Archives of Orthopaedic and Trauma Surgery

, Volume 138, Issue 6, pp 791–802 | Cite as

Non-prosthetic peri-implant fractures: classification, management and outcomes

  • Lester W. M. Chan
  • Antony W. Gardner
  • Merng Koon Wong
  • Kenon Chua
  • Ernest B. K. Kwek
  • on behalf of the Singapore Orthopaedic Research CollaborativE (SORCE)
Trauma Surgery



Non-prosthetic peri-implant fractures (NPPIFs) are an under-reported entity. Management is challenging because of alterations in anatomy, the presence of orthopaedic implants and phenomena such as stress shielding, disuse osteopenia and fracture remodeling. The aims of this paper were to review patterns of injury, management and outcomes and to propose a classification system to aid further research.

Materials and methods

This study is a multi-centered retrospective case series. Patients were identified from the orthopaedic department trauma databases of public hospitals in Singapore and individual surgeon case series of members of the Singapore Orthopaedic Research Collaborative (SORCE) group.


We collected a series of 60 NPPIFs in 53 patients. 38 fractures involved the femur, 12 the radius/ulna, 5 humeri, 3 tibia/fibula and 1 clavicle. 39 patients had fractures around plates and screws, 12 around nails, and 3 around screws. Fractures were managed with a variety of surgical techniques. Six patients had surgical complications with refracture in four and non-union in two cases. Two patients had multiple refractures (total 12 additional fractures). All surgical complications required further surgery. Three patients had deep vein thrombosis and one patient died of post-operative pneumonia. Fractures were classified according to the initial implant (plate or nail), the position of the new fracture relative to the original implant (at the tip or distant) and the status of the original fracture (healed, not healed or failing). Surgical strategies for common subtypes were reviewed.


This study represents the largest series in the literature. NPPIFs are a challenging clinical problem with a high rate of post-operative complications. They are distinct from peri-prosthetic fractures and should be understood as a separate entity. We, therefore, propose a novel classification system. Further research is needed to determine the optimal treatment for the various subtypes.

Level of evidence

Therapeutic Level IV—case series.


Peri-implant fracture Peri-prosthetic fracture Complication Osteosynthesis Non-prosthetic peri-implant fracture Classification 



This manuscript was prepared by the Singapore Orthopaedic Research CollaborativE (SORCE), c/o Lester W. M. Chan, MBBS, FRCS(Ed) and Ernest B. K. Kwek MBBS, MRCS(Edin), M.Med(Ortho), FAMS, FRCS(Edin)(Ortho). Principal Investigator: Lester W. M. Chan. Manuscript Preparation: Lester W. M. Chan, Antony W. Gardner, Ernest B. K. Kwek, Merng Koon Wong, Kenon Chua. Case contributors: Lester W. M. Chan (Tan Tock Seng Hospital/Khoo Teck Puat Hospital), Antony W. Gardner (Ng Teng Fong General Hospital), Ernest B. K. Kwek (Tan Tock Seng Hospital), Merng Koon Wong (Singapore General Hospital), Fareed Kagda (Ng Teng Fong General Hospital/National University Hospital), Diarmuid Murphy (National University Hospital), Kein Boon Poon (Changi General Hospital).

Compliance with ethical standards


The authors have no sources of funding to declare.

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

For this type of study formal consent is not required. This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Not required.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Lester W. M. Chan
    • 1
  • Antony W. Gardner
    • 2
  • Merng Koon Wong
    • 3
  • Kenon Chua
    • 1
  • Ernest B. K. Kwek
    • 1
  • on behalf of the Singapore Orthopaedic Research CollaborativE (SORCE)
  1. 1.Tan Tock Seng HospitalSingaporeSingapore
  2. 2.Ng Teng Fong General HospitalSingaporeSingapore
  3. 3.Singapore General HospitalSingaporeSingapore

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