No Survival Difference Found Between Fixation and Revision After Vancouver B Fracture
Key findings
- Choice of surgical technique (open reduction internal fixation alone, or revision arthroplasty with or without fixation) did not influence overall mortality after Vancouver B fracture
- In terms of mortality, either surgical technique was suitable for patients with Vancouver B2/3 fractures and those whose Vancouver classification was indeterminate on radiography
- Reoperation rates were similar in patients treated with fixation alone or revision arthroplasty
- At one-year after surgery, the only independent risk factor for mortality was a higher Charlson Comorbidity Index
Optimal management of Vancouver B periprosthetic femur fractures is an ongoing debate. Many surgeons advocate revision arthroplasty for loose femoral components or open reduction internal fixation for fractures surrounding well-fixed or stable femoral components. However, the patient survival rates associated with these recommendations had never been evaluated. Marilyn Heng, MD, FRCSC, orthopedic trauma surgeon, and Mitchel B. Harris, MD, chief of the Department of Orthopedic Surgery at Massachusetts General Hospital, and colleagues report in the Journal of Orthopaedic Trauma that both of these surgical techniques are acceptable with regard to survival.
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The team reviewed records on all patients who were treated for periprosthetic femur fractures at three Harvard Medical School-affiliated hospitals between 2003 and 2014. They identified 203 patients who had Vancouver B fractures, including 82 that were classified as Vancouver B1, 96 classified as Vancouver B2, and 25 classified as Vancouver B3. Of these, 110 fractures were treated with fixation alone and 93 were treated with revision arthroplasty (with or without fixation).
The primary outcome measure of the study was mortality. Overall survival was 87% at one-year and 54% at five-years. On multivariate regression analysis, only the Charlson Comorbidity Index was a significant independent risk factor for one-year mortality. The secondary outcome, the overall rate of reoperation due to infection or mechanical failure, was low at 13%.
There were no significant differences between the group that underwent fixation alone and the group that underwent revision arthroplasty with regard to one-year survival (86% vs 87%), five-year survival (51% vs 58%) or rate of reoperation (11% vs 16%).
The researchers conducted a subgroup analysis of 121 patients whose femoral components were ultimately judged to be loose (Vancouver B2/3 fractures). Of these, 35% were treated with fixation alone and 65% were treated with revision. There were no significant differences between these groups in one-year survival (83% vs 85%) or five-year survival (41% vs 58%).
It can be challenging to distinguish well-fixed from loose femoral components based on radiographs alone. In a second subgroup analysis, the researchers analyzed data on 50 patients whose radiographs were initially classified as indeterminate. Again, there were no differences in one-year and five-year survival between patients who underwent fixation alone and those who underwent revision.
From strictly a survival perspective, the researchers conclude that either fixation or revision arthroplasty is a reasonable treatment for Vancouver B periprosthetic fractures. Surgeons should use other patient-related or injury-related factors to choose between these techniques. That recommendation holds among fractures with loose femoral components and those that are difficult to classify radiographically.
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