Review Question - QID 219873

This patient presents with a periprosthetic femur fracture around a well-fixed stem (Vancouver B1) treated with open reduction and internal fixation (ORIF) (Figure B). The most common indication for reoperation in patients with well-fixed stems treated with ORIF is non-union.

Periprosthetic femur fractures are an unfortunate injury or complication following total hip arthroplasty that often requires surgical intervention. Classically, the treatment algorithm relies on a combination of the location, stem stability, and bone quality. Fractures around the implant stem are categorized as Vancouver “B” and can further be delineated in B1, B2, and B3 subtypes. In B1, the fracture occurs around the stem, but the stem remains well fixed to the bone. These fractures are most frequently treated with ORIF, and nonunion is the most common cause of reoperation. B2 fractures also occur around the stem, however, this subtype is accompanied by femoral stem loosening. These fractures are often treated with femoral component revision to a tapered component or a long-stem fully coated prosthesis and fixation of the fracture fragments with plates and/or cables. The most common indication for revision surgery following combined ORIF and femoral revision is infection. Lastly, B3 fractures occur around the stem, resulting in a loose implant in the setting of poor quality or severely comminuted proximal bone. B3 fractures are particularly difficult to treat because of extensive bone loss and require distal femoral fixation. Today, B3 fractures are often treated with cementless fully coated curved stems or more commonly with tapered fluted revision stems. Bone loss is managed with reapproximation of the remaining proximal bone with cerclage cables and bone grafting as needed. Proximal femoral replacement may be used in older low-demand patients with severe comminution and significant proximal bone loss.

Gausden et al. reviewed their series of periprosthetic fractures after THA and categorized patients based on the fixation of the femoral stem (well-fixed vs unstable). They found that among patients with well-fixed stems (Vancouver B1), the most common indication for reoperation was non-union. In contrast, patients with loose femoral stems treated with revision arthroplasty were most likely to be additionally revised for infection. Based on their results, the authors recommend that surgeons incorporate additional strategies to mitigate these risks including additional antiseptic precautions or fixation augmentation.

Lewallen et al. presented on periprosthetic fractures of the femur after THA. They report on the prevalence of various fracture patterns and treatment outcomes of different approaches. The authors describe an overall increase in the prevalence of periprosthetic fractures and attribute this growth to expanding indications to include younger, heavier, and sicker patients. They recommend scheduled and routine follow-up of all THA patients to monitor for potential complications to intervene before a fracture occurs. The authors recommend applying the Vancouver classification to guide procedure selection.

Figure A demonstrates a periprosthetic femur fracture at the level of the femoral implant (Vancouver B). Figure B shows the original femoral component in place with additional hardware following ORIF.

Incorrect answers:
Answer 2: Infection risk is increased with any revision surgery; however, non-union is the most common cause of reoperation following ORIF for well-fixed stems.
Answers 3 & 4: The implant was well-fixed intraoperatively, making the Vancouver classification B1.
Answer 5: The fracture is at the level of the implant stem. Fractures distal to femoral stems are categorized as Vancouver C.