Modified Extended Trochanteric Osteotomy for the Treatment of Vancouver B2/B3 Periprosthetic Fractures of the Femur

Background

Femoral component revision is the treatment of choice for Vancouver type B2/B3 periprosthetic femur fractures (PFFs). The purpose of this study was to report the clinical outcome of revision total hip arthroplasty with the use of a modified extended trochanteric osteotomy (ETO) in PFF treatment.

Cement-in-Cement Femoral Revision for the Treatment of Highly Selected Vancouver B2 Periprosthetic Fractures

The use of the cement-in-cement technique for femoral component revisions has been well described. The application of this technique in the management of selected Vancouver B2 periprosthetic femur fractures, after careful preoperative and intraoperative evaluation, offers a novel alternative that is rapid and technically less demanding, with resulting decreased blood loss and decreased risk of iatrogenic fragmentation of bone during cement removal.     

The Impact of Exchanging Cerclage Fixation after Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty for Periprosthetic Joint Infection

BackgroundAn extended trochanteric osteotomy (ETO) is a powerful tool for femoral component revision. There is limited evidence that directly supports its use in the setting of a periprosthetic joint infection (PJI). Cerclage fixation raises the theoretical concern for persistent infection.MethodsOur institutional database included 76 ETOs for revision hip arthroplasty between January 1, 2008 and December 31, 2019. The cohort was divided based on indication for femoral component revision: PJI versus aseptic revision. The PJI group was subdivided based on second-stage exchange versus retention of initial cerclage fixation. Operative time, estimated blood loss, complications, and rate of repeat revision surgery were evaluated.ResultsForty-nine patients (64%) underwent revision for PJI and 27 patients (36%) underwent aseptic revision. There was no significant difference in operative times (P = .082), postoperative complications (P = .258), or rate of repeat revision surgery (P = .322) between groups. Of the 49 patients in the PJI group, 40 (82%) retained cerclage fixation while 9 (18%) had cerclage exchange. Cerclage exchange did not significantly impact operative time (P = .758), blood loss (P = .498), rate of repeat revision surgery (P = .302), or postoperative complications (P = .253) including infection (P = .639).ConclusionAn ETO remains a powerful tool for femoral component removal, even in the presence of a PJI. A multi-institutional investigation would be required to validate observed trends toward better infection control with cerclage exchange. Cerclage exchange did not appear to increase operative time, blood loss, or postoperative complication rates.     

The Use of Extended Trochanteric Osteotomy in 2-Stage Reconstruction of the Hip for Infection

BackgroundThe effect of extended trochanteric osteotomy (ETO) with immediate cerclage wire fixation on the scene of chronic periprosthetic joint infection on infection eradication and the osteotomy healing remains unclear.MethodsOne hundred seventeen patients who underwent two-stage revision total hip arthroplasty for chronic periprosthetic joint infection were enrolled in the study. The minimum follow-up was 2 years. Of these, 48 patients had underwent ETO and immediate cerclage wire fixation during the first-stage surgery, while 69 did not undergo ETO or any other osteotomy. In addition, 18 patients had underwent ETO in the second-stage reimplantation surgery. Repeated debridement, curative rate of infection, and complications were compared between the 2 groups. Meanwhile, osteotomy healing between the first and second osteotomy were also compared.ResultsThe repeated debridement rate and curative rate of infection were 2.1% and 95.8% in the ETO group, compared with 13.0% and 82.6% in the non-ETO group; there were significant difference between the 2 groups in these parameters (P = .037 and .030, respectively). Meanwhile, osteotomy healing rate was 93.8% in first-stage surgery with infection scene and 100% in second-stage surgery without infection; no significant difference was detected in osteotomy healing rate and time to healing (P = .278 and .803, respectively). The rate of complication was similar in both groups.ConclusionsETO combined with immediate cerclage wire fixation does not appear to reduce the rate of infection eradication. There was no harmful effect on complication rate and osteotomy healing.     

Extended Trochanteric Osteotomy Followed by Cemented Impaction Allografting in Revision Hip Arthroplasty

The aim of this study is to present the medium- to long-term results of all cases of femoral impaction allografting revision at our institution that required an extended trochanteric osteotomy (ETO) at the time of surgery. Eighteen patients with a mean age of 60 years were evaluated. Indication for revision was aseptic loosening in all cases. The mean follow-up was 123 months (51-170). Charnley-D'Aubigné-Postel scores, stem length, ETO length, ETO healing, and complications were recorded. No patient was lost to follow-up. Signs of clinical healing were noted within the first 6 postoperative months. The difference between the preoperative and postoperative clinical scores was statistically significant. No nonunion of the ETO was observed in any case. These results give support to the combined use of these techniques.     

Outcomes and Risk Factors of Extended Trochanteric Osteotomy in Aseptic Revision Total Hip Arthroplasty: A Systematic Review

BackgroundAlthough extended trochanteric osteotomy (ETO) is an effective technique for femoral stem removal and for the concomitant management of proximal femoral deformities, complications including persistent pain, trochanteric nonunion, and painful hardware can occur.MethodsThe US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: “extended” AND “trochanteric” AND “osteotomy.”ResultsNineteen articles were included in the present study with 1478 ETOs. The mean overall union rate of the ETO was 93.1% (1377 of 1478 cases), while the overall rate of radiographic femoral stem subsidence >5 mm was 7.1% (25 of 350 cases). ETO union rates and femoral stem subsidence rates were similar between patients with periprosthetic fractures treated with total hip arthroplasty (THA) revision and ETO and patients treated with THA revision and ETO for reasons other than fractures. There was limited evidence that prior femoral cementation and older age might negatively influence ETO union rates.ConclusionThere was moderate quality evidence to show that the use of ETO in aseptic patients undergoing single-stage revision THA is safe and effective, with a 7% rate of ETO nonunion and subsidence >5 mm in 7%. ETO can be safely used in cases with periprosthetic fractures in which stem fixation is jeopardized and a reimplantation is required. A well-conducted ETO should be preferred in selective THA revision cases to prevent intraoperative femoral fractures which are associated with deteriorated clinical outcomes. The use of trochanteric plate with cables should be considered as the first choice for ETO fixation.     

Use of Cortical Strut Allograft After Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty

Background

Cortical strut allografts restore bone stock and improve postoperative clinical scores after revision total hip arthroplasty (THA). However, use of a cortical strut allograft is implicated in delayed healing of an extended trochanteric osteotomy (ETO). To date, there are no reports directly comparing ETO with or without cortical strut allografts.

Usefulness of Histology for Predicting Infection at the Time of Hip Revision for the Treatment of Vancouver B2 Periprosthetic Fractures

When facing a Vancouver B2 periprosthetic fracture, the most recommended treatment is the prosthesis replacement. Current tests do not provide enough reliability to identify whether the fracture has been produced on a septic or an aseptic loosened prosthesis. Our aim was to evaluate the usefulness of the histology for the diagnosis of infection in these cases. A total of 11 hip revision procedures were performed (mean age: 78.1 years, 8 women and 3 men). Sensitivity, specificity, positive predictive value and negative predictive value of the histology were 100%, 55.5%, 33.3% and 100% respectively. Of the six patients presenting with a positive histology, four of them had negative cultures (66.6% of false positives). Our results suggest that periprosthetic fractures are a cause of false-positive histology results for the diagnosis of infection during revision of a hip prosthesis for the treatment of Vancouver B2 periprosthetic fractures.     

The Effect of Strut Allograft and Its Position on Vancouver Type B1 Periprosthetic Femoral Fractures: A Biomechanical Study

The aim of this study is to assess the biomechanical advantage of adding strut allograft and the effect of its position on the construct in Vancouver type B1 fractures. Fifteen forth-generation synthetic femurs were used and created a fracture model at the tip of prosthesis, and subsequently fixated with a lateral plate only, lateral plate and medial strut, lateral plate and anterior strut. Rotational and axial tests were performed. In all loading tests, the plate with medial strut group was stiffer than the other constructs and had higher failure load values and had less displacement in the fracture site. A combination of a plate with a medial strut allograft provides more mechanical stability on periprosthetic femoral fractures near the tip of a total hip arthroplasty.     

Comparison of Functional and Radiographic Outcomes Between Two Fixation Methods for Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty: A Retrospective Cohort Study

BackgroundTo compare the functional and radiographic outcomes between two fixation methods for extended trochanteric osteotomy (ETO) in revision total hip arthroplasty (rTHA).MethodsIncluded in this study were 64 patients who underwent ETO in rTHA using either claw-plate fixation (claw-plate group, n = 31) or cable-alone fixation (cable group, n = 33) in our hospital from 2008 to 2020. The functional and radiographic results and complications were compared between the groups during a mean follow-up period of 64 and 78 months.ResultsThe Harris hip score and visual analogue scale at the last follow-up improved significantly in both groups, showing no significant statistical difference between the two fixation methods. In the cable group, the mean abductor lever arm, the proximal migration, and medial migration in the affected hip were significantly decreased compared to those in the contralateral normal hip (P < .05), whereas in the claw-plate group no significant statistical differences were observed between two sides. No or slight limping occurred in 25 patients (81%) in the claw-plate group and 16 patients (48%) in the cable group (P = .007). A multiple logistic regression demonstrated that claw-plate fixation could reduce the incidence of postoperative moderate-to-severe limping.ConclusionBoth claw-plate fixation and cable-alone fixation could improve the functional performance of rTHA with ETO, whereas claw-plate fixation could offer superior biomechanical results and gait improvement as compared with cable-alone fixation.     

Predictors of Perioperative Vancouver B Periprosthetic Femoral Fractures Associated With the Direct Anterior Approach to Total Hip Arthroplasty

BackgroundThere is an association between intraoperative and postoperative femoral fractures and the direct anterior approach (DAA) to total hip arthroplasty (THA). The purpose of our study is to identify risk factors for Vancouver B fractures and to establish a predictable timeline for when these occur.MethodsWe retrospectively identified patients with Vancouver B periprosthetic femoral fractures (n = 49) after 11,509 elective primary cementless THA procedures through the DAA between 2012 and 2018 at a single institution. Fracture patients were matched to nonfracture patients (n = 267) by date of surgery and surgeon. Clinical and radiographic factors were collected for multivariable analysis to identify predictors of fracture.ResultsPeriprosthetic Vancouver B femoral fracture incidence was 0.4%. 48 (98%) fractures were postoperative. Fractures occurred at an average of 44 days after surgery (range: 1 to 653 days) with >85% of fractures occurring in the first 6 weeks postoperatively. Significant variables predictive of fracture included >3 degrees valgus and >5 degrees varus coronal stem malalignment, Dorr B and C femoral geometry, lower canal flare index (2.75 vs 3.20), advanced age, increased comorbidities, greater stem canal fill, and right-sided procedures.ConclusionDespite an overall low rate of Vancouver B perioperative periprosthetic femoral fractures, it is a devastating complication that typically presents within the first 6 weeks after DAA THA surgery. The risk is increased in patients with unfavorable proximal femoral geometry, coronal stem malalignment, advanced age, increased comorbidities, and right-sided procedures.     

High Rates of Spacer Fracture in the Setting of Extended Trochanteric Osteotomy With a Specific Thin-Core Articulating Antibiotic Hip Spacer

BackgroundTwo-stage revision remains the standard of care for prosthetic joint infection after total hip arthroplasty. However, there are substantial complications associated with articulating antibiotic hip spacers. Handmade and molded spacers have been shown to have higher rates of spacer fracture than antibiotic-coated prostheses (ACPs). The aim of this study is to review outcomes with an implant that is often categorized as an ACP spacer, the Zimmer-Biomet StageOne Select Femoral Spacer (ZBSO).MethodsA retrospective review was performed of 63 patients who underwent placement of a ZBSO. Patients were compared based on whether or not an extended trochanteric osteotomy (ETO) was performed using Fisher’s exact and t-tests.ResultsFive patients were excluded due to lack of follow-up or death shortly after stage 1 surgery, leaving 58 patients. Spacer fracture was noted in 5 of 58 patients (8.6%). Sixteen patients underwent ETO and 25.0% suffered a spacer fracture compared to 2.3% without ETO (odds ratio 13.7, P = .0248). There was no association between patient demographics or ETO length and spacer fracture. Two patients had periprosthetic fractures (3.4%) and 4 had dislocations (6.9%). Forty-nine patients (84.4%) went on to second-stage revision; of those 26.5% failed to clear the infection and required an average of 2.2 additional surgeries.ConclusionThe ZBSO spacer has overall complication rates similar to previously reported spacer series. Although the ZBSO looks like an ACP spacer, in the setting of ETO, it behaves like a molded or handmade spacer with a high rate of spacer fracture (25%) due to the small diameter of the core. This implant should be used with caution in combination with an ETO.     

Seasonality of Periprosthetic Femur Fractures in 12,700 Primary and Revision Total Hip Arthroplasties

Background

Periprosthetic femur fractures after primary and revision total hip arthroplasty (THA) are one of the most common long-term reasons for reoperation after THA. Previous investigations have analyzed the incidence and risk factors of these fractures. No previous study, however, has analyzed a variation in periprosthetic femur fractures between meteorologic seasons. The aim of this study was to compare the incidence of periprosthetic femur fractures after primary and revision THAs depending on the meteorologic season.

Management of Vancouver B2 and B3 Periprosthetic Proximal Femoral Fractures by Distal Locking Femoral Stem (Cannulok) in Patients 75 Years and Older

Background

Periprosthetic fracture following total hip arthroplasty is a significant problem faced by hip surgeons, and its management in elderly patients remains a considerable challenge.

Extended trochanteric osteotomy for the treatment of vancouver B2/B3 periprosthetic fractures of the femur

Periprosthetic femur fractures after total hip arthroplasty are a growing concern as their prevalence is expected to rise. A retrospective review was performed of all patients undergoing revision total hip arthroplasty with an extended trochanteric osteotomy (ETO) for treatment of a Vancouver B2/B3 fracture at our institution. Fourteen patients were identified having a minimum of 2-year follow-up. Clinical and radiographic evaluation was performed for all patients. At a mean 44.5 months of follow-up, mean modified D'Aubigne and Postel scores were 8.6. In all cases the ETO and fracture healed with radiographic evidence of osseointegration of the femoral component. Use of an ETO for the treatment of periprosthetic femur fractures provides excellent exposure, facilitates component implantation, and is compatible with fracture healing and good short-term clinical results.     

Cementless,Fluted, Long-Stem Hemiarthroplasty for Vancouver B2 and B3 Periprosthetic Fractures Around Hip Hemiarthroplasty

BackgroundThe 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.MethodsThis 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 the Merle d’Aubigné score, and the Katz scale based on activities of daily living. Comorbidity was assessed by the Charlson index, and cognitive function by a mini-mental test score. Radiological evaluation was also performed.ResultsMean 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 = .001) although the mean Merle (P = .121) and Katz (P = .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.ConclusionThe 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.     

The Outcome and Complications of the Locked Plating Management for the Periprosthetic Distal Femur Fractures after a Total Knee Arthroplasty

Background

The osteosynthesis of the periprosthetic fractures following a total knee arthroplasty (TKA) can be technically difficult with the relatively small satisfactory outcomes and the high complication rates. The purpose of the study is to analyze the mid-term radiological and functional outcomes following the locked plating of the distal femur periprosthetic fractures after a TKA.

Methods

Records of 20 patients with a periprosthetic distal femur fracture following TKA treated by the locked plate osteosynthesis were retrospectively evaluated. The union rate, complications and functional outcome measures were analyzed.

Results

Successful union was achieved in 18 of the 19 patients available for the follow-up. The mean follow-up was 39 ± 10 months. Significant reductions (p < 0.05) in the range of motion and Western Ontario and McMaster Universities Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were evident in the follow-up. Secondary procedures were required in 5 patients to address the delay in union and the reduced knee range of motion. The osteosynthesis failed in 1 patient who underwent a revision TKA.

Conclusions

The satisfactory union rates can be achieved with the locked plate osteosynthesis in the periprosthetic distal femur fractures after TKA. Prolonged rehabilitation coupled with the un-modifiable risk factors can decrease the activity and satisfaction levels, which can significantly alter the functional outcome.     

Treatment Results of a Periprosthetic Femoral Fracture Case Series: Treatment Method for Vancouver Type B2 Fractures Can Be Customized

Background

Currently, an algorithmic approach for deciding treatment options according to the Vancouver classification is widely used for treatment of periprosthetic femoral fractures after hip arthroplasty. However, this treatment algorithm based on the Vancouver classification lacks consideration of patient physiology and surgeon''s experience (judgment), which are also important for deciding treatment options. The purpose of this study was to assess the treatment results and discuss the treatment options using a case series.

Methods

Eighteen consecutive cases with periprosthetic femoral fractures after total hip arthroplasty and hemiarthroplasty were retrospectively reviewed. A locking compression plate system was used for osteosynthesis during the study period. The fracture type was determined by the Vancouver classification. The treatment algorithm based on the Vancouver classification was generally applied, but was modified in some cases according to the surgeon''s judgment. The reasons for modification of the treatment algorithm were investigated. Mobility status, ambulatory status, and social status were assessed before the fracture and at the latest follow-up. Radiological results including bony union and stem stability were also evaluated.

Results

Thirteen cases were treated by osteosynthesis, two by revision arthroplasty and three by conservative treatment. Four cases of type B2 fractures with a loose stem, in which revision arthroplasty is recommended according to the Vancouver classification, were treated by other options. Of these, three were treated by osteosynthesis and one was treated conservatively. The reasons why the three cases were treated by osteosynthesis were technical difficulty associated with performance of revision arthroplasty owing to severe central migration of an Austin-Moore implant in one case and subsequent severe hip contracture and low activity in two cases. The reasons for the conservative treatment in the remaining case were low activity, low-grade pain, previous wiring around the fracture and light weight. All patients obtained primary bony union and almost fully regained their prior activities.

Conclusions

We suggest reaching a decision regarding treatment methods of periprosthetic femoral fractures by following the algorithmic approach of the Vancouver classification in addition to the assessment of each patient''s hip joint pathology, physical status and activity, especially for type B2 fractures. The customized treatments demonstrated favorable overall results.     

Revision Total Hip Arthroplasty for a Vancouver Type B3 Periprosthetic Fracture Using an Allograft-Cemented Stem Composite by the Telescoping Technique

We describe a case of successful revision total hip arthroplasty for a Vancouver type B3 periprosthetic femoral fracture with extensive bone stock deficiency and osteoporotic diaphyseal bone. The femur was reconstructed with an allograft-cemented stem composite using a telescoping technique and a drainage hole for surplus cement. This procedure facilitated stable stem fixation to the host femur without cement interference and bony fusion between the allograft and host bone, as revealed by bone scintigraphy. This technique provides a surgical option for a severe periprosthetic femoral fracture in which the femoral diaphyseal bone is too osteoporotic to support the fixation of an allograft-cementless stem composite.