Managing Vancouver B2 Periprosthetic Femoral Fractures in the Elderly: Is Open Reduction and Internal Fixation Superior to Stem Revision?

doi:10.21203/rs.3.rs-7841350/v1

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Managing Vancouver B2 Periprosthetic Femoral Fractures in the Elderly: Is Open Reduction and Internal Fixation Superior to Stem Revision?

https://doi.org/10.21203/rs.3.rs-7841350/v1

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Purpose

The aim of this study was to compare stem revision(SR) and open reduction and internal fixation(ORIF) for the treatment of Vancouver B2 periprosthetic fractures of the femur.

Methods

From June 2013 to May 2023, 56 consecutive patients were studied at our institution. Four patients were lost to follow-up, four had incomplete data. Thus, 48 cases were included in the analysis. The patients were divided into a stem revision group (SR group with 25 patients) and an open reduction and internal fixation group (ORIF group with 23 patients). The surgical complications, perioperative parameters, and 1-year mortality rates were assessed, the functional outcomes were assessed with the Harris Hip Score, and the radiographic outcomes were assessed in accordance with the Beals and Tower criteria.

Results

In SR group, the mean follow-up time was 61.2 months, 36% of patients experienced complications, the mean HHS was 75.27, and 92% of the patients had “excellent–good” radiographic outcomes. In ORIF group, the mean follow-up time was 63.7 months, 21.7% of patients experienced complications, the mean HHS was 73.56, and 91.3% of the patients had “excellent–good” radiographic outcomes. The total number of postoperative complications, dislocation rate, blood loss volume, operation time and transfusion rate were lower in ORIF group, and two patients in SR group experienced hip dislocation. There were no significant differences in the 1-year mortality rate, bone healing time and reoperation rate between the two groups. However, the time to total weight-bearing in the SR group was shorter than that in the ORIF group, and the radiographic subsidence rate in the SR group was lower than that in the ORIF group, especially for patients with poor compliance. Most of these patients in both groups did not return to their preoperative mobility status.

Conclusions

Although SR is the gold standard for Vancouver B2 fracture treatment. ORIF can be a viable alternative for elderly patients on account of signifcantly less perioperative blood loss and a shorter operating time, But showed disadvantages in terms of earlier weight-bearing and the radiographic subsidence rate.

Periprosthetic fracture

Vancouver B2 fracture

Open reduction and internal fixation

Stem revision

The risk of periprosthetic femoral fracture (PFF) within 20 years after primary total hip arthroplasty (THA) has been reported to be 3.5% ^[1], and the incidence of periprosthetic fracture after THA revision is as high as 4–12% ^[2]. Femoral periprosthetic fractures can occur during surgery or after surgery. PFFs are associated with serious complications, such as long operating times, an increased risk of bleeding, high reoperation rates and mortality, all of which pose challenges for surgeons. The Vancouver classification^[3] is the most common and reproducible classification used for predicting the best treatment for PFFs. The classification is based on fracture type, implant stability and bone quality. Vancouver type B2 PFFs are characterized by a loose stem with good bone stock. In previous studies, stem revision (SR) was considered the gold standard for the surgical treatment of Vancouver type B2 fractures ^[4]. Compared with SR, open reduction and internal fixation (ORIF) results in a significantly longer bone healing time and less mobility. However, other studies revealed that compared with those of ORIF only, the mid- to long-term results of SR for B2 and B3 PFFs in elderly patients were satisfactory. Thus, SR is a less invasive procedure with a lower risk of perioperative complications^[5]. The optimal treatment for femoral periprosthetic fractures is still unclear, especially for type B2 fractures with a loose stem. Thus, the aim of this investigation was to compare the functional and radiographic outcomes as well as the complications of SR with those of ORIF for Vancouver B2 fractures in geriatric trauma patients.

The clinical data of patients who developed Vancouver type B2 PFFs after undergoing THA at our hospital were retrospectively reviewed, and the institutional review board approved the study. We included only patients with type B2 periprosthetic femur fractures, If the fracture location is more than 5 centimeters away from the distal end of the femoral prosthesis, it is considered not to affect the stability of the femoral prosthesis, and open reduction and internal fixation surgery can be performed. Otherwise, revision surgery for replacing the femoral prosthesis is required^[10]. All the patients had complete medical records and radiographic data. Patients with pathological fractures met the exclusion criteria and were followed up for at least 24 months.

The Deyo‒Charlson index and American Society of Anaesthesiologist (ASA) comorbidity score were recorded to assess mortality^[6]. The primary diagnosis and fixation type were also assessed. The posterior lateral approach was used for all patients. The length of hospital stay, operation duration and blood transfusion volume were recorded. Radiographs were evaluated by a surgeon who was blinded to the clinical outcome. Bone healing was defined based on callus formation, and the status of bone healing was assessed radiologically on both anteroposterior and lateral radiographs. According to the Beals and Tower criteria for radiological classification^[7], outcomes were graded as excellent (a stable implant with minimal deformity), good (a stable implant, minimal or no subsidence, and a well-healed fracture with moderate deformity) or poor (loosening, nonunion, sepsis, severe deformity or new fracture). Implants were considered stable if there were no radiolucent lines around the stem, progressive implant migration, or subsidence^[8].

The clinical outcome was assessed based on patient mobility. Mobility in the period prior to fracture and after fracture healing was categorized as follows (ranging from best to worst) able to walk without help, able to walk with a walking stick, able to walk with a walking frame or two crutches, or unable to walk^[9]. In addition, the Harris Hip Score (HHS) was used to evaluate functional outcomes.

Statistical analysis

The mean and standard deviation were calculated for continuous variables, and the frequencies and percentages were calculated for qualitative data. The Kruskal‒Wallis nonparametric test was used for continuous variables, and the chi‒square test was used to assess categorical variables. SPSS 22.0 was used for all statistical analyses, and p values < 0.05 were indicated significance.

Surgical procedure

The posterolateral approach was used for all patients. The positioning and fracture reduction during operation should be done gently because of severe osteoporosis in the elderly patients, otherwise, it may lead to iatrogenic fractures. Due to the displacement of the proximal femoral fracture fragment resulting in anatomical structural variations, the sciatic nerve is prone to injury during the posterolateral surgical approach. Therefore, during the exposure process, the soft tissue should be stripped closely to the posterior side of the greater trochanter of the femur to avoid injury of the sciatic nerve. After exposure the hip, a single hook was used to dislocate the hip joint. the wear of the linner, femoral head and acetabulum stability were assessed. At the meanwhile, the type of fracture and the stability of the femoral prosthesis were evaluated too. If more than 5 centimeters of the prosthesis was contacte with the distal part of the fracture, it is considered not to affect the stability of the femoral prosthesis^[10], and open reduction and internal fixation surgery can be performed. Otherwise, revision surgery for replacing the femoral prosthesis is required.

In the ORIF group, the fracture segments were reduced by rotating the lower limbs and using two reduction forceps, therefore, frequently 2–4 cerclage wires were used to tie up the fracture. Then, The claw-shaped steel plate(Dabo, Beijing, China)hooks the tip of the greater trochanter of the femur, which bypassed the segments of the femur with at least eight cortices. After plate fixation, the reliability of fracture fixation and joint stability were evaluated. Then reducing the hip joint, reconstructing the external rotator muscle group, and closing the incision.

In SR group, Due to the personal habits of the surgeons, The tapered fluted modular titanium stem (SL; AiKang, Beijing, China) was choosen for all the patients. Firstly, The stem was carefully removed without causing additional iatrogenic fracture, Before expanding the medullary cavity, 1 to 2 steel wires were pre-bound to the distal part of the fracture. Then, Gradually expand the femoral marrow cavity from small to large using femoral reamers, It was considered the femoral prosthesis size was suitable until the internal and external rotation of the femoral test mold could drive the distal part of femur. then the proper size of tapered fluted modular titanium stem was implanted at least 5 cm below the fracture^[10]. And then, the appropriate neck length and femoral head diameter were choosen to ensure the stability of the hip joint. After that, the fracture was subsequently reduced anatomically and fixed using wires or cables. Then reconstructing the external rotator muscle group, and closing the incision.

Demographic characteristics

The distribution of patients’characteristics between SR group and ORIF group in Vancouver type B2 fracture were showed in Table1. There were no statistically significant correlations with the ASA score, CCI, implant type, Reason for primary arthroplasty, time-to-fracture,sex,age and BMI between the two surgical groups(p > 0.05)(Table 1).

Table 1
Patient characteristics
Parameters	SR (n = 25)	ORIF(n = 23)	P value
Follow-up(m)	61.2	63.7	0.32
Age(years)	72.8	74.3	0.15
BMI(kg/m²)	24.6	23.5	0.22
Sex(n)
male	10(40%)	9(39.2%)
female	15(60%)	14(60.9%)
ASA score(n)			0.23
1	1(4%)	0(0%)
2	16(64%)	14(60.8%)
3	7(28%)	6(26.1%)
4	1(4%)	3(13.0%)
CCI	5.2(3.1)	5.5(2.6)	0.16
Reason for primary arthroplasty(n)			0.41
Fracture	12(48%)	13(56.5%)
Osteoarthritis	13(52%)	10(43.5%)
Implant type of primary THA			0.35
Hemihip arthroplasty	12(48%)	11(47.8%)
Total hip arthroplasty	13(52%)	12(52.2%)
Type of fixation(cementless)	25(100%)	23(100%)	0.67
Time-to-fracture(m)	41.5	38.6	0.18

The values are presented as the mean value and standard deviation. ORIF, open reduction internal fixation;

SR, stem revision; BMI, body mass index; ASA, American Society of Anaesthesiologists; CCI, Charlson Comorbidity Index.

Perioperative parameters

The ORIF group comparing with the SR group demonstrated superior outcomes in multiple perioperative parameters, including less intraoperative blood loss (612.2 ± 173.0 mL vs 1100.8 ± 200.4 mL), shorter operative time (104.5 ± 30.7 min vs 136.2 ± 48.5 min), lower volume of RBCs transfused (106.1 ± 24.5 mL vs 251.5 ± 30.2 mL) and shorter hospital stay time (10.5 ± 3.0 day vs 14.1 ± 5.7 day) (Table 2).

Table 2
Perioperative parameters
Group	SR(n = 25)	ORIF(n = 23)	P value
Operation duration(min)	136.2 ± 48.5	104.5 ± 30.7	0.014
Intraoperative blood loss volume(ml)	1100.8 ± 200.4	612.2 ± 173.0	0.022
Volume of RBCs transfused (ml)	251.5 ± 30.2	106.1 ± 24.5	0.025
Hospital stay(day)	14.1 ± 5.7	10.5 ± 3.0	0.031

Clinical outcomes and complications

In the SR group(Fig. 1), the mean follow-up was 61.2 months༈24–117 months༉. the mean HHS was 75.27, and 92% of the patients had “excellent–good” radiographic outcomes. Sixteen patients (64%) in the SR group experienced a significant deterioration in ambulation postoperatively. The most recent follow-up examination revealed that only 36% patients in the SR group returned to their pre-fracture walking status. Thirty-six percent of patients in the SR group experienced complications, and the reoperation rate was 16% (Table 3). One patient (4%) developed a deep infection within 3 weeks after surgery. A DAIR (debridement, antibiotics and implant retention) procedure was performed in combination with a 6-week course of antibiotics, which successfully eradicated the infection. Two patients experienced hip dislocation (8%). One hip underwent close reduction, and there were no signs of dislocation recurrence, but the other hip was revised with a dual-mobility acetabular component because of repeated dislocation. Medical complications occurred in 24% of patients (n = 6): two patients developed renal failure, and four patients developed postoperative pneumonia. The 1-year mortality for SR patients was 12%.

In the ORIF group(Fig. 2), the mean follow-up time was 63.7 months༈24–120 months༉, the mean HHS was 73.56, and 91.3% of the patients experienced “excellent-good” radiographic outcomes. Fifteen patients (65.2%) in the ORIF group experienced significant deterioration of ambulation postoperatively. The most recent follow-up examination revealed that only 34.8% of the patients in the ORIF group returned to their pre-fracture walking status. A total of 21.7% of patients experienced complications, and the reoperation rate was 8.7%. However, in the ORIF group, 2 patients experienced subsidence of 7 mm and 9 mm with persistent pain due to earlier weight-bearing and poor compliance, undergo revision surgery due to a loose stem 14 and 26 months after surgery. The 1-year mortality rate for patients who underwent ORIF was 13.1%(Table 3).

The total postoperative complication rate and dislocation rate were lower in the ORIF group. There were no significant differences in the 1-year mortality rate, bone healing time and reoperation rate between the two groups. However, the total weight-bearing time in the SR group was shorter than that in the ORIF group, While the radiographic subsidence rate in the SR group was lower than that in the ORIF group. Whatever treatment was adopted, there was an overall worsening of quality of life. This worsening of postoperative ambulatory status was not statistically significant (p = 0.461). The mean HHS at the most recent follow-up was not statistically significant (p = 0.212). According to the Beals and Tower classification, the two surgeries had relatively similar results (p = 0.765)(Table 3).

Table 3
Function and complications
Group	SR(n = 25)	ORIF(n = 23)	P value
Harris Hip Score	75.27(10.51)	73.56(11.27)	0.212
Beals and Tower Classification			0.524
Excellent	10(40%)	11(47.8%)
Good	13(52%)	10(43.5%)
Poor	2(8%)	2(8.7%)
Difference between pre- and postoperative ambulation status			0.461
1 level increase	0	0
No change	9(36%)	8(34.8%)
1 level decrease	12(48%)	14(60.9%)
2 level decrease	4(16%)	1(4.3%)
Dislocation	2(8%)	0	0.005
Dislocation without surgery	1(4%)	0	0.012
Deep infection(n)	1(4%)	0	0.012
Radiographic subsidence(mm)	1.14(1.07)	1.37(1.52)	0.186
Subsidence more than 2 mm(n)	5(20%)	6(26.1%)	0.250
Reoperation rate	2(8%)	2(8.7%)	0.373
Medical complications(n)	6(24%)	2(8.7%)	0.032
Total complications(n)	9(36%)	4(17.4%)	0.028
One-year mortality	3(12%)	3(13.1%)	0.531

Typical cases

The incidence of periprosthetic femoral fractures has increased with the aged patients, while the number of total hip arthroplasty has been increasing year by year^{[11, 12]}. Periprosthetic femoral fractures(PFFs) can occur intraoperatively or postoperatively. PFFs are associated with serious complications, such as long operating times, an increased risk of bleeding, high reoperation rates and mortality, especially in elderly patients with severe osteoporosis, thus posing challenges for orthopaedic surgeons ^[13–15]. However, femoral stem revision is still the standard of care for Vancouver B2 PFFs because of unstable or loose stems^[16]. In recent years, there have been different opinions to treat with the Vancouver B2 PFFs, Which suggested that ORIF may be considered as a viable alternative options in selected cases of Vancouver B2 PFFs ^[17–21].

Comparative analysis revealed distinct complication profiles between the ORIF and SR groups. The total complication rates were 17.4% and 32% in the ORIF and SR groups, respectively. The complication rates were 8.7% and 24% in the ORIF and SR groups, respectively, Which is comparable with those reported in previous studies^[5]. This may be related to the shorter operation time and lower blood loss volumes in ORIF group, althought there were no statistically significant correlations with the ASA and CCI scores between the two groups. Some authors have suggested that in patients with Vancouver B2 fractures who undergo SR or ORIF, The demand to maintain a particular level of function and the risk of anaesthesia of the patients should be considered^[18].

We reported similar one-year mortality rates for SR (12%) and ORIF (13.1%). This finding is remarkable because our groups did not differ in terms of ASA score or CCI score. This finding was similar to the results reported by Lindahl et al.^[22]. The one-year mortality rate of SR was similar to that reported in previous research (13.4%) [6]. Drew et al^[23] reported no difference in mortality between ORIF and SR for patients with periprosthetic femoral fractures. Bhattacharyya et al. ^[24] reported a significantly lower mortality rate for revision arthroplasty (12%) than for ORIF (33%).

It is true that the subsidence of the femoral stem is one of the complications of the treatment of Vancouver B2 periprosthetic fractures with ORIF, however, the subsidence is asymptomatic or paucisymptomatic and does not require further surgery in most cases^[25]. The ORIF group was prohibited from weight-bearing until the fracture completely healed. Two patients in the ORIF group experienced subsidence of 7 mm and 9 mm due to early weight-bearing because of poor compliance and needed revision because of persistent pain due to a loose stem 14 and 26 months after surgery. However, the SR group was allowed early weight-bearing because the stem was placed 5 cm below the fracture line, which facilitated primary stability. According to the literature^[26], earlier weight-bearing postoperatively is conducive to faster recovery of muscle, bone and joint function. The patients in the SR group were allowed earlier weight-bearing and therefore recovered faster.

Two patients occurred hip dislocation in the SR group. The first one resulted from extensive soft tissue dissection and unclear anatomical signs of proximal femur. During the operation, the polyethylene liner was adjusted. Another dislocation event occurred three months after surgery, attributed to the gluteus medius insufficiency, There were no recurrent dislocations after closed reduction followed by 6 weeks of brace immobilization.

The dislocation rate in the SR group was approximately 8%, which was close to that reported in the literature (5–10%)^[11]. After the treatment of Vancouver B2 periprosthetic fractures with SR to reduce the risk of further complications such as dislocations or periprosthetic refractures, accurate preoperative planning for the measurements of the prosthetic components, including the dimensions of the prosthetic stem, is essential^[28]. The authors measured and marked the anatomical location of the contralateral lower limb to help improve the accurate placement of the prosthesis^[27]. The reoperation rates after ORIF and SR can be as high as 23%[10], but are currently 13.7% [6]. In our study, the reoperation rate was 8.7% in the ORIF group and 8% in the SR group. Although the 1-year mortality rates did not significantly differ between the two groups, the length of hospital stay significantly differed, mostly due to the medical complication rates in the SR group, which were comparable with those reported in previous studies^[29].

Limitations

The main drawback of our study were showed as follows. Firstly, the retrospective design introduces potential selection bias and unmeasured confounders inherent to observational analyses; Secondly, while the statistical power was constrained by the small cohort size and lack of long-term outcomes because of the low incidence of periprosthetic femoral fractures, However, due to the standardized clinical and radiologic follow-up protocol and the excellent documentation by the orthopaedic surgeons of our institution, all required patient data were available for the current analysis. Thirdly, In SR group, Due to the personal habits of the surgeons, The tapered fluted modular titanium stem (SL; AiKang, Beijing, China) was choosen for all the patients, what was impossible to compare the different implant types, but increased the comparability with ORIF.

We reported good radiographic and clinical results for ORIF and SR for the treatment of Vancouver B2 periprosthetic fractures. However, most of these patients did not return to preoperative mobility status. Two patients in the ORIF group experienced radiographic subsidence and fixation failure due to early weight-bearing with poor compliance. Two patients in the SR group experienced dislocation because of excessive soft tissue dissection, the gluteus medius insufficiency and inappropriate anterior angle of the acetabulum. The reoperation rate and one-year mortality rate were not significantly different. Although SR is the gold standard for Vancouver B2 fracture treatment. ORIF can be a viable alternative for elderly patients on account of signifcantly less perioperative blood loss and a shorter operating time, But showed disadvantages in terms of earlier weight-bearing and the radiographic subsidence rate.

Acknowledgements

The authors thank all participants that agreed to participate in this study.

Authors’contributions

Funding

Not applicable.

Data Availability

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the . All participants signed informed consent forms.

Clinical trial number

Not applicable.

Consent for publication

Not applicable.

Conflict of interests

The authors declare that they have no competing financial interests.

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Managing Vancouver B2 Periprosthetic Femoral Fractures in the Elderly: Is Open Reduction and Internal Fixation Superior to Stem Revision?

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Abstract

Purpose

Methods

Results

Conclusions

Figures

Introduction

Materials and methods

Statistical analysis

Surgical procedure

Results

Demographic characteristics

Perioperative parameters

Clinical outcomes and complications

Typical cases

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

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