https://orcid.org/0000-0002-1982-6641
The incidence of periprosthetic femoral fracture (PPFF) after total hip arthroplasty (THA) has increased dramatically in the last 20 years due to the increased number of THACitation1,Citation2. PPFF are difficult to manage and may lead to poor outcomes. Post-THA treatment of PPFF remains a surgical challenge and the complications burdened by a high morbidity and mortality rateCitation3,Citation4. Therefore, reasonable and individualized treatment principles should be established to obtain ideal outcomesCitation5.
The Vancouver Classification System (VCS)Citation6 for PPFF was once universally accepted. It focuses on the location of the fracture relative to the stem, the stability of the implant, and the associated bone loss. The VCS has been shown to be reliable and valid, but needs to be refinedCitation7–9. Lee et al.Citation10 recently tested the reliability and validity of the VCS exclusively on type B fractures in cementless stems. The results also confirmed that radiographic assessment alone may be inadequate for the determination of stability of cementless stems in PPFF.
The Unified Classification System (UCS)Citation5 expanded upon and updated the VCS, and covers the management of all periprosthetic fractures. When applied to the femur, the UCS incorporates the previous VCS but is expanded to include two new fracture patterns, Type D and E. As for the UCS, two previous studiesCitation11,Citation12 evaluated the reproducibility applied to the femur. The results showed it to be reliable and valid. More recently, De Meo et al.Citation13 reassessed the reliability and validity of the UCS by comparing the results of the VCS in PPFF in 40 patients. The results showed that the UCS is reliable and had a slightly higher validity when compared with the VCS.
The original VCS and subsequent UCS were intended be simple systems to classify fractures and guide management. The UCS covers the management of all periprosthetic fractures, not just the femur. When applied to the proximal femur, however, the UCS fails to resolve the VCS controversy, linked to the difficulty of evaluating the stem’s stability in type B fractures. Another limitation is the absence of some specific fracture pattern in PPFFCitation13–15. Due to this reason, Huang et al.Citation15 modified the UCS for PPFF by adding two new B2 subtypes and a new category to encompass stem fracture alone or accompanied by PPFF. Intra- and interobserver reliability and validity of the modified UCS was tested by the same group, and the results revealed clinical significance with high reliability and validityCitation16.
The goal of any classification system is to improve outcomes. To achieve this goal, the classification system should be easy to learn and simple to use, and also provide reasonable, credible and effective treatment guidanceCitation12,Citation15. I suggest that trainee surgeons master the original VCS and subsequent UCS, and consultants master the modified UCS.
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Declaration of financial/other relationships
The author has no relevant or other financial disclosures for this commentary.
Acknowledgements
None reported.
References
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