Osteosynthesis versus revision arthroplasty in Vancouver B2 periprosthetic hip fractures: a systematic review and meta-analysis.

PURPOSE: Several studies comparing osteosynthesis and stem revision in Vancouver B2 (VB2) periprosthetic hip fractures (PPHF) have been published. This work aims to be the first systematic review and meta-analysis to include only studies involving statistical comparison between the two techniques. METHODS: MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were systematically searched from inception to October 2021 for studies involving a comparison between VB2 treated by osteosynthesis versus revision arthroplasty. The effect size (ES) was calculated using Cohen´s d index. RESULTS: From 17 published studies selected, a total of 856 patients were recruited (363 osteosynthesis / 493 revision arthroplasty). The pooled ES estimates for the Parker mobility score were 1.03 (95% CI, 0.22-1.84; I2 = 87.7%) for ORIF surgery, and 0.54 (95% CI, - 0.10-1.17; I2 = 83%) for revision surgery. The pooled ES estimates for the operative time, reintervention, complications, hospital stay and needing for blood transfusion were significant lower in ORIF than in revision surgery. There were no differences in first-year mortality between groups. There was a higher proportion of ASA > 3 patients in the ORIF group. CONCLUSION: Osteosynthesis versus revision arthroplasty has a shorter operative time, less need for blood transfusion, fewer complications and reoperation rate and shorter hospital stay. Nonetheless, similar results were found for functional tests and first-year mortality. These results support the use of osteosynthesis in selected patients (low functional demand, multiple comorbidities, and high anesthetic risk). LEVEL OF EVIDENCE: III.

New Sub-Classification of Vancouver B2 Periprosthetic Hip Fractures According to Fracture Pattern.

INTRODUCTION: There is currently a debate on whether all Vancouver type B2 (V-B2) periprosthetic hip fractures (PPHF) should be revised. Vancouver classification takes into account fracture location, implant stability and bone stock, but it does not distinguish between fracture patterns. The aim of our work was to study the different fracture patterns of V-B2 PPHF and to analyze if there is any pattern that presents lower osteosynthesis failure rates. MATERIAL AND METHODS: All patients with V-B2 PPHF treated by osteosynthesis between January 2009 and January 2019 were included in the study. Using the Gruen system the proximal femur was divided into 3 zones. The lateral zone (Gruen 1±2±3), medial zone (Gruen 5±6±7), and distal zone (Gruen 4±3±5) were analysed and it was determined whether each of the 3 zones was fractured. RESULTS: 56 patients were included in the study. Their mean age was 79 years (R 45 - 92). The chosen treatment was: 39 Open reduction and internal fixation (ORIF), 10 Stem revision and 7 nonoperatively treatment. In ORIF group, no implant complications (0/24) were found in patients with a single fractured zone, while 5 implant complications (5/15) were discovered in patients with two or more fractured areas; this difference was significant (p=0.0147). All patients treated by stem revision had a fracture that involved two or more zones. In the nonoperatively group, the fracture pattern did not influence the treatment because of all of them had a very precarious functional and medical situation. CONCLUSIONS: V-B2 PPHF treated via ORIF affecting only one zone (medial, lateral, or distal) have a lower risk of complication than those affecting two or more zones. We propose a sub-classification of Vancouver B2 type fractures: B2.1 (1 fractured zone) and B2.2 (≥2 fractured zones). LEVEL OF EVIDENCE: Historical cohorts. Level III.

Periprosthetic Hip Fractures With a Loose Stem: Open Reduction and Internal Fixation Versus Stem Revision.

BACKGROUND: It is recommended revision for periprosthetic hip fractures (PPHF) with a loose stem. However, several authors have argued that under certain conditions, this fracture could be treated using osteosynthesis. The aim is to compare stem revision versus internal fixation in the treatment of PPHF with a loose stem. METHODS: All patients with PPHF with a loose stem treated by osteosynthesis and stem revision between January 2009 and January 2019 were included. We assessed hospital stay, American Society of Anesthesiologists, Charlson comorbidity index, surgery time, blood transfusion, complications, reoperation rate, first-year mortality, radiological, and functional results. RESULTS: A total of 57 patients were included (40 osteosyntheses and 17 stem revision), with an average follow-up time of 3.1 years. Their mean age was 78.47 years (R 45-92). In the osteosynthesis group, fewer patients required blood transfusion (32.5% vs. 70.6%), surgical times were shorter (108 minutes vs. 169 minutes), and the cost was lower, both in terms of total cost (€14,239.07 vs. €21,498.45 and operating room cost (€5014.63 vs. €8203.34). No significant differences were found between the groups in terms of complications, reoperation rate, or functional outcomes. CONCLUSION: Compared with stem revision, osteosynthesis requires less surgery time, has a lower need for blood transfusions, and a reduced hospital cost. Stem revision remains the treatment of choice in PPHF with a loose stem, but in V-B2 fractures in elderly patients with low functional demand, high anesthetic risk (American Society of Anesthesiologists ≥3), and many comorbidities (Charlson comorbidity index ≥5) in whom anatomic reconstruction is possible, osteosynthesis can be a viable option. EVIDENCE LEVEL: Historical cohorts. Level III.