Effectiveness of open reduction internal fixation versus revision arthroplasty around Vancouver type B2 periprosthetic femoral fractures: a systematic review and meta-analysis

When orthopedic surgeons encounter periprosthetic femoral fractures after hip arthroplasty, the task they face becomes challenging. Controversy continues to surround the fixation of Vancouver type B2 fractures in particular. The most discussed and successful method is open reduction and internal fixation (ORIF) versus femoral stem revision arthroplasty (RA). Therefore, this article discusses both methods in order to compare the indications for both approaches. We systematically searched PubMed, Cochrane Library, Embase, and Web of Science (from January 1, 2006, to July 30, 2024) and included all studies comparing the outcomes of open reduction and internal fixation (ORIF) versus revison arthroplasty (RA) techniques. The primary outcome measures assessed were: injury to surgery time (ITST, days), union time (UT, months), length of hospital stay (LOS, days), surgical time (ST, minutes), and the Harris Hip Score (HHS). Complication metrics included: first-year mortality (FYM), blood transfusion rate (BT), as well as rates of revision, refracture, loosening, infection, dislocation, nonunion, subsidence, reoperation, total complications, and the proportion of patients with an American Society of Anesthesiologists (ASA) classification ≥ 3. Quality assessment (using the Newcastle-Ottawa Scale [NOS] for cohort studies) and data extraction were independently performed by two reviewers. This review included 34 studies comprising a total of 5137 patients.The injury to surgery time (days) was significantly shorter in the ORIF technique compared to the RA technique [Mean Difference (MD)=-0.66, [95% CI -1.16 to -0.15]; I2 = 65%, P = 0.01].In terms of the union time(days) (MD=-0.92, 95% CI -3.49-1.65, P = 0.57), surgical time (minutes) (MD=-0.87, 95%CI -2.80-1.07, P = 0.38), Harris hip score (MD = 0.66, 95% CI -3.44-4.77, P = 0.75) were superior in the ORIF technique compared to the RA technique.However the length of hospital stay (days), there were no significant differences observed. The ORIF technique exhibited a lower incidence of revision [Odds Ratio(OR)=-0.42, 95%CI 0.24–0.74, P = 0.0003] infection(OR = 0.61, 95%CI 0.41–0.92, P < 0.00001),dislocation(OR = 0.28, 95%CI 0.17–0.47, P < 0.00001) and nonunion(OR = 0.34, 95%CI 0.13–0.90, P = 0.03) compared to the RA technique alone.However the subsidence (OR = 0.48, 95% CI 0.23–0.99, P = 0.05) ,reoperation (OR = 0.73, 95% CI 0.35–1.53, P = 0.41), loosening (OR = 1.06, 95% CI 0.58–1.94, P = 0.86), and total complications (OR = 0.96, 95% CI 0.70–1.31, P = 0.79),there were no significant differences observed. Remaining complications, such as refracture rate(OR = 1.81, 95%CI 1.11–2.97, P = 0.02),the RA technique was superior than ORIF technique.In the anesthesia risk assessment of patients, more patients in the ORIF group had an ASA ≥ 3 than in the RA group, suggesting that patients in the former group were in worse general condition. ORIF poses a low risk to patients because it requires less surgical time; results in better postoperative union and functional recovery; and has lower rates of revision, dislocation, nonunion, and infection than other methods. ORIF that leads to fracture healing without the need for subsequent revision is advantageous, as reduced surgical time and complexity benefit patients. Finally, avoiding the use of long-stem implants during periprosthetic fracture fixation can benefit young patients who may require further revisions in the future.