A comparative study of ORIF and stem revision for Vancouver B2 periprosthetic fractures of the femur in elderly patients

doi:10.21203/rs.3.rs-4869946/v1

Download PDF

Research Article

A comparative study of ORIF and stem revision for Vancouver B2 periprosthetic fractures of the femur in elderly patients

https://doi.org/10.21203/rs.3.rs-4869946/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Purpose

The aim of this study was to compare stem revision and ORIF for the treatment of Vancouver B2 periprosthetic fractures of the femur.

Methods

From June 2012 to May 2022, 56 consecutive patients were studied at our institution. Four patients were lost to follow-up, four had incomplete data. Thus, 48 cases were included in the analysis. The patients were divided into a stem revision group (SR, group 1 with 25 patients) and an open reduction and internal fixation group (ORIF, group 2 with 23 patients). The surgical complications, perioperative parameters, and 1-year mortality rates were assessed, the functional outcomes were assessed with the Harris Hip Score, and the radiographic outcomes were assessed in accordance with the Beals and Tower criteria.

Results

In group 1, the mean follow-up time was 41.2 months, 40% of patients experienced complications, the mean HHS was 75.27, and 92% of the patients had “excellent–good” radiographic outcomes. In group 2, 21.7% of patients experienced complications, the mean HHS was 73.56, and 91.3% of the patients had “excellent–good” radiographic outcomes. The total number of postoperative complications, dislocation rate, blood loss volume, operation time and transfusion rate were lower in group 1 (ORIF), and two patients in group 2 (SR) experienced hip dislocation. There were no significant differences in the 1-year mortality rate, bone healing time or reoperation rate between the two groups. However, the time to total weight-bearing in the SR group was shorter than that in the ORIF group, and the radio subsidence rate in the SR group was lower than that in the ORIF group, especially for patients with poor compliance. The postoperative quality of life of the patients in the two groups was worse than their original quality of life before fracture.

Conclusions

Stem revision and ORIF are effective treatments for Vancouver B2 fractures. However, ORIF can be an option for elderly patients with several medical disorders, while stem revision is advantageous in terms of earlier weight bearing.

Periprosthetic fracture

Vancouver B2 fracture

Open reduction and internal fixation

Stem revision

The risk of periprosthetic femoral fracture (PFF) within 20 years after primary total hip arthroplasty (THA) has been reported to be 3.5% ^[1], and the incidence of periprosthetic fracture after THA revision is as high as 4–12% ^[2]. Femoral periprosthetic fractures can occur during surgery or after surgery. PFFs are associated with serious complications, such as long operating times, an increased risk of bleeding, high reoperation rates and mortality, all of which pose challenges for surgeons. The Vancouver classification^[3] is the most common and reproducible classification used for predicting the best treatment for PFFs. The classification is based on fracture type, implant stability and bone quality. Vancouver type B2 PFFs are characterized by a loose stem with good bone stock. In previous studies, stem revision (SR) was considered the gold standard for the surgical treatment of Vancouver type B2 fractures ^[4]. Compared with SR, open reduction and internal fixation (ORIF) results in a significantly longer bone healing time and less mobility. However, other studies revealed that compared with those of ORIF only, the mid- to long-term results of SR for B2 and B3 PFFs in elderly patients were satisfactory. Thus, SR is a less invasive procedure with a lower risk of perioperative complications^[5]. The optimal treatment for femoral periprosthetic fractures is still unclear, especially for type B2 fractures with a loose stem. Thus, the aim of this investigation was to compare the functional and radiographic outcomes as well as the complications of SR with those of ORIF for Vancouver B2 fractures in geriatric trauma patients.

The clinical data of patients who developed Vancouver type B2 PFFs after undergoing THA at our hospital were retrospectively reviewed, and the institutional review board approved the study.

We included only patients with type B2 periprosthetic femur fractures, and all the patients had complete medical records and radiographic data. Patients with pathological fractures met the exclusion criteria and were followed up for at least 24 months.

The Deyo‒Charlson index and American Society of Anaesthesiologist (ASA) comorbidity score were recorded to assess mortality^[6]. The primary diagnosis and fixation type were also assessed. The posterior lateral approach was used for all patients. The length of hospital stay, operation duration and blood transfusion volume were recorded. Radiographs were evaluated by a surgeon who was blinded to the clinical outcome. Bone healing was defined based on callus formation, and the status of bone healing was assessed radiologically on both anteroposterior and lateral radiographs. According to the Beals and Tower criteria for radiological classification^[7], outcomes were graded as excellent (a stable implant with minimal deformity), good (a stable implant, minimal or no subsidence, and a well-healed fracture with moderate deformity) or poor (loosening, nonunion, sepsis, severe deformity or new fracture). Implants were considered stable if there were no radiolucent lines around the stem, progressive implant migration, or subsidence^[8].

The clinical outcome was assessed based on patient mobility. Mobility in the period prior to fracture and after fracture healing was categorized as follows (ranging from best to worst) able to walk without help, able to walk with a walking stick, able to walk with a walking frame or two crutches, or unable to walk^[9]. In addition, the Harris Hip Score (HHS) was used to evaluate functional outcomes.

Statistical analysis

The mean and standard deviation were calculated for continuous variables, and the frequencies and percentages were calculated for qualitative data. The Kruskal‒Wallis nonparametric test was used for continuous variables, and the chi‒square test was used to assess categorical variables. SPSS 22.0 was used for all statistical analyses, and p values < 0.05 were indicated significance.

Surgical procedure

The posterolateral approach was used for all patients. After the hip joint was exposed, the stability of the stem was assessed. In the group 1 (ORIF), the fracture segments were reduced and fixed with at least two cerclage wires. Then, a 4.5 mm locking compression plate (Dabo, CHINA), which bypassed the segments of the femur with at least eight cortices, was applied.

In group 2 (SR), after the hip joint was exposed, 3–5 samples were taken from different areas of the hip for microbiological and histological evaluation. After hip joint dislocation, the stability of the stem and acetabular cup was assessed. The stem was then carefully removed without causing an iatrogenic fracture. In the modular group, first, the medulla of the distal femur was expanded, and then a tapered fluted modular titanium stem (SL; AiKang, Beijing, China) was implanted at least 5 cm below the fracture^[10]. The fracture was subsequently reduced anatomically and fixed using wires or cables. Then, an appropriately sized implant was selected, taking the femoral head and neck components as well as limb length discrepancy and hip stability into account. In the nonmodular group, first, the fracture segments were reduced and fixed using wires or cables. The medulla of the femur was then expanded, and the appropriately sized implant was selected, considering the size of the components to ensure that the hip joint was stable.

Demographic characteristics

The distribution of patients’characteristics between SR group and ORIF group in Vancouver type B2 fracture were showed in Table1. There were no statistically significant correlations with the ASA score, CCI, implant type, Reason for primary arthroplast, time-to-fracture,sex,age and BMI between the two surgical groups(p > 0.05).

Table 1

Patient characteristics
Parameters	SR (n = 25)	ORIF(n = 23)	P value
Follow-up(m)	41.2	43.7	0.32
Age(years)	72.8	74.3	0.15
BMI(kg/m²)	24.6	23.5	0.22
Sex(n)
male	10(40%)	9(39.2%)
female	15(60%)	14(60.9%)
ASA score(n)			0.23
1	1(4%)	0(0%)
2	16(64%)	14(60.8%)
3	7(28%)	6(26.1%)
4	1(4%)	3(13.0%)
CCI	5.2(3.1)	5.5(2.6)	0.16
Reason for primary arthroplasty(n)			0.41
Fracture	12(48%)	13(56.5%)
Osteoarthritis	13(52%)	10(43.5%)
Implant type of primary THA			0.35
Hemihip arthroplasty	12(48%)	11(47.8%)
Total hip arthroplasty	13(52%)	12(52.2%)
Type of fixation(cementless)	25(100%)	23(100%)	0.67
Time-to-fracture(m)	41.5	38.6	0.18

The values are presented as the mean value and standard deviation. ORIF, open reduction internal fixation;

SR, stem revision; BMI, body mass index; ASA, American Society of Anaesthesiologists; CCI, Charlson Comorbidity Index.

Clinical outcomes

The mean operation duration in the ORIF group was 52.3 min shorter than that in the SR group. The intraoperative blood loss volume in the ORIF group was 488.6 mL lower than that in the SR group. The volume of RBCs transfused in the ORIF group was 145.6 mL less than that in the SR group. The hospital stay in the ORIF group was 3.6 days shorter than that in the SR group. (Table 2).

Table 2

Perioperative parameters
Group	RS(n = 25)	ORIF(n = 23)	P value
Operation duration(min)	136.2 ± 48.5	104.5 ± 30.7	0.014
Intraoperative blood loss volume(ml)	1100.8 ± 200.4	612.2 ± 173.0	0.022
Volume of RBCs transfused (ml)	251.5 ± 30.2	106.1 ± 24.5	0.025
Hospital stay(day)	14.1 ± 5.7	10.5 ± 3.0	0.031

The mean follow-up was 41.2 months. In the SR group, the mean HHS was 75.27, and 92% of the patients had “excellent–good” radiographic outcomes. Sixteen patients (64%) in the SR group experienced a significant deterioration in ambulation postoperatively (64%). The most recent follow-up examination revealed that only 36% patients in the SR group returned to their pre-fracture walking status. Thirty-six percent of patients in the SR group experienced complications, and the reoperation rate was 16% (Table 3). One patient (4%) developed a deep infection within 3 weeks after surgery. A DAIR (debridement, antibiotics and implant retention) procedure was performed in combination with a 6-week course of antibiotics, which successfully eradicated the infection. Two patients experienced hip dislocation (8%). One hip underwent close reduction, and there were no signs of dislocation recurrence, but the other hip was revised with a dual-mobility acetabular component because of repeated dislocation. Medical complications occurred in 24% of patients (n = 6): two patients developed renal failure, and four patients developed postoperative pneumonia. The 1-year mortality for SR patients was 12%.

In the ORIF group, the mean HHS was 73.56, and 91.3% of the patients experienced “excellent-good” radiographic outcomes. Fifteen patients (65.2%) in the ORIF group experienced significant deterioration of ambulation postoperatively. The most recent follow-up examination revealed that only 34.8% of the patients in the ORIF group returned to their pre-fracture walking status. A total of 21.7% of patients experienced complications, and the reoperation rate was 8.7%. However, in the ORIF group, 2 patients experienced subsidence of 7 mm and 9 mm due to earlier weight because of poor compliance and needed revision because of persistent pain due to a loose stem 14 and 26 months after surgery. The 1-year mortality rate for patients who underwent ORIF was 13.1%.

Complications

The total postoperative complication rate, dislocation rate, blood loss volume, operation duration and transfusion rate were lower in group 1 (ORIF). There were no significant differences in the 1-year mortality rate, bone healing time or reoperation rate between the two groups. However, the time to total weight-bearing in the SR group was shorter than that in the ORIF group, and the radiographic subsidence rate in the SR group was lower than that in the ORIF group, especially for patients with poor compliance. Whatever treatment was adopted, there was an overall worsening of quality of life. This worsening of postoperative ambulatory status was not statistically significant (p = 0.461). The mean HHS at the most recent follow-up was not statistically significant (p = 0.212). According to the Beals and Tower classification, the two surgeries had relatively similar results (p = 0.765).

Table 3

Function and complications
Group	SR(n = 25)	ORIF(n = 23)	P value
Harris Hip Score	75.27(10.51)	73.56(11.27)	0.212
Beals and Tower Classification			0.524
Excellent	10(40%)	11(47.8%)
Good	13(52%)	10(43.5%)
Poor	2(8%)	2(8.7%)
Difference between pre- and postoperative ambulation status			0.461
1 level increase	0	0
No change	9(36%)	8(34.8%)
1 level decrease	12(48%)	14(60.9%)
2 level decrease	4(16%)	1(4.3%)
Dislocation	2(8%)	0	0.005
Dislocation without surgery	1(4%)	0	0.012
Deep infection(n)	1(4%)	0	0.012
Radiographic subsidence(mm)	1.14(1.07)	1.37(1.52)	0.186
Subsidence more than 2 mm(n)	5(20%)	6(26.1%)	0.250
Reoperation rate	2(8%)	2(8.7%)	0.373
Medical complications(n)	6(24%)	2(8.7%)	0.032
Total complications(n)	9(36%)	4(17.4%)	0.028
One-year mortality	3(12%)	3(13.1%)	0.531

Typical cases

Figure 1

Figure 2

Figure 3

The incidence of periprosthetic femoral fractures has increased with the aging of the population, and the rate of total hip arthroplasties has increased^{[11, 12]}. Periprosthetic femoral fractures can occur intraoperatively or postoperatively. PPFFs are associated with serious complications, such as long operating times, an increased risk of bleeding, high reoperation rates and mortality, especially in elderly patients with severe osteoporosis, thus posing challenges for orthopaedic surgeons ^[13–15]. However, femoral stem revision is still the standard of care for Vancouver type B2 PFFs because of unstable or loose stems^[16]. In recent years, there have been different opinions on open reduction and internal fixation with plates, so fixation with screws and cerclage wires can be considered viable alternative options in selected cases of Vancouver type B2 PFFs ^[17–21].

The total complication rates were 17.4% and 32% in the ORIF and SR groups, respectively. The complication rates were 8.7% and 24% in the ORIF and SR groups, respectively, which is comparable with those reported in previous studies^[5]. This may be related to the shorter operation time, lower blood loss volumes, and shorter postoperative hospital stay. Some authors have suggested that in patients with Vancouver B2 fractures who undergo stem revision or internal fixation, the patient’s desire to maintain a particular level of function and the risk of anaesthesia should be considered^[18].

We reported similar one-year mortality rates for SR (12%) and ORIF (13.1%). This finding is remarkable because our groups did not differ in terms of ASA score or CCI score. This finding was similar to the results reported by Lindahl et al.^[22]. The one-year mortality rate of SR was similar to that reported in previous research (13.4%) [6]. Drew et al^[23] reported no difference in mortality between ORIF and SR for patients with periprosthetic femoral fractures. Bhattacharyya et al. ^[24] reported a significantly lower mortality rate for revision arthroplasty (12%) than for ORIF (33%).

Two patients in the ORIF group experienced subsidence of 7 mm and 9 mm due to early weightbearing because of poor compliance and needed revision because of persistent pain due to a loose stem 14 and 26 months after surgery. The ORIF group was prohibited from weightbearing before the fracture had completely healed; however, the SR group was allowed early weightbearing because the stem was placed 5 cm below the top of the fracture, which facilitated primary stability. According to the literature^[25], earlier weightbearing postoperatively is conducive to faster recovery of muscle, bone and joint function. The patients in the stem revision group was allowed to bear weight earlier and therefore recovered faster.

Two patients in the SR group experienced hip dislocation, which was caused by the use of modular stems; modular stems were not used in the ORIF group. In the SR group, the wide range of local soft tissue dissection and unclear anatomical signs of proximal femoral fracture affected the correct intraoperative angling of the component. One patient died 1 month after surgery due to an increase in the anterior angle of the acetabulum. The high side of the polyethylene liner was adjusted, and the 36 mm femoral head was replaced. Three months after surgery, another patient experienced dislocation due to the presence of soft tissue around the hip. There were no recurrent dislocations after closed reduction followed by 6 weeks of brace immobilization. The dislocation rate in the SR group was approximately 8%, which was close to that reported in the literature (5–10%)^[11]. The authors measured and marked the anatomical location of the contralateral lower limb to help improve the accurate placement of the prosthesis^[26]. We suggest templating the contralateral radiograph and predicting the ideal size of the component using artificial intelligence before the operation. The reoperation rates after ORIF and SR can be as high as 23%[10] but are currently 13.7% [6]. In our study, the reoperation rate was 8.7% in the ORIF group and 8% in the SR group. Although the 1-year mortality rates did not significantly differ between the two groups, the length of hospital stay significantly differed, mostly due to the medical complication rates in the SR group, which were comparable with those reported in previous studies^[27].

Limitations

This research was limited in terms of its retrospective design and small sample size, both which were due to the mortality rate of patients with periprosthetic femoral fractures. As a result of such limitations, the preoperative HHS could not be compared with the postoperative scores.

We reported good radiographic and clinical results for ORIF and SR for the treatment of Vancouver B2 periprosthetic fractures. However, most of these patients did not return to their preoperative mobility status. Two patients in the ORIF group experienced radiographic subsidence and fixation failure because of early weightbearing due to poor compliance. Two patients in the SR group experienced dislocation because of global tissue release increasing the anterior angle of the acetabulum. The reoperation rate and one-year mortality rate were not significantly different. Moreover, ORIF is advantageous for elderly patients because of its less invasiveness, shorter procedure, less blood loss, shorter hospital stay, and fewer medical complications. While stem revision allows for a shorter time to weightbearing and causes less radiographic subsidence, and modular stems can easily mitigate the complications associated with the operation despite failing to reduce dislocation rates, most patients do not return to the preoperative level.

Acknowledgements

The authors thank all participants that agreed to participate in this study.

Authors’ contributions

Conceptualization: Tihui Wang,Zhenbao Lu; formal analysis and investigation:Qijin Wang, Feiyue Lin; writing-review and editing: Hongwei Xu,Jinqing Wu; resources:Qiujin Xia, Tihui Wang. All authors read and approved the final manuscript.

Funding

No.

Data Availability

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Affiliated Mindong Hospital of Fujian Medical University Ethics Committee. All participants signed informed consent forms.

Consent for publication

Not applicable.

Conflict of interests

The authors declare that they have no competing financial interests.

Author details

1Department of Orthopedics, Mindong Hospital Affiliated to Fujian Medical Univesity, Ningde 355000, Fujian, China

2Department of Orthopedics, College of Clinical Medicine for Oncology , Fujian Medical University, Fuzhou, 350000, Fujian, China

Abdel M P, Roth P V, Harmsen W S, et al. What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty[J]. Bone Joint J, 2016,98-B(11):1436-1440.
Meek R M, Norwood T, Smith R, et al. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement[J]. J Bone Joint Surg Br, 2011,93(1):96-101.
Duncan C P, Masri B A. Fractures of the femur after hip replacement[J]. Instr Course Lect, 1995,44:293-304.
Garbuz D S, Masri B A, Duncan C P. Periprosthetic fractures of the femur: principles of prevention and management[J]. Instr Course Lect, 1998,47:237-242.
De Maio F, Caterini A, Cesaretti L, et al. Vancouver B2 and B3 periprosthetic femoral fractures treated by ORIF. Mid to long-term follow-up study in 28 patients[J]. Eur Rev Med Pharmacol Sci, 2022,26(1 Suppl):1-8.
Deyo R A, Cherkin D C, Ciol M A. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases[J]. J Clin Epidemiol, 1992,45(6):613-619.
Beals R K, Tower S S. Periprosthetic fractures of the femur. An analysis of 93 fractures[J]. Clin Orthop Relat Res, 1996(327):238-246.
Engh C A, Massin P, Suthers K E. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components[J]. Clin Orthop Relat Res, 1990(257):107-128.
Moreta J, Uriarte I, Ormaza A, et al. Outcomes of Vancouver B2 and B3 periprosthetic femoral fractures after total hip arthroplasty in elderly patients[J]. Hip international, 2019,29(2):184-190.
Kamineni S, Vindlacheruvu R, Ware H E. Peri-prosthetic femoral shaft fractures treated with plate and cable fixation[J]. Injury, 1999,30(4):261-268.
Schwartz A M, Farley K X, Guild G N, et al. Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2030[J]. J Arthroplasty, 2020,35(6S):S79-S85.
Deng Y, Kieser D, Wyatt M, et al. Risk factors for periprosthetic femoral fractures around total hip arthroplasty: a systematic review and meta-analysis[J]. ANZ J Surg, 2020,90(4):441-447.
Boylan M R, Riesgo A M, Paulino C B, et al. Mortality Following Periprosthetic Proximal Femoral Fractures Versus Native Hip Fractures[J]. J Bone Joint Surg Am, 2018,100(7):578-585.
Fuchtmeier B, Galler M, Muller F. Mid-Term Results of 121 Periprosthetic Femoral Fractures: Increased Failure and Mortality Within but not After One Postoperative Year[J]. J Arthroplasty, 2015,30(4):669-674.
Holley K, Zelken J, Padgett D, et al. Periprosthetic fractures of the femur after hip arthroplasty: an analysis of 99 patients[J]. HSS J, 2007,3(2):190-197.
Masri B A, Meek R M, Duncan C P. Periprosthetic fractures evaluation and treatment[J]. Clin Orthop Relat Res, 2004(420):80-95.
Spina M, Scalvi A. Vancouver B2 periprosthetic femoral fractures: a comparative study of stem revision versus internal fixation with plate[J]. Eur J Orthop Surg Traumatol, 2018,28(6):1133-1142.
Gonzalez-Martin D, Pais-Brito J L, Gonzalez-Casamayor S, et al. Treatment algorithm in Vancouver B2 periprosthetic hip fractures: osteosynthesis vs revision arthroplasty[J]. EFORT Open Rev, 2022,7(8):533-541.
Lewis D P, Tarrant S M, Cornford L, et al. Management of Vancouver B2 Periprosthetic Femoral Fractures, Revision Total Hip Arthroplasty Versus Open Reduction and Internal Fixation: A Systematic Review and Meta-Analysis[J]. J Orthop Trauma, 2022,36(1):7-16.
Haider T, Hanna P, Mohamadi A, et al. Revision Arthroplasty Versus Open Reduction and Internal Fixation of Vancouver Type-B2 and B3 Periprosthetic Femoral Fractures[J]. JBJS Rev, 2021,9(8).
Baum C, Leimbacher M, Kriechling P, et al. Treatment of Periprosthetic Femoral Fractures Vancouver Type B2: Revision Arthroplasty Versus Open Reduction and Internal Fixation With Locking Compression Plate[J]. Geriatr Orthop Surg Rehabil, 2019,10:1467839237.
Lindahl H, Garellick G, Regner H, et al. Three hundred and twenty-one periprosthetic femoral fractures[J]. J Bone Joint Surg Am, 2006,88(6):1215-1222.
Drew J M, Griffin W L, Odum S M, et al. Survivorship After Periprosthetic Femur Fracture: Factors Affecting Outcome[J]. J Arthroplasty, 2016,31(6):1283-1288.
Bhattacharyya T, Chang D, Meigs J B, et al. Mortality after periprosthetic fracture of the femur[J]. J Bone Joint Surg Am, 2007,89(12):2658-2662.
Huang L, Han W, Qi W, et al. Early unrestricted vs. partial weight bearing after uncemented total hip arthroplasty: a systematic review and meta-analysis[J]. Front Surg, 2023,10:1225649.
Sun L, Song W, Zhang Z, et al. Femoral offset restoration affects the early outcome of revision in patients with periprosthetic femoral fractures of Vancouver B2 - a single-center retrospective cohort study[J]. BMC Musculoskelet Disord, 2023,24(1):567.
Spina M, Scalvi A. Vancouver B2 periprosthetic femoral fractures: a comparative study of stem revision versus internal fixation with plate[J]. Eur J Orthop Surg Traumatol, 2018,28(6):1133-1142.

No competing interests reported.

Download PDF

Reviews received at journal
27 Oct, 2024
Reviewers agreed at journal
27 Oct, 2024
Reviews received at journal
17 Oct, 2024
Reviews received at journal
01 Oct, 2024
Reviewers agreed at journal
26 Sep, 2024
Reviewers agreed at journal
21 Sep, 2024
Reviewers invited by journal
21 Sep, 2024
Editor assigned by journal
14 Aug, 2024
Submission checks completed at journal
14 Aug, 2024
First submitted to journal
06 Aug, 2024

You are reading this latest preprint version

A comparative study of ORIF and stem revision for Vancouver B2 periprosthetic fractures of the femur in elderly patients

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusions

Figures

Introduction

Materials and methods

Statistical analysis

Surgical procedure

Results

Demographic characteristics

Clinical outcomes

Complications

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1