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Nonunion After Periprosthetic Femoral Fracture Associated with Total Hip Arthroplasty*

JOHN R. CROCKARELL, JR., M.D., DANIEL J. BERRY, M.D. and DAVID G. LEWALLEN, M.D., ROCHESTER, MINNESOTA

Investigation performed at the Department of Orthopedics, Mayo Clinic, Rochester

	Abstract

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Background: Nonunion after a periprosthetic femoral fracture associated with total hip arthroplasty occurs rarely. There is little information, to our knowledge, regarding the prevalence of this complication, its treatment, and the functional outcomes of treatment. The purpose of this study was to identify the patterns and frequency of nonunions of femoral fractures around total hip prostheses and to evaluate the results and problems associated with treatment of this complication in a consecutive series of patients. Methods: The study included twenty-three nonunions of periprosthetic femoral fractures in twenty-three patients with an average age of fifty-five years (range, twenty-two to eighty-five years) at the time of the initiation of treatment of the nonunion. Thirteen of the fractures occurred during or after a primary total hip arthroplasty, and ten occurred during or after a revision total hip arthroplasty. According to the classification system of Duncan and Masri, there were six B₁ fractures (associated with a well fixed prosthesis), seven B₂ fractures (associated with a loose stem), and ten B₃ fractures (associated with very poor proximal bone). Ten patients were managed with revision to a long-stem prosthesis. Six patients had revision to a proximal femoral replacement prosthesis. A two-stage technique consisting of removal of the prosthesis and open reduction and internal fixation of the nonunion followed by reimplantation of the prosthesis was used in two patients. Two patients were managed initially with bone-grafting alone, and two patients were managed nonoperatively. One patient who had an infection at the site of the nonunion was managed definitively with resection arthroplasty. Results: The duration of clinical follow-up averaged 8.3 years (range, three months to twenty-three years), and that of radiographic surveillance averaged 7.0 years (range, eight months to seventeen years). Of the thirteen patients in whom an attempt to achieve union was made and for whom radiographs were available, nine eventually had bone-healing. Five of the twenty-three femora became infected and were treated with resection arthroplasty. Of the seventeen patients who had not had a resection arthroplasty for infection and for whom radiographs were available at the time of the most recent follow-up, eleven had a stable and well fixed implant and six had a loose implant as seen radiographically or had had a revision because of aseptic loosening. Seventeen patients had no or mild pain at the time of the most recent follow-up, but ten required two-handed support to walk. The overall complication rate was 52 percent (twelve of twenty-three patients). Conclusions: Nonunion of a femoral fracture associated with a total hip prosthesis is an infrequent problem. Treatment is difficult, with a high rate of complications and relatively poor functional outcomes. The data from this series must be interpreted with caution, as patients were managed over a period of three decades and many did not have the advantage of modern techniques of revision hip arthroplasty. Prevention of nonunion by optimum treatment of the initial fracture is most important. Treatment of a femoral nonunion about a total hip implant should be implemented on the basis of the status of the fixation of the prosthesis and the quality of the surrounding bone.

	Introduction

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Fracture of the femur in association with total hip arthroplasty is a challenging complication that has been well described^2,8,12,19,20. The prevalence of these fractures has ranged from 0.1 percent (seven of 5400)¹⁰ to 20 percent (sixteen of seventy-nine)¹⁶ in series ranging in size from seventy-nine to 5400 hips^{1,3,5-7,9-11,13-18}. Risk factors include female gender, rheumatoid arthritis, cortical perforation, osteopenia, osteoporosis, preoperative femoral deformity, a revision operation, osteolysis, and loosening of the stem^1,4,10,17.

The methods available to treat periprosthetic fractures include traction, cast-bracing, open reduction and internal fixation with or without bone-grafting, and revision of the femoral component, either at the time of the initial treatment of the fracture or, less commonly, in a staged fashion after fixation of the fracture and bone-grafting. In cases of extremely poor-quality bone, resection of the proximal fragment and revision to a proximal femoral replacement with a so-called tumor prosthesis or an allograft-prosthesis composite has also been used.

While the various treatment modalities often provide successful results, nonunions were described after 17 percent (five) of twenty-nine periprosthetic femoral fractures complicating total hip arthroplasties in one series¹ (Figs. 1-A and 1-B). To our knowledge, data about this complication are confined to a few cases mentioned in series of acute periprosthetic fractures. We are aware of no previous reports specifically addressing management of a number of patients who had a nonunion of a periprosthetic femoral fracture. The purpose of the present study was to identify the patterns and frequency of nonunions of femoral fractures around total hip prostheses and to evaluate the results and problems associated with treatment of this complication in a consecutive series of patients.

View larger version (79K): [in this window] [in a new window]   Figs. 1-A and 1-B: Case 23. Fig. 1-A: Radiograph, made when the patient was seventy-two years old, demostrating a femoral fracture around a total hip prosthesis.

View larger version (80K): [in this window] [in a new window]   Fig. 1-B: Radiograph made 2.5 years after revision with a long-stem proximally porous-coated implant inserted without cement. The nonunion remained unhealed, and the femoral component was loose. The patient had little pain and was managed nonoperatively.

	Materials and Methods

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A review of our institution's total joint registry identified 807 patients who were managed at our institution for a femoral fracture around a total hip prosthesis between 1971 and 1995. During the same time-period, twenty-three periprosthetic fracture nonunions in twenty-three patients were treated at our institution. Of these, six complicated arthroplasties performed at our institution and seventeen complicated arthroplasties performed elsewhere in patients who were referred to our institution. Nonunion was defined as a fracture without signs of healing for longer than six months after the initial injury. Nonunions of the greater trochanter were not included in the study.

The twenty-three patients included thirteen women and ten men with an average age of fifty-five years (range, twenty-two to eighty-five years) (Table I). The diagnoses before the original arthroplasty included osteoarthritis in five patients, avascular necrosis in four, congenital dysplasia in three, nonunion of the femoral neck in three, rheumatoid arthritis in two, posttraumatic arthritis in two, and systemic lupus erythematosus, ankylosing spondylitis, fracture of the femoral neck, and an unknown diagnosis in one each. Fifteen left and eight right femora were fractured. The average height of the patients was 163 centimeters (range, 140 to 185 centimeters), and the average weight was seventy-one kilograms (range, fifty-one to 103 kilograms). An average of three previous hip procedures (range, one to five procedures) had been done before the operative treatment of the nonunion in the operatively treated patients. Thirteen fractures occurred during or after a primary total hip arthroplasty, and ten occurred during or after a revision total hip replacement. The nonunions were associated with thirteen different types of femoral prostheses, all but two of which had been implanted with cement. Eight of the fractures occurred intraoperatively, and fifteen occurred postoperatively.

Treatment of the nonunion was determined by the preference of the surgeon, as no specific protocol was in place during this time-period. Ten patients were managed with revision to a long-stem implant. Cement was used to fix nine of these stems (three long-stem Charnley implants [Thackray, Leeds, England], two long-stem Omnifit implants [Osteonics, Allendale, New Jersey], one long-stem Harris Precoat implant [Zimmer, Warsaw, Indiana], one 6-Ti-28 implant [Zimmer], one long-stem Harris Design-2 implant [Howmedica, Rutherford, New Jersey], and one custom long-stem Harris-Galante implant [Zimmer]). One BIAS stem (Zimmer) was inserted without cement. Six patients were managed with revision to a proximal femoral replacement prosthesis with cement. These so-called tumor prostheses included two custom Charnley components (Thackray), two custom Müller components (Howmedica), one custom Howmedica component, and one custom Osteonics component. The proximal part of the femur was resected in five of these patients and retained (and wrapped around the new implant) in one. Two patients were managed in a staged fashion with removal of the implant combined with open reduction and plate-and-screw fixation of the nonunion site followed by a second-stage reimplantation (performed at eight months in one patient and at twelve months in the other). Two patients were initially managed with bone-grafting without revision or more adjunctive internal fixation. Two were managed nonoperatively (Figs. 1-A and 1-B). One patient who had a deep infection in addition to a nonunion was managed definitively with resection arthroplasty.

Postoperative follow-up consisted of clinical examinations and radiographs at the time of routine appointments. Patients who were unable to return to our clinic were followed by letter and had radiographs sent in by their local physician.

Clinical follow-up after the treatment of the nonunions averaged 8.3 years (range, three months to twenty-three years). The only patient who was followed for less than two years died ninety-one days postoperatively of sepsis and adult respiratory distress syndrome. Postoperative radiographs were available for all but one patient. The most recent radiographs were made at an average of 7.0 years (range, eight months to seventeen years).

	Results

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Revision to a Long-Stem Prosthesis
Of the ten nonunions that were treated with revision to a long-stem prosthesis, four were categorized as B₁; two, as B₂; and four, as B₃. One of the revisions involved insertion of a proximally patch-porous-coated stem without cement, and in the remaining nine revisions the stem was fixed with cement. Bone-grafting was performed in nine of these patients. Autogenous cancellous or corticocancellous bone was used in five; allogenic cancellous bone, in two; mixed autogenous and allogenic cancellous bone, in one; and a proximal femoral allograft, in one. No patient was managed with a strut allograft. No trends could be identified between the type of bone graft (autogenous or allogenic) and the likelihood of healing, although the number of patients in each group was small. Five of these nonunions, including four treated with insertion of the stem with cement (Cases 2, 3, 5, and 8) and one treated with insertion of a proximally patch-porous-coated stem without cement (Case 9), failed to heal and were treated with another operation. Of these five nonunions, two (Cases 3 and 9) ultimately healed. Four nonunions (Cases 4, 6, 7, and 10) healed with no additional operation after the initial revision (Figs. 2-A and 2-B). Two patients (Cases 2 and 4) were managed with resection arthroplasty because of deep infection. One of these procedures was performed at three months after the revision and the other, at more than two years after the revision.

View larger version (113K): [in this window] [in a new window]   Figs. 2-A and 2-B: Case 6. Fig. 2-A: Radiograph, made when the patient was sixty-seven years old, demonstrating nonunion of a femoral fracture distal to a total hip prosthesis.

View larger version (79K): [in this window] [in a new window]   Fig. 2-B: Radiograph made four months after revision with a long-stem femoral component inserted with cement and bone-grafting at the site of the nonunion.

Proximal Femoral Replacement (Tumor Prosthesis)
Of the six nonunions that were treated with a proximal femoral replacement prosthesis, one was classified as B₁, one was classified as B₂, and four were classified as B₃. At the time of the most recent follow-up, three of the tumor prostheses were stable radiographically and two were loose. One had been removed because of deep infection more than three years after it had been inserted.

Staged Open Reduction and Internal Fixation Followed by Reimplantation
Both of the nonunions that were treated with removal of the prosthesis and open reduction and internal fixation with a dynamic compression plate and screws followed, in a second stage, by reimplantation were classified as B₂. Autogenous cancellous graft was used in one patient, and allogenic cancellous graft was used in the other. Both nonunions healed, and both prostheses were radiographically well fixed at the time of the most recent follow-up.

Bone-Grafting without Internal Fixation or Exchange of the Prosthesis
Of the two nonunions that were treated with bone-grafting alone, one was classified as B₁ and the other, as B₃. Both nonunions failed to heal. The B₁ nonunion had been treated initially with autogenous corticocancellous bone-grafting, and this was followed by revision of the femoral component with bone-grafting six months later. A deep infection developed and was treated with resection arthroplasty. The prosthesis was later reimplanted, and the nonunion healed. The femoral component was stable radiographically at the time of the most recent follow-up. The B₃ nonunion did not heal after treatment with a mixture of autogenous and allogenic cancellous bone, but the stem was radiographically stable at the time of the most recent follow-up.

Other Types of Treatment
One patient was managed initially with resection arthroplasty because of an infection at the site of the nonunion. In two older patients, the nonunion was treated nonoperatively; neither nonunion healed (Figs. 1-A and 1-B).

Overall Group
Overall, the nonunion eventually healed in ten of the sixteen patients in whom the proximal part of the femur was retained and for whom radiographs were available. Seven nonunions healed after the first operative intervention, and three required more than one operation. One patient needed four additional procedures to obtain union, one needed two additional procedures, and one needed one additional operation. At the time of the most recent follow-up, eleven of the seventeen femoral components that had not been resected because of infection and for which radiographs were available were radiographically stable, whereas six were radiographically loose or had been revised because of aseptic loosening.

In the group of twenty-one operatively treated patients, fourteen needed additional operative procedures after the initial operative treatment of the nonunion.

In total, twelve (52 percent) of the twenty-three patients had one or more complications of treatment of the nonunion or (in one patient [Case 21]) of the nonunion itself. These complications included deep infection (resulting in resection arthroplasty) in five patients; persistent nonunion in six; and fracture of the femoral prosthesis, a new postoperative femoral fracture, and recurrent dislocations in one each. Of the four deep infections that developed after treatment of the nonunion, one (Case 4) developed early after the initial operation to treat the nonunion (a revision to a long-stem prosthesis), one (Case 20) developed early after a second operation to treat the nonunion (revision with grafting, which followed bone-grafting alone [the initial operation]), and two developed more than two years after a single operative procedure to treat the nonunion (a revision to a long-stem prosthesis [Case 2] and a revision to a tumor prosthesis [Case 12]).

Clinical information regarding pain was available for twenty patients at the time of the most recent follow-up, and information regarding walking aids was available for twenty-one patients. Seventeen patients had no or mild pain, and three had moderate or severe pain. At the time of the most recent follow-up, five patients were able to walk without support, six needed to use a cane, and ten needed two-handed support.

	Discussion

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To our knowledge, no reports in the literature have dealt specifically with the outcome of treatment of a periprosthetic femoral nonunion associated with a total hip arthroplasty.

The present study showed that nonunion of a periprosthetic femoral fracture associated with a total hip arthroplasty is a rare occurrence. Regardless of the method of management that was chosen, the nonunions were extremely difficult to treat, and treatment was associated with a substantial rate of complications. Sixty-seven percent (fourteen) of twenty-one patients needed another operation after the initial operative treatment of the nonunion; the most common reasons for the reoperations were aseptic loosening, persistent nonunion, or deep infection. The high rate of problems associated with treatment of nonunion of periprosthetic femoral fracture mandates that efforts be made to prevent the problem from occurring by minimizing the frequency of circumstances that lead to periprosthetic femoral fracture and by optimum treatment of any acute periprosthetic femoral fracture that does occur. Periprosthetic femoral fractures may be prevented by (1) avoidance and proper treatment of intraoperative femoral cracks or perforations at the time of hip arthroplasty, (2) bypassing of substantial femoral cortical defects with longer-stem implants or protection of such defects with cortical strut grafts or plates, and (3) timely revision operations in patients who have progressive periprosthetic bone loss that puts them at high risk for fracture. The risk of nonunion of acute femoral fractures can be minimized by rigid and durable fracture fixation (with the femoral implant or a plate) and by the routine use of bone graft for many fractures.

Exact data regarding the prevalence of nonunion after periprosthetic femoral fracture are difficult to obtain from this study. Only nonunions that were identified in our total joint registry were included in our review. Some fractures that were initially treated at our institution may have resulted in nonunions that were subsequently treated elsewhere and thus could have escaped surveillance. Recognizing these limitations, we can state that periprosthetic fracture nonunions accounted for 3 percent (twenty-three) of the 807 intraoperative and postoperative periprosthetic fractures that were treated at our institution during the study period. A critical review of the literature, limited to articles that included the total number of arthroplasties, associated fractures, and nonunions, revealed an approximate prevalence of periprosthetic fracture of 224 (1.27 percent) of 17,644 total hip arthroplasties (Table II). Nine nonunions were reported in these same series^{1,3,6,7,10,11,14-18}, for an overall prevalence of 4 percent of periprosthetic fractures and 0.05 percent of total hip arthroplasties complicated by nonunion. To our knowledge, Adolphson et al.¹ described the largest group of patients in whom a periprosthetic femoral fracture following a total hip arthroplasty went on to nonunion. In that retrospective review, five of twenty-nine fractures went on to nonunion. No recommendations were made regarding treatment of periprosthetic nonunion.

Because of the limited number of patients who have a nonunion of a periprosthetic femoral fracture and the various methods of treatment that are used, comparison of specific treatment techniques is not possible. However, general principles for treatment of nonunions are similar to those for treatment of acute periprosthetic fractures; they are based on the status of the prosthesis and the quality of the available bone. A nonunion in association with a well fixed prosthesis and good-quality bone should generally be treated with rigid fixation and liberal bone-grafting, although revision to a long-stem device to gain the advantages of intramedullary fixation may also be considered under some circumstances. A loose stem should be revised, and fixation of the fracture should be obtained with the implant and ancillary fixation as needed. A stem that provides fixation in the diaphysis of the femur may be inserted without cement in patients who have adequate diaphyseal bone stock, whereas impaction-grafting techniques or revision with a long-stem component fixed with cement is reserved for those who have deficient diaphyseal bone. Regaining fracture stability is of utmost importance and should always be achieved with the previously mentioned methods of revision and, if necessary, with ancillary internal fixation devices. Onlay cortical strut grafts offer the advantage of providing both a mechanical and a biological contribution to the effort to achieve union of the fracture. Cancellous bone-grafting of the nonunion site is also advisable. Unreconstructible proximal femoral bone presents the most difficult scenario and can be managed in a variety of ways. In relatively young patients, the proximal part of the femur can be reconstructed either with an allograft-prosthesis composite or with staged treatment, whereas patients who have limited demands or life expectancy, or both, may be considered for management with a proximal femoral replacement prosthesis.

In summary, nonunions of periprosthetic femoral fractures after total hip arthroplasty occur infrequently. To our knowledge, this report describes the largest experience with these problems to date. Treatment of these nonunions is associated with a high rate of complications. Although most patients had pain relief, few were able to walk without support. It is our hope that better results will be achieved with the use of modern implants and improved operative techniques.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Campbell Clinic, 1500 West Poplar, Suite 301, Collierville, Tennessee 38017.

Department of Orthopedics, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.

	References

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				B. D. Springer, D. J. Berry, and D. G. Lewallen Treatment of Periprosthetic Femoral Fractures Following Total Hip Arthroplasty with Femoral Component Revision J. Bone Joint Surg. Am., November 1, 2003; 85(11): 2156 - 2162. [Abstract] [Full Text] [PDF]

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