periprosthetic fractures
An 83-year-old female with a history of THR performed 14 years ago presents after an acute fall. She has a 2 year history of increasing thigh pain that initially began atraumatically. Figure 7–16 reveals a hip radiograph taken 1 month prior to the fall when she returned to her orthopaedic surgeon complaining of thigh pain. She has been unable to ambulate since the fall and presents to the emergency department for evaluation with new radiographs as seen in Figure 7–17.
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Figure 7–16
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Figure 7–17
How is this fracture classified?
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Vancouver A
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Vancouver B1
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Vancouver B2
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Vancouver B3
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Vancouver C
Discussion
The correct answer is (C). Periprosthetic femoral fractures around a total hip replacement are classified based upon location and whether or not the femoral stem is loose. According to the Vancouver classification, type A fractures involve the greater or lesser trochanters and type B involve the region of the femoral stem or immediately below the tip of the stem. Subtypes of B include B1 (implant stable), B2 (implant unstable with good bone stock), and B3 (implant unstable with poor bone
stock). Type C fractures are below the stem and cement mantle. In this patient, the fracture is just distal to the tip of the stem and the implant is loose, therefore it is a Vancouver B2 fracture.
What is the recommended treatment for this fracture?
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Open reduction internal fixation with a proximal femoral trochanteric plate
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Minimally invasive reduction and internal fixation with a LISS plate
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Revision of the femoral stem and strut allograft
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Nonoperative treatment
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Revision of both acetabular and femoral components
Discussion
The correct answer is (C). The patient has a stem that is loose clinically and radiographically. Now that she has sustained a fracture, the recommended treatment is revision to a diaphyseal engaging stem that bypasses the fracture. This should be augmented with either a cable-plate construct or a strut allograft to obtain additional rotational stability (Fig. 7–18). Open reduction internal fixation can be performed only in the setting of a well-fixed implant. In this situation, the implant will be likely to subside if open reduction internal fixation is performed with retention of the loose femoral stem. Open reduction internal fixation is the treatment of choice in a Vancouver B1 fracture in which the stem is stable or in a type C when the fracture is distal and remote from the stem. Type B3 fractures in which the metadiaphyseal bone is insufficient, require the use of structural allograft or tumor-type endoprosthesis.
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Figure 7–18
The classification and treatment of periprosthetic fractures?