Review Question - QID 219013

This patient has sustained a total hip arthroplasty (THA) periprosthetic fracture. The correct treatment for fracture located at/near the tip of the stem, in the setting of a subsided/loose femoral stem (Vancouver B2), is a revision to a diaphyseal-engaging stem with concomitant open reduction and internal fixation (ORIF) (Answer D).

THA periprosthetic fractures are an increasingly common complication encountered by orthopaedic surgeons secondary to the higher demand of modern elderly patients and the rapid expansion of arthroplasty procedures performed. While intraoperative fractures are more common than postoperative fractures, 1-3/1000 patients will sustain a postoperative fracture, most commonly occurring at the stem tip. Femoral-sided fractures are more common than acetabular-sided fractures, and the risk factors for these complications include poor bone quality, cementless prostheses, and revision procedures.

THA periprosthetic fractures are classified by the Vancouver classification system (Illustration A), which denotes both diagnostic and therapeutic purposes and requires only plain-film radiographs for application. A variety of factors make up the final Vancouver classification of a fracture, but important fracture characteristics with respect to the application of this classification include fracture location, implant stability/instability, and the host bone quality/stock. Fractures with a loose femoral component will always require component revision to either a long, diaphyseal-engaging, cementless stem or a modular fluted, tapered stem that bypasses the fracture site by at least two cortical diameters.

Abdel et al. report on the use of modular, fluted tapered stems in the treatment of 24 Vancouver B2 and 19 Vancouver B3 patients. The mean patient age was 72 years and the minimum follow-up was 2 years (mean 4.5 years, range 2-8). Overall, 43/44 (98%) of fractures demonstrated radiographic union and 43/44 (98%) of femoral components were stable at the latest follow-up. The most common complication encountered was postoperative instability (5/43), and the authors purport that larger femoral head diameters could help to decrease the rate of postoperative instability.

Shah et al. provide a review of the management of THA periprosthetic fractures in the setting of a loose femoral component. The authors note that these fractures are increasing in incidence and that femoral component revision is a critical surgical step in the management of fractures around loose femoral components. The authors note that while Vancouver B2 fractures were classically treated with long, diaphyseal-engaging femoral stems, modular tapered stems have recently gained popularity, and both components appear to be appropriate for the treatment of these fractures.

Figure A demonstrates a well-fixed femoral component with a fracture far distal to the tip of the stem, consistent with a Vancouver C fracture. Figure B demonstrates a loose femoral component with poor proximal bone stock and a fracture at/near the tip of the stem consistent with a Vancouver B3 fracture. Figure C demonstrates a fracture of the greater trochanter in the setting of a well-fixed femoral component, consistent with a Vancouver AG fracture. Figure D demonstrates a fracture at/near the tip of the stem in the setting of a loose femoral component, consistent with a Vancouver B2 fracture. Figure E demonstrates a fracture at/near the tip of the stem in the setting of a well-fixed femoral component, consistent with a Vancouver B1 fracture. Illustration A demonstrates the postoperative Vancouver Classification System.

Incorrect Answers:
Answer 1: Vancouver C fractures are best treated with ORIF.
Answer 2: Vancouver B3 fractures are best treated with femoral component revision with either proximal femoral allograft prosthetic composites or proximal femur replacement.
Answer 3: Vancouver AG fractures are best treated with either nonoperative management with partial weight-bearing (nondisplaced or poor surgical candidates) or with ORIF alone (active, healthy patients).
Answer 5: A Vancouver B1 fracture is best treated with ORIF alone.