Review Question - QID 5954

Figure A shows an interprosthetic femur fracture in between a total hip and total knee prosthesis. This is an example of a Vancouver C fracture best treated with a locking plate and cerclage wires with retention of components.

Periprosthetic fractures are an increasingly common problem with our increasing geriatric population and amount of joint replacement being performed on an annual basis. The Vancouver classification system has become widely accepted, mostly because of the ability to determine treatment based on fracture classification. The most important decision in pre-operative planning involves the determination of stem stability. While radiographs can give the correct diagnosis pre-operatively, intra-operative stability of the stem remains the gold-standard. For fractures below a well-fixed femoral component (Vancouver C), the best treatment is ORIF with a locking plate and cerclage wires/screws. Pre-operative history should include whether there was pain prior to the fall, which may indicate a loose stem.

Masri et al. review the evaluation and management of periprosthetic femur fractures. They stress the importance of the site of the fracture, implant stability, and remaining bone stock when determining the ultimate operative treatment. They also state that in Vancouver C interprosthetic fractures where a stemmed total knee replacement was used, the plate must span the entirety of the stem.

Figure B shows a Vancouver B3 fracture, with poor proximal bone stock. Figure C shows what appears to be a Vancouver B2 fracture based on its location and spiral pattern. This is commonly associated with a loose femoral stem. Figure D shows a Vancouver B3 fracture with massive lysis and likely poor proximal bone stock. Figure E shows a Vancouver B2 fracture.

Illustration A shows the Vancouver classification with treatment considerations for each type of fracture.

Incorrect Answers:
Answer 2: Vancouver B3 fractures may require the use of a proximal femoral replacement or proximal femoral allograft in younger patients.
Answer 3: Vancouver B2 fractures are best treated with femoral component revision and application of a plate that bypasses the distal aspect of the fracture by 2 cortical diameters.
Answer 4: Vancouver B3 fractures may require the use of a proximal femoral replacement or proximal femoral allograft in younger patients.
Answer 5: Vancouver B2 fractures are best treated with femoral stem revision that bypasses the distal aspect of the fracture by 2 cortical diameters as well as a plate to span the fracture and femoral stem.