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Diagnosis and management of periprosthetic femoral fractures after hip arthroplasty
Injury, Int. J. Care Injured 50S2 (2019) S29–S33
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Diagnosis and management of periprosthetic femoral fractures after hip arthroplasty Stefano Giarettaa , Alberto Momolia , Giovanna Porcellib , Gian Mario Michelonia,* a b
Orthopedic and Traumatology Unit, Ospedale San Bortolo, Vicenza, Italy Department of Orthopaedic Surgery, University Hospital of Udine, Udine, Italy
A R T I C L E I N F O
Keywords: Periprosthetic fractures ORIF Revision surgery
A B S T R A C T
Introduction: 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. Materials and methods: 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. Results: 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. Conclusions: 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. © 2019 Elsevier Ltd. All rights reserved.
Introduction Total hip arthroplasty (THA) is a successful surgical procedure that increases annually and leads to satisfactory quality of life [1]. Periprosthetic femoral fractures are severe and technically demanding complications, actually the third cause of revision surgery with an estimated incidence from 0,1 to 2,1% [2]. 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 [3,4]. Common risk factors are: osteoporosis, autoimmune diseases, steroidstherapy, osteolysis, loosening and also lowenergy trauma [5–7].
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. Materials and methods
* Corresponding author at: Orthopedic and Traumatology Unit, Ospedale San Bortolo, V.le Rodolfi 37, 36100, Vicenza, Italy. E-mail addresses: [email protected] (S. Giaretta), [email protected] (A. Momoli), [email protected] (G. Porcelli), [email protected] (G.M. Micheloni). https://doi.org/10.1016/j.injury.2019.01.053 0020-1383/© 2019 Elsevier Ltd. All rights reserved.
A retrospective review was conducted of all periprosthetic femur fracture treated surgically after THA or hemiartroplasty (HA) in our institution from January 2012 and October 2016.
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Intraoperative fractures and conservative patterns were excluded. We analysed instrumental exams and surgical reports focusing on type of procedure, surgical access, operative time and type of fixation. Patients were divided in groups according to American Society of Anesthesiologists (ASA) scale. Regarding fracture classification we based on Vancouver system: type A involved proximal metaphysis, type B around the stem or just below it (subdivided in B1 if the stem was stable, B2 in case of loose stem with adequate bone stock and B3 loose stem without fair bone stock) and type C below the stem tip (Fig. 1). Particular attention was paid on stem stability evaluation conducted in all patients with computer tomography (CT) scans (Figs. 2 and 3) and intraoperative assessment. After the exposure the fracture site we accurately evaluated the stem stability for ultimate surgical decision Checking of acetabulum was conducted in case of previous THAs and if loosening was suspected the acetabular component was revised. The treatment was classified as open reduction and internal fixation (ORIF) and revision. The length of hospitalization and time to union were analysed. Radiological and clinical evaluations are conducted after 1, 3, 6, 12 months and then annually after surgery (Fig. 4).
Beals and Towers’ criteria were chosen for radiological assessments and outcomes were divided in poor, good an excellent [11]. Formation of bone callus in anteroposterior and lateral x-rays, absent of radiolucent signs, implant migration or subsidence in association with no pain in weight bearing are healing parameters. Moreover functional outcomes were collected based on Harris Hip Score (HHS). Local and systemic complication were reported and investigated. Results 64 patients (37 female and 27 male) with an average age of 809 years (range 72–96) were included. The mean follow-up time was 231 months (range 6–58) and the mean time between index operation and periprosthetic fracture was 8,7 years (range 6 months - 28 years). Primary implant was THA in 53 hips and HA in 11. In 56 patients the fracture was caused by minor trauma such as fall to floor, in 6 by major trauma (car accident) and in 2 occurred without history of traumatic event. Regarding comorbidity and clinical performance 9 patients had an ASA class 4, 45 ASA class 3 and 10 ASA class 2. According to Vancouver system 26 fracture were classified as type B1, 31 were type B2, 3 type B3 and 4 type C.
Fig. 1. Our institution periprosthetic fracture algorithm.
S. Giaretta et al. / Injury, Int. J. Care Injured 50S2 (2019) S29–S33
Fig. 2. Periprosthetic fracture evaluation: CT scan image (frontal plan).
An anterolateral Watson-Jones approach was performed in 57 cases (89%) while direct lateral approach or Bauer trans-gluteal in 7 cases (11%). Of the 26 fractures classified as B1 20 were treated with plates and cables, 3 fractures with cerclage wiring alone while 3 patients underwent revision surgery after intraoperative evidence of stem loosening. All type B2 and B3 type of fractures were treated with revision surgery in association with cerclage wiring (29 cases) or plates and cables (5 cases). ORIF with plate and metallic cables was
Fig. 4. Periprosthetic fracture: 1 month after surgery x-ray.
Fig. 3. Periprosthetic fracture evaluation: CT scan image (3D reconstruction).
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conducted in all type C fractures. All revision stems implanted were cementless. In five patients the acetabular component was substituted after the evaluation of clear signs of mobilization. Average surgical time was 143 min and mean hospital stay was 19 days. Ten patients (156%) died within 3 years after surgery. Follow up results are divided on the basis of the surgical treatment: ORIF group (23 type B1 fractures and 4 type C fracture) Radiological findings were excellent in 6 patients (222%), good in 10 (371%) and poor in 11 (407%). Fracture union was obtained in 16 cases (593%) in a mean time of 4,8 months. Regarding the HHS score at last clinical evaluation the mean values was 6161. One patient underwent a fracture at the same level one month after surgery. It was treated surgically with metallic wire removal, reduction and stabilization with another plate. After nine months bone healing was achieved and gradual weight bearing was allowed. One case of fracture with broken hardware was reported 12 months after surgery. Hardware removal, revision stem implantation with metallic cerclage wiring are performed. Unfortunately this patient showed peroneal nerve palsy after last surgery and restarted walking with codivilla-spring support. In a patient varus deformity and breaking of two metallic cerclage wires were reported on radiological evaluation after 6 months with occasional pain. Conservative treatment with decrease of weight bearing was suggested and evidence of bone callus formation in association with symptoms improvement were reported at 9 months follow up. Furthermore two cases of haematoma and a case of superficial tissue infection were founded in this group. Revision group (3 type B1, 31 type B2 and 3 type B3) The radiological results according to Beals and Towers’ criteria were excellent in 15 patients (406%), good in 13 (351%) and poor in 9 (243%). Bone healing was reported in 26 cases (703%) with a mean union time of 575 months. Mean HHS score at last clinical analysis was 7194. One case of dislocation was observed 7 months after revision surgery: close reduction in operatory room and one month with hip brace assistance lead to correct healing. Three cases of haematoma and two case or superficial infection were reported. Re-fracture, stem loosening or deep infection weren’t founded in this series. Discussion The main objective of periprosthetic hip fracture 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 [12]. Evaluation of ASA scale and comorbidity, in association with multidisciplinary discussion improve the quality of treatment especially in high-risk patients. Proper haemostasis, tranexamic acid and intensive care unit monitoring are often needed. Regarding classification the Vancouver system there is large consensus in literature. Nevertheless differentiation between B1 type and B2 type is often crucial and demanding also after CT scan studies. In 3 cases classified as Vancouver B1 type before surgery we decide to perform the revision of the stem on the basis of evident signs of mobilization.
In Lindhall et al study 47% of B2 fractures were classified initially as B1, in relation with radiological findings [13]. Also Fleischman et al reported high number of failure in B1 fracture (assumed fix stem) treated with ORIF techniques comparing with B2 fracture underwent revision [14]. Khan et al suggest accurate radiological evaluation especially in patients with pre-existing thigh pain [15]. Specific localization of the fracture, such as near area of lysis below an apparently wellfixed stem should lead to decide for revision surgery [16,17]. This is supported by Swedish National Hip Arthroplasty Register data that show higher percentage of re-operation after ORIF without stem revision (32%) compare with revision alone (10%) or revision in association with internal fixation (23%) [13]. Approaches performed were chosen in relation with previous incision and technique if the fracture occurred within 6 months. For the other cases the decision should be taken considering surgeon own experience and confidence. Radiological evaluation showed excellent and good results in the majority of patients (respectively 593% in ORIF group and 757% in revision group) in line with last literature findings [2]. Analysing HHS our study collected better results in revision group (7194 instead of 6161)probably due to an early mobilization andassisted weight bearing in these patients compared to ORIF group patients [18,19]. Low scores are related to demanding surgical procedure in association with high rate of comorbidity and aging [20,21]. Complication (207%) and mortality rates (156%) reported are in line or lower than other studies in literature [22–25]. Possible explanations are better clinical condition of the population analysed and experience of surgical team. In our institution orthopaedic surgeons treating these kind of fractures have good experience in traumatologic surgery and with hip replacements at the same time. These skills are crucial to obtain satisfactory results in complexes cases [26]. Periprosthetic fractures are characterized by long operative time and hospitalization that implicate high costs in financial and clinical resources [27]. Bozic et al observed increase of surgical time (+41%), blood losses (+160%), complications (+32%) and hospital stay time compared to primary implant procedures [28]. In selected B2 or B3 cases with high ASA score maybe ‘tumor type’ prostheses could be utilized to achieve good stability and rapid mobilization with decrease of surgical time but this solution is not yet performed or reported. Conclusions Periprosthetic fracture surgery is nowadays a critical challenge for orthopaedic surgeons [29]. Our findings point out the role of their correct classification and treatment obtained through validated diagnostic algorithm, intraoperative findings and skilled surgical team. Particular attention in the evaluation of stem stability is suggested considering an implant mobilized until the opposite is clearly evident. Megaprosthesis could be performed in some patients with stem mobilization for achieve surgical time reduction and early mobilization. Our study has several limitations such as small sample size, retrospective evaluation and high variability of follow up. Randomized trials are needed to confirm our results. References [1] Laermonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet 2007;370:1508–19. [2] Moreta J, Aguirre U, Saez de Ugarte O, Jauregui I, Martnez-De Los Mozos JL. Functional and radiological outcome of periprostethic femoral fracures after hip arthroplasty. Injury 2015;46:292–8.
S. Giaretta et al. / Injury, Int. J. Care Injured 50S2 (2019) S29–S33 [3] Tsiridis E, Pavlou G, Venkatesh R, Bobak P, Gie GA. Periprosthetic femoral fracture around hip artrhoplasty: current concepts in their management. Hip Int 2009;19:75–86. [4] Della Rocca GJ, Leung KS, Pape HC. Periprostethic fracures: epidomiolgy and future projections. J Orthop Trauma 2011;25:s66–70. [5] Franklin J, Malchau H. Risk factors for periprosthetic femoral fracture. Injury 2007;38:655–60. [6] Singh JA, Jensen MR, Harmnsen SW, Lewallen DG. Are gender, comorbidity, and obesity risk factors for postoperative periprosthetic fractures after primary total hip arthroplasty? J Arthroplasty 2013;28(1):126–31. [7] Friedman SM, Mendelson DA, Kates SL, McCann RM. Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatr Soc 2008;56(7):1349–56. [8] Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293–304. [9] Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res 2004;420:80–95. [10] Ko PS, Lam JJ, Tio MK, Lee OB, Ip FK. Distal fixation with wagner revision stem in treating vancouver type B2 periprosthetic femur fractures in geriatric patients. J Arthroplasty 2019;18(4):446–52. [11] Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop 1996;327:238–46. [12] Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures: classification and demographics of 1049 periprosthetic femoral fractures from the Swedish national hip arthroplasty register. J Arthroplasty 2005;20:857–65. [13] Lindahl H, Garellick G, Regnér H, Herberts P, Malchau H. Three hundred and twenty-one periprosthetic femoral fractures. J Bone Joint Surg Am. 2006;88 (June 6):1215–22. [14] Fleischman AN, Chen AF. Periprosthetic fractures around the femoral stem: overcoming challenges and avoiding pitfalls. Ann Transl Med 2015;3(16):234. [15] Khan T, Grindlay D, Ollivere BJ, Scammell BE, Manktelow ARJ, Pearson RG. A systematic review of vancouver B2 and B3 periprosthetic fractures. Bone Joint J 2017;(4 Suppl B):17–25. [16] Learmonth ID. The management of periprosthetic fractures around the femoral stem. J Bone Joint Surg Br 2004;8:613–9.
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[17] Berry DJ. Periprosthetic fractures associated with osteolyis: a problem on the rise. J Arthroplasty 2003;18:107–11. [18] Sledge 3rd JB, Abiri A. An algorithm for the treatment of vancouver type B2 periprosthetic proximal femoral fractures. J Arthroplasty 2002;17(7):887–92. [19] Rayan F, Konan S, Haddad FS. Uncemented revision hip arthroplasty in B2 and B3 periprosthetic femoral fractures - a prospective analysis. Hip Int. 2010;20 (1):38–42. [20] Tsiridis E, Narvani AA, Timperley JA, Gie GA. Dynamic compression plates for vancouver type B periprosthetic femoral fractures: a 3-year follow-up of 18 cases. Acta Orthop. 2005;76(August):531–7. [21] Parvizi J, Rapuri VR, Purtill JJ, Sharkey PF, Rothman RH, Hozack WJ. Treatment protocol for proximal femoral periprosthetic fractures. J Bone Joint Surg Am. 2004;86-A(Suppl 2):8–16. [22] Lindahl H, Oden A, Garellick G, Malchau H. The excess mortality due to periprosthetic femur fracture. A study from the Swedish national hip arthroplasty register. Bone 2007;40(5):1294–8. [23] Bhattacharyya T, Chang D, Meigs JB, Estok 2nd DM, Malchau H. Mortality after periprosthetic fracture of the femur. J Bone Joint Surg Am 2007;89 (12):2658–62. [24] Spina M, Rocca G, Canella A, Scalvi A. Causes of failure in periprosthetic fractures of the hip at 1- to 14-year follow-up. Injury 2014;45(Suppl 6):S85–92. [25] Drew JM, Griffin WL, Odum SM, Van Doren B, Weston BT, Stryker LS. Survivorship after periprosthetic femur fracture: factors affecting outcome. J Arthroplasty. 2016;31(6):1283–8. [26] Kinov P, Volpin G, Sevi R, Tanchev PP, Antonov B, Hakim G. Surgical treatment of periprosthetic femoral fractures following hip arthroplasty: our institutional experience. Injury 2015;46(October):1945–50. [27] Vanhegan IS, Malik AK, Jayakumar P, Ul Islam S, Haddad FS. A financial analysis of revision hip arthroplasty: the economic burden in relation to the national tariff. J Bone Joint Surg Br. 2012;94(May):619–23. [28] Bozic KJ, Katz P, Cisternas M, Ono L, Ries MD, Showstack J. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am 2005;87-A:570–6. [29] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Diagnosis and management of periprosthetic femoral fractures after hip arthroplasty Stefano Giarettaa , Alberto Momolia , Giovanna Porcellib , Gian Mario Michelonia,* a b
Orthopedic and Traumatology Unit, Ospedale San Bortolo, Vicenza, Italy Department of Orthopaedic Surgery, University Hospital of Udine, Udine, Italy
A R T I C L E I N F O
Keywords: Periprosthetic fractures ORIF Revision surgery
A B S T R A C T
Introduction: 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. Materials and methods: 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. Results: 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. Conclusions: 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. © 2019 Elsevier Ltd. All rights reserved.
Introduction Total hip arthroplasty (THA) is a successful surgical procedure that increases annually and leads to satisfactory quality of life [1]. Periprosthetic femoral fractures are severe and technically demanding complications, actually the third cause of revision surgery with an estimated incidence from 0,1 to 2,1% [2]. 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 [3,4]. Common risk factors are: osteoporosis, autoimmune diseases, steroidstherapy, osteolysis, loosening and also lowenergy trauma [5–7].
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. Materials and methods
* Corresponding author at: Orthopedic and Traumatology Unit, Ospedale San Bortolo, V.le Rodolfi 37, 36100, Vicenza, Italy. E-mail addresses: [email protected] (S. Giaretta), [email protected] (A. Momoli), [email protected] (G. Porcelli), [email protected] (G.M. Micheloni). https://doi.org/10.1016/j.injury.2019.01.053 0020-1383/© 2019 Elsevier Ltd. All rights reserved.
A retrospective review was conducted of all periprosthetic femur fracture treated surgically after THA or hemiartroplasty (HA) in our institution from January 2012 and October 2016.
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Intraoperative fractures and conservative patterns were excluded. We analysed instrumental exams and surgical reports focusing on type of procedure, surgical access, operative time and type of fixation. Patients were divided in groups according to American Society of Anesthesiologists (ASA) scale. Regarding fracture classification we based on Vancouver system: type A involved proximal metaphysis, type B around the stem or just below it (subdivided in B1 if the stem was stable, B2 in case of loose stem with adequate bone stock and B3 loose stem without fair bone stock) and type C below the stem tip (Fig. 1). Particular attention was paid on stem stability evaluation conducted in all patients with computer tomography (CT) scans (Figs. 2 and 3) and intraoperative assessment. After the exposure the fracture site we accurately evaluated the stem stability for ultimate surgical decision Checking of acetabulum was conducted in case of previous THAs and if loosening was suspected the acetabular component was revised. The treatment was classified as open reduction and internal fixation (ORIF) and revision. The length of hospitalization and time to union were analysed. Radiological and clinical evaluations are conducted after 1, 3, 6, 12 months and then annually after surgery (Fig. 4).
Beals and Towers’ criteria were chosen for radiological assessments and outcomes were divided in poor, good an excellent [11]. Formation of bone callus in anteroposterior and lateral x-rays, absent of radiolucent signs, implant migration or subsidence in association with no pain in weight bearing are healing parameters. Moreover functional outcomes were collected based on Harris Hip Score (HHS). Local and systemic complication were reported and investigated. Results 64 patients (37 female and 27 male) with an average age of 809 years (range 72–96) were included. The mean follow-up time was 231 months (range 6–58) and the mean time between index operation and periprosthetic fracture was 8,7 years (range 6 months - 28 years). Primary implant was THA in 53 hips and HA in 11. In 56 patients the fracture was caused by minor trauma such as fall to floor, in 6 by major trauma (car accident) and in 2 occurred without history of traumatic event. Regarding comorbidity and clinical performance 9 patients had an ASA class 4, 45 ASA class 3 and 10 ASA class 2. According to Vancouver system 26 fracture were classified as type B1, 31 were type B2, 3 type B3 and 4 type C.
Fig. 1. Our institution periprosthetic fracture algorithm.
S. Giaretta et al. / Injury, Int. J. Care Injured 50S2 (2019) S29–S33
Fig. 2. Periprosthetic fracture evaluation: CT scan image (frontal plan).
An anterolateral Watson-Jones approach was performed in 57 cases (89%) while direct lateral approach or Bauer trans-gluteal in 7 cases (11%). Of the 26 fractures classified as B1 20 were treated with plates and cables, 3 fractures with cerclage wiring alone while 3 patients underwent revision surgery after intraoperative evidence of stem loosening. All type B2 and B3 type of fractures were treated with revision surgery in association with cerclage wiring (29 cases) or plates and cables (5 cases). ORIF with plate and metallic cables was
Fig. 4. Periprosthetic fracture: 1 month after surgery x-ray.
Fig. 3. Periprosthetic fracture evaluation: CT scan image (3D reconstruction).
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conducted in all type C fractures. All revision stems implanted were cementless. In five patients the acetabular component was substituted after the evaluation of clear signs of mobilization. Average surgical time was 143 min and mean hospital stay was 19 days. Ten patients (156%) died within 3 years after surgery. Follow up results are divided on the basis of the surgical treatment: ORIF group (23 type B1 fractures and 4 type C fracture) Radiological findings were excellent in 6 patients (222%), good in 10 (371%) and poor in 11 (407%). Fracture union was obtained in 16 cases (593%) in a mean time of 4,8 months. Regarding the HHS score at last clinical evaluation the mean values was 6161. One patient underwent a fracture at the same level one month after surgery. It was treated surgically with metallic wire removal, reduction and stabilization with another plate. After nine months bone healing was achieved and gradual weight bearing was allowed. One case of fracture with broken hardware was reported 12 months after surgery. Hardware removal, revision stem implantation with metallic cerclage wiring are performed. Unfortunately this patient showed peroneal nerve palsy after last surgery and restarted walking with codivilla-spring support. In a patient varus deformity and breaking of two metallic cerclage wires were reported on radiological evaluation after 6 months with occasional pain. Conservative treatment with decrease of weight bearing was suggested and evidence of bone callus formation in association with symptoms improvement were reported at 9 months follow up. Furthermore two cases of haematoma and a case of superficial tissue infection were founded in this group. Revision group (3 type B1, 31 type B2 and 3 type B3) The radiological results according to Beals and Towers’ criteria were excellent in 15 patients (406%), good in 13 (351%) and poor in 9 (243%). Bone healing was reported in 26 cases (703%) with a mean union time of 575 months. Mean HHS score at last clinical analysis was 7194. One case of dislocation was observed 7 months after revision surgery: close reduction in operatory room and one month with hip brace assistance lead to correct healing. Three cases of haematoma and two case or superficial infection were reported. Re-fracture, stem loosening or deep infection weren’t founded in this series. Discussion The main objective of periprosthetic hip fracture 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 [12]. Evaluation of ASA scale and comorbidity, in association with multidisciplinary discussion improve the quality of treatment especially in high-risk patients. Proper haemostasis, tranexamic acid and intensive care unit monitoring are often needed. Regarding classification the Vancouver system there is large consensus in literature. Nevertheless differentiation between B1 type and B2 type is often crucial and demanding also after CT scan studies. In 3 cases classified as Vancouver B1 type before surgery we decide to perform the revision of the stem on the basis of evident signs of mobilization.
In Lindhall et al study 47% of B2 fractures were classified initially as B1, in relation with radiological findings [13]. Also Fleischman et al reported high number of failure in B1 fracture (assumed fix stem) treated with ORIF techniques comparing with B2 fracture underwent revision [14]. Khan et al suggest accurate radiological evaluation especially in patients with pre-existing thigh pain [15]. Specific localization of the fracture, such as near area of lysis below an apparently wellfixed stem should lead to decide for revision surgery [16,17]. This is supported by Swedish National Hip Arthroplasty Register data that show higher percentage of re-operation after ORIF without stem revision (32%) compare with revision alone (10%) or revision in association with internal fixation (23%) [13]. Approaches performed were chosen in relation with previous incision and technique if the fracture occurred within 6 months. For the other cases the decision should be taken considering surgeon own experience and confidence. Radiological evaluation showed excellent and good results in the majority of patients (respectively 593% in ORIF group and 757% in revision group) in line with last literature findings [2]. Analysing HHS our study collected better results in revision group (7194 instead of 6161)probably due to an early mobilization andassisted weight bearing in these patients compared to ORIF group patients [18,19]. Low scores are related to demanding surgical procedure in association with high rate of comorbidity and aging [20,21]. Complication (207%) and mortality rates (156%) reported are in line or lower than other studies in literature [22–25]. Possible explanations are better clinical condition of the population analysed and experience of surgical team. In our institution orthopaedic surgeons treating these kind of fractures have good experience in traumatologic surgery and with hip replacements at the same time. These skills are crucial to obtain satisfactory results in complexes cases [26]. Periprosthetic fractures are characterized by long operative time and hospitalization that implicate high costs in financial and clinical resources [27]. Bozic et al observed increase of surgical time (+41%), blood losses (+160%), complications (+32%) and hospital stay time compared to primary implant procedures [28]. In selected B2 or B3 cases with high ASA score maybe ‘tumor type’ prostheses could be utilized to achieve good stability and rapid mobilization with decrease of surgical time but this solution is not yet performed or reported. Conclusions Periprosthetic fracture surgery is nowadays a critical challenge for orthopaedic surgeons [29]. Our findings point out the role of their correct classification and treatment obtained through validated diagnostic algorithm, intraoperative findings and skilled surgical team. Particular attention in the evaluation of stem stability is suggested considering an implant mobilized until the opposite is clearly evident. Megaprosthesis could be performed in some patients with stem mobilization for achieve surgical time reduction and early mobilization. Our study has several limitations such as small sample size, retrospective evaluation and high variability of follow up. Randomized trials are needed to confirm our results. References [1] Laermonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet 2007;370:1508–19. [2] Moreta J, Aguirre U, Saez de Ugarte O, Jauregui I, Martnez-De Los Mozos JL. Functional and radiological outcome of periprostethic femoral fracures after hip arthroplasty. Injury 2015;46:292–8.
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