1. The operation of pseudarthrosis of the hip joint is described and the results are assessed in ninety-three patients. 2. The result was good in eighty-three cases and poor in seven cases. Three patients died as a result of the operation. 3.
Introduction: Spine fractures are common manifestation of osteoporosis. After an acute osteoporotic vertebral compression fracture pain persisting even after 3 months and clinical tenderness should raise the suspicion of pseudarthrosis.
PURPOSE. To report the experience and evolution of treatment of Congenital
Supraglenoidal dislocation of the humerus is uncommon. The anatomical findings in a bilateral example in which efficient pseudarthrosis had developed are described, and the probable evolution of the lesion is discussed.
1. Thirty-three cases of congenital pseudarthrosis of the clavicle are presented. 2. The lesions all occurred in the right clavicle and are thought to be due to abnormal intrauterine development rather than non-union of birth fractures. 3. Methods of treatment are reviewed. Excision and bone grafting is favoured.
1. Thirteen cases of congenital pseudarthrosis of the clavicle conforming to the classical picture are presented, together with five cases of pseudarthrosis occurring for various other reasons, and nine cases of congenital pseudarthrosis that form a special group because there was a strong family history. 2. Treatment, if desired by the patient, is easy, but should be deferred until the age of four or five years. 3. The etiology remains obscure. Our embryological study does not support the theory that the clavicle normally develops from two ossification centres that may fail to coalesce. Although in thirteen of our patients there was no family history of pseudarthrosis, there was another group of nine patients who presented a strong family history, and it seems certain that in some instances congenital pseudarthrosis of the clavicle can be transmitted genetically.
1. Three cases of infantile pseudarthrosis of the tibia treated successfully by delayed autogenous by-pass graft are reported. 2. The delayed autogenous graft is stouter, stronger and more easily handled and has enhanced osteogenic properties than a graft transferred immediately. 3. The by-pass graft commends itself, firstly, because it does not disturb the pseudarthrosis, which in consequence helps the immobilisation of the graft; secondly, because it is well embedded in healthy bone above and below, well away from the abnormal bone; thirdly, because it lies under compression and, ideally, is vertically disposed between the knee and the ankle; and fourthly, because there is no devitalising stripping of periosteum or introduction of foreign bodies. 4. Support to the grafted leg is needed for at least five years, but only by a polythene splint after four to six months. 5. With early grafting the deformity straightens out and shortening is overcome, as there is early return to normal use of the limb. 6. Prolonged follow-up is called for lest the basic lesion in the tibia should extend. 7. Fibrous dysplasia and similar fibrous lesions of bone account for many cases of infantile pseudarthrosis of the tibia. Many of these lesions are congenital and subsequently lead to fracture. 8. Postponement of surgery should not be countenanced.
1. Congenital pseudarthrosis of the clavicle is described. 2. The distinction from cranio-cleido-dysostosis and from birth fracture is stressed. 3. Details are given of two patients reported in the literature and a further nine patients are described. 4. The embryology, natural history and treatment of the condition are discussed.
1. The results of the by-pass grafting operation in eleven cases of pseudarthrosis of the tibia in childhood are presented. 2. The operation was successful in securing sound bone union in nine cases, and unsuccessful in two. 3. The causes of failure in the two unsuccessful cases are analysed. 4. The possible causes of occurrence and persistence of tibial pseudarthrosis in childhood are discussed. 5. It is suggested that the pseudarthrosis results from a fatigue fracture of a congenitally abnormal tibia, but that its persistence depends entirely on mechanical factors. 6. There is evidence to suggest that the underlying congenital abnormality may arise from dysplasia of the mesenchyme.
CPT is a uniquely difficult condition, often associated with Neurofibromatosis (NF1), where bone healing is compromised. Although rare, the severity of this condition and the multiple procedures often entailed in treating it, warrant research attention. As study material is limited, animal models of the disorder are desirable for testing new treatments. We sought to create a model of CPT where both copies of the NF1 gene were ablated at the fracture site, as has been found in some clinical specimens. NF1 floxed mice had fracture surgery; both closed fracture and open osteotomy were performed. Either a Cre- or control GFP-adenovirus was injected into the fracture site at day zero. Recombination was confirmed in ZAP reporter mice. Additionally, cell culture studies were used to examine the possible responses of NF1+/+ (wild type) NF1+/− or NF1−/− to drugs which may rescue the dysregulated Ras/MAPK pathway in NF1. In closed fractures, radiographic bridging was 100% in NF1+/+ calluses and <40% in NF1−/− calluses (P<0.05). In open fractures, radiographic bridging was 75% in NF1+/+ calluses and <30% in NF1−/− calluses (P<0.05). In both fracture repair models the NF1−/− state was associated with a significant up to 15-fold increase in fibrotic tissue invading the callus by week 3. In NF1−/− fractures, large numbers of TRAP+ cells were observed histologically in the fibrotic tissue. Closed fractures also showed a significant increase in BRDU labelled proliferating cells in the callus. In cell culture models of NF1 deficient osteogenesis, NF1−/− progenitors were found to be significantly impaired in their capacity to form a calcified matrix as measured by Alizarin Red S staining and osteogenic markers (Runx2, Osteocalcin, Alp expression). However, when differentiated calvarial NF1 floxed osteoblasts were treated with Cre adenovirus, mineralization was not affected, suggesting that NF1 impacts on osteogenic differentiation rather than mature cell function. Treatment with MEK inhibitor PD0325901 was found to rescue the NF1−/− progenitor differentiation phenotype and permit robust mineralization. Treatment with the JNK inhibitor SP600125 was also able to improve ALP activity and mineralization in NF1+/− osteoprogenitors compared to control cells. This model of NF1 −/− induction at a fracture or osteotomy site closely replicates the clinical condition of CPT, with lack of bone healing and fibrous tissue invasion. Underlying defects in bone cell differentiation in NF1 deficiencies can be at least partially rescued by JNK and MEK inhibitors.
1. The cases of four children who presented with bowing or pseudarthrosis of the fibula only, are described. 2. There is a gradation in the severity and significance of this condition. There may be fibular bowing without fibular pseudarthrosis; fibular pseudarthrosis without ankle deformity; fibular pseudarthrosis with deformity but without the late development of tibial pseudarthrosis; or fibular pseudarthrosis with the late development of tibial pseudarthrosis. 3. Proper management is dependent on a knowledge of this range of conditions.
The problem of retained drain fragments is a well known but under reported complication in the literature. The authors present the case of a 66 years old male, who suffered a right distal humerus fracture luxation six years ago that was treated conservatively. He went to the emergency service with fever and right elbow purulent drainage. Physical examination showed deformity, swelling and fluctuation of the right elbow with purulent drainage through cutaneous fistula. The x-ray showed instable inveterate pseudarthrosis of the distal humerus. Leucocytosis and neutrophylia with increased CRP were presente in the blood tests and the patient started empiric treatment with Ceftiaxone IV. A MRSA was isolated in cultural exam of the exsudate, and a six weeks treatment with Vancomycin IV was iniciated. Exhaustive surgical cleaning was performed and two plastic foreing bodies (fragmented drains) were removed. At the time of discharge the patient was afebrile, with normal analytical parameters and negative culture tests. The orthopaedic surgeon should considerate the presence of a foreign body in patients with infected abcess and traumatic or surgery previous history.
Three or more years after completion of treatment, we re-examined 16 patients with orthopaedic problems associated with neurofibromatosis I (NF-I) who were treated at our institution between 1976 and 1999. Seven boys and five girls between the ages of 5 and 15 years presented with congenital pseudarthrosis of the tibia (CPT). All had undergone previous surgery elsewhere. The patients had typical skin lesions and the associated radiological appearances of pseudarthrosis of the tibia. There were two cystic types of CPT, five hourglass and five normotrophic types, mostly at the level of the distal third of the tibia. Primary consolidation of the CPT was not obtained in any patient. Three patients underwent below-knee amputation after multiple surgical procedures. Eight had consolidations of the pseudarthrosis after multiple operations, but all had residual deformities and/or shortening. One patient remained with a non-consolidation. The surgical procedures included intramedullary rodding with or without bone grafting, fibular bypass grafting, Soffield turn-about rodding, electrical stimulation, and, in patients seen since 1989, various Ilizarov techniques including lengthening and bone transport. Our results suggest that the best treatment of this perplexing paediatric orthopaedic problem remains undetermined. Considerations for the selection of treatment include the pathologic anatomic pattern of NF-I and the patient’s age and expectations. A National Orthopaedic Neurofibromatosis Register will be useful in the decision-making process.
Presenters Position: To perform a retrospective audit of the spectrum of management of tibial pseudarthrosis by a single surgeon over a seven year time period. All discharge summaries and operation logs from 2004 to 2011 were reviewed to identify patients, and their case notes and x-rays were examined. Patients were contacted telephonically for follow-up examination.Purpose of Study:
Description of Methods:
Fourteen cases of pseudarthrosis of the tibia in childhood presented at a hospital in Burma over a period of eight years. The ages of the patients ranged from one month to seventeen years. Nine were treated by a pointed graft driven into the medullary cavity of the distal tibia, and usually across the ankle joint into the body of the talus, before fixation to the proximal tibia. In six of the nine union was secured, but one case required a second grafting. Transarticular segments of graft showed a marked tendency to undergo absorption. No significant deformity was observed to follow central penetration of the growth plate and epiphysis of the lower tibia.
1. The danger of fracture and subsequent pseudarthrosis in congenital anterior bowing of the tibia is emphasised. The fate of seven such patients is described. 2. With the object of preventing fracture, early and urgent bone grafting is advocated.
Percutaneous vertebroplasty is an effective procedure for the treatment of osteoporotic vertebral compression fractures, spinal metastasis and other pathologic spinal diseases. However, there has been no mention in the relevant literature of the use of percutaneous vertebroplasty for the treatment of spinal pseudarthrosis in ankylosing sponyloarthritis. A 58-year-old male with a long standing ankylosing spondylitis presented with increasing, intolerable and non-intractable back pain. There was a 16- month-old history of a non-significant minor fall. Various radiological imaging technicques showed spinal pseudarthrosis with extensive discovertebral destruction and fracture of the posterior elements at the level T11–T12. Under local anaesthesia, and through a transpedicular approach with the guidance of CT, the cannula of a large bore needle was introduced into the level of spinal pseudarthrosis. Bone cement was then instilled into the affected spinal level. Results were documented by spiral CT and with sagittal reconstructions. Extraosseous cement leakage was seen at the puncture site of the vertebra and in the epidural veins and the paravertebral vessels. However, the patient did not present any immediate or late neurological and systemic complications. Percutaneous vertebroplasty of spinal pseudarthrosis in patients with ankylosing spondylitis is an effective procedure for stabilization of the affected spine segments and pain management.
Congenital pseudarthrosis of the tibia remains difficult to treat. With variable success, children are subjected to many surgical procedures. We review our experience using titanium elastic nails in this condition. We have treated 10 patients, six boys and four girls. Five had associated neurofibromatosis and pseudarthrosis of the fibula. In seven children, a mean of four previous operations had been done. The mean follow-up time was 4 years. In our patients, union occurred at a mean of 18 weeks, with a mean limb length discrepancy of 3 cm. The range of movement in the knee and ankle was good. Our early results are encouraging.
Seventeen patients underwent surgery, at a mean age of 6 years and 4 months. The procedure always included excision of the pseudarthrosis at both ends and internal fixation with a wire or a plate. In only eight cases a bone graft was used. Healing was achieved in fourteen patients. Three patients needed a second surgical procedure. In these 3 cases we had not used bone grafting. All patients had a normal range of shoulder motion, except a twelve year old girl who complained of discomfort of the right upper limb. The cosmetic result was good in eleven cases, one surgical wound was noted as hypertrophic, and one developed a keloid. An asymmetry of the trunk was still noted in seven cases. The x-rays showed symmetric clavicles in ten cases. Eight patients were treated conservatively. All of them had a normal range of motion of the shoulder, six had a good cosmetic result and two cases a poor one. Discussion According to Alldred, the anomaly results from the failed coalescence of the two primary ossification centers of the clavicle. The overview of the literature and our findings (in one case) confirm that the cartilage which covers both ends of the bone is made of growth cartilage. However, the true mechanism of the nonunion is still unknown. The three familial cases of our work suggest a possible genetic transmission of the disease. The diagnosis is based on the following criteria: right side lesion, found in infancy, without previous fracture, increasing size with growth, without major functional consequences, without neurofibromatosis or cleidocranial dysostosis symptom. X-rays or histologic examination will confirm the diagnosis showing the usual findings described above. Complications of the pseudarthrosis of the clavicle are rare and late. Conservative management appears to give good results as seen with our eight patients. However surgical treatment ensures symmetrical shoulder girdles and good function with few complications. Therefore, we recommend performing an excision of the cartilaginous caps, followed by an iliac bone graft and an internal fixation with wire. Surgical management will be preferred in symptomatic patients, in the case of major or increasing deformity, or on parental request.
A 10-year-old boy who sustained a fracture through a cyst in the ulna later developed a pseudarthrosis. During 13 years' follow-up the characteristic short bowed forearm developed but, instead of the more usual spontaneous dislocation of the head of the radius, the patient also developed the previously unreported complication of osteoarthritis of the elbow.
The cause of pseudarthrosis of the clavicle is obscure. Right-sidedness is an almost constant feature. We have proposed that the lesion is sometimes due to pressure upon the developing clavicle by the subclavian artery which is normally at a higher level on the right side. This may be accentuated in the presence of cervical ribs or unduly elevated first ribs, both of which we have observed in association with pseudarthrosis. We have also noted pseudarthrosis on the left side in association with dextrocardia (when the relative positions of the subclavian arteries are reversed) and in the presence of a large left cervical rib. We have speculated upon the nature of the clavicular defect in cranio-cleido dysostosis, in which disorder the first ribs are habitually elevated. A similar mechanism may be involved.
Congenital pseudarthrosis of the tibia (CPT)
is a rare but well recognised condition. Obtaining union of the pseudarthrosis
in these children is often difficult and may require several surgical
procedures. The treatment has changed significantly since the review
by Hardinge in 1972, but controversies continue as to the best form
of surgical treatment. This paper reviews these controversies. Cite this article:
We have performed simple bone grafting in four elderly patients with pain due to unstable pseudarthroses in the osteoporotic spine after compression fracture. At operation, we observed abnormal movement of the affected vertebral body which was covered with a hypertrophic membrane; this seemed to inhibit the blood supply to the lesion. The thick membrane and avascular granulation in the false joint were excised and bone grafting carried out. Symptoms were dramatically improved immediately after operation and bony union was confirmed in the three surviving patients.
Dysfunction of the distal radio-ulnar joint caused by traumatic, congenital and inflammatory onditions is usually treated by excision of the head of the ulna. This operation can induce ulnar carpal shift, with complications such as instability with poor grip, pain and clumsiness of the wrist, if the lower articular surface of the radius is normally inclined, or overinclined towards the ulna. These complications can be avoided by use of an operation producing pseudarthrosis of the distal part of the ulna, with fusion of the radio-ulnar joint (Lauenstein) if there is dislocation, radio-ulnar discrepancy or arthritis, or without fusion (Baldwin) if the joint, in spite of keeping normal articular surfaces, has its movement blocked by malunion of a radial fracture.
1. A case of congenital bowing of the tibia is described in which pseudarthrosis developed and recurred after nine operations performed by the age of ten years. 2. Union was finally secured by a procedure based on deep impaction of the trimmed upper fragment into the reamed-out lower fragment. This was followed by a Boyd type of partial amputation of the foot with calcaneo-tibial arthrodesis. 3. The end-bearing stump four years later is entirely satisfactory and the simple prosthesis gives equality of leg lengths.
The “Zemel technique” for scaphoid pseudarthrosis without major carpal collpse is a modification of the Matti-Russe procedure, using only cancelous bone graft and 2 Kirchner wires for fixation – these are introduced under direct vision after a large curetage of the pseudarthrosis, then partially withdrawn and reintroduced after tight local cancelous bone packing. We used it in 51 cases, obtaining bone union in 48. In 9 patients bone, union was not certain after 12 weeks of plaster and K wires were replaced by a screw with no further immobilization, but we still had 3 nonunions. This procedure, technically easy to perform and using current orthopaedic material, seems a good alternative to non-angulated pseudarthrosis of the scaphoid, except of its proximal pole.
This paper reviews the outcome of 13 children with congenital pseudarthrosis of the tibia after intramedullary rodding and autogenous bone grafting. The oldest patient was aged nine years at the time of surgery. The ages of the others ranged from 12 to 24 months. The oldest patient at follow-up was 18 years. All 13 had bone defect and angulation. Ten children had clinical features of neurofibromatosis. Ten had pseudarthrosis involving the distal third of the tibia, two the middle third and one the proximal third. Autogenous iliac crest chips were used following excision of fibrous tissue and dense and atrophic bone. Rodding was done across the ankle joint in 10 patients. Postoperatively an above-knee cast was applied for 6 to 12 months, after which an above-knee brace was used to protect the rodding. At follow-up, which ranged from 10 months to 16 years after surgery, all patients were fully weight-bearing and ambulant. Three patients were lost to follow-up after 2 to 4 years. Complications included refracture and rod breakage (two), rod migration (three), and growth retardation with shortening of up to 5 cm. Ten patients had ankle and subtalar joint stiffness and two had valgus deformities of the ankle. Three patients underwent repeat rodding and bone grafting. Radiological union was observed to be progressing in all patients. Intramedullary rodding of the tibia for congenital pseudarthrosis of the tibia is a simple procedure and can be repeated. It avoids prolonged hospital stay and permits early weight-bearing. Careful supervision is necessary, and until there are signs of good bony union, external support is mandatory.
To determine the preferable treatment for congenital pseudarthrosis of the tibia, we retrospectively reviewed 19 patients (20 limbs) treated consecutively over a 22 year period (1988–2007). Fifteen were followed up to maturity. The patients were assessed for union, leg length discrepancy (LLD), ankle valgus, range of ankle movement and distal tibial physeal injury. The median age at surgery was 3 years. At surgery nineteen of the tibiae had a dysplastic constriction with a fracture (Crawford II-C or Boyd II) lesion. To obtain union in the 20 tibiae, 29 procedures were done. Nine failed primarily and required a second procedure to obtain union. Older patients (≥ 5 years) had a significantly higher success rate. Excision, intramedullary rodding and bone graft (IMR) was done in 14 tibiae: 10 (71.4%) were successful. Six of 10 primary operations and all 4 secondary operations after a previous failed procedure were successful. Ipsilateral vascularized fibula transfer (IVFT) was successful in 5 tibiae (3 primary and 2 secondary). Ilizarov with bone transport only, failed in two patients. Ilizarov with excision, intramedullary rodding and bone graft with lengthening was successful in 2 of 5 cases (40%); two sustained fractures at the proximal lengthening site. A median leg length discrepancy (LLD) of 3 cms occurred post surgery which was treated with contralateral epiphysiodesis. At maturity 3 patients had a LLD of ≥ 2cms. Six limbs had ankle valgus and were treated with stapling and tibio-fibular syndesmosis. Decreased range of movement of the ankle (< 50%) occurred in 7 patients. Distal tibial physeal injury occurred in 4 patients and was associated with repeated rodding.Aim
Results
We report the long-term results of the Matti-Russe operation for pseudarthrosis of the scaphoid in 100 cases, reported previously by Mulder in 1968. Clinical results for 77 patients and radiographic data for 74 were reviewed at 22 to 34.8 years after surgery. In general, there was satisfactory relief of pain and stiffness but some patients had limitation of motion and reduced grip-strength, with usually slight osteoarthritic changes. There was poor correlation between subjective, objective, and radiographic results but 88% of the patients were satisfied with their results.
1. Operative treatment of scaphoid pseudarthrosis by the Matti-Russe method is a reliable procedure which in our series has given ninety-seven cases of bony union in a total of 100 operations. 2. We do not hesitate to advise operation for this condition as soon as it is discovered, except in cases with severe secondary osteoarthritis. Equally good results have been reported by Murray (1946) from a series of 100 cases treated with cortical grafts from the tibia (blind method) and by Agner (1963) from a series of twenty-four patients treated by Bentzon's operation (interposition of a pedicled soft-tissue flap). 3. In our opinion, Russe's open operation has great technical advantages over Murray's blind method. 4. We have no experience of Bentzon's operation, which seems attractive on account of its technical simplicity and as not more than two weeks' immobilisation in plaster after operation are needed. 5. It would be interesting to see Agner's results confirmed from other sources. It is true that many scaphoid pseudarthroses remain symptomless for years, as London (1961) has pointed out, but many of them sooner or later cause pain, and we do not agree with London's opinion that a few weeks of immobilisation will usually make the wrist painless. 6. Although severe osteoarthritis is very slow to develop in wrists with pseudarthrosis of the scaphoid bone it cannot be denied that these wrists are constantly threatened with suddenly developing pain and by progressive deterioration of function. 7. Therefore, early repair of pseudarthrosis of the scaphoid bone is advisable; it can be expected to save many wrists from progressive loss of function and from final development of severe degenerative change.
Congenital pseudarthrosis of the lower limb is not uncommon, with an incidence of approximately 1 in 150,000. In contrast, isolated congenital pseudarthrosis of the fibula without tibial involvement is a very rare. There were only 11 cases of true isolated congenital pseudarthrosis of the fibula described in the English literature till 1999. We describe 3 patients diagnosed and treated in our institution. The current management is also discussed, highlighting the unique treatment options in this rare condition.
We evaluated the clinical outcome of IM nailing for the treatment of femoral shaft pseudarthrosis in patients who had multiple failed plate osteosyntheses. From January 2000 untill April 2001, 20 (19 male-1 female, mean age 28) patients were treated because of femoral shaft non-union in our institution. All patients had two or more failed plate osteosyntheses. There were no septic non-unions in this group. Eight patients had an established non-union on an average of nine months post-op and the remaining eleven had radiological and clinical evidence of implant failure. There was no segmental bone loss, hi all patients the implants were removed and nailing was performed. Extensive periosteal stripping, bone necrosis and soft-tissue scaring were constant findings in all patients. Twelve patients received interlocking nails. Eight femurs were grafted with iliac crest bone graft. All patients were followed by serial x-rays until union. There were no postoperative complications. All pseudarthroses were healed within an average of 9.7 months (8–12). Non-unions which received bone graft (eight out of twenty) in day one, were healed faster than those which didn’t. There were no re-operations among these patients. Among the remaining ten patients five were grafted five to six months postoperatively and three had had nail dynamization. IM nailing for femoral shaft non-unions after multiple failed plate osteosyntheses is a safe and effective method of treatment. Autologous bone graft reduces healing time and re-operation rate.
We present a case of a 19-year-old white female patient with neurofibromatosis type I who, 10 years ago, underwent free vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius. An external fixator was applied for gradual distraction and correction of the deformity of the pseudarthrosic site for five weeks. Wide resection of pseudarthrosis with surrounding fibrotic and thick scar tissue and bridging of the gap with a free vascularized fibular graft followed. Four months postoperatively, union was established in both graft ends. At the last follow-up, 10 years postoperatively, the patient has excellent function with full wrist flexion-extension and forearm pronation-supination. Free vascularized fibula transfer is considered the treatment of choice for congenital radial pseudarthrosis. It allows complete excision of the pathologic tissue and covering of the gap in one operation. Due to the vascularity of the free vascularized fibular graft both sides of fibula unite easily with no additional intervention.
Our aim is to study the epidemiology of delayed union and pseudarthrosis of femoral fractures which were treated in our clinic with intramedullary nailing technique and simultaneously to speculate for the application of the method and for the reasons which might guide to these complications. During a 36 month-period, from 1999 to 2001, 46 patients suffering femoral shaft fractures were treated in our clinic. They were 43 men and 3 women and their average age was 22.8 years. Twenty-eight fractures were in the right leg and 18 in the left. All patients underwent primary closed intramedullary locked nailing with AO type of nail, except 4 patients who also suffered a unilateral intertrochanteric fracture and were treated with AO-PFN nail. Reaming was done in 33 cases. No condition or disease able to inhibit fracture healing was observed. All patients were operated in the first three days after submission by the same team of surgeons. Thirty patients underwent static intranaedullary locked nailing and the rest dynamic from the beginning. The average time of post-operative follow up, clinical and radiological, was seven months. Thirty-three fractures were healed successfully in six months (mean: 4.2 months). In 10 cases delayed union was observed (mean: 7.2 months) and in the rest three pseudarthrosis. The last group underwent revision of the intramedullary nailing with an AO nail of greater diameter. Reasons for delayed union (21, 74%) and pseudarthrosis (6, 52%) are considered: a)soft tissues enclosed between the bony segments, b)lated nail dynamization, c)factors concerning the technique. Undoubtfully, closed intramedullary locked nailing is the method of choice for the surgical treatment of femoral fractures. However, fracture healing sometimes exceeds the usual period of 4–6 months. Unfortunately, whereas infrequently, the surgeon also faces pseudarthrosis which is a difficult to solve problem.
It is generally accepted that children treated for congenital pseudarthrosis of the tibia (CPT) should be followed-up until skeletal maturity, before drawing conclusions about the efficacy of treatment. We undertook this study in order to evaluate the long-term results of treatment of CPT by excision of the pseudarthrosis, intramedullary rodding and onlay cortical bone grafting. Among a total of 46 children with CPT treated by a single surgeon during a 20-year period, 38 had been treated by this technique and 11 of these children have reached skeletal maturity. These eleven cases (nine boys and two girls) formed the basis for this study. The mean age at presentation was 3.1 years (range 0.4–7 years); the mean age at index surgery was 3.2 years (range 0.7–7 years). The mean age at follow-up was 18.4 years (range 16–21.6 years) with a mean interval between surgery and final follow-up of 15.2 years (range 12.8–17.4 years). In all 11 children bone graft was harvested from the contralateral tibial diaphysis. Rods passed from the heel were used in nine children and in two Sheffield telescopic rods were passed from the ankle into the tibia. The fibula was divided in three children to ensure that the tibial fragments were in good contact before placing the graft astride them; the fibula was not touched in the remaining eight instances. To ensure that the intramedullary rod supported the pseudarthrosis site till skeletal maturity, revision rodding was performed as needed when the tip of the rod receded into the distal third. A thermoplastic clamshell orthosis was used till skeletal maturity. At final follow-up the union at the pseudarthrosis site was deemed to be ‘sound’ only if two independent observers concurred that there was definite bony continuity of the cortices on both the anteroposterior and lateral radiographs. Deformities of the tibia and ankle and ranges of motion of the knee, ankle and subtalar joints were noted. The limb lengths were measured with scanograms. The morbidity at the bone graft donor site was recorded. The function of the ankle was assessed by applying the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Score. Primary union of the tibial pseudarthrosis was achieved in nine of 11 cases with a mean time to union of 6.1 months. Secondary union was achieved in the remaining two cases following further intervention. At final follow-up sound union of the tibial pseudarthrosis was noted in all eleven patients but persistent pseudarthrosis of the fibula was present in 10 of 11 cases. The lateral malleolus was proximally situated in six cases. Ten of eleven children underwent a total of 21 secondary operations on an average of 2.6 years (range 0.5–5.1 years) after initial union was achieved. Six re-fractures were encountered in five patients at a mean of 6.1 years after index surgery. All the re-fractures united following the single episode of intervention. The overall mean shortening at final follow-up was 2.6 cm. At final follow-up, five patients had ankle valgus greater than 10 degrees. All the 11 patients walked without pain. Only two patients had significant motion at the ankle. Despite the ankle stiffness in the remaining children the AOFAS ankle-hindfoot scores ranged between 70 and 98 (mean 83.3). Our long-term results are comparable to the results of other studies in terms of the rate of union, the re-fracture rate, limb length discrepancy, residual deformity and the frequency of surgery.
For every case the implants were planned with a total leg x-ray and manufactured (Link). The implants were removed and the knee and hip joint prepared. The approach was performed with two incisions (knee, hip) to reduce the invasivity. The implantation started with the knee implants connected with the intramedullary rod and was finished with the hip implants. Postoperative weight bearing was following pain.
The pain diminuished significant in all patients in the questionnaires and the pain medication could be reduced substantially. All patients gained mobility already three months after the procedure, every patient could walk with crutches. No patients needed to be reoperated in the follow-up period. Every patient could keep the mobility over the the follow-up time. Two patients reported some pain in the knee. Radiologically the defects of the femur were partially consolidated and we could not see further bone loss.
plain x-ray plain xray and flexion/extension x-rays and plain x-ray and flexion/extension x-rays and CT scan. These results were correlated with a fusion rate based on the micro CT. The specificity and sensitivity of these radiological measures in diagnosing pseudarthrosis and inter-rater reliability using Fleiss’ Kappa scores for each method were calculated.
Introduction and Objective. Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) represent the most popular techniques in performing an interbody fusion amongst spine surgeons.
Re-positioning osteotomy in the treatment of un-united fracture neck of femur in young patients improves the biomechanical pre-conditions to promote bone union of the
We evaluated the efficacy of anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. Anterior fusion alone was undertaken in 15 patients (group A) and combined anterior and posterior fusion was carried out in a further 15 (group B). The degree and maintenance of the angle of correction, the incidence of graft subsidence, degeneration at adjacent levels and the rate of fusion were assessed radiologically and clinically and the rate of complications recorded. The mean angle of correction in group B was significantly higher than in group A (p = 0.0009). The mean visual analogue scale and the neck disability index in group B was better than in group A (p = 0.043, 0.0006). The mean operation time and the blood loss in B were greater than in group A (p <
0.0001, 0.037).
We reviewed 24 displaced fractures through the physis of the medial epicondyle of the distal humerus. One was a Salter-Harris type-II fracture-separation of the whole distal humeral epiphysis; the others involved only the medial epicondylar centre of ossification. Two cases had presented as pseudarthroses. One fracture had been treated closed in a plaster slab and 21 had had open reduction and internal fixation with sutures, Kirschner wires or Palmer nails. At 2 to 13 years later we found five types of deformity of the epicondyle: pseudarthrosis, an ulnar sulcus, a double-contoured epicondyle, hypoplasia or hyperplasia.