Vancouver B periprosthetic fractures involving the Exeter cemented stem

Abstract

Aims The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). Methods This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan–Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. Results Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision. Conclusion When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309–320.

Development of the Revision Hip Complexity Classification using a modified Delphi technique

“…Furthermore, there may be complex situations where a B1 fracture does require revision. 15 , 16 As a result of these discussions, B1 was classified into H2 complexity (96%). Classifying C and D was also a challenge for similar reasons.…”

Risk factors influencing fracture characteristics in postoperative periprosthetic femoral fractures around cemented stems in total hip arthroplasty

“…Although associated with higher complication rates, revision surgery is more likely to give better outcomes for these fractures than internal fixation due to the increased risks of nonunion and metalwork failure. 21 - 24 …”

“…Equally successful results have been reported with both fixation and revision of PFFs around PTS stems, although it is accepted that the fracture and cement mantle must be anatomically reducible for fixation to be deemed an appropriate management strategy. 22 , 24 , 37 In addition to UCS grade, surgical decision-making is also likely to be multifactorial relating to training, local experience, availability of implants, and patient factors such as fitness for revision surgery. As might be expected, more transverse and metaphyseal split fractures were observed in the revision group as these are inherently unstable fracture patterns that benefit from revision surgery over internal fixation.…”

“…As might be expected, more transverse and metaphyseal split fractures were observed in the revision group as these are inherently unstable fracture patterns that benefit from revision surgery over internal fixation. 21 - 24 …”

“… 20 Simple fractures can be treated successfully with internal fixation and have more predictable outcomes than revision surgery, which is commonly indicated for comminuted fractures, transverse fractures, or those that occur around a loose stem or with severe bone loss. 21 - 24 A more detailed understanding of fracture patterns around cemented stems and associated risk factors may help guide preventative and therapeutic strategies. 25 …”