case_images: PMC10905061_01
case_images: Vancouver B1, Case three. (A) Seven years post total hip arthroplasty, slight deterioration; (B) 11 years post arthroplasty, significant deterioration with discomfort; (C-G) CT scans confirm femoral lysis and acetabular loss; (H) Revision hip arthroplasty includes cerclage wires stabilizing the extended stem; (I) One year post-revision, successful healing and prosthesis integration, emphasizing the importance of postoperative monitoring and potential revision procedures for specific fracture characteristics.
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case_images: FIG3
case_images: After a period of seven years following the operation, the radiographic examination revealed slight deterioration without any notable clinical symptoms, as illustrated in Figure 3A. The radiographic assessment conducted at this particular stage (Figure 3B), exhibited significant deterioration observed at both the femoral and acetabular levels. Additional imaging modalities, such as CT scans (Figures 3C-3G), corroborated the presence of notable femoral lysis and considerable loss of acetabular substance. In order to tackle this issue, a pair of cerclage wires were employed to provide stability to the extended revision stem, as depicted in Figure 3H. After one year following the revision procedure, the patient exhibited positive results, as indicated by radiographic evidence demonstrating successful healing of the fracture and integration of the prosthesis (Figure 3I).
case_images: Vancouver B2, Case one. (A) The fracture in question is categorized as Vancouver B2 owing to the radiological instability observed in the prosthesis stem. Nevertheless, the bone quality of the patient was remarkably high, enabling a precise anatomical realignment of the fracture during the surgical procedure. Considering the effective decrease in symptoms and the presence of concurrent medical conditions in the patient, it was determined that a more conservative surgical approach would be suitable; (B) The conventional approach for managing these fractures frequently entails the utilization of plate and screw fixation. Nevertheless, in this particular instance, osteosynthesis was accomplished through the utilization of four cerclage wires, deviating from the customary treatment protocol. The patient's postoperative course was without any notable incidents, which serves to underscore the significance of tailoring treatment plans to address intricate Vancouver B2 fractures.
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case_images: FIG4
case_images: The patient, experienced a spiroid fracture during a skiing activity, as illustrated in Figure 4.
case_images: Vancouver B2, Case two. (A) Spiroid fracture; (B) Radiological assessment following open reduction and internal fixation (ORIF) using a proximal hook plate, cerclages, and self-locking screws
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case_images: FIG5
case_images: Association (NYHA) Class 3 chronic heart failure, and notable cerebrovascular stenosis affecting her carotid arteries. After experiencing an episode of lipothymia, the patient exhibited a multifaceted, lengthy spiral fracture that spanned from the greater trochanter to a location roughly 2 cm below the femoral stem (Figure 5).
case_images: PMC10905061_02
case_images: Vancouver B2, Case three. (A) A spiroid fracture located at the femur level, accompanied by an unstable femoral stem; (B) The anatomical realignment of the periprosthetic fracture using proximal and distal screws in conjunction with plates to enhance its stability. Additionally, a relatively large number of cerclages have been employed at the plate level to maintain the fracture's position. While this approach does indeed enhance resistance, it also elevates the risk of compromising the vascularization of the bone at this particular site.
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case_images: FIG6
case_images: The fracture exhibited a spiral pattern and encompassed an intricate "butterfly wing" element, thereby introducing an extra level of intricacy to the already demanding clinical situation (Figure 6).
case_images: PMC10905061_03
case_images: Vancouver B3, Case one. (A) A spiroid fracture originating from the trochanteric massif and extending approximately 5 centimeters below the distal end of the femoral stem. The radiological observations pose a particularly complex situation. In this instance of a comminuted fracture, a butterfly fragment become detached, covering a span of approximately two-thirds along the entire length of the fracture. The detachment of the fracture greatly intensifies its instability, presenting a challenging surgical predicament; (B, C) The fracture was anatomically reduced and stabilized using open reduction and internal fixation (ORIF) technique, which involved the application of a self-locking plate supplemented with cables. The selection of this approach was likely made with the intention of optimizing the likelihood of achieving fracture union, while simultaneously minimizing the potential for exacerbating the already delicate nature of the fracture.
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case_images: FIG7
case_images: The presence of morbid obesity in the patient, as evidenced by a body mass index (BMI) of 33, introduced an additional level of intricacy in the process of making surgical decisions. The radiographic results demonstrated a lengthy, fragmented spiral fracture with a butterfly fragment, suggesting substantial instability and a reduction in bone density (Figure 7).
case_images: PMC10905061_04
case_images: Vancouver B3, Case two. Image (A) poses a significant clinical dilemma. The radiographic image demonstrates a comminuted fracture that affects the trochanteric massif and the proximal third of the femur. It is worth noting that there is a considerable degree of telescoping and shortening observed in the femur, which serves as an indication of pronounced instability and displacement. Due to the intricate nature of the fracture and its inherent instability, it is probable that a simple internal fixation would not provide adequate long-term stability and promote fracture union. Within this particular context, the surgical team made the decision to pursue a more assertive course of action, as illustrated in Images (B) and (C). A modification was made to the femoral component by utilizing a longer revision stem in order to improve stability and promote the growth of bone tissue. In order to enhance the stability of the fracture in its anatomical alignment, two cerclages were employed. The utilization of a combined strategy involving the modification of the femoral component and the implementation of cerclages is intended to effectively tackle both the immediate mechanical instability and the enduring biological prerequisites for fracture healing.
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case_images: FIG8
case_images: The individual in question had previously undergone surgical intervention for coxarthrosis approximately 10 years prior to presentation and had since maintained a physically active lifestyle without experiencing any notable issues (Figure 8).
case_images: Vancouver B3, Case three. (A) A distinctive and demanding clinical situation wherein a spiroid fracture is observed that extends to the apex of the femoral stem. Interestingly, the primary cause of instability in this particular scenario is not solely attributed to the fracture, but rather to the considerable peri-implant lysis that compromised the stability of the pre-existing femoral stem during the occurrence of the trauma. The occurrence of lysis, which refers to the pathological degradation of bone tissue surrounding the implant, further intensified the mechanical instability following the traumatic event. Due to the compromised quality of the tissue and the destabilizing effects caused by the lysis process, it was not feasible to preserve the original stem; (B, C) The surgical team made the decision to perform a revision arthroplasty utilizing a thicker, uncemented modular stem. The utilization of this method facilitated a comprehensive removal of fibrous tissue from the femoral canal until reaching a state of high-quality bone, thereby establishing a more robust base for the subsequent implantation. In order to augment stability and promote the process of fracture healing, two cerclages were administered at the site of the fracture. Every instance mentioned emphasizes the necessity of an individualized strategy for the management of Vancouver B3 fractures. This approach should consider the distinct difficulties and requirements posed by the medical and lifestyle factors of each patient.
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case_images: FIG9
case_images: Radiographic evidence revealed the presence of peri-implant lysis surrounding the femoral component, which was further supported by the patient's reported experience of mild pain during movement (Figure 9).