Classification system
Vancouver Classification
Vancouver Classification of Periprosthetic Femoral Fractures
The Vancouver classification sorts a periprosthetic femoral fracture occurring after hip arthroplasty into type A at the trochanters, type B around or just below the stem — subdivided by whether the stem is well fixed (B1), loose with adequate bone stock (B2), or loose with deficient bone stock (B3) — and type C well distal to the stem, and it is the system that decides whether the fracture is fixed or the stem is revised.
What the Vancouver category means
Vancouver categories describe different patterns, not increasing severity — a higher-lettered or higher-numbered category is not necessarily a worse problem. The groups below are descriptive.
- Type A — trochanteric1–2
Usually managed non-operatively; address the underlying osteolysis.
- Type B1 — stem stable3–3
Open reduction and internal fixation, retaining the prosthesis.
- Type B2 — stem loose, bone adequate4–4
Revision to a long stem fixed distal to the fracture, with fracture fixation.
- Type B3 — stem loose, bone deficient5–5
Revision with proximal femoral reconstruction, allograft–prosthetic composite or proximal femoral replacement.
- Type C — distal to the stem6–6
Fixed as an isolated femoral fracture; the plate must overlap the stem to avoid a stress riser.
Published criteria and reliability
The published cut-offs that define this instrument, and the measured agreement between observers using it. Each is reported with the population it was derived in.
| Type | Value | Subscale | Population | Follow-up | Source |
|---|---|---|---|---|---|
| Criterion | Interobserver kappa 0.61 and 0.64 on two readings; intraobserver 0.73–0.83. Within type B, the radiographic type agreed with the intraoperative findings at kappa 0.78 | — | Six observers (three experts, three non-experts) classifying 40 radiographs twice, in the developers’ own reliability and validity study | — | Brady OH 2000 |
| Criterion | Interobserver kappa 0.72–0.74 for consultants, 0.68–0.70 for trainees, 0.61 for medical students; intraobserver 0.59–0.67. Type B fractures were correctly subtyped in 77% | — | Six consultants, six trainees and six medical students, each reading the radiographs on two occasions | — | Rayan F 2008 |
Criterion is a published cut-off, definition or performance figure belonging to a classification or decision rule — it is not a change score and should not be read as one.
How the score is calculated
Stated in full so the calculation can be independently checked, and reproduced by hand if needed.
The classification asks three questions in order. First, where is the fracture? A fracture of the greater or lesser trochanter is type A (A_G and A_L respectively). A fracture around the stem or just distal to its tip is type B. A fracture well distal to the stem, leaving the prosthesis uninvolved, is type C. Second, for type B only, is the stem well fixed? A well-fixed stem makes the fracture B1. Third, for a loose stem only, is the proximal bone stock adequate? Adequate bone makes it B2 and deficient bone makes it B3. The numeric ordering used on this page (A_G = 1, A_L = 2, B1 = 3, B2 = 4, B3 = 5, C = 6) simply follows the published order of the subtypes; it is not a severity score, and type C is generally a more straightforward problem than type B3.
Missing data
Only the branch relevant to the selected region is required. A type C fracture is settled by location alone, a type A fracture needs the trochanter, and a type B fracture needs the fixation status and, if the stem is loose, the bone stock. Until the branch is complete the result explains which answer is outstanding rather than guessing a type.
Instrument profile
- Developer
- Clive P. Duncan and Bassam A. Masri
- Institution
- University of British Columbia, Vancouver, Canada
- First published
- 1995
- Custodian
- Extended as the Unified Classification System (UCS) by Duncan and Haddad, 2014
- Items
- 4
- Response format
- Branching radiographic and intraoperative assessment
- Score range
- 1 to 6
- Direction
- Categories are not ranked by severity
- Completion time
- About 2 minutes
- Age range
- Adults with a femoral implant in situ
- Regions
- Hip
- Conditions
- Periprosthetic femoral fracture, Periprosthetic fracture after total hip arthroplasty, Periprosthetic fracture after hemiarthroplasty, Loose femoral stem
- Procedures
- Open reduction and internal fixation, Revision total hip arthroplasty, Long-stem femoral revision, Allograft–prosthetic composite, Proximal femoral replacement
- Validity
- The classification is prescriptive: each type maps onto a distinct operative plan, which is why it displaced purely descriptive schemes. Its weak point is the B1 versus B2 distinction, which depends on a judgement about stem fixation that radiographs taken through a fracture make unreliably; the practical consequence is that a stem judged well fixed before surgery is not infrequently found loose at exploration.
- Reliability
- Reported agreement is substantial for the A/B/C regions and lower for the B subtypes, where the disagreement concentrates.
When to use the Vancouver
Well suited to
- Any femoral fracture presenting after hip arthroplasty or hemiarthroplasty, to decide between fixation and revision.
- Planning implants and theatre resources, since the type determines whether a revision stem, allograft or megaprosthesis must be available.
- Reporting periprosthetic fracture outcomes in registries and trials, where it is the standard descriptive language.
Limitations and poor fits
- Fractures occurring during the index or revision operation — those are graded by the separate intraoperative classification.
- Periprosthetic acetabular fractures, periprosthetic fractures around knee or shoulder implants, and interprosthetic fractures between two implants; use the Unified Classification System for those.
- As a substitute for intraoperative assessment of stem fixation — the type may have to be revised once the femur is exposed.
- In isolation: patient physiology, bone quality, implant type and the availability of revision expertise all bear on whether the indicated operation is the right one for that patient.
Vancouver compared with other instruments
Instruments measuring a related construct, with the practical difference between them.
| Instrument | Items | Range | What it adds |
|---|---|---|---|
| Garden | 2 | 1–4 | The Garden classification grades intracapsular femoral neck fractures into four types by the completeness of the fracture line and the degree of displacement on an anteroposterior radiograph, where types I and II are non-displaced and types III and IV are displaced. |
| Harris Hip Score | — | 0–100 | The Harris Hip Score is a 100-point clinician-administered hip assessment combining 44 points for pain, 47 for function, 4 for absence of deformity and 5 for range of motion, where 90 or above is graded excellent and below 70 poor. |
Copyright and permitted use
Published openly because it is the question every clinician and researcher asks before using an instrument, and almost nobody answers it.
A published classification system for describing fracture patterns, not a copyrightable questionnaire. It is freely reproducible and no licence is required.
References
- Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instructional Course Lectures. 1995.
- Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. Journal of Arthroplasty. 2000.
- Rayan F, Dodd M, Haddad FS. European validation of the Vancouver classification of periprosthetic proximal femoral fractures. Journal of Bone and Joint Surgery (British). 2008.
- Naqvi GA, Baig SA, Awan N. Interobserver and intraobserver reliability and validity of the Vancouver classification system of periprosthetic femoral fractures after hip arthroplasty. Journal of Arthroplasty. 2012.
- Duncan CP, Haddad FS. The Unified Classification System (UCS): improving our understanding of periprosthetic fractures. Bone & Joint Journal. 2014.
Editorial status
This page has not yet been signed off by a named clinical reviewer. The scoring logic is stated in full above so it can be independently verified, and every threshold is traceable to its source. See our editorial methodology.