Revision hip arthroplasty in Vancouver B2/B3 fractures—best practice in a nutshell
Although there are some recent literature suggesting that under certain special conditions, Vancouver type B2 fractures may be managed with osteosynthesis alone, it is general practice that periprosthetic femoral fractures (PPFF) with loose stems (ie, Vancouver types B2 and B3 fractures) and with either adequate or poor bone stock, should be treated with revision to achieve a better outcome and rapid recovery of the patient.
Aims of PPFF management for Vancouver types B2 and B3 fractures
Surgical revision due to PPFF is a demanding treatment for both patients and surgeons. Revision surgery can be long and strenuous for patients who are oftentimes elderly, with high comorbidity, and have inadequate bone stock. Luigi Zagra, Head of the Hip Department, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy and Past President of the European and Italian Hip Societies, shares with us, "In revision surgery for Vancouver types B2 and B3 fractures, the management goals are, 1) to achieve safe early mobilization, 2) a pain-free hip, 3) stable fixation of the prosthesis and fracture healing in near-anatomical alignment so as to restore hip biomechanics and function, and 4) durable implant." In this article, Luigi Zagra will demonstrate how optimal revision hip arthroplasty should be performed.
Assessing the stem
As has been discussed in Part 2 of this series, one essential diagnosis in treating PPFF is to determine whether a stem is loose. This question often translates into, "Is the fracture Vancouver type B1 or type B2/B3?" To achieve a reasonably accurate diagnosis, it is essential to take high-quality x-rays in at least two planes at the pelvis level to determine if the stem is loose or stable. Radiolucent lines detected around the prosthesis or cement is an indication of osteolysis, stem loosening, or stem subsidence . A computed tomographic (CT) scan is helpful in showing fracture pattern, extension of osteolysis, and even implant fixation. If the imaging does not offer a conclusive diagnosis of a stable stem, and during surgery implant stability is still doubtful, then a stem revision should be carried out.
Open reduction and internal fixation or revision?
There are a few recent studies suggesting that open reduction and internal fixation (ORIF) alone should be considered and in some circumstances may be more beneficial than stem revision in treating Vancouver type B2 and B3 fractures [1–3]. The justifications for this suggestion are that patients would benefit from a shorter operation, shorter anesthesia time, fewer complications, reduced operative risks, and maintain bone stock for future revisions. In addition, the operation would be less costly and technically less difficult. However, since these studies were all small and have high risk of a biased result, as well as lacking information on prognostic factors, additional supportive data will be necessary to confidently recommend ORIF over stem revision .
Recently, a systematic literature review of 22 studies (343 B2 and 167 B3 fractures, mean follow-up time of 32 months) showed that in Vancouver type B2 fractures, internal fixation alone is associated with a higher reoperation rate, although the increased relative risk did not reach statistical significance. In Vancouver type B3 fractures treated with internal fixation alone, two out of seven (28.6%) patients required reoperation, in comparison to 23 out of 160 (14.4%) patients that were treated with revision . Summarizing the situation, Spina and Scalvi concluded that in general, revision is still the preferred method of treatment in PPFF with a loose stem. Of course, in some circumstances, such as extremely frail patients with low functional expectations or fractures of specific patterns, Vancouver B2 and B3 fractures around a loose stem could be fixed by osteosynthesis, assuming the bone stock is adequate in supporting weight bearing and that anatomical reduction can be achieved [4, 6].
Planning PPFF surgery
Revision hip arthroplasty for PPFF is major surgery and it is not emergency surgery to be performed at night. As has been introduced in Parts 1 and 2 of this series, even when the x-rays are studied with extreme care, surgeons can still encounter unexpected findings intraoperatively. The availability of experienced personnel and the appropriate hardware are both crucial to ensure that the surgery goes smoothly. Both orthopedic traumatologists and arthroplasty surgeons should be present or on standby during surgery. As for the hardware required, all scenarios should be considered. For example, not only the implants (revision stems, acetabular components and liners, plates, screws, cerclage, and cables) and ample bone graft materials must be available, the surgical tools (bone reduction forceps, canal scrapers, cement restrictor, reamers, etc) for their application must also be available—not just for the planned procedure, but also for backup.
Templating, ie, the trial run of the surgery, should include a trial reduction and placement of the trial implants to ensure that the femoral component is of the correct length and would seat at a level that adequately restore leg length and hip stability, which may be important in preventing dislocation [7, 8].
Planning the surgery: Watch out for infection
Understanding the clinical history of pain and injury is essential in decision-making when treating PPFF patients. Ask the patient about his/her history of pain and the function of the joint before the injury. Both may indicate prosthetic loosening or infection . As has been reviewed in Part 1, the predictive power of laboratory values (eg, white blood cell count and inflammatory markers) is relatively poor. A joint aspiration for cell count and culture is not easily performed in patients with PPFF; it may cause excessive delay in surgery and should be restricted to selected cases at risk of major septic complication. In any case, infection should be ruled out by cultures in all patients and in highly suspected cases intraoperative frozen sections or leukocyte esterase plus cell count and neutrophils count should be performed .
Timing of surgery
Although there were suggestions that a delay in surgery for PPFF patients might cause worse outcomes, the relationship between delayed surgery and outcomes (morbidity and mortality) is not well established. Reports of a delay of more than five days  or two days  after trauma having significant effects on outcome contradict another recent study showing that postoperative length of hospital stay and mortality were not affected by time to definitive fixation (cutoff time: 48 hours) . Boddapati et al reported that patients with a nonexpedited (< 24 hours) procedure had higher rates of overall complications, respiratory complications, urinary tract infections and blood transfusions, but multivariate analysis showed that there was no statistical difference in mortality .
Delays to surgery of PPFF may be due to factors such as prolonged medical clearance, unavailability of specific revision implants, and unavailability of appropriately qualified surgeons. In addition, quality improvement programs including regional anesthetic blocks, fluid replacement protocols, and calorie supplementation can stabilize the general health of the patient in anticipation of an invasive surgery. In balancing an expedited surgery and a well-prepared treatment, a slight delay in surgery may be justified.
Choosing the correct stem
The choice of stem depends on two considerations, 1) the performance of the prosthesis (including the durability and the complication rate), and 2) its suitability in recreating the patient's anatomy. Luigi Zagra reminds us, “In treating Vancouver types B2 and B3 fractures, the fracture and loose stem are treated simultaneously.” He further explains, “In the treatment of PPFF, a distal fixation in the femur is essential. The long femoral stem prosthesis bypasses cortical deficiencies and achieves distal anchorage. This means that the revision arthroplasty and the fracture fixation are achieved simultaneously. Personally, I prefer cementless long tapered fluted stems of the Wagner type of revision stems. Moreover, systems with reliable modularity make the reconstruction much simpler.”
To cement or not to cement?
Although cemented long-stem prostheses were originally used for revision total hip arthroplasty (THA), Springer et al analyzed 42 patients with types B2 and B3 fractures treated with a cemented long-stem prosthesis and reported that only 60% of patients had a stable implant with fracture union. This is in accordance with other reports from other authors that cemented components had demonstrated a high rate of loosening, nonunion, and refracture [7, 15-18] (see also Part 1 for more information). The advocates for the superiority of uncemented stems in fixation of the femoral component pointed in addition to the problem of cement leakage and that cementless stems can also preserve bone stock in younger patients [7, 9].
To avoid subsidence in cementless stems, a regime of postoperative restricted (touch-toe) weight bearing followed by partial weight bearing is usually prescribed, which might be more difficult for elderly patients both in terms of compliance and balance [7, 19]. It has also been reported that in 49 fractures treated with long cementless stems, patients older than 75 years had significantly higher incidence of complications (ie, death, infection, falls with secondary dislocation, and PPFF) than patients in the younger age group. The authors therefore suggested that the use of extensively coated cementless stems should be reevaluated in patients older than 75 years . An additional important advantage of cemented stems over press-fit uncemented stems is the tolerance to immediate weight bearing without an increased risk of subsidence. Therefore, while cementless implants can be used in younger and more active patients who can tolerate a prolonged period of nonweight bearing, in frailer patients cemented stems that allow early weight bearing will be beneficial  and could be considered.
Currently there are many cementless stems available. Different classification systems exist based on many factors, such as their fixation characteristics, shape, modularity, and surface treatment. The basic elements of a femoral stem are illustrated in Figure 3. Both extensive porous titanium-coated long femoral stem prostheses and tapered fluted titanium stems (modular or nonmodular, Figure 3) have shown encouraging clinical and imaging results in treating PPFF, the latter is increasingly more popular even outside Europe, where it initially gained popularity [7, 20-24].
Aside from having the usual properties of long stems, ie, providing concurrent intramedullary fixation and distal diaphyseal stability, the extensive porous coating presumably promotes biological ingrowth to provide long-term prosthetic stability . In the tapered fluted stem design, the tapered geometry presumably provides axial fixation and the flutes provide rotational stability, and similar to the extensive porous titanium-coated stems, the rough surface promotes bone ingrowth that facilitates long-term fixation .
Modular versus nonmodular stems
Several studies have been carried out to compare nonmodular (monobloc) and modular stems. So far, there does not seem to be a clear advantage of one versus the other [23, 26-28]. On the one hand, modular stems offer flexibility that allows better adjustment to individual patient anatomy and fracture configuration and can achieve better offset, neck orientation, soft-tissue tension, and less leg-length discrepancy. On the other hand, nonmodular monobloc stems are once again gaining popularity. They are cheaper and have provided reliable fixation and fracture healing when used effectively [8, 27].
In a study of 218 revision THA patients with a mean follow-up of 101.5 months, Feng et al reported the following balance comparing modular versus nonmodular stems. They found that modular stems performed better in terms of subsidence and leg-length discrepancies, but worse in terms of intraoperative fractures (Table 1) .
All other variables, ie, operative time, length of hospital stay, intraoperative blood loss, postoperative drainage, and total blood loss did not show statistical differences . With the currently available data, it should be safe to say that the decision to use a modular or a nonmodular stem is largely a matter of surgeon preference. However, it should be noted that, in osteoporotic patients with patulous canals and major isthmus damage, a modular fluted, tapered stem will not allow for distal fixation and therefore is not suitable .
Take tribology into consideration when choosing the hip prosthesis
In selecting the articular component of hip prosthesis, a good approach should balance the risks posed by mixing and matching different materials and the functional demands of individual patients [29-31].
About ten years after the initial development of metal-on-polyethylene (MoP, ie, metal femoral head and polyethylene acetabular cap) bearings in the early 1960s, cases of aseptic loosening of prostheses started to capture attention. It is now accepted that the relative movements between the articular components cause wear and tear of the polyethylene (PE) and generate debris particles between 0.3 and 10 μm. These particles can trigger a series of biochemical reactions, leading to enhanced osteoclast activity, osteolysis, and eventually, aseptic loosening of implants [30, 31].
Over time, many different materials have been developed for the purpose of improving the performance of the articular components for THA, such as metal-on-metal (MoM), ceramic-on-metal, and ceramic-on-ceramic (CoC). Each different combination has its theoretical or clinically proven advantages and disadvantages . Currently, the MoM constructs are no longer expected to be used due to their higher revision rate in comparison to MoP implants . Apart from MoM (CoCrMo alloy) implants, CoC implants have been shown to have good wear characteristics and deliver good clinical results; it has been suggested that they are particularly suitable for young active patients . For older patients with a moderate range of activity, the conventional hip prostheses with polyethylene cups and metal balls remains a good choice .
Articular implants comprising highly cross-linked polyethylene have been developed to be paired with either a metal or a ceramic head. This highly promising combination displays low wear, and yet is more forgiving for the cup positioning than other materials .
The principles of a revision surgery for PPFF are stable fixation of the prostheses to the host bones and to prevent common complications such as aseptic loosening, dislocation, and infection. The functionality and longevity of the prostheses should be considered and based on individual patient's needs.
In addition, the bone stock of the patient should be improved whenever possible. It has been advocated that bone graft can improve fracture stability, restore bone stock, and potentially improve fracture healing, and they have been applied to PPFF patients with good results [19, 35–39]. In a report of 144 types B2 and B3 fractures treated with long-stem revision, fractures treated with impaction grafting with morselized cancellous bone graft were four times more likely to achieve fracture union than those without impaction grafting .
Fractures involving cemented stems
Since the exact fracture pattern and its extent are often unclear and underestimated on plain x-rays, it may be possible to assess these only at the time of surgery. Usually, the cement mantle can be assumed to be fractured if there is an overlying bone fracture . Loose cement may prevent anatomical reduction and bone union so it should be removed . Recently, good results have been reported for the cement-in-cement revision technique. Therefore, in case of small cement deficiencies and in older patients, the cement may be repaired to shorten the surgery time and simplify the surgical process [9, 40].
Loose stem removal and provisional reduction
The first step in a revision surgery is to remove the loose stem. As Abdel et al has reported, most intraoperative femoral fractures during the revision procedure occurred at, 1) placement of the femoral component (216 fractures, 34.5%), 2) removal of the previous prosthesis (192 fractures, 30.7%), and 3) trial reduction (141 fractures, 22.5%) . Therefore, particular care should be taken at this stage.
Unless the stem is grossly loose, the fractures may have to be propagated proximally in the case of Vancouver types B2 or B3 fractures, to gain a direct access to the prosthesis. To achieve this, an extended trochanteric osteotomy may be necessary to allow access to the proximal femur. If the acetabular component shows major signs of wear, the liner should be revised at this time.
Following this step the distal end of the fracture is identified and fixed to prevent further propagation of the fracture during reaming or stem insertion. For for this purpose, one or more preventive cerclage wires or cables can be applied just distal to the fracture.
Before the revision stem can be inserted, the diaphysis should be prepared by sequentially reaming with tapered stem reamers. The result of the reaming should be a strong, supportive, distal medullary canal with an appropriate taper to receive the stem [7, 42]. It has also been suggested that overreaming could help reduce hoop stresses and the risk of fracture when inserting press-fit stems .
Revision THA is typically carried out with long-stem prosthesis [7, 9]. The revision stem should be long enough to achieve adequate distal fixation and should bypass the fracture by at least two to three cortical diameters (at least 6 cm). Since these stems bypass the cortical deficiencies, they provide intramedullary fixation of the fracture fragments. Concurrently, distal diaphyseal stability is achieved through tight press-fit contact using a canal-fitting implant in the short term and eventual bone ingrowth in the long term [17, 21]. Once the femoral stem has been inserted, the proximal femur can be approximated around the implant with cable or wire cerclages. Especially in older adults with poor bone stock, less emphasis should be placed on reconstructing the bone or anatomical reduction; instead, supplementary fixation with cortical strut allografts may increase the stability [21, 43].
Limb length, offset, and orientation
To minimize the possibility of a dislocation, it is vital to restore the correct soft-tissue tension, limb length, and offset. Correct femoral and acetabular rotation and version also reduce the possibility of dislocation. PPFF revision tend to render the abductor mechanism deficient; therefore, attention should be given so that the greater trochanter is well anchored to prevent trochanteric escape . As mentioned before, modular stems may provide more flexibility, ie, better proximal offset and tissue tension and better distal anchorage to reduce leg-length discrepancy .
Reapproximate femur proximally
The proximal femur can then be reconstructed around the new implant. Minimal internal fixation should be employed—this means that cerclage wires, cables, or tension bands are preferred over plates for the fixation of large fracture fragments around the upper portion of the femur (Figure 4). Although anatomical reduction may not always be possible, biomechanical parameters (such as the offset and the position of the trochanter) should be restored. Should there be autogenous bone graft reamed from the femur or acetabulum, they can be packed into fracture lines.
Conclusion: Revision hip arthroplasty
- Revisions are not for emergencies; an accurate planning is necessary
- Revise the loose stem but be ready to revise the cup as well; be ready for bone grafting
- Look for reliable distal fixation; reconstruct the femur around the stem; use cables for internal fixation
This series of articles was created with the support of the following specialists (in alphabetical order):
This issue was written by Maio Chen, AO Innovation Translation Center, Clinical Science, Switzerland.
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