Impaction Bone Grafting for the Treatment of Vancouver Type B3 Periprosthetic Femoral Fractures. Survivorship and Complication Rate Analysis
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Published:
Dec 16, 2021
Keywords:
B3 periprosthetic femoral fractures, impaction bone grafting technique, complications, survivorship analysis
Main Article Content
Abstract
Aims: Because the gold standard for the treatment of Vancouver type B3 periprosthetic femoral fractures (PFFs) is yet to be defined, we sought to analyze the complication rate of the impaction bone grafting (IBG) technique with a cemented stem for the treatment of this fractures.
Materials and Methods: We retrospectively studied 33 B3 PFFs treated with the IBG technique operatedbetween 2000 and 2016, analyzing the complication rate. The median follow-up was 75 months (interquartile range [IQR], 36-111). The median age was 78 years (IQR, 74-83). The median grade of EndoKlink femoral bone defect was 3 (IQR, 3-3). We performed a multiple regression analysis to determine risk factors for complications, including the following variables: number of previous surgeries, femoral head diameter, and femoral bone defect.
Results: As for infection outcomes, 2-stage revision surgery was performed in 4 patients. We registered 5 implant failures and 2 dislocations in the whole series. Multiple regression analysis showed a significant association between the grade of EndoKlink femoral bone defect and complication rate (P=0.04).
Conclusion: Femoral reconstruction with the IBG technique evidenced a high complication rate for the treatment of B3 PFF.
Materials and Methods: We retrospectively studied 33 B3 PFFs treated with the IBG technique operatedbetween 2000 and 2016, analyzing the complication rate. The median follow-up was 75 months (interquartile range [IQR], 36-111). The median age was 78 years (IQR, 74-83). The median grade of EndoKlink femoral bone defect was 3 (IQR, 3-3). We performed a multiple regression analysis to determine risk factors for complications, including the following variables: number of previous surgeries, femoral head diameter, and femoral bone defect.
Results: As for infection outcomes, 2-stage revision surgery was performed in 4 patients. We registered 5 implant failures and 2 dislocations in the whole series. Multiple regression analysis showed a significant association between the grade of EndoKlink femoral bone defect and complication rate (P=0.04).
Conclusion: Femoral reconstruction with the IBG technique evidenced a high complication rate for the treatment of B3 PFF.
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Díaz Dilernia, F., Oñativia, J. I., Slullitel, P., & Buttaro, M. (2021). Impaction Bone Grafting for the Treatment of Vancouver Type B3 Periprosthetic Femoral Fractures. Survivorship and Complication Rate Analysis. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 86(6), 737-746. https://doi.org/10.15417/issn.1852-7434.2021.86.6.1280
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Clinical Research
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References
1. Tsiridis E, Haddad FS, Gie GA. The management of periprosthetic femoral fractures around hip replacements.
Injury 2003;34(2):95-105. https://doi.org/10.1016/s0020-1383(02)00257-7
2. Meek RMD, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and
revision total hip and knee replacement. J Bone Joint Surg Br 2011;93(1):96-101. https://doi.org/10.1302/0301-620X.93B1.25087
3. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the
United States from 2005 to 2030. J Bone Joint Surg Am 2007;89(4):780-5. https://doi.org/10.2106/JBJS.F.00222
4. Tsiridis E, Spence G, Gamie Z, El Masry MA, Giannoudis PV. Grafting for periprosthetic femoral fractures: strut,
impaction or femoral replacement. Injury 2007;38(6):688-97. https://doi.org/10.1016/j.injury.2007.02.046
5. Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty 2000;15(1):59-62. https://doi.org/10.1016/s0883-5403(00)91181-1
6. Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics
of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty
2005;20(7):857-65. https://doi.org/10.1016/j.arth.2005.02.001
7. Rodriguez JA, Berliner ZP, Williams CA, Robinson J, Hepinstall MS, Cooper HJ. Management of Vancouver
type-B2 and B3 periprosthetic femoral fractures: restoring femoral length via preoperative planning and surgical
execution using a cementless, tapered, fluted stem. JBJS Essent Surg Tech 2017;7(3):e27.
https://doi.org/10.2106/JBJS.ST.17.00007
8. Garbuz DS, Toms A, Masri BA, Duncan CP. Improved outcome in femoral revision arthroplasty with tapered fluted modular titanium stems. Clin Orthop Relat Res 2006;453:199-202. https://doi.org/10.1097/01.blo.0000238875.86519.cf
9. Kwong LM, Miller AJ, Lubinus P. A modular distal fixation option for proximal bone loss in revision total hip
arthroplasty: a 2- to 6-year follow-up study. J Arthroplasty 2003;18(3 Suppl 1):94-7. https://doi.org/10.1054/arth.2003.50083
10. Van Houwelingen AP, Duncan CP, Masri BA, Greidanus NV, Garbuz DS. High survival of modular tapered stems for proximal femoral bone defects at 5 to 10 years followup. Clin Orthop Relat Res 2013;471(2):454-62.
https://doi.org/:10.1007/s11999-012-2552-8
11. Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am 2003;85(11):2156-62.
https://doi.org/10.2106/00004623-200311000-00015
12. Abdel MP, Cottino U, Mabry TM. Management of periprosthetic femoral fractures following total hip arthroplasty: a review. Int Orthop 2015;39(10):2005-10. https://doi.org/10.1007/s00264-015-2979-0
13. Khan T, Grindlay D, Ollivere BJ, Scammell BE, Manktelow ARJ, Pearson RG. A systematic review of Vancouver
B2 and B3 periprosthetic femoral fractures. Bone Joint J 2017;99-B(4 Suppl B):17-25.
https://doi.org/10.1302/0301-620X.99B4.BJJ-2016-1311.R1
14. Maury AC, Pressman A, Cayen B, Zalzal P, Backstein D, Gross A. Proximal femoral allograft treatment
of Vancouver type-B3 periprosthetic femoral fractures after total hip arthroplasty. J Bone Joint Surg Am
2006;88(5):953-8. https://doi.org/10.2106/JBJS.E.00120
15. Berry DJ. Treatment of Vancouver B3 periprosthetic femur fractures with a fluted tapered stem. Clin Orthop Relat Res 2003;(417):224-31. https://doi.org/10.1097/01.blo.0000096821.67494.f6
16. Engelbrecht E, Heinert K. Klassifikation und Behandlungsrichtlinien von Knochensubsanzverlusten bei
Revisionsoperationen am Huftgelenk mittelfrsige Ergebnisse. En: Primare und Revisionsalloarthroplastik Hrsg-
Endo-Klinik, Hamburg. Berlin: Springer-Verlag; 1987:189-201.
17. Nuñez LV, Buttaro MA, Morandi A, Pusso R, Piccaluga F. Frozen sections of samples taken intraoperatively for
diagnosis of infection in revision hip surgery. Acta Orthop 2007;78(2):226-30. https://doi.org/10.1080/17453670710013726
18. Mowe JC. Standards for tissue banking. Arlington, VA: American Association of Tissue Banks; 1988.
19. Gie GA, Linder L, Ling RS, Simon JP, Slooff TJ, Timperley AJ. Impacted cancellous allografts and cement for
revision total hip arthroplasty. J Bone Joint Surg Br 1993;75(1):14-21. https://doi.org/10.1302/0301-620X.75B1.8421012
20. Salvati EA, Sharrock NE, Westrich G, Potter HG, Valle AGD, Sculco TP. The 2007 ABJS Nicolas Andry Award:
three decades of clinical, basic, and applied research on thromboembolic disease after THA: rationale and clinical
results of a multimodal prophylaxis protocol. Clin Orthop Relat Res 2007;459:246-54.
https://doi.org/10.1097/BLO.0b013e31805b7681
21. Klein GR, Parvizi J, Rapuri V, Wolf CF, Hozack WJ, Sharkey PF, et al. Proximal femoral replacement for the
treatment of periprosthetic fractures. J Bone Joint Surg Am 2005;87(8):1777-81. https://doi.org/10.2106/JBJS.D.02420
22. Park M-S, Lim Y-J, Chung W-C, Ham D-H, Lee S-H. Management of periprosthetic femur fractures treated with
distal fixation using a modular femoral stem using an anterolateral approach. J Arthroplasty 2009;24(8):1270-6.
https://doi.org/10.1016/j.arth.2009.07.013
23. Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type femoral components: a
radiographic analysis of loosening. Clin Orthop Relat Res 1979;(141):17-27. PMID: 477100
24. Loudon JR, Charnley J. Subsidence of the femoral prosthesis in total hip replacement in relation to the design of the stem. J Bone Joint Surg Br 1980;62(4):450-3. https://doi.org/10.1302/0301-620X.62B4.7430222
25. Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res 1990;(257):107-28. PMID: 2199114
26. Richards CJ, Garbuz DS, Masri BA, Duncan CP. Vancouver type B3 periprosthetic fractures: evaluation and
treatment. Instr Course Lect 2009;58:177-81. PMID: 19385531
27. Tsiridis E, Narvani AA, Haddad FS, Timperley JA, Gie GA. Impaction femoral allografting and cemented revision
for periprosthetic femoral fractures. J Bone Joint Surg Br 2004;86(8):1124-32. https://doi.org/10.1302/0301-620x.86b8.14854
28. Li D, Hu Q, Kang P, Yang J, Zhou Z, Shen B, Pei F. Reconstructed the bone stock after femoral bone loss in
Vancouver B3 periprosthetic femoral fractures using cortical strut allograft and impacted cancellous allograft. Int
Orthop 2018 4;42(12):2787-95. https://doi.org/10.1007/s00264-018-3997-5
29. Wilson MJ, Hook S, Whitehouse SL, Timperley AJ, Gie GA. Femoral impaction bone grafting in revision hip
arthroplasty: 705 cases from the originating centre. Bone Joint J 2016;98B(12):1611-9.
https://doi.org/10.1302/0301-620X.98B12.37414
30. Ornstein E, Linder L, Ranstam J, Lewold S, Eisler T, Torper M. Femoral impaction bone grafting with the Exeter
stem - the Swedish experience: survivorship analysis of 1305 revisions performed between 1989 and 2002. J Bone
Joint Surg Br 2009;91(4):441-6. https://doi.org/10.1302/0301-620X.91B4.21319
31. Buttaro M, Comba F, Zanotti G, Piccaluga F. Fracture of the C-Stem cemented femoral component in revision hip surgery using bone impaction grafting technique: report of 9 cases. Hip Int 2015;25(2):184-7.
https://doi.org/10.5301/hipint.5000210
32. Schreurs BW, Arts JJC, Verdonschot N, Buma P, Slooff TJJH, Gardeniers JWM. Femoral component revision with
use of impaction bone-grafting and a cemented polished stem. Surgical technique. J Bone Joint Surg Am 2006;88
(Suppl 1)Pt 2:259-74. https://doi.org/10.2106/JBJS.F.00340
33. Te Stroet MAJ, Rijnen WHC, Gardeniers JWM, Schreurs BW, Hannink G. Predictors of unsuccessful outcome
in cemented femoral revisions using bone impaction grafting; Cox regression analysis of 208 cases. Hip Int
2016;26(5):444-50. https://doi.org/10.5301/hipint.5000370
34. Hassaballa M, Mehendale S, Poniatowski S, Kalantzis G, Smith E, Learmonth ID. Subsidence of the stem after
impaction bone grafting for revision hip replacement using irradiated bone. J Bone Joint Surg Br 2009;91(1):37-43. https://doi.org/10.1302/0301-620X.91B1.20376
35. Abdel MP, Lewallen DG, Berry DJ. Periprosthetic femur fractures treated with modular fluted, tapered stems. Clin Orthop Relat Res 2014;472(2):599-603. https://doi.org/10.1007/s11999-013-2936-4
36. Mulay S, Hassan T, Birtwistle S, Power R. Management of types B2 and B3 femoral periprosthetic fractures by a tapered, fluted, and distally fixed stem. J Arthroplasty 2005;20(6):751-6. https://doi.org/10.1016/j.arth.2004.11.020
37. Moreta J, Uriarte I, Ormaza A, Mosquera J, Iza K, Aguirre U, et al. Outcomes of Vancouver B2 and B3
periprosthetic femoral fractures after total hip arthroplasty in elderly patients. Hip Int 2019;29(2):184-90.
https://doi.org/10.1177/1120700018772163
Injury 2003;34(2):95-105. https://doi.org/10.1016/s0020-1383(02)00257-7
2. Meek RMD, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and
revision total hip and knee replacement. J Bone Joint Surg Br 2011;93(1):96-101. https://doi.org/10.1302/0301-620X.93B1.25087
3. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the
United States from 2005 to 2030. J Bone Joint Surg Am 2007;89(4):780-5. https://doi.org/10.2106/JBJS.F.00222
4. Tsiridis E, Spence G, Gamie Z, El Masry MA, Giannoudis PV. Grafting for periprosthetic femoral fractures: strut,
impaction or femoral replacement. Injury 2007;38(6):688-97. https://doi.org/10.1016/j.injury.2007.02.046
5. Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty 2000;15(1):59-62. https://doi.org/10.1016/s0883-5403(00)91181-1
6. Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics
of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty
2005;20(7):857-65. https://doi.org/10.1016/j.arth.2005.02.001
7. Rodriguez JA, Berliner ZP, Williams CA, Robinson J, Hepinstall MS, Cooper HJ. Management of Vancouver
type-B2 and B3 periprosthetic femoral fractures: restoring femoral length via preoperative planning and surgical
execution using a cementless, tapered, fluted stem. JBJS Essent Surg Tech 2017;7(3):e27.
https://doi.org/10.2106/JBJS.ST.17.00007
8. Garbuz DS, Toms A, Masri BA, Duncan CP. Improved outcome in femoral revision arthroplasty with tapered fluted modular titanium stems. Clin Orthop Relat Res 2006;453:199-202. https://doi.org/10.1097/01.blo.0000238875.86519.cf
9. Kwong LM, Miller AJ, Lubinus P. A modular distal fixation option for proximal bone loss in revision total hip
arthroplasty: a 2- to 6-year follow-up study. J Arthroplasty 2003;18(3 Suppl 1):94-7. https://doi.org/10.1054/arth.2003.50083
10. Van Houwelingen AP, Duncan CP, Masri BA, Greidanus NV, Garbuz DS. High survival of modular tapered stems for proximal femoral bone defects at 5 to 10 years followup. Clin Orthop Relat Res 2013;471(2):454-62.
https://doi.org/:10.1007/s11999-012-2552-8
11. Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am 2003;85(11):2156-62.
https://doi.org/10.2106/00004623-200311000-00015
12. Abdel MP, Cottino U, Mabry TM. Management of periprosthetic femoral fractures following total hip arthroplasty: a review. Int Orthop 2015;39(10):2005-10. https://doi.org/10.1007/s00264-015-2979-0
13. Khan T, Grindlay D, Ollivere BJ, Scammell BE, Manktelow ARJ, Pearson RG. A systematic review of Vancouver
B2 and B3 periprosthetic femoral fractures. Bone Joint J 2017;99-B(4 Suppl B):17-25.
https://doi.org/10.1302/0301-620X.99B4.BJJ-2016-1311.R1
14. Maury AC, Pressman A, Cayen B, Zalzal P, Backstein D, Gross A. Proximal femoral allograft treatment
of Vancouver type-B3 periprosthetic femoral fractures after total hip arthroplasty. J Bone Joint Surg Am
2006;88(5):953-8. https://doi.org/10.2106/JBJS.E.00120
15. Berry DJ. Treatment of Vancouver B3 periprosthetic femur fractures with a fluted tapered stem. Clin Orthop Relat Res 2003;(417):224-31. https://doi.org/10.1097/01.blo.0000096821.67494.f6
16. Engelbrecht E, Heinert K. Klassifikation und Behandlungsrichtlinien von Knochensubsanzverlusten bei
Revisionsoperationen am Huftgelenk mittelfrsige Ergebnisse. En: Primare und Revisionsalloarthroplastik Hrsg-
Endo-Klinik, Hamburg. Berlin: Springer-Verlag; 1987:189-201.
17. Nuñez LV, Buttaro MA, Morandi A, Pusso R, Piccaluga F. Frozen sections of samples taken intraoperatively for
diagnosis of infection in revision hip surgery. Acta Orthop 2007;78(2):226-30. https://doi.org/10.1080/17453670710013726
18. Mowe JC. Standards for tissue banking. Arlington, VA: American Association of Tissue Banks; 1988.
19. Gie GA, Linder L, Ling RS, Simon JP, Slooff TJ, Timperley AJ. Impacted cancellous allografts and cement for
revision total hip arthroplasty. J Bone Joint Surg Br 1993;75(1):14-21. https://doi.org/10.1302/0301-620X.75B1.8421012
20. Salvati EA, Sharrock NE, Westrich G, Potter HG, Valle AGD, Sculco TP. The 2007 ABJS Nicolas Andry Award:
three decades of clinical, basic, and applied research on thromboembolic disease after THA: rationale and clinical
results of a multimodal prophylaxis protocol. Clin Orthop Relat Res 2007;459:246-54.
https://doi.org/10.1097/BLO.0b013e31805b7681
21. Klein GR, Parvizi J, Rapuri V, Wolf CF, Hozack WJ, Sharkey PF, et al. Proximal femoral replacement for the
treatment of periprosthetic fractures. J Bone Joint Surg Am 2005;87(8):1777-81. https://doi.org/10.2106/JBJS.D.02420
22. Park M-S, Lim Y-J, Chung W-C, Ham D-H, Lee S-H. Management of periprosthetic femur fractures treated with
distal fixation using a modular femoral stem using an anterolateral approach. J Arthroplasty 2009;24(8):1270-6.
https://doi.org/10.1016/j.arth.2009.07.013
23. Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type femoral components: a
radiographic analysis of loosening. Clin Orthop Relat Res 1979;(141):17-27. PMID: 477100
24. Loudon JR, Charnley J. Subsidence of the femoral prosthesis in total hip replacement in relation to the design of the stem. J Bone Joint Surg Br 1980;62(4):450-3. https://doi.org/10.1302/0301-620X.62B4.7430222
25. Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res 1990;(257):107-28. PMID: 2199114
26. Richards CJ, Garbuz DS, Masri BA, Duncan CP. Vancouver type B3 periprosthetic fractures: evaluation and
treatment. Instr Course Lect 2009;58:177-81. PMID: 19385531
27. Tsiridis E, Narvani AA, Haddad FS, Timperley JA, Gie GA. Impaction femoral allografting and cemented revision
for periprosthetic femoral fractures. J Bone Joint Surg Br 2004;86(8):1124-32. https://doi.org/10.1302/0301-620x.86b8.14854
28. Li D, Hu Q, Kang P, Yang J, Zhou Z, Shen B, Pei F. Reconstructed the bone stock after femoral bone loss in
Vancouver B3 periprosthetic femoral fractures using cortical strut allograft and impacted cancellous allograft. Int
Orthop 2018 4;42(12):2787-95. https://doi.org/10.1007/s00264-018-3997-5
29. Wilson MJ, Hook S, Whitehouse SL, Timperley AJ, Gie GA. Femoral impaction bone grafting in revision hip
arthroplasty: 705 cases from the originating centre. Bone Joint J 2016;98B(12):1611-9.
https://doi.org/10.1302/0301-620X.98B12.37414
30. Ornstein E, Linder L, Ranstam J, Lewold S, Eisler T, Torper M. Femoral impaction bone grafting with the Exeter
stem - the Swedish experience: survivorship analysis of 1305 revisions performed between 1989 and 2002. J Bone
Joint Surg Br 2009;91(4):441-6. https://doi.org/10.1302/0301-620X.91B4.21319
31. Buttaro M, Comba F, Zanotti G, Piccaluga F. Fracture of the C-Stem cemented femoral component in revision hip surgery using bone impaction grafting technique: report of 9 cases. Hip Int 2015;25(2):184-7.
https://doi.org/10.5301/hipint.5000210
32. Schreurs BW, Arts JJC, Verdonschot N, Buma P, Slooff TJJH, Gardeniers JWM. Femoral component revision with
use of impaction bone-grafting and a cemented polished stem. Surgical technique. J Bone Joint Surg Am 2006;88
(Suppl 1)Pt 2:259-74. https://doi.org/10.2106/JBJS.F.00340
33. Te Stroet MAJ, Rijnen WHC, Gardeniers JWM, Schreurs BW, Hannink G. Predictors of unsuccessful outcome
in cemented femoral revisions using bone impaction grafting; Cox regression analysis of 208 cases. Hip Int
2016;26(5):444-50. https://doi.org/10.5301/hipint.5000370
34. Hassaballa M, Mehendale S, Poniatowski S, Kalantzis G, Smith E, Learmonth ID. Subsidence of the stem after
impaction bone grafting for revision hip replacement using irradiated bone. J Bone Joint Surg Br 2009;91(1):37-43. https://doi.org/10.1302/0301-620X.91B1.20376
35. Abdel MP, Lewallen DG, Berry DJ. Periprosthetic femur fractures treated with modular fluted, tapered stems. Clin Orthop Relat Res 2014;472(2):599-603. https://doi.org/10.1007/s11999-013-2936-4
36. Mulay S, Hassan T, Birtwistle S, Power R. Management of types B2 and B3 femoral periprosthetic fractures by a tapered, fluted, and distally fixed stem. J Arthroplasty 2005;20(6):751-6. https://doi.org/10.1016/j.arth.2004.11.020
37. Moreta J, Uriarte I, Ormaza A, Mosquera J, Iza K, Aguirre U, et al. Outcomes of Vancouver B2 and B3
periprosthetic femoral fractures after total hip arthroplasty in elderly patients. Hip Int 2019;29(2):184-90.
https://doi.org/10.1177/1120700018772163