Fixation versus revision arthroplasty for Unified Classification System type B periprosthetic fractures around cemented polished tapered femoral components : a systematic review and meta-analysis

Abstract

Aims: Periprosthetic femoral fractures (PFF) around hip arthroplasty implants are increasingly common, often occurring in frail elderly patients. Polished taper-slip (PTS) cemented femoral components are commonly used and have been associated with increased PFF rates compared with other cemented femoral component types. In managing Unified Classification System (UCS) type B fractures around PTS stems, surgical treatment options include open reduction and internal fixation (ORIF) and revision arthroplasty (RA), but there is limited evidence comparing these.

Methods: A systematic review and meta-analysis was undertaken. Results from database searching were screened and data were extracted by two authors independently. Reoperation was the primary outcome measure, and the secondary outcome measures included mortality, blood transfusion requirements, and length of stay.

Results: There were 4,640 unique results, and four comparative studies were included in the final analysis. These were published between 2015 to 2023, totalling 539 patients, with 339 treated with ORIF and 200 treated with RA. There was a signal for a clinically large, but not statistically significant, benefit of ORIF compared with RA in reoperation risk (risk ratio (RR) 0.444; 95% CI 0.162 to 1.218; p = 0.115), with an absolute risk reduction of 9.15%. There was also a non-significant signal for increased mortality in the ORIF group at both 90 days and one year. ORIF was associated with a significant decrease in blood transfusion requirements (RR 0.65; 95% CI 0.482 to 0.876; p = 0.005), with an absolute risk reduction of 14.07%. There was also a significant decrease in length of stay following ORIF (mean reduction 2.45 days; 95% CI 0.09 to 4.82; p = 0.042).

Conclusion: Fixation alone is associated with significantly reduced length of stay and blood transfusion, and also with a trend towards reduced reoperation and increased mortality, which may reflect a frailer patient group that receive this treatment, but neither of these findings reached statistical significance. Fixation may have benefits when applied in suitable cases.

Fig. 1

PRISMA flowchart. ORIF, open reduction and internal fixation; PTS, polished taper-slip; RA, revision arthroplasty.

Fig. 2

ROBINS-I assessment.

Fig. 3

Reoperation risk in open reduction and internal fixation compared with revision arthroplasty. RE, random effects; RR, risk ratio.

Fig. 4

The 90-day mortality risk in open reduction and internal fixation compared with revision arthroplasty. RE, random effects; RR, risk ratio.

Fig. 5

One-year mortality risk in open reduction and internal fixation compared with revision arthroplasty. RE, random effects; RR, risk ratio.

Fig. 6

Blood transfusion requirement risk in open reduction and internal fixation compared with revision arthroplasty. RE, random effects; RR, risk ratio.

Fig. 7

Length of stay mean difference in open reduction and internal fixation compared with revision arthroplasty (log (risk ratio) (95% CI)). RE, random effects.