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Review Question - QID 511

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QID 511 (Type "511" in App Search)
A 65-year-old healthy patient fell 18 years after a total hip arthroplasty and sustained the fracture shown in Figure A. Which of the following would be the most appropriate treatment?
  • A

Non weight bearing for 6-8 weeks

1%

22/3113

Open reduction internal fixation (ORIF) with cerclage cables

4%

123/3113

Revision to a long cemented femoral stem which bypasses the fracture

75%

2328/3113

Revision to a fully porous coated uncemented femoral stem + ORIF

14%

440/3113

Revision to a proximal femoral replacement

6%

174/3113

  • A

Select Answer to see Preferred Response

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This patient has a Vancouver B3 periprosthetic femur fracture which is most appropriately managed with a proximal femoral replacement (PFR).

The Vancouver classification of periprosthetic femur fractures is based on the fracture site, implant stability, and remaining bone stock. The patient in the question has a type B3 fracture. The cemented stem is loose and there is very poor remaining bone stock. He should be treated with a PFR due to the lack or proximal bone stock. Historically, proximal femoral allograft bone grafting was also an option but this has fallen out of favor due to better results with PFR and is only considered in younger patients with B3 fractures.

Klein et al. reviewed PFR for the treatment of B3 periprosthetic proximal femur fractures. They noted that with mean follow up of 3.2 years, all but one patient was able to walk with minimal to no pain. This said, they do report a relatively high complication rate including wound drainage, dislocation, re-fracture, and acetabular cage failure.

Rasouli et al. looked at the utilization of PFR and allograft composite prosthesis in the treatment of B3 periprosthetic femur fractures. They recommend allograft composite protheses in younger, more active patients in order to preserve any residual bone stock while they consider older and less active patients better candidates for PFR. Regardless of the procedure performed, complication rates are high for these patients and outcomes are not as good as for primary hip replacements.

Figure A demonstrates an AP radiograph showing a periprosthetic femur fracture with a loose stem and poor proximal femoral bone stock.

Incorrect Answers:
Answer 1: In a B3 periprosthetic femur fracture, nonoperative management with non weight bearing is not appropriate as the fracture will not heal in appropriate position and the patient is at risk for other medical problems during this time period.
Answer 2: ORIF is appropriate for B1 and C type fractures where the fracture occurs distal the stem (C) or around a well-fixed stem (B1).
Answers 3 & 4: Revision to a long, cemented stem is appropriate in rare circumstances with B2 fractures but a full porous coated uncemented stem is preferable. In this case of a B3 fracture, a PFR is the better choice.

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