Review Question - QID 219160

When treating Vancouver B1 periprosthetic femur fractures with ORIF, adequate proximal fixation with locking screws optimizes the fixation in poor-quality bone to maintain adequate proximal fixation (Answer 3).

Periprosthetic femur fractures around a total hip implant are not uncommon and are increasing in frequency. The Vancouver classification (Illustration A) is most commonly used for these fractures, and this particular fracture would be classified as a B1 fracture. B1 fractures are typically treated with a lateral plate construct. Most authors would recommend a lateral plate contoured to accommodate the proximal trochanteric flare with bicortical locking screws proximally. Cerclage cables or wires are used proximally between the lesser trochanter and the tip of the stem. Higher stability and success is found when a minimum of 6-8 cortices are fixed distally with locking screws.

Ricci provided a review of periprosthetic femur fracture management. In regards to Vancouver B1 fractures, the author recommends a lateral plate with locking screws proximally in the trochanteric region, cerclage cables spanning the fracture, and distal locking screws. The author makes note that the isolated use of unicortical locking screws alone in the proximal segment is not recommended as this will not provide adequate rotational stability.

Martinov et al. performed a retrospective analysis on 81 Vancouver B2 periprosthetic femur fractures treated with either ORIF or stem revision. The authors found that patients who underwent ORIF were significantly older, had less intraoperative blood loss, and underwent less surgical time. The authors found no significant difference in radiographical outcomes and concluded that ORIF of B2 fractures is a viable option in older patients.

Joestl et al. performed a retrospective study of 36 patients with Vancouver B2 fractures treated with either locked compression plating or revision arthroplasty. The results of the study found no secondary stem migration, malalignment, or hardware failure in the ORIF group. The study also showed no difference in mobility outcomes between the two groups. The authors concluded that ORIF with locked compression plating is a sufficient option for Vancouver B2 fractures.

Figures/Illustrations:
Figure A demonstrates a periprosthetic proximal femur fracture without obvious loosening of the femoral component and adequate bone stock, classified as a Vancouver B1 fracture.
Illustration A is a table of the Vancouver periprosthetic femur fracture classification system.

Incorrect Answers:
Answer choice 1: Cerclage wires are recommended when plating a periprosthetic femur fracture. Some authors recommend placing 2-3 wires/cables between the lesser trochanter and the femoral stem. Although placing a cerclage cable is associated with greater disruption of soft tissue, newer instrumentation helps minimize this risk.
Answer choice 2: The highest success rate and strongest biomechanical construct features 3 bicortical screws distal to the stem. Some authors recommend 8 cortices of fixation in the distal extent of the construct. Less than 3 screws would jeopardize fixation.
Answer choice 4: Strut allografts are not indicated in this patient. The indication for strut allografts includes fractures with significant bone loss and appreciable component migration.
Answer choice 5: This is a stable femoral stem based on the information provided (no pain prior to fall, no signs of stem subsidence or loosening on radiograph). Therefore, this fracture is indicated for ORIF and not revision.