixation stability of Vancouver B2 fractures treated with 2 techniques. MethodsA common B2 fracture was created by reviewing 30 type B2 cases. The fracture was then reproduced in 7 pairs of cadaveric femora. The specimens were divided into 2 groups. In Group I (“reduce-first”), the fragments were reduced first, followed by implantation of a tapered fluted stem. In Group II (“ream-first”), the stem was implanted in the distal femur first, followed by fragment reduction and fixation. Each specimen was loaded in a multiaxial testing frame with 70% of peak load during walking. A motion capture system was used to track the motion of the stem and fragments. ResultsThe average stem diameter in Group II was 16.1 ± 0.4 mm, versus 15.4 ± 0.5 mm in Group I. The fixation stability was not significantly different in the 2 groups. After the testing, the average stem subsidence was 0.36 ± 0.31 mm and 0.19 ± 0.14 mm (P = .17) and the average rotation was 1.67 ± 1.30° and 0.91 ± 1.11° (P = .16) in Groups I and II, respectively. Compared to the stem, there was less motion of the fragments and there was no difference between the 2 groups (P > .05). ConclusionsWhen tapered fluted stems were used in combination with cerclage cables for treatment of Vancouver type B2 periprosthetic femoral fractures, both the “reduce-first” and “ream-first” techniques showed adequate stem and fracture stability.

Revision Total Hip Arthroplasty with a Modular Fluted Tapered Stem for a Periprosthetic Femoral Fracture.

As the number of primary total hip arthroplasty procedures performed each year continues to rise, so too do the number of complications, including periprosthetic femoral fracture1-9. Vancouver B2 and B3 periprosthetic femoral fractures are difficult to treat because they require the surgeon to simultaneously manage a femoral fracture and gain new implant fixation. Fluted tapered stems have advanced the treatment of periprosthetic femoral fractures by providing immediate axial and rotational implant fixation distal to the fracture10-18. Modular fluted tapered stems provide the added practical advantage of allowing length and anteversion adjustment after implantation of the distal fixation portion of the stem. In this technique, a modified extended trochanteric osteotomy incorporating the fracture is utilized to gain access to the loose femoral implant and femoral diaphyseal canal. The femoral diaphyseal canal is then sequentially reamed in 1-mm increments. A fluted tapered stem with the appropriate length, diameter, and axial and rotational stability is inserted into the canal. A proximal body is then chosen that establishes the appropriate leg length, femoral offset, and version. The final proximal body is engaged into the fluted tapered stem. Finally, the fracture is fixed around the implant with a combination of cables or wires. Historically, implants such as extensively porous coated stems were utilized to treat Vancouver B2 or B3 periprosthetic femoral fractures. Unfortunately, these implants were associated with high rates of failure and revision7,9. The introduction of a fluted tapered stem provided a more reliable implant that achieves immediate axial and rotational stability. In addition, utilizing a fluted tapered stem allowed for a more soft-tissue-preserving approach to these complex injuries, in turn allowing the fracture to be reduced around the implant proximally with cerclage cables and or wires. Modular fluted tapered stems provide the additional advantage of allowing the surgeon to modify leg length, offset, and femoral version, independently of the fluted tapered stem. As a result of these unique advantages, these stems were introduced several years ago for the treatment of Vancouver B2 or B3 periprosthetic femoral fractures. Contemporary series have demonstrated that the use of a modular fluted tapered stem leads to improved implant survivorship and clinical outcomes with lower complication rates for Vancouver B2 and B3 periprosthetic femoral fractures1,10-12,14-19. Template both the fluted tapered stem and proximal body preoperatively. The proximal body should be templated at the ideal hip center of rotation that appropriately restores leg lengths and offset. Template the fluted tapered stem so that it provides appropriate isthmic fit and bypasses the most distal extent of the fracture by at least 2 cortical diameters.Utilize a modified extended trochanteric osteotomy for your exposure in order to facilitate visualization of the fracture and to provide direct access to the femoral canal.Place a prophylactic cable prior to preparing the femur for the implant in order to help prevent iatrogenic fracture.Place a trial stem and obtain intraoperative anteroposterior and lateral radiographs in order to assess the position of the implants and the risk of anterior cortical perforation.When placing the final implants, be sure the fluted tapered stem has both axial and rotational stability.Reduce and fix the fracture after the final implants are placed and the hip is reduced. AP = anteroposteriorMFT = modular fluted tapered (stem)ETO = extended trochanteric osteotomyTHA = total hip arthroplastyCT = computed tomographyPJI = periprosthetic joint infection.

Outcomes of cable fixation after Vancouver type B1 periprosthetic femoral fractures.

In this study, it was aimed to evaluate the patients who underwent cable plate fixation due to a Vancouver-type B1 periprosthetic femur fracture and their clinical results. Vancouver-type B1 patients who were operated on for periprosthetic fractures between 2014 and 2019 were investi-gated. Age, gender, body mass index (BMI), follow-up time, operation time, bleeding amount, non-union fracture, last surgery before fracture, the time between previous surgery and fracture, implant survival, patient survival, and complications were recorded. In addi-tion, the postoperative clinical functions of these patients were compared. 23 patients who met the study criteria (Vancouver type B1 fracture) were identified. The mean age of the patients was 60 (49-76) years, the mean BMI was 26.3 (17.5-40.7), and the postoperative mean follow-up period was 14 (6-36) months. Considering the gender distribution, there were 5 (22%) men and 18 (78%) women. The mean time between the last surgery before the fracture and the fracture was 6 months (0-30). While the mean operation time was 95 min (60-180), the average amount of bleeding was 310 mL (150-600). Functional evaluations of patients: In total, five patients had decreased ambulatory abilities after surgery. Nonunion was observed in 2 patients during the follow-ups, and these patients underwent open surgery for treatment. Cable and locking plate applications are successful in Vancouver type B1 fractures, which are one of the most common forms of periprosthetic fractures. In this technique, the duration of the operation can be shortened under ideal conditions, and the need for blood and blood products is reduced as blood loss is reduced. If there is a complication, you still have the chance to treat it with the option of revision arthroplasty.

Impact of bone health on the mechanics of plate fixation for Vancouver B1 periprosthetic femoral fractures

BackgroundCondyle-spanning plate-screw constructs have shown potential to lower the risks of femoral refractures after the healing of a primary Vancouver type B1 periprosthetic femoral fracture. Limited information exists to show how osteoporosis (a risk factor for periprosthetic femoral fractures) may affect the plate fixation during activities of daily living. MethodsUsing total hip arthroplasty and plate-implanted finite element models of three osteoporotic femurs, this study simulated physiological loads of three activities of daily living, as well as osteoporosis associated muscle weakening, and compared the calculated stress/strain, load transfer and local stiffness with experimentally validated models of three healthy femurs. Two plating systems and two construct lengths (a diaphyseal construct and a condyle-spanning construct) were modeled. FindingsOsteoporotic femurs showed higher bone strain (21.9%) and higher peak plate stress (144.3%) as compared with healthy femurs. Compared with shorter diaphyseal constructs, condyle-spanning constructs of two plating systems reduced bone strains in both healthy and osteoporotic femurs (both applying ‘the normal’ and ‘the weakened muscle forces’) around the most distal diaphyseal screw and in the distal metaphysis, both locations where secondary fractures are typically reported. The lowered resultant compressive force and the increased local compressive stiffness in the distal diaphysis and metaphysis may be associated with strain reductions via condyle-spanning constructs. InterpretationStrain reductions in condyle-spanning constructs agreed with the clinically reported lowered risks of femoral refractures in the distal diaphysis and metaphysis. Multiple condylar screws may mitigate the concentrated strains in the lateral condyle, especially in osteoporotic femurs.

Effectiveness of shape memory alloy embracing device in treatment of Vancouver B2 periprosthetic femoral fracture

To analyze the effectiveness of shape memory alloy embracing device in the treatment of Vancouver B2 periprosthetic femoral fracture after primary hip arthroplasty. The clinical data of 30 patients (30 hips) with Vancouver B2 periprosthetic femoral fracture after primary hip arthroplasty between January 2019 and January 2021 were analyzed retrospectively. Among them, 15 cases were treated with shape memory alloy embracing device for fracture fixation (group A) and 15 cases with titanium cable cerclage (group B). There was no significant difference in general data such as gender, age, body mass index, the cause of primary arthroplasty and surgical method, prosthesis type, the cause and side of femoral fracture, the time from injury to operation, and comorbidities between the two groups ( P>0.05). The operation time, intraoperative blood loss, and hospital stay of the two groups were recorded. The fracture healing was examined by X-ray film, and the hip joint function was evaluated by Harris score. The operations in both groups were completed successfully, and the incisions healed by first intention after operation with no vascular or nerve injury. The operation time and hospital stay in group A were significantly shorter than those in group B ( P<0.05), but there was no significant difference in intraoperative blood loss between group A and group B ( t=-0.518， P=0.609). Patients were followed up 12-20 months (mean, 16.3 months) in group A and 12-22 months (mean, 16.7 months) in group B. X-ray film showed that all fractures healed, the healing time was (14.73±2.05) weeks in group A and (17.27±2.60) weeks in group B, and there was a significant difference between the two groups ( t=-2.960， P=0.006). During follow-up, there was no complication such as prosthesis loosening, periprosthetic infection, joint stiffness, or internal fixator loosening. The Harris score of group A was significantly better than that of group B at 3, 6, and 12 months after operation ( P<0.05). Compared with titanium cable cerclage, using shape memory alloy embracing device to fix Vancouver B2 periprosthetic femoral fracture can accelerate fracture healing, shorten operation time, and reduce intraoperative blood loss. Patients can perform functional exercise earlier and restore joint function better.

Metal and composite bone plates for B1 periprosthetic femoral fracture in healthy and osteoporotic condition: A comparative biomechanical study.

The major concern after total hip arthroplasty (THA) is the incidence of periprosthetic fracture in the weaker bone, which can lead to subsequent revision surgery. Achieving the suitable fixation without affecting the stability of the well-fixed prosthesis remains controversial. Most of the studies examined the behavior of the Periprosthetic Fracture (PF) fixation (Vancouver "B1" type) through computational and experimentation on healthy bone condition with metal plates. The aim of the present study is to analyze the influences of the metal and composite bone plate PF fixation on the axial and shear movement at the fracture site. The PF fixation constructs were modeled with medical graded stainless-steel plate (construct A), titanium plate (construct B) and carbon/epoxy composite bone plate (construct C) with 12 holes and a 4 mm fracture gap. Analysis was carried out for all the stages (stage 1-Normal bone, stage 2-THA, stage 3-Immediate Post-Operative (IPO), stage 4-Post-Operative (PO) and, stage 5-Healed Bone (HB)) under various loadings for intact and osteoporosis conditions. The results showed higher stress in cortical bone for stage 3, whereas in all the other stages lower stresses were experienced in the cortical and cancelous bone under peak load in construct C for osteoporosis model compared with other constructs. The present study suggested the construct C may be suitable for osteoporosis bone conditions.

The effect of onlay cortical fibula strut grafts on biomechanical features of Vancouver type B1 periprosthetic femoral fractures.

This study aimed to investigate biomechanically the effects of onlay fibula grafts on Vancouver Type B1 Periprosthetic Femoral Fractures (PPFs). Vancouver Type B1 PFF models were created in 25 fourth-generation synthetic femurs and fixed with locking plates using bicortical, unicortical screws, and cables. While no graft was used in group 1, onlay fibula grafts were placed anteriorly in group 2 and medially in group 3. In group 4, the cortical strut allograft was placed on the medial femoral cortex, and a locking compression plate (LCP) was applied to the lateral femoral cortex. In group 5, the strut allograft was placed over the anterior cortex of the femur and fixed with the same technique as in group 4. All models were then subjected to rotational and axial cyclical stiffness tests and load to failure to measure and compare the mechanical strengths of the constructs. The mean stiffness values of group 4 with medial allograft, before and after cyclical loading, were higher than all other groups, under both rotational and axial forces. The mean stiffness values of fibula autografts (groups 2 and 3) were similar to that of anterior allografts (group 5) in each test except that the mean initial axial stiffness of group 5 was higher than group 2. Failure loads were also not different between the groups. Although the rigidity of Vancouver type B1 periprosthetic femur fractures is highest if allografts are placed medially, fibula autografts can also provide similar fixation strengths to allografts if locking plates with unicortical and bicortical screws and cables are used.

Modular Fluted Tapered Stems for Periprosthetic Femoral Fractures: Excellent Results in 171 Cases.

Modular fluted tapered (MFT) stems have advanced treatment of Vancouver B2 and B3 periprosthetic femoral fractures, but series to date have been limited with respect to cohort size and follow-up duration. The purpose of this study was to determine implant survivorship, radiographic results, complications, and clinical outcomes of Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems in a large series of patients. We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femoral fractures treated with an MFT stem between 2000 and 2018 using our institutional total joint registry. The mean age was 75 years, 50% were female, and the mean body mass index was 29 kg/m2. The median stem diameter was 18 mm and median stem length was 210 mm. The cumulative incidences of revision and reoperation with death as the competing risk were calculated, radiographs were reviewed, and clinical outcomes were evaluated using the Harris hip score (HHS). The mean follow-up was 5 years. The 10-year cumulative incidence of any revision was 10%. There were 17 revisions, of which only 3 were for the distal fluted portion of the MFT stem. Revision indications included periprosthetic joint infection (PJI) (n = 6) and dislocation (n = 11). The 10-year cumulative incidence of any reoperation was 15%. In addition to the above 17 revisions, there were 7 reoperations for superficial wound complications (n = 4), Vancouver B1 periprosthetic femoral fracture (n = 1), vascular occlusion (n = 1), and acetabular cartilage degeneration requiring an acetabular component (n = 1). Radiographically, there was 1 fracture nonunion. All unrevised MFT stems were radiographically well fixed. Subsidence of ≥5 mm occurred in 11%, but all implants were stable at the most recent follow-up. The mean HHS was 75 at 2 years (n = 71). In this large series of 171 Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems, we found that such constructs were associated with a high rate of fracture healing and provided extremely reliable and durable implant fixation, with no revisions for aseptic loosening. Dislocation and PJI were the most common complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Optimal configuration of a three-rod ortho-bridge system in the treatment of Vancouver type B1 periprosthetic femoral fractures: A finite element analysis

Introduction and AimPeriprosthetic femoral fractures (PFF) represent an increasing clinical and economic burden. This study aims to determine the optimal configuration of a bridge-combined internal fixation system in the treatment of Vancouver type B1 PFF, using finite element analysis. Materials and methodsA three-rod ortho-bridge system (OBS) fixation model was used to evaluate the optimal configuration of four target parameters: position of the third rod; intersection angle between the proximal screws; connecting rod diameter; and number of screws used. Femoral displacement and the maximum von Mises stress of the OBS were used as the evaluation indices, to analyze the PFF and to determine the optimal use of an OBS. For each parameter, various candidate options were tested. ResultsFinite element analysis revealed that the rate of femoral displacement and the maximum von Mises stress of the OBS were at a minimum when there was a 35 mm downward movement of the third rod from the baseline. Therefore, the optimal position of third rod fixation was 35 mm below the fovea capitis of the femur. The optimal intersection angles between the proximal screws were found to be 71.92° or 84°. A 6 mm diameter connecting rod proved to be most effective. Configuration d, utilizing 7 screws, represented the most clinically appropriate screw number configuration, despite configuration f, utilizing 9 screws, eliciting the best evaluation indices. ConclusionAn OBS used in the above-described configuration is well suited to the characteristics of PFF and provides an effective and reliable means for their treatment.

Treatment of Vancouver Type B Periprosthetic Femoral Fractures Using Cortical Strut Allografts.

IntroductionThe optimal surgical treatment for Vancouver B2 and B3 fractures has not been determined, and bone defects and delays in fracture healing significantly affect treatment outcomes. Some authors have argued that when a serious bone defect is present, the use of cortical strut allografts for the treatment of type B2 and B3 periprosthetic femoral fractures (PFFs) after hip joint replacement may be beneficial. This study aimed to determine the usefulness of cortical strut allografts based on mid-to long-term clinical radiologic results after surgical treatment of Vancouver B-type PFFs.MethodsWe retrospectively reviewed the outcomes of 48 patients with postoperative PFFs. The mean duration of follow-up was 6.7 years. The 22 patients were treated with cortical strut allograft. Each case was characterized and described in detail, including the length of allograft and the union period, and possible correlations between allograft length and strut-to-host bone union were analyzed. Clinical evaluations included Parker mobility and Harris hip scores. At the final follow-up, we assessed the radiological results using the Beals and Tower’s criteria, stem subsidence, and fracture union time.ResultsAll 48 fractures united at an average of 21.5 weeks, and strut-to-host bone union was typically observed within 32 months. No positive correlation was identified between the allograft length and incorporation period. There was one deep infection and four cases of dislocation, but there was no fracture or malunion of the cortical strut allografts. No evidence of femoral loosening was observed in any of the patients.ConclusionCortical strut allografts used to treat type B PFFs showed high rates of bone union and survival. In mid-to long-term follow-up, the cortical strut allograft length did not affect to incorporation time. The author concluded that cortical strut allografts are useful treatment for PFFs regardless subtype classification of the Vancouver type B.

Impaction Bone Grafting for Severe Femoral Bone Loss: Surgical Technique in Revision Total Hip Arthroplasty.

The specific steps to perform this procedure include (1) preoperative planning; (2) positioning of the patient and surgical approach; (3) cautious removal of the previous components; (4) preparation of the bone graft; (5) implantation of the appropriate IBG revision system, restoring bone loss from distal to proximal and utilizing metal mesh as needed; (6) implantation of the new stem, bypassing the defect; and (7) aftercare with protected weight-bearing in order to avoid subsidence of the stem and periprosthetic fracture. There are several alternatives to the IBG technique in the setting of revision total hip arthroplasty with extensive femoral bone loss. These alternatives include distal cementless fixation (either modular or nonmodular), a megaprosthesis, or an allograft-prosthesis composite. The rationale for use of the IBG technique is restoration of bone stock. Although this issue may be irrelevant in low-demand elderly patients, we believe it is of the utmost importance among young (i.e., <60 years old) and active patients. This technique is versatile enough to be utilized in different scenarios such as periprosthetic fracture, periprosthetic joint infection (2-stage protocols), and aseptic loosening. We have reported favorable clinical and radiographic outcomes for the treatment of both aseptic and septic femoral component loosening. In all cases, we utilized vancomycin-supplemented impacted cancellous allograft without evidence of secondary effects with regard to bone incorporation, nephrotoxicity, or allergic reactions. Although it was initially contraindicated, we further extended the indication for this reconstruction alternative to cases of circumferential proximal bone loss with non-neoplastic bone defects of ≤15 cm, utilizing encompassing metal mesh and a bypassing long stem. Recently, we reported on poorer outcomes following IBG compared with the use of uncemented modular stems for the treatment of type B3 periprosthetic femoral fractures, with a significantly higher rate of infection and implant breakage for the former treatment. Nowadays, we advocate the use of this technique in young, active patients (i.e., <60 years old) with a femoral bone defect Paprosky grade IIIB or IV, in which reconstitution of bone stock is crucial to avoid an eventual implant failure in the long term. This technique requires an experienced team. This procedure should be avoided in the presence of active periprosthetic joint infection.The gluteus maximus tendon should be detached to avoid tensioning the sciatic nerve and to decrease the chance of periprosthetic femoral fracture.Massive bone loss can jeopardize correct implant orientation and restoration of biomechanics. In this scenario, surgeons might consider the intercondylar axis as a guide for femoral version.Try to avoid (if possible) trochanteric or extended trochanteric osteotomy because proximal bone stock is necessary to contain the bone grafts. In some cases, such as those in which the removal of the stem is difficult, especially with certain uncemented stem designs, an extended trochanteric osteotomy must be performed. Whether or not a cemented stem is removed, it is mandatory to remove all remaining cement in the femoral canal.Preoperative templating is a necessity to reconstruct leg length. Accurately determining the length of the mesh is the most important step to avoid shortening or overlengthening of the lower extremity.Approximately 10 cm of circumferential metal mesh should be fixed with 3 to 5 double cerclage metal wires to the remaining bone. The new femoral stem should bypass extend beyond the mesh for approximately 5 cm. If the stem does not bypass the mesh, there is an increased risk of postoperative fracture.In order to decrease the risk of intraoperative femoral fracture, the distal aspect of the femur should be secured with cerclage wires, and the proximal aspect of the femur should also be protected with cerclage wires over the mesh. As in any other complex femoral revision procedure, torsional forces in the supracondylar zone should be avoided, especially during trial or stem reduction maneuvers.Always utilize a bone graft mixed with antibiotic powder.Retrograde cementation must be done with cement that is in a more liquid state than in primary total hip arthroplasty. PO = postoperativePMMA = polymethyl methacrylateIV = intravenousLMWH = low molecular weight heparinDVT/EP = deep vein thrombosis and extended prophylaxis.

The impact of stem fixation method on Vancouver Type B1 periprosthetic femoral fracture management.

Introduction: Our understanding of the impact of the stem fixation method in total hip arthroplasty (THA) on the subsequent management of periprosthetic femoral fractures (PFF) is still limited. This study aimed to investigate and quantify the effect of the stem fixation method, i.e., cemented vs. uncemented THA, on the management of Vancouver Type B1 periprosthetic femoral fractures with the same plate. Methods: Eight laboratory models of synthetic femora were divided into two groups and implanted with either a cemented or uncemented hip prosthesis. The overall stiffness and strain distribution were measured under an anatomical one-legged stance. All eight specimens underwent an osteotomy to simulate Vancouver type B1 PFF’s. Fractures were then fixed using the same extramedullary plate and screws. The same measurements and fracture movement were taken under the same loading conditions. Results: Highlighted that the uncemented THA and PFF fixation constructs had a lower overall stiffness. Subsequently, the mechanical strain on the fracture plate for the uncemented construct was higher compared to the cemented constructs. Conclusion: PFF fixation of a Vancouver type B1 fracture using a plate may have a higher risk of failure in uncemented THAs.

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

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). 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. Included studies were retrospective studies comparing ORIF and rTHA for the management of Vancouver B2 PFFs. 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. 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. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of periprosthetic femoral fracture fixation plating constructs on local stiffness, load transfer, and bone strains

Secondary femoral fractures after the successful plate-screw fixation of a primary Vancouver type B1 periprosthetic femoral fracture (PFF) have been associated with the altered state of stress/strain in the femur as the result of plating. The laterally implanted condyle-spanning plate-screw constructs have shown promises clinically in avoiding secondary bone and implant failures as compared with shorter diaphyseal plates. Though the condyle-spanning plating has been hypothesized to avoid stress concentration in the femoral diaphysis through increasing the working length of the plate, biomechanical evidence is lacking on how plate length may impact the stress/strain state of the implanted femur. Through developing and experimentally validating finite element (FE) models of 3 cadaveric femurs, this study investigated the impact of plating on bone strains, load transfer and local stiffness, which were compared between FE models of 2 different plating systems that each had a diaphyseal configuration and a condyle-spanning configuration. Under simulated gait-loading, the condyle-spanning constructs of both plating systems were shown to lower the bone strains around the distal fixation screws (up to 24.8% reduction in maximum principal strain and 26.6% reduction in minimum principal strain) and in the distal metaphyseal shaft of the femur (up to 15.9% and 25.7% reductions in maximum and minimum principal strains, respectively), where secondary bone fractures have been typically reported. In the distal diaphyseal and metaphyseal shaft of femur, FE models of the condyle-spanning constructs were shown to increase the local compressive stiffness (up to 152.9% increases under simulated gait-loading) and decrease the transfer of compressive load (37.1% decreases under simulated gait-loading), which may be indicative of the lowered risks of bone damage.