Management of periprosthetic fractures of the femur: a comprehensive review

Introduction

By periprosthetic fractures of the femur we mean all those fractures that occur at the level of the prosthetic femoral region; in recent decades, the increase in the number of prosthetic implants associated with the increase in the average age, has led to an increase in the number of such fractures and consequently the number of prosthetic revision surgeries has increased (1). We can distinguish periprosthetic fractures of the femur in iatrogenic and post-traumatic periprosthetic fractures; however, there are multiple factors in the development of these lesions, such as the patient’s clinical condition, type and technique of positioning the femoral stem (2). Therefore, proper management of periprosthetic fractures of the femur involves the analysis of various factors, such as factors related to the patient, the type of implant and the fracture pattern (3). The latter is determined by the type of treatment which in most cases turns out to be surgical; the literature documents the classification systems that describe the type of fracture, the possible mobilization of the stem and bone loss (4). As mentioned, such fractures occur in old age, therefore in patients suffering from various comorbidities and the management of such cases is a challenge for the orthopedic surgeon; the purpose of this article is to describe the management of periprosthetic femur fractures, from clinical evaluation of the patient to definitive treatment.

Materials and methods

The preparation of this scientific work involved the contemplation of all the scientific works regarding periprosthetic femur fractures of the last 20 years considering the epidemiology, risk factors, clinical classification, classification of the various fracture patterns, type of treatment based on the type of fracture and finally comparison of the clinical-radiographic results for each surgical technique.

Results

From an epidemiological point of view, periprosthetic fractures of the femur prefer female sex, the average age is 74 years and the 1-year mortality rate is 17.7%; these represent the third cause of total hip arthroplasty (THA) revision lesion manifesting from 0.1% to 18% of cases in first implant prostheses, in particular in 6% of cases 30 days after surgery, in 18% of cases 6 months after surgery and in 25% of cases 1 year after surgery, while in revision prostheses, periprosthetic fractures occur from 4% to 11% of cases (5,6). Risk factors can be divided into general factors and specific factors; the former are related to the patient and are: female sex, concomitant pathologies (rheumatoid arthritis, M. Paget, osteoporosis), drug therapy (corticosteroids), while the former are related to the surgical technique as a type of positioning of the femoral stem; the specific, that is related to the procedure, include the type of implant which, according to the type, the press-fit type and the varus positioning factors, the surgical risk of periprosthetic fractures; in particular, the incorrect positioning caused an altered functioning of the stem, therefore the development of “stress riser”, mobilization of the implant and consequent fractures (7-10). We can analyze periprosthetic fractures of the femur in various ways; on the basis of the time of onset, i.e., in acute and extension whose onset occurs respectively within and beyond 6 months; on the basis of the traumatic mechanism, intraoperative periprosthetic fractures attributable to the surgical procedure and post-traumatic fractures, considering the most common since they occur in about 86% of cases and arise mainly from low trauma; the most important classification that is considered in the management of periprosthetic fractures of the femur refers to the injury pattern through the Vancouver classification; this system developed by Vancouver takes into account not only the fracture site, but also the stability of the prosthetic component and the possible loss of bone tissue and is distinguished in fractures of type A, B (in turn distinguished in B1, B2 and B3) and C; the former concern fractures proximal to the femoral stem and can not determine the mobilization of the same, the latter instead occur in correspondence with the stem, therefore causing a mobilization of the implant; type B1 fractures, although involving the prosthetic bone segment, do not cause mobilization of the stem, type B2 fractures instead cause mobilization of the stem, those of type B3 are characterized by mobilization of the stem and concomitant loss of periprosthetic bone tissue; as far as type C fractures are concerned, they occur distal to the femoral stem, not causing mobilization of the same (Figure 1) (11).

Figure 1 The image represents the Vancouver’s classification: the type A concern fractures proximal to the femoral stem and can not determine the mobilization of the same, the type B regard a fracture of the bone around the stem; in particular, the type B1 fractures involving the prosthetic bone segment without mobilization of the stem, type B2 fractures instead cause mobilization of the stem, those of type B3 are characterized by mobilization of the stem and concomitant loss of periprosthetic bone tissue, the type C fractures are concerned, they occur distal to the femoral stem, not causing mobilization of the same. AG, greater trochanter fracture; AL, lesser trochanter fracture.

The type of treatment depends on the type of absence of fracture and the presence or mobilization of the stem and any loss of substance and the Vancouver classification system is still contemplated today (Figure 2). Type A fractures, acronym for apophyseal because these fractures involve the apophyseal region of the prosthetic femur, represent 4% of all periprosthetic fractures and can involve either the lesser or greater trochanter; in case of compound periprosthetic fracture, these fractures are stable, therefore the treatment is conservative consisting of functional rest, as well as load and analgesic therapy; in case of displacement greater than 2 cm, a surgical treatment of osteosynthesis with plates and screws is used (12). Type B1 fractures occur in 29% of cases, they do not involve loosening of the implant or loss of bone stock; however, they are unstable fractures and as such deserve surgical treatment through various osteosynthesis techniques such as cerclages isolated or associated with screws and plates (compression or stability), bridging plates in the case of comminuted fractures or plates with trochanteric grip (13). Fractures B2 occur in 59% of cases, and are characterized by an instability of the stem but the bone stock is still preserved, so the surgical intervention will consist in replacing the stem; The new stem will be a revision stem, having a more distal grip than the previous one, and it can be either uncemented or cemented in case of poor bone quality; the implant will then be subsequently stabilized with cerclages (14). Type B3 fractures occur in 4% of cases and represent the most serious and most difficult to treat type B fractures, as they can hide various pitfalls during the surgical procedure; they cause not only a mobilization of the stem but also a loss of bone stock; they occur in 4% of cases and surgical treatment involves replacing the femoral stem with a revision stem stabilized with cerclage and adding bone graft (15). The bone graft is used in type B3 periprosthetic fractures characterized by a mobilization of the femoral stem and a loss of bone tissue, the main characteristics of which are: restoration of the bone stock, improvement of the stability of the means of synthesis and of the femoral stem, intensification bone healing through its osteoinductive and osteoconductive properties (16). The literature highlights various types of bone grafts: autograft (whose tissue comes from the patient himself and is usually taken from the iliac crest), allografts (from cadaver, are generally larger in size, so they are used when there is a greater bone loss), we have synthetic bone and stem cells (17). Type C fractures occur in 10% of cases and being distal to the femoral stem they do not cause any loosening of the implant, so we will treat them as a normal fracture; using dedicated instruments the fracture is reduced and stabilized with the appropriate means of synthesis, i.e., a plate that is compression or stability in relation to the fracture pattern (18). As regards the prevention of periprosthetic fractures, the preventive strategies concern both the anamnestic evaluation of the patient and the surgical technique; the factors related to the patient concern any condition of osteoporosis that must be treated with a drug therapy based on vitamin C and bisphosphonates; as far as the surgical technique is concerned, the use of a cemented stem in selected patients could be appropriate, finally, periodic clinical-radiographic follow-up is of considerable importance in order to detect any loosening of the implant (19,20). As far as complications are concerned, refractures, pseudarthrosis, infections and consolidation defects are the main complications of their treatment (21).

Figure 2 The image represents the various types of treatment of the periprosthetic fractures; the surgery approach depends on the pattern of fractures and the stability of the stem.

Discussions

Periprosthetic fractures are the first complication in the field of prosthetics; the study by Pagani et al. analyzed the implants performed between 2006 and 2015 in the USA and concludes by stating that the annual incidence seems stable, but that the number of revision surgeries has increased compared to osteosynthesis (22). The retrospective study by Crutcher et al. on the other hand, it analyzes periprosthetic fractures of the hip and knee in the elderly population and the consequent economic impact in the period between 2018 and 2019; the study concludes that the higher health costs deriving from prosthetic revision interventions (23). Risk factors may determine the type and outcome of treatment for periprosthetic fractures; the meta-analysis by Bissias et al. suggested that female gender, autoimmune disease, and previous revision surgery are major risk factors for periprosthetic fractures (24). The study by Toogood et al. evaluated the frequency of periprosthetic fractures and concluded by stating that the percentage of hospitalizations for periprosthetic fractures varies from 4.2% to 7.4% per year and that the cases of periprosthetic fracture concerned elderly patients, mainly female, sometimes hospitalized in wards of emergency/urgency, longer hospital stays and death arises emergency (25). Regarding the risk factors again, Liu et al. identified six risk factors: osteoporosis, previous surgical history, type A femoral canal according to Door’s classification, insufficient level of neck osteotomy, implantation of a metaphyseal-diaphyseal socket stem, and implantation of a stem with an anteversion design (26). As for the clinical evaluation, the symptomatology must have an instrumental consideration which, however, may not dare to confirm a definitive diagnosis; in fact, according to the literature on the calculation of the stability of an implant, referring exclusively to radiographic examination, it is a complex of 20% of the still undiagnosed mobilized femoral stems (27,28). It appears that this discrepancy arises from the high failure rates following osteosynthesis of periprosthetic femoral fractures (29,30). This condition could arise from a misinterpretation of the classification systems, as Lee et al. regarding the reliability of the Vancouver classification whose reliability in press-fit hip prostheses is lower than compared to cemented stems, but is still used, despite the development of the Unified Classification System (UCS) described in 2015, which appears to be unsatisfactory for the analysis of periprosthetic fractures on polished cemented stems (31,32). Regarding the treatment, it appears to be predominantly surgical, apart from type A periprosthetic fractures which deserve a bloodless treatment only in the case of dislocations such as to cause malunion (33). With regard to type B1 fractures, Min et al. analyzed the clinical-radiographic results of 21 cases of periprosthetic fractures B1 treated surgically according to minimally invasive plate osteosynthesis (MIPO) technique by comparing them with the osteosynthesis technique on other fractures of the same type; the authors conclude that there are no statistically significant differences between the two samples analyzed, however, MIPO can be a valid option in terms of stability of the synthesis medium (34). Apivatthakakul et al. analyzed the clinical-radiographic results in patients with Vancouver fractures type B1 treated with osteosynthesis according to MIPO technique and cerclage and in the light of the results obtained, they believe that this osteosynthesis methodology can be advantageous not only for the quality and stability of the reduction, but above all in the preventive field of acute and late complications (35). In the retrospective study by Park et al., the outcomes of 27 B2 periprosthetic fractures were analyzed by internal osteosynthesis with an open technique, demonstrating satisfactory clinical-radiographic results with the average time to union was 18.3 weeks (36). The Stoffel’s research analyzed the B2 and B3 periprosthetic fractures treated according to the open reduction and internal fixation (ORIF) technique and prosthetic revision; they identified 14 studies including cases of B2 and B3 periprosthetic fractures treated both according to the ORIF technique and by prosthetic revision and concluded that the choice of treatment depends on the type of implant, fracture pattern and bone stock, but although the prosthetic revision gives excellent results in B3 periprosthetic fractures, the ORIF technique could be considered a valid choice in cases where the optimal bone stock, intact periprosthetic cement layer or stable fracture pattern (37). In the systemic review by Khan et al., 22 studies for 343 B2 and 167 B3 fractures are reviewed; the mean follow-up ranged from 32 months to 74 months, and in particular a total of 23 patients (14.4%) treated with revision arthroplasty and 2 (28.6%) treated only with internal fixation required a reoperation; the authors conclude that B2 fractures treated without stem revision were more sensitive to a higher reoperation rate, treatment of B3 fractures without stem revision resulted in a higher reoperation rate; these results show that in the management of periprosthetic fractures, a careful assessment of the fracture pattern is essential for a correct choice of surgical technique (16). In a retrospective study, Moreta et al. evaluated the treatment outcomes of 44 periprosthetic fractures (31 type B2 and 13 type B3) in patients older than 65 years; with a minimum follow-up of 2 years, a Wagner stem was used in 19 patients and a modular rectangular stem was implanted in 24 patients, fracture union was achieved in 93% of cases; as regards the clinical results, the authors obtained an average Harris Hip Score of 73 (range, 34–87), with 41.9% of patients not fully resuming normal daily activities (P=0.0049), dislocation was the most common complication (16.3%), no difference between B2 and B3 fractures or between modular and monobloc stems; the authors conclude that although there have been satisfactory results in terms of fracture healing, there has nevertheless been a high rate of complications, particularly dislocations in patients older than 64 years (38). Canton et al. evaluated the mortality rate and the results of periprosthetic fractures B2 and B3 treated respectively with the ORIF technique and prosthetic revision in old age; included 29 patients (>65 years) surgically treated for B2–B3 periprosthetic femoral fractures (PFF) at the Orthopedic and Traumatology Unit of Cattinara University Hospital in Trieste (Italy) between January 2015 and December 2019, 16 patients were treated with ORIF and 13 with revision arthroplasty (RA). Mortality and functional outcomes were analyzed. Results In-hospital (6.25% vs. 7.69%) and 3 months (6.25% vs. 15.38%) mortality was higher in the RA group. Mortality rates were particularly high in the >85-year-old patients within four months of RA treatment. One year (38.46% and 16.67%) and overall mortality (69.22% and 25%) was higher after ORIF; average time to weight-bearing and ambulation was 2.6 and 5.25 months for ORIF patients and 1.3 and 2.4 months for RA. A correlation was found between delayed weight-bearing and overall mortality; in conclusion, the age is a risk factor for short term mortality following RA. Patients >85 years of age could benefit from a less invasive procedure such as ORIF; long term outcomes are generally better for patients who undergo RA but further studies are necessary to evaluate the risk-benefit ratio of RA treatment compared to ORIF in elderly patients (39). In the retrospective study by Barghi et al., the clinical-radiographic results of B2 and B3 periprosthetic fractures in 94 patients aged over 65 were analysed, of which 75 cases (79.8%) treated according to the ORIF technique and 19 cases (20.2%) treated with stem revision; the one-year mortality rate was 26.3%, without any statistically significant in this regard and as regards complications, the RA group had a higher incidence of subsidence, as well as a higher blood loss than the ORIF group; the authors conclude that in the geriatric population, ORIF may offer as safe a treatment method as revision arthroplasty (40). Schöfl et al. analyzed the mid-term outcomes of B2/B3 periprosthetic fractures using a modular tapered and grooved stem with the mETO approach between 2007 and 2009; in particular, 80 cases were studied with an average age of 78.1 years, body mass index (BMI) 25.8 kg/m², 85.6% B2 fractures; from a clinical point of view, 38 patients recover a good gait cycle, 74 patients experience fracture consolidation in 1 year, 7 cases died in hospital, postoperative complications were 18.8% and 13.8% for periprosthetic fractures and subsidence; from these results, the authors obtained good clinical and radiological results with low complication and revision rates (41). In the retrospective study by Amenabar et al., the clinical and radiographic outcomes of 76 fractures were evaluated (66 Vancouver B2 treated with distal fixation stem and 10 cases were Vancouver B3 and a proximal femoral allograft technique was used); the mean age was 76 years with a mean follow-up of 74.4 months, and the overall five-year Kaplan-Meier survival rate for patients was 77.9% [95% confidence interval (CI): 67.4–88.4%] and at ten years it was 65.1% (95% CI: 51.4–78.8%), seven failures, mean mental SF-12 was 55.1 (range, 31–68; standard deviation, 8.1) and the physical one equal to 37.4; the authors conclude that the mortality rate in the treatment of periprosthetic fractures with prosthetic revision is higher than that of primary implant surgery and that the Kaplan-Meier analysis showed that it tends to stabilize after five years (42). In the systematic review and meta-analysis by Haider et al., the results of periprosthetic fractures B2 and B3 are compared with the ORIF technique and prosthetic revision; they believe that there are no statistically significant differences between type B2 and type B3 periprosthetic fractures in terms of weight bearing, mortality and complications, but they noted a higher rate of reoperation and subsidence on cases treated with ORIF compared to those treated with stem revision (43). In the systemic review by Stoffel et al., the results of the ORIF technique versus prosthetic revision in the treatment of B2 and B3 periprosthetic fractures are analyzed and the 14 studies highlighted show that the choice of surgical technique depends on the characteristics of the fracture, the implant and the bone; the ORIF technique may be effective in cases with optimal bone stock uncemented or tapered polished stems with an intact cement mantle, and the fracture geometry allows stable anatomical reconstruction (37). González-Martín et al. evaluated 39 B2 periprosthetic fractures between 2009 and 2019 treated with osteosynthesis in which they evaluated the clinical results, type of arthroplasty, type of stem, American Society of Anesthesiologists (ASA), Charlson Comorbidity Index (CCI), medical and implant complications, reoperation rate, mortality to the first year, radiological outcomes (time to union; mean age was 78.82 years, 35 cases ASA ≥3 and 32 CCI ≥5, fracture healing occurred in 93.5% of patients, mean score the Parker test before admission was 5.84 while the current one was 4.92 (5.16 years of follow-up); from what emerges from the study, the authors argue that internal fixation in B2 periprosthetic fractures is a valid alternative to revision surgery in patients with periprosthetic hip fracture (PPHF) V-B2, according to previous mobility, type of fracture (possible anatomical reconstruction), anesthetic risk, comorbidities, and previous hip pain (44). Malige et al. evaluated the stabilization of periprosthetic fractures with and without cerclage in 295 fractures from 2007 to 2018 (33% B1, 48.4% B2 and 18.6% B3); demographic data, fracture pattern, surgical technique, fracture union, and postoperative complications are evaluated; regarding the results, 65.9% were female, 65.6% of cases were over 71 years old, without diabetes (63.3%) or smoking history (92.2%), 69 patients (76.7%) experienced impaired fracture union, including 2 (2.2%) with delayed union and 19 (21.1%) with nonunion, no difference in union rate (P=0.98) or time to adherence (P=0.91, infection rate (P=0.81), refraction rate (P=0.87), or reoperation rate (P=0.75) across methods of fixation; the authors conclude that the majority of our patients were female (65.9%) and were over 71 years old (65.6%) without diabetes (63.3%) or smoking history (92.2%), 69 patients progressed to fracture union (76.7%), 2 (2.2%) to delayed union and 19 (21.1%) to nonunion, there was a difference in union rate (P=0.98) or merge time (P=0.91) between fixation methods, not there was no difference in infection rate (P=0.81), refraction rate (P=0.87), or reoperation rate (P=0.75) between fixation methods; the authors conclude that geriatric periprosthetic fractures of the femur result from low-energy trauma, are more prevalent in females, the Vancouver classification helps guide the surgical design used for fixation, the use of cerclage wires does not affect the bony union in these lesions (45). Maggs et al. evaluated the management of periprosthetic fractures with cemented taper-slip femoral prostheses; 87 fractures were analyzed divided according to the fixation of the periprosthetic cement and according to the healing time; in total, 47 B2W fractures (54.0%) and one B3 fracture (1.1%) had cementum that remained well fixed at the cementum-bone interface; these cases were treated with cement-in-cement (CinC) revision arthroplasty, a total of 43 fractures had fractures secondary to pseudarthrosis, for which further revision surgery was required; 19 B2L fractures (21.8%) and 19 B3 fractures (21.8%) had loose cementum at the cementum-bone interface and were treated by revision arthroplasty with cemented or uncemented femoral components, or proximal femoral arthroplasty; the authors would amend the original Vancouver system to include a sub-classification of B2 fractures around cemented femoral prostheses to include B2W (where the cement is firmly attached to the bone) and B2L (where the cement is loose), plus fractures around stems with tapered slip designs are more likely to fracture in a B2W pattern than fractures around (46). The registry-based retrospective study by Park et al. covers periprosthetic fracture cases from 2010 to 2017 in South Korea across the Health Insurance Review and Evaluation (HIRA) database; out of a total of 14,456 patients, the annual number of patients with periprosthetic fracture increased from 1,322 in 2010 to 2,636 in 2017, particularly in the age groups 70–79 and ≥80, patients were 9,752 in women and 4,704 in men during the study period, mean personal costs were $1,155.4 in women and $1,185.5 in men, total periprosthetic fracture cost increased from $779,533 in 2010 to $3,888,402 in 2017. increased from USD 589.7 in 2010 to USD 1,475.1 in 2017 and particularly in the year 2017, the number of patients with periprosthetic fracture increased exponentially after the age of 50 years, especially in women (47). A focused article search of Heu et al. used online databases of PubMed (National Library of Medicine) to analyze articles published from January 2008 to November 2021 focusing on risk factors and treatment strategies for periprosthetic fractures on cemented stems; the authors reported few reports on periprosthetic fractures on a cemented stem, but it appears that the risk of periprosthetic fractures on cemented stems is lower than on uncemented stems; from what emerges from the literature, the authors confirm the conservative treatment in periprosthetic fractures of type Ag and Al, osteosynthesis for B1 periprosthetic fractures, revision surgery and osteosynthesis for B2 and addition of bone grafts for B3 periprosthetic fractures, finally internal osteosynthesis for type C periprosthetic fractures (48). Yoon et al. believed that cementing the femoral stem in old age can prevent the finding of periprosthetic fractures; through a retrospective study, the authors evaluate the incidence and risk factors of cementless periprosthetic fractures in bipolar hemiarthroplasty in old age; the authors evaluate 1,563 (1,177 women and 386 men) who underwent cementless bipolar endoprosthesis for femoral neck fracture (1,061 patients) or intertrochanteric fracture (502 patients), the mean age was 79.6 years (range, 65–103 years) and the clinical picture and radiological evaluations were performed and Kaplan-Meier survival was analyzed; from what emerges from the study, thirty-seven PFFs (2.4%) with a mean follow-up of 44.4 months, two thirds of PFFs (67%) occurred within 1 year, in particular PFFs (22/27) were Vancouver type B and 7/9 was Vancouver type A; the incidence rate of survival was 1.7% (95% CI: 1.6–1.8%) at 12 months, 2.2% (95% CI: 2.1–2.3%) at 36 months and 3.8% (95% CI: 3.6–4.0%) at 144 months postoperatively (49).

Conclusions

From what emerges from this article, the management of periprosthetic fractures is very complex, starting from the clinical evaluation of the patient up to treatment. The clinical evaluation as we have described, is the first step to be faced and is fundamental as through the history and the physical examination we obtain information about the management of the case in question which can sometimes condition the final choice of treatment, since these traumas they occur mainly in the geriatric age. The analysis of the fracture through radiographic examination allows us to describe the fracture pattern, but also to grasp any indirect signs of stem mobilization and grasp the characteristics of the implant at the same time. Regarding the results, the literature still shows conflicting opinions regarding the management of periprosthetic fractures, in particular in the treatment of B2 and B3 fractures by means of osteosynthesis or stem revision. The Vancouver classification helps us to describe the fracture pattern, especially in the case of suspected mobilization of the stem and bone loss, but it is essential to test the stability of the implant during the surgical procedure. The management of periprosthetic fractures relates to an experienced surgery, and imposes a learning curve although each fracture pattern has a certain type of intervention as described in the literature, let us not forget that trauma surgery is a functional surgery and that therefore the type of treatment should not depend exclusively on the extent of the fracture, but also on the patient’s daily needs and comorbidities.

Acknowledgments

Funding: None.

Footnote

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