A multicentre comparative analysis of fixation versus revision surgery for periprosthetic femoral fractures following total hip arthroplasty with a cemented polished taper-slip femoral component

Abstract

Aims The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA). Methods Data were collected for patients admitted to five UK centres. The primary outcome measure was the two-year reoperation rate. Secondary outcomes were time to surgery, transfusion requirements, critical care requirements, length of stay, two-year local complication rates, six-month systemic complication rates, and mortality rates. Comparisons were made by the form of treatment (ORIF vs revision) and UCS type (B1 vs B2/B3). Kaplan-Meier survival analysis was performed with two-year reoperation for any reason as the endpoint. Results A total of 317 periprosthetic fractures (in 317 patients) with a median follow-up of 3.6 years (interquartile range (IQR) 2.0 to 5.4) were included. The fractures were type B1 in 133 (42.0%), B2 in 170 (53.6%), and B3 in 14 patients (4.4%). ORIF was performed in 167 (52.7%) and revision in 150 patients (47.3%). The two-year reoperation rate (15.3% vs 7.2%; p = 0.021), time to surgery (4.0 days (IQR 2.0 to 7.0) vs 2.0 days (IQR 1.0 to 4.0); p < 0.001), transfusion requirements (55 patients (36.7%) vs 42 patients (25.1%); p = 0.026), critical care requirements (36 patients (24.0%) vs seven patients (4.2%); p < 0.001) and two-year local complication rates (26.7% vs 9.0%; p < 0.001) were significantly higher in the revision group. The two-year rate of survival was significantly higher for ORIF (91.9% (standard error (SE) 0.023%) vs 83.9% (SE 0.031%); p = 0.032) compared with revision. For B1 fractures, the two-year reoperation rate was significantly higher for revision compared with ORIF (29.4% vs 6.0%; p = 0.002) but this was similar for B2 and B3 fractures (9.8% vs 13.5%; p = 0.341). The most common indication for reoperation after revision was dislocation (12 patients; 8.0%). Conclusion Revision surgery has higher reoperation rates, longer surgical waiting times, higher transfusion requirements, and higher critical care requirements than ORIF in the management of periprosthetic fractures around polished taper-slip femoral components after THA. ORIF is a safe option providing anatomical reconstruction is achievable. Cite this article: Bone Joint J 2023;105-B(2):124–134.

Hip & Pelvis

“…We were delighted to see this large multicentre study from Leeds (UK) that aimed to compare, in large numbers, the treatment options of open reduction and internal fixation (ORIF) with revision surgery (of all types) for patients presenting with Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip stem. 3 The study was conducted at five large UK centres retrospectively, and included follow-up to two years for reoperation, surgical outcomes (including wait for surgery, blood loss, length of stay, and complications), and mortality rates. The study cohort consisted of 317 periprosthetic fractures (in 317 patients) with a median follow-up of 3.6 years.…”

Which Unified Classification System type B periprosthetic fractures around cemented polished tapered stems should not be fixed?

“…In another single-centre study, Slullitel et al 16 also found that selected B2 fractures around PTS stems can be safely treated with fixation. Most recently, Jain et al 17 reported the results of a large multicentre study on 317 periprosthetic fractures around PTS stems managed across five UK centres and found that fixation surgery (n = 167) was associated with lower reoperation rates, lower local complication rates, a shorter time to surgery, and lower critical care requirements than revision arthroplasty (n = 150). Specifically, for type B2 and B3 fractures there was no difference in reoperation rate at two years between fixation and revision arthroplasty.…”

“…Our clinical outcomes have been published previously. 15,17,[19][20][21][22][23] This paper details our experience of which UCS type B fractures around cemented PTS stems cannot, or should not, be treated with fixation.…”

“…From the current evidence, it appears that some periprosthetic fractures around cemented PTS stems should be fixed in preference to revision surgery. 15,17 Revision arthroplasty for periprosthetic fracture is associated with higher mortality than revision for other modes of failure. 18 Revision surgery is also associated with longer waiting times for surgery, greater critical care requirements, higher reoperation rates, higher readmission rates, and higher 30-day mortality rates compared to fixation.…”

“…18 Revision surgery is also associated with longer waiting times for surgery, greater critical care requirements, higher reoperation rates, higher readmission rates, and higher 30-day mortality rates compared to fixation. 14,15,17 However, not all fractures are fixable and not all should be fixed. In the UK, there is ongoing implementation of a hub-and-spoke strategy to perform complex revision arthroplasty in regionalized ‘major revision centres’.…”