Exploring Individualized Approaches to Managing Vancouver B Periprosthetic Femoral Fractures: Insights from a Comprehensive Case Series Analysis

Abstract

The increasing prevalence of periprosthetic femoral fractures, specifically in the vicinity of the hip, has emerged as a significant issue in recent times. Consequently, there is a need for a thorough examination to enhance the effectiveness of management and treatment approaches. The findings of this study emphasize a significant disparity in the occurrence and characteristics of these fractures, and the multiple cases have highlighted the efficacy of various treatment strategies, such as open reduction and internal fixation, as well as the utilization of cortical strut allografts. Furthermore, the study has identified potential risk factors that have an impact on the characteristics of fractures, providing valuable insights that could be crucial in the development of preventive strategies. This study provides a thorough examination of periprosthetic femoral fractures, highlighting the importance of a cohesive treatment algorithm to improve the handling of such fractures. Moreover, it promotes the need for a collaborative endeavor in conducting research in this field, cultivating a more profound comprehension that has the potential to drive progress in therapeutic approaches, ultimately enhancing patient results over an extended period of time. It is crucial that forthcoming research endeavors persist in expanding upon these discoveries, striving towards a unified methodology in tackling this substantial clinical obstacle.

Keywords: open reduction and internal fixation; periprosthetic femoral fractures; revision arthroplasty; risk factors; vancouver classification.

Figure 1. Vancouver B1, Case one

One of the instances that exemplify the intricacy of Vancouver B1 periprosthetic femoral fractures involved a 76-year-old individual who had previously received cemented total hip arthroplasty eight years ago. (A) Surgery was required as per the patient's age, cemented stem stability, and fracture characteristics. A specialized plate with distal screws and proximal cerclage wires stabilizes the fracture after an open reduction procedure; (B) Post-surgery radiographs confirm reduction and fixation. These results match the recommended fracture treatment for older patients with stable, cemented prostheses.

Figure 2. Vancouver B1, Case two

(A) A periprosthetic Vancouver type B1 fracture in an octogenarian patient with Alzheimer's disease. Despite initial considerations for non-surgical intervention due to cognitive impairments, surgical intervention become imperative; (B, C) Successful fracture reduction and osteosynthesis following surgery; (D) The humerus's viceous calus

Figure 3. Vancouver B1, Case three

(A) Seven years post total hip arthroplasty, slight deterioration; (B) 11 years post arthroplasty, significant deterioration with discomfort; (C-G) CT scans confirm femoral lysis and acetabular loss; (H) Revision hip arthroplasty includes cerclage wires stabilizing the extended stem; (I) One year post-revision, successful healing and prosthesis integration, emphasizing the importance of postoperative monitoring and potential revision procedures for specific fracture characteristics.

Figure 4. Vancouver B2, Case one

(A) The fracture in question is categorized as Vancouver B2 owing to the radiological instability observed in the prosthesis stem. Nevertheless, the bone quality of the patient was remarkably high, enabling a precise anatomical realignment of the fracture during the surgical procedure. Considering the effective decrease in symptoms and the presence of concurrent medical conditions in the patient, it was determined that a more conservative surgical approach would be suitable; (B) The conventional approach for managing these fractures frequently entails the utilization of plate and screw fixation. Nevertheless, in this particular instance, osteosynthesis was accomplished through the utilization of four cerclage wires, deviating from the customary treatment protocol. The patient's postoperative course was without any notable incidents, which serves to underscore the significance of tailoring treatment plans to address intricate Vancouver B2 fractures.

Figure 5. Vancouver B2, Case two

(A) Spiroid fracture; (B) Radiological assessment following open reduction and internal fixation (ORIF) using a proximal hook plate, cerclages, and self-locking screws

Figure 6. Vancouver B2, Case three

(A) A spiroid fracture located at the femur level, accompanied by an unstable femoral stem; (B) The anatomical realignment of the periprosthetic fracture using proximal and distal screws in conjunction with plates to enhance its stability. Additionally, a relatively large number of cerclages have been employed at the plate level to maintain the fracture's position. While this approach does indeed enhance resistance, it also elevates the risk of compromising the vascularization of the bone at this particular site.

Figure 7. Vancouver B3, Case one

(A) A spiroid fracture originating from the trochanteric massif and extending approximately 5 centimeters below the distal end of the femoral stem. The radiological observations pose a particularly complex situation. In this instance of a comminuted fracture, a butterfly fragment become detached, covering a span of approximately two-thirds along the entire length of the fracture. The detachment of the fracture greatly intensifies its instability, presenting a challenging surgical predicament; (B, C) The fracture was anatomically reduced and stabilized using open reduction and internal fixation (ORIF) technique, which involved the application of a self-locking plate supplemented with cables. The selection of this approach was likely made with the intention of optimizing the likelihood of achieving fracture union, while simultaneously minimizing the potential for exacerbating the already delicate nature of the fracture.

Figure 8. Vancouver B3, Case two

Image (A) poses a significant clinical dilemma. The radiographic image demonstrates a comminuted fracture that affects the trochanteric massif and the proximal third of the femur. It is worth noting that there is a considerable degree of telescoping and shortening observed in the femur, which serves as an indication of pronounced instability and displacement. Due to the intricate nature of the fracture and its inherent instability, it is probable that a simple internal fixation would not provide adequate long-term stability and promote fracture union. Within this particular context, the surgical team made the decision to pursue a more assertive course of action, as illustrated in Images (B) and (C). A modification was made to the femoral component by utilizing a longer revision stem in order to improve stability and promote the growth of bone tissue. In order to enhance the stability of the fracture in its anatomical alignment, two cerclages were employed. The utilization of a combined strategy involving the modification of the femoral component and the implementation of cerclages is intended to effectively tackle both the immediate mechanical instability and the enduring biological prerequisites for fracture healing.

Figure 9. Vancouver B3, Case three

(A) A distinctive and demanding clinical situation wherein a spiroid fracture is observed that extends to the apex of the femoral stem. Interestingly, the primary cause of instability in this particular scenario is not solely attributed to the fracture, but rather to the considerable peri-implant lysis that compromised the stability of the pre-existing femoral stem during the occurrence of the trauma. The occurrence of lysis, which refers to the pathological degradation of bone tissue surrounding the implant, further intensified the mechanical instability following the traumatic event. Due to the compromised quality of the tissue and the destabilizing effects caused by the lysis process, it was not feasible to preserve the original stem; (B, C) The surgical team made the decision to perform a revision arthroplasty utilizing a thicker, uncemented modular stem. The utilization of this method facilitated a comprehensive removal of fibrous tissue from the femoral canal until reaching a state of high-quality bone, thereby establishing a more robust base for the subsequent implantation. In order to augment stability and promote the process of fracture healing, two cerclages were administered at the site of the fracture. Every instance mentioned emphasizes the necessity of an individualized strategy for the management of Vancouver B3 fractures. This approach should consider the distinct difficulties and requirements posed by the medical and lifestyle factors of each patient.