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Review Question - QID 213933

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QID 213933 (Type "213933" in App Search)
A 73-year-old male sustains a ground-level fall onto his left side when he trips on his cat. The patient had immediate hip pain and inability to bear weight on the left side and is brought to the ER via EMS, where you are consulted. He has a history of a total hip arthroplasty on the same side. His baseline function is community ambulator with an assistive device. He did not have any antecedent hip pain. Laboratory studies were obtained which demonstrate a serum white blood cell of 9.0 (normal 4.5-10), CRP of 0.3 mg/L (normal <1.0 mg/L), and ESR of 21 mm/hr (normal 0-25 mm/hr). Figure A is an x-ray obtained in the ER. What is the most appropriate treatment?
  • A

Proximal femoral replacement

4%

65/1837

Open reduction and internal fixation (ORIF) with place and screws

8%

145/1837

Resection arthroplasty

0%

5/1837

Revision with antibiotic spacer placement and ORIF

0%

7/1837

Revision of femoral component and ORIF

87%

1604/1837

  • A

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The patient has a Vancouver B2 periprosthetic fracture without evidence of infection. This is best treated with femoral stem revision and open reduction and internal fixation. Specifically, you want a femoral stem that is diaphyseal engaging and bypasses the fracture by two cortical diameters.

Periprosthetic fractures can be devastating injuries with complex surgeries required to fix them. Three important characteristics in proximal femur periprosthetic fractures are the location of the fracture, evidence of component loosening, and quality of bone stock as these will dictate your treatment. The postoperative periprosthetic Vancouver classification can be used to describe these fractures with Vancouver A being at the level of the trochanters, Vancouver B being at the level of the stem and Vancouver C being distal to the stem. Vancouver B is subsequently divided into B1 (no stem loosening), B2 (loose stem with good bone stock), and B3 (loose stem with poor bone stock). In B2 fractures, the goal is to stable femoral component fixation within the diaphysis and open reduction and internal fixation at the fracture site for any displaced bone fragments.

Shah et al. did a retrospective review of 121 patients who had periprosthetic fractures. Of these, 11.6 % had chronic periprosthetic joint infections (PJI) by MSIS criteria. They compared synovial WBC, synovial percent PMNs, serum CRP and ESR for which was the most indicative of PJI. Receiver operating curves were used to show that synovial WBC count and percent PMNs were the best tests for the diagnosis of infection in the setting of periprosthetic fractures. Both markers had AUC of 84%, meaning a good test. A synovial WBC cut-off of 2707 was 100% sensitive and 63% specific. While PMNs >77% had a sensitivity of 100% and specificity of 63%. CRP and ESR were deemed bad and fair markers, respectively.

Munro et al. investigated the use of modular tapered titanium stems in the management of Vancouver B2 and B3 femoral fractures. They treated 46 patients with a mean follow up of 54 months. Following treatment, eighty-nine percent of those treated had maintenance or improvement of bone stock, twenty-four percent had subsided, and one patient went on to a nonunion. The majority of those that subsided, the migration was less than 3 mm. There was not any correlation between subsidence and pain & function.

Figure A demonstrates a periprosthetic fracture at the level of the stem with evidence of femoral component loosening but overall good bone stock remains. Illustration A shows the Vancouver classification system.

Incorrect Answers:
Answer 1: This patient has overall good bone stock and can be treated with femoral revision and ORIF alone.
Answer 2: ORIF alone would not fully treat this patient as he has a loose femoral component.
Answer 3: This patient is a community ambulator at baseline and resection arthroplasty would likely prohibit ambulation in this patient.
Answer 4: This patient does not have evidence of a chronic PJI, therefore an antibiotic spacer is not required.

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