The treatment of periprosthetic femoral fractures (PPFx) is really challenging for orthopaedic surgeon. These fractures require often senior surgeons with competence both in ORIF and RA. Also the patients itself are challenging for usually present severe comorbidities (12)(13). The treatment of PPFx has been associated with high risk of failure, poor outcomes and worst survival outcome compared to general population at one year and this item persists for five-eight years after surgery (8)(14).
The treatment goals are restoring stem stability and limb alignment, recovery of pre-fracture functional mobility and early mobilization. In B1 and C fracture types advocated standard treatment is ORIF, but in older patients it could be demanding due to weakened bone quality and potential bone loss (6)(15). Recommended treatment of B2 and B3 fractures is femoral stem revision, eventually reinforced with plating or isolated cerclage wires, using long stems with diaphyseal fixation to achieve a more stable construct. (1)(16)
In this study, a strong statistic correlation was found between the type of fracture, according to UCS Periprosthetic Fractures classification, and the surgical treatment used, conforming the main indications of treatment.
Authors evaluated the clinical outcome based on difference of Oxford Score post and pre-surgery, after RA compared to ORIF of the periprosthetic fractures. The univariate analysis showed a better clinical post-operative outcome of patients treated with prosthetic revision (B2) instead of those treated with ORIF (B1 or C); these data disagree with current literature that did not demonstrated a different functional outcome depending on treatment modality (17). To better address this topic, we performed a statistical analysis between functional outcome of ORIF in B1 or C fracture cases, with relatively similar groups, and found no significant differences (p = 0,143). Therefore, RA better outcomes are not related to abnormal indications to ORIF but relates to better functional postoperative status of patients treated with revision stems, underlying that revision, when indicated, can predict a better outcome in these fragile patients. These results are not completely aligned to literature data but are not related to ORIF technique or stem stability. (18)
Although the functional outcome is closely related with the type of surgical treatment, the multivariable analysis of this study reveals also that is influenced by the patient’s age, pre-operative Barthel Score and the CIRS score.
The level of clinical outcome, based on the Delta Oxford Score (post- and pre-operative), has a statistical relation with CIRS score, even if this correlation is not linear. The CIRS score is a questionnaire based on the various comorbidities of the patient that have a different influence on the post-operative rehabilitation and functional outcome, such as the respiratory disease compared to gastrointestinal disorders, but they all result in the same score. Consequently, Authors recorded different Delta Oxford Score in patients with same CIRS score. The association between CIRS score and Delta Oxford score is also related to the age, pre-operative Barthel score and type of fractures but does not correlate with the surgical treatment.
In literature data survival after PPFx is worse than any other cause of revision THA, like infection, aseptic loosening and dislocation. Cnudde et al (8) found that survival in the repeated surgery after THA is influenced by the reason for re-operation, and PPFx have a five-year survival rate of 54%, worse than the rates of RA for different complications. (19) Young et al. (20) analysed the functional outcome of revision for periprosthetic fractures and found that patients had poorer outcome and higher death rates compared to those undergoing revision THA for aseptic loosening. On the same side Young underline also the lower mortality rate in patient who had been operated by experienced surgeons and at larger centers.
According to literature, the patient mortality rates at one year remain high (13–17%) despite improvements in surgical and fixation techniques (15)(21). However, Bhattacharyya et al. (22) reported that one year mortality rate in patients treated for type B fractures with internal fixation was 33% while those treated with femoral stem revision experienced a 12% mortality rate. Tucker et al reported that Vancouver classification is an accurate system to choose the surgical treatment but is not correlated with the 12 months mortality rates, nor was the length of surgical procedure (23).
Stoffel et al. (18) compared the functional outcomes of patients undergoing ORIF or RA in Vancouver type B2 and B3 PPFx. Their study highlighted that ORIF could be a viable treatment option considering the type of prosthetic stem, anatomical reduction of fracture and intact cement mantle.