Aims

We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis.

INTRODUCTION: The postoperative periprosthetic femoral fracture is a severe complication after total hip surgery. It has become the third most common reason for revision. Three-hundred and twenty one fractures operated during 1999–2000, were followed in a prospective nationwide study. The study focused on the failure rate, patient satisfaction, treatment and radiographic evaluation.

PATIENTS AND METHODS: During 1999–2000, 230 fractures after a primary THR and 91 after a revision THR were reported to the Swedish National Hip Arthroplasty Register. All hospital records were collected. At follow-up the Harris hip score, a health-related quality of life measure (EQ-5D) and patient satisfaction were used as outcome measurement. A radiologist performed the radiographic evaluation.

RESULTS: A high number of patients had a loose implant at fracture time (66% in the primary group and 51% in the revision group). Eighty-eight percent of the fractures were classified as Vancouver type B fractures. A major finding was the association between the type of implant and the risk of a periprosthetic fracture. The Charnley and the Exeter prostheses were significantly over represented among patients with fractures and the Lubinus prosthesis significantly under represented. The surgeons grading of the Vancouver type B1 fracture was not in agreement with the study radiologist in more than 34% of the cases. Patient’s satisfaction concerning mobility, self-care, normal activities, pain and anxiety compared to an age matched population with a THR were poor. There was a high failure rate and by December 31, 2004, 22% had been reoperated.

DISCUSSION: A recommendation is to follow all THR patients with regularly radiographic monitoring and to intervene before the fracture. Implant related factors have to be considered when choosing implant for routine use. Difficulty in evaluating the x-rays concerning the stability of the prostheses might lead to sub optimal treatment. We recommend exploration of the implant for all patients with a Vancouver type B fracture if there is any doubt about the fixation status.

Periprosthetic fracture of the femur is an uncommon complication after total hip replacement, but appears to be increasing. We undertook a nationwide observational study to determine the risk factors for failure after treatment of these fractures, examining patient- and implant-related factors, the classification of the fractures and the outcome.

Between 1979 and 2000, 1049 periprosthetic fractures of the femur were reported to the Swedish National Hip Arthroplasty Register. Of these, 245 had a further operation after failure of their initial management. Data were collected from the Register and hospital records. The material was analysed by the use of Poisson regression models.

It was found that the risk of failure of treatment was reduced for Vancouver type B2 injuries (p = 0.0053) if revision of the implant was undertaken (p = 0.0033) or revision and open reduction and internal fixation (p = 0.0039) were performed. Fractures classified as Vancouver type B1 had a significantly higher risk of failure (p = 0.0001). The strongest negative factor was the use of a single plate for fixation (p = 0.001). The most common reasons for failure in this group were loosening of the femoral prosthesis, nonunion and re-fracture.

It is probable that many fractures classified as Vancouver type B1 (n = 304), were in reality type B2 fractures with a loose stem which were not recognised. Plate fixation was inadequate in these cases. The difficulty in separating type B1 from type B2 fractures suggests that the prosthesis should be considered as loose until proven otherwise.

Aim: The postoperative periprosthetic femoral fracture is a severe Complication after total hip surgery. Although, uncommon, such a fracture presents a major challenge to the orthopaedic surgeon.

In many cases the surgeon has to solve the problems of aseptic loosening, bone loss and fracture in one surgical procedure.

It is necessary to study a large population. Methods: We have analyzed the postoperative periprosthetic femoral fractures reported to the Swedish National Hip Registry. The databases of the registry, including 205 000 primary procedures and 37 000 reoperations, give a unique opportunity to analyze the prosthesis related femoral fracture. In the present study we report the retrospective data between 1979 and 2000, 1254 cases were found. The aim of the study were to estimatethe incidence of the periprosthetic fracture, classify the fractures and to analyze correlation to different factors. All living patients have received a self-administrated clinical outcome questionnaire. Results: The main results were that we found high frequencies of complications and reoperations and that 80% of the patients had a loose femoral component at the time of the periprosthetic fracture. A questionnaire was sent to the patient still alive. We found a high frequency of complication. 31% of the 374 had been reoperated. Conclusions: A future recommendation is to follow all patients with a hip prosthesis with regularly radiographic monitoring and try to intervene surgically before they sustain their fracture.