Vancouver Type B1 Research Articles

Cement-in-Cement Revision for Selected Vancouver Type B1 Femoral Periprosthetic Fractures: A Biomechanical Analysis

The aim of this study was to perform a biomechanical analysis of the cement-in-cement (c-in-c) technique for fixation of selected Vancouver Type B1 femoral periprosthetic fractures and to assess the degree of cement interposition at the fracture site. Six embalmed cadaveric femora were implanted with a cemented femoral stem. Vancouver Type B1 fractures were created by applying a combined axial and rotational load to failure. The femora were repaired using the c-in-c technique and reloaded to failure. The mean primary fracture torque was 117 Nm (SD 16.6, range 89–133). The mean revision fracture torque was 50 Nm (SD 16.6, range 29–74), which is above the torque previously observed for activities of daily living. Cement interposition at the fracture site was found to be minimal.

Operative Treatment of Periprosthetic Unstable Femoral Fractures of Vancouver Type B1 and C with Variable Plates

Purpose: The purpose of this study is to evaluate the outcome after operative treatment with plate fixation in Vancouver B1 and C periprosthetic unstable femoral fractures. Materials and Methods: We conducted a retrospective assessment of 15 patients who had under gone treatment for a periprosthetic unstable femoral fracture around primary hip arthroplasty between April 1997 and July 2010. The mean age of patients was 69 years(53 to 82 years) at the time of surgery and the mean duration of follow-up was 29.2 months (six to 110 months). According to Vancouver classification, 10 patients were type B1 and five were type C. According to the time of operation, open reduction and internal fixation was performed using four different plates. Bone graft was applied in all patients, regardless of the type of plate. The present review describes the clinical and radiographic results. Results: All patients were able to ambulate without assistance of crutches or walkers. Of the 15 patients, the fracture site was united in all patients. Postoperative dislocation of the ipsilateral hip was observed in one patient; however, there was no occurrence of further complications, such as infections, nerve injuries, or loosening of the femoral stems. Conclusion: In Vancouver type B1 and C fractures, without any loosening of the femoral stems, open reduction with plate fixation using our operative methods provided a satisfactory result.

Clinical Outcome following Surgical Intervention for Periprosthetic Hip Fractures at a Tertiary Referral Centre

Complications following surgical intervention for periprosthetic hip fractures are not uncommon. We report the clinical outcome following definitive surgical intervention for this indication at a single tertiary referral centre. All patients admitted between 2003 and 2009 undergoing such treatment were included. Patient demographics, all surgical interventions, complications following definitive fracture treatment, and postoperative mortality were recorded. Radiographs were reviewed to determine the Vancouver classification for each fracture. There were 67 patients (mean age at revision 76.7 years; 61% female). Fractures occurred around primary total hip arthroplasties (43%), revision arthroplasties (34%), and hip hemiarthroplasties (23%). Mean time to fracture from the most recent arthroplasty performed was 7.0 years. Most fractures were Vancouver type B2 (49%). The majority of patients underwent revision total hip arthroplasty (96%), using long-stemmed prostheses or proximal femoral endoprostheses, with cables for fracture fixation. Wound infection and systemic complications were seen in 16% and 13% respectively. One or more further surgical interventions were performed in 12%. There were no deaths in-hospital or at 30-days, with 10 fatalities (15%) at a mean 2-year follow-up. Lower rates of re-intervention and mortality were observed when surgery for acute periprosthetic hip fractures was performed at a tertiary centre. Revision hip arthroplasty with or without fracture fixation proved an effective and safe treatment of periprosthetic hip fractures in a high-risk patient population.

A Review of Periprosthetic Femoral Fractures Associated With Total Hip Arthroplasty

Periprosthetic fractures of the femur in association with total hip arthroplasty are increasingly common and often difficult to treat. Patients with periprosthetic fractures are typically elderly and frail and have osteoporosis. No clear consensus exists regarding the optimal management strategy because there is limited high-quality research. The Vancouver classification facilitates treatment decisions. In the presence of a stable prosthesis (type-B1 and -C fractures), most authors recommend surgical stabilization of the fracture with plates, strut grafts, or a combination thereof. In up to 20% of apparent Vancouver type-B1 fractures, the femoral stem is loose, which may explain the high failure rates associated with open reduction and internal fixation. Some authors recommend routine opening and dislocation of the hip to perform an intraoperative stem stability test to rule out a loose component. Advances in plating techniques and technology are improving the outcomes for these fractures. For fractures around a loose femoral prosthesis (types B2 and 3), revision using an extensively porous-coated uncemented long stem, with or without additional fracture fixation, appears to offer the most reliable outcome. Cement-in-cement revision using a long-stem prosthesis is feasible in elderly patients with a well-fixed cement mantle. It is essential to treat the osteoporosis to help fracture healing and to prevent further fractures. We provide an overview of the causes, classification, and management of periprosthetic femoral fractures around a total hip arthroplasty based on the current best available evidence.

Treatment of Vancouver B1 fractures—contemporary principles for the use of locking plates

A number of factors complicate the treatment of periprosthetic fractures of the proximal femur. These include bonequality, fixationofthe stem, relationofthe fracturetothe stem, healing potential of the bone and the patient's future risk of another fall. Vancouver type B1 fractures are commonly fixed with locking plates, but even though results have im- proved, complication rate is still rather high. Recent studies suggest that most complications can be avoided if contempo- rary principles are followed; these include anatomical reduc- tion of the fracture, using long plates from the major trochanter to the supracondylar area and improved fixation over the stem. Studies are small and retrospective and further studies are necessary for more definitive conclusions.

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.

Comparison of therapeutic outcomes of periprosthetic femoral fracture between treatments employing locking and conventional plates

Locking plate is considered biomechanically advantageous for porotic bone, compared with conventional plate. However, clinical evaluations of locking and conventional plates for periprosthetic femoral fracture are still controversial. Thus, we investigated the usefulness of a locking plate compared with the conventional plate for treatment for this fracture. We reviewed 40 patients (40 fractures) who had undergone internal fixation for Vancouver type B1 or C periprosthetic fracture. Locking and conventional plates were applied for 21 and 19 patients, respectively. No significant difference was found between locking and conventional plate groups in Merle d' Aubigné hip score, walking ability, operation time, and blood loss. Regarding postoperative complications, delayed union was noted in one patient in the locking plate group and subsidence of the stem in one in the conventional plate group. On the final follow-up, bone union was achieved in all patients. We cannot suggest the usefulness of locking plate for periprosthetic femoral fracture. However, functional training was performed in the same rehabilitation schedule in our comparative study. Considering the angle stability of the locking plate, weight may be loaded on the locking plate, earlier than that on the conventional plate, which may be an advantage of the locking plate.

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.

Percutaneous cerclage wiring and minimally invasive plate osteosynthesis (MIPO): a percutaneous reduction technique in the treatment of Vancouver type B1 periprosthetic femoral shaft fractures

Periprosthetic femoral fractures (PPFs) associated at or near a well-fixed femoral prostheses (Vancouver type-B1) present a clinical challenge due to the quality of the bone stock and instability of the fracture. The purpose of this study was to present a novel reduction technique and analyze clinical and radiographic outcome in patients with Vancouver type-B1 fractures treated with percutaneous cerclage wiring for fracture reduction and maintenance of reduction with minimally invasive plate osteosynthesis (MIPO) utilizing a locking compression plate (LCP). Between March 2007 and December 2008, ten consecutive patients with spiral, oblique or wedge Vancouver type-B1 were treated with closed percutaneous cerclage wiring using a new cerclage passer instrument (Synthes) through small 2-3 cm incisions for reduction and maintenance of reduction. Internal fixation with MIPO was obtained utilizing a long LCP Synthes bridging the fracture. The reduction time, fixation time and operative time were recorded. The rehabilitation protocol consisted of partial weight bearing as tolerated. Clinical and radiographic outcomes included evidence of union, return to pre-injury mobility, and surgical complications were recorded. There were three men and seven women with an average age of 74 years (range 47-84 years) at the time the fracture occured. The average follow-up was 13.2 months. One patient died 2 months after surgery due to cardiovascular problems and was excluded. The average reduction time with percutaneous cerclage wiring was 24.4 min (range 7-45 min). The average fixation time was 79 min (range 53-100 min). The average operative time was 103 min (range 75-140 min). Blood loss was minimal and only two patients needed a blood transfusion. All fractures healed with a mean time to union of 18 weeks (range 16-20 weeks). There was one implant which bent 10° in the post-operative period but went on to heal uneventfully within 16 weeks. There was no evidence of loosening of any implants. Seven patients returned to their previous level of mobility. Two patients required a walker. There were no implant failures, wound complications or infections. Percutaneous reduction of spiral, oblique or wedge-type B1 PPFs with percutaneous cerclage wiring combined with minimally invasive locking plate osteosynthesis provided satisfactory reduction, adequate stability and healing in nine patients. Our early results suggest that this reduction technique and fixation may be a useful solution for this growing challenge in orthopaedics. The authors caution that this technique must be done carefully to avoid serious complications, e.g., vascular injury.

Finite element analysis of different repair methods of Vancouver B1 periprosthetic fractures after total hip arthroplasty

ObjectiveTo use finite element analysis to study the stability of different fixation methods used to repair Vancouver type B1 periprosthetic fractures occurring after total hip arthroplasty (THA). MethodsAn artificial femur was used as the basis for the solid model; U2 series femoral stem (United Orthopedic Corporation, Hsinchu, Taiwan) was used for modelling of the prosthesis; and the modelling of the cable plate, wires and screws was based on information given in the manufacturer's catalogue (Zimmer, Warsaw, IN, USA). The analysis model was constructed using the ANSYS software, and all material settings were based on literature values. A six-orifice cable plate, unicortical screws (20mm long and 4.5mm in diameter) and bicortical screws (50mm long and 4.5mm in diameter) were constructed. Four analysis models were defined. The basic model had a plate and three cable wires above the fracture line and two bicortical screws below the fracture line. In the second model, two unicortical screws were added above the fracture line. In the third model, three wires were added below the fracture line. In the fourth model, both the proximal screws of the second model and the distal wires of the third model were added to the basic model. To ensure that the numerical values produced by analysis reached convergence, mesh convergence was tested. ResultsAdding two proximal unicortical screws to the basic Ogden construct (plate, proximal wires and distal screws) lessened displacement of the fracture and decreased the von Mises stress on the repair. Adding three distal wires to the basic construct had no noticeable effect. ConclusionBetter fixation power is achieved by using both proximal and distal screws (the locking-plate concept) in treating Vancouver type B1 periprosthetic fracture after THA.

Aggressive Surgical Treatment of Periprosthetic Femur Fractures Can Reduce Mortality: Comparison of Open Reduction and Internal Fixation versus a Modular Prosthesis Nail

The purpose of this study was to determine if immediate full weightbearing after surgical treatment for periprosthetic femur fractures can decrease perioperative and total mortality. Retrospective review. Level II trauma center. Fifty-two consecutive patients with a periprosthetic femur fracture during a 16-year time period. Comparison of open reduction and internal fixation with a plate (non- or partial postoperative weightbearing) versus stem exchange to a modular prosthesis nail (immediate full postoperative weightbearing). Six-month and total mortality using a Kaplan-Meier survival analysis. An additional matched subanalysis was performed for Vancouver Type B1 fractures. Patients permitted immediate postoperative full weightbearing had a significantly decreased total (P < 0.001) and 6-month mortality (P = 0.007). Subanalysis of patients with Vancouver Type B1 fractures also showed decrease in mortality, which was significant for total (P < 0.005) but not for 6-month mortality (P = 0.121). Treatment of periprosthetic femur fractures with femoral component exchange to a modular prosthetic nail that allows immediate postoperative full weightbearing may decrease mortality.

Nickel-titanium shape-memory sawtooth-arm embracing fixator for periprosthetic femoral fractures

We reviewed data to determine outcomes for 21 consecutive Vancouver type B1 or type C periprosthetic fractures that we treated between 2001 and 2008 using a nickel-titanium shape-memory sawtooth-arm embracing fixator. The study participants were 12 men and 9 women (mean age, 70.8 years; range, 42-85 years). The average duration of follow-up monitoring was 39.7 months (range, 1-78 months). In five cases, cables and screws were used for further stabilisation. No bone grafting was performed for any of the patients. Results were satisfactory, except for one patient who died one month after surgery from a cause unrelated to arthroplasty. Bone union was achieved in the remaining 20 cases within an average of 5.25 months. No implant failures or malunions occurred in any of the patients. The average Harris hip score at the final follow-up examination was 79.3 points. Our results show that the embracing fixator is a valid alternative treatment for Vancouver type B1 or type C periprosthetic femoral fractures.

Results of Cemented Femoral Revisions for Periprosthetic Femoral Fractures in the Elderly

The treatment goals of Vancouver type B2 periprosthetic femoral fractures in elderly patients with a limited life expectancy are early weight bearing without compromising the fracture healing. Thirty-one patients with a mean age of 82 years were treated with a long cemented stem with additional allograft or plate fixation, followed by immediate full weight bearing. Seven major complications occurred within the first 3 months postoperatively. Forty-three percent of patients had died within the first year with their implant in place. Sixteen patients had survived more than 1 year. None of the implants had to be revised at a mean follow-up of 46 months. The results of this series suggest that this technique can provide acceptable results and offers the advantages of reduced cost and early weight bearing.

Biomechanical Comparison of 2 Different Locking Plate Fixation Methods in Vancouver B1 Periprosthetic Femur Fractures

Locking plates are commonly used to treat fractures around a well-fixed femoral component. The optimal construct should provide sufficient fixation while minimizing soft-tissue dissection. The purpose of the current study was to determine whether plate length, working length, or bone mineral density affects survival of locking plate fixation for Vancouver type B1 periprosthetic hip fractures. A transverse osteotomy was created just distal to cemented femoral prostheses in 9 pairs of cadaveric femurs. Fractures were stabilized with long (20-hole) or short (12-hole) locking plates that were secured proximally with cables and screws and distally with screws only. Specimens were then cycled 10000 times at 2500 N of axial force and 15 Nm of torque to simulate full weightbearing. A motion capture system was used to record fracture displacement during cycling. Failure occurred in 5 long and 3 short plates, with no significant differences found in the number of cycles to failure. For the specimens that survived, there were no significant differences found between long and short plates for displacement or rotation observed at the fracture site. A shorter working length was not associated with increased failure rate. Lower bone mineral density was significantly associated with failure (P = .02). We concluded that long locked plates do not appear to offer a biomechanical advantage over short locking plates in terms of fixation survival, and that bone mineral density was a better predictor of failure than was the fixation construct type.

Outcome after operative treatment of Vancouver type B1 and C periprosthetic femoral fractures: open reduction and internal fixation versus revision arthroplasty

The rate of periprosthetic femoral fractures after hip arthroplasty is rising and the estimated current lifetime incidence is 0.4-2.1%. While most authors recommend revision arthroplasty in patients with loose femoral shaft components, treatment options for patients with stable stem are not fully elucidated. Against this background we performed a retrospective chart analysis with clinical follow-up examination of 32 cases that sustained a Vancouver type B1 or C periprosthetic fracture (stable stem). Overall 16 cases were treated by open reduction and internal fixation (ORIF) by plate osteosynthesis and 16 cases by revision arthroplasty (RA). Both groups were comparable regarding age, gender, follow-up time interval, time interval from primary hip arthroplasty to fracture and rate of cemented femoral components, but more type C fractures were treated by ORIF. Functional outcome expressed by the median timed "Up and Go" test did not differ significantly (30 s ORIF vs. 24 s RA, P = 0.19). However, by comparable systemic complications surgery-related complications were significantly more frequent in plate osteosynthesis (ORIF n = 10 vs. RA n = 3, P = 0.03). Based on our results, further studies, preferable via a multicenter approach, should focus on identifying patients that benefit from ORIF in periprosthetic fractures. A misinterpretation of type B2 fractures with loose implant as type B1 fractures may cause implant failure in case of ORIF. The use of angular stable implants, additional cable wires or bone enhancing means is recommended.

Rifrattura di femore in osteoporosi severa non trattata: descrizione di un caso

In orthopaedic practice, periprothesic fractures are gaining relevance. Their incidence after first implantation is 1.5% and they increase to 6% in revisions. However, their etiology is still uncertain, as evidenced by the present case report of a femoral periprosthetic re-fracture. A female 83-years-old patient, admitted to another hospital for a femoral subcapital fracture and treated with the implantation of an endoprosthesis, was discharged for a long rehabilitative period. After some time the patient had a new periprosthetic fracture, followed by prolonged bed rest due to a synthesis with long plate. Less than one year later she had her third femoral fracture of Vancouver type B1 involving the diaphysis between hip stem of the endoprosthesis and the plate implanted in the two previous occasions. During hospitalization at our institute bone turnover markers and vertebral DEXA revealed a severe poromalacic status characterized by high bone resorption and vitamin D3 deficiency related to secondary hyperparathyroidism. After surgery, in view of 3 months of wheel-chair and no weight-bearing, she started teriparatide, a bone anabolic agent, with daily calcium carbonate and vitamin D3 supplementation; 5 months after the intervention she walked on weight-bearing with crutches. At 2 years f.u. she is free from new fractures and lives and walks in autonomy with one crutch.

Locking Compression Plates for the Treatment of Periprosthetic Femoral Fractures Around Well-Fixed Total Hip and Knee Implants

There are currently few published studies examining the use of locking compression plates for the treatment of periprosthetic femoral fractures. Fifteen total hip or knee arthroplasty patients with 16 Vancouver type B1 and C fractures with an average age of 76 years were fixed and followed clinically and radiographically for 2 years. Fourteen patients achieved radiographic union by 6 months, and 13 patients were ambulatory by 6 months. There were no intraoperative complications. In summary, locking plates offer a viable treatment option for these difficult fractures. We advocate a minimum of 10 cortices of fixation (with unicortical or bicortical screws and cable combinations) above and below the fracture. Bone grafting should be used if the soft tissue envelope is violated with extensive dissection, and cortical struts should be considered in cases of failed hardware and revision fixation.

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.

Early Post-operative Periprosthetic Femur Fracture in the Presence of a Non-cemented Tapered Wedge Femoral Stem

Non-cemented femoral fixation in hip arthroplasty has become the standard of practice in the USA. However, recent literature has brought attention to an increasing incidence of periprosthetic femur fractures with certain stem designs. This study examines reasons for early periprosthetic femur fractures in patients with a hip arthroplasty performed using a non-cemented tapered wedge stem design. A multivariate analysis using a matched-cohort design was performed to assess any potential risk factors that may predispose to such fractures. Six of 2,220 hips (0.3%) suffered a periprosthetic femur fracture within the first year after surgery; five of six were Vancouver Type B2. The average time to fracture was 9weeks. This group of patients had a significantly higher canal-flare index and lower canal-calcar ratio. This complication may be preventable by having a better appreciation of the fit between the implant and the bone during pre-operative planning, with the goal of avoiding a proximal-distal mismatch.