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Periprosthetic femoral nonunions treated with internal fixation and bone grafting
Accepted Manuscript Title: PERIPROSTHETIC FEMORAL NONUNIONS TREATED WITH INTERNAL FIXATION AND BONE GRAFTING Authors: Jonne Prins, Johanna C.E. Donders, David L. Helfet, David S. Wellman, Craig E. Klinger, Mariya Redko, Peter Kloen PII: DOI: Reference:
S0020-1383(18)30618-1 https://doi.org/10.1016/j.injury.2018.10.019 JINJ 7889
To appear in:
Injury, Int. J. Care Injured
Accepted date:
15-10-2018
Please cite this article as: Prins J, Donders JCE, Helfet DL, Wellman DS, Klinger CE, Redko M, Kloen P, PERIPROSTHETIC FEMORAL NONUNIONS TREATED WITH INTERNAL FIXATION AND BONE GRAFTING, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
PERIPROSTHETIC FEMORAL NONUNIONS TREATED WITH
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INTERNAL FIXATION AND BONE GRAFTING
Ms. No. JINJ-D-18-00871 r1
PERIPROSTHETIC FEMORAL NONUNIONS TREATED WITH INTERNAL FIXATION AND BONE GRAFTING
Jonne Prins, MD1
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Johanna C.E. Donders, MD1 David L. Helfet, MD2
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David S. Wellman, MD2 Craig E. Klinger, BA2
Orthopaedic Trauma Service, Center for Hip Preservation, Hospital for Special Surgery and New York
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Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Peter Kloen, MD, PhD1
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Mariya Redko, BS3
Presbyterian Hospital, New York, NY, Weill Cornell Medicine, New York, NY Metabolic Bone Disease Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell
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Corresponding Author:
Medicine, New York, NY
Ms. No. JINJ-D-18-00871 r1
David L. Helfet M.D. 535 East 70th Street New York, NY, 10021 212-606-1888
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[email protected]
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ABSTRACT
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Introduction: Periprosthetic femoral nonunions (PPFN) have a reported incidence of 3-9%.
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Literature on PPFN management is scarce. The study aim was to review combined results of
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two academic teaching hospitals using comparable PPFN treatment strategies. Materials and Methods: A retrospective review was conducted of all patients treated for a
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PPFN between February 2005 and December 2016. All patients treated with internal fixation for a PPFN with complete clinical and radiological follow-up until healing were included.
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Nineteen patients were identified (mean age 71.2 years, range 49-87). Treatment consisted of failed hardware removal, debridement, reduction, and rigid internal fixation with or
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without bone graft. For revision PPFN surgery, use of dual-plating and bone graft
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augmentation was common. Results: Eighteen of 19 patients (94.7%) progressed to osseous union. One patient was converted to a total femoral prosthesis. No patients were lost to follow-up. All were ambulatory at last follow-up and mean follow-up was 39.8 months. Fourteen patients (73.7%) united after our index nonunion surgery at mean 9.8 months. Five patients (26.3%)
required revision surgery after our index nonunion treatment and in 4 of these cases union was achieved at mean 18.0 months. Conclusions: Our results suggest debridement, revision of fixation and liberal use of bone grafting can lead to reliable healing in the majority of PPFNs. For those PPFNs that do not
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heal following initial treatment, good healing potential persists with an additional procedure.
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Level of Evidence: Prognostic Level III.
INTRODUCTION Nonunion is common after periprosthetic femoral fracture (PPFF) treatment, occurring in 39% of patients. These cases present a treatment challenge, often in already compromised patient.[1-4] As the number of total hip and knee arthroplasties performed continues to
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rise, the number of nonunions will also likely rise [1, 4]. A periprosthetic femoral nonunion (PPFN) represents a complex reconstructive problem associated with high failure risk [3, 5].
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The patient is often weakened from the initial periprosthetic fracture surgery and either
wheelchair bound or ambulatory with a mobility aid; this leads to a significant decrease in quality of life and independence. There is often poor bone stock, failed implants, limited
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motion, and stiffness. Co-morbidities are often present including osteoporosis, rheumatoid
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arthritis, poor compliance to weight-bearing restrictions, and use of medication such as
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prednisone and insulin that can compromise bone and soft tissue healing [2, 6-10].
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Few PPFN treatment guidelines exist. Most literature on surgical management of PPFN involves few patients treated with a variety of techniques [3, 6, 9-14]. The largest series to
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date is almost 20 years old consisting mostly of revision to long-stem prostheses without internal fixation [5]. Following their report, plate and screw technology has improved
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allowing multi-planar locking fixation with periprosthetic fracture-specific plates. Additionally, bone graft supplements and commercial bone inductive agents are now widely
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available. These techniques have been employed successfully in nonunion treatment throughout the skeleton [15-22]. PPFN surgical outcomes have yet to be reported using these techniques.
Our study aim was to review combined results of two academic teaching hospitals using a comparable strategy for PPFN treatment consisting of failed fracture implant removal, debridement, assessment of prosthetic stability (with component revision as needed), soft tissue or capsular release as needed, multiple deep tissue cultures, realignment,
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compression, stable internal fixation and liberal bone graft augmentation. In addition, the available literature on PPFN treatment was reviewed. Institutional Review Board approval
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was granted for this research study.
PATIENTS AND METHODS
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Following Institutional Review Board approval, a retrospective search was performed in the
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electronic databases of three orthopedic trauma surgeons for patients with a PPFN.
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Inclusion criteria consisted of (i) no radiographic signs of bony healing at minimum 3 months
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after initial PPFF treatment, (ii) surgical intervention consisting of internal fixation with or
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without bone graft augmentation for PPFN treatment, and (iii) age greater than 18 years. Patients were excluded if (i) no information on previous PPFF management was available, (ii) they received surgical intervention for PPFN other than internal fixation and/or bone
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grafting with or without prosthetic revision, or if (iii) they received chemotherapy or
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radiotherapy prior to PPFN treatment. Some patients were referred after at least one attempt of nonunion surgery. For study purposes, index nonunion surgery was considered
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the first surgery performed by one of the senior authors. Antero-posterior (AP) and lateral PPFF radiographs before and after initial treatment were evaluated as well as before index PPFN surgery and at time of last follow-up. Each PPFF was classified using the Vancouver classification system for femoral fractures around a total hip replacement (THR), or the Neer classification system for femoral fractures around a total knee replacement (TKR) [23, 24].
Surgical Technique The patient is positioned supine on a radiolucent table. Antibiotics are withheld until five deep cultures of the nonunion are obtained. If implants are removed, they too are
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submitted for cultures. We do not use sonication to increase culture yield in our departments. Selection of autologous iliac crest bone graft (ICBG) or allograft demineralized
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bone matrix (DBM) is based upon surgeon preference. For ICBG, either anterior or posterior harvest technique is utilized. If anterior ICBG is either unavailable as a bone harvest or a large volume of autologous bone is needed, posterior ICBG is harvested first with the
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patient positioned prone. Once ICBG is harvested, the posterior wound(s) are closed and
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the patient is turned supine and repeat prepped and draped. Atraumatic surgical exposure
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is utilized, ideally through the prior scar. For a PPFN around a THR, a subvastus approach is
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utilized. The lateral femoral aspect and lateral plate is exposed. For a PPFN around a TKR, a
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subvastus approach is used for lateral plating and/or a medial subvastus approach if a medial plate or bone graft is added medially. All failed fixation implants are removed, including broken screws. Necrotic tissue and any intervening bony prominences are
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removed with a rongueur. Intravenous antibiotics (first generation cephalosporin) are given.
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If a tourniquet is employed, the IV antibiotic is given after which the tourniquet is released briefly to allow antibiotic circulation. Depending on operative time and/or blood loss, a
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second IV antibiotic dose is given. The prosthesis is checked for presence of loosening. The nonunion is inspected and debrided back to healthy bleeding bone edges. The femoral canal is opened with drill or curette until blood egresses from the medullary canal. Using an osteotome, the bone is petalled for about 2-3 cm on either side of the nonunion until the cortex evidences punctate bleeding. This procedure is performed on lateral, anterior and
posterior cortices with minimal soft tissue dissection. Alignment is achieved using standard AO techniques with pointed reduction clamps. Fluoroscopic views are obtained to confirm acceptable alignment in coronal and sagittal planes. Plating under compression is performed laterally, orthogonally (anterior and lateral) or in parallel (medially and laterally). In earlier
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years, we mainly utilized 95° blade plates (DePuy-Synthes, Johnson&Johnson, Westchester, PA; Amersfoort, the Netherlands). More recently we switched to locking plates. Currently,
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variable angle locking plates allow increased control of drilling direction while aiming for
optimal bone stock. Medially, Philos plates have been found to provide good fit with more 3.5mm locking screw fixation points. We err towards longer plates with bicortical fixation,
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whenever possible. If diaphyseal bone quality is good, there is no need for locking screws as
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this can make the construct too stiff. Not all screw holes are filled; providing balanced
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fixation. Unicortical locking screws are occasionally placed at the level of the prosthesis
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stem. If possible, lag screws are used through the plate and through the nonunion obliquity.
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We frequently utilize the articulated tension device to maximize compression. In Europe, mostly titanium plates were used whereas in the USA stainless was more common. Most nonunions were oligotrophic, requiring additional bone grafting. Based on surgeon
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preference, we use combinations of bone graft including autologous, allograft chips or
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struts, bone morphogenetic protein-2 (BMP-2, Medtronic, Minneapolis, MN), Plexur P (Medtronic, Minneapolis, MN) and demineralized bone matrix (DBM, Grafton Flex,
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Biohorizons, Birmingham, AL).
Patients follow fairly similar post-operative rehabilitation protocols with physical therapy starting on post-operative day one. Mobilization includes at least 6 weeks of toe-touch weight-bearing. Antibiotics are continued until all cultures are negative. If more than 2 of at
least 3 tissue cultures are positive (ideally 6 cultures are taken), an infectious disease specialist is consulted. In two patients, subcutaneous parathyroid hormone (PTH, Eli Lilly, Indianapolis, IN) was added for osteoporosis treatment based on individual patient assessment. Follow-up consisted of clinical and radiographic evaluation at routine clinical
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follow-up at 6 weeks, 3 and 6 months and one year, or until considered necessary.
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RESULTS
Nineteen patients were treated for a PPFN between February 2005 and November 2016 by three orthopedic trauma surgeons at the Academic Medical Center (AMC; Amsterdam, the
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Netherlands) and Hospital for Special Surgery (HSS; New York, NY). There were nine males
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and ten females with average age 71.2 years (range, 49-87) and average BMI 30.5 kg/m^2
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(range, 22.8-39.9). Thirteen nonunion patients were referred from another institution. Time
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between initial PPFF and PPFN index surgery averaged 11.2 months (range, 3-34). Ten
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patients sustained a femoral fracture above a TKR, eight around a THR and one had an interprosthetic fracture (between THR and TKR). Around a THR, there were 4 Vancouver B1, 1 B2 and 3 Vancouver C Type fractures. Around a TKR there were 4 Neer II, 5 Neer III and 1
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Neer IV Type fractures. One patient sustained both a Neer II and Vancouver C Type fracture
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(interprosthetic). Two patients had a broken plate at presentation. Low-energy trauma such as a standing height fall was the most common injury mechanism (16/19 cases; 84.2%)
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patients. Other injury mechanisms included high-energy trauma (2), and a stress fracture (1). Initial PPFF treatment differed. Ten patients had single-plating, five had single-plating with bone graft, two had dual-plating, one had dual-plating and bone graft, and one had revision THR with cable fixation. The most common presumed underlying nonunion cause was inadequate fixation (13/19; 68.4%), based on PPFN radiographs at presentation. Prior to
referral to our care, many patients underwent multiple surgeries. Eight patients underwent a total of thirteen additional surgeries after initial PPFF treatment at an outside institution before our index PPFN surgery. Two patients presented with infected nonunions (S. Aureus and P. Acnes; respectively). Twelve patients had an oligotrophic nonunion, 6 hypertrophic,
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and 1 atrophic. Prior to PPFN surgery, two patients were wheelchair bound while eleven required a walker or cane for ambulation. Six were able to ambulate without mobility aids
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but complained of pain. Mean number of medications was 5.9 per patient (range, 0-14). Comorbidities included hypertension (n=11), hypercholesterolemia (n=7), osteoporosis (n=1),
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osteoarthritis (n=3) and rheumatoid arthritis (n=1).
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For 15 patients the index nonunion treatment protocol consisted of failed hardware
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removal, debridement, internal fixation using AO techniques and liberal bone graft use. One
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patient solely received autologous bone graft and strut allograft without revision of fixation.
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One patient received internal fixation with antibiotic beads due to a recurring S. Aureus infection. In two patients, prosthetic revision was performed during index PPFN surgery. In one of these cases, a THR revision was done in addition to plate fixation, BMP-2, and DBM
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treatment. In the second patient, a longer stemmed hip prosthesis was implanted in
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addition to strut allograft and cable fixation. The prosthetic revisions were performed with
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assistance of an experienced revision arthroplasty surgeon.
Revision fixation in the remaining 15 patients consisted of single 4.5mm locked plating laterally (4 cases), 95° condylar blade plate laterally (3 cases) and dual-plating in 8 patients (orthogonal in 6 cases, and parallel plating in 2 cases); (Table 1).
Hospitalization averaged 7.4 days (range, 3-14). During hospitalization for the index procedure, no patients developed an infection, post-operative bleeding or required reoperation. Patients were followed an average of 39.8 months (range, 4-137) post-index nonunion surgery. Time to union for all patients averaged 11.0 months (range, 2-36). No
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intraoperative cultures from the index operation had positive culture results. In 14 patients (73.6%), union occurred following index surgery without complication. Mean months to
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union of this group was 9.8 months (range, 2-36); (Figs 1,2,3).
Complications
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Five patients (26.3%) required revision surgery for persistent nonunion after our index
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surgery (Table 2). In 2 patients, persistent nonunion with hardware failure occurred. After
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hardware removal and revision open reduction and internal fixation (ORIF) with bone graft
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augmentation, one patient healed 18 months after index surgery (case 2). The second
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patient underwent hardware removal and revision to a long-stem prosthesis, strut allograft and cable fixation. A second revision due to progressive deformity was necessary and comprised hardware removal and a longer long-stem prosthesis with cable fixation.
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Subsequently, this nonunion united 36 months post index surgery (case 13). In the third
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patient, nonunion requiring revision surgery had initially been treated using a LCP, autologous bone graft and DBM bone graft. Additional bone grafting at 4.5 months was
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done after radiographic evaluation showed insufficient consolidation. Osseous union was found 6 months following initial nonunion treatment (case 4). A fourth patient with persistent nonunion underwent revision surgery at 3 months with the addition of a medial LCP, strut allograft, Plexur P and BMP-2 after which the nonunion united at 12 months after the index surgery (case 17). The fifth patient required 4 additional surgeries after initial
locking plate fixation for her nonunion including additional plating and long-stem revision of her total knee prosthesis. She was treated with a total femoral prosthesis at 68 months after the index nonunion surgery (case 12).
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DISCUSSION AND CONCLUSIONS Scarce literature is available on operative PPFN treatment [3, 5-7, 10-13, 16, 25-29]. Most
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are case reports or small series (Table 3). With differing treatment strategies presented in
small patient groups, treatment guidelines remain unclear. A combination of biological and biomechanical problems is often present in this frail population. Careful planning is required
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to optimize chances for success. Key surgical aspects are the following: 1) removal of failed
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fixation implants 2)nonunion debridement 3)ruling-out and treatment of infection
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4)reduction/alignment 5)interfragmentary compression and 6) achieving stable fixation.
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Bone graft augmentation should be considered, with options including autograft, bone-
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inducing stimulants, allograft bone or DBM. BMP-2 is currently not advised for this indication and should therefore be considered off-label. The three treating surgeons in this study are experienced, orthopedic trauma fellowship-trained, adhering to the same
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concepts and techniques with a large segment of their practice involving nonunion surgery.
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This study illustrates challenges of PPFN treatment with relatively extended time to osseous union. Although 94.7% (18/19 patients) ultimately healed, five needed one or more revision
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surgeries to achieve union. It is difficult to compare our results to those of Crockarell et al. who treated most PPFN with long-stemmed prostheses [5].
The presumed underlying nonunion cause in our cohort was most often inadequate fixation and/or lack of inter-fragmentary lag screws (68.4%). As most patients ended up uniting their
PPFN with dual-plating (orthogonal or parallel) it seems single-plating may be insufficient in some instances. This is also reflected in the literature of recalcitrant nonunion treatment of other long bones [18, 30-33].
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Benefits of autologous bone graft for oligotrophic and atrophic nonunions are well known. Biological augmentation is easily achieved with local biologic supplements such as BMPs,
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DBM and allograft. In this cohort, all patients received either autologous bone graft or allograft in different forms (BMP-2, Plexur P, DBM or a combination) with the aim of
improving local biology. At this time, there is no evidence exogenous growth factors make a
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difference in nonunion treatment and the same holds for PTH usage. Only anecdotal
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evidence exists that PTH is beneficial in nonunion treatment [27, 32, 33]. Associated costs in
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light of limited evidence of benefit of these adjunctive measures is of concern.
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Strengths of our report are similar treatment strategies of ORIF employed by three experienced orthopedic trauma fellowship-trained surgeons. No patients were lost to follow-up and all follow-up data was obtained and registered in similar fashion. This study
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also has several limitations. It is retrospective in design which inherently creates bias. The
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numbers are still relatively small with short- to mid-term follow up. It also represents a heterogeneous group with different co-morbidities, medication, previous surgeries and
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bone quality. However, this is representative of the PPFN patient group with relatively old age.
To our knowledge, this article presents the largest PPFN series treated with ORIF. Multiple factors make treatment challenging including compromised biology and biomechanics,
often in a frail patient population. However, our study suggests outcomes of PPFN treatment can be rewarding. Patients should carefully be evaluated, and counseled that in a fairly large percentage of patients osseous union may necessitate more than one operation
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and therefore come at higher costs.
In our current treatment protocol, we have a low threshold to use double plating to
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increase stability of fixation. For the proximal femur a second plate is added anteriorly.
For the distal femur, addition of a medial buttress plate has proven successful to salvage these nonunions and aid in deformity correction. When choosing plate lengths, we err on
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the long side, often spanning the entire femur. Locking screw use is minimized, except in
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the distal femur metaphyseal region. Compression with interfragmentary fixation is a
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primary goal. Despite the availability of costly adjuncts to improve bone healing,
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S0020-1383(18)30618-1 https://doi.org/10.1016/j.injury.2018.10.019 JINJ 7889
To appear in:
Injury, Int. J. Care Injured
Accepted date:
15-10-2018
Please cite this article as: Prins J, Donders JCE, Helfet DL, Wellman DS, Klinger CE, Redko M, Kloen P, PERIPROSTHETIC FEMORAL NONUNIONS TREATED WITH INTERNAL FIXATION AND BONE GRAFTING, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
PERIPROSTHETIC FEMORAL NONUNIONS TREATED WITH
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INTERNAL FIXATION AND BONE GRAFTING
Ms. No. JINJ-D-18-00871 r1
PERIPROSTHETIC FEMORAL NONUNIONS TREATED WITH INTERNAL FIXATION AND BONE GRAFTING
Jonne Prins, MD1
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Johanna C.E. Donders, MD1 David L. Helfet, MD2
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David S. Wellman, MD2 Craig E. Klinger, BA2
Orthopaedic Trauma Service, Center for Hip Preservation, Hospital for Special Surgery and New York
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Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Peter Kloen, MD, PhD1
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Mariya Redko, BS3
Presbyterian Hospital, New York, NY, Weill Cornell Medicine, New York, NY Metabolic Bone Disease Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell
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Corresponding Author:
Medicine, New York, NY
Ms. No. JINJ-D-18-00871 r1
David L. Helfet M.D. 535 East 70th Street New York, NY, 10021 212-606-1888
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[email protected]
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ABSTRACT
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Introduction: Periprosthetic femoral nonunions (PPFN) have a reported incidence of 3-9%.
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Literature on PPFN management is scarce. The study aim was to review combined results of
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two academic teaching hospitals using comparable PPFN treatment strategies. Materials and Methods: A retrospective review was conducted of all patients treated for a
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PPFN between February 2005 and December 2016. All patients treated with internal fixation for a PPFN with complete clinical and radiological follow-up until healing were included.
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Nineteen patients were identified (mean age 71.2 years, range 49-87). Treatment consisted of failed hardware removal, debridement, reduction, and rigid internal fixation with or
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without bone graft. For revision PPFN surgery, use of dual-plating and bone graft
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augmentation was common. Results: Eighteen of 19 patients (94.7%) progressed to osseous union. One patient was converted to a total femoral prosthesis. No patients were lost to follow-up. All were ambulatory at last follow-up and mean follow-up was 39.8 months. Fourteen patients (73.7%) united after our index nonunion surgery at mean 9.8 months. Five patients (26.3%)
required revision surgery after our index nonunion treatment and in 4 of these cases union was achieved at mean 18.0 months. Conclusions: Our results suggest debridement, revision of fixation and liberal use of bone grafting can lead to reliable healing in the majority of PPFNs. For those PPFNs that do not
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heal following initial treatment, good healing potential persists with an additional procedure.
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Level of Evidence: Prognostic Level III.
INTRODUCTION Nonunion is common after periprosthetic femoral fracture (PPFF) treatment, occurring in 39% of patients. These cases present a treatment challenge, often in already compromised patient.[1-4] As the number of total hip and knee arthroplasties performed continues to
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rise, the number of nonunions will also likely rise [1, 4]. A periprosthetic femoral nonunion (PPFN) represents a complex reconstructive problem associated with high failure risk [3, 5].
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The patient is often weakened from the initial periprosthetic fracture surgery and either
wheelchair bound or ambulatory with a mobility aid; this leads to a significant decrease in quality of life and independence. There is often poor bone stock, failed implants, limited
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motion, and stiffness. Co-morbidities are often present including osteoporosis, rheumatoid
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arthritis, poor compliance to weight-bearing restrictions, and use of medication such as
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prednisone and insulin that can compromise bone and soft tissue healing [2, 6-10].
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Few PPFN treatment guidelines exist. Most literature on surgical management of PPFN involves few patients treated with a variety of techniques [3, 6, 9-14]. The largest series to
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date is almost 20 years old consisting mostly of revision to long-stem prostheses without internal fixation [5]. Following their report, plate and screw technology has improved
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allowing multi-planar locking fixation with periprosthetic fracture-specific plates. Additionally, bone graft supplements and commercial bone inductive agents are now widely
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available. These techniques have been employed successfully in nonunion treatment throughout the skeleton [15-22]. PPFN surgical outcomes have yet to be reported using these techniques.
Our study aim was to review combined results of two academic teaching hospitals using a comparable strategy for PPFN treatment consisting of failed fracture implant removal, debridement, assessment of prosthetic stability (with component revision as needed), soft tissue or capsular release as needed, multiple deep tissue cultures, realignment,
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compression, stable internal fixation and liberal bone graft augmentation. In addition, the available literature on PPFN treatment was reviewed. Institutional Review Board approval
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was granted for this research study.
PATIENTS AND METHODS
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Following Institutional Review Board approval, a retrospective search was performed in the
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electronic databases of three orthopedic trauma surgeons for patients with a PPFN.
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Inclusion criteria consisted of (i) no radiographic signs of bony healing at minimum 3 months
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after initial PPFF treatment, (ii) surgical intervention consisting of internal fixation with or
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without bone graft augmentation for PPFN treatment, and (iii) age greater than 18 years. Patients were excluded if (i) no information on previous PPFF management was available, (ii) they received surgical intervention for PPFN other than internal fixation and/or bone
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grafting with or without prosthetic revision, or if (iii) they received chemotherapy or
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radiotherapy prior to PPFN treatment. Some patients were referred after at least one attempt of nonunion surgery. For study purposes, index nonunion surgery was considered
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the first surgery performed by one of the senior authors. Antero-posterior (AP) and lateral PPFF radiographs before and after initial treatment were evaluated as well as before index PPFN surgery and at time of last follow-up. Each PPFF was classified using the Vancouver classification system for femoral fractures around a total hip replacement (THR), or the Neer classification system for femoral fractures around a total knee replacement (TKR) [23, 24].
Surgical Technique The patient is positioned supine on a radiolucent table. Antibiotics are withheld until five deep cultures of the nonunion are obtained. If implants are removed, they too are
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submitted for cultures. We do not use sonication to increase culture yield in our departments. Selection of autologous iliac crest bone graft (ICBG) or allograft demineralized
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bone matrix (DBM) is based upon surgeon preference. For ICBG, either anterior or posterior harvest technique is utilized. If anterior ICBG is either unavailable as a bone harvest or a large volume of autologous bone is needed, posterior ICBG is harvested first with the
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patient positioned prone. Once ICBG is harvested, the posterior wound(s) are closed and
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the patient is turned supine and repeat prepped and draped. Atraumatic surgical exposure
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is utilized, ideally through the prior scar. For a PPFN around a THR, a subvastus approach is
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utilized. The lateral femoral aspect and lateral plate is exposed. For a PPFN around a TKR, a
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subvastus approach is used for lateral plating and/or a medial subvastus approach if a medial plate or bone graft is added medially. All failed fixation implants are removed, including broken screws. Necrotic tissue and any intervening bony prominences are
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removed with a rongueur. Intravenous antibiotics (first generation cephalosporin) are given.
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If a tourniquet is employed, the IV antibiotic is given after which the tourniquet is released briefly to allow antibiotic circulation. Depending on operative time and/or blood loss, a
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second IV antibiotic dose is given. The prosthesis is checked for presence of loosening. The nonunion is inspected and debrided back to healthy bleeding bone edges. The femoral canal is opened with drill or curette until blood egresses from the medullary canal. Using an osteotome, the bone is petalled for about 2-3 cm on either side of the nonunion until the cortex evidences punctate bleeding. This procedure is performed on lateral, anterior and
posterior cortices with minimal soft tissue dissection. Alignment is achieved using standard AO techniques with pointed reduction clamps. Fluoroscopic views are obtained to confirm acceptable alignment in coronal and sagittal planes. Plating under compression is performed laterally, orthogonally (anterior and lateral) or in parallel (medially and laterally). In earlier
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years, we mainly utilized 95° blade plates (DePuy-Synthes, Johnson&Johnson, Westchester, PA; Amersfoort, the Netherlands). More recently we switched to locking plates. Currently,
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variable angle locking plates allow increased control of drilling direction while aiming for
optimal bone stock. Medially, Philos plates have been found to provide good fit with more 3.5mm locking screw fixation points. We err towards longer plates with bicortical fixation,
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whenever possible. If diaphyseal bone quality is good, there is no need for locking screws as
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this can make the construct too stiff. Not all screw holes are filled; providing balanced
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fixation. Unicortical locking screws are occasionally placed at the level of the prosthesis
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stem. If possible, lag screws are used through the plate and through the nonunion obliquity.
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We frequently utilize the articulated tension device to maximize compression. In Europe, mostly titanium plates were used whereas in the USA stainless was more common. Most nonunions were oligotrophic, requiring additional bone grafting. Based on surgeon
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preference, we use combinations of bone graft including autologous, allograft chips or
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struts, bone morphogenetic protein-2 (BMP-2, Medtronic, Minneapolis, MN), Plexur P (Medtronic, Minneapolis, MN) and demineralized bone matrix (DBM, Grafton Flex,
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Biohorizons, Birmingham, AL).
Patients follow fairly similar post-operative rehabilitation protocols with physical therapy starting on post-operative day one. Mobilization includes at least 6 weeks of toe-touch weight-bearing. Antibiotics are continued until all cultures are negative. If more than 2 of at
least 3 tissue cultures are positive (ideally 6 cultures are taken), an infectious disease specialist is consulted. In two patients, subcutaneous parathyroid hormone (PTH, Eli Lilly, Indianapolis, IN) was added for osteoporosis treatment based on individual patient assessment. Follow-up consisted of clinical and radiographic evaluation at routine clinical
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follow-up at 6 weeks, 3 and 6 months and one year, or until considered necessary.
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RESULTS
Nineteen patients were treated for a PPFN between February 2005 and November 2016 by three orthopedic trauma surgeons at the Academic Medical Center (AMC; Amsterdam, the
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Netherlands) and Hospital for Special Surgery (HSS; New York, NY). There were nine males
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and ten females with average age 71.2 years (range, 49-87) and average BMI 30.5 kg/m^2
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(range, 22.8-39.9). Thirteen nonunion patients were referred from another institution. Time
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between initial PPFF and PPFN index surgery averaged 11.2 months (range, 3-34). Ten
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patients sustained a femoral fracture above a TKR, eight around a THR and one had an interprosthetic fracture (between THR and TKR). Around a THR, there were 4 Vancouver B1, 1 B2 and 3 Vancouver C Type fractures. Around a TKR there were 4 Neer II, 5 Neer III and 1
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Neer IV Type fractures. One patient sustained both a Neer II and Vancouver C Type fracture
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(interprosthetic). Two patients had a broken plate at presentation. Low-energy trauma such as a standing height fall was the most common injury mechanism (16/19 cases; 84.2%)
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patients. Other injury mechanisms included high-energy trauma (2), and a stress fracture (1). Initial PPFF treatment differed. Ten patients had single-plating, five had single-plating with bone graft, two had dual-plating, one had dual-plating and bone graft, and one had revision THR with cable fixation. The most common presumed underlying nonunion cause was inadequate fixation (13/19; 68.4%), based on PPFN radiographs at presentation. Prior to
referral to our care, many patients underwent multiple surgeries. Eight patients underwent a total of thirteen additional surgeries after initial PPFF treatment at an outside institution before our index PPFN surgery. Two patients presented with infected nonunions (S. Aureus and P. Acnes; respectively). Twelve patients had an oligotrophic nonunion, 6 hypertrophic,
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and 1 atrophic. Prior to PPFN surgery, two patients were wheelchair bound while eleven required a walker or cane for ambulation. Six were able to ambulate without mobility aids
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but complained of pain. Mean number of medications was 5.9 per patient (range, 0-14). Comorbidities included hypertension (n=11), hypercholesterolemia (n=7), osteoporosis (n=1),
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osteoarthritis (n=3) and rheumatoid arthritis (n=1).
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For 15 patients the index nonunion treatment protocol consisted of failed hardware
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removal, debridement, internal fixation using AO techniques and liberal bone graft use. One
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patient solely received autologous bone graft and strut allograft without revision of fixation.
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One patient received internal fixation with antibiotic beads due to a recurring S. Aureus infection. In two patients, prosthetic revision was performed during index PPFN surgery. In one of these cases, a THR revision was done in addition to plate fixation, BMP-2, and DBM
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treatment. In the second patient, a longer stemmed hip prosthesis was implanted in
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addition to strut allograft and cable fixation. The prosthetic revisions were performed with
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assistance of an experienced revision arthroplasty surgeon.
Revision fixation in the remaining 15 patients consisted of single 4.5mm locked plating laterally (4 cases), 95° condylar blade plate laterally (3 cases) and dual-plating in 8 patients (orthogonal in 6 cases, and parallel plating in 2 cases); (Table 1).
Hospitalization averaged 7.4 days (range, 3-14). During hospitalization for the index procedure, no patients developed an infection, post-operative bleeding or required reoperation. Patients were followed an average of 39.8 months (range, 4-137) post-index nonunion surgery. Time to union for all patients averaged 11.0 months (range, 2-36). No
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intraoperative cultures from the index operation had positive culture results. In 14 patients (73.6%), union occurred following index surgery without complication. Mean months to
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union of this group was 9.8 months (range, 2-36); (Figs 1,2,3).
Complications
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Five patients (26.3%) required revision surgery for persistent nonunion after our index
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surgery (Table 2). In 2 patients, persistent nonunion with hardware failure occurred. After
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hardware removal and revision open reduction and internal fixation (ORIF) with bone graft
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augmentation, one patient healed 18 months after index surgery (case 2). The second
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patient underwent hardware removal and revision to a long-stem prosthesis, strut allograft and cable fixation. A second revision due to progressive deformity was necessary and comprised hardware removal and a longer long-stem prosthesis with cable fixation.
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Subsequently, this nonunion united 36 months post index surgery (case 13). In the third
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patient, nonunion requiring revision surgery had initially been treated using a LCP, autologous bone graft and DBM bone graft. Additional bone grafting at 4.5 months was
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done after radiographic evaluation showed insufficient consolidation. Osseous union was found 6 months following initial nonunion treatment (case 4). A fourth patient with persistent nonunion underwent revision surgery at 3 months with the addition of a medial LCP, strut allograft, Plexur P and BMP-2 after which the nonunion united at 12 months after the index surgery (case 17). The fifth patient required 4 additional surgeries after initial
locking plate fixation for her nonunion including additional plating and long-stem revision of her total knee prosthesis. She was treated with a total femoral prosthesis at 68 months after the index nonunion surgery (case 12).
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DISCUSSION AND CONCLUSIONS Scarce literature is available on operative PPFN treatment [3, 5-7, 10-13, 16, 25-29]. Most
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are case reports or small series (Table 3). With differing treatment strategies presented in
small patient groups, treatment guidelines remain unclear. A combination of biological and biomechanical problems is often present in this frail population. Careful planning is required
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to optimize chances for success. Key surgical aspects are the following: 1) removal of failed
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fixation implants 2)nonunion debridement 3)ruling-out and treatment of infection
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4)reduction/alignment 5)interfragmentary compression and 6) achieving stable fixation.
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Bone graft augmentation should be considered, with options including autograft, bone-
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inducing stimulants, allograft bone or DBM. BMP-2 is currently not advised for this indication and should therefore be considered off-label. The three treating surgeons in this study are experienced, orthopedic trauma fellowship-trained, adhering to the same
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concepts and techniques with a large segment of their practice involving nonunion surgery.
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This study illustrates challenges of PPFN treatment with relatively extended time to osseous union. Although 94.7% (18/19 patients) ultimately healed, five needed one or more revision
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surgeries to achieve union. It is difficult to compare our results to those of Crockarell et al. who treated most PPFN with long-stemmed prostheses [5].
The presumed underlying nonunion cause in our cohort was most often inadequate fixation and/or lack of inter-fragmentary lag screws (68.4%). As most patients ended up uniting their
PPFN with dual-plating (orthogonal or parallel) it seems single-plating may be insufficient in some instances. This is also reflected in the literature of recalcitrant nonunion treatment of other long bones [18, 30-33].
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Benefits of autologous bone graft for oligotrophic and atrophic nonunions are well known. Biological augmentation is easily achieved with local biologic supplements such as BMPs,
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DBM and allograft. In this cohort, all patients received either autologous bone graft or allograft in different forms (BMP-2, Plexur P, DBM or a combination) with the aim of
improving local biology. At this time, there is no evidence exogenous growth factors make a
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difference in nonunion treatment and the same holds for PTH usage. Only anecdotal
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evidence exists that PTH is beneficial in nonunion treatment [27, 32, 33]. Associated costs in
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light of limited evidence of benefit of these adjunctive measures is of concern.
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Strengths of our report are similar treatment strategies of ORIF employed by three experienced orthopedic trauma fellowship-trained surgeons. No patients were lost to follow-up and all follow-up data was obtained and registered in similar fashion. This study
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also has several limitations. It is retrospective in design which inherently creates bias. The
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numbers are still relatively small with short- to mid-term follow up. It also represents a heterogeneous group with different co-morbidities, medication, previous surgeries and
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bone quality. However, this is representative of the PPFN patient group with relatively old age.
To our knowledge, this article presents the largest PPFN series treated with ORIF. Multiple factors make treatment challenging including compromised biology and biomechanics,
often in a frail patient population. However, our study suggests outcomes of PPFN treatment can be rewarding. Patients should carefully be evaluated, and counseled that in a fairly large percentage of patients osseous union may necessitate more than one operation
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and therefore come at higher costs.
In our current treatment protocol, we have a low threshold to use double plating to
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increase stability of fixation. For the proximal femur a second plate is added anteriorly.
For the distal femur, addition of a medial buttress plate has proven successful to salvage these nonunions and aid in deformity correction. When choosing plate lengths, we err on
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the long side, often spanning the entire femur. Locking screw use is minimized, except in
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the distal femur metaphyseal region. Compression with interfragmentary fixation is a
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primary goal. Despite the availability of costly adjuncts to improve bone healing,
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