Midterm follow-up with modular fluted tapered stem in the management of Vancouver B3 femoral periprosthetic fracture

doi:10.21203/rs.3.rs-17450/v1

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Midterm follow-up with modular fluted tapered stem in the management of Vancouver B3 femoral periprosthetic fracture

https://doi.org/10.21203/rs.3.rs-17450/v1

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Background

To evaluate the technique and clinical results of the uncemented fluted, tapered, modular stems in treating Vancouver B3 periprosthetic femoral fractures.

Methods

A retrospective study was carried out on 56 patients (56 hips) with the use of the modular femoral stem in revision of total hip arthroplasty between August 2007 and January 2009. The mean patient age was 73.4±6.6 years(rang, 62-82years). Bone defect was categorised as Paprosky types：32 Type IIIA , 20 Type IIIB, 4 Type Ⅳ. 28 hips had allograft struts placed around the fracture. 44 patients had concomitant revision of the acetabular component. The mean duration of follow-up was 102.1±12.2 months (rang, 84-120 months). Hip function and treatment outcome were assessed using Harris Hip Score System and Beals and Tower 's standard. Radiography were used to evaluate the implant stability, bone stock restoration, fracture healing, stem subsidence and complications.

Results

The mean HHS improved from 45.6 ±5.4 points (range, 32-53 points) preoperatively to 86.3±8.4 points (range, 81-92 points) at the most recent follow-up. Radiographic review showed all fractures of patients united, with maintenance or improvement of bone stock in 96% of patients. The average value of the stem subsidence 4.9±1.5mm (rang, 0-9mm), happening mainly within the first six months after the operation. No implant had been revised because of aseptic loosening or dislocation. 8 of all the 28 allografts united to the host bone. In the last follow-up, 20 cases of treatment results were excellent, 36 cases were good. There were four patients occuring complications such as deep vein thrombosis of lower limbs or subcutaneous haematomas after surgery, all cured during hospitalization. There were no patients occurring the dislocation of hips after revision.

Conclusion

The uncemented fluted, tapered, modular prosthesis is a good choice with a high rate of fracture union and implant osteointegration when the treatment of the Vancouver B3 femoral periprosthetic fracture.

General Surgery

Femoral periprosthetic fracture

Stem

Surgery

Bone stock

Femoral periprosthetic fracture is the common complication after total hip arthroplasty with the incidence increasing year by year, and is the third most frequently reported cause for revisions, following infection and prosthetic aseptic loosening^[1]. In the studies of 6458 primary cemented femoral prosthetic implants, the incidence of fracture was 0.8% at 5 years, and at 10 years 3.5%^[2].

Femoral periprosthetic fracture type is the most commonly classified according to the Vancouver system^[3]. Based on this classification, the treating surgeon has several options based on fracture location, implant stability, and bone stock. Vancouver type A, type B1, type C can be treated by non-surgical or open reduction and internal fixation. If the stem is loose with good remaining bone stock, it is subcategorized as B2. Fracture reduction and fixation, coupled with longer-stem revision, is usually preferred. Finally, if in addition to a loose stem there is inadequate bone to support a straightforward revision, this is subclassified as B3. Due to complex fracture patterns, poor bone stock, osteoporosis, and altered femoral anatomy from the prior hip replacement, Vancouver type B3 fracture is the most complicated type of fracture^[^3-^5]. The prosthesis is not effectively fixed within the medullary cavity, which will easily cause prosthetic sinking and loosening after revision. In addition, the prosthetic offset and length are difficult to are controlled in revision which will lead to high risk of postoperative hip joint dislocation. Therefore, the choice of the prosthesis is the primary consideration when revision procedures.

Nowadays, a number of different femoral stem designs and reconstructive techniques have been proposed to manage type B3 fracture, including the uncemented stems with or without impaction bone grafting, the total coated-porous prosthesis, the tumour prosthesis, the cemented prosthesis and modular fluted tapered stems, but their clinical results are not identical with great arguments^[6]. The uncemented fluted, tapered, modular stem has a unique advantage in the realization of the fracture union and the long-term axial and rotational stability of implant^[7]. A few series have demonstrated the potential value of this stem, but the follow-up time was short and most investigations didn’t refer to the bone deficiency^[1,5,7]. From August 2007 and January 2009, the uncemented fluted, tapered, modular stem was used in our department to treat the 56 cases (56 hips) of Vancouver B3 femoral fracture. We wanted to determine the percentage of united fractures, bone defect restoration, the stability of the implants and whether there was a difference in outcome when allograft struts placed around the fracture.

From August 2007 and January 2009, there were 56 cases(56 hips) who underwent revision using the uncemented fluted, tapered, modular stem to treat Vancouver type B3 femoral periprosthetic fracture and all were followed up, including 16 males and 40 females. The mean age at the time of revision was 75.6±6.6 years (range , 62-82 years).

The primary diseases of hip replacement in 56 patients, there were 36 cases of femoral neck fracture (64.3%, 36/56), 12 cases (21.4%, 12/56) of femoral head avascular necrosis, 8 cases (14.3%, 8/56) of the developmental dislocation of the hip (DDH). The prosthetic types of the primary hip replacement were 36 cases (64.3%, 36/56) of the cemented prosthesis and 20 cases (35.7%, 20/56) of the cementless prosthesis. The interval time between primary hip replacement and revision was 141.9±15.9 months (range,120-163 months), all of which were the first revision. The preoperative femoral bone defects were categorized according to the Paprosky classification^[8]: type IIIA 32 cases (57.1%, 32/56), type IIIB 20 cases (35.7%, 20/56), type Ⅳ 4 cases (7.1%, 4/56).

Femoral stems included the Link MP Reconstruction stem (Waldemar Link, Hamburg, Germany; 12 patients, 21%), and icahn MR stem (icahn, Beijing, China; 44 patients, 79%). The mean stem diameter and length was 16±3 mm (range, 12-24 mm) and 210±33 mm (range, 122-310 mm), respectively. Additional fixation was used in 56 patients, including cables (5 patients, 9%); wires (51 patients, 91%); and strut allografts (28 patients, 56%). Thirty-nine hips underwent a combined acetabular and femoral revision and five hips underwent an isolated acetabular liner exchange with the femoral revision.

Patients were followed up at six weeks, three months, six months and annually. Clinical outcomes were assessed using the Harris hip score (HHS) preoperatively and at the most recent follow-up. All intraoperative or postoperative complications were also recorded, including fractures, dislocations, nerve palsies, infection, or need for subsequent surgeries. Femoral union was defined as bone bridging across the fracture site on three of four corticess on AP and lateral radiographs. Stem subsidence was measured basing on the vertical distance from the tip of the stem to steel wire cerclage position. Beals and Tower 's standard is used in the outcome of treatment: excellent, good, or poor^[11]. An excellent result was when the arthroplasty was stable and the fracture healed with minimal deformity and no shortening. A good result was when there was stable subsidence of the prosthesis or when the fracture healed with moderate deformity or shortening. A poor result was defined as a loose prosthesis, painful or not, or a nonunion, sepsis, new fracture, severe deformity, or severe shortening.

Operative technique

The posterolateral approach was used in all patients. Extract prosthesis by using revision tools. If the existing stem was not able to be

removed safely from above, the Extended Trochanteric Osteotomy(ETO) was performed to allow component or cement removal^[9]. After removal of the failed stem, the femoral canal was debrided and sequentially reamed guided by preoperative templating until a firm resistance in supportive bone was achieved. A distal stem of adequate length and the same diameter as that of the final reamer was inserted so that the stem was anchored in cortical bone for at least 5 cm or two canal diameters below the tip of the existing implant or femoral defect. Trial stems were

used to check stability and trial bodies suitable restoration of length and offset. After trialing, the definitive proximal cone body was inserted, and strut allograft were placed on the lateral side of the proximal femur if necessary. Suction drains were used in all cases. The muscular tissue and the joint capsule suture to the greater trochanter^[10](figure 1).

When drainage fluid is less than 50 ml, remove drainage tube. Antibiotic prophylaxis with a first-generation cephalosporin was used in all patients for 3 to 7 days. The Apixaban for the prevention of deep vein thrombosis. Partial progressive weight-bearing after 4 weeks and total weight bearing at least eight weeks.

All 56 patients were reviewed with follow-up of 102.1±12.2 months (rang, 84-120 months). The mean HHS improved from 45.6 ±5.4 points (range, 32-53 points) preoperatively to 86.3±8.4 points (range, 81-92 points) at the most recent follow-up. In the last follow-up, 44 cases of lateral body are free to discomfort, while the other reported occasionally slight to mild thigh pain, despite well-fixed and functioning implants. All of the patients are free to walk without help, 16 hips of which have a slight limp. After operation, 4 cases with lower extremity deep vein thrombosis recovered after the filter implantation treatment in inferior vena cava and 4 cases with subcutaneous hematoma were cured. there was no patient of dislocation, infection, allograft bone fracture. No patient required repeated femoral revision.

The average time to union for fracture of all patients was 6.2±2.5 months (3-12 months). For 28 patients with the use of cortical bone plate, adequate radiographic onlay strut allografts union and incorporation were presented in 8 patients, the other host-allograft junction nonunion were observed (figure 2). Measurable stem subsidence occurred in 52 (93%) hips. Mean subsidence measured 4.9±1.5 mm(range, 0-9 mm), occurring mainly within the first postoperatively 6 months. No one stem was considered radiologically loose. 4 cases of femoral bone stock radiologically unchanged while the rest of the patients with bone stock all have varying degrees of restoration. In the last follow-up, 20 cases of radiographic results were excellent, 36 cases were good.

Vancouver type B3 periprosthetic fracture often occurs in the late period of primary hip replacement. The challenges in treating such fractures include advanced age, the complexity of the fracture itself, poor bone stock, and altered femoral anatomy from the prior arthroplasty. Surgeons have several implant choices when managing Vancouver B3 periprosthetic fractures about the hip. The appropriate prosthesis is in favour of the fracture union and enhanced recovery after surgery. Because the femoral bone cortex defect of Vancouver type B3 fracture is segmental or penetrating, the cemented prosthesis is easy to cause bone cement outflow so as to the sinking and loosening of prosthesis or the nounion of fracture^[12]. Proximal porous coated implants with proximal bone defect is easy to prevent osseointegration which is not suitable for type B3 periprosthetic fracture. The axial and rotational stability of an uncemented, extensively porous-coated stem depends on the effective fixation in femoral shaft, which obtains the good curative effect in the application of type II and IIIA fracture but the failure rate is as high as 21% for bone defect type IIIB or type IV^[13]. The reason of failure is the serious bone defects leading to mechanical instability and retroverted deformity after femoral remodeling so that the joint is easy to occur dislocation after revision^[13]. In addition, The angle and offset of integrated prosthesis is not easy to control and will increase the risk of postoperative prosthetic dislocation. As the elastic modulus of stem is dissimilar to the host bone, there may be stress shielding of the host bone, which expresses postoperative thigh pain symptoms^[14]. Comparing with other types of prosthesis, the uncemented fluted, tapered, modular stem has many advantages. The modular stem meets the need of the distal and proximal medullary cavity respectively, which is more matched with it and realizes "individualization"^[15]. The distal prosthesis groove structure makes for intraoperative instant stability, which is convenient for patients with early activity on fields and functional exercise. The proximal stem contacts with host bone effectively and proximal porous coating can promote the ingrowth of proximal bone, getting prosthetic long-term stability. One possible complication of modular fluted tapered stems is the modular junction fracture, but the biomechanic test finds that the prosthetic joint is enough to tolerate the biological stress load^[13].

Onlay strut allograft is used to support the implant where there was severe bone deficiency, and act as biological plate, which stabilizes the fracture confirmatorily. There are 28 cases in this study using allograft bone plate and bone stock significantly restore. But at the last follow-up, 20 cases were not typically seen strut-to-host bone union, the cause of which is that the bone plate damaged the femoral blood supply and immune rejection. With the passage of time, the mechanical strength of allograft bone plate is falling, which would increase the risk of fatigue fracture. In addition, allograft bone plate will increase the operation time, trauma, the risk of infection and operation expenses. Park^[5]think whether revision procedures need bone graft depends on the initial stability of prosthesis in the medullary cavity. This emphasizes the critical surgical step of reaming an adequate taper into the distal femur to receive an appropriately sized stem. Because distal intramedullary fixation is enough to get postoperative prosthetic stability and avoid the adverse effects of bone defect^[16]. Amanatullah ^[17] reported 92 cases of paprosky type III or IV bone defect using the uncemented fluted, tapered, modular stem and clinical average follow-up time of 6.4 years (range, 2-12 years), only 1 case (1%) occurring postoperative aseptic loosening. Parry et al ^[18]previously reviewed 61 Vancouver B2 and B3 fractures treated with modular fluted tapered stems, all of which did have a trend for subsidence in those with greater femoral bone loss (Paprosky classification type 3A and 3B), but this did not reach statistical significance. Therefore, if bone stock loss don’t interfere with the stability of the prosthesis, the modular fluted tapered stems without allograft transplantation promotes the rapid recovery of the patients.

Severe femoral bone loss poses a formidable challenge for orthopedic surgeons in revision. Enough bone stock can reduce the incidence of postoperative prosthetic loosening and promote the union of fracture. Before the fracture occurring, the vast majority of patients have different degree of bone absorption and even appear prosthetic loosening. The uncemented fluted, tapered, modular stem allows surgeons to fix prosthesis in the distal part of fractures and retain bone stock of shaft. Enough bone around implants is good for the healing of fracture and long-term stability of the prosthesis. At the same time, the taper of the stem allows the load uniformly transmit between host bone and implant, and metal elastic modulus is similar to the femoral body, which avoid disuse bone atrophy and bone resorption of fracture site. Our study found that bone stock was preserved or increased in 93% of cases. According to the literature, the use of Wagner long stemmed implant can effectively fix fracture, promote healing and the restoration of proximal femoral bone^[19]. Abdel overhauled 44 hips by the uncemented fluted, tapered, modular stem, 43 patients do not appear loosening and proximal bone stock were reconstructed^[7].

Stem subsidence is a common problem after revision surgery. The uncontrolled subsidence has been regarded as a major cause for failure of uncemented revision stemsand the pain of side limb. 52 cases of nonprogressive subsidence in our investigation were detected within 6 months after surgery. The mean subsidence of the stem in our series was 4.9±1.5 mm, in accordance with previous studies on the same implant, which have reported mean subsidence 5.0 mm^[20]. However, all subsided stems stabilized with no cases of progressive aseptic loosening or stem revision. Multiple other studies have also demonstrated similar low rates of mechanical failure with these implants with subsidence occurring in 2%-17% and aseptic loosening occurring in 0%-10%^{[4,5,7,12,18,20]}. We analyzed, because of the prosthetic taper design, that early subsidence can promote better pressure distribution, reach the stability of the prosthesis. It allows for immediate full weight bearing which can be of vital importance to the geriatric patient. When bone stock restoration and bone ingrowth, sinking will no longer continue. Subsidence occurs mainly in the first six months after the surgery, without complications such as prosthetic loosening, similar to our follow-up results. Therefore, the early mild prosthetic sinking has no adverse effect on prosthetic long-term stability.

Dislocation was the most frequently encountered complication with 18% of the patients having a dislocation at one point^[2¹^]. In the 56 patients of this study, prosthetic dislocation did not occur. It is generally accepted that restoration of offset is an important surgical goal in order to prevent dislocation and achieve adequate soft tissue tension. Given the high risk of dislocation in revision hip arthroplasty, we now favor the use of large-diameter femoral heads routinely to improve intraoperative stability and range of motion.

The study is retrospective and has no control group, which has potential to introduce bias. The duration of follow-up is short, and the long-term efficacy and complications still needs further follow-up. With

regard to radiographic analysis, radiostereometric analysis was not performed to calculate precise subsidence.

The uncemented fluted, tapered, modular prosthesis for treatment of Vancouver type B3 fracture has obvious advantages, with intraoperative prosthetic instant stability, postoperative sinking achieving more stable, low dislocation rate of prosthesis. Clinical effect in midterm provides a better choice for us in treating the complicated femoral periprosthetic fracture.

DDH: Developmental dislocation of the hip; HHS: Harris hip score

Availability of data and materials

We do not wish to share our data, because some of patients data regarding individual privacy, and according to the policy of our hospital, the data could not be shared to others without permission.

Acknowledgements

Not applicable.

Authors’contributions

QC drafted the manuscript. FCZ, LZ and YZD performed data collection and data analysis. QC and FCZ conceived of the study, participated in the design of the study, performed data interpretation, and participated in coordination. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Xuzhou Third Hospital.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Midterm follow-up with modular fluted tapered stem in the management of Vancouver B3 femoral periprosthetic fracture

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