Bifocal treatment for peri-articular femoral nonunions: A retrospective case series review

AIM: This is a retrospective review of complex periarticular femoral nonunions where bone loss from comminution at original fracture, subsequent infection or lysis was identified and treated by radical excision, internal fixation, and concurrent femoral lengthening from a different level. MATERIAL AND METHOD: Sixteen patients with a mean age of 41 years were treated. There were 6 infected nonunions. Ten nonunions were located in the distal femur and the remaining proximal. Case notes and radiograph review were used to determine fracture union, lengthening achieved, and complications. Patient outcome was assessed using the SF-12, Tegner–Lysholm Knee Score, and Oxford Hip Score. RESULTS: Fracture union was achieved in all patients. The mean lengthening performed was 51 mm (range 30–80) with a fixator time averaging 39 weeks (range 17–80). The bone healing index was 1.9 months/cm. All but 2 patients were restored to within 5 mm of opposite leg length; 1 patient subsequently underwent contralateral limb shortening. The SF-12 had a mean Physical Health Composite Score of 40.0 (22.4–52.9) and a mean Mental Health Composite Score of 49 (30.7–62.0). The Oxford Hip Score was scored at a mean of 39 (21–47) and the Tegner–Lysholm score had a mean of 71 (36–94). There were 3 cases of fracture/deformity from the lengthened bone column (regenerate) and 2 patients required a quadricepsplasty for knee stiffness that was present prior to the treatment for the nonunion. CONCLUSION: Bifocal treatment of complex periarticular femoral nonunions offers a single solution for dealing with bone loss, nonunion, and instability. The method is safe and reliable but has, as with all methods involving distraction osteogenesis, a significant complication rate. Despite this caution, the patients’ outcomes were satisfactory.