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Cementless, Fluted, Long-Stem Hemiarthroplasty for Vancouver B2 and B3 Periprosthetic Fractures Around Hip Hemiarthroplasty
The Journal of Arthroplasty 34 (2019) 1179e1183
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The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Revision Arthroplasty
Cementless, Fluted, Long-Stem Hemiarthroplasty for Vancouver B2 and B3 Periprosthetic Fractures Around Hip Hemiarthroplasty ~ o, MD a, Alejandro Lizaur-Utrilla, PhD, MD a, b, *, Santiago Gonzalez-Parren ~ oz, MD a, Fernando A. Lopez-Prats, PhD, MD b Francisco A. Miralles-Mun a b
Department of Orthopaedic Surgery, Elda University Hospital, Elda, Alicante, Spain Department of Traumatology and Orthopaedics, Miguel Hernandez University, San Juan de Alicante, Alicante, Spain
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 January 2019 Received in revised form 14 February 2019 Accepted 18 February 2019 Available online 25 February 2019
Background: The purpose of this study was to assess the effectiveness of a cementless, modular, fluted, long-stem hemiarthroplasty for the treatment of Vancouver type B2 and B3 periprosthetic femoral fracture around hip hemiarthroplasty. Methods: This was a retrospective case-control study comparing 46 patients revised to hemiarthroplasty (HA group) and 31 revised to total hip arthroplasty (THA group). Functional outcome was evaluated by score, and the Katz scale based on activities of daily living. Comorbidity was the Merle d’Aubigne assessed by the Charlson index, and cognitive function by a mini-mental test score. Radiological evaluation was also performed. Results: Mean postoperative follow-up was 3.3 (range, 2-4) years in the HA group and 3.9 (range, 2-5) in the THA group. The need for transfusion and hospital stay were significantly higher in the THA group. Postoperatively, both groups had a significant decrease in mean hip function (P ¼ .001) although the mean Merle (P ¼ .121) and Katz (P ¼ .214) scores were similar at final follow-up. Likewise, there were no significant differences between groups in pain or loss of life independence. All fractures were united but one in the HA group. There were no dislocations in the HA group, and 3 in the THA group. Conclusion: The management of Vancouver B2 and B3 periprosthetic femoral fracture around hemiarthroplasties with a long-stem revision cementless bipolar hemiarthroplasty, supplemented with wire cerclages and cancellous allograft, was an effective option in terms of fracture healing and stability of the implant with a low rate of complications. Nevertheless, a significant functional impairment was also observed in either group. © 2019 Elsevier Inc. All rights reserved.
Keywords: femoral neck fracture hemiarthroplasty periprosthetic fracture revision cementless hemiarthroplasty revision total hip arthroplasty
Periprosthetic femoral fracture (PFF) is a serious complication after hemiarthroplasty for femoral neck fracture in elderly patients, and a challenge for the surgeon. Numerous studies have been reported on PFF around total hip arthroplasty (THA) [1e3]. However, there is little evidence regarding PFF around hemiarthroplasty. Most published studies on PFF after hemiarthroplasty have analyzed only epidemiological data and risk factors in small series, but including heterogeneous fracture types and treatments [4e8]. The incidence of PFF after hip hemiarthroplasty varies with rates between 2% and 14% [6,7,9,10]. Several risk factors have been
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.02.036. * Reprint requests: Alejandro Lizaur-Utrilla, PhD, MD, Department of Orthopaedic Surgery, Elda University Hospital, Ctra Elda-Sax s/n, 03600 Elda, Alicante, Spain. https://doi.org/10.1016/j.arth.2019.02.036 0883-5403/© 2019 Elsevier Inc. All rights reserved.
described, such as cementless stem [4], cemented polished tapered stem [11], male gender, and osteopenia [8]. Regarding the fracture type, Vancouver [12] types B are the most common among the postoperative fractures with incidence between 59% and 81% [5,7,13]. Vancouver types B2 and B3 are fractures with stem loosening, and the revision to a cementless long-stem and fixation of fracture fragments is currently recommended [2,14]. Patients who receive a hemiarthroplasty for femoral neck fracture are usually elderly, with comorbidity, low physiological reserve, and moderate or low physical activity [15]. After Vancouver types B2 and B3 PFF around a hemiarthroplasty, revision to a THA has usually been used in the literature [16,17]. However, no studies in the literature have analyzed outcomes of revision to a new hemiarthroplasty. We hypothesized that in those patients who had had indication for hemiarthroplasty after femoral neck fracture, PFF treatment should also be a hemiarthroplasty especially whether the
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Surgical Procedure
Table 1 Preoperative Data at the Time of Index Hemiarthroplasty. Variables
HA Group (N ¼ 46)
THA Group (N ¼ 31)
P
Gender (F/M) Age (y) BMI (kg/m2) ASA (1-2/3-4) Charlson index Mental score Trauma Fall to the floor Traffic No trauma Vancouver fracture B2 B3
35/11 76.3 (5.2) 28.3 (3.1) 13/33 2.7 (1.8) 7.1 (2.9)
21/10 74.2 (7.0) 29.2 (4.5) 13/18 2.2 (2.4) 7.6 (3.1)
.291 .135 .301 .159 .299 .472 .319
29 5 12
22 1 8
25 21
17 14
.576
Continuous variables: median (SD). ASA, American Society of Anesthesiologists score; BMI, body mass index; F, female; HA, hemiarthroplasty; M, male; SD, standard deviation; THA, total hip arthroplasty.
acetabulum did not show erosion or degeneration or the life expectancy was relatively short. The purpose of this study was to evaluate the effectiveness of a cementless, modular, fluted, longstem hemiarthroplasty for Vancouver types B2 and B3 PFF around hip hemiarthroplasty.
Materials and Methods This retrospective case-control study was approved by our institutional review board, and informed consent was not required. A retrospective review of our hip-trauma database was performed to identify the patients treated with hemiarthroplasty for femoral neck fracture and who then had a Vancouver type B2 or B3 PFF between 2001 and 2015. Exclusion criterion was pathological fracture due to tumor disease (1 patient). A minimum follow-up of 2 postoperative years after PFF was required for outcome analysis. For the purpose of this study, the patients were included in 1 of 2 groups: patients who underwent revision with a hemiarthroplasty (HA group) for PFF, and those who underwent revision THA (THA group). The indication for revision to a hemiarthroplasty was the absence of substantial acetabular arthritis determined radiologically in the preoperative period and confirmed intraoperatively. It is noted that patients who undergo hemiarthroplasty after femoral neck fracture were usually older than 70 years and with moderate physical activity or low physiological reserve. A total of 86 patients met the criteria: 51 in the HA group and 36 in the THA group. In the HA group, 3 patients died from reasons unrelated to the surgery and 2 other were lost to follow-up within 2 years after PFF. In the THA group, 4 died and 1 was lost. All these patients were excluded. At the time of the study, 8 other patients in the HA group and 5 in the THA group had died but they had been followed for at least 2 years and their last evaluations were included in the study. Thus, the study consisted of 46 patients in the HA group and 31 in the THA group. The preoperative data of each group at the time of index hemiarthroplasty are shown in Table 1. At the time of the index hemiarthroplasty, there were no significant differences between groups. Overall, the mean time interval between the index hemiarthroplasty and PFF was 12.2 (range, 2-26) months. The PFF was caused by minor trauma (fall to the floor) in 29 patients of the HA group vs 22 of the THA group, in 6 vs 1 by pedestrian traffic accident, and in 11 vs 7 spontaneously without a history of apparent traumatic event. According to the Vancouver system [12], in the HA group 25 fractures were classified as type B2 and 21 as type B3, and in the THA group 17 and 14, respectively.
All index femoral neck fractures in both groups had been managed with a cemented bipolar hemiarthroplasty (Self-Locking system, Lima LTO, Italy) through a Hardinge lateral approach, under spinal anesthesia. All revisions were performed with the use of the MGS cementless modular revision stem (Samo, Bologna, Italy). This is a modular fluted tapered femoral stem in titanium alloy based on the Wagner concept of distal fixation. For revision hemiarthroplasty, a bipolar chrome-cobalt head for hemiarthroplasty was used (SBA, Samo). For revision THA, a press-fit cup in titanium plasma-sprayed with metal-polyethylene bearing and head of 28 mm (Duofit; Samo) was used. The same standard operative technique was used in all patients. A Hardinge approach was used and distally extended as required to allow reduction and fixation of the fracture. Trochanter lateral osteotomies were necessary in 4 hips to remove the index stems. A wire cerclage was placed at the distal femur to prevent fracture propagation during reaming or stem impaction. The long stem required a press-fit distal fixation in the isthmus zone, and it has been recommended that the fracture be bypassed by at least 2 cortical diameters with a long stem [18]. Nevertheless, we bypassed fracture at least 8 cm to maximize distal fixation when possible. Then, the fracture fragments were reduced and fixed with wire cerclages around the implant. Bank cancellous bone allograft was used over the proximal fracture lines and medial cortical in all hips. Postoperatively, touch weight-bearing using a walker was allowed for 6 to 8 weeks, and then full weight-bearing with a support for 6 other weeks.
Evaluations The clinical records and radiographs of each patient were reviewed. The hip-trauma database of our department collects prospective data on all hip fractures treated, including patient demographics, preoperative and postoperative data, and clinical and radiological assessments. In a standardized way, all patients had been evaluated preoperatively at the time of the index fracture, and postoperatively after PFF every 3 months during the first postoperative year, every 6 months in the next year, and then at least 1 more year. If the patient did not return for examination, their families were interviewed by telephone. For this study, preoperative data were referred to the time of the index hemiarthroplasty. At admission, comorbidity was assessed by the American Society of Anesthesiologists scale [19] and Charlson index [20]. Hip score functional outcome was evaluated by the Merle D’Aubigne [21]. The Katz scale [22] based on independence in 6 activities of daily living was also applied. Cognitive function at admission was evaluated by a mini-mental test score validated for elderly [23], where the maximum score was 10 points and a result of 6 or less was suggestive of dementia. Radiological evaluation included standard anteroposterior and lateral hip radiographs. The initial postoperative radiographs after revision were compared with final radiographs for evidence failure, loosening, or stem migration. Radiological outcomes were classified using the criteria proposed by Beals and Tower [24] for PFF as excellent (stable stem with minimal deformity), good (stable stem with moderate subsidence and fracture healed with moderate deformity), or poor (stem loosening, nonunion, sepsis, or severe deformity). An implant was described as stable if there was an absence of continuous radiolucent lines around the stem, progressive stem subsidence, or migration. Failure was defined as stem requiring revision surgery for any reason. Fracture healing was defined as the presence of radiological bone callus or bridging in both the anteroposterior and lateral planes, and capacity for
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Table 2 Comparison of Preoperative and Postoperative Data Between Groups. Variables
Follow-up Merle score Walking aid No Cane Walking Chair/bed Hip/groin pain No/mild Moderate Severe Thigh pain No/mild Moderate Severe Katz score Residence Home Nursing
HA Group
THA Group
Preoper
At Final
8.9 (3.1)
3.3 (1.4) 6.2 (2.9)
28 17 1 0
13 25 4 4
41 5 0
32 9 5
45 1 0 5.2 (1.7)
28 14 4 3.7 (1.8)
46 0
36 10
P
Preoper
At Final
.001 .015
9.3 (2.6)
3.9 (2.2) 7.3 (3.2)
18 13 0 0
9 15 5 2
27 4 0
17 10 4
29 2 0 5.8 (2.5)
17 12 2 4.3 (2.4)
31 0
26 5
.018
.001
.001 .003
P*
P**
.009 .013
.556 .655
.147 .121 .572
.005
.527
.141
.001
.353
.384
.019 .005
.213 .999
.214 .381
P
Continuous data as mean (SD). P*dbetween preoperative data. P**dbetween data at final follow-up. At final, at final follow-up; HA, hemiarthroplasty; Preoper, preoperative data; SD, standard deviation; THA, total hip arthroplasty.
weight-bearing without pain at the fracture site. Subsidence of the stem was defined [25] by a movement of at least 6 mm. Statistical Analysis Statistical analyses were conducted with IBM-SPSS v.19. Normal distribution was assessed by the Kolmogorov-Smirnov test. For univariate analysis, categorical variables were analyzed by the chisquare test, Fisher exact test, or Mantel-Haenszel test, and continuous variables by t-Student t-test or Mann-Whitney U-test. For comparison between preoperative and postoperative data, the paired t-test or Wilcoxon signed-rank test was used. A P value less than .05 was considered significant in all tests. Results
between groups in the rate of patients who walked without aids or with a cane (P ¼ .572). Regarding the hip or groin pain, in the HA group 41 (89.1%) patients reported no or mild preoperatively and 32 (69.5%) had pain at final follow-up (P ¼ .018), while in the THA these were 27 (7.0%) and 17 (54.8%) (P ¼ .005), respectively. At final follow-up, there was no significant difference between groups in the rate of patients with no or mild pain at hip or groin (P ¼ .141). Regarding the thigh pain at final follow-up, in the HA group 28 (60.8%) patients had no or mild pain, and 17 (54.8%) in the THA group (P ¼ .384). Regarding the ability for daily activities (Table 2), there was no preoperative significant difference between groups in the Katz score (P ¼ .213). Postoperatively, both groups had a significant decrease in mean Katz score (P HA ¼ .001; P THA ¼ .019) with no significant difference between groups at final follow-up (P ¼ .214).
The mean postoperative follow-up after PFF was 3.3 (range, 2-4) years in the HA group, and 3.9 (range, 2-5) years in the THA group (P ¼ .147). The mean surgical time for revision PFF was 72.7 (SD, 15.3) minutes in the HA group, and 116.2 (SD, 12.8) in the THA group (P ¼ .001). Preoperatively, 22 (47.8%) patients in the HA group needed blood transfusion, and 13 (41.9%) in the THA group (P ¼ .392). Postoperatively, 33 (71.7%) patients in the HA group and 30 (96.7%) in the THA group received blood transfusion (P ¼ .004). The mean hospital stay was 7.1 (SD, 3.6) days in the HA group and 9.8 (SD, 2.7) in the THA group (P ¼ .001). Clinical Outcomes Preoperatively (Table 2), there was no significant difference between groups in the mean hip function (Merle, P ¼ .556). Postoperatively, both groups had a significant decrease in mean Merle score (P ¼ .001) with no significant difference between groups at final follow-up (P ¼ .121). Preoperatively, in the HA group 45 (97.8%) patients walked without aids or with a cane, and at final follow-up these were 38 (82.6%; P ¼ .015), while in the THA group there were 31 (100%) preoperatively and 24 (77.4%) at final follow-up (P ¼ .013). At final follow-up, there was no significant difference
Fig. 1. (A) Vancouver type B3 periprosthetic femoral fracture. (B) Radiological result at 3 y after cementless, long-stem hemiarthroplasty supplemented with wire cerclages and cancellous allograft.
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All patients lived in their home preoperatively, and postoperatively 10 patients (21.7%) in the HA group and 5 (16.1%) in the THA group were transferred after rehabilitation to a nursing home (P ¼ .381). Radiological Results All patients in the HA group but one showed radiological union (Fig. 1). One patient had nonunion of the proximal aspect of the fracture involving the greater trochanter but the stem remained stable although had a slight varus angulation of 6 . These patients reported moderate hip pain. Two other patients had a nonprogressive subsidence of 6 and 8 mm, respectively. In the THA group, all patients had fracture healing. One patient had a subsidence of 14 mm. No patients in either group had evidences of stem or cup loosening. The stem radiological results according to the Beals and Tower’s criteria were excellent in 43 (93.4%) patients and good in 3 (6.6%) in the HA group, and in 30 (96.7%) and 1 (3.3%), respectively, in the THA group. This difference was not significant (P ¼ .468). Complications There was no hip dislocation in the HA group, while in the THA group, 3 (9.6%) patients had arthroplasty dislocation between 3 and 21 days after THA. Two of these were reduced under general anesthesia with external manipulations, and then immobilization in bed with the hip in abduction neutral rotation for 2 weeks. The third patient needed open reduction without exchange of the components. The fracture remained stable in these 3 patients. Superficial wound infection occurred in 2 patients of the HA group and 1 of the THA group. All these infections were treated with debridement and antibiotic therapy, and removal of the implant was not required. Staphylococcus epidermidis was identified in all hips. At the time of the final follow-up, no patients in either group needed revision of the arthroplasty. Discussion The main finding of the present study was the effectiveness of mechanical and clinical outcomes of the cementless, fluted, longstem revision hemiarthroplasty supplemented with cerclages for the treatment of Vancouver types B2 and B3 periprosthetic fractures after cemented hemiarthroplasty. The need for blood transfusion and hospital stay were significantly higher in the THA group. In addition, no dislocation occurred in the HA group, while there were 3 dislocations in the THA group. In the present study, there were 2 subsidences less than 10 mm but no dislocations using revision hemiarthroplasty. Dislocation after revision THA for Vancouver type B2 or B3 fractures is a relatively frequent complication reported in the literature [2,3,26]. Moreta et al [2], in 43 B2 and B3 periprosthetic fractures after THA treated with cementless, tapered long-stem, reported 16% dislocations and it was associated with a mean subsidence greater than 4 mm. However, in that study both monoblock and modular stems were used. Joestl et al [3] reviewed 28 B2 PFF after THA revised with a long-stem THA, and they reported 3 (8%) dislocations. In the present study, both groups had a significant decrease in the functional status from the preoperative to postoperative followup. It should be noted that all these patients who underwent index hemiarthroplasty were of advanced age and severe comorbidities. However, there were no significant differences at final follow-up between groups in clinical outcomes. Comparison with the literature is difficult because there were no studies using revision hemiarthroplasty for PFF. Thus, we have compared our outcomes with those of studies that had used
modular fluted titanium stems in treating Vancouver B2 and B3 periprosthetic fractures about THA [2,16]. Moreta et al [2], in a study of 43 B2-B3 fractures after THA in patients with mean age of 78 years, found a mean postoperative Harris Hip Score of 73, and 42% did not return to their previous ambulatory levels. Canbora et al [16] using revision cementless THA with a long femoral stem observed a mean postoperative Harris Hip Score of only 68 after B2 or B3 periprosthetic fractures, although those authors also reported 76% excellent and good radiological results using the Beals and Towers’ criteria. On the contrary, other authors achieved better functional outcomes after treatment of periprosthetic fractures [17,27]. Rayan et al [28] reviewed 26 patients with Vancouver type B2 or B3 periprosthetic fractures managed by revision THA. The mean postoperative Harris Hip Score was 83, and no patient needed more than 1 stick as a walking aid by 1 year postoperatively. However, the mean age was 68 years in that series. In the present study, the cementless, fluted, long-stem, modular hemiarthroplasty provided successful mechanical outcomes for Vancouver types B2 and B3 PFF around hip hemiarthroplasty. All patients had clinical and radiological fracture union and no adverse events were found. This may be attributed to a combination of good stem fixation distally and to our use of wire cerclages and cancellous allograft, as evidenced by other authors [28]. We believe that the cancellous allograft used in the present study enhanced the osteogenesis in the fracture and could have helped recover the deficient bone stock in Vancouver type B3 fractures. In our opinion, the extended Hardinge lateral approach facilitates the control of the fracture during the removal of the index stem. However, as recommended by Berry [29], it is important to minimize stripping of soft tissue from the fragments in order to preserve the blood supply of the bone fragments. In the studies by Canbora et al [16] and Fink and Oremek [17], with revision long femoral stem, all fractures were also united. Similar results in terms of fracture healing were found by Munro et al [30] in a cohort of 38 Vancouver type B2 and 17 Vancouver type B3. In the present study, there were 2 subsidences after revision HA and 1 after revision THA. Similar findings were reported with modular femoral stems in the literature [28]. Fink and Oremek [17] studied 32 cases of Vancouver types B2 and B3 fractures treated also with cementless, modular tapered, and fluted long stem. In that study, after a mean follow-up of 32 months, no subsidence was observed and all patients resulted with excellent radiological outcome. Parry et al [31] reviewed 61 Vancouver B2 and B3 periprosthetic hip fractures around THA treated with modular fluted tapered implants. At mean follow-up of 4 years, the authors observed 13% stem subsidence with a mean of 18 mm, and all those cases stabilized without revision. Like other authors [5], we believe that stem subsidence can be avoided by sufficiently filling the canal using a modular tapered and fluted long-stem. In the present study, mortality after PFF was similar to that for patients surgically treated for hip fracture in our institution. In the study by Amenabar et al [1], there were no deaths within the first 30 days after surgery and only 1 patient (1.3%) died within the first 2 months. Jennison and Yarlagadda [13] reported 1-year mortality rate of 28% after PFF following a hemiarthroplasty, but most of their patients had nonsurgical treatment. Phillips et al [5] reported 1-year mortality rate of 34%. However, these authors included all Vancouver types of fractures, and diverse procedures such as internal fixation, revision hemiarthroplasty, and nonsurgical treatment. Haughom et al [32] found that patients with periprosthetic hip fractures have a similar mortality to those with native hip fractures. The present study had several limitations. First, it was a retrospective study. The minimum follow-up of 2 years was short but adequate to achieve the main objective of the study, and it was
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similar to other previous studies. However, the survival of the revision stem should be taken with caution. In order to obtain relevant conclusions on the management of complex periprosthetic fractures around hemiarthroplasties, prospective randomized studies involving multiple medical centers could be beneficial. In conclusion, the management of Vancouver B2 and B3 PFF around hemiarthroplasties with a long-stem revision cementless bipolar hemiarthroplasty, supplemented with wire cerclages and cancellous allograft, was an effective option in terms of fracture healing and stability of the implant with a low rate of complications. Nevertheless, a significant functional impairment was also observed in either group. References [1] Amenabar T, Rahman WA, Avhad VV, Vera R, Gross AE, Kuzyk PR. Vancouver type B2 and B3 periprosthetic fractures treated with revision total hip arthroplasty. Int Orthop 2015;39:1927e32. [2] Moreta J, Uriarte I, Ormaza A, Mosquera J, Iza K, Aguirre U, et al. Outcomes of Vancouver B2 and B3 periprosthetic femoral fractures after total hip arthroplasty in elderly patients. Hip Int 2018;29:184e90. https://doi.org/10.1177/ 1120700018772163. [3] Joestl J, Hofbauer M, Lang N, Tiefenboeck T, Hajdu S. Locking compression plate versus revision-prosthesis for Vancouver type B2 periprosthetic femoral fractures after total hip arthroplasty. Injury 2016;47:939e43. [4] Foster AP, Thompson NW, Wong J, Charlwood AP. Periprosthetic femoral fractures: a comparison between cemented and uncemented hemiarthroplasties. Injury 2005;36:424e9. [5] Phillips JR, Moran CG, Manktelow AR. Periprosthetic fractures around hip hemiarthroplasty performed for hip fracture. Injury 2013;44:757e62. [6] McGraw IW, Spence SC, Baird EJ, Eckhardt SM, Ayana GE. Incidence of periprosthetic fractures after hip hemiarthroplasty: are uncemented prostheses unsafe? Injury 2013;44:1945e8. [7] Yoon BH, Lee YK, Jo WL, Ha YC, Choi DH, Koo KH. Incidence and risk period of periprosthetic femoral fracture after cementless bipolar hemiarthroplasty in elderly patients. J Arthroplasty 2016;31:1326e30. [8] Kouyoumdjian P, Dhenin A, Dupeyron A, Coulomb R, Asencio G. Periprosthetic fracture in the elderly with anatomic modular cementless hemiarthroplasty. Orthop Traumatol Surg Res 2016;102:701e5. [9] Parker MI, Pryor G, Gurusamy K. Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures: a randomised controlled trial in 400 patients. J Bone Joint Surg Br 2010;1-B:116e22. [10] Taylor F, Wright M, Zhu M. Hemiarthroplasty of the hip with and without cement: a randomized clinical trial. J Bone Joint Surg Am 2012;7-A:577e83. [11] Kristensen TB, Dybvik E, Furnes O, Engesæter LB, Gjertsen JE. More reoperations for periprosthetic fracture after cemented hemiarthroplasty with polished taper-slip stems than after anatomical and straight stems in the treatment of hip fractures: a study from the Norwegian hip fracture register 2005 to 2016. Bone Joint J 2018;100-B:1565e71.
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[12] Duncan CP, Masri BA. Fracture of the femur after hip replacement. Instr Course Lect 1995;44:293e304. [13] Jennison T, Yarlagadda R. Mortality in patients sustaining a periprosthetic fracture following a hemiarthroplasty. J Orthop 2018;15:798e801. [14] Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am 2003;85-A:2156e62. [15] Rogmark C, Leonardsson O. Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. Bone Joint J 2016;98-B: 291e7. [16] Canbora K, Kose O, Polat A, Aykanat F, Gorgec M. Management of Vancouver type B2 and B3 femoral periprosthetic fractures using an uncemented extensively porous-coated long femoral stem prosthesis. Eur J Orthop Surg Traumatol 2013;23:545e52. [17] Fink B, Oremek D. Hip revision arthroplasty for failed osteosynthesis in periprosthetic Vancouver type B1 fractures using a cementless, modular, tapered revision stem. Bone Joint J 2017;4(Suppl. B):11e6. [18] Parvizi J, Vegari DN. Periprosthetic proximal femur fractures: current concepts. J Orthop Trauma 2011;25(Suppl 1):S77e81. [19] American Society of Anesthesiologists. Relative value guide. 2008. http:// www.asahq.org [accessed 21.07.17]. [20] Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol 1994;47:1245e51. R, Postel M. Functional results of hip arthroplasty with [21] Merle D’Aubigne acrylic prosthesis. J Bone Joint Surg Am 1954;36:451e75. [22] Katz S, Ford A, Moskowitz R, Jackson B, Jaffe M. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychological function. JAMA 1963;185:914e9. [23] Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;4:233e8. [24] Beals RK, Tower SS. Periprosthetic fractures of the femur: an analysis of 93 fractures. Clin Orthop Relat Res 1996;327:238e46. [25] Loudon JR, Charnley J. Subsidence of the femoral prosthesis in total hip replacement in relation to the design of the stem. J Bone Joint Surg Br 1980;62-B:450e3. [26] Sah AP, Estok 2nd DM. Dislocation rate after conversion from hip hemiarthroplasty to total hip arthroplasty. J Bone Joint Surg Am 2008;90-A: 506e16. [27] Abdel MP, Lewallen DG, Berry DJ. Periprosthetic femur fractures treated with modular fluted, tapered stems. Clin Orthop Relat Res 2014;472:599e603. [28] Rayan F, Konan S, Haddad FS. Uncemented revision hip arthroplasty in B2 and B3 periprosthetic femoral fractures: a prospective analysis. Hip Int 2010;20:38e42. [29] Berry DJ. Treatment of Vancouver B3 periprosthetic femur fractures with a fluted tapered stem. Clin Orthop Relat Res 2003;417:224e31. [30] Munro JT, Garbuz DS, Masri BA, Duncan CP. Tapered fluted titanium stems in the management of Vancouver B2 and B3 periprosthetic femoral fractures. Clin Orthop Relat Res 2014;472:590e8. [31] Parry JA, Hernandez NM, Berry DJ, Abdel MP, Yuan BJ. Risk factors for subsidence of modular fluted tapered stems used during revision total hip arthroplasty for periprosthetic hip fractures. J Arthroplasty 2018;33:2967e70. https://doi.org/10.1016/j.arth.2018.05.006. [32] Haughom BD, Basques BA, Hellman MD, Brown NM, Della Valle CJ, Levine BR. Do mortality and complication rates differ between periprosthetic and native hip fractures? J Arthroplasty 2018;33:1914e8.
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Revision Arthroplasty
Cementless, Fluted, Long-Stem Hemiarthroplasty for Vancouver B2 and B3 Periprosthetic Fractures Around Hip Hemiarthroplasty ~ o, MD a, Alejandro Lizaur-Utrilla, PhD, MD a, b, *, Santiago Gonzalez-Parren ~ oz, MD a, Fernando A. Lopez-Prats, PhD, MD b Francisco A. Miralles-Mun a b
Department of Orthopaedic Surgery, Elda University Hospital, Elda, Alicante, Spain Department of Traumatology and Orthopaedics, Miguel Hernandez University, San Juan de Alicante, Alicante, Spain
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 January 2019 Received in revised form 14 February 2019 Accepted 18 February 2019 Available online 25 February 2019
Background: The purpose of this study was to assess the effectiveness of a cementless, modular, fluted, long-stem hemiarthroplasty for the treatment of Vancouver type B2 and B3 periprosthetic femoral fracture around hip hemiarthroplasty. Methods: This was a retrospective case-control study comparing 46 patients revised to hemiarthroplasty (HA group) and 31 revised to total hip arthroplasty (THA group). Functional outcome was evaluated by score, and the Katz scale based on activities of daily living. Comorbidity was the Merle d’Aubigne assessed by the Charlson index, and cognitive function by a mini-mental test score. Radiological evaluation was also performed. Results: Mean postoperative follow-up was 3.3 (range, 2-4) years in the HA group and 3.9 (range, 2-5) in the THA group. The need for transfusion and hospital stay were significantly higher in the THA group. Postoperatively, both groups had a significant decrease in mean hip function (P ¼ .001) although the mean Merle (P ¼ .121) and Katz (P ¼ .214) scores were similar at final follow-up. Likewise, there were no significant differences between groups in pain or loss of life independence. All fractures were united but one in the HA group. There were no dislocations in the HA group, and 3 in the THA group. Conclusion: The management of Vancouver B2 and B3 periprosthetic femoral fracture around hemiarthroplasties with a long-stem revision cementless bipolar hemiarthroplasty, supplemented with wire cerclages and cancellous allograft, was an effective option in terms of fracture healing and stability of the implant with a low rate of complications. Nevertheless, a significant functional impairment was also observed in either group. © 2019 Elsevier Inc. All rights reserved.
Keywords: femoral neck fracture hemiarthroplasty periprosthetic fracture revision cementless hemiarthroplasty revision total hip arthroplasty
Periprosthetic femoral fracture (PFF) is a serious complication after hemiarthroplasty for femoral neck fracture in elderly patients, and a challenge for the surgeon. Numerous studies have been reported on PFF around total hip arthroplasty (THA) [1e3]. However, there is little evidence regarding PFF around hemiarthroplasty. Most published studies on PFF after hemiarthroplasty have analyzed only epidemiological data and risk factors in small series, but including heterogeneous fracture types and treatments [4e8]. The incidence of PFF after hip hemiarthroplasty varies with rates between 2% and 14% [6,7,9,10]. Several risk factors have been
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.02.036. * Reprint requests: Alejandro Lizaur-Utrilla, PhD, MD, Department of Orthopaedic Surgery, Elda University Hospital, Ctra Elda-Sax s/n, 03600 Elda, Alicante, Spain. https://doi.org/10.1016/j.arth.2019.02.036 0883-5403/© 2019 Elsevier Inc. All rights reserved.
described, such as cementless stem [4], cemented polished tapered stem [11], male gender, and osteopenia [8]. Regarding the fracture type, Vancouver [12] types B are the most common among the postoperative fractures with incidence between 59% and 81% [5,7,13]. Vancouver types B2 and B3 are fractures with stem loosening, and the revision to a cementless long-stem and fixation of fracture fragments is currently recommended [2,14]. Patients who receive a hemiarthroplasty for femoral neck fracture are usually elderly, with comorbidity, low physiological reserve, and moderate or low physical activity [15]. After Vancouver types B2 and B3 PFF around a hemiarthroplasty, revision to a THA has usually been used in the literature [16,17]. However, no studies in the literature have analyzed outcomes of revision to a new hemiarthroplasty. We hypothesized that in those patients who had had indication for hemiarthroplasty after femoral neck fracture, PFF treatment should also be a hemiarthroplasty especially whether the
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Surgical Procedure
Table 1 Preoperative Data at the Time of Index Hemiarthroplasty. Variables
HA Group (N ¼ 46)
THA Group (N ¼ 31)
P
Gender (F/M) Age (y) BMI (kg/m2) ASA (1-2/3-4) Charlson index Mental score Trauma Fall to the floor Traffic No trauma Vancouver fracture B2 B3
35/11 76.3 (5.2) 28.3 (3.1) 13/33 2.7 (1.8) 7.1 (2.9)
21/10 74.2 (7.0) 29.2 (4.5) 13/18 2.2 (2.4) 7.6 (3.1)
.291 .135 .301 .159 .299 .472 .319
29 5 12
22 1 8
25 21
17 14
.576
Continuous variables: median (SD). ASA, American Society of Anesthesiologists score; BMI, body mass index; F, female; HA, hemiarthroplasty; M, male; SD, standard deviation; THA, total hip arthroplasty.
acetabulum did not show erosion or degeneration or the life expectancy was relatively short. The purpose of this study was to evaluate the effectiveness of a cementless, modular, fluted, longstem hemiarthroplasty for Vancouver types B2 and B3 PFF around hip hemiarthroplasty.
Materials and Methods This retrospective case-control study was approved by our institutional review board, and informed consent was not required. A retrospective review of our hip-trauma database was performed to identify the patients treated with hemiarthroplasty for femoral neck fracture and who then had a Vancouver type B2 or B3 PFF between 2001 and 2015. Exclusion criterion was pathological fracture due to tumor disease (1 patient). A minimum follow-up of 2 postoperative years after PFF was required for outcome analysis. For the purpose of this study, the patients were included in 1 of 2 groups: patients who underwent revision with a hemiarthroplasty (HA group) for PFF, and those who underwent revision THA (THA group). The indication for revision to a hemiarthroplasty was the absence of substantial acetabular arthritis determined radiologically in the preoperative period and confirmed intraoperatively. It is noted that patients who undergo hemiarthroplasty after femoral neck fracture were usually older than 70 years and with moderate physical activity or low physiological reserve. A total of 86 patients met the criteria: 51 in the HA group and 36 in the THA group. In the HA group, 3 patients died from reasons unrelated to the surgery and 2 other were lost to follow-up within 2 years after PFF. In the THA group, 4 died and 1 was lost. All these patients were excluded. At the time of the study, 8 other patients in the HA group and 5 in the THA group had died but they had been followed for at least 2 years and their last evaluations were included in the study. Thus, the study consisted of 46 patients in the HA group and 31 in the THA group. The preoperative data of each group at the time of index hemiarthroplasty are shown in Table 1. At the time of the index hemiarthroplasty, there were no significant differences between groups. Overall, the mean time interval between the index hemiarthroplasty and PFF was 12.2 (range, 2-26) months. The PFF was caused by minor trauma (fall to the floor) in 29 patients of the HA group vs 22 of the THA group, in 6 vs 1 by pedestrian traffic accident, and in 11 vs 7 spontaneously without a history of apparent traumatic event. According to the Vancouver system [12], in the HA group 25 fractures were classified as type B2 and 21 as type B3, and in the THA group 17 and 14, respectively.
All index femoral neck fractures in both groups had been managed with a cemented bipolar hemiarthroplasty (Self-Locking system, Lima LTO, Italy) through a Hardinge lateral approach, under spinal anesthesia. All revisions were performed with the use of the MGS cementless modular revision stem (Samo, Bologna, Italy). This is a modular fluted tapered femoral stem in titanium alloy based on the Wagner concept of distal fixation. For revision hemiarthroplasty, a bipolar chrome-cobalt head for hemiarthroplasty was used (SBA, Samo). For revision THA, a press-fit cup in titanium plasma-sprayed with metal-polyethylene bearing and head of 28 mm (Duofit; Samo) was used. The same standard operative technique was used in all patients. A Hardinge approach was used and distally extended as required to allow reduction and fixation of the fracture. Trochanter lateral osteotomies were necessary in 4 hips to remove the index stems. A wire cerclage was placed at the distal femur to prevent fracture propagation during reaming or stem impaction. The long stem required a press-fit distal fixation in the isthmus zone, and it has been recommended that the fracture be bypassed by at least 2 cortical diameters with a long stem [18]. Nevertheless, we bypassed fracture at least 8 cm to maximize distal fixation when possible. Then, the fracture fragments were reduced and fixed with wire cerclages around the implant. Bank cancellous bone allograft was used over the proximal fracture lines and medial cortical in all hips. Postoperatively, touch weight-bearing using a walker was allowed for 6 to 8 weeks, and then full weight-bearing with a support for 6 other weeks.
Evaluations The clinical records and radiographs of each patient were reviewed. The hip-trauma database of our department collects prospective data on all hip fractures treated, including patient demographics, preoperative and postoperative data, and clinical and radiological assessments. In a standardized way, all patients had been evaluated preoperatively at the time of the index fracture, and postoperatively after PFF every 3 months during the first postoperative year, every 6 months in the next year, and then at least 1 more year. If the patient did not return for examination, their families were interviewed by telephone. For this study, preoperative data were referred to the time of the index hemiarthroplasty. At admission, comorbidity was assessed by the American Society of Anesthesiologists scale [19] and Charlson index [20]. Hip score functional outcome was evaluated by the Merle D’Aubigne [21]. The Katz scale [22] based on independence in 6 activities of daily living was also applied. Cognitive function at admission was evaluated by a mini-mental test score validated for elderly [23], where the maximum score was 10 points and a result of 6 or less was suggestive of dementia. Radiological evaluation included standard anteroposterior and lateral hip radiographs. The initial postoperative radiographs after revision were compared with final radiographs for evidence failure, loosening, or stem migration. Radiological outcomes were classified using the criteria proposed by Beals and Tower [24] for PFF as excellent (stable stem with minimal deformity), good (stable stem with moderate subsidence and fracture healed with moderate deformity), or poor (stem loosening, nonunion, sepsis, or severe deformity). An implant was described as stable if there was an absence of continuous radiolucent lines around the stem, progressive stem subsidence, or migration. Failure was defined as stem requiring revision surgery for any reason. Fracture healing was defined as the presence of radiological bone callus or bridging in both the anteroposterior and lateral planes, and capacity for
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Table 2 Comparison of Preoperative and Postoperative Data Between Groups. Variables
Follow-up Merle score Walking aid No Cane Walking Chair/bed Hip/groin pain No/mild Moderate Severe Thigh pain No/mild Moderate Severe Katz score Residence Home Nursing
HA Group
THA Group
Preoper
At Final
8.9 (3.1)
3.3 (1.4) 6.2 (2.9)
28 17 1 0
13 25 4 4
41 5 0
32 9 5
45 1 0 5.2 (1.7)
28 14 4 3.7 (1.8)
46 0
36 10
P
Preoper
At Final
.001 .015
9.3 (2.6)
3.9 (2.2) 7.3 (3.2)
18 13 0 0
9 15 5 2
27 4 0
17 10 4
29 2 0 5.8 (2.5)
17 12 2 4.3 (2.4)
31 0
26 5
.018
.001
.001 .003
P*
P**
.009 .013
.556 .655
.147 .121 .572
.005
.527
.141
.001
.353
.384
.019 .005
.213 .999
.214 .381
P
Continuous data as mean (SD). P*dbetween preoperative data. P**dbetween data at final follow-up. At final, at final follow-up; HA, hemiarthroplasty; Preoper, preoperative data; SD, standard deviation; THA, total hip arthroplasty.
weight-bearing without pain at the fracture site. Subsidence of the stem was defined [25] by a movement of at least 6 mm. Statistical Analysis Statistical analyses were conducted with IBM-SPSS v.19. Normal distribution was assessed by the Kolmogorov-Smirnov test. For univariate analysis, categorical variables were analyzed by the chisquare test, Fisher exact test, or Mantel-Haenszel test, and continuous variables by t-Student t-test or Mann-Whitney U-test. For comparison between preoperative and postoperative data, the paired t-test or Wilcoxon signed-rank test was used. A P value less than .05 was considered significant in all tests. Results
between groups in the rate of patients who walked without aids or with a cane (P ¼ .572). Regarding the hip or groin pain, in the HA group 41 (89.1%) patients reported no or mild preoperatively and 32 (69.5%) had pain at final follow-up (P ¼ .018), while in the THA these were 27 (7.0%) and 17 (54.8%) (P ¼ .005), respectively. At final follow-up, there was no significant difference between groups in the rate of patients with no or mild pain at hip or groin (P ¼ .141). Regarding the thigh pain at final follow-up, in the HA group 28 (60.8%) patients had no or mild pain, and 17 (54.8%) in the THA group (P ¼ .384). Regarding the ability for daily activities (Table 2), there was no preoperative significant difference between groups in the Katz score (P ¼ .213). Postoperatively, both groups had a significant decrease in mean Katz score (P HA ¼ .001; P THA ¼ .019) with no significant difference between groups at final follow-up (P ¼ .214).
The mean postoperative follow-up after PFF was 3.3 (range, 2-4) years in the HA group, and 3.9 (range, 2-5) years in the THA group (P ¼ .147). The mean surgical time for revision PFF was 72.7 (SD, 15.3) minutes in the HA group, and 116.2 (SD, 12.8) in the THA group (P ¼ .001). Preoperatively, 22 (47.8%) patients in the HA group needed blood transfusion, and 13 (41.9%) in the THA group (P ¼ .392). Postoperatively, 33 (71.7%) patients in the HA group and 30 (96.7%) in the THA group received blood transfusion (P ¼ .004). The mean hospital stay was 7.1 (SD, 3.6) days in the HA group and 9.8 (SD, 2.7) in the THA group (P ¼ .001). Clinical Outcomes Preoperatively (Table 2), there was no significant difference between groups in the mean hip function (Merle, P ¼ .556). Postoperatively, both groups had a significant decrease in mean Merle score (P ¼ .001) with no significant difference between groups at final follow-up (P ¼ .121). Preoperatively, in the HA group 45 (97.8%) patients walked without aids or with a cane, and at final follow-up these were 38 (82.6%; P ¼ .015), while in the THA group there were 31 (100%) preoperatively and 24 (77.4%) at final follow-up (P ¼ .013). At final follow-up, there was no significant difference
Fig. 1. (A) Vancouver type B3 periprosthetic femoral fracture. (B) Radiological result at 3 y after cementless, long-stem hemiarthroplasty supplemented with wire cerclages and cancellous allograft.
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All patients lived in their home preoperatively, and postoperatively 10 patients (21.7%) in the HA group and 5 (16.1%) in the THA group were transferred after rehabilitation to a nursing home (P ¼ .381). Radiological Results All patients in the HA group but one showed radiological union (Fig. 1). One patient had nonunion of the proximal aspect of the fracture involving the greater trochanter but the stem remained stable although had a slight varus angulation of 6 . These patients reported moderate hip pain. Two other patients had a nonprogressive subsidence of 6 and 8 mm, respectively. In the THA group, all patients had fracture healing. One patient had a subsidence of 14 mm. No patients in either group had evidences of stem or cup loosening. The stem radiological results according to the Beals and Tower’s criteria were excellent in 43 (93.4%) patients and good in 3 (6.6%) in the HA group, and in 30 (96.7%) and 1 (3.3%), respectively, in the THA group. This difference was not significant (P ¼ .468). Complications There was no hip dislocation in the HA group, while in the THA group, 3 (9.6%) patients had arthroplasty dislocation between 3 and 21 days after THA. Two of these were reduced under general anesthesia with external manipulations, and then immobilization in bed with the hip in abduction neutral rotation for 2 weeks. The third patient needed open reduction without exchange of the components. The fracture remained stable in these 3 patients. Superficial wound infection occurred in 2 patients of the HA group and 1 of the THA group. All these infections were treated with debridement and antibiotic therapy, and removal of the implant was not required. Staphylococcus epidermidis was identified in all hips. At the time of the final follow-up, no patients in either group needed revision of the arthroplasty. Discussion The main finding of the present study was the effectiveness of mechanical and clinical outcomes of the cementless, fluted, longstem revision hemiarthroplasty supplemented with cerclages for the treatment of Vancouver types B2 and B3 periprosthetic fractures after cemented hemiarthroplasty. The need for blood transfusion and hospital stay were significantly higher in the THA group. In addition, no dislocation occurred in the HA group, while there were 3 dislocations in the THA group. In the present study, there were 2 subsidences less than 10 mm but no dislocations using revision hemiarthroplasty. Dislocation after revision THA for Vancouver type B2 or B3 fractures is a relatively frequent complication reported in the literature [2,3,26]. Moreta et al [2], in 43 B2 and B3 periprosthetic fractures after THA treated with cementless, tapered long-stem, reported 16% dislocations and it was associated with a mean subsidence greater than 4 mm. However, in that study both monoblock and modular stems were used. Joestl et al [3] reviewed 28 B2 PFF after THA revised with a long-stem THA, and they reported 3 (8%) dislocations. In the present study, both groups had a significant decrease in the functional status from the preoperative to postoperative followup. It should be noted that all these patients who underwent index hemiarthroplasty were of advanced age and severe comorbidities. However, there were no significant differences at final follow-up between groups in clinical outcomes. Comparison with the literature is difficult because there were no studies using revision hemiarthroplasty for PFF. Thus, we have compared our outcomes with those of studies that had used
modular fluted titanium stems in treating Vancouver B2 and B3 periprosthetic fractures about THA [2,16]. Moreta et al [2], in a study of 43 B2-B3 fractures after THA in patients with mean age of 78 years, found a mean postoperative Harris Hip Score of 73, and 42% did not return to their previous ambulatory levels. Canbora et al [16] using revision cementless THA with a long femoral stem observed a mean postoperative Harris Hip Score of only 68 after B2 or B3 periprosthetic fractures, although those authors also reported 76% excellent and good radiological results using the Beals and Towers’ criteria. On the contrary, other authors achieved better functional outcomes after treatment of periprosthetic fractures [17,27]. Rayan et al [28] reviewed 26 patients with Vancouver type B2 or B3 periprosthetic fractures managed by revision THA. The mean postoperative Harris Hip Score was 83, and no patient needed more than 1 stick as a walking aid by 1 year postoperatively. However, the mean age was 68 years in that series. In the present study, the cementless, fluted, long-stem, modular hemiarthroplasty provided successful mechanical outcomes for Vancouver types B2 and B3 PFF around hip hemiarthroplasty. All patients had clinical and radiological fracture union and no adverse events were found. This may be attributed to a combination of good stem fixation distally and to our use of wire cerclages and cancellous allograft, as evidenced by other authors [28]. We believe that the cancellous allograft used in the present study enhanced the osteogenesis in the fracture and could have helped recover the deficient bone stock in Vancouver type B3 fractures. In our opinion, the extended Hardinge lateral approach facilitates the control of the fracture during the removal of the index stem. However, as recommended by Berry [29], it is important to minimize stripping of soft tissue from the fragments in order to preserve the blood supply of the bone fragments. In the studies by Canbora et al [16] and Fink and Oremek [17], with revision long femoral stem, all fractures were also united. Similar results in terms of fracture healing were found by Munro et al [30] in a cohort of 38 Vancouver type B2 and 17 Vancouver type B3. In the present study, there were 2 subsidences after revision HA and 1 after revision THA. Similar findings were reported with modular femoral stems in the literature [28]. Fink and Oremek [17] studied 32 cases of Vancouver types B2 and B3 fractures treated also with cementless, modular tapered, and fluted long stem. In that study, after a mean follow-up of 32 months, no subsidence was observed and all patients resulted with excellent radiological outcome. Parry et al [31] reviewed 61 Vancouver B2 and B3 periprosthetic hip fractures around THA treated with modular fluted tapered implants. At mean follow-up of 4 years, the authors observed 13% stem subsidence with a mean of 18 mm, and all those cases stabilized without revision. Like other authors [5], we believe that stem subsidence can be avoided by sufficiently filling the canal using a modular tapered and fluted long-stem. In the present study, mortality after PFF was similar to that for patients surgically treated for hip fracture in our institution. In the study by Amenabar et al [1], there were no deaths within the first 30 days after surgery and only 1 patient (1.3%) died within the first 2 months. Jennison and Yarlagadda [13] reported 1-year mortality rate of 28% after PFF following a hemiarthroplasty, but most of their patients had nonsurgical treatment. Phillips et al [5] reported 1-year mortality rate of 34%. However, these authors included all Vancouver types of fractures, and diverse procedures such as internal fixation, revision hemiarthroplasty, and nonsurgical treatment. Haughom et al [32] found that patients with periprosthetic hip fractures have a similar mortality to those with native hip fractures. The present study had several limitations. First, it was a retrospective study. The minimum follow-up of 2 years was short but adequate to achieve the main objective of the study, and it was
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similar to other previous studies. However, the survival of the revision stem should be taken with caution. In order to obtain relevant conclusions on the management of complex periprosthetic fractures around hemiarthroplasties, prospective randomized studies involving multiple medical centers could be beneficial. In conclusion, the management of Vancouver B2 and B3 PFF around hemiarthroplasties with a long-stem revision cementless bipolar hemiarthroplasty, supplemented with wire cerclages and cancellous allograft, was an effective option in terms of fracture healing and stability of the implant with a low rate of complications. Nevertheless, a significant functional impairment was also observed in either group. References [1] Amenabar T, Rahman WA, Avhad VV, Vera R, Gross AE, Kuzyk PR. Vancouver type B2 and B3 periprosthetic fractures treated with revision total hip arthroplasty. Int Orthop 2015;39:1927e32. [2] Moreta J, Uriarte I, Ormaza A, Mosquera J, Iza K, Aguirre U, et al. Outcomes of Vancouver B2 and B3 periprosthetic femoral fractures after total hip arthroplasty in elderly patients. Hip Int 2018;29:184e90. https://doi.org/10.1177/ 1120700018772163. [3] Joestl J, Hofbauer M, Lang N, Tiefenboeck T, Hajdu S. Locking compression plate versus revision-prosthesis for Vancouver type B2 periprosthetic femoral fractures after total hip arthroplasty. Injury 2016;47:939e43. [4] Foster AP, Thompson NW, Wong J, Charlwood AP. Periprosthetic femoral fractures: a comparison between cemented and uncemented hemiarthroplasties. Injury 2005;36:424e9. [5] Phillips JR, Moran CG, Manktelow AR. Periprosthetic fractures around hip hemiarthroplasty performed for hip fracture. Injury 2013;44:757e62. [6] McGraw IW, Spence SC, Baird EJ, Eckhardt SM, Ayana GE. Incidence of periprosthetic fractures after hip hemiarthroplasty: are uncemented prostheses unsafe? Injury 2013;44:1945e8. [7] Yoon BH, Lee YK, Jo WL, Ha YC, Choi DH, Koo KH. Incidence and risk period of periprosthetic femoral fracture after cementless bipolar hemiarthroplasty in elderly patients. J Arthroplasty 2016;31:1326e30. [8] Kouyoumdjian P, Dhenin A, Dupeyron A, Coulomb R, Asencio G. Periprosthetic fracture in the elderly with anatomic modular cementless hemiarthroplasty. Orthop Traumatol Surg Res 2016;102:701e5. [9] Parker MI, Pryor G, Gurusamy K. Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures: a randomised controlled trial in 400 patients. J Bone Joint Surg Br 2010;1-B:116e22. [10] Taylor F, Wright M, Zhu M. Hemiarthroplasty of the hip with and without cement: a randomized clinical trial. J Bone Joint Surg Am 2012;7-A:577e83. [11] Kristensen TB, Dybvik E, Furnes O, Engesæter LB, Gjertsen JE. More reoperations for periprosthetic fracture after cemented hemiarthroplasty with polished taper-slip stems than after anatomical and straight stems in the treatment of hip fractures: a study from the Norwegian hip fracture register 2005 to 2016. Bone Joint J 2018;100-B:1565e71.
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[12] Duncan CP, Masri BA. Fracture of the femur after hip replacement. Instr Course Lect 1995;44:293e304. [13] Jennison T, Yarlagadda R. Mortality in patients sustaining a periprosthetic fracture following a hemiarthroplasty. J Orthop 2018;15:798e801. [14] Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am 2003;85-A:2156e62. [15] Rogmark C, Leonardsson O. Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. Bone Joint J 2016;98-B: 291e7. [16] Canbora K, Kose O, Polat A, Aykanat F, Gorgec M. Management of Vancouver type B2 and B3 femoral periprosthetic fractures using an uncemented extensively porous-coated long femoral stem prosthesis. Eur J Orthop Surg Traumatol 2013;23:545e52. [17] Fink B, Oremek D. Hip revision arthroplasty for failed osteosynthesis in periprosthetic Vancouver type B1 fractures using a cementless, modular, tapered revision stem. Bone Joint J 2017;4(Suppl. B):11e6. [18] Parvizi J, Vegari DN. Periprosthetic proximal femur fractures: current concepts. J Orthop Trauma 2011;25(Suppl 1):S77e81. [19] American Society of Anesthesiologists. Relative value guide. 2008. http:// www.asahq.org [accessed 21.07.17]. [20] Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol 1994;47:1245e51. R, Postel M. Functional results of hip arthroplasty with [21] Merle D’Aubigne acrylic prosthesis. J Bone Joint Surg Am 1954;36:451e75. [22] Katz S, Ford A, Moskowitz R, Jackson B, Jaffe M. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychological function. JAMA 1963;185:914e9. [23] Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;4:233e8. [24] Beals RK, Tower SS. Periprosthetic fractures of the femur: an analysis of 93 fractures. Clin Orthop Relat Res 1996;327:238e46. [25] Loudon JR, Charnley J. Subsidence of the femoral prosthesis in total hip replacement in relation to the design of the stem. J Bone Joint Surg Br 1980;62-B:450e3. [26] Sah AP, Estok 2nd DM. Dislocation rate after conversion from hip hemiarthroplasty to total hip arthroplasty. J Bone Joint Surg Am 2008;90-A: 506e16. [27] Abdel MP, Lewallen DG, Berry DJ. Periprosthetic femur fractures treated with modular fluted, tapered stems. Clin Orthop Relat Res 2014;472:599e603. [28] Rayan F, Konan S, Haddad FS. Uncemented revision hip arthroplasty in B2 and B3 periprosthetic femoral fractures: a prospective analysis. Hip Int 2010;20:38e42. [29] Berry DJ. Treatment of Vancouver B3 periprosthetic femur fractures with a fluted tapered stem. Clin Orthop Relat Res 2003;417:224e31. [30] Munro JT, Garbuz DS, Masri BA, Duncan CP. Tapered fluted titanium stems in the management of Vancouver B2 and B3 periprosthetic femoral fractures. Clin Orthop Relat Res 2014;472:590e8. [31] Parry JA, Hernandez NM, Berry DJ, Abdel MP, Yuan BJ. Risk factors for subsidence of modular fluted tapered stems used during revision total hip arthroplasty for periprosthetic hip fractures. J Arthroplasty 2018;33:2967e70. https://doi.org/10.1016/j.arth.2018.05.006. [32] Haughom BD, Basques BA, Hellman MD, Brown NM, Della Valle CJ, Levine BR. Do mortality and complication rates differ between periprosthetic and native hip fractures? J Arthroplasty 2018;33:1914e8.