Effectiveness of operative interventions in individuals with a hemi or total hip arthroplasty who sustain a Vancouver B2 peri-prosthetic femoral fracture

Abstract

Hip arthroplasty is a commonly performed orthopaedic intervention employed in the management of various hip pathologies. Australian registry data indicate that over 42,000 primary hip arthroplasties including a stemmed femoral prosthesis were performed during 2016 (Australian Orthopaedic Association 2017). Post-operative peri-prosthetic femur fractures (PFFs) around hip arthroplasties have an incidence around 0.4% to 4% and although infrequent, are a significant complication imparting a heavy burden upon patient, orthopaedic surgeon and the health care system, costing on average around AUD 40,000 per patient, per fracture to manage (Phillips, Boulton et al. 2011). The Vancouver classification system, devised by Brady and colleagues is the most commonly utilised system for classifying PFFs, with Type B fractures occuring at the level of or just below the femoral stem, further subdivided according to stem stability and bone stock, with our study population, type B2 exhibiting an unstable stem with preserved proximal bone stock (Brady, Garbuz et al. 1999). Although revision arthroplasty is currently recommended for management of Vancouver Type B2 PFFs, open reduction internal fixation (ORIF) has been shown in some small studies to yield similar outcomes when compared to revision. If selected Vancouver type B2 fractures were shown to be amenable to ORIF alone rather than revision, it would be beneficial given that much intra-operative risk would be mitigated by way of shorter operative times, and a reduction in skill set demands upon the surgeon, reduce implant costs, and allow for subsequent revision in arthroplasty in younger individuals. The objective of this thesis was to identify the effectiveness of operative interventions for individuals who have undergone a hemi or total hip arthroplasty who sustain a Vancouver type B2 peri-prosthetic femoral fracture or equivalent, by conducting a systematic review. Specifically, the review investigated open reduction and internal fixation and femoral revision arthroplasty with or without internal fixation. Unpublished and published studies across PubMed Medline, EMBASE, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, ClinicalTrials.gov and Proquest Theses and Dissertations were considered for the systematic review. We assessed both experimental and observational studies written in English from 1990 or later, which reported on five or more Vancouver B2 periprosthetic fractures and assessed at least one outcome of interest, including intra-operative (e.g. surgical time, bleeding), radiographic (e.g. subsidence), clinical (e.g. union, mortality, parker mobility) and patient reported outcomes (e.g. functional status and health-related quality of life). The quality assessment of the papers was performed by two independent reviewers using standardised critical appraisal instruments according to the study design from the Joanna Briggs Institute. The critical appraisal was compared and in case of disagreement a third reviewer’s opinion was sought for further discussion. Data was extracted from papers included in the review using the standardised data extraction tool from the JBI-System for the Unified Management, Assessment and Review of Information (SUMARI). From the electronic searches, 1805 potential articles were found, of which 860 duplicates were removed. In the first screening, 213 studies were selected for full text reading. The reference lists of these articles revealed another 45 articles, and a total of 258 studies were selected for full-text reading. After the evaluation, 37 studies were finally included in the systematic review. There were 27 retrospective case series and 10 retrospective cohort studies, which together evaluated outcomes of 926 Vancouver B2 fracture cases. With regards to the intervention, 25 studies evaluated revision with or without wires, cables or cerclage, while three studies investigated revision plus ORIF with plate. There were three studies that analysed revision and cortical strut allografts. There were 11 studies that evaluated revision with mixed methods or without specifying the revision technique. Ten studies assessed ORIF with plate. Two studies evaluated ORIF with wires, cerclage or cables. Three studies evaluated ORIF with mixed methods or without specifying ORIF technique. One study evaluated a non-operative intervention. Among the 37 included studies, 24 papers evaluated one intervention of interest, six articles included two interventions, five studies included three interventions and two studies investigated four interventions of interest. Comparative meta-analysis revealed small differences between management strategies across different outcomes. While the surgical time was shorter and the transfusion requirement was less for ORIF with plate vs Revision +/- wires, cerclage and cables, pre and post-operative parker mobility scores, subsidence, union, mortality, dislocation and infection rates were similar. Regarding Revision via any method vs ORIF any method, union, malunion and infection rates were similar, however, mortality rates were lower for ORIF and re-operation rates were lower for revision. Overall, no management strategies have been shown to be consistently superior for the outcomes included in this systematic review and meta-analysis.