Revision surgery, nonunion, and failed fixation

When is revision surgery needed?

Revision surgery fixes or redoes an earlier repair. It may be considered when:

• The bone did not heal (nonunion). The broken ends never joined, so the area stays painful or moves.
• The bone healed crooked (malunion). The foot or ankle is out of line, which can strain other joints.
• The hardware failed or hurts. Plates or screws can loosen, break, or rub.
• Arthritis set in after an old injury. The joint slowly wears out.

Signs to watch for

• Pain at the old injury or surgery site that is not getting better
• Hardware you can feel, or that rubs in shoes
• Warmth, redness, or drainage near an old incision

What can slow bone healing?

Things that can slow healing include:

• Smoking or other nicotine use
• Diabetes, especially when blood sugar is high
• Infection in the bone or around the hardware
• Poor blood flow to the foot
• Low vitamin D or poor nutrition (your doctor may check your levels)

Finding the cause

The first step is finding out why the first repair did not work. This often includes X-rays and a CT scan, which shows the bone in more detail. Blood tests, and sometimes a tissue or bone sample, may be used to look for infection. If blood flow seems low, you may be sent for a blood flow test.

Treatment options

Some slow-healing bones heal with more time in a boot or cast, plus quitting smoking and better blood sugar control. When surgery is needed, it may include:

• Removing hardware that is loose, broken, or painful
• Bone grafting: adding bone, from your own body or a donor, to help the area heal
• Re-fixation: new plates, screws, or rods to hold the bone still
• Correcting alignment (osteotomy): cutting and re-setting a crooked bone
• Joint fusion: joining bones so they heal as one when a joint is badly damaged
• An external frame (external fixation): a metal frame outside the leg, attached to the bone with pins or wires. It can hold bones still or slowly correct a deformity.

If infection is found, it is usually treated first, often by cleaning out the area and with antibiotics.

What to expect

Revision surgery is often more involved than the first surgery, and recovery is usually longer. Many people need several weeks or more off the foot, then a walking boot (CAM boot), then physical therapy. Full recovery often takes many months and depends on the problem, your bone healing, and your health. Sometimes more than one surgery is needed. Learn more about getting around after surgery.

How Dr. Nafal can help

Dr. Nafal is board qualified by the American Board of Foot and Ankle Surgery in Foot Surgery and in Reconstructive Rearfoot and Ankle Surgery. He performs revision and nonunion surgery, including external fixation (frames). He explains every option in plain words, including options that don't involve surgery.

Common questions

Why didn't my bone heal the first time?

Often there is more than one reason, such as smoking, diabetes, infection, poor blood flow, or too much motion at the break. Finding the cause guides the next step.

Can my hardware just be taken out?

Sometimes. If the bone has fully healed and the hardware hurts, removing it may help. If the bone has not healed, more is usually needed.

What is it like to have an external frame?

The frame often stays on for weeks to months. You will learn how to clean the pin sites to lower the risk of infection. The frame is removed once the bone is stable.