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Review Question - QID 5782

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QID 5782 (Type "5782" in App Search)
A 74-year-old female who underwent a hemiarthroplasty 6 weeks ago now presents to the emergency department after a low energy fall while walking. Her x-ray is shown in Figure A. What is the optimal treatment for this injury?
  • A

Protected weight bearing with the use of a walker

1%

26/3627

Open reduction internal fixation using cerclage wires

6%

211/3627

Open reduction internal fixation using a locking plate +/- allograft strut

4%

140/3627

Fracture fixation and revision arthroplasty with a diaphyseal engaging component

86%

3136/3627

Revision arthroplasty with a proximal femoral replacement

2%

65/3627

  • A

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The question stem describes a Vancouver B2 fracture (fracture around the stem, with a loose stem), and thus the stem should be revised to a longer stem.

Masri et al. describe the treatment of femoral periprosthetic femur fractures based primarily on implant stability, fracture location, and the quality of the surrounding bone. The resultant Vancouver classification utilizes these factors to assist with fracture classification and treatment. Only Vancouver B2/B3 fractures compromise stem fixation and thus are the only ones that generally require revision arthroplasty. A Vancouver B2 is a fracture about the stem where the implant is no longer stable, and is generally treated with revision arthroplasty to a longer stem. A Vancouver B3 is a fracture about the stem where the implant is no longer stable and the proximal bone is of very poor quality, generally treated with proximal femoral replacement.

Ko et al. retrospectively reviewed the outcomes of Vancouver B2 periprosthetic femur fractures treated with the placement of a fluted tapered monoblock stem bypassing the fracture site and engaging the diaphysis. There were no cases of neurovascular injury, continued thigh pain, post-operative dislocation, or need for further surgery. The authors concluded that this fluted tapered stem is a satisfactory option for the treatment of this fracture.

Illustration A shows the post-operative x-ray in this case after fracture fixation and revision arthroplasty with a diaphyseal engaging component. Illustration B details the Vancouver classification.

Incorrect answers:
Answer 1: This would be an appropriate treatment of a Vancouver A fracture.
Answer 2: This would be an appropriate treatment of a Vancouver B1 fracture.
Answer 3: This would be an appropriate treatment of a Vancouver B1/C fracture.
Answer 5: This would be an appropriate treatment of a Vancouver B3 fracture.

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