Review Question - QID 219607

Vancouver B1 periprosthetic femur fractures are appropriately managed with open reduction and internal fixation (ORIF) of the fracture without femoral component revision.

Periprosthetic femur fractures in the setting of prior total hip arthroplasty (THA) are relatively uncommon, with an incidence averaging 0-3%. The Vancouver classification (Illustration A) is helpful in classifying fractures based on fracture location, stem stability, and bone quality. Therefore, the classification is actually quite helpful in deciding how the fractures are managed. In the setting of a Vancouver B1 fracture where there is no loosening of the femoral stem, open reduction and internal fixation is the most appropriate method of management. Internal fixation is performed with a lateral plate and a combination of bicortical and unicortical screws or cables. In the setting of femoral component loosening (B2/3), femoral revision must be considered.

Springer et al. looked at the treatment of periprosthetic femur fractures, which had stem loosening (Vancouver B2) and ultimately required femoral component revision. They noted survivability of the revision implants was 90% at five years and 79.2% at 10 years. Prosthetic loosening and fracture nonunion were the main cause of issues long-term and better results were seen using an uncemented, extensively porous-coated stem.

Ricci et al. reviewed the indirect reduction and plating of periprosthetic femur fractures with stable femoral implants (Vancouver B1). They noted that out of 41 patients reviewed, all healed in satisfactory alignment at an average of 12 weeks. They concluded that single, lateral plate fixation was appropriate for this subset of patients and resulted in reliable healing.

Illustration A is a table depicting the Vancouver classification and associated management strategies.

Incorrect Answers:
Answer 1: Nonoperative management is typically performed for Vancouver AG fractures with <2 cm of displacement.
Answer 2: Nonoperative management is almost always indicated for Vancouver AL fractures involving the lesser trochanter with a stable stem and no fracture extension into the femoral shaft.
Answer 4: Vancouver B2 fractures encompass those with loosening of the femoral stem and retained bone quality. Typically revision of the femoral stem +/- ORIF is recommended.
Answer 5: Vancouver B3 fractures have a loose femoral stem and poor proximal bone quality and should be treated with proximal femoral allograft (APC) or proximal femoral replacement (PFR).