Fig. 11.1
a Anteroposterior and b lateral radiographs of the right knee showing hardware failure, shortening and varus
The patient was evaluated and found only to have hepatitis C. The patient denied any history of wound problems or infections after the definitive procedure. The patient had not smoked for 30 years and quit drinking 10 years prior to presentation. Laboratory markers were all within normal limits for his white blood cell (WBC) count , C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) . Dual-energy X-ray absorptiometry (DEXA) scan had been obtained by his primary care provider and was normal. He had normal 25-OH vitamin D levels. His physical examination showed well-healed surgical scars as well as traumatic lacerations from the original injury, varus malalignment of the limb at the nonunion site and flexion only to 30°. A CT scan with coronal and sagittal reconstructions (Fig. 11.2) was obtained, which showed healing of the intra-articular component but a clear nonunion of the metaphyseal portion with varus collapse with pullout of screws as well as broken screws.
Fig. 11.2
a Axial computed tomography (CT) image showing healing of the intra-articular component; the gap between the plate and the bone is well visualized; b coronal CT image showing the varus alignment, failure of hardware and the metaphyseal nonunion; c sagittal image also showing the nonunion
The patient underwent hardware removal with debridement of all fibrous tissue from the nonunion site. The RIA system was utilized in a retrograde fashion to obtain bone graft from the femoral canal of the affected leg. A retrograde nail with a fixed angle blade component distally was inserted and statically locked proximally with two screws. The RIA bone graft was packed into the nonunion. The postoperative images are shown in Fig. 11.3.
Fig. 11.3
Immediate postoperative images after retrograde intramedullar nailing and bone grafting. a Full length right femur showing re-establishment of femoral anatomical axis; b, c anteroposterior and lateral of the right knee showing the nonunion site with bone graft
The patient went onto heal the nonunion by 7 months (Fig. 11.4). At this point, he underwent manipulation under anesthesia of his right knee, quadricepsplasty and an arthrotomy with lysis of adhesions for persistent poor knee motion (0° to 65°). The patient eventually achieved 110° of motion.
Fig. 11.4
a Anteroposterior and b lateral radiographs of the right knee at 7 months showing consolidation of the nonunion site
The patient did well and returned to his activities, which included downhill skiing. Patient returned 7 years later with complaints of knee pain, which was felt to be consistent with arthritic-like symptoms and probably a degenerative medial meniscal tear (Fig. 11.5). He was also having hardware symptoms distally at the lateral aspect of the knee. Arthroscopic debridement along with hardware removal was discussed with the patient since the patient was going under anesthesia. The patient had arthroscopic debridement of the knee. He was found to have Grade III medial tibial compartment disease but only Grade I lateral compartment disease. The nail was removed without difficulty (Fig. 11.6). Patient returned to his snow skiing and has improved motion to 120° of flexion and has always maintained his extension.
Fig. 11.5
a Anteroposterior and b lateral radiographs of the right femur at 7 years showing well-healed femur with stable hardware
Fig. 11.6
a Anteroposterior and b lateral radiographs of the right femur at 3 months after hardware removal
Case 2
The patient is a 54-year-old Latin American female who sustained multiple injuries in an MVA in 2006. The patient was treated for a left distal femur fracture with ORIF at an outside institution. The patient was followed for approximately 17 months, after which she was told she was healed and discharged. She apparently was fully weight bearing.
She then presented 2 years out from the initial injury with hardware failure and a nonunion of the left distal femur (Fig. 11.7). The patient was unable to give details of the injury as to whether or not it was an open fracture. The patient is morbidly obese. She has diabetes, hypertension and a history of deep vein thrombosis. Her laboratory evaluation showed a normal WBC but an elevated ESR of 74 and CRP of 21.3. Her other laboratory studies were within normal limits. The nuclear medicine studies obtained were negative. Clinically, she did not have any evidence of infection nor did she report ever having any wound problems or any other issues after the index procedure until 22 months later when she noticed the sudden pain. A CT scan was obtained and confirmed the nonunion and hardware failure. The joint was healed (Fig. 11.8).
Fig. 11.7
a Anteroposterior and b lateral radiographs of the left knee 2 years after the initial fixation showing loosening of hardware and nonunion. a The loose screw is easily visualized; b the break in the plate is well visualized as well as the recurvatum deformity at the nonunion site
Fig. 11.8
Computed tomography scan images showing the nonunion: a axial image showing lack of bone, b coronal image showing the varus and nonunion, c sagittal image showing the recurvatum deformity and nonunion
The patient underwent removal of the hardware, RIA of the femur for bone graft and placement of a retrograde nail with a fixed angle blade component distally. It was statically locked proximally with two screws. Her postoperative images are shown in Fig. 11.9.
Fig. 11.9
Immediate a anteroposterior and b lateral postoperative left femur radiographs showing stabilization of the nonunion with a retrograde nail and bone grafting
The patient was allowed to be immediately weight bearing and went on to heal by 6 months. (Figure 11.10). At her last follow-up of 13 months, she was ambulating fully with the use of a cane for long distances. She was pain-free with 0° to 95° of motion (Fig. 11.11).
Fig. 11.10
a Anteroposterior and b lateral left femur radiographs at 6 months showing consolidation across the nonunion site
Fig. 11.11
Final follow-up a anteroposterior and b lateral left femur radiographs at 13 months showing a well-healed femur without hardware complications
Case 3
The patient is a 38-year-old white male who was initially injured in an MVC while working out of town. He had sustained a left Grade IIIA open distal femur fracture/dislocation. His operative report indicated that both the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) were out, but no indication regarding the status of his collaterals. He had an initial irrigation and debridement with application of a temporary bridging external fixator. He subsequently underwent ORIF at the outside institution. Patient returned to the area and presented to our institution approximately 6 weeks out (Fig. 11.12).
Fig. 11.12
a Anteroposterior and b lateral left knee radiographs at 6 weeks after open reduction internal fixation. The fracture appears well reduced and restoration of the anatomical axis
The patient is otherwise healthy. His physical examination at that time showed well-healed incisions and traumatic lacerations. He was followed and felt to be progressively healing (Fig. 11.13; 6 months). He was fully weight bearing, but at 9 months he developed increased pain. The radiographs showed subsidence of the hardware and some collapse (Fig. 11.14). The patient underwent a CT scan (Fig. 11.15), which showed a persistent nonunion of the metaphyseal area as well as part of the intra-articular region. The allograft bone had not been incorporated.
Fig. 11.13
a Anteroposterior and b lateral left knee radiographs at 6 months. a There appears to be some consolidation at the medial cortex as well as in the metaphyseal region, but some subsidence of the plate is seen with collapse at the fracture site but stable hardware; b lateral shows increasing consolidation anteriorly
Fig. 11.14
a Anteroposterior and b lateral left knee radiographs at 9 months. a There appears to be further subsidence of the plate and thus collapse at the fracture site; b lateral shows increasing consolidation posteriorly and intact plate
Fig. 11.15
A computed tomography scan was obtained to evaluate the fracture site. a Axial image showing the allograft bone still unincorporated and a lack of bridging; b coronal image showing again the allograft bone and its lack of incorporation as well as subtle varus collapse; c the obvious nonunion is clearly visualized on the sagittal image
The patient underwent revision ORIF as opposed to nailing because of concern for a persistent intra-articular nonunion. The hardware was removed, and the allograft bone was nonviable and had not incorporated; it was debrided, resulting in the large void shown in Fig. 11.16. The intra-articular nonunion was stabilized with a screw (Fig. 11.17). Bone graft was obtained via the RIA system from the left femur after the hardware was removed. It was done retrograde through the nonunion site (Fig. 11.18). Revision ORIF with a variable angle locked plate was performed and the bone graft placed into the nonunion site with additional bone graft extender (demineralized bone matrix [DBM]) (Fig. 11.19). The final postoperative radiographs are shown in Fig. 11.20.
Fig. 11.16
Intra-operative fluoroscopic image after plate removal and debridement of the allograft showing the large void
Fig. 11.17
Intra-operative fluoroscopic image showing the additional partially threaded cancellous screw for lag screw fixation of the articular nonunion
Fig. 11.18
Intra-operative fluoroscopic image showing the reamer for the reamer–irrigator–aspirator (RIA) going retrograde through the mobile nonunion site
Fig. 11.19
Intra-operative fluoroscopic image after stabilization and bone grafting of the nonunion site
Fig. 11.20
Immediate postoperative a anteroposterior and b lateral left knee images showing the final construct
Patient went onto heal the nonunion with abundant bone around the site and was functioning well at 18 months. His range of motion was 0° to 115°. His last follow-up radiographs are shown in Fig. 11.21.
Fig. 11.21
Follow-up a anteroposterior and b lateral radiographs at 18 months after the revision open reduction internal fixation and bone grafting of the left knee, showing consolidation of the nonunion site
Case 4
The patient is a 51-year-old morbidly obese woman who is referred for a nonunion of her right distal femur. She is approximately one year out from her initial injury, which was a right grade III A open distal femur fracture. She was managed with ORIF at an outside institution. The radiographs showed bending of the plate and loosening of the screws distally. There was an obvious nonunion of the meta-diaphyseal region (Fig. 11.22).
