Which B2 Fractures Can Be Treated with ORIF? Validation of the "Beyond the Vancouver Classification"

Background and objectives: The objective was to validate the Beyond the Vancouver classification. Based on this algorithm, it was hypothesized that cemented polished tapered stems with an intact cement mantle and cementless stable stems with defined criteria could be classified as stable and therefore treated with open reduction and internal fixation (ORIF). Materials and Methods: This retrospective, single-center cohort study re-analyzed patients initially diagnosed with Vancouver type B2 fractures treated with ORIF between 2007 and 2020. Clinical and radiological outcomes were extracted from medical reports. A combined radiological and clinical score was used as the main outcome measure. Patients categorized according to the Beyond the Vancouver classification were compared for functional outcome. Results: 42 patients (25 male, 17 female) with a median (range) age of 83 years (75-88 years) and follow-up time of 25 weeks (12-35 weeks) were reviewed. It was found that ORIF achieved excellent or good results in 81% of cases for stems classified as stable (n = 16) and in 30% of cases for stems classified as loose (n = 23). Successful cases (30%), although classified as loose, all had the same fracture pattern: an intact greater trochanter and a fracture fragment attached laterally to the stem with distal fixation of the stem. Conclusions: This case series suggests that certain Vancouver B2 fractures can be treated with ORIF. The Beyond the Vancouver classification may support the categorization of 'stable' and 'loose' stems. The validity of the algorithm was supported by the observation that ORIF provided excellent and good results for the majority of stems classified as 'stable', but poor results for stems classified as 'loose'. Furthermore, the fracture pattern has been shown to be a crucial factor that should be considered when treating distally fixed cementless stems. The classification was therefore expanded to include the specific fracture patterns in cementless distally fixed stems that can be successfully treated with ORIF. The Beyond the Vancouver classification can provide further guidance in the identification of 'loose' or 'stable' stems.