Comparative outcomes of uncemented and cemented stem revision in managing periprosthetic femoral fractures: a retrospective cohort study

Axenhus et al. Journal of Orthopaedics and Traumatology (2024) 25:35 https://doi.org/10.1186/s10195-024-00777-z ORIGINAL ARTICLE Journal of Orthopaedics and Traumatology Open Access Comparative outcomes of uncemented and cemented stem revision in managing periprosthetic femoral fractures: a retrospective cohort study Michael Axenhus1* , Sebastian Mukka2, Martin Magnéli1 and Olof Sköldenberg1 Abstract Introduction Periprosthetic femoral fractures (PFFs) following hip arthroplasty, especially Vancouver B2 and B3 fractures, present a challenge due to the association with a loose femoral stem, necessitating either open reduction and internal fixation or stem revision. This study aims to compare outcomes between uncemented and cemented stem revisions in managing Vancouver B2 and B3 fractures, considering factors such as hip-related complications, reoperations, and clinical outcome. Methods A retrospective cohort study was conducted at Danderyd Hospital, Sweden, from 2008 to 2022, encompassing operatively treated Vancouver B2 and B3 fractures. Patients were categorized into uncemented and cemented stem revision groups, with data collected on complications, revision surgeries, fracture healing times, and clinical outcomes. Results A total of 241 patients were identified. Significant differences were observed between the two groups in patient demographics, with the cemented group comprising older patients and more females. Follow up ranged from 1 to 15 years. Average follow up time was 3.9 years for the cemented group and 5.5 years for the uncemented group. The cemented stems demonstrated lower rates of dislocation (8.9% versus 22.5%, P = 0.004) and stem loosening (0.6% versus 9.3%, P = 0.004) than the uncemented method. Moreover, the cemented group exhibited shorter fracture healing times (11.4 weeks versus 16.7 weeks, P = 0.034). There was no difference in clinical outcome between groups. Mortality was higher in the cemented group. Conclusions This retrospective study indicates that cemented stem revision for Vancouver B2–3 fractures is correlated with lower dislocation and stem loosening rates, necessitating fewer reoperations and shorter fracture healing times compared with the uncemented approach. The cemented group had a notably higher mortality rate, urging caution in its clinical interpretation. Level of evidence III Keywords Arthroplasty, Femoral fractures, Revision surgery, Stem fixation, Vancouver classification *Correspondence: Michael Axenhus 1 Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm, Sweden 2 Department of Diagnostics and Intervention (Orthopaedics), Umeå University, Umeå, Sweden © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Axenhus et al. Journal of Orthopaedics and Traumatology (2024) 25:35 Introduction Periprosthetic femoral fractures (PFFs) following hip arthroplasty present a significant challenge in orthopedics and are becoming increasingly common due to the number of primary and revision total hip arthroplasties being performed [1, 2]. The Vancouver classification system categorizes periprosthetic fractures around hip implants into four types (A, B, and C) based on fracture location and extent relative to the implant, aiding surgeons in treatment decisions [3]. Vancouver B2–3 fractures pose a distinct challenge, as they are associated with a loose femoral stem, indicating inherent instability that frequently requires more than fracture stabilization alone [4]. Addressing these fractures involves choosing between open reduction and internal fixation (ORIF) or stem revision. The management of Vancouver B2–3 fractures often leaned toward stem revision, aiming to restore biomechanical stability, which can be performed using uncemented or cemented techniques. Cemented stem revision could entail higher risks of systemic complications, including bone cement implantation syndrome [5, 6]. On the other hand, uncemented stem revision requires a prosthetic stem designed to allow bone growth for long-term fixation [7]. While this method might reduce the risk of cementrelated complications, achieving immediate stability can be challenging, potentially leading to increased risks of fracture displacement or subsidence [8]. The comparative effectiveness of uncemented versus cemented stem revision in treating PFFs is inadequately explored, and management paradigms are changing [9, 10]. The potential risks associated with stem revision necessitate a comprehensive evaluation of the treatment outcomes associated with both methods [11]. This study aims to evaluate clinical outcomes, including mortality, between uncemented and cemented stem revision in the treatment of Vancouver B2 and B3 PFF. Methods Study design and setting This retrospective cohort study was conducted at the Orthopedic Department of Danderyd Hospital in Stockholm, Sweden, spanning from 2008 to 2022. Danderyd Hospital, affiliated with the Karolinska Institute, serves approximately 800,000 inhabitants. Data were collected using REDCap electronic data capture tools until September 2023, with a minimum 1-year follow-up postsurgery [12]. Ethical approval was obtained, and the study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology Page 2 of 9 (STROBE) guidelines for reporting observational cohorts [13]. Participants Patients were identified from the local surgical planning system, medical records, and the Swedish Arthroplasty register. The study encompassed a consecutive series of all surgically treated periprosthetic Vancouver B2–3 fractures. Patient flow and baseline data A total of 241 patients were identified during the study period (Fig. 1). The cemented group was older, had fewer females, and were less cognitive intact. There was no difference in Vancouver class (Table 1). Surgery The stability of all stems was assessed preoperatively and classified as Vancouver B1 fractures if deemed stable and ineligible for the study or B2/B3 fractures with loose stem. Procedures were performed by 1 of 19 experienced consultant orthopedic surgeons specializing in traumatology or hip arthr (...truncated)