Review Question - QID 219985

This patient sustained a periprosthetic femur fracture around a well-fixed total hip arthroplasty (Vancouver B1). This injury should be treated with open reduction and internal fixation (ORIF) alone, utilizing a lateral femoral locking plate (Answer 1).

Periprosthetic femur fractures are an increasingly common injury pattern as the number of hip arthroplasties continues to rise worldwide. Patients typically present after a ground-level fall with deformity and inability to bear weight. An important consideration in the treatment of periprosthetic femur fracture in the setting of hip arthroplasty is the stability of the femoral stem within the proximal femur. The Vancouver classification is the most commonly utilized system. Patients with fractures at the level of a stable stem (Vancouver B1) can be treated with ORIF alone. Fixation typically involves the use of a long lateral femoral locking plate and screws, with adjunctive cables or wires when necessary to obtain adequate proximal fixation. Unstable stems (Vancouver B2 or B3) often require revision to an uncemented long diaphyseal-engaging stem, although there is some modern literature that advocates for ORIF in select cases.

Abdel et al. performed a retrospective review of 49 Vancouver B2 and B3 fractures that were treated with femoral revision to long modular tapered fluted stems. They had excellent results at two years, with only 5 deaths within two years postoperatively, and the remaining patients ambulatory at the latest follow-up.

Ricci et al. conducted a retrospective review of 50 patients who sustained periprosthetic femur fractures while maintaining a stable stem (Vancouver B1). They treated all patients with lateral locking plates with indirect reduction methods and no addition of allograft. Four postoperative deaths were noted and 5 patients were lost to follow-up, but the remaining 41 achieved fracture union and 30 returned to their baseline ambulatory status. They concluded that single lateral locking plate fixation with indirect reduction techniques is successful in the treatment of periprosthetic femur fractures about a stable hip arthroplasty.

Figures A and B are the AP and lateral radiographs of a left periprosthetic femur fracture around a stable total hip arthroplasty implant.

Incorrect Answers
Answer 2, 3, 4, 5: Revision total hip arthroplasty is not indicated in the presence of a stable implant.