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Open reduction and internal fixation with locked plates and cables through an extensile approach
21%
1028/5001
Revision with a proximally porous-coated stem
3%
160/5001
Revision with an extensively porous-coated stem
74%
3716/5001
Nonoperative management
0%
20/5001
Minimally invasive plate osteosynthesis
1%
37/5001
Select Answer to see Preferred Response
The patient has a Vancouver B2 periprosthetic fracture. There is a loose stem that should be treated with revision to an extensively coated stem that bypasses the fracture site. Revision of the femoral component is recommended for Vancouver B2 and B3 periprosthetic fractures. Type B1 fractures are treated with ORIF and stem retention, and proximally deficient B3 fractures may be treated with allo-prosthetic composites or tumor prostheses. Springer et al. retrospectively reviewed 118 hips with Vancouver B fractures. Seventy-seven percent of 30 extensively coated stems, 60% of 42 cemented stems, 36% of 28 proximally coated stems, and 61% of 18 tumor prosthesis/allo-prosthetic composite stems were well fixed and demonstrated fracture union. Nonunion and loosening were the most common complications. They recommend extensively porous-coated stems for better results. Haidukewych et al. review revision of periprosthetic fractures. They found that most acetabular components are well fixed. When the distal fragment has parallel endosteal cortices with >=5 cm of tubular diaphysis (usually with a diameter of <18 mm), they recommend an extensively coated, uncemented, monoblock long-stemmed prosthesis. If the distal diaphysis is divergent, has <5 cm of parallel endosteal cortex, or large endosteal diameters, a fluted, grit-blasted, titanium, tapered modular stem can be used. Figure A shows Vancouver B2 fracture. The stem has subsided relative to the proximal fracture fragment, indicating that it is loose. Illustration A shows revision of the same fracture with an extensively porous-coated stem. Illustration B shows the endoskeleton technique using an osteotomy to split the proximal fragment coronally for stem removal, followed by insertion of a modular, fluted, tapered stem and cerclage fixation of the proximal fragments. Incorrect Answers: Answers 1 and 5: This is appropriate for Type B1 fractures. Answer 2: It is not enough to achieve fixation in the proximal fragment. Loosening and nonunion rates are higher with this type of revision compared with an extensively-coated stem. Answers 4: Nonoperative management is not appropriate in the setting of a loose femoral component.
2.1
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