Revision hip arthroplasty in Vancouver B2/B3 fractures—best practice in a nutshell


Although there are some recent literature suggesting that under certain special conditions, Vancouver type B2 fractures may be managed with osteosynthesis alone, it is general practice that periprosthetic femoral fractures (PPFF) with loose stems (ie, Vancouver types B2 and B3 fractures) and with either adequate or poor bone stock, should be treated with revision to achieve a better outcome and rapid recovery of the patient. 


Aims of PPFF management for Vancouver types B2 and B3 fractures

Surgical revision due to PPFF is a demanding treatment for both patients and surgeons. Revision surgery can be long and strenuous for patients who are oftentimes elderly, with high comorbidity, and have inadequate bone stock. Luigi Zagra, Head of the Hip Department, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy and Past President of the European and Italian Hip Societies, shares with us, "In revision surgery for Vancouver types B2 and B3 fractures, the management goals are, 1) to achieve safe early mobilization, 2) a pain-free hip, 3) stable fixation of the prosthesis and fracture healing in near-anatomical alignment so as to restore hip biomechanics and function, and 4) durable implant." In this article, Luigi Zagra will demonstrate how optimal revision hip arthroplasty should be performed.

Luigi Zagra

IRCCS Galeazzi Orthopaedic Institute Milan
Milan, Italy

Assessing the stem

As has been discussed in Part 2 of this series, one essential diagnosis in treating PPFF is to determine whether a stem is loose. This question often translates into, "Is the fracture Vancouver type B1 or type B2/B3?" To achieve a reasonably accurate diagnosis, it is essential to take high-quality x-rays in at least two planes at the pelvis level to determine if the stem is loose or stable. Radiolucent lines detected around the prosthesis or cement is an indication of osteolysis, stem loosening, or stem subsidence [1]. A computed tomographic (CT) scan is helpful in showing fracture pattern, extension of osteolysis, and even implant fixation. If the imaging does not offer a conclusive diagnosis of a stable stem, and during surgery implant stability is still doubtful, then a stem revision should be carried out.


Open reduction and internal fixation or revision?

There are a few recent studies suggesting that open reduction and internal fixation (ORIF) alone should be considered and in some circumstances may be more beneficial than stem revision in treating Vancouver type B2 and B3 fractures [1–3]. The justifications for this suggestion are that patients would benefit from a shorter operation, shorter anesthesia time, fewer complications, reduced operative risks, and maintain bone stock for future revisions. In addition, the operation would be less costly and technically less difficult. However, since these studies were all small and have high risk of a biased result, as well as lacking information on prognostic factors, additional supportive data will be necessary to confidently recommend ORIF over stem revision [4].

Recently, a systematic literature review of 22 studies (343 B2 and 167 B3 fractures, mean follow-up time of 32 months) showed that in Vancouver type B2 fractures, internal fixation alone is associated with a higher reoperation rate, although the increased relative risk did not reach statistical significance. In Vancouver type B3 fractures treated with internal fixation alone, two out of seven (28.6%) patients required reoperation, in comparison to 23 out of 160 (14.4%) patients that were treated with revision [5]. Summarizing the situation, Spina and Scalvi concluded that in general, revision is still the preferred method of treatment in PPFF with a loose stem. Of course, in some circumstances, such as extremely frail patients with low functional expectations or fractures of specific patterns, Vancouver B2 and B3 fractures around a loose stem could be fixed by osteosynthesis, assuming the bone stock is adequate in supporting weight bearing and that anatomical reduction can be achieved [4, 6].

Luigi Zagra advises, "When in doubt or the patient has poor bone quality, treat it as if the stem is loose and revise! One-shot surgery is advisable for these patients, moreover treatment of loose stems after plate fixation for PPFF can be extremely demanding. There is a high risk of infection due to repeated surgeries and recurrence of loosening due to devascularized bone after previous exposures and plate fixation. Dislocations due to subsidence and malunions with poor functional outcome are also frequent in such situations when the femur is fixed while the stem is loose." In addition to assisting in the assessment of stem stability, CT scans help determine the location and the extent of the fracture, the number of fragments, and the extent of osteolysis. This is information that will help the preoperative planning and determine the surgical exposure.

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  • Planning PPFF surgery
  • Watch out for infection
  • Timing of surgery
  • Choosing the correct stem
  • To cement or not to cement?
  • Cementless stems
  • Modular versus nonmodular stems
  • Take tribology into consideration when choosing the hip prosthesis
  • Fractures involving cemented stems
  • Loose stem removal and provisional reduction
  • Reaming
  • Long-stem prosthesis
  • Limb length, offset, and orientation
  • Reapproximate femur proximally
  • Conclusion: Revision hip arthroplasty

Part 1 | Risk factors in treatment of periprosthetic fractures

Part 2 | Osteosynthesis in periprosthetic fractures: Indications, tips, and tricks

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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Baochao Ji

First Affiliated Hospital of Xinjiang Medical University
Urumqi, China

Cao Li

First Affiliated Hospital of Xinjiang Medical University
Urumqi, China

Karl Stoffel

University Hospital Basel
Basel, Switzerland

Luigi Zagra

IRCCS Galeazzi Orthopaedic Institute Milan
Milan, Italy

This issue was written by Maio Chen, AO Innovation Translation Center, Clinical Science, Switzerland.



  1. Solomon LB, Hussenbocus SM, Carbone TA, et al. Is internal fixation alone advantageous in selected B2 periprosthetic fractures? ANZ journal of surgery. 2015 Mar;85(3):169–173.
  2. Quah C, Porteous M, Stephen A. Principles of managing Vancouver type B periprosthetic fractures around cemented polished tapered femoral stems. European journal of orthopaedic surgery and traumatology : orthopedie traumatologie. 2017 May;27(4):477–482.
  3. Joestl J, Hofbauer M, Lang N, et al. Locking compression plate versus revision-prosthesis for Vancouver type B2 periprosthetic femoral fractures after total hip arthroplasty. Injury. 2016 Apr;47(4):939–943.
  4. Stoffel K, Blauth M, Joeris A, et al. Fracture fixation versus revision arthroplasty in Vancouver type B2 and B3 periprosthetic femoral fractures: a systematic review. Arch Orthop Trauma Surg. 2020 Feb 21.
  5. Khan T, Grindlay D, Ollivere BJ, et al. A systematic review of Vancouver B2 and B3 periprosthetic femoral fractures. Bone Joint J. 2017 Apr;99-b(4 Supple B):17–25.
  6. Spina M, Scalvi A. Vancouver B2 periprosthetic femoral fractures: a comparative study of stem revision versus internal fixation with plate. European journal of orthopaedic surgery and traumatology : orthopedie traumatologie. 2018 Aug;28(6):1133–1142.
  7. Abdel MP, Lewallen DG, Berry DJ. Periprosthetic femur fractures treated with modular fluted, tapered stems. Clinical orthopaedics and related research. 2014 Feb;472(2):599–603.
  8. Rodriguez JA, Berliner ZP, Williams CA, et al. Management of Vancouver Type-B2 and B3 Periprosthetic Femoral Fractures: Restoring Femoral Length via Preoperative Planning and Surgical Execution Using a Cementless, Tapered, Fluted Stem. JBJS Essent Surg Tech. 2017 Sep 28;7(3):e27.
  9. Marsland D, Mears SC. A review of periprosthetic femoral fractures associated with total hip arthroplasty. Geriatr Orthop Surg Rehabil. 2012 Sep;3(3):107–120.
  10. Zagra L, Villa F, Cappelletti L, et al. Can leucocyte esterase replace frozen sections in the intraoperative diagnosis of prosthetic hip infection? Bone Joint J. 2019 Apr;101-B(4):372–377.
  11. Spina M, Rocca G, Canella A, et al. Causes of failure in periprosthetic fractures of the hip at 1- to 14-year follow-up. Injury. 2014 Dec;45 Suppl 6:S85–92.12.
  12. Bhattacharyya T, Chang D, Meigs JB, et al. Mortality after periprosthetic fracture of the femur. J Bone Joint Surg Am. 2007 Dec;89(12):2658–2662.
  13. Sellan ME, Lanting BA, Schemitsch EH, et al. Does Time to Surgery Affect Outcomes for Periprosthetic Femur Fractures? J Arthroplasty. 2018 Mar;33(3):878–881.
  14. Boddapati V, Grosso MJ, Sarpong NO, et al. Early Morbidity but Not Mortality Increases With Surgery Delayed Greater Than 24 Hours in Patients With a Periprosthetic Fracture of the Hip. J Arthroplasty. 2019 Nov;34(11):2789-2792.e2781.
  15. Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am. 2003 Nov;85(11):2156–2162.
  16. Mont MA, Maar DC. Fractures of the ipsilateral femur after hip arthroplasty. A statistical analysis of outcome based on 487 patients. J Arthroplasty. 1994 Oct;9(5):511–519.
  17. Yasen AT, Haddad FS. Periprosthetic fractures: bespoke solutions. Bone Joint J. 2014 Nov;96-b(11 Supple A):48–55.
  18. Fleischman A, Chen AF. Management of Vancouver B2 peri-prosthetic femoral fractures: following the evidence. Annals of Joint. 2016;1(4).
  19. Corten K, Macdonald SJ, McCalden RW, et al. Results of cemented femoral revisions for periprosthetic femoral fractures in the elderly. J Arthroplasty. 2012 Feb;27(2):220–225.
  20. Canbora K, Kose O, Polat A, et al. Management of Vancouver type B2 and B3 femoral periprosthetic fractures using an uncemented extensively porous-coated long femoral stem prosthesis. European journal of orthopaedic surgery and traumatology : orthopedie traumatologie. 2013 Jul;23(5):545–552.
  21. O'Shea K, Quinlan JF, Kutty S, et al. The use of uncemented extensively porous-coated femoral components in the management of Vancouver B2 and B3 periprosthetic femoral fractures. J Bone Joint Surg Br. 2005 Dec;87(12):1617–1621.
  22. Wang Q, Li D, Kang P. Uncemented extensive porous titanium-coated long femoral stem prostheses are effective in treatment of Vancouver type B2 periprosthetic femoral fractures: A retrospective mid- to long-term follow-up study. J Orthop Surg (Hong Kong). 2019 May–Aug;27(2):2309499019857653.
  23. Feng S, Zhang Y, Bao YH, et al. Comparison of modular and nonmodular tapered fluted titanium stems in femoral revision hip arthroplasty: a minimum 6-year follow-up study. Sci Rep. 2020 Aug 13;10(1):13692.
  24. Munro JT, Masri BA, Garbuz DS, et al. Tapered fluted modular titanium stems in the management of Vancouver B2 and B3 peri-prosthetic fractures. Bone Joint J. 2013 Nov;95-b(11 Suppl A):17-20.
  25. Konan S, Garbuz DS, Masri BA, et al. Non-modular tapered fluted titanium stems in hip revision surgery: gaining attention. Bone Joint J. 2014 Nov;96-b(11 Supple A):56–59.
  26. Moreta J, Uriarte I, Ormaza A, et al. Outcomes of Vancouver B2 and B3 periprosthetic femoral fractures after total hip arthroplasty in elderly patients. Hip Int. 2019 Mar;29(2):184–190.
  27. Clair AJ, Cizmic Z, Vigdorchik JM, et al. Nonmodular Stems Are a Viable Alternative to Modular Stems in Revision Total Hip Arthroplasty. J Arthroplasty. 2019 Jul;34(7s):S292-s296.
  28. Wang L, Dai Z, Wen T, et al. Three- to seven-year follow-up of a tapered modular femoral prosthesis in revision total hip arthroplasty. Arch Orthop Trauma Surg. 2013 Feb;133(2):275–281.
  29. Rajpura A, Kendoff D, Board TN. The current state of bearing surfaces in total hip replacement. Bone Joint J. 2014 Feb;96-b(2):147–156.
  30. Rieker CB. Tribology of total hip arthroplasty prostheses: What an orthopaedic surgeon should know. EFORT Open Rev. 2016 Feb;1(2):52–57.
  31. Green TR, Fisher J, Matthews JB, et al. Effect of size and dose on bone resorption activity of macrophages by in vitro clinically relevant ultra high molecular weight polyethylene particles. J Biomed Mater Res. 2000 Sep;53(5):490–497.
  32. Drummond J, Tran P, Fary C. Metal-on-Metal Hip Arthroplasty: A Review of Adverse Reactions and Patient Management. J Funct Biomater. 2015 Jun 26;6(3):486–499.
  33. Zagra L, Gallazzi E. Bearing surfaces in primary total hip arthroplasty. EFORT Open Rev. 2018 May 21;3(5):217–224.
  34. Semlitsch M, Willert HG. Clinical wear behaviour of ultra-high molecular weight polyethylene cups paired with metal and ceramic ball heads in comparison to metal-on-metal pairings of hip joint replacements. Proc Inst Mech Eng H. 1997;211(1):73–88.
  35. Lewallen DG, Berry DJ. Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instructional course lectures. 1998;47:243–249.
  36. Haddad FS, Duncan CP, Berry DJ, et al. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 2002 Jun;84(6):945–950.
  37. Tsiridis E, Spence G, Gamie Z, et al. Grafting for periprosthetic femoral fractures: strut, impaction or femoral replacement. Injury. 2007 Jun;38(6):688–697.
  38. Tsiridis E, Narvani AA, Haddad FS, et al. Impaction femoral allografting and cemented revision for periprosthetic femoral fractures. J Bone Joint Surg Br. 2004 Nov;86(8):1124–1132.
  39. Lee GC, Nelson CL, Virmani S, et al. Management of periprosthetic femur fractures with severe bone loss using impaction bone grafting technique. J Arthroplasty. 2010 Apr;25(3):405–409.
  40. Briant-Evans TW, Veeramootoo D, Tsiridis E, et al. Cement-in-cement stem revision for Vancouver type B periprosthetic femoral fractures after total hip arthroplasty. A 3-year follow-up of 23 cases. Acta Orthop. 2009 Oct;80(5):548–552.
  41. Abdel MP, Houdek MT, Watts CD, et al. Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties: a 40-year experience. Bone Joint J. 2016 Apr;98-b(4):468–474.
  42. Munro JT, Garbuz DS, Masri BA, et al. Tapered fluted titanium stems in the management of Vancouver B2 and B3 periprosthetic femoral fractures. Clinical orthopaedics and related research. 2014 Feb;472(2):590–598.
  43. Velkes S, Stoffel K. Periprosthetic fractures around the hip. In: Schutz M, Perka C, ed. Osteoporotic Fracture Care—Medical and Surgical Management. Stuttgart: Thieme; 2018. 461–478.