This is a report of the outcome of management of congenital pseudoarthrosis of the tibia (CPT) at skeletal maturity. Retrospective study. Inclusion criteria:
CPT Crawford IV Skeletally maturity. Availability of radiographs and medical records. Outcome: union rate, healing time, residual deformities, ablation and refracture.Introduction
Materials and Methods
Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of CPT include intramedullary rodding, external fixation, combined intramedullary rodding and external fixation, vascularized fibular graft, and most recently cross-union. The current study aims to compare the outcomes and complication rates of cross-union versus other surgical approaches as an index surgery for the management of CPT. Our hypothesis was that a good index surgery for CPT achieves union and minimizes complications such as refractures and limb length discrepancy. A multicentre study was conducted involving two institutions in Singapore and China. All patients with CPT who were surgically managed between January 2009 and December 2021 were included. The patients were divided based on their index surgery. Group 1 included patients who underwent excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for their index surgery. Group 2 included patients who underwent all other surgical procedures for their index surgery, including excision of hamartoma, intramedullary rodding, and/or external fixation, without cross-union of the tibia and fibula. Comparisons of the rates of union, refracture, limb length discrepancy, reoperations, and other complications were performed between the two groups.Aims
Methods
The authors present their experience using osteogenic protein 1 (OP-1; “Osigraft”) in the treatment of recalcitrant atrophic pseudoarthrosis (PA) of the limbs in patients in whom osteosynthesis surgery failed at least two to four, and more, times. All patients with PA who were treated showed a preoperative radiographic pattern of severe bone atrophy surrounding the peri-fracture zone, without evident signs of reparative activity. All osteosynthesis hardware showed clear evidence of mechanical failure (rupture or mobilisation) so they were changed in all patients during the surgery. From January 2003 to February 2004 we used Osigraft to treat 10 patients with an atrophic PA at the following level: two femurs, three humera, one forearm, three tibiae (1/4 distal) and one tibia (1/3 medium). Osigraft was associated in seven patients with an autograft and in three patients with an allograft plus platelet growth factors (one distal femur, one distal tibia and one humerus). Mean age of patients was 38 years (range: 22–54) and mean duration of disease from the initial trauma was 36 months (range 26–40). The radiological aspect of the newly formed bone, both endostal and periostal, was very similar to that observed in primary healing, with an inter-fragmentary callus as observed in similar cases treated since the beginning with the most appropriate therapy and that healed after the first operation. In all cases we observed healing of the PA focus in a time period of 6–11 months (mean 8.5) with a satisfactory functional recovery in eight cases; in two cases residual articular stiffness, one knee and one ankle, will require arthroscopic surgery. Because of the limited number of patients treated with this new method, we can only draw preliminary conclusions. However, compared with our previous experience, we can confirm that Osigraft (OP-1) significantly contributes to bone healing whenever biological reparative potential is strongly compromised because of the type of original trauma, the long time elapsed since then and the many preceding surgeries. Healing times, even if they appear to be quite long, are actually short considering the severity of our cases, usually requiring further surgery for PA not healing after the third intervention (more than 30 %) and cured, if reached, in 12–18 months.
A method of treatment is described whereby the affected tibia is united and lengthened.
All patients suffered from Boyd 1 or 2 Psuedoarthrosis of the Tibia. All patients had had previous surgery (three to thirteen operations) and three to ten centimeter of shortening. All patients were treated by lengthening of the tibia and open debridement and compression of the pseudoarthrosis till union using Ilizarov techniques.
Eight patients achieved union length and normalization of the tibial axis with the first operation and two patients had recurrence of the pseudoarthrosis and had re-operation with success.
To achieve this success a number of basic principles need to be followed. These principles are:
Correction of the axis of the limb. Debridement of the pseudoarthrosis and opening of the intra medullary canal with insertion of one of the ends of the tibia into the other. Lengthening of the tibia with proximal osteotomy and concurrent compression of the fracture site. Absolute correction of the tibial axis. This treatment regime has shown success in the failed management of the pseudoarthrosis and if these principles are adhered to this regime will have success in the management of this pathology and prevent re-operation.
Proximal humeral fracture occurs most frequently in elderly and usually unite within 12 weeks. Malunion is more common than nonunion. And even if nonunion occurs, we usually treat it by the blade plate. Norris et al. reported hemiarthroplasty is indicated for severe degenerative changes of the articular surface, osteonecrosis of the humeral head, or osteopenia severe enough to jeopardize fixation in order patients. Therefore, it is not common that hemiarthroplasty is used for primary treatment of the proximal humeral pseudoarthrosis. We report a case of proximal humerus pseudoarthrosis which was treated by hemiarthroplasty. A patients is 75 years old male. He was injured by falling from ladder. He was diagnosed proximal humeral fracture Neer type2. After he was followed conservatively for one year, he was referred to our hospital. In X-ray film and CT, the humeral head was scraped by the humeral shaft that was tucked inward to humeral head.(Figure 1) In MRI, rotator cuff muscles were left. The fatty infiltration was stage 1 in the Gourtallier classification. (Figure 2)And osteoarthritis of shoulder was not so severe. Therefore, we decided to do hemiarthroplasty. We used the SMR implant (Lima Corporate, Milano, Italy). Surgical reconstruction was done using a deltpectral approach. Lesser tuberosity was cut from greater tuberosity with subscaplaris muscle. We used the cementless stem. Each fragments and stem was fixed using FiberWire (Arthrex, Florida USA), after autograft which scraped from the reseceted humeral head was stuffed. After the operation, the shoulder was fixed by brace for 4weeks. The passive ROM exercise was started from 21 days later. The Active ROM exercise was started at 28 days later. Three months later, the pseudoarthrosis united successfully. (Figure 3) The active flexion was improved from 20 degrees to 110 degrees. The active abduction was from 20 degrees to 90 degrees. USLA score was improved from 10 to 26.Introduction
Case
The treatment of relapsing pseudoarthrosis of ulna presents quite a lot of perplexities as regards the surgical strategy to follow which means of synthesis to solve the biomechanical problems (lack of favourable loading stimuli and, on the contrary, presence of unfavourable torsional strengths due to the movement of pronosupination of the forearm),and how to interact in order to favour the restoration of osteogenesis (homologous or autologous bone graft, vascularized or not, bone substitutes, employment of autologous growth factors, of morphogenetic proteins (BMP),and of autologous staminal cells). The authors report about 4 particular cases of relapsing pseudoarthrosis of the ulna previously treated with autologous bone grafts but with no recovery. In order to activate osteogenesis, the authors have employed a graft of autologous bone enriched with platelet derived growth factors + adult mesenchymal stem cells from drawing from the iliac wing. The osteosyntesis has been carried out in 3 cases with endomidollar locked nail and, in one case, with external fixation. All the four cases have reached prompt lasting clinical recovery (following up from 8 to 28 month) and Rx precocious evidence of osteointegration of the grafts independently from the synthesis means. The limited casuistry does not enable us to report any comparable statistical data. The authors think that association of AGF + adult mesenchymal stem cells can be determinant and encouraging and, thanks to the results, they suggest its spreading.
Several reports showed superior fusion rates, as high as 100%, using rhBMP-2 with ALIF cages. This has led to the widespread off-label use of rhBMP-2 in several other lumbar fusion procedures. There is paucity of reports analysing the clinic-radiological outcome of using rhBMP-2 to promote bone union in cases of symptomatic pseudoarthosis following lumbar spine fusion. 52 consecutive patients who underwent revision spinal surgery for symptomatic pseudoarthosis utilizing rhBMP-2 between 2008 and 2013 were included in the study. Demographic, and surgical data were collected from medical records. Functional outcomes were recorded using the ODI. All patients had preoperative fine-cut CT scan to confirm pseudoarthosis. Postoperative CT-scan at 6 months was routinely done to confirm fusion.Introduction:
Methods:
Thirteen consecutive patients with scoliosis, treated with anterior spinal fusion with a single rigid rod, were followed up clinically and radiographically for 19 months. The mean major curve, 52° preoperatively, improved to 10° at follow-up. The results of anterior single-rod spinal fusion in patients with idiopathic scoliosis are excellent. No development of kyphosis or incidence of hardware failure was seen.
CPT is a rare disorder often leading to multiple surgical procedures in an attempt to achieve union but frequently ending in amputation. The author presents a personal series of four cases (ages 3 + 4, 3 + 4, 4 + 3, 7 + 9 years) three of which had had a total of ten previous procedures. All patients underwent removal of previous fixation, excision of the abnormal periosteal tissue, freshening of the bone ends and “ram rodding” together under compression with the application of an lIizarov frame. A separate proximal osteotomy was performed for lengthening. The non-union was grafted primarily at the time of fixator application. Following frame removal a custom made telescopic nail was inserted in the three most recent cases. Average frame time was 263 days (184–301). All four cases have healed primarily and remain healed (19, 28, 31 and 70 months) post frame removal. The case not treated with a nail underwent bending of the proximal regenerate bone and required a second osteotomy to correct the deformity. Other than pin infections managed by antibiotics and local cares, the only other complication was the backing out of a cross-locking wire from the IM nail which required reinsertion. The use of the llizarov frame enables a radical excision of pathological tissue and rigid compression of the non-union with concurrent restoration of limb length. The telescoping rod that is locked in the epiphyses proximally and distally enables normal rehabilitation of the joints without the need for prolonged bracing. The ongoing success of this treatment has encouraged the author to recommend it as the primary management for established congenital pseudarthrosis of the tibia.
The Masquelet technique, also known as the ‘induced membrane technique’ has been utilised in adult reconstruction with varied success. However, there is limited literature on its use in children and this study aims to share our experience. Materials & Methods. Between 2014 and 2022, 7 children underwent bone defect/infection reconstruction using Masquelet technique, four for complications of Congenital
Purpose: A retrospective review of 180 consecutive luque unit rod instrumentations for neuromuscular scoliosis revealed a low rate (7%) of reoperation for hardware related issues. The results of this cost effective instrumentation are good, and we question whether moving to more expensive systems (eg pedicle screws) will provide benefit to patients. Method: A retrospective clinical and radiographic review of 180 consecutive patients, treated with the unit rod and sublaminar wires for progressive neuromuscular scoliosis and cerebral palsy, between 1994 and 2004 was done. Preoperative, intraoperative, and outcome data were obtained from hospital and clinic records with 2 to 12 years of followup. Results: Mean age at surgery was 13 years. Of 180 patients, 158 were full time wheelchair users. 112 patients underwent isolated posterior surgery, 68 underwent anterior &
posterior surgeries. Allograft was used in 96%. Mean surgical time was 5 hours 45 minutes, blood loss was 1325 cc. Mean cobb angles improved from 72° to 32°, pelvic obliquity improved from 20° to 9°. Overall postoperative complications were 222, with 36 (20%) of 180 patients experiencing no complication. Only 13 patients of 180 required revision surgery for hardware related problems.
Introduction and Aims: To review the existing classifications in characterising the pathologic morphology of congenital lower limb deficiencies (CLLLD) and their usefulness in planning limb reconstruction. Method: Ninety-five patients undergoing limb reconstruction were classified using existing classifications. Predominantly femoral deficiencies were classified using Aitken, Amstutz, Hamanishi, Gillespie and Torode, Fixsen and Lloyd-Roberts, Kalamchi, and Pappas systems and fibular deficiencies were classified using Coventry and Johnston, Achterman and Kalamchi, and Birch systems. Results: All patients with predominant deficiency of one segment (femoral or fibular) also had associated shortening of the other segment in the same limb. Acetabular dysplasia, knee instability due to cruciate insufficiency and lateral femoral condylar hypoplasia were found in both femoral and fibular deficiencies. None of the existing classification systems were able to represent the complete pathologic morphology in any given patient. Due consideration of alignment, joint stability and length discrepancy of affected limb as a whole at the planning stage of reconstruction could not be ascertained using these classification systems. Instead, it was useful to characterise the morphology of the involved limb using the following method:. Acetabulum: Dysplastic/Non-dysplastic. Ball (Head of femur): Present/Absent. Cervix (Neck of femur):
Introduction:
Late wound infection is a recognised complication of instrumented spinal deformity surgery. In most cases it is a benign complication which usually resolves after implant removal. However, some of our patients with late infection developed a pseudoarthrosis. To investigate this further we undertook a retrospective review of all patients undergoing implant removal for deep infection between 1991 and 2000. Twenty-one patients were identified, representing a late infection rate of at least 6%. They showed no specific pre- or intra-operative risk factors. Nine had some problems with early post-operative wound healing, which settled with minimal treatment. Late infection presented as localised swelling or a discharging sinus between 4 and 84 months (average 31 months) post-surgery. Blood parameters were abnormal in 15 cases, frank infection demonstrated in 19 cases, loosening of the implant in four cases and positive bacteriology culture in 14 cases. Wounds healed within 2 to 17 weeks (average 5 weeks) following implant removal, wound debridement and antibiotic therapy lasting 2 to 20 weeks (average 6 weeks). This was delayed until one year post-surgery in the three cases presenting early. Follow-up of between 6 and 92 months (average 38 months) revealed no persistent infection.
PURPOSE OF THE STUDY. Occipitocervical fixation and spondylodesis is indicated in various cases of occipitocervical instability. The aim of this retrospective study was to evaluate the results of occipitocervical fixation at our institutions. MATERIAL + METHODS. Between 1997 and 2007, a total of 57 patients underwent occipitocervical fixation (OC) there were 25 men and 32 women, from 4 to 77 years of age. 2 groups, group one - tying wires or cables and group two - screw-rod or screw-plate systems. Indications included trauma in 15, rheumatoid arthritis (RA) in 28, destruction due to psoriasis in one, tumour in eight, and congenital anomalies in five patients. The patients were evaluated at a final follow-up ranging between 12 and 132 months after the primary surgery (average, 42.7 months). Indications for surgery and the method and extent of instrumentation were recorded. The evaluation included pain and neurological deficit assessment, radiographic evidence of the stability of fixation and bone union and intra-operative and early and late post-operative complications. RESULTS. Of the 57 patients, bone fusion was the aim of surgery in 52. Five patients died of associated injuries or serious medical complications shortly after the operation. Of the remaining 47, bone union was achieved in 44 patients (93.6%).