Review Question - QID 213117

This patient has a displaced (> 2cm) greater trochanteric periprosthetic fracture around her previous right total hip arthroplasty (THA). Her fracture is classified in the Vancouver classification as AG, and is best treated with open reduction internal fixation (ORIF) using a trochanteric claw plate.

The Vancouver hip periprosthetic classification system is one of the most useful classifications in the field of orthopaedic surgery, as it can reliably guide decision-making regarding fixation versus revision of the femoral component. Vancouver A fractures confer fractures about the femoral trochanters, with AG and AL fractures depicting greater and lesser trochanters, respectively. While nondisplaced and minimally displaced (<2cm) Vancouver AG fractures may be managed nonoperatively with protected weight-bearing, displaced AG fractures should be treated with ORIF using wires, cables, or claw plates.

Sariyilmaz et al. performed a biomechanical study to compare fixation techniques (cables, trochanteric grip plates, and locking plates) in Vancouver type AG periprosthetic femoral fractures. They reported that locking plate versus cable fixation and grip plate fixation versus cable fixation showed statistically significant superior results in axial distraction tests. They concluded that Vancouver type AG fractures may be treated with either grip plate fixation or locking plates, with the former ensuring more stable osteosynthesis.

Masri et al. published a review article on the evaluation and management of periprosthetic fractures. They reported that the best outcome is achieved when the surgeon has a thorough understanding of the principles of treatment of periprosthetic fractures with access to various fixation and prosthetic devices. They concluded that the Vancouver classification offers a reproducible description of these factors and easily guides treatment.

Figure A depicts a displaced greater trochanteric periprosthetic fracture. Illustration A depicts the Vancouver periprosthetic hip classification system. Illustration B depicts an example of a Vancouver AG fracture treated with ORIF using a claw plate.

Incorrect Answers:
Answers 1 & 3: Displaced Vancouver AG fractures should be treated with ORIF using either trochanteric cables, claw plates, or locking plates.
Answer 4: A Vancouver AL fractures occur at the lesser trochanter, not the greater trochanter.
Answer 5: Vancouver B1 fractures occur around or just below a well-fixed stem. They are treated with ORIF.