Distal fixation with Wagner revision stem in treating Vancouver type B2 periprosthetic femur fractures in geriatric patients

doi:10.1016/S0883-5403(03)00148-7

The Journal of Arthroplasty

Volume 18, Issue 4, June 2003, Pages 446-452

https://doi.org/10.1016/S0883-5403(03)00148-7 Get rights and content

Abstract

Periprosthetic fractures around hip prostheses are difficult problems. We reviewed the results of treatment with Wagner revision stems in geriatric patients (≥ 65 years old) with Vancouver type B2 periprosthetic fractures. Over a 5-year period, 14 patients with Vancouver’s type B2 periprosthetic fractures in the proximal femur were revised. The mean follow-up for these patients was 58.5 months (range, 36 to 64 months). The average age was 74.5 years (67 to 83 years). Twelve patients were available for assessment; all 12 reconstructions showed a stable prosthesis and solid fracture union. Seven patients had excellent outcome, 3 had a good outcome, and 2 had a poor outcome. Our series shows that the Wagner revision stem is a satisfactory prosthesis in revision of Vancouver type B2 periprosthetic fractures in geriatric patients.

Section snippets

Materials and methods

All patients with periprosthetic femoral fractures after hip arthroplasty who were treated in our department between January 1996 and December 2000 were included. The medical records and radiographs were analyzed, and the fractures were classified according to the Vancouver system [10]. Radiographic assessment focused on the regeneration of bone at the stem interface, healing of the fracture, and osteotomy as well as remodeling of the old prosthetic bed 22, 23, 24. To assess stem subsidence, we

Results

Over the 5-year period, 32 patients with periprosthetic proximal femoral fractures were treated in our department. In this cohort, 14 patients met the criteria: older than 65 years old, with type B2 fractures treated using the Wagner revision stem, and a minimum of 3 years of follow-up evaluation (Fig. 5). One patient died 26 days after revision because of a methicillin-resistant Staphylococcus aureus (MRSA) deep wound infection and fulminant pneumonia. This patient’s results were excluded

Discussion

Unstable periprosthetic fractures around the tip of loosened hip prostheses (Vancouver type B) in elderly patients pose a great challenge to both the orthopaedic surgeon and the patient. There is a 20% mortality rate within the first 3 months of surgery because of significant medical comorbidities [26]. In a series from community experience, a complication rate of 41% related to the fracture (deformity, fixation failure, nonunion) and 33% related to the arthroplasty (loosening, sepsis,

Conclusions

In this series, we have shown that the Wagner stem is a satisfactory prosthesis in the treatment of Vancouver B2 periprosthetic fractures in geriatric patients because of its ability to directly transmit forces into the femoral shaft distal to the fracture. It also provides an optimal environment for bone healing.

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Despite the clinical success of tapered splined titanium stems, a knowledge gap still exists between spline design and its primary mechanical stability, which is critical to the long-term success of revision hip arthroplasty. Additionally, almost all published pre-clinical studies relied on resource-intensive benchtop and cadaveric testing. Hence, the present study developed a novel computational model to investigate effects of spline geometry and configuration on axial and torsional stability of tapered stem. Dynamic explicit Finite Element Analysis coupled with a state-of-the-art adaptive meshing technique was used to simulate the highly non-linear contacts and large bony material deformations. Hybridising primary straight splines with secondary angled splines results in 41% and 10% increases of peak insertion force and post-seating moment than the predicate device for the same seating position. The primary straight splines cut at multiple circumferential bony locations, enhancing torsional stability; while the alternatively placed secondary angled splines form wedges with the bone, providing reliable seating and additional torsional resistance. To the best knowledge of the author, this is the first in-silico investigation of its kind to simulate multi-strike seating and torsional resistance of revision hip stems, offering an effective and efficient platform for future multi-factorial parametric study and uncertainty quantification.
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L’appréciation de la fixation prothétique au décours d’une fracture périprothétique de hanche de type Vancouver B1 est un élément décisionnel majeur en vue d’un geste chirurgical d’ostéosynthèse et/ou de révision prothétique. L’objectif principal de cette étude était de montrer la corrélation entre la mesure radiographique d’un Index spécifique de fixation restante (IFR) et le risque de descellement prothétique au dernier recul chez les patients ayant eu une ostéosynthèse pour fracture périprothétique Vancouver B1.
Cette étude rétrospective multicentrique a permis d’inclure 50 patients ayant présenté une fracture périprothétique Vancouver B1 non cimentée entre 2013 et 2019. L’ensemble des radiographies préopératoires des patients ont été analysées de manière indépendante par deux orthopédistes seniors. Deux groupes ont alors pu être constitués (IFR > 2/3 et < 2/3). La dernière étape a consisté à analyser les radiographies postopératoires et au dernier recul de l’ensemble à la recherche de signes de descellement complet de l’implant fémoral.
L’âge médian était de 89 ans (minimum 36 ; maximum 99). Dans le groupe ayant un IFR > 2/3, deux patients présentaient un descellement prothétique (8 %) contre 9 patients dans le groupe IFR < 2/3 (36 %) montrant de manière significative une corrélation positive entre descellement précoce et IFR < 2/3 (p = 0,005). Concernant la mesure radiographique de l’IFR et l’évaluation radiographique au dernier recul, la concordance interobservateur était alors de 98 % avec un coefficient de corrélation Kappa de 0,96 [0,88–1].
La mesure d’un Index de fixation restante inférieur à 2/3 chez les patients présentant une fracture périprothétique de hanche Vancouver B1 est un facteur de risque de descellement prothétique précoce après ostéosynthèse seule. Chez ces patients, souvent âgés et fragiles, un geste de changement prothétique de première intention doit être discuté en fonction du rapport bénéfice-risque pour le patient. Ces résultats confirment la nécessité d’une évaluation radiographique préopératoire rigoureuse de la zone de fixation restante en cas de fracture Vancouver B1.
IV.
Contribution of the remaining attachment index in the management of Vancouver B1 periprosthetic hip fracture
2020, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
In type B, the choice between internal fixation and implant exchange is more problematic [11]. In B3 or B2 fracture, where fixation is obviously defective and/or accompanied by osteolysis, exchange is logical, as advocated by Berry [15], Ko [16] and Springer [17]. Most series focused on internal fixation for B1 fracture [4–6,18], but analysing the remaining attachment area is essential to guide indications and avoid long-term loosening and surgical revision.
Implant fixation assessment following Vancouver B1 periprosthetic hip fracture is a major decision factor for internal fixation and/or implant revision. The main aim of the present study was to assess the correlation between radiographic Remaining Attachment Index (RAI) and risk of implant loosening at last follow-up following internal fixation of Vancouver B1 periprosthetic hip fracture.
A multicentre retrospective study included 50 patients with Vancouver B1 periprosthetic hip fracture with uncemented femoral stem between 2013 and 2019. Preoperative radiographs were analysed independently by 2 senior orthopedic surgeons, distinguishing 2 groups: RAI > 2/3 versus < 2/3. Postoperative and last follow-up radiographs were then screened for signs of complete femoral component loosening.
Median age was 89 years (range: 36–99 years). Two RAI > 2/3 patients showed implant loosening (8%) versus 9 RAI < 2/3 patients (36%), disclosing a significant correlation between early loosening and RAI < 2/3 (p = 0.005). Interobserver agreement for both radiographic RAI and radiographic loosening assessment at last follow-up was 98% with kappa correlation coefficient 0.96 [range: 0.88–1].
Remaining Attachment Index < 2/3 in Vancouver B1 periprosthetic hip fracture was a risk factor for early implant loosening after isolated internal fixation. In these often frail elderly patients, first-line implant exchange is to be considered in the light of the risk/benefit ratio. The present results confirm the need for rigorous preoperative radiographic work-up of the remaining attachment area in Vancouver B1 fracture.
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Periprosthetic femoral fractures after total hip arthroplasty: An algorithm of treatment
2019, Injury
Citation Excerpt :
A long-cemented stem can provide adequate stability, but cement may interpose between the fracture fragments and inhibit union. Thus, uncemented long-stem extensively porous-coated femoral implants can be used successfully in the management of PFFs [23,24]. Predictable fracture union and bone growth into the components were achieved in all patients.
Periprosthetic femoral fractures (PFFs) following total hip arthroplasty are becoming more prevalent and management of these fractures is often demanding. The surgeon has to assess in detail implant loosening, bone loss and type of fracture. The aim of the study is to identify the suitability of a treatment algorithm, based on the Vancouver classification that takes into account the activity and comorbidity of each patient.
This study retrospectively assessed 38 patients who were surgically treated for a PFF around total hip arthroplasty between 2010 and 2014. All fractures were classified according to the Vancouver classification. There were 14 type B1, 8 type B2, 10 type B3 and 6 type C fractures. The data examined were age, sex, mechanism of injury, type of fracture, ASA score, type of surgery and complications. Radiographic evaluations were performed at 1, 3, 6 months and every 12 months thereafter. Clinical results were measured using the Merle-d’Aubigné-Postel score. Treatment options included an ORIF in 22 patients and a stem revision in 16 patients, with or without plates or supplemental cortical strut grafting when required.
The mean duration of follow-up was 3.1 years, mean age was 71.2 years and six patients (15.7%) died. Union was obtained in all patients in a mean of 16 weeks. Three patients required a surgical revision: one for stem loosening and two for re-fracture after a new fall. One patient had varus malunion of the femur. The mean postoperative Merle-d’Aubigné-Postel score was 13.2. Thirteen patients showed excellent results, 14 had a good result, three had a fair outcome and two had a poor result. Twenty patients returned to their baseline mobility status, while 12 patients had either a decline in their ambulatory status or a need for additional assistive devices.
PFF remains a serious complication of hip arthroplasty that is accompanied by high morbidity and mortality rates. This study shows how patients’ comorbidities and functional demand can direct the proper treatment. This is a suitable algorithm for the treatment of PFF, which can provide satisfactory results in terms of pain and function.
Diagnosis and management of periprosthetic femoral fractures after hip arthroplasty
2019, Injury
Citation Excerpt :
The Vancouver classification system according to Duncan e Masri [8] is commonly used worldwide and considered the most reliable method based on location of the fracture, implant stability and residual bone stock. Different surgical strategies are needed also on the basis of primitive implant and its type of fixation, however the objective is adequate fracture reduction and stabilization with early and effective patient mobilization [9,10]. The aim of this retrospective study is analyze the diagnostic and therapeutic decision making processes performed in patients treated surgically for periprosthetic fractures.
Periprosthetic femoral fracture represent a severe complication, at present the third cause of revision surgery, with an estimated incidence from 0,1 to 2,1%. The number of these fracture can be expect to increase in line with the aging of population and amount of THA implants also in younger high demanding patients.
The aim of this study is analyze the diagnostic and therapeutic decision making processes performed in 64 patients with periprosthetic fractures treated surgically from January 2012 and October 2016 in our center. We analysed instrumental exams and surgical reports focusing on type of procedure, surgical access, operative time and type of fixation.
Average age was 809 years and a mean follow-up 231 months.
According to Vancouver system and after X-rays, CT scan and intraoperative evaluation, 26 fractures were classified as type B1, 31 as type B2, 3 type B3 and 4 type C.
Follow up results were divided on the basis of the surgical treatment: in ORIF group (23 type B1 fractures and 4 type C fracture) fracture union was obtained in 16 cases (593%) and the final HHS mean value was 6161; in Revision group (3 type B1, 31 type B2 and 3 type B3) bone healing was reported in 26 cases (703%) with mean HHS score of 7194.
In this surgery the objectives are provide an adequate bone healing and return to previous functional status as soon as possible. Many reasons make these goals challenging, in particular advanced age, osteoporosis, co-morbidity and weakness that lead to low energy trauma, the most frequent cause of these injuries. In our opinion a crucial aspect is the evaluation of stem stability, considering an implant mobilized until the opposite is clearly evident. Reduction of surgical time and early mobilization are goals of this surgery, often associated with several complications and high mortality rate.
Mid-term results of 121 periprosthetic femoral fractures: Increased failure and mortality within but not after one postoperative year
2015, Journal of Arthroplasty
Periprosthetic femoral fractures are associated with high failure rates and mortality, particularly within one postoperative year. However, mid-term results related to this issue are lacking. Thus, we performed a retrospective follow-up evaluation. Between 2007 and 2012, we treated a total of 121 consecutive patients for periprosthetic femoral fractures. After a mean of 57.2 postoperative months, we documented a total surgical revision rate of 16.5% within the first year, and the one-year mortality rate was 13.2%. Between one year and up to 7.3 postoperative years, only one surgical revision was necessary, and the mortality rate also decreased. No significant factors related to surgical revisions were detected. However, the initial hip fracture, older age, higher ASA score and dementia were associated with a higher mortality rate.

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^☆: No benefits or funds were received in support of this study.

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Distal fixation with Wagner revision stem in treating Vancouver type B2 periprosthetic femur fractures in geriatric patients☆

Abstract

Section snippets

Materials and methods

Results

Discussion

Conclusions

J Arthroplasty

J Arthroplasty

J Arthroplasty

Orthop Clin North Am

Injury

J Arthroplasty

Injury

J Arthroplasty

Orthop Clin North Am

Orthop Clin North Am

J Arthroplasty

Periprosthetic fracture of the femur after total hip arthroplasty

J Bone and Joint Surg Am

Periprostheic fractures of the femur

Clin Orthop

Femoral fracture following hip arthroplasty

Acta Orthop Scand

Femoral fractures following total hip prosthesis

Unfallchirurg

Femoral fractures associated with total hip arthroplasty

Orthop Clin North Am

Fractures of the femur after total hip arthroplasty

Instr Course Lect

Fractures of the femur in relation to cemented hip prostheses

J Bone and Joint Surg Br

Bilateral femoral fracture at the site of bilateral hip prosthesesa case report

Unfallchirurg