B2 Periprosthetic Fractures Research Articles

Immediate results of treatment periprosthetic femoral fractures after hip replacement

Periprosthetic fractures are one of the most serious complications after hip replacement. Nineteen periprosthetic femoral fractures operated on during the period 2011-2015 were followed-up retrospectively. Periprosthetic fractures were classified according to the Vancouver classification. The functional results were evaluated using Harrison scale. Bone healing and implant stability were evaluated clinically, on plain radiographs and computed tomography. The periprosthetic fractures in all patients occurred in the postoperative period. Time from operation until fracture varied from 2 weeks to 11 years. A wedge-shaped cemented or cementless stems were implanted during the first surgery: Versys ET, Spotorno, CPT (Zimmer, США): cementless fixation was performed in 16 (84,2%) patients, hybrid -in 2 (10,5%) and cemented fixation - in 1 (5,3%) patient. The fractures of greater trochanter were diagnosed in all patients with type A periprosthetic fractures. In type B1 periprosthetic fracture (8 patients) open reduction, cerclage wiring and internal plate osteosynthesis were applied. Loosening stems in 3 patients with type B2 fractures were replaced with Wagner cementless revision component (Wagner SL Revision Stem). Angle-stable plate osteosynthesis and cerclage wiring were also performed. Closed reduction and internal minimal invasive plate osteosynthesis were performed in patients with type C periprosthetic fractures. Bone consolidation was achieved in 18 (94,7%) patients, the average term was 14,3±5,2 weeks. The average Harris hip score in all patients 3 months after treatment was 64,9±16,7 points, and in 12 patients (63,2%) after a year - 86,5±15,9. Femoral periprosthetic fractures require a specialized approach to choosing the treatment tactic depending on the fracture type and quality of bone tissue. It is necessary to evaluate the femoral component stability, especially in differential diagnosis of type B1 and B2 periprosthetic fractures. Computed tomography is one of the necessary methods of diagnosis.

Vancouver type B2 and B3 periprosthetic fractures treated with revision total hip arthroplasty

Periprosthetic fractures are the fourth most common cause for hip revision and a devastating complication. Our purpose is to report results and quality of life following revision THA for Vancouver B2 and B3 fractures. This was a retrospective review from January 2000 to November 2012 to identify all revision THA performed for Vancouver types B2 and B3 that had a minimum follow-up of two years. Routine post-operative and radiographic evaluation to assess patient survival, implant failure, complications and quality of life was involved. Statistical analysis was made with the Kaplan-Meier survival curve with 95 % confidence interval and the log rank (Mantel-Cox) test. A total of 76 fractures were included, with an average follow-up 74.4 months. Mean age at the revision surgery was 75.7 years (range, 41-97 years; SD, 12.4). Sixty-six cases were classified as Vancouver B2 and treated with distal fixation stem. Ten cases were Vancouver B3 and a proximal femoral allograft technique was used. The overall five-year Kaplan-Meier survival rate for the patients was 77.9 % (95 % CI, 67.4-88.4), and the ten-year rate was 65.1 % (95 % CI, 51.4-78.8). Five-year Kaplan-Meier survival rate for the implants was 89.6 % (95 % CI, 82.2-97); we presented seven failures. The mean SF-12 mental was 55.1 (range, 31-68; SD, 8.1) and the physical was 37.4 (range, 16-55; SD, 9.4). Mortality rate after periprosthetic fractures is high as compared to other hip surgeries; our Kaplan-Meier analysis showed that it tends to plateau after five years. In our series the failure rate was low and occurred early in the post-operative period.

Treatment of periprosthetic femoral fractures with modular stems.

The purpose of this study was to analyse the efficacy of modular femoral stems for the treatment of certain post-operative periprosthetic fractures in patients with hip arthroplasty. Of a total series of 61 modular revision stems, 17 were used to address periprosthetic femoral fractures and 12 of these are the object of this study. The average follow-up was 3.7 years (range 1-14 years). The evaluations were performed at three and six months, and then annually using the HHS score and radiographic studies for the assessment of loosening, subsidence and bone integration of the stem. Seven cases had type B2 fractures and five type B3 ones. All patients walked freely, eight of them using canes. HHS improved to a post-operative mean of 78 (range 72-83). Radiographically, fracture healing was observed at three months in nine cases. In six cases stem subsidence of a mean of 3.9 mm (range 2-12 mm) was observed, which stabilized a year following implantation and did not need revision surgery. In two cases a subsequent dislocation (at three and seven months after surgery) occurred, which were treated with constrained acetabular systems. In nine cases hypotrophy of the cortex in the diaphyseal area was noted, which did not alter the patients' clinical course. Modular femoral stems are an acceptable treatment in type B2 and B3 periprosthetic fractures.

Modular revision stems: how can they help us in the management of Vancouver B2 and B3 periprosthetic fractures?

Over recent years, revision stems have been introduced for the treatment of periprosthetic fractures. Modular stems are supposed to provide some advantages to the surgical treatment of this complication. To evaluate the midterm radiological and functional results of periprosthetic hip fractures treated with modular revision stems. A retrospective review of 21 patients with a mean age of 77 years (47–88) is here presented. They had suffered a periprosthetic femoral fracture around a total hip arthroplasty between 2004 and 2010. Sixteen of them were a Vancouver classification type B2 and 5 were type B3. In all cases, a transfemoral approach was performed. Previous stems were exchanged for Revitan® (Zimmer) modular stems. There were 14 curved stems and 7 straight stems. The mean patient follow-up period was 22 months. Functional results were assessed using the Merle d’Aubigne score. The degree of subsidence was determined by comparing the postoperative images with those taken during the very last follow-up. No stem loosening was observed during follow-up. There was one non-union of the femoral osteotomy which was not of either clinical or functional relevance. Subsidence was less than 4 mm in 19 cases; one case showed 7 mm of subsidence and the other had 21 mm at final follow-up. Three patients (14 %) had to be operated on again. One of them was due to a refracture, another for acetabular loosening and one more due to reiterative dislocation (an additional case of dislocation was conservatively treated). The mean Merle d’Aubigne score at final follow-up was 5-5-4. Mortality stood at 19 % throughout follow-up. Modular revision stems provide some advantages compared with osteosynthesis in that they make early weight bearing possible. In addition, version, offset, and limb length is easier to control and calculate. Therefore, modular revision stems should be considered the treatment of choice for periprosthetic femoral fractures.

Tapered fluted modular titanium stems in the management of Vancouver B2 and B3 peri-prosthetic fractures

Tapered, fluted, modular, titanium stems are increasingly popular in the operative management of Vancouver B2 and selected B3 peri-prosthetic femoral fractures. We have reviewed the results at our institution looking at stem survival and clinical outcomes and compared this with reported outcomes in the literature. Stem survival at a mean of 54 months was 96% in our series and 97% for combined published cases. Review of radiology showed maintenance or improvement of bone stock in 89% of cases with high rates of femoral union. Favourable clinical outcome scores have reported by several authors. No difference in survival or clinical scores was observed between B2 and B3 fractures. Tapered stems are a useful option in revision for femoral fracture across the spectrum of femoral bone deficiency.

Tapered Fluted Titanium Stems in the Management of Vancouver B2 and B3 Periprosthetic Femoral Fractures

Surgeons have several implant choices when managing Vancouver B2 and B3 periprosthetic fractures about the hip. Few long-term studies have reported outcomes for tapered fluted titanium stems. We determined (1) survival, with femoral revision as the end point, of distal taper stems in the treatment of Vancouver B2 and B3 periprosthetic fractures at our institution, (2) radiographic outcomes, and (3) quality of life and hip function after revision. Of the 200 patients with Vancouver B2 or B3 periprosthetic fractures treated with femoral revision between February 2000 and February 2010, 55 (38 B2, 17 B3) were treated with modular tapered titanium stems. Of the surviving 47 patients, one was lost to followup, leaving 46 (30 B2, 16 B3) available for review at a mean of 54 months (range, 24-143 months). Initial indications for using these implants were treatment of periprosthetic fractures where less than 4 cm of diaphyseal fit was available, but this evolved during the study period to all fractures unless no diaphysis remained, in which case complex revision techniques were used. Radiographs were assessed to establish fracture healing, stem subsidence, and bone stock restoration. Quality of life and hip function were assessed using WOMAC, Oxford, SF-12, UCLA activity level, and satisfaction scores. Two femoral stems were revised: one subsided and was revised at 12 months; the other had deep infection and underwent two-stage revision at 49 months. Radiographic review showed one nonunion, with maintenance or improvement of bone stock in 89% of patients. Subsidence occurred in 24%. Mean Oxford score was 76 of 100, WOMAC function and pain scores were 75 and 82 of 100, satisfaction score was 91 of 100, and SF-12 mental and physical scores were 53 and 40 of 100. We report encouraging short-term results in terms of survival of distal taper stems in the treatment of B2 and B3 periprosthetic fractures. Although subsidence was frequent, most migrated less than 3 mm without correlation to poor pain and functional scores.

Periprosthetic Femoral Fractures: Treatments and Outcomes. An Analysis of 47 Cases

We evaluated the treatment and outcome of 47 cases of periprosthetic femoral fracture presenting to our unit over a nine-year period. The average follow-up period was 48 months (range 24-114). Surgical treatment involved stem revision in 29 hips, open reduction and internal fixation in 11 hips and conservative treatment in seven hips. The mean HHS at the most recent follow-up was 74 (range 49-91). Twenty-five patients were pain-free (53%), 10 patients had occasional mild pain (21%), eight patients had a limp and pain (17%) and four patients had severe disability (9%). Postoperative radiographs showed complete fracture union in all 47 patients. There were 11 complications: three further periprosthetic fractures, two aseptic loosenings, two dislocations, two aseptic loosenings of the primary prostheses, one stem breakeage, and one intraoperative fracture. Our results suggest cementless revision with tapered fluted stems used without cortical strut grafts are a valid procedure for the treatment of Vancouver B2 and B3 periprosthetic fractures.

Periprosthetic Femur Fractures Treated With Modular Fluted, Tapered Stems

Treatment of periprosthetic femur fractures is challenging, and high failure and complication rates have been reported in many series. The optimal techniques and implants for the management of Vancouver B2 and B3 fractures remain in debate. The purpose of this study was to evaluate the results of a relatively new class of femoral implants, uncemented fluted, tapered, modular stems, to treat periprosthetic femur fractures; we specifically evaluated (1) fracture union; (2) implant stability; (3) patient outcomes; and (4) complications. We retrospectively identified 44 Vancouver B2 (25 patients) and B3 (19 patients) periprosthetic femur fractures treated consecutively with fluted, tapered stems at a single institution from 2000 to 2006. The mean patient age was 72 years (range, 34-92 years), and 24 were women. The minimum followup was 2 years (mean, 4.5 years; range, 2-8 years). Forty-three of 44 (98%) fractures healed radiographically and 43 of 44 (98%) femoral components were stable radiographically at latest followup. The mean postoperative Harris hip score was 83. There were seven additional reoperations (five for recurrent instability, two for deep infections). Modular fluted, tapered stems provide a reliable treatment method for Vancouver B2 and B3 periprosthetic femoral fractures with a high rate of fracture union and implant osteointegration. The most common complication, instability, may be reduced by more consistent use of larger femoral head diameters.

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.

Increase of Cortical Bone After a Cementless Long Stem in Periprosthetic Fractures

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. 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. 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). 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. 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.

Management of Vancouver type B2 and B3 femoral periprosthetic fractures using an uncemented extensively porous-coated long femoral stem prosthesis

The purpose of this study was to evaluate the clinical results of femoral revision using an uncemented extensively porous-coated long femoral stems with or without onlay strut allografts in the treatment of Vancouver type B2 and B3 periprosthetic femoral fractures. We retrospectively reviewed 17 cases of periprosthetic femoral fracture (eight B2 and nine B3) treated with the uncemented extensively porous-coated long femoral stem. Clinical outcomes were assessed with Harris Hip Score and Barthel ADL index. Radiological evaluations were conducted using Beals and Towers' criteria. Any complication during the follow-up period was recorded. The average follow-up period was 41.7 ± 31.08 (range, 15-132) months. The average Harris Hip Score was 68.2 ± 18.4 (range, 32-100), and the average Barthel ADL index was 80.1 ± 19.75 (range, 30-100) points at the final follow-up. All fractures were united, and a good graft consolidation was achieved in 5 of 9 cases. There was femoral stem subsidence in 4 cases less than 10 mm without an evidence of loosening both radiologically and clinically. The radiological results using Beals and Towers' criteria were excellent in eight hips, good in five and poor in four. An uncemented extensively porous-coated long femoral stem together with or without onlay strut allografts provides a good fracture stability that promotes fracture healing and offers a successful solution for the management of Vancouver type B2 and B3 femoral periprosthetic fractures.

Peri-Prosthetic Femoral Fractures Treated with the Uncemented Wagner Revision Stem

The clinical and radiological results of Vancouver type B2 and B3 peri-prosthetic fractures treated with an uncemented Wagner revision stem (3rd generation) were analysed. Two groups were identified, 15 patients had a B2 and 14 cases a B3 periprosthetic fracture. The mean follow-up was 74 months after the index operation. All fractures had united radiographically. No cases of non-union were found. There was only one case of aseptic loosening. The clinical scores presented encouraging results for both groups. The uncemented distal fixation stem was an effective solution in the treatment of type B2 and B3 periprosthetic femur fractures at mid-term follow up.

Hip Revision Arthroplasty in Periprosthetic Fractures of Vancouver Type B2 and B3

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. Prospective study. Orthopaedic specialized clinic and center for joint replacement. Twenty-two patients with periprosthetic fractures of Vancouver Type B2 and 10 of Type B3 were followed of at least 24 months. Fracture healing, stability of the prosthesis stem, complications, and clinical outcome. 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. 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. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intermediate outcomes of alumina-on-alumina bearing total hip arthroplasty

To explore the intermediate outcomes of third-generation alumina-on-alumina total hip arthroplasty (THA). A consecutive series of 165 primary alumina-on-alumina total hip arthroplasties were performed in 135 patients. Three patients died and 13 patients lost follow-up so that a total of 119 patients (146 hips) were available for study. The mean patient age was 53.4 ± 11.0 years old (range: 26 - 79). Hydroxyapatite. (HA)-coated press-fit acetabular cups were used in all cases. At femoral side, 123 cases were implanted with HA-coated uncemented stems and 23 cases implanted with high polished double taped cemented stems. All patients were evaluated clinically and radiographically after a minimal follow-up duration of 60 months. The preoperative mean Harris hip score of 49.6 ± 7.9 points improved to 91.7 ± 3.0 points at the last follow-up (P < 0.05). The 5-year survival for any reason lead to revision was 96.6%. Five hips were under revision, 1 for acetabular shell loosening and migration, 1 for Vancouver B2 periprosthetic fracture, 1 for fracture of pure alumina liner and 2 for infections. All other prostheses demonstrated no radiographic evidence of loosening. No periprosthetic osteolysis was found. There were 2 cases of dislocations and 2 patients presented postoperatively with "squeaking-like" hips. The clinical and radiographic outcomes after primary THA with third-generation ceramic-on-ceramic bearing surfaces are favorable after a minimal follow-up duration of 5 years. The modified alumina-on-alumina bearing implants offer a better option for younger and active patients.

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

We reviewed our experience with the management of B2 and B3 femoral periprosthetic fractures using a distally fixed modular femoral stem in 55 patients. All periprosthetic fractures were managed immediately after injury without using allograft; 53 hips were available for a mean follow up of 67 months. 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. In these severe cases of periprosthetic fracture, the technique reviewed here proved to be reliable.

Revision Total Hip Arthroplasty for a Vancouver Type B3 Periprosthetic Fracture Using an Allograft-Cemented Stem Composite by the Telescoping Technique

We describe a case of successful revision total hip arthroplasty for a Vancouver type B3 periprosthetic femoral fracture with extensive bone stock deficiency and osteoporotic diaphyseal bone. The femur was reconstructed with an allograft-cemented stem composite using a telescoping technique and a drainage hole for surplus cement. This procedure facilitated stable stem fixation to the host femur without cement interference and bony fusion between the allograft and host bone, as revealed by bone scintigraphy. This technique provides a surgical option for a severe periprosthetic femoral fracture in which the femoral diaphyseal bone is too osteoporotic to support the fixation of an allograft-cementless stem composite.

Cement-in-Cement Femoral Revision for the Treatment of Highly Selected Vancouver B2 Periprosthetic Fractures

The use of the cement-in-cement technique for femoral component revisions has been well described. The application of this technique in the management of selected Vancouver B2 periprosthetic femur fractures, after careful preoperative and intraoperative evaluation, offers a novel alternative that is rapid and technically less demanding, with resulting decreased blood loss and decreased risk of iatrogenic fragmentation of bone during cement removal.

Treatment of Periprosthetic Femoral Fractures after Hip Arthroplasty

Purpose: To determine results of treatment according to the guidelines of the Vancouver classification in periprosthetic femoral fractures after total hip arthroplasty. Materials and Methods: Among 44 cases of periproshtetic femoral fractures after hip arthroplasty treated between Aug. 1991 and Feb. 2008, thirty-two cases with minimum follow-up greater than one year were included. Outcomes were evaluated using the Beals and Tower's critieria. Results: Outcomes were excellent in 27 cases, and poor in 5 cases. Four of 5 cases with poor result were due to non-union. Three cases were treated with internal fixation and 1 case was treated with a conservative method. One case with a poor result was due to loosening of the cemented stem of a Vancouver type B1 fracture. Loosening of the stem after mid to long term follow up occurred in an additional 4 cases (3 cases with a cemented stem in a type B1 fracture, 1 case with a cemented stem of a type C fracture). Loosened stems were revised with a long revision stem. Conclusion: For type B1 periprosthetic fractures around a cementless stem, and for type B2, type B3 periprosthetic fractures, treatment according to the guidelines of the Vancouver classification showed excellent results. However, type B1 periprosthetic fractures around a cemented stem showed poor results with non-union or stem loosening. Hence, more rigid fixation using a bone graft or revision of the stem is needed. In type C periprosthetic fractures in osteoporotic patients, closer attentions is needed to avoid complications.

Vancouver Type B2 and B3 periprosthetic femur fractures treated with modular femoral implants

Vancouver Type B2 and B3 periprosthetic femur fractures treated with modular femoral implants

The use of uncemented extensively porous-coated femoral components in the management of Vancouver type B2 periprosthetic femoral fractures

To assess the outcome of patients with Vancouver type B2 periprosthetic fractures treated with femoral revision using an uncemented extensively porous-coated implant. From October 2002 to May 2007, a retrospective clinical and radiographic assessment of 10 patients with Vancouver type B2 periprosthetic fractures treated with femoral revision was evaluated, among which 4 was cement fixation, 6 was non-cement fixation in the index procedure. The mean follow-up for these patients was 44 months (range, 12 to 67 months). The mean Harris hip score was 87.6 points. All 10 reconstructions showed solid fracture union and a stable prosthesis, 8 was bone ingrowth, 2 was fibrous ingrowth. Complications in 4 patients included thigh pain in 1, stress shield in 3. Vancouver type B2 periprosthetic fractures treated with uncemented extensively porous-coated femoral stems incorporate distally allowing stable fixation.