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REVIEW ARTICLE
Principles and methods of fixation of periprosthetic fractures in stem region of hip prosthesis (Vancouver B)
Copyright (c) 2021 Slovenian Medical Journal. This work is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License.
Principles and methods of fixation of periprosthetic 
fractures in stem region of hip prosthesis (Vancouver B) – 
review article
Principi in načini učvrstitve obproteznih zlomov ob deblu kolčne proteze (Vancouver B) 
– pregledni članek
Anže Kristan
Abstract
An increasing number of implanted hip endoprostheses correlates with the number of complications. Periprosthetic frac-
tures in the femur area after the hip endoprosthesis is a serious complication that can rarely occur during the insertion of 
the stem and more often a few years after the primary operation. The frequency of these fractures is influenced by several 
factors that are interdependent. Depending on the position of the fracture and bone quality, these fractures are divided ac-
cording to the Vancouver classification. The surgery of fractures with stable stem (B1) generally consists of internal fixation 
while maintaining the stem of primary prosthesis. Opinions on the treatment of fractures in which the stem is not stable 
but there are no bone defects (B2) are controversial. The classic method is to change the prosthesis with or without addi-
tional fixing of the fracture, but lately there are more studies that support osteosynthesis of the fracture with the preserva-
tion of the original prosthesis. The basic principle of the osteosynthesis in the region of the prosthesis stem is the anatomic 
reduction of the fracture by stable fixation. In this way, we re-establish the perfect fit of the prosthesis to the bone. The 
stem of the prosthesis represents an obstacle to osteosynthesis, rarely also to reduction. In this article we mainly discuss 
the problems of attaching the plate around the stem of the prosthesis. The simplest way to fix the plate to the bone is by 
using cerclage, but it offers poor torsional stability and is always required to be additionally fixed with screws. Due to the 
age-related osteopenia of the bone, which is practically always present, it is ideal to use angle-stable plates with locking 
bi-cortical screws, but this is only possible when using special plates that allow it. The plate must bridge the maximum 
length of the bone a in order to reduce the stress raiser at the end of the plate. In the article we presented a one-year series 
of operated B1 and B2 periprosthetic femoral fractures after hip prosthesis performed at the Department of Traumatology 
of the UMC Ljubljana.
Department of Traumatology, Division of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
Correspondence / Korespondenca: Anže Kristan, e: anze.kristan@siol.net
Key words: periprosthetic fracture; femoral fracture; hip prosthesis; fixation
Ključne besede: obprotezni zlomi; zlomi stegnenice; kolčna proteza; učvrstitev
Received / Prispelo: 23. 6. 2020 | Accepted / Sprejeto: 12. 11. 2020
Cite as / Citirajte kot: Kristan A. Principles and methods of fixation of periprosthetic fractures in stem region of hip prosthesis (Vancouver 
B) – review article. Zdrav Vestn. 2021;90(11–12):603–13. DOI: https://doi.org/10.6016/ZdravVestn.3120
eng slo element
en article-lang
10.6016/ZdravVestn.3120 doi
23.6.2020 date-received
12.11.2020 date-accepted
Surgery, orthopaedics, traumatology Kirurgija, ortopedija, travmatologija discipline
Review article Pregledni znanstveni članek article-type
Principles and methods of fixation of peripros-
thetic fractures in stem region of hip prosthe-
sis (Vancouver B) – review article
Principi in načini učvrstitve obproteznih zlomov 
ob deblu kolčne proteze (Vancouver B) – pregledni 
članek
article-title
Principles and methods of fixation of peripros-
thetic fractures in stem region of hip prosthe-
sis (Vancouver B)
Principi in načini učvrstitve obproteznih zlomov 
ob deblu kolčne proteze (Vancouver B) alt-title
periprosthetic fracture, femoral fracture, hip 
prosthesis, fixation
obprotezni zlomi, zlomi stegnenice, kolčna prote-
za, učvrstitev kwd-group
The authors declare that there are no conflicts 
of interest present.
Avtorji so izjavili, da ne obstajajo nobeni 
konkurenčni interesi. conflict
year volume first month last month first page last page
2021 90 9 10 603 613
name surname aff email
Anže Kristan 1 anze.kristan@siol.net
name surname aff
eng slo aff-id
Department of Traumatology, 
Division of Surgery, University 
Medical Center Ljubljana, 
Ljubljana, Slovenia
Klinični oddelek za 
travmatologijo, Kirurška klinika, 
Univerzitetni klinični center 
Ljubljana, Ljubljana
1
Slovenian Medical Journallovenian Medical Journal
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1 Introduction
Hip arthroplasty is a successful treatment for degen-
erative diseases of the hip joint, as well as femoral neck 
fractures in the elderly. In general, complications fol-
lowing the procedure are rare. A periprosthetic femoral 
fracture (PFF) is one such complication in which the en-
doprosthesis stem reduces bone elasticity and thus resis-
tance to fracture by about a third (1,2). This is the most 
important reason for revision surgery from the fourth 
postoperative year onwards (3). The average cost of treat-
ing these fractures in the UK is £23,000 per patient (4).
PFF can occur during or after surgery. During prima-
ry surgery, fractures occur in 1% with cemented fixation 
and up to 5% with uncemented fixation, while in revision 
surgery (most often due to endoprosthesis loosening), 
they are more common, with 4% occurring with cement-
ed fixation and 20% with uncemented fixation (5).
After surgery, PFF most commonly occurs with low 
energy trauma (falls from a standing height). The in-
cidence of these injuries is around 1% with cemented 
endoprostheses and between 4%–5% with uncemented 
endoprostheses (5). The majority occur for the active 
elderly with osteoporosis. There are several risk factors 
listed in the literature and most of them are intercon-
nected: age, osteopenia, comorbidities, secondary (al-
ready changed) endoprosthesis, and sex.  Fractures in 
femurs with an endoprosthesis occur more frequently in 
the elderly with osteoporosis. It has been found that with 
each year of age, the chance of fracture increases by 1% 
(6). The number of comorbidities increases with age, af-
fecting the probability of a fall. The higher probability of 
fractures in women is due to more frequent osteoporosis 
Izvleček
Z večanjem števila vstavljenih endoprotez kolka se veča število zapletov. Obprotezni zlom v predelu stegnenice po endo-
protezi kolka je zaplet, ki redko nastane ob operaciji, pogosteje pa do zloma pride nekaj let po primarni operaciji. Na pogo-
stost tega zapleta vplivajo številni dejavniki, ki so med seboj soodvisni. Glede na mesto zloma in kakovost kosti se ti zlomi 
delijo po Vancouverski razdelitvi. Zlomi s stabilnim deblom (B1) se praviloma operirajo z notranjo učvrstitvijo ob ohranitvi 
debla primarne proteze. Mnenja glede zdravljenj zlomov, ob katerih pride do omajanja debla, ni pa prisotnih okvar na kosti 
(B2), so deljena. Klasična metoda je menjava debla z dodatno učvrstitvijo ali brez nje. V zadnjem času pa se pojavlja vse več 
študij, ki podpirajo notranjo učvrstitev z ohranitvijo izvirne proteze. Osnovno načelo ob učvrstitvi zloma v predelu debla 
proteze je anatomska naravnava zloma s stabilno učvrstitvijo. Na ta način ponovno vzpostavimo popolno prileganje pro-
teze kosti. Deblo proteze predstavlja oviro za učvrstitev, le redko tudi za naravnavo. V članku govorimo predvsem o načinu 
pritrditve plošče na kost v predelu debla proteze. Najlažja je uporaba t. i. cerklaž, ki pa nudijo slabo torzijsko stabilnost. 
Zato je potrebno zlom še dodatno učvrstiti z vijaki. Zaradi osteopenije kosti, ki je pri starostnikih praktično vedno prisotna, 
je idealno uporabiti kotno stabilne plošče in zaklepne vijake, ki so v kosti učvrščeni v obeh kortikalisih (bikortikalni vijaki). 
Vendar pa je to možno zelo redko oziroma ob uporabi plošč, ki to dopuščajo. S ploščo je vedno treba premostiti čim večjo 
dolžino kosti, saj na ta način zmanjšamo obremenitev kosti na koncu plošče. Članek prikazuje serijo obproteznih zlomov v 
predelu debla kolčne proteze brez okvar kosti (B1 in B2), operiranih na Kliničnem oddelku za travmatologijo UKC Ljubljana 
v obdobju enega leta.
as well as a higher number of inserted hip endoprosthe-
ses, mainly due to degenerative causes. With an ageing 
population, the need for replacing the endoprosthesis 
increases due to their limited lifespan as well as loos-
ening of the prosthesis. PFF incidence increases either 
during endoprosthesis replacement or afterwards (5,7).
In a younger, very active population, the injury is 
most commonly secondary to high energy trauma, or 
loosening occurs as a consequence of osteolysis due to 
microparticles peeling under load, which can occur in 
intensely active lifestyles. Endoprosthesis stem loosen-
ing increases the possibility of PFF (8).
Postoperative PFF occurs more frequently with un-
cemented endoprosthesis stems than with cemented fix-
ation. The incidence of such injuries begins to rise six 
months after primary surgery. The reason for this can be 
found in increased loads on the bone around the stem 
due to a perfect fit of the endoprosthesis, inserted into 
bone. In cemented stems, the fracture is most common-
ly found in the transition of the stem to normal bone, 
which occurs years after the primary surgery and is most 
probably the consequence of cement microparticles, 
formed under load (9).
A femoral fracture is a serious injury and is most 
commonly treated with surgery. It enables the patient 
to rehabilitate earlier on, and effectively return to their 
pre-injury activities. We are trying to achieve the same 
goal with PFFs. The basic difference between PFF and 
other femoral fractures is the presence of an endopros-
thesis. Additionally, during the primary operation (i.e., 
insertion of the endoprosthesis), the blood supply within 
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the usually osteopenic bone is always destroyed, and frac-
tures are multifragmentary due to bone fragility (10).
Periprosthetic fractures are divided according to the 
relationship between the fracture line and the endopros-
thesis, via the Vancouver classification (VC); the Unified 
Classification System for Periprosthetic Fractures (UCPF) 
has been derived from this, developed by the AO Foun-
dation. According to the VC, fractures around the stem 
directly supporting the endoprosthesis, or just below it, 
are classified as type B. A stable stem fracture is classified 
as B1; if the stem is loose but the bone stock is adequate, 
the fracture is classified as B2. In case of inadequate bone 
stock, most commonly secondary to a loose stem, the 
fracture is classified as B3 (11,12) (Figures 1 and 2).
Type B PFF is treated surgically. The method is de-
cided according to the type of fracture and the general 
condition and expectations of the (elderly) patient.
Stable stem fractures (B1) are treated with internal 
fixation (osteosynthesis, OS). Loose stem PFF (B2) and 
loose stem fractures with bone defects (B3) are treated 
with endoprosthesis replacement with or without osteo-
synthesis (11,12).
The presence of the endoprosthesis stem in the femur 
Figure 1: Periprosthetic femoral fracture type B1. (A) 
an X-ray image of a fracture at the stem of the right hip 
endoprosthesis. (B) computed tomography scan with 
tridimensional reconstruction.
In stable stem fractures, displacement is often only minimal.
Source: archive of the Clinical Department of Traumatology, 
University Medical Center Ljubljana.
Figure 2: Periprosthetic femoral fracture type B2. Left 
femoral fracture with fragment displacement and a loose 
stem (subsidence, varus position and stem rotation).
Source: archive of the Clinical Department of Traumatology, 
University Medical Center Ljubljana.
makes fixation a biomechanical and technical challenge. 
The purpose of this article is to present the principles 
and methods of PPF internal fixation by preserving the 
stem and to show a one-year series of stem PFF without 
bone defects (B1 and B2) operations at the Department 
of Traumatology, Medical Centre Ljubljana.
2 Principles of periprosthetic femoral 
fracture osteosynthesis
Femoral fractures are treated according to the prin-
ciples of treatment of the long bones of the lower limbs. 
The aim is to achieve a functional anatomy of the femur, 
which means that the bone maintains the appropriate 
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length, axis and torsion after healing (13).
In simple fractures (two fragments), anatomical re-
duction is technically possible. However, care should be 
taken to avoid additionally damaging the fragment’s per-
fusion, already affected by the trauma. Adequate bone 
perfusion is crucial for healing (14,15). With anatomical 
reduction, perfect (absolute) and stable fixation (com-
pression between the fragments) should be achieved, 
which leads to primary fracture healing. Fragment com-
pression can be achieved with the use of lag screws (and, 
on rarer occasions, with cerclage) and the fracture area 
should always be relieved (neutralized) with a plate (16).
In multifragmentary fractures, anatomical reduction 
is practically impossible without additional impairment 
to bone perfusion. Thus, the goal is to achieve function-
al reduction. With non-anatomical reduction, absolute 
stability is impossible to achieve, so partially (relatively) 
stable reduction is always performed. Such fractures he-
al with a callus. Relative stability can be achieved with 
intramedullary fixation or a bridging plate. When try-
ing to achieve relative stability, there is a danger that the 
fracture will not heal without enough stability, due to ex-
cessive fragment displacement under load; on the other 
hand, a too-stable osteosynthesis in non-anatomical re-
duction can also lead to nonunion and a repeat fracture 
(13,17,18).
PFF that occur well below the stem (type C in the AC) 
can be treated using both principles. With good bone 
quality (younger patients) and simple fractures, anatom-
ical reduction and stable fixation is chosen. With osteo-
penic patients or multifragmentary fractures, reduction 
is functional and fixation relatively stable. Anatomical 
reduction of multifragmentary fractures is technically 
impossible to achieve due to the large number and small 
size of fragments; additionally, in osteopenic bone, ade-
quate fragment compression to ensure absolute stability 
is impossible to achieve. Due to the presence of the stem 
in the proximal femur, an intramedullary nail cannot be 
used with PFF, so the fracture is always bridged with a 
plate (19).
In stem PFF (type B), the fracture is located in an ar-
ea of bone that provides support to the endoprosthesis. 
In uncemented endoprostheses, the base is completely 
adjusted to the stem, while in cemented endoprostheses, 
the bone is in close contact with cement. While main-
taining the primary stem, a perfect fit of the bone to 
the endoprosthesis or the periprosthetic cement mantle 
needs to be maintained or restored to ensure stem sta-
bility. It is therefore imperative to achieve anatomical re-
duction of bone fragments; with anatomical reduction, 
the goal is also to achieve absolute fracture stability. The 
stem completely occupies the medullary canal for most 
of its length, so compression between the fragments 
cannot be achieved with gap screws; instead, cerclage is 
commonly used for this purpose. Stability is further pro-
tected with a plate (11,12).
3 Osteosynthesis in type B periprosthetic 
femoral fractures
With PFF fixation, only extramedullary implants are 
used. The construct, made of an extramedullary implant 
(plate, allograft), is fixed to the bone with cerclage or 
screws (standard or locking), to ensure fracture stability. 
Bone screws can be bicortical or monocortical. 
Some biomechanical studies have shown that the 
strength of the periprosthetic fracture union is the same 
when using an allograft, plate or revision arthroplasty 
(24,25). On the other hand, some studies have shown the 
plate to be more stable than one or even two allografts 
(25). The combination of a plate and allograft offers the 
strongest support (21,27-29); however, the force that 
causes a fracture under such constructs is significantly 
greater than can be expected under normal physiolog-
ical loads.
The stability of PFF fixation does not only depend 
on the type of implant, but also on the osteosynthesis 
method at the stem area. It is characteristic of all endo-
prostheses that the contact between the stem or cement 
surrounding the endoprosthesis and the bone must be 
perfect. The stem of the prosthesis represents an obsta-
cle to osteosynthesis, due to a lack of space in the bone 
and the possibility of damage to the cement stabilizing 
the cemented endoprosthesis stem, while the screws 
increase the load on the bone, which can cause a frac-
ture. The plate can be attached to the bone with standard 
screws, screws that offer angular stability, or cerclage.
The technically simplest method of attachment is 
with cerclage. The basic biomechanical disadvantage of 
this method is its poor torsional stability. The biological 
disadvantage of the method is perfusion impairment. In 
recent years, cables have been used for cerclage, being 
mechanically more stable and less prone to impairing 
the periosteal perfusion than wires (30,31).
Comparisons of bicortical and monocortical screws 
and cerclage for osteosynthesis at the stem have shown 
that bicortical screws offer the greatest stability (32-34).
Fixation with locking bicortical screws at the stem 
offers the greatest stability, but it is often not technically 
feasible due to the presence of the implant in the bone. 
Newer locking plates for PFF treatment allow the lock-
ing screws to be placed at different angles. Additionally, 
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plates that attach to the base plate are also used and allow 
the locking screws to avoid the stem when being placed. 
With good bone stock, osteosynthesis with standard 
screws is also possible (35). In case such plates are not 
available, biomechanical studies have shown that a con-
struct with monocortical locking screws with or without 
cerclage is also acceptable (36,37). Other studies have 
shown even better results with the use of monocortical 
locking screws without cerclage (33).
With screw fixation near cemented endoprostheses, 
contact between screws and cement is often unavoidable. 
It is presumed that the screws in contact with cement 
cause a crack which can cause endoprosthesis loosening, 
but evidence to support this theory is weak. However, it 
has been proven that screws that only partially enter in-
to the cement cause a crack significantly less often than 
if they are completely anchored in the cement, or even 
touch the stem (38). It has also been proven that with the 
use of plates that enable the screws to avoid the cement, 
damage to the cement is therefore avoided, thus ensur-
ing the stem remains stable (39).
The presence of an implant in bone reduces the force, 
necessary to cause a fracture, by approximately a third 
(1). With PFF fixation, it should be noted that by im-
planting a new endoprosthesis, the most vulnerable 
Figure 3: Type B1 fracture osteosynthesis: anatomical reduction was achieved; the plate was attached to the bone at the 
stem with cerclage and two standard bicortical screws. Under the endoprosthesis, the plate was attached to the bone with 
three locking bicortical screws; the final screw was standard.
Source: archive of the Clinical Department of Traumatology, University Medical Center Ljubljana.
Figure 4: Osteosynthesis of a type B2 fracture without 
stem replacement: anatomical reduction was achieved. At 
the stem, the plate was attached with two cerclages, one 
bicortical and one monocortical standard screw, and under 
the endoprosthesis, the plate was attached to the bone 
with three bicortical locking screws; the final screw was a 
standard monocortical screw.
Source: archive of the Clinical Department of Traumatology, 
University Medical Center Ljubljana.
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spot for a periprosthetic fracture is moved distally on 
the femur. The probability of a distal endoprosthesis 
fracture is around 8%, so the maximum length of bone 
must always be bridged (20-22). Due to increased loads 
at the end of the plate, the choice of fixation method 
is of utmost importance. The bicortical locking screw 
increases load the most, followed by the monocortical 
locking screw. The load is least increased with standard 
screws or cerclage. The load difference between bicor-
tical locking screws and standard screws or cerclage is 
40% (22,23). Bridging the entire bone and with implant 
overlap (endoprosthesis and extramedullary implant), 
the force that would cause a fracture returns to normal 
(1).
The standard position of extramedullary implants 
is on the lateral side of the femur. According to Wolff ’s 
diagram, the normal distribution of forces on the femur 
is such that there are compression forces on the medi-
al side and tension forces on the lateral side (40). With 
lateral fixation, problems arise when the bone on the 
medial side is shattered and approximation between 
the main fragments cannot be achieved with fracture 
reduction. In such cases, tension forces on the laterally 
lying implant increase significantly, and the screws may 
be pulled out, or the plate may break, leading to osteo-
synthesis disintegration. Such a fracture requires more 
than just lateral fixation. The two-plane fixation options 
in the proximal femur are in the 900-900 configuration, 
when one implant is attached to the lateral side and the 
other to the anterior side of the femur, or 1800-1800, 
when one implant is attached to the lateral side and the 
other to the medial side of the bone. In the first case, 
both implants can be plates attached to the bone with 
screws or a plate on the lateral side and an allograft on 
the anterior side, the latter attached with cerclage. In the 
second case, the plate is attached to the lateral side and 
the allograft, attached with cerclage, to the medial side 
(21,25,27,28,41-43). In both cases, attaching multiple 
implants in different configurations leads to significant-
ly more soft tissue injury, which further impairs bone 
perfusion.
Therefore, modern literature suggests an anatomi-
cal fracture reduction at the stem. Fixation should be 
stable with the use of cerclage, which are relieved by a 
long plate covering the entire length of the bone. In the 
stem area, the plate should ideally be attached to the 
bone with bicortical locking screws. The end of the plate 
should be attached less rigidly to the bone in the area 
without an implant, either with monocortical standard 
screws or cerclage (Figures 3 and 4).
4 An overview of management of trauma 
patients with periprosthetic femoral 
fracture type B at the Department of 
Traumatology, Medical Centre Ljubljana
In the last 5 years, the number of proximal femoral 
fractures treated at the Department of Traumatology at 
the Medical Centre Ljubljana has risen by approximate-
ly 15%. Periprosthetic femoral fractures are included 
among them, and their number has risen by more than 
50% in the same period. The majority of our patients 
with PFF had primary hip arthroplasty performed due 
to arthrosis.
Using a retrograde analysis of patients with peri-
prosthetic proximal femoral fractures who had surgery 
from 1. 1. 2019 to 31. 12. 2019, we checked how man-
agement recommendations were followed and what the 
radiographic (X-ray) results were.
Using our department’s list of operations, we ob-
tained data on trauma patients who had surgery for PFF 
over a one-year period. With the help of X-ray images, 
fractures were classified, data obtained on the method 
and type of fixation, and X-ray images were analyzed at 
the end of treatment. Due to a relatively small sample 
size, the data has not been statistically processed.
In 2019, we performed 931 operations for proximal 
femoral fractures at the Department of Traumatology. 
We inserted 299 partial or total hip endoprostheses due 
to fractures. In this period, we operated on 35 patients 
with periprosthetic femoral fractures; 17 of them had 
type B fractures. Ten patients were female. The age 
ranged from 56 to 90 years (median 78 years). In this 
year, we also operated on one patient with a repeat PFF.
Seven patients (41%) had type B1 fractures and in 10 
cases (59%), the fracture caused stem instability (type 
B2). In all our patients, the bone stock was assessed as 
adequate, meaning there were no type B3 fractures in 
our series. 
Ten patients were treated with fixation (7 B1 and 3 
B2); the median age with type B1 was 78 years, and 81 
years in type B2. Two patients with type B2 fractures 
who had osteosynthesis had an uncemented stem and 
one had a cemented stem, while five patients (71%) 
with type B1 fractures had an uncemented stem. In all 
patients, the LCP (locking compression plate) was used 
as an implant, offering the choice of using both lock-
ing and standard screws. With type B1 fractures, we 
performed an anatomical fracture reduction in 6 cases 
(86%) and always with type B2 fractures. In all patients 
with type B2 fractures, the fracture healed without a 
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visible callus, signifying primary healing and absolute 
fixation stability. In type B1, there were 5 such patients 
(71%).
At the stem in type B1 fractures, we used only stan-
dard screws in 2 cases (29%), only locking screws in 4 
cases (57%) and a combination in 1 (14%). In 3 patients 
(42%), all the screws were bicortical, in 2 (29%) only 
monocortical, and in 2 (29%) a combination of mono- 
and bicortical. In type B2, we used a combination of 
screws at the stem in 1 patient (33%) and in 2 (67%), 
we used only locking screws; however, in 2 (67%) they 
were bicortical and in 1 (33%) a combination of mo-
no- and bicortical. Cerclage around the stem was used 
in type B1 in 6 cases (86%) and always in type B2. The 
final screw on the lower end of the fixation was always 
bicortical in type B1, 2 of these (29%) were standard, 
and 5 (71%) a locking screw was used; in type B2, the 
final screw was locking in 1 case (33%), and standard 
in 2 (67%); in 2 cases, it was bicortical (67%) and in 1 
(33%) it was monocortical.
Endoprosthesis subsidence or other mechanical 
complications did not occur in type B1 fractures. On 
average, these fractures healed in 4.6 months. In type 
B2 fractures, endoprosthesis subsidence occurred twice 
by 0.5 cm, and in one case, varus deformation of 10 de-
grees at the fracture site occurred. The median duration 
of fracture healing was 5 (Table 1).
In 7 cases (70%), type B2 fractures were treated with 
stem replacement and in all cases, additional fixation 
was performed. The median age of these patients was 
75 years. In all cases, cerclage was used, and in one case, 
an additional plate and screws (Table 2).
B 1 B 2
Number 7 3
Age (median) 78 (56–90) 81 (80–85)
Type of endoprosthesis uncemented 5 (71%) 2 (66,7%)
cemented 2 (29%) 1 (33.3%)
Reduction anatomical 6 (86%) 3 (100%)
functional 1 (14%) 0
Healing primary 5 (71%) 3 (100%)
secondary 2 (29%) 0
Screws standard 2 (29%) 0
locking 4 (57%) 2 (67%)
combination 1 (14%) 1 (33%)
bicortical 3 (42%) 2 (67%)
monocortical 2 (29%) 0
combination 2 (29%) 1 (33%)
Cerclage 6 (86%) 3 (100%)
Final screw bicortical 7 (100%) 2 (67%)
monocortical 0 1 (33%)
locking 5 (71%) 1 (33%)
standard 2 (29%) 2 (67%)
Healing duration (average) 4.6 months 5 months
Endoprosthesis subsidence 0 2
Mechanical problems 0 1 (varus)
Table 1: Comparison of periprosthetic femoral fracture of type B1 and B2 treatment.
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5 Comparison of our results with results 
from the literature
Compared to 2005, the number of primary hip ar-
throplasties is projected to increase by 174% by 2030; 
the number of periprosthetic fractures will increase by 
a similar proportion (44). As patients with these frac-
tures are mostly elderly with comorbidities, it will put 
a strain on the healthcare system. A similar growing 
trend is also noticeable in patients treated at the Depart-
ment of Traumatology at the Medical Centre Ljublja-
na. In the last five years, the number of periprosthetic 
fractures has increased by about half. In our series, all 
but one of the patients are over the age of 65, which is 
consistent with observations of other studies that show 
that a periprosthetic fracture is an injury of the elderly 
(45). In the literature, maintaining the stem is always 
recommended if it is stable, even after a fracture. It has 
been debated for several years whether stem replace-
ment is truly always necessary in cases where stem in-
stability occurs after a femoral fracture. By definition, 
the authors of classical studies have always advised re-
placement due to fracture of the shaken prosthesis (46-
48). Newer studies show that stem replacement is not 
always necessary and that good results can be achieved 
with fracture fixation. Besides pre-injury activity and 
patient expectations after surgery, bone stock and the 
type of fracture should be taken into account as they 
should allow anatomical reduction and stable fixation. 
It is important that the endoprosthesis for this treat-
ment method was stable prior to injury; if it was loos-
ened beforehand, the stem must always be replaced 
during PFF surgery. In cemented stems, osteosynthesis 
without stem replacement should only be considered 
if the cement mantle remained intact after the fracture 
in the area of contact between the cement and bone 
(4,49-51).
In our series, patients with a stable stem (B1) were 
younger than those with an unstable stem after fracture 
(B2); from this, we can indirectly infer the bone stock, 
as stronger bone provides better support to the stem. In 
type B2 fractures, the patients in which we decided on 
fracture fixation without stem replacement were older 
than patients in which we replaced the stem (81 vs. 75 
years). This shows that we also decided on the meth-
od of treatment on the basis of expected activity. Most 
fractures occurred at the uncemented part of the stem, 
which is consistent with studies that showed that the 
probability of a periprosthetic fracture in the elderly is 
reduced if a cemented stem is used (5). In 90% of our 
patients, the anatomical reduction of the fracture en-
sured the re-fitting of the stem or cement mantle to the 
femur, and in this way established the support of the 
endoprosthesis, which is also advised in the literature 
(4,49-51). The fracture healed without radiographic 
signs of a callus in 80%, indicating the absolute fixation 
stability that is desirable in these fractures (11,12). As 
the use of gap screws is impossible due to the presence 
of the stem, we tried to achieve absolute stability in 90% 
of the fractures with the use of cerclage. 
In most cases (except one), this ensured sufficient 
stability for primary healing. However, due to the poor-
er resistance of this type of fixation to torsional forces, 
we also always used a plate and screws to protect and 
Table 2: Comparison of periprosthetic femoral fracture of type B2 treatment between the group with osteosynthesis and 
the group with endoprosthesis replacement.
B 2
osteosynthesis endoprosthesis replacement
Number 3 7
Age (median) 81 (80–85) 75 (64–85)
Type of endoprosthesis uncemented 3 (100%) 5 (71%)
cemented 0 2 (29%)
Cerclage 3 (100%) 7 (100%)
Healing duration (average) 5 months 3.7 months
Endoprosthesis subsidence 2 0
Mechanical problems 1 (varus) 0
611
REVIEW ARTICLE
Principles and methods of fixation of periprosthetic fractures in stem region of hip prosthesis (Vancouver B)
References
1. Lehmann W, Rupprecht M, Hellmers N, Sellenschloh K, Briem D, 
Püschel K, et al. Biomechanical evaluation of peri- and interprosthetic 
fractures of the femur. J Trauma. 2010;68(6):1459-63. DOI: 10.1097/
TA.0b013e3181bb8d89 PMID: 20093986 
2. Rupprecht M, Schlickewei C, Fensky F, Morlock M, Püschel K, Rueger JM, 
et al. Periprosthetic and interimplant femoral fractures: biomechanical 
analysis. Unfallchirurg. 2015;118(12):1025-32. DOI: 10.1007/s00113-014-
2591-6 PMID: 24893727 
3. Khan T, Grindlay D, Ollivere BJ, Scammell BE, Manktelow AR, Pearson 
RG. A systematic review of Vancouver B2 and B3 periprosthetic femoral 
fractures. Bone Joint J. 2017;99-B(4):17-25. DOI: 10.1302/0301-620X.99B4.
BJJ-2016-1311.R1 PMID: 28363890 
4. Stoffel K, Blauth M, Joeris A, Blumenthal A, Rometsch E. Fracture fixation 
versus revision arthroplasty in Vancouver type B2 and B3 periprosthetic 
femoral fractures: a systematic review. Arch Orthop Trauma Surg. 
2020;140(10):1381-94. DOI: 10.1007/s00402-020-03332-7 PMID: 32086558 
5. Tsiridis E, Pavlou G, Venkatesh R, Bobak P, Gie G. Periprosthetic femoral 
fractures around hip arthroplasty: current concepts in their management. 
Hip Int. 2009;19(2):75-86. DOI: 10.1177/112070000901900201 PMID: 
19462362 
6. Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral 
fractures classification and demographics of 1049 periprosthetic 
femoral fractures from the Swedish National Hip Arthroplasty Register. 
J Arthroplasty. 2005;20(7):857-65. DOI: 10.1016/j.arth.2005.02.001 PMID: 
16230235 
7. Australian Orthopaedic Association National Joint Replacement 
RegistryAnnual Report. Adelaide: AOA; 2013. 
8. Lindahl H, Garellick G, Regnér H, Herberts P, Malchau H. Three hundred 
and twenty-one periprosthetic femoral fractures. J Bone Joint Surg Am. 
2006;88(6):1215-22. DOI: 10.2106/JBJS.E.00457 PMID: 16757753 
increase fixation stability. In most cases (80%), the plate 
was attached with bicortical screws. If locking screws 
could not be used due to the stem, standard ones were 
used. Modern literature also advocates such a principle 
(32-34).
Biomechanical studies warn of the possibility of a 
fracture at the implant if the plate is too short (ends 
in the diaphysis) or is attached to the bone too rigidly 
at the distal part or at the transition to unstrengthened 
bone (20-22,28). 
In our series, all plates reach to at least the begin-
ning of the distal femoral metaphysis. In 60%, the final 
screw was a locking screw, and in all cases but one, bi-
cortical. Despite quite rigid fixation at the distal femur, 
no fractures occurred at the implant under the plate. 
The reason for this can probably be found in the plate 
length, which did not end in the diaphysis, but rather in 
the significantly wider metaphysis.
All periprosthetic fractures at the stem have healed; 
in type B1 fractures, healing was, on average, half a 
month faster than in type B2 fractures. In patients with 
type B2 fractures who were treated with stem replace-
ment, the fracture healed 1.3 months faster than in 
those whose stem was not replaced. 
In type B1 fractures, all fractures healed without 
subsidence or deformations, confirming the stability 
of the stem before and after injury. With a loose stem 
(type B2), fixation achieved union, but in two cases of 
uncemented fixation, subsidence of the original stem 
by 0.5 cm occurred, and with a cemented endoprosthe-
sis, varus position of 10 degrees occurred. Such defor-
mations cause mild shortening of the lower limb, which 
is disruptive in functionally demanding patients and 
should therefore be avoided.
6 Conclusion
With the increase in arthroplasties due to degener-
ative hip joint disease and femoral neck fractures, the 
rise in the number of PFF is expected. Our goal should 
always be anatomical reduction with stable fixation in 
the case of these injuries and a stable stem. In fractures 
causing endoprosthesis instability, bone stock, type of 
fracture, endoprosthesis stability before the fracture 
and the expected patient functionality should all be tak-
en into account. If it is possible to ensure a stable stem 
after anatomical reduction and stable fixation with ad-
equate bone stock, fixation of type B2 fractures in the 
less active elderly can be a successful method of treat-
ment. When deciding on such a method, we must always 
consider the biomechanical properties of fixation at the 
stem. Anatomical reduction and stable fixation must be 
ensured. Most commonly, cerclage is used, but always 
with the addition of a plate that extends over most of 
the bone and ends in the metaphyseal part of the dis-
tal femur, where it should not be attached too rigidly. At 
the stem, the plate should always be attached to the bone 
with screws, which can be monocortical, but are ideally 
bicortical. In case of endoprosthesis loosening prior to 
injury, or if the type B2 fracture occurs in a younger and 
very active patient, the stem should be replaced, for only 
in this way can we ensure healing in the proper position.
Treatment of periprosthetic fractures is difficult. Treat-
ment should be adjusted to the type of fracture and pa-
tient characteristics, therefore, knowledge of osteosynthe-
sis techniques as well as revision arthroplasty is essential.
Conflict of interest
None declared.
612
SURGERY, ORTHOPAEDICS, TRAUMATOLOGY
Zdrav Vestn | November – December 2021 | Volume 90 | https://doi.org/10.6016/ZdravVestn.3120
9. Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 
fractures. Clin Orthop Relat Res. 1996;327:238-46. DOI: 10.1097/00003086-
199606000-00029 PMID: 8641069 
10. Quah C, Porteous M, Stephen A. Principles of managing Vancouver type 
B periprosthetic fractures around cemented polished tapered femoral 
stems. Eur J Orthop Surg Traumatol. 2017;27(4):477-82. DOI: 10.1007/
s00590-016-1883-7 PMID: 27889849 
11. Holzapfel BM, Prodinger PM, Hoberg M, Meffert R, Rudert M, Gradinger 
R. Periprosthetic fractures after total hip arthroplasty : classification, 
diagnosis and therapy strategies. Orthopade. 2010;39(5):519-35. DOI: 
10.1007/s00132-010-1612-6 PMID: 20405105 
12. Gaski GE, Scully SP. In brief: classifications in brief: Vancouver 
classification of postoperative periprosthetic femur fractures. Clin 
Orthop Relat Res. 2011;469(5):1507-10. DOI: 10.1007/s11999-010-1532-0 
PMID: 20809166 
13. de Boer P. Diaphyseal fractures: principles. In: Rüedi TP, Murphy WM. 
Principles of Fracture Management. Stuttgart: Thieme; 2010. pp. 93-104. 
14. Farouk O, Krettek C, Miclau T, Schandelmaier P, Tscherne H. The 
topography of the perforating vessels of the deep femoral artery. Clin 
Orthop Relat Res. 1999;368:255-9. DOI: 10.1097/00003086-199911000-
00031 PMID: 10613176 
15. Gautier E, Cordey J. Porosity and remodeling of plated bone after internal 
fixation: Result of stress shielding or vascular damage? Amsterdam: 
Elsevier Science Publishers; 1984. pp. 195-200. 
16. Wittner B, Holz U. Plates. In: Rüedi TP, Murphy WM. Principles of Fracture 
Management. Stuttgart: Thieme; 2010. pp. 169-84. 
17. Marongiu G, Dolci A, Verona M, Capone A. The biology and treatment 
of acute long-bones diaphyseal fractures: overview of the current 
options for bone healing enhancement. Bone Rep. 2020;12:100249. DOI: 
10.1016/j.bonr.2020.100249 PMID: 32025538 
18. Hollensteiner M, Sandriesser S, Bliven E, von Rüden C, Augat P. 
Biomechanics of Osteoporotic Fracture Fixation. Curr Osteoporos Rep. 
2019;17(6):363-74. DOI: 10.1007/s11914-019-00535-9 PMID: 31755030 
19. Ganji R. Challenges of Plate Fixation for Vancouver Type-C fractures 
after a Well-fixed Hip Arthroplasty Femoral Stem. Arch Bone Jt Surg. 
2019;7(6):571-2. PMID: 31970264 
20. Bottlang M, Doornink J, Byrd GD, Fitzpatrick DC, Madey SM. A nonlocking 
end screw can decrease fracture risk caused by locked plating in the 
osteoporotic diaphysis. J Bone Joint Surg Am. 2009;91(3):620-7. DOI: 
10.2106/JBJS.H.00408 PMID: 19255222 
21. OʼConnell RS, Owen JR, Hansen EJ, Bashir AS, Wayne JS, Satpathy J, et al. 
Biomechanical Evaluation of Osteoporotic Proximal Periprosthetic Femur 
Fractures With Proximal Bicortical Fixation and Allograft Struts. J Orthop 
Trauma. 2018;32(10):508-14. DOI: 10.1097/BOT.0000000000001261 PMID: 
30247278 
22. Alexander J, Morris RP, Kaimrajh D, Milne E, Latta L, Flink A, et al. 
Biomechanical evaluation of periprosthetic refractures following distal 
femur locking plate fixation. Injury. 2015;46(12):2368-73. DOI: 10.1016/j.
injury.2015.09.033 PMID: 26553428 
23. Bottlang M, Doornink J, Byrd GD, Fitzpatrick DC, Madey SM. A nonlocking 
end screw can decrease fracture risk caused by locked plating in the 
osteoporotic diaphysis. J Bone Joint Surg Am. 2009;91(3):620-7. DOI: 
10.2106/JBJS.H.00408 PMID: 19255222 
24. Mihalko WM, Beaudoin AJ, Cardea JA, Krause WR. Finite-element 
modelling of femoral shaft fracture fixation techniques post total 
hip arthroplasty. J Biomech. 1992;25(5):469-76. DOI: 10.1016/0021-
9290(92)90087-H PMID: 1592852 
25. Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler 
HP. Periprosthetic femoral fractures around well-fixed implants: use of 
cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 
2002;84(6):945-50. DOI: 10.2106/00004623-200206000-00008 PMID: 
12063328 
26. Dennis MG, Simon JA, Kummer FJ, Koval KJ, Di Cesare PE. Fixation of 
periprosthetic femoral shaft fractures: a biomechanical comparison 
of two techniques. J Orthop Trauma. 2001;15(3):177-80. DOI: 
10.1097/00005131-200103000-00005 PMID: 11265007 
27. Zdero R, Walker R, Waddell JP, Schemitsch EH. Biomechanical evaluation 
of periprosthetic femoral fracture fixation. J Bone Joint Surg Am. 
2008;90(5):1068-77. DOI: 10.2106/JBJS.F.01561 PMID: 18451400 
28. Wilson D, Frei H, Masri BA, Oxland TR, Duncan CP. A biomechanical study 
comparing cortical onlay allograft struts and plates in the treatment 
of periprosthetic femoral fractures. Clin Biomech (Bristol, Avon). 
2005;20(1):70-6. DOI: 10.1016/j.clinbiomech.2004.08.008 PMID: 15567539 
29. Lochab J, Carrothers A, Wong E, McLachlin S, Aldebeyan W, Jenkinson R, 
et al. Do Transcortical Screws in a Locking Plate Construct Improve the 
Stiffness in the Fixation of Vancouver B1 Periprosthetic Femur Fractures? 
A Biomechanical Analysis of 2 Different Plating Constructs. J Orthop 
Trauma. 2017;31(1):15-20. DOI: 10.1097/BOT.0000000000000704 PMID: 
28002219 
30. Schmotzer H, Tchejeyan GH, Dall DM. Surgical management of intra- and 
postoperative fractures of the femur about the tip of the stem in total 
hip arthroplasty. J Arthroplasty. 1996;11(6):709-17. DOI: 10.1016/S0883-
5403(96)80010-6 PMID: 8884447 
31. Fulkerson E, Koval K, Preston CF, Iesaka K, Kummer FJ, Egol KA. Fixation of 
periprosthetic femoral shaft fractures associated with cemented femoral 
stems: a biomechanical comparison of locked plating and conventional 
cable plates. J Orthop Trauma. 2006;20(2):89-93. DOI: 10.1097/01.
bot.0000199119.38359.96 PMID: 16462560 
32. Hoffmann MF, Burgers TA, Mason JJ, Williams BO, Sietsema DL, Jones CB. 
Biomechanical evaluation of fracture fixation constructs using a variable-
angle locked periprosthetic femur plate system. Injury. 2014;45(7):1035-
41. DOI: 10.1016/j.injury.2014.02.038 PMID: 24680467 
33. Lewis GS, Caroom CT, Wee H, Jurgensmeier D, Rothermel SD, Bramer MA, 
et al. Tangential Bicortical Locked Fixation Improves Stability in Vancouver 
B1 Periprosthetic Femur Fractures: A Biomechanical Study. J Orthop 
Trauma. 2015;29(10):e364-70. DOI: 10.1097/BOT.0000000000000365 
PMID: 26053467 
34. Konstantinidis L, Hauschild O, Beckmann NA, Hirschmüller A, Südkamp 
NP, Helwig P. Treatment of periprosthetic femoral fractures with 
two different minimal invasive angle-stable plates: biomechanical 
comparison studies on cadaveric bones. Injury. 2010;41(12):1256-61. 
DOI: 10.1016/j.injury.2010.05.007 PMID: 21288467 
35. Wähnert D, Schröder R, Schulze M, Westerhoff P, Raschke M, Stange R. 
Biomechanical comparison of two angular stable plate constructions for 
periprosthetic femur fracture fixation. Int Orthop. 2014;38(1):47-53. DOI: 
10.1007/s00264-013-2113-0 PMID: 24114243 
36. Dennis MG, Simon JA, Kummer FJ, Koval KJ, DiCesare PE. Fixation of 
periprosthetic femoral shaft fractures occurring at the tip of the stem: a 
biomechanical study of 5 techniques. J Arthroplasty. 2000;15(4):523-8. 
DOI: 10.1054/arth.2000.4339 PMID: 10884215 
37. Lenz M, Perren SM, Gueorguiev B, Richards RG, Hofmann GO, Fernandez 
dell’Oca A, et al. A biomechanical study on proximal plate fixation 
techniques in periprosthetic femur fractures. Injury. 2014;45:S71-5. DOI: 
10.1016/j.injury.2013.10.027 PMID: 24252576 
38. Konstantinidis L, Schmidt B, Bernstein A, Hirschmüller A, Schröter S, 
Südkamp NP, et al. Plate fixation of periprosthetic femur fractures: what 
happens to the cement mantle? Proc Inst Mech Eng H. 2017;231(2):138-
42. DOI: 10.1177/0954411916682769 PMID: 28013577 
39. Bibiano L, Stamboltsyan G, Touloupakis G, Ghirardelli S, Biancardi E, 
Longo GE, et al. Plate fixation in periprosthetic femur fractures Vancouver 
type B1: preliminary report of macroscopic evaluation of the cement 
mantle and short literature review. Acta Biomed. 2019;90(1):31-6. PMID: 
30889152 
613
REVIEW ARTICLE
Principles and methods of fixation of periprosthetic fractures in stem region of hip prosthesis (Vancouver B)
40. Wolff J. The law of bone remodelling. Berlin: SpringerVerlag; 1986. pp. 
3-22. DOI: 10.1007/978-3-642-71031-5_2 
41. Leonidou A, Moazen M, Lepetsos P, Graham SM, Macheras GA, Tsiridis 
E. The biomechanical effect of bone quality and fracture topography 
on locking plate fixation in periprosthetic femoral fractures. Injury. 
2015;46(2):213-7. DOI: 10.1016/j.injury.2014.10.060 PMID: 25467710 
42. Dehghan N, McKee MD, Nauth A, Ristevski B, Schemitsch EH. Surgical 
fixation of Vancouver type B1 periprosthetic femur fractures: a 
systematic review. J Orthop Trauma. 2014;28(12):721-7. DOI: 10.1097/
BOT.0000000000000126 PMID: 24736696 
43. Muizelaar A, Winemaker MJ, Quenneville CE, Wohl GR. Preliminary 
testing of a novel bilateral plating technique for treating periprosthetic 
fractures of the distal femur. Clin Biomech (Bristol, Avon). 2015;30(9):921-
6. DOI: 10.1016/j.clinbiomech.2015.07.008 PMID: 26233532 
44. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and 
revision hip and knee arthroplasty in the United States from 2005 to 
2030. J Bone Joint Surg Am. 2007;89(4):780-5. DOI: 10.2106/00004623-
200704000-00012 PMID: 17403800 
45. Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ. Epidemiology 
of periprosthetic fracture of the femur in 32 644 primary total hip 
arthroplasties: a 40-year experience. Bone Joint J. 2016;98-B(4):461-7. 
DOI: 10.1302/0301-620X.98B4.37201 PMID: 27037427 
46. Morrey BF, Kavanagh BF. Complications with revision of the femoral 
component of total hip arthroplasty. Comparison between cemented 
and uncemented techniques. J Arthroplasty. 1992;7(1):71-9. DOI: 
10.1016/0883-5403(92)90035-O PMID: 1564469 
47. Stuchin SA. Femoral shaft fracture in porous and press-fit total hip 
arthroplasty. Orthop Rev. 1990;19(2):153-9. PMID: 2181387 
48. Larson JE, Chao EY, Fitzgerald RH. Bypassing femoral cortical defects 
with cemented intramedullary stems. J Orthop Res. 1991;9(3):414-21. 
DOI: 10.1002/jor.1100090314 PMID: 2010846 
49. Antoniadis A, Camenzind R, Schelling G, Helmy N. Is primary 
osteosynthesis the better treatment of periprosthetic femur fractures 
Vancouver type B2? Br J Surg. 2017;104:17. 
50. Joestl J, Hofbauer M, Lang N, Tiefenboeck T, Hajdu S. Locking 
compression plate versus revision-prosthesis for Vancouver type B2 
periprosthetic femoral fractures after total hip arthroplasty. Injury. 
2016;47(4):939-43. DOI: 10.1016/j.injury.2016.01.036 PMID: 26872997 
51. Lunebourg A, Mouhsine E, Cherix S, Ollivier M, Chevalley F, Wettstein M. 
Treatment of type B periprosthetic femur fractures with curved non-
locking plate with eccentric holes: retrospective study of 43 patients with 
minimum 1-year follow-up. Orthop Traumatol Surg Res. 2015;101(3):277-
82. DOI: 10.1016/j.otsr.2015.01.015 PMID: 25817903