Do All Postoperative Vancouver B2 Fractures Require Revision Arthroplasty With Cementless Stems?

Abstract

Background: Management of periprosthetic fractures has been guided by the Vancouver classification, which recommends revision for fractures around a loose femoral implant (B2). New studies have challenged this approach, demonstrating acceptable outcomes with internal fixation. This study evaluates our experience with Vancouver B2 fractures, comparing internal fixation to femoral revision. We hypothesized that in select cases with cementless stems, internal fixation would provide acceptable results with reduced morbidity.

Methods: A retrospective review was performed of periprosthetic hip fractures treated at our institution between 1 January 2012 and 4 November 2022. We excluded patients who did not have prior radiographs and evidence of stem subsidence, suggestive of a Vancouver B2 fracture. Thirteen patients were included in the analysis.

Results: Four patients (31%) underwent revision of the femoral component, 4 patients (31%) underwent plating, and 5 patients (38%) underwent internal fixation with cerclage cabling. The average operative duration was 158 minutes, 203 minutes, and 62 minutes for the revision, plating, and cabling cohorts, respectively (P = .009). Blood loss was 463 cc, 510 cc, and 90 cc for the revision, plating, and cabling cohorts, respectively (P = .036). Three patients in both the revision and plating cohorts each received a transfusion (75%), whereas no patients in the cabling cohort required a transfusion (P = .033). All patients demonstrated fracture healing on the postoperative radiographs. No patients required additional surgery during the follow-up period.

Conclusions: We have demonstrated that Vancouver B2 periprosthetic fractures with intact lateral cortices may be treated with internal fixation with cerclage cabling with excellent results.

Keywords: Hip fracture; Periprosthetic fracture; Revision; Vancouver classification.

Figure 1

The technique for measuring stem subsidence includes correcting for magnification with the femoral head, followed by drawing lines from the tip of the greater trochanter to the shoulder of the implant, and from the center of the femoral head to the lesser trochanter.

Figure 2

A Vancouver B2 periprosthetic fracture with subsidence of the stem (a), followed by revision to a long, fully porous implant. At 5 years, the patient was doing well (b).

Figure 3

A cementless stem removed during revision to a long fully porous femoral implant. Note the exposed on-growth surface and fragments of attached bone, for bone-to-implant and bone-to-bone healing.

Figure 4

The intraoperative fluoroscopy during a direct anterior THA demonstrates initial placement of the stem (a). After a fall 23 days postoperatively, the implanted demonstrated subsidence of the stem (b), which was treated with cerclage cabling. The patient was doing well 1 year postoperatively with no complaints (c).

Figure 5

A Vancouver B2 periprosthetic with involvement of the lateral cortex (a). This was treated with a lateral plate and cerclage cables. At 2-years postoperative the patient was doing well (b and c).

Figure 6

Cerclage cabling the Vancouver B2 fracture. At least 2 cables were placed and alternately tightened to provide even compression of the fractured fragment and stem against the lateral cortex, which acted as a buttress.

Figure 7

Radiographs of a periprosthetic femur fracture in an 85-year-old man after a fall demonstrate a Vancouver B2 periprosthetic fracture with subsidence of the stem (a). Intraoperative fluoroscopy was utilized to reduce the fracture with 2 cables (b). At 13 months postoperatively, the patient was doing well, with no complaints of pain in the hip (c).