Orthopedics

Feature Article Supplemental Data

Treatment of Periprosthetic Nonunions of the Lower Extremity

Krishna C. Vemulapalli, MD; Stephen L. Davis, MD; Vasilios Mathews, MD; Robin N. Goytia, MD; Gregory W. Stocks, MD; Warren R. Dunn, MD, MPH; Mitzi S. Laughlin, PhD; Mark R. Brinker, MD

Abstract

Multiple studies have reported nonunion rates of 3% to 17% following peri-prosthetic fractures. Determining management strategies based on the available literature is difficult because existing studies are small and involve heterogeneous treatments and multiple surgeons. The purpose of this study was to describe a consecutive series of patients who presented to the authors' clinic with a periprosthetic nonunion of the lower extremity and to report the methods used to achieve limb salvage and the associated complications. Patients were included if they were indicated for surgery for a nonunion of a periprosthetic fracture of the lower extremity that had previously undergone either closed or open intervention. A total of 26 patients were included in this study. Average follow-up was 58 months. Average age was 69 years, and 77% of the patients were female. Twenty-three patients had periprosthetic nonunions of the femur, with 6 being associated with total hip arthroplasty, 15 with total knee arthroplasty, and 2 with both a total hip arthroplasty and a total knee arthroplasty. Three patients had a periprosthetic nonunion of the tibia associated with a total knee arthroplasty. Limb salvage was successful in 25 of 26 cases. This was achieved by either healing of the nonunion using exuberant fixation with prosthesis revision when necessary (n=20) or resection of the nonunion with placement of a tumor prosthesis (n=5). Four of the 26 patients (15%) incurred at least 1 complication during treatment. Exuberant fixation of the nonunion (with prosthesis revision when necessary) or nonunion resection with placement of a tumor prosthesis was successful in 96% of cases. [Orthopedics. 2020;43(x):xx–xx.]

Abstract

Multiple studies have reported nonunion rates of 3% to 17% following peri-prosthetic fractures. Determining management strategies based on the available literature is difficult because existing studies are small and involve heterogeneous treatments and multiple surgeons. The purpose of this study was to describe a consecutive series of patients who presented to the authors' clinic with a periprosthetic nonunion of the lower extremity and to report the methods used to achieve limb salvage and the associated complications. Patients were included if they were indicated for surgery for a nonunion of a periprosthetic fracture of the lower extremity that had previously undergone either closed or open intervention. A total of 26 patients were included in this study. Average follow-up was 58 months. Average age was 69 years, and 77% of the patients were female. Twenty-three patients had periprosthetic nonunions of the femur, with 6 being associated with total hip arthroplasty, 15 with total knee arthroplasty, and 2 with both a total hip arthroplasty and a total knee arthroplasty. Three patients had a periprosthetic nonunion of the tibia associated with a total knee arthroplasty. Limb salvage was successful in 25 of 26 cases. This was achieved by either healing of the nonunion using exuberant fixation with prosthesis revision when necessary (n=20) or resection of the nonunion with placement of a tumor prosthesis (n=5). Four of the 26 patients (15%) incurred at least 1 complication during treatment. Exuberant fixation of the nonunion (with prosthesis revision when necessary) or nonunion resection with placement of a tumor prosthesis was successful in 96% of cases. [Orthopedics. 2020;43(x):xx–xx.]

Total joint arthroplasty (TJA) of major joints is a common and highly successful operation. Periprosthetic fractures complicate up to 5% of all TJAs, and they are a major cause of re-operation along with infection and aseptic loosening.1–9 Complications such as infection, failure of fixation, nerve injury, and aseptic loosening accompany the treatment of periprosthetic fractures.1,5,6,8–11 Additionally, mortality can be particularly high after periprosthetic fracture of the femur, with rates between 10% and 17% reported.5,6,10,11

The number of TJAs performed each year is increasing.4,12 Thus, the number of periprosthetic fractures and nonunions occurring each year will likely increase proportionally.1,5,6,13,14 Due to the success of TJA, the indications for the procedure are widening and the average age of patients is decreasing. Consequently, patients with a TJA in situ are younger, are more active, are living longer with their prosthesis, and ultimately will undergo more revision arthroplasty procedures.1,5–7,9,11,14 Meanwhile, the reported rates of periprosthetic fractures are higher after revision TJA than after primary TJA, further increasing the number of potential nonunions after periprosthetic fracture.2,5,6,8,9 With all of these factors combined, the number of periprosthetic fractures and nonunions following TJA will likely continue to increase.

Multiple studies have reported a non-union rate of 3% to 17% following periprosthetic fractures.1,3,5,6,11,15 Treatment of a periprosthetic nonunion is based on the evaluation of the patient and the characteristics of the nonunion.16 Thus, treatment protocols are highly individualized, and few case series are available for review. The authors identified only two studies documenting treatment of a series of periprosthetic nonunions.2,7 Determining management strategies based on the available literature is difficult, as both of these series2,7 were small and involved heterogeneous treatments and multiple surgeons.

The purpose of this study was to document patient, fracture, and nonunion characteristics in a consecutive series of patients who presented to the authors' clinic with a periprosthetic nonunion of the lower extremity and to report the methods used to achieve limb salvage and the associated complications.

Materials and Methods

This retrospective consecutive case series was performed at a private quaternary referral center and received the approval of the hospital's institutional review board. The patients were identified from the senior author's (M.R.B.) patient database. Patients were included if they were indicated for surgery for a nonunion of a periprosthetic fracture of the lower extremity that had previously undergone either closed or open intervention. A total of 34 patients were identified. Eight were lost to follow-up, leaving 26 patients with 26 lower extremity periprosthetic nonunions.

Data collected for the study included patient factors (age, sex, comorbidities, and smoking status), nonunion characteristics, and surgical procedure performed and any associated complications. Nonunion was defined as a fracture with no signs of radiographic or clinical progression toward healing that, in the opinion of the senior author, lacked the potential for healing without further intervention.16,17 An acceptable end result was considered to be a salvaged limb allowing ambulation.

Preoperative Assessment

All patients had a similar preoperative workup consisting of a complete blood cell count, comprehensive metabolic panel, coagulation profile, erythrocyte sedimentation rate, C-reactive protein, and nonunion site aspiration for culture. Aspiration of the adjacent joint arthroplasty was performed for cases in which the non-union was contiguous with a prosthesis component, the nonunion was intracapsular, or there was a history of or clinical suspicion for periprosthetic infection. All patients were sent for preoperative medical optimization and anesthesia clearance. In cases of nonunions that were otherwise well reduced and stabilized without obvious technical errors or other explanations for their development, or in the case of multiple prior low-energy fractures with at least one fracture developing a non-union, an endocrinology consultation was obtained.16 Consultation with an arthroplasty surgeon was obtained whenever component revision was considered.

Nonunion Treatment

Surgical treatment was individualized, but it followed a general principle that the authors present as “exuberant fixation.” For patients with adequate bone stock proximal and distal to the nonunion, the authors advocated robust internal fixation, consisting of multiple components. First, existing implants were removed if they conflicted with the new treatment plan, were broken or had lost fixation, or were inadequately applied or inappropriate for the current application. Next, length, rotation, and alignment were restored if deformity was present. New oblique, parallel, flat bone cuts were used when possible to allow placement of lag screws. Atrophic and oligotrophic non-unions were debrided, compressed, and sometimes grafted with posterior iliac crest autograft (at the discretion of the treating surgeon), while hypertrophic nonunions were typically treated with augmented stability alone. The nonunion was dual plated, often with a combination of large fragment locking plates for the femur or a large fragment locking plate and a small fragment locking plate on the tibia. In some cases, an intramedullary nail with an augmentative locking plate was used in lieu of dual plates. Often, a bulk allograft strut was added to the dual plate construct with cerclage cables, especially in cases involving the femur.

If the arthroplasty was loose, then component revision was performed at the time of nonunion fixation. Distal femoral nonunions associated with total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) were first stabilized with a long, lateral, distal femoral locking plate with or without component revision. Medial large fragment locked plating and autografting was performed through a separate medial approach approximately 6 weeks later. A flow chart for decision-making in periprosthetic femoral non-unions is presented in Figure 1.

Decision-making flow chart for treatment of periprosthetic femoral nonunions.

Figure 1:

Decision-making flow chart for treatment of periprosthetic femoral nonunions.

In femoral nonunion cases with inadequate bone stock to allow for exuberant fixation, revision arthroplasty became the mainstay of treatment with either a tumor-type prosthesis and nonunion resection or long-stemmed revision and augmentation with strut allograft and cerclage cables. If revision arthroplasty was not possible due to poor bone stock, infection, or inadequate soft tissue coverage or incompetent and unreconstructable extensor mechanism, arthrodesis was considered.

Periprosthetic tibial nonunions were treated with one of the following strategies. Proximal tibial nonunions were treated with exuberant fixation and autogenous bone graft for atrophic and oligotrophic nonunions. Distal tibial nonunions were typically treated using the Ilizarov method, being careful to keep all proximal implants several centimeters distal to the most distal aspect of the tibial component of the TKA.

Infected nonunions were treated with aggressive serial debridements, possible segmental bone resection, antibiotic spacers, and two-stage revision arthroplasty, if necessary. Once the infection was cleared, treatment proceeded as previously described.

Results

A total of 26 patients were included in this series. Twenty-three patients had periprosthetic nonunions of the femur. Of these, 6 were associated with a THA, 15 with a TKA, and 2 with both a THA and a TKA. Three patients had a periprosthetic nonunion of the tibia associated with a TKA.

The average age was 69 years, and 77% of the patients were female. Comorbidities were common (Table 1). Seven patients were current or former smokers, having an average of 36 pack-years. The average time from most recent arthroplasty to fracture was 55.3 months, and the average time from fracture to presentation to the authors' clinic was 10.2 months. Three patients, 2 with THA and 1 with TKA, had already undergone revision arthroplasty at the time of presentation to the authors' clinic. There were 4 hypertrophic, 7 oligotrophic, and 15 atrophic nonunions (1 infected based on culture results). Patients had an average of 1.2 previous surgeries on their periprosthetic fracture prior to presentation, with 1 patient undergoing no prior surgery and 5 patients undergoing 2 prior surgeries. The patient who did not have a prior surgery was treated in a cast for a tibia fracture associated with a TKA.

Patient Demographics and Comorbidities

Table 1:

Patient Demographics and Comorbidities

The treatment details for each case are presented in Table A (available in the online version of the article). Patients in this cohort underwent an average of 1.6 surgeries at the authors' institution for their nonunions. Follow-up was obtained for 76% of the patients, averaging 58 months. Average time to union was 15.4 months; however, because many patients returned to the clinic after several months between visits, the authors could not determine the precise time union occurred. Furthermore, for 6 patients, the nonunion was resected and an endoprosthesis was implanted.

Periprosthetic nonunion characteristics, treatment, and complicationsPeriprosthetic nonunion characteristics, treatment, and complicationsPeriprosthetic nonunion characteristics, treatment, and complications

Table A.

Periprosthetic nonunion characteristics, treatment, and complications

Femoral Nonunion With THA (N=6)

Three femoral nonunions with THA were successfully treated with exuberant fixation alone after 1 surgery. Three others were treated with exuberant fixation and femoral stem revision. One patient treated with exuberant fixation and femoral stem revision healed following a single surgery, while 2 patients required 2 surgeries to achieve union.

Femoral Nonunion With TKA (N=15)

Five femoral nounions with TKA were treated with exuberant fixation alone, 2 with an intramedullary nail and exuberant fixation, 1 with an intramedullary nail alone, 1 with an exchange intramedullary nail, and 5 with an endoprosthesis and nonunion resection. Additionally, 1 patient was referred for an endocrinology evaluation; during treatment, the nonunion subsequently healed without surgery.

The 5 patients treated with exuberant fixation underwent an average of 1.2 surgeries and all experienced healing. One of these patients had lateral locked plating of the distal femur, followed by staged medial locked plating and bone grafting. One patient (patient 13) had exuberant fixation including an intramedullary nail, locked lateral plating, and a bulk allograft with cerclage cables as a single procedure (Figure 2). One patient had exuberant fixation plus an intramedullary nail and revision of the TKA. One patient treated with an intramedullary nail alone had 1 surgery and was initially lost to follow-up but returned after many months having healed. One patient treated with an exchange intra-medullary nail had 2 surgeries and healed. This patient had nail dynamization after the exchange procedure. Five patients were treated with an endoprosthesis. One of these patients was originally treated with intramedullary nail dynamization and marrow injection, then underwent an endoprosthesis for persistent nonunion. After developing a periprosthetic infection, this patient had serial debridements and an explant. This patient ultimately required an above-the-knee amputation after 5 surgeries. The remaining 4 patients were ambulating pain free at final follow-up. One of these patients initially presented with an infected nonunion and underwent 3 total surgeries for explant, debridement, and antibiotic spacer placement before revision to an endoprosthesis.

A 52-year-old man (patient 13) 4 months after having a periprosthetic femur fracture. At presentation to the authors' facility, the anteroposterior and lateral radiographs showed an atrophic femoral nonunion, broken hardware, and an oblique plane angular and translational deformity (A–C). The patient was treated with exuberant fixation including an intramedullary nail, a locked lateral plating, and a bulk allograft with cerclage cables, which restored alignment and bone contact (D, E). At 5.5 months after surgery, the femoral nonunion site showed solid bony union and the patient was ambulating pain free (F, G).

Figure 2:

A 52-year-old man (patient 13) 4 months after having a periprosthetic femur fracture. At presentation to the authors' facility, the anteroposterior and lateral radiographs showed an atrophic femoral nonunion, broken hardware, and an oblique plane angular and translational deformity (A–C). The patient was treated with exuberant fixation including an intramedullary nail, a locked lateral plating, and a bulk allograft with cerclage cables, which restored alignment and bone contact (D, E). At 5.5 months after surgery, the femoral nonunion site showed solid bony union and the patient was ambulating pain free (F, G).

Femoral Nonunion With THA and TKA (N=2)

One patient with femoral nonunion with THA and TKA was treated with exuberant fixation. The second patient was treated with a TKA endoprosthesis and prophylactic plating of the femur between the total knee and hip stems. The patient treated with a TKA endoprosthesis was ambulating without pain at final follow-up.

Tibial Nonunion With TKA (N=3)

One patient with tibial nonunion with TKA was treated with exuberant fixation, and 2 such patients were treated with Ilizarov external fixation. The patient treated with exuberant fixation required 1 additional surgery for irrigation and debridement but ultimately had healing free of infection. Of the 2 patients treated with Ilizarov external fixation, 1 patient had 2 surgeries before healing. The other patient had 1 surgery, but developed cellulitis and was admitted to the hospital for intravenous antibiotics. This patient ultimately had healing of the nonunion and was infection free at final follow-up.

Overall, limb salvage was successful in 25 of 26 patients (96%). The nonunion healed in 20 of 26 patients (77%), including 1 successfully treated with correction of metabolic/endocrine abnormalities without surgery. In 5 of 26 patients, the nonunion was resected and treated with an endoprosthesis. Limb salvage failed in 1 patient and resulted in above-the-knee amputation. Attempting limb salvage by either achieving union or resecting the nonunion and implanting an endoprosthesis was not without complications. Four of the 26 cases incurred a complication (15%), 1 of which was loss of the limb.

Discussion

To the authors' knowledge, this study is the largest series of periprosthetic non-unions to be reported. Additionally, this case series was from a single surgeon's practice; other reports in the literature involve cases pooled from multiple surgeons and centers. The authors have presented a patient cohort with lower extremity periprosthetic nonunions associated with THA and/or TKA. The evaluation and treatment of these cases is complex, as many of these patients are elderly and have multiple comorbidities. Additionally, almost all of these patients had multiple prior surgical procedures on the affected limb, thus complicating reconstruction.

Periprosthetic nonunion is currently an uncommon problem, but it will likely increase in the future. The authors were unable to reach specific conclusions about the treatment of this problem due to the small sample, but they believe that exuberant fixation along with prosthesis revision for loose components are important aspects. Risk factors for periprosthetic nonunion can be categorized as mechanical and biological.16 The former are primarily due to inadequate fixation, whereas the latter can be local (poor bone quality and/or severity of injury) or systemic (eg, comorbidities and/or metabolic, such as vitamin D deficiency). A majority of patients affected with this condition have poor bone quality, have had prior fixation attempts, and have compromised bone healing capacity due to medical comorbidities. Additionally, the biomechanical environment of a periprosthetic nonunion is unfavorable for healing due to limited space available for implant placement, as well as a stiff prosthesis that concentrates stress at the nonunion site. Thus, healing time for periprosthetic nonunions may be exceptionally longer than that for acute fractures, or even that of nonunions not associated with an arthroplasty.

The authors are aware of only two other studies in the literature reporting a series of periprosthetic nonunions. One study included 23 consecutive periprosthetic femoral nonunions about a THA stem collected from 1971 to 1995.2 Those authors defined a nonunion as “a fracture without signs of healing for longer than 6 months after the initial injury.”2 Thirteen of the nonunions occurred during or after a primary arthroplasty, while 10 occurred during or after a revision. The nonunion type was not reported in that study. Fourteen stems were found to be loose radiographically, and 10 patients were treated with revision to a long stem component (9 cemented), 6 were revised to a proximal femoral endoprosthesis, 2 were treated with two-stage explantation/open reduction and internal fixation and replantation at 10 to 12 months, and 2 patients were treated with bone grafting alone. Two of the remaining patients were treated nonoperatively, and 1 was treated with resection arthroplasty secondary to infection. Bone graft type was variable, including both autogenous and allogeneic cancellous grafts. In conclusion, these authors advised durable and rigid fixation with plates, cortical strut grafts, and long stem revision prostheses to avoid loss of fixation and allow healing.2 The complication rate was 52%. Limitations of that study included multiple surgeons and a treatment period spanning 24 years. Many current implant technologies, such as certain revision stem devices and locking plates, were not available to those authors, making conclusions about treatment from their study difficult to apply to current strategies.

In a more recent study, 13 patients with femoral nonunions around THA stems were treated between 1995 and 2002 by 4 surgeons at 2 centers.7 Nonunion was defined as either no healing at 6 months or failure of fixation. Nonunions were classified as atrophic in 12 patients and hypertrophic in 1 patient. Patients were treated based on implant stability and available bone stock. Four patients had complications requiring further surgery. Two patients had a dislocation of the hip, 1 had a new periprosthetic fracture, and 1 had symptomatic implants requiring implant removal. In all, those authors concluded that treatment with contemporary implants and fixation strategies led to improved outcomes over the previously described study. They recommended open reduction and internal fixation with a lateral plate and strut allograft augmentation for biplanar fixation in patients with a stable implant and adequate bone stock. For nonunions with an unstable implant but adequate bone stock, those authors recommended revision to a fully porous-coated stem combined with open reduction and internal fixation and grafting. Finally, for patients with inadequate bone stock, they recommended cemented proximal femoral replacement. Those authors also stressed the importance of identifying infection preoperatively, and suggested that cortical strut allografts are necessary to augment fixation and improve healing rates.7

Conclusion

A single-surgeon experience with subsequent homogeneity of patient evaluation and surgical approach during a 15-year period has been reported. Overall, limb salvage was successful in 25 of 26 patients. Attempting limb salvage by either achieving union with exuberant fixation or resecting the nonunion and implanting an endoprosthesis had a 15% complication rate, with 1 complication being loss of the limb. Exuberant fixation and prosthesis revision when necessary are vital to successful treatment of this difficult problem.

References

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Patient Demographics and Comorbidities

Patient No.Age, ySexComorbidities
171MHTN, kidney disease
264FHTN, DM, anemia, asthma
361FCAD, HTN, DM, HLD
466FCAD, HTN, HLD, TIA, GERD, hypothyroidism, anemia, lumbar stenosis
548FHLD, GERD, hip dysplasia
681MPrior radiation to thigh
779FHTN, heart murmur, thyroid problem
859FHTN, osteoporosis
981FDVT, HTN, CAD, pacemaker, warfarin, HLD, sick sinus syndrome, PE
1058FDM, HTN, HLD, polio RLE
1175FDM, HTN, HLD
1291FHTN, mitral valve prolapse, tragic dentition
1352MHTN, DM, HLD
1469FCAD, HTN, RA, GERD, osteoporosis, arrhythmia, anemia, pneumonia, neuropathy
1565MHTN, gout
1670FHeart murmur, abnormal EKG, HTN, stroke
1776FHTN, kidney disease, DM
1879FHTN, DM, anemia, lymphedema, CAD, TIA, GERD, obesity, chronic pain
1982FStroke, hepatitis
2068FSeizure disorder, breast cancer, depression, anxiety
2164FRA, DVT, hepatitis B, mitral valve prolapse, fibromyalgia
2259FHTN, asthma, heart murmur, chronic renal insufficiency
2383FCAD, HTN, splenic artery aneurysm, asthma, arrhythmia
2457FOsteoporosis, HLD, chronic osteomyelitis
2569MIDDM, HTN
2677MHTN, HLD

Periprosthetic nonunion characteristics, treatment, and complications

IDProsthesisFracture siteInitial InjuryNonunion TypeTreatment of nonunion (# and type of procedure)Follow-up duration (mo)Complications
1THAFemurClosedOligotrophic1: Hardware removal, PICBG, OP-1, bulk allograft, head exchange, lateral locked plating 2: Hardware removal at 4.5yr93
2THAFemurClosedAtrophic1: Removal of hardware, posterior strut allograft, PICBG, lateral locking plate, InFuse12
3THAFemurClosedOligotrophic1: Removal hardware, Lateral and posterior dual locking plates, Interfrag fixation, Bulk allograft with cables, PICBG28
4THAFemurClosedAtrophic1: Dual locking plates, PICBG 2: Removal hardware, PICBG, osteoplasty/shortening of femur, revision long stem femoral component, ant/lateral plates & posterior allograft strut16Lost fixation at 8 months.
5THAFemurClosedAtrophic1: ROH, RIA L femur, Long stem revision, lateral/posterior locked plates, medial allograft strut 2: Resection of distal allograft15
6THAFemurClosedAtrophic1: ROH, dual plates and PICBG, revision long stem THA2
7THA & TKAFemurClosedAtrophic1: ROH, Trinity bone graft, posterior & lateral locked plates, allograft strut & cables15
8THA & TKAFemurClosedAtrophic1: Revision long stem femoral component (TKA) and prophylactic plating of the femur20
9TKAFemurOpenAtrophic1: Medial augmentative plating, PICBG. Retention of laterally based locking plate27
10TKAFemurClosedHypertrophic1: Removal medial and lateral plates 2: Revision TKA, shortening osteoplasty, local bone graft, retrograde IM nail, medial & lateral allograft struts, lateral locking plate and cables, OP-195
11TKAFemurClosedHypertrophic1: Removal hardware, local autograft, revision ORIF distal femur37
12TKAFemurClosedHypertrophic1: Medial augmentative plating with local bone graft, retained lateral plate, and patellar resurfacing17
13TKAFemurClosedAtrophic1: Removal hardware, distal femoral corticotomy, retrograde IM nail, RIA, locking plate, allograft strut42
14TKAFemurClosedAtrophic1: Removal IM nail, PICBG, parallel flat cuts, lag screws, distal femoral locking plate, InFuse8Iliac crest wound breakdown
15TKAFemurClosedHypertrophic1: Removal hardware, IM Nail62
16TKAFemurClosedOligotrophic1: Exchange nail 2: Nail dynamization15
17TKAFemurClosedOligotrophic1: Nail dynamization 2: Resection of nonunion and tumor prosthesis23
18TKAFemurClosedAtrophic1: Marrow injection, nail dynamization 2: ROH, tumor replacement prosthesis 3: I&D, poly exchange 4: I&D, explant, abx spacer 5: AKA26Infected tumor replacement prosthesis leading to AKA.
19TKAFemurClosedAtrophic1: ROH, tumor replacement prosthesis7
20TKAFemurClosedAtrophic1: Resection distal femoral nonunion, tumor endoprosthesis replacement5
21TKAFemurOpenOligotrophic1: Removal retained implants, I&D, abx beads 2: Resect nonunion, abx spacer 3: Tumor prosthesis9
22TKAFemurClosedAtrophicSurgery planned. Patient referred for endocrinology evaluation and treatment; patient lost to follow up for 14 months. Repeat CT at 14 months showed solid healing.18
23TKAFemurClosedOligotrophic1: Removal deep implant, revision ORIF 2: PICBG, augmentative medial plating24
24TKATibiaClosedAtrophic & Infected1: Posterior crest marrow aspiration, Ilizarov, partial fibulectomy 2: Removal and new Ilizarov, PICBG, trimming to flat bone ends59
25TKATibiaClosedOligotrophic1: ROH, PICBG, partial fibulectomy, Ilizarov158Cellulitis - admitted for IV antibiotics. Infection free at final follow-up.
26TKATibiaClosedAtrophic

HWR, PICBG, dual plating tibia

I&D, abx beads

7
Authors

The authors are from the Department of Orthopedic Surgery (KCV), University of Texas Medical School at Houston, Fondren Orthopedic Group (VM, RNG, GWS, MRB), and Fondren Orthopedic Research Institute (WRD, MSL), Houston, Texas; and the Bone and Joint Institute (SLD), Hartford Hospital, University of Connecticut, Hartford, Connecticut.

Drs Vemulapalli, Davis, Dunn, Laughlin, and Brinker have no relevant financial relationships to disclose. Dr Mathews is a paid consultant for DePuy. Dr Goytia receives royalties from Innomed. Dr Stocks holds stock in Nimbic Systems, Inc.

Correspondence should be addressed to: Warren R. Dunn, MD, MPH, Fondren Orthopedic Research Institute, 7401 S Main St, Houston, TX 77030 ( warren.dunn@fondren.com).

Received: October 02, 2019
Accepted: February 05, 2020
Posted Online: May 05, 2020

10.3928/01477447-20200428-04

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