Is there a place for conservative treatment of a Vancouver B2 fracture around a cemented polished tapered stem?

Abstract

Revision of the unstable stem of a total hip replacement following a peri-prosthetic fracture of the femur is a complex procedure with a high complication rate.

With this study we aim to describe the radiologic findings of a specific fracture around polished tapered cemented stems and we present the results of a two- stage treatment plan for non-displaced Vancouver type B2 fractures.

Eight male patients with a cemented polished, tapered stem presented after a fall. Standard radiographs did not show any direct signs of a fracture. CT scans showed a complex burst fracture with cement mantle cracks in all cases. Partial weight bearing with 2 crutches was initiated for at least 6 weeks. A cement- in-cement revision was conducted at 3 months in case the patient was not pain free.

After 3 months of weight bearing as tolerated, none of the fractures had displaced any further, neither had the stem further subsided. Five patients were pain free and did not require surgical intervention. One patient underwent a cement-in-cement stem revision because of persistent pain.

Normal radiographs of a post-traumatic and painful polished tapered stem do not exclude a Vancouver type B2 fracture and should be followed by a CT-scan. Cement cracks, eccentric gaps and subsidence are highly suspicious signs for a non-displaced fracture pattern. Conservative treatment remains an option for these fractures and can be followed by a cement- in-cement stem revision after fracture healing, if this is still required.

Level of evidence: IV, retrospective series