The radiograph shows a Vancouver B3 periprosthetic fracture with poor proximal femoral bone stock. Given her age, co-morbidities, and dementia, the appropriate management of her condition would be a proximal femoral replacement with megaprosthesis. This can allow for immediate weight-bearing in the post-operative period.
Vancouver B3 periprosthetic fractures are fractures around or just below the tip of a loose stem with poor proximal femoral bone stock. Options for management of this fracture include a fully coated stem, a fluted tapered stem, a proximal femoral replacement with megaprosthesis, allograft-prosthesis composite, and impaction bone grafting. In elderly patients with co-morbidities and an inability to maintain the strict weight-bearing precautions that impaction bone grafting and allograft prosthetic replacements require, proximal femoral replacement with a megaprosthesis is the best option.
Duncan and Masri were the originators of the Vancouver classification system for periprosthetic fractures. Type A fractures are peritrochanteric, type B fracture are around the stem tip, and type C fractures are well below the stem tip.
Parvizi and Sim provide review the indications for proximal femoral replacements with megaprostheses. They conclude it is a reasonable option for elderly patients with massive proximal femoral bone loss. The most frequent complications are aseptic loosening and dislocation.
Klein and Parvizi et al. identified 23 patients who underwent proximal femoral replacement for a Vancouver type-B3 periprosthetic fracture. At a follow-up of 3 years, 22 of 23 patients were walking with minimal pain. The most frequent complications were persistent drainage (2), dislocation (2), refracture (1) and acetabular cage failure (1).
Figure A shows a Vancouver B3 periprosthetic fracture with loose stem and poor proximal bone stock. Illustration A shows an example of a proximal femoral replacement. Illustration B shows a radiograph of a proximal femoral replacement used for a failed total hip replacement with massive bone loss. Illustration C shows the Vancouver classification (A, B1, B2, B3, C)
Answer 1: Operative management is indicated to reduce pain and prevent complications associated with bedrest.
Answer 2: Given the degree of proximal femoral bone loss and loose stem, open reduction and internal fixation with a plate is not the best option.
Answer 4: Impaction bone grafting is an option for Vancouver B3 fractures, but are typically reserved for younger patients who have bone stock that needs to be restored.
Answer 5: Given the degree of proximal femoral bone loss and loose stem, cortical strut allograft with cerclage wiring is not the best option.
Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.
PMID:7797866 (Link to Abstract)
Parvizi J, Sim FH: Proximal femoral replacements with megaprostheses. Clin Orthop 2004;420:169-175.
PMID:15057093 (Link to Abstract)
Klein GR, Parvizi J, Rapuri V, et al: Proximal femoral replacement for treatment of periprosthetic fractures. J Bone Joint Surg Am 2005;87:1777-1781.
PMID:16085618 (Link to Abstract)