
==== Front
Arthroplast Today
Arthroplast Today
Arthroplasty Today
2352-3441
Elsevier

S2352-3441(24)00113-4
10.1016/j.artd.2024.101428
101428
Original Research
Who Is Treating Periprosthetic Femur Fractures? An Analysis of the Periprosthetic Research Consortium
Pohl Nicholas B. MS nickbpohl@gmail.com
a∗
Saxena Arjun MD, MBA a
Stambough Jeffrey B. MD b
Martin John Ryan MD c
Mears Simon C. MD, PhD d
Periprosthetic Research ConsortiumJordan Eric BS
Egan Cameron R. MD
Chen Antonia F. MD, MBA
Erens Greg A. MD
Chabib Samir MD
Wall Bryce MD
Fernando Navin D. MD
Nichols Jordan MD
Schwarzkopf Ran MD, MSc
Lygrisse Katherine A. MD
Amanatullah Derek F. MD, PhD
Arora Prerna MTech
Ivanov David MD
Loughran Galvin
Browne James MD
Hogarth Danielle BS
Hudson Parke MD
Donaldson Thomas K. MD
Buttacavoli Frank MD
Kari Ravi MD
Mills Galen MD
1
Lichstein Paul M. MD, MS e
a Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
b Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
c Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN, USA
d Department of Orthopaedic Surgery, University of Florida, Gainsville, FL, USA
e Novant Health Orthopaedics and Sports Medicine, Brigham and Women’s Hospital, Salisbury, NC, USA
∗ Corresponding author. Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA. Tel.: +1 267 339 7864. nickbpohl@gmail.com
1 Periprosthetic Research Consortium: Eric Jordan, BS, fBrigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA, USA; Cameron R. Egan, MD, fBrigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA, USA; Antonia F. Chen, MD, MBA, fBrigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA, USA; Greg A. Erens, MD, gEmory University, Department of Orthopaedic Surgery, Atlanta, GA, USA; Samir Chabib, MD, gEmory University, Department of Orthopaedic Surgery, Atlanta, GA, USA; Bryce Wall, MD, cVanderbilt University, Department of Orthopaedic Surgery, Nashville, TN, USA; Navin D. Fernando, MD, hUniversity of Washington, Department of Orthopaedic Surgery, Seattle, WA, USA; Jordan Nichols, MD, hUniversity of Washington, Department of Orthopaedic Surgery, Seattle, WA, USA; Ran Schwarzkopf, MD, MSc, iNew York University Hospital for Joint Diseases, Department of Orthopaedic Surgery, New York, NY, USA; Katherine A. Lygrisse, MD, iNew York University Hospital for Joint Diseases, Department of Orthopaedic Surgery, New York, NY, USA; Derek F. Amanatullah, MD, PhD, jStanford University, Department of Orthopaedic Surgery, Redwood City, CA, USA; Prerna Arora, M. Tech, jStanford University, Department of Orthopaedic Surgery, Redwood City, CA, USA; David Ivanov, MD, jStanford University, Department of Orthopaedic Surgery, Redwood City, CA, USA; Galvin Loughran, jStanford University, Department of Orthopaedic Surgery, Redwood City, CA, USA; James Browne, MD, kUniversity of Virginia, Department of Orthopaedic Surgery, Charlottesville, VA, USA; Danielle Hogarth, BS, kUniversity of Virginia, Department of Orthopaedic Surgery, Charlottesville, VA, USA; Parke Hudson, MD, kUniversity of Virginia, Department of Orthopaedic Surgery, Charlottesville, VA, USA; Thomas K. Donaldson, MD, lLoma Linda University Health, Department of Orthopaedic Surgery, Loma Linda, CA, USA; Frank Buttacavoli, MD, mUniversity of Texas Health San Antonio, Department of Orthopaedic Surgery, San Antonio, TX, USA; Ravi Kari, MD, mUniversity of Texas Health San Antonio, Department of Orthopaedic Surgery, San Antonio, TX, USA; Galen Mills, MD, mUniversity of Texas Health San Antonio, Department of Orthopaedic Surgery, San Antonio, TX, USA.

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© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Periprosthetic femur fractures (PPFFs) following total hip arthroplasty (THA) have increased in the past decade as the demand for primary surgery continues to grow. Although there is now more evidence to describe the treatment of Vancouver B fractures, there is still limited knowledge regarding factors that cause surgeons to perform either an open reduction and internal fixation (ORIF) or revision THA (rTHA). The purpose of this study was to determine what type of surgeons treat Vancouver B PPFFs at 11 major academic institutions and if there are trends in treatment decision-making regarding the use of ORIF or rTHA based on surgical training or patient factors.

Methods

This multicenter retrospective study evaluated patients surgically treated for Vancouver B PPFF after THA between 2014 and 2019. Patients from 11 academic centers located in the United States were included in this study. Surgical outcomes and patient demographics were evaluated based on surgeon training, surgical treatment type, and institution.

Results

Presence of Vancouver B2 (odds ratio [OR]: 0.02, P < .001) or B3 (OR: 0.04, P < .001) fractures were independent risk factors for treatment with rTHA. Treatment by a trauma (OR: 12.49, P < .001) or other-specified surgeon (OR: 13.63, P < .001) were independent risk factors for ORIF repair of Vancouver B fractures. There were no differences in outcomes based on surgeon subspecialty training.

Conclusions

This study showed the trends in surgeons who surgically manage Vancouver B fractures at 11 major academic institutions and highlighted that regardless of surgical training or surgical treatment type, postoperative outcomes following management of PPFF were similar.

Keywords

Periprosthetic femur fracture
Arthroplasty
Open reduction internal fixation
Revision total hip arthroplasty
Surgical training
==== Body
pmcIntroduction

Periprosthetic femur fractures (PPFFs) are a rare complication of total hip arthroplasty (THA) that have increased in the past decade as the demand for primary surgery continues to grow [1,2]. Previous research has postulated that the increase in PPFF may be due to the expanded indications for THA in younger and older patients as well as an increase in life expectancy, leading to more primary THA being performed in osteoporotic patients [3,4]. PPFF is 1 of the most serious complications of THA, with a previously reported incidence range of 1%-11% and a mortality of 11% [1,5]. In particular, the proportions of Vancouver B1, B2, and B3 fractures among PPFFs have been documented as 14.5%, 24.5%, and 9.2%, respectively [6].

Management of PPFFs frequently includes surgical intervention, and treatment strategy is most often determined based on the validated Vancouver classification system [7,8]. Specifically, Vancouver B fractures have been historically treated with open reduction and internal fixation (ORIF) to ensure stabilization or revision total hip arthroplasty (rTHA), which have been shown to improve mortality rates [9]. The use of ORIF and rTHA and surgical outcomes for Vancouver B subcategory fractures have been evaluated at several single institutions [10,11] and more recently by the Periprosthetic Research Consortium [12]. Further recommendations for the subcategories of Vancouver B fractures have been proposed [13]. However, adherence to these recommendations may differ among surgeons due to their training background and the hospital setting where PPFFs are treated. Surgical management historically has been performed by arthroplasty or trauma orthopaedic surgeons; however, there are no specified guidelines as to the allocation of treatment based on surgical training [14].

Previously, the Periprosthetic Research Consortium established a database with the collaboration of 11 centers in the United States to study the differences in reoperations after Vancouver B PPFF based on fracture characteristics, surgical treatment, and surgeon training. Specifically, the consortium found that patients with Vancouver B type and B3 subtype PPFFs who were treated by a non-arthroplasty-trained surgeon tended to have a higher risk of reoperation. Additionally, the use of ORIF or rTHA did not lead to an increased risk of reoperation [12].

Although there is now more evidence to describe the treatment of Vancouver B fractures, there is still limited knowledge regarding factors that cause surgeons to perform either an ORIF or rTHA. Additionally, information regarding whether PPFFs are predominantly treated by trauma or arthroplasty-trained surgeons at the institution or regional level is unknown. The purpose of this study was to (1) determine what type of surgeons treat Vancouver B PPFFs at 11 major academic institutions as well as (2) determine if there are trends in treatment decision-making regarding the use of ORIF or rTHA based on surgical training or patient factors.

Material and methods

This is a multicenter retrospective review of adult patients (>18 years old) who underwent treatment for PPFF after THA between 2014 and 2019. Patients from 11 academic centers located in the United States were included in this study. Institutional review board approval was obtained at each center prior to the commencement of this retrospective review. Patients were excluded if their postoperative follow-up was less than 6 months, unless they underwent a reoperation prior to 6 months of follow-up.

At each participating institution, patient demographics, surgical characteristics, postoperative outcome measurements, the number of surgeons treating PPFFs, and surgeon fellowship training were collected. Of the 11 centers included in this study, 3 were regionally located in the Northeast (Centers 1, 2, and 4), 5 were located in the South (Centers 3, 6, 7, 8, and 11), and 3 were located in the West region of the United States (Centers 5, 9, and 10). Six hundred one PPFFs were included in this study from the participating 11 institutions. Of those patients with fractures, 343 had 6 months of follow-up and were classified as Vancouver B fractures based on radiographic imaging review. Of patients with Vancouver B fractures, median ages between centers ranged from 69 to 82 years, and all centers had a higher proportion of females than males (Table 1).Table 1 Center-specific information regarding demographics, Vancouver B periprosthetic fracture classification, and treatment by arthroplasty, trauma, or other orthopaedic surgeons.

Variable	Center 1 (N = 41)	Center 2 (N = 40)	Center 3 (N = 11)	Center 4 (N = 41)	Center 5 (N = 18)	Center 6 (N = 32)	Center 7 (N = 5)	Center 8 (N = 16)	Center 9 (N = 63)	Center 10 (N = 22)	Center 11 (N = 54)	
Arthroplasty	38 (92.7%)	33 (82.5%)	9 (81.8%)	30 (73.2%)	10 (55.6%)	30 (93.8%)	2 (40.0%)	16 (100%)	39 (61.9%)	17 (77.3%)	39 (72.2%)	
Other	3 (7.30%)	5 (12.5%)	2 (18.2%)	0 (0.00%)	0 (0.00%)	0 (0.00%)	1 (20.0%)	0 (0.00%)	7 (11.1%)	3 (13.6%)	15 (27.8%)	
Orthopaedic trauma	0 (0.00%)	2 (5.00%)	0 (0.00%)	11 (26.8%)	8 (44.4%)	2 (6.2%)	2 (40.0 %)	0 (0.00%)	17 (27.0%)	2 (9.10%)	0 (0.00%)	
Age	69.1 (11.1)	74.8 (10.6)	69.8 (14.7)	72.9 (10.5)	70.7 (10.2)	72.2 (10.7)	45.4 (15.4)	80.2 (10.0)	77.1 (13.0)	72.4 (20.9)	74.6 (10.6)	
Sex: female	31 (75.6%)	31 (77.5%)	6 (54.5%)	25 (61.0%)	14 (77.8%)	22 (68.8%)	4 (80.0%)	10 (62.5%)	36 (57.1%)	13 (59.1%)	43 (79.6%)	
BMI	27.4 (6.51)	28.0 (5.18)	26.1 (5.57)	29.7 (5.75)	28.4 (6.58)	29.1 (6.42)	24.7 (1.95)	25.9 (8.45)	27.0 (5.69)	27.6 (5.98)	28.7 (6.89)	
Smoking:												
 Nonsmoker	18 (43.9%)	38 (95.0%)	11 (100%)	38 (92.7%)	15 (83.3%)	23 (71.9%)	3 (60.0%)	16 (100%)	57 (90.5%)	20 (90.9%)	49 (90.7%)	
 Smoker	23 (56.1%)	2 (5.00%)	0 (0.00%)	3 (7.32%)	3 (16.7%)	9 (28.1%)	2 (40.0%)	0 (0.00%)	6 (9.52%)	2 (9.09%)	5 (9.26%)	
CKD	1 (2.44%)	3 (7.50%)	1 (9.09%)	7 (17.1%)	2 (11.1%)	2 (6.25%)	0 (0.00%)	1 (6.25%)	13 (20.6%)	2 (9.09%)	14 (25.9%)	
PVD	3 (7.32%)	4 (10.0%)	2 (18.2%)	3 (7.32%)	1 (5.56%)	1 (3.12%)	2 (40.0%)	1 (6.25%)	13 (20.6%)	3 (13.6%)	9 (16.7%)	
Diabetes	2 (4.88%)	3 (7.50%)	2 (18.2%)	8 (19.5%)	2 (11.1%)	5 (15.6%)	2 (40.0%)	3 (18.8%)	16 (25.4%)	3 (13.6%)	16 (29.6%)	
Vancouver:												
 B1	1 (2.44%)	4 (10.0%)	1 (9.09%)	9 (22.0%)	5 (27.8%)	7 (21.9%)	3 (60.0%)	3 (18.8%)	19 (30.2%)	7 (31.8%)	6 (11.1%)	
 B2	40 (97.6%)	35 (87.5%)	10 (90.9%)	29 (70.7%)	12 (66.7%)	21 (65.6%)	2 (40.0%)	9 (56.2%)	39 (61.9%)	13 (59.1%)	48 (88.9%)	
 B3	0 (0.00%)	1 (2.50%)	0 (0.00%)	3 (7.32%)	1 (5.56%)	4 (12.5%)	0 (0.00%)	4 (25.0%)	5 (7.94%)	2 (9.09%)	0 (0.00%)	
Cement-primary	1 (2.44%)	3 (7.69%)	2 (18.2%)	1 (2.44%)	3 (16.7%)	0 (0.00%)	0 (0.00%)	6 (37.5%)	0 (0.00%)	0 (0.00%)	3 (5.56%)	
Data are presented as N (%).

CKD, chronic kidney disease; PVD, peripheral vascular disease.

Regionally, 122 fractures were treated at northeastern centers, 118 were treated at southern centers, and 103 were treated at western centers. Of the Vancouver B fractures treated at northeastern centers, 82.8% were treated by an arthroplasty surgeon, while 81.4% and 64.1% fractures were treated by arthroplasty surgeons at southern and western centers, respectively. The highest proportion of patients receiving treatment by an arthroplasty surgeon at 1 center was 100%, while the highest proportion of patients receiving treatment by an orthopaedic trauma surgeon at 1 center was 44.4% (Table 1). Only 7 of the 11 centers had a Vancouver B3 fracture in their cohort. Across all centers, 105 surgeons were identified who treat PPFFs, of which 51.4% were arthroplasty surgeons, 40.9% were trauma surgeons, and 7.6% were other-trained surgeons. The majority of northeast and southern surgeons who treated PPFFs were arthroplasty-trained (55.1% and 55.2%, respectively), while western surgeons were primarily trauma-trained (Fig. 1). Across all centers, the average age of arthroplasty surgeons was 46.9 years, while the average age of trauma surgeons was 42.6 years. Additionally, the average years of experience of arthroplasty and trauma surgeons were 15.3 and 10.3 years, respectively.Figure 1 Vancouver B fractures and surgeon training by geographic region.

Collected patient demographic data included age, sex, body mass index (BMI), smoking status, chronic kidney disease, peripheral vascular disease, diabetes mellitus, and preinjury ambulatory status. Data pertaining to surgical characteristics included the use of cementation vs press-fit during the primary THA. Outcome measurements included reoperation, nonunion, malunion, infection, instability, and postoperative ambulatory status following primary THA.

Surgical treatment types as well as outcomes of PPFF were also collected from participating centers. Treatment type was categorized as nonsurgical, ORIF, or rTHA with or without ORIF. Similar to Toci et al., revision arthroplasty with internal fixation components were considered to be rTHA, while surgical treatment with plate, screw, and/or cerclage cable fixation with no revision of the femoral stem component was considered ORIF [12]. Additionally, orthopaedic surgeons at each institution reviewed radiographic images prior to ORIF, rTHA, or nonsurgical treatment to classify each PPFF based on the Vancouver scale (A, B1, B2, B3, or C) [15,16].

To assess the influence of surgical training on PPFF treatment, surgeons were classified as arthroplasty, orthopaedic trauma, or other. An arthroplasty specialist was defined as a surgeon who completed an adult reconstruction fellowship or routinely performed more than 200 total joint arthroplasties per year [12]. Orthopaedic trauma specialists were defined as surgeons who completed an orthopaedic trauma fellowship. If a surgeon completed both an orthopaedic trauma and adult reconstruction fellowship, they were considered to be an arthroplasty surgeon for the purposes of this study, as all these surgeons performed at least 200 TJAs per year. Of the 11 centers included, 10 reported having at least 1 trauma surgeon who treats PPFFs. The 10 centers also described their protocol, which involved the trauma team directing PPFF patients to the subspecialty/subspecialist selected by the trauma team, with 1 center permitting the on-call physician to refer the patient to the subspecialty/subspecialist chosen by the on-call physician.

Surgeon fellowship training information was evaluated collectively as well as at the individual center level. Subgroup analysis for outcome measurements and surgical characteristics was performed for patients who underwent ORIF or rTHA after primary THA. Additionally, analysis was also performed to evaluate surgical characteristics for patients treated by arthroplasty, trauma, or other orthopaedic surgeons. Multivariate logistic regression analyses were performed for patients with Vancouver B fractures undergoing ORIF as opposed to rTHA for reoperation. Independent variables used in the multivariate logistic regression analyses included surgeon type (arthroplasty, trauma, or other) and patient demographics (age, sex, BMI, smoking status [current or nonsmoker], chronic kidney disease, peripheral vascular disease, and diabetes status). A P value of < .05 was considered statistically significant for all statistical analyses. All analyses were performed using RStudio Version 4.0.2 (Boston, MA).

Results

Surgeon training

Patients operated on by trauma surgeons were the oldest (79.0 vs 73.0 for arthroplasty and 71.5 for others, P = .035). Arthroplasty surgeons performed the highest rate of rTHA (89.0% vs 36.4% for trauma specialists and 58.3% for others, P < .001), and orthopaedic trauma surgeons operated on the highest proportion of Vancouver B1 PPFFs (50.0% vs 13.3% for arthroplasty and 22.2% for others, P < .001). There was not a significant difference in outcomes such as rate of reoperation, nonunion, malunion, infection, instability, or postoperative ambulatory status based on surgeon subspecialty training (Table 2).Table 2 Surgical characteristics based on surgeon training.

Variable	Arthroplasty	Other	Trauma	P-value	
n = 263	n = 36	n = 44	
Treatment:				<.001a	
 ORIF	29 (11.0%)	15 (41.7%)	28 (63.6%)		
 Revision THA	234 (89.0%)	21 (58.3%)	16 (36.4%)		
Vancouver:				<.001a	
 B1	35 (13.3%)	8 (22.2%)	22 (50.0%)		
 B2	212 (80.6%)	28 (77.8%)	18 (40.9%)		
 B3	16 (6.08%)	0 (0.00%)	4 (9.09%)		
Cemented primary:	14 (7.25%)	2 (6.90%)	3 (12.0%)	.570	
Reoperation:	50 (19.0%)	9 (25.0%)	14 (31.8%)	.134	
Nonunion:	14 (6.33%)	4 (11.1%)	3 (8.57%)	.463	
Malunion:	14 (6.33%)	4 (11.1%)	3 (8.57%)	.505	
Infection:	23 (10.3%)	5 (13.9%)	5 (14.3%)	.631	
Instability:	22 (9.69%)	2 (5.56%)	4 (11.4%)	.659	
Ambulatory at 3 months postoperatively:	214 (89.9%)	29 (82.9%)	31 (86.1%)	.341	
Ambulatory at 6 months postoperatively:	207 (95.4%)	29 (96.7%)	28 (93.3%)	.872	
a Indicates statistical significance (P < .05). Data are presented as N (%).

Treatment type

Of 343 Vancouver B PPFFs treated operatively, 72 (21.0%) were treated with ORIF alone, while 271 (79.0%) were treated with rTHA with or without ORIF. Patients who underwent rTHA were most often performed by an arthroplasty surgeon (86.3%) in comparison to only 40.3% of ORIF surgeries (P < .001). Additionally, Vancouver B2 fractures were more commonly treated with rTHA (88.2%), while B1 fractures were treated with ORIF (69.4%, P < .001). There were no other significant differences in demographics between Vancouver B fracture patients who received surgical repair with either rTHA or ORIF. (Table 3). There was a higher rate of instability in the rTHA group (11.3% vs 1.67%, P = .041) and a higher rate of nonunion in the ORIF group (15.0% vs 5.17%, P = .020). Those treated with rTHA were more likely to be ambulatory at the 3-month postoperative timepoint (92.7% vs 73.4%, P < .001). There was not a significant difference in reoperation rate based on treatment type (Table 4).Table 3 Surgical treatment characteristics.

Variable	Total data	Revision THA	ORIF	P-value	
N = 343	N = 271	N = 72	
Age:	73.3 (12.8)	73.1 (11.5)	74.0 (16.8)	.156	
Sex:				.961	
 Female	235 (68.5%)	185 (68.3%)	50 (69.4%)		
 Male	108 (31.5%)	86 (31.7%)	22 (30.6%)		
BMI (range)	27.9 (6.22)	28.1 (6.39)	27.2 (5.49)	.305	
Smoking status:				.987	
 No	288 (84.0%)	227 (83.8%)	61 (84.7%)		
 Yes	55 (16.0%)	44 (16.2%)	11 (15.3%)		
CKD:	46 (13.4%)	34 (12.5%)	12 (16.7%)	.473	
PVD:	42 (12.2%)	32 (11.8%)	10 (13.9%)	.782	
Diabetes:	62 (18.1%)	45 (16.6%)	17 (23.6%)	.230	
Data are presented as N (standard deviation) and N (%).

CKD, chronic kidney disease; PVD, peripheral vascular disease.

Table 4 Surgical characteristics based on treatment type.

Variable	ORIF	Revision THA	P-value	
N = 72	N = 271	
Surgeon type:			<.001a	
 Arthroplasty	29 (40.3%)	234 (86.3%)		
 Other	15 (20.8%)	21 (7.75%)		
 Trauma	28 (38.9%)	16 (5.90%)		
Vancouver:			<.001a	
 B1	50 (69.4%)	15 (5.54%)		
 B2	19 (26.4%)	239 (88.2%)		
 B3	3 (4.17%)	17 (6.27%)		
Cemented primary:	1 (2.27%)	18 (8.87%)	.211	
Reoperation:	18 (25.0%)	55 (20.3%)	.481	
Nonunion:	9 (15.0%)	12 (5.17%)	.020a	
Malunion:	1 (1.67%)	10 (4.33%)	.470	
Infection:	10 (16.4%)	23 (9.87%)	.227	
Instability:	1 (1.67%)	27 (11.3%)	.041a	
Ambulatory at 3 months postoperatively:	47 (73.4%)	227 (92.7%)	<.001a	
Ambulatory at 6 months postoperatively:	53 (93.0%)	211 (95.9%)	.314	
a Indicates statistical significance (P < .05). Data are presented as N (%).

Regression analysis

Having either a Vancouver B2 or B3 were significant independent risk factors for treatment with rTHA (odds ratio [OR]: 0.02, P < .001, and OR: 0.04, P < .001, respectively). Treatment by a trauma or other-specified surgeon was also an independent risk factor for ORIF repair of Vancouver B fractures (OR: 12.49, P < .001, and OR: 13.63, P < .001, respectively). Demographic factors such as age, sex, BMI, smoking status, chronic kidney disease, peripheral vascular disease, or diabetes were not found to be independent factors in receiving treatment with rTHA or ORIF (Table 5).Table 5 Multivariate logistic regression for receiving treatment with open reduction and internal fixation (ORIF) in Vancouver B fractures.

Variable	Estimate	P-value	Odds ratio	Lower 95	Upper 95	
Surgeon type:						
 Arthroplasty	Reference					
 Other	2.52	<.001a	12.49	4.30	37.73	
 Trauma	2.61	<.001a	13.63	4.78	41.44	
Vancouver:						
 B1	Reference					
 B2	−3.97	<.001a	0.02	0.01	0.05	
 B3	−3.24	<.001a	0.04	0.01	0.18	
Age	−0.01	.712	0.99	0.96	1.03	
Male	−0.17	.682	0.84	0.36	1.90	
BMI	−0.04	.224	0.96	0.89	1.02	
Smoker	0.23	.690	1.26	0.39	3.75	
CKD	0.15	.805	1.16	0.33	3.79	
PVD	0.28	.630	1.33	0.41	4.12	
Diabetes	−0.43	.456	0.65	0.21	1.95	
CKD, chronic kidney disease; PVD, peripheral vascular disease.

a Indicates statistical significance (P < .05).

Discussion

PPFFs around THA are becoming increasingly more prevalent [2]. We evaluated the institution-specific and overall allocation patterns for surgical treatment of Vancouver B fractures at 11 diverse institutions, as well as treatment decision-making based on surgical training and patient factors. Overall, the number of patients treated for Vancouver B fractures substantially varied among the centers included in this study. Across all regions of the United States, the majority of surgeries for Vancouver B fractures were performed by an arthroplasty surgeon, although centers from the western region of the United States included the largest cohort of patients treated by a trauma surgeon. Furthermore, 10 of the 11 centers stated their PPFF management protocol consisted of the orthopaedic on-call team referring patients to the subspecialist of the on-call team’s choice. While the reasoning for this regional trend is not fully understood, it is possibly due to the increasing number of arthroplasty surgeons practicing in comparison to orthopaedic trauma surgeons in the United States [17], the average number of completed applications for arthroplasty fellowship is nearly double that of trauma fellowship [18], and additional insight regarding triage methodology at the participating centers.

Surgical training background was determined to influence the surgical strategy selected for managing Vancouver B fractures, as bivariate and multivariate analyses both demonstrated that trauma surgeons were more likely to perform ORIF in comparison to arthroplasty and other surgeons. Additionally, arthroplasty surgeons performed significantly more rTHA than ORIF for all subgroup fracture types evaluated. Previous research has demonstrated a training-based trend for primary femoral neck fractures and periprosthetic femoral fractures following total knee arthroplasty [14,19]. Furthermore, Perry et al. demonstrated that 10 of 11 patients with Vancouver B2 fractures at a single trauma center treated by a fellowship-trained arthroplasty surgeon were managed with rTHA [10]. This further supports our findings that arthroplasty surgeons are more likely to perform revision surgery, while trauma surgeons perform fixation. Although the differences in surgical procedure type were significant between surgeons with various training backgrounds, the reoperation rates, postoperative ambulation, and rates of complications were comparable, therefore indicating similar outcomes. As this study only included major academic centers, the level of fellowship training and resources available may be substantially different from those in community hospitals and other hospital systems. Therefore, the outcomes demonstrated in this multicenter cohort study may not be generalizable to all hospital systems. However, this information does suggest that in hospital systems with limited availability of either highly skilled trauma or arthroplasty surgeons, outcomes can be expected to be similar regardless of the surgical subspecialty training.

There were no demographic factors to predict which patients received treatment with either ORIF or rTHA except for preoperative radiographic Vancouver classification. Both bivariate and multivariate analyses demonstrated Vancouver B2 and B3 fractures were more likely to be surgically reconstructed using rTHA in lieu of ORIF. Overall, the average BMI in both surgical treatment cohorts was less than 30, but BMI was not shown to be a predictor of ORIF or rTHA. It is likely arthroplasty surgeons may be more comfortable treating patients with a BMI over 40 using a revision procedure, while trauma surgeons may elect to treat with ORIF. However, due to the multicenter nature of this study, our results did not provide granular detail on the relationship between BMI and treatment in obese patients. Additionally, Vancouver B fractures treated with rTHA had lower nonunion rates and earlier postoperative ambulation, while those treated with ORIF resulted in decreased instability compared to rTHA. In a systematic review by González-Martín et al., which reviewed 856 patients with Vancouver B2 fractures, 57.6% were treated with rTHA and functional testing, and first-year mortality results were similar between ORIF and rTHA management. However, ORIF allowed for shorter operative time, less need for transfusion, fewer complications, lower reoperation rate, and shorter length of stay [20]. Additionally, a meta-analysis by Haider et al. consisting of 1132 patients with either Vancouver B2 or B3 fractures showed 84.8% of cases were treated with rTHA, while functional outcomes, mortality rates, and overall complication rates did not differ between the rTHA and ORIF cohorts [21]. There is no consensus in the current literature or in our study in regard to functional outcomes and complications to support a superior approach to treating Vancouver B2 or B3 fractures; however, it is clear that the most common treatment used was rTHA. It is possible this finding is due to the recommendations previously supported by the authors of the Vancouver classification on Vancouver B fracture treatment as well as comfortability regarding technique surgeons have based on fellowship training [16].

Our study also demonstrated Vancouver B1 fractures were more likely to be treated with ORIF in comparison to rTHA. The original PPFF treatment guidelines by Duncan and Masri in 1995 recommended B1 fractures be treated with ORIF due to their stable stem [16,20]. B1 fractures have previously been treated conservatively; however, if nondisplaced, it has been suggested that surgical management is best when the patient is an appropriate candidate for surgery [1,22]. Additionally, in an observational retrospective study by Roche-Albero et al., 37 patients with B1 fractures were shown to be appropriately treated with ORIF, as this technique allowed for good results even in elderly patients or those with poor bone quality [23]. A cross-sectional survey of both trauma and arthroplasty surgeons also showed ORIF to be the most preferred management technique, with only 2.3% of respondents preferring nonoperative management [24]. However, in a retrospective study by Efird et al., there was no difference in 1-year mortality, union rate, or return to preinjury ambulatory status in select nonoperative and operative patients with B1 fractures [25]. Our findings support the original recommendations and cross-sectional survey study data; however, there is still discussion as to the appropriate management of B1 fractures among surgeons for select patients such as those with minimally displaced fractures and partial remaining distal fixation.

There are several limitations to this study. First, across all centers, patients with a PPFF were retrospectively identified, and therefore, as with all retrospective studies, there is the risk of sampling bias. Each center included in the study was responsible for the collection of patient data, and differences in data extraction, completeness of data, and fracture type classification may have occurred. Second, the participating centers primarily consisted of adult reconstruction-trained surgeons, and therefore the regional treatment trends demonstrated in this study may not be generalizable or reflect the practices in other centers throughout the United States. Lower extremity PPFFs have been shown to be treated predominantly in large and urban teaching hospitals, with the majority of patients managed at their presenting hospital without transfer to a tertiary care center [26,27]. However, to our knowledge, there is no prior research assessing PPFF management that describes hospital demographics regarding surgeon fellowship training. It is likely other centers primarily consist of trauma fellowship-trained surgeons who treat Vancouver B fractures. Third, because the majority of surgeons included in this study were arthroplasty-trained, there was possibly further selection bias to treat marginal Vancouver B1 and B2 fractures with rTHA in lieu of ORIF due to surgeon comfort level. Fourth, classification of fractures was performed using preoperative imaging, and previous research has shown intraoperative classification may be more accurate [28,29]. Additionally, while preoperative imaging was utilized for diagnosis, further imaging information pertaining to stem position and fracture assessment was not available from all participating centers. Future research should include additional preoperative and postoperative radiographic characteristics to further assess outcomes of Vancouver B fracture surgical management. Fifth, indications for primary THA and mechanism of injury-causing PPFF were not collected in this study, which may further affect revision treatment decision-making. Finally, many patients with less than 6-month follow-up were excluded from our analysis, and therefore this may have resulted in fewer patients with excellent outcomes necessitating shorter follow-up.

Conclusions

Our study evaluated 1 of the largest cohorts of Vancouver B PPFFs. Surgical treatment for Vancouver B fractures was predominantly treated by arthroplasty surgeons at all centers. Arthroplasty surgeons most commonly performed rTHA, and orthopaedic trauma surgeons had the highest rate of choosing ORIF. rTHA was more likely used to treat B2 and B3 fractures and resulted in lower nonunion rates and earlier postoperative ambulation for all Vancouver B features in comparison to those treated by ORIF. Additionally, ORIF was used more for the management of B1 fractures and resulted in increased stability for all Vancouver B fractures compared to rTHA. Overall, this study showed the trends in surgeons who surgically manage Vancouver B fractures at 11 major academic institutions and highlighted that regardless of surgical training or surgical treatment type, postoperative outcomes following management of PPFF were similar.

Conflicts of interest

S. C. Mears has stock options in Delta Ortho LLC; is an editorial board member of the Journal of the American Geriatrics Society and SAGE; and is a board/committee member of Fragility Fracture Network. A. Saxena is a paid consultant for Corin USA; has stock options in Parvizi Surgical Innovations; receives research support from United Orthopaedics; is an editorial board member of the Journal of Arthroplasty, Journal of Bone and Joint Surgery–American, and Journal of the American Academy of Orthopaedic Surgeons; and is a board/committee member of the Eastern Orthopaedic Association, American Association of Hip and Knee Surgeons, American Board of Orthopaedic Surgery, Inc., and AAOS. J. B. Stambough receives royalties from Signature Orthopaedics; is a CurveBeam speaker; is a paid consultant for Smith & Nephew and Medacta; is an editorial board member of the Journal of Arthroplasty; and is a board/committee member of the American Association of Hip and Knee Surgeons and the American Joint Replacement Registry (AJRR). P. M. Lichstein is a board/committee member of the American Association of Hip and Knee Surgeons. J. R. Martin is a paid consultant for DePuy and A Johnson & Johnson Company. The other author declares no potential conflicts of interest.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2024.101428.

CRediT authorship contribution statement

Nicholas B. Pohl: Writing – original draft, Investigation, Formal analysis, Data curation. Arjun Saxena: Writing – review & editing, Methodology, Investigation, Formal analysis, Data curation. Jeffrey B. Stambough: Writing – review & editing, Methodology, Investigation, Formal analysis, Data curation. John Ryan Martin: Writing – review & editing, Methodology, Investigation, Formal analysis, Data curation. Simon C. Mears: Writing – review & editing, Methodology, Investigation, Formal analysis, Data curation. Paul M. Lichstein: Writing – review & editing, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Appendix A Supplementary Data

Conflict of Interest Statement for Mears

Conflict of Interest Statement for Saxena

Conflict of Interest Statement for Stambough

Conflict of Interest Statement for Pohl

Conflict of Interest Statement for Lichstein

Conflict of Interest Statement for Martin
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