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. Pseudarthrosis is the most satisfactory and the most reliable operation: 1) in ankvlosing spondylitis, and 2) in patients over sixty years of age with disabling osteoarthritis. 4. The more formidable operation of cup arthoplasty may prove to be superior in younger patients with osteoarthritis

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.

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.

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.

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: Bone Joint J 2013;95-B:1027–34.

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.

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.

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). Pseudarthrosis, subsidence of the cage, and problems related to the hardware were more prevalent in group A than in group B (p = 0.034, 0.025, 0.013). Although the combined procedure resulted in a longer operating time and greater blood loss than with anterior fusion alone, our results suggest that for the treatment of degenerative cervical kyphosis the combined approach leads to better maintenance of sagittal alignment, a higher rate of fusion, a lower incidence of complications and a better clinical outcome

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. Pseudarthrosis had developed after either no treatment, closed reduction and plaster, or open reduction and suturing. Hypoplasia followed nailing, as did a trend to varus tilting of the joint surface. One very young patient, with fracture-separation of the whole distal epiphysis treated by nailing, developed marked cubitus varus

Aims

The aims of the study were to analyze differences in surgical and oncological outcomes, as well as quality of life (QoL) and function in patients with ankle sarcomas undergoing three forms of surgical treatment, minor or major limb salvage surgery (LSS), or amputation.

Aims

The direct posterior approach with subperiosteal dissection of the paraspinal muscles from the vertebrae is considered to be the standard approach for the surgical treatment of adolescent idiopathic scoliosis (AIS). We investigated whether or not a minimally-invasive surgery (MIS) technique could offer improved results.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients.

A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation.

The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients.

Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Cite this article: Bone Joint J 2015;97-B:1377–84.

Aims

This study assessed the association of classes of body mass index in kg/m² (classified as normal weight 18.5 kg/m² to 24.9 kg/m², overweight 25.0 kg/m² to 29.9 kg/m², and obese ≥ 30.0 kg/m²) with short-term complications and functional outcomes three to six years post-operatively for closed ankle fractures.

Aims

Transtrochanteric rotational osteotomy (TRO) is performed for young patients with non-traumatic osteonecrosis of the femoral head (ONFH) to preserve the hip. We aimed to investigate the long-term outcomes and the risk factors for failure 15 years after this procedure.

Objectives

We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis.

Aims

The aims of this study were to evaluate the clinical and radiological outcomes of instrumented posterolateral fusion (PLF) performed in patients with rheumatoid arthritis (RA).

Several techniques have been described to reconstruct a mobile wrist joint after resection of the distal radius for tumour. We reviewed our experience of using an osteo-articular allograft to do this in 17 patients with a mean follow-up of 58.9 months (28 to 119).

The mean range of movement at the wrist was 56° flexion, 58° extension, 84° supination and 80° pronation. The mean ISOLS-MSTS score was 86% (63% to 97%) and the mean patient-rated wrist evaluation score was 16.5 (3 to 34). There was no local recurrence or distant metastases. The procedure failed in one patient with a fracture of the graft and an arthrodesis was finally required. Union was achieved at the host-graft interface in all except two cases. No patient reported more than modest non-disabling pain and six reported no pain at all. Radiographs showed early degenerative changes at the radiocarpal joint in every patient.

A functional pain-free wrist can be restored with an osteo-articular allograft after resection of the distal radius for bone tumour, thereby avoiding the donor site morbidity associated with an autograft. These results may deteriorate with time.

The management of nonunion following high tibial osteotomy by total knee replacement (TKR) has been reported previously. We have extended the treatment to embrace cases with an infected high tibial osteotomy by performing an initial debridement with a period of antibiotic treatment followed by TKR. We have reviewed the results of seven knees in six patients with a mean follow-up of 40.5 months (20 to 57) after the staged TKR. At the latest follow-up, all the pseudarthroses had healed and there had been no recurrence of infection. The mean Hospital for Special Surgery knee score improved from 51.2 (35 to 73) to a mean of 91.7 (84 to 98) at final review.

Management of nonunion following high tibial osteotomy with a TKR can be extended to infected cases when treated in two stages with a debridement and antibiotic therapy prior to TKR.

The presacral retroperitoneal approach for axial lumbar interbody fusion (presacral ALIF) is not widely reported, particularly with regard to the mid-term outcome. This prospective study describes the clinical outcomes, complications and rates of fusion at a follow-up of two years for 26 patients who underwent this minimally invasive technique along with further stabilisation using pedicle screws. The fusion was single-level at the L5-S1 spinal segment in 17 patients and two-level at L4–5 and L5-S1 in the other nine. The visual analogue scale for pain and Oswestry Disability Index scores were recorded pre-operatively and during the 24-month study period. The evaluation of fusion was by thin-cut CT scans at six and 12 months, and flexion-extension plain radiographs at six, 12 and 24 months. Significant reductions in pain and disability occurred as early as three weeks postoperatively and were maintained. Fusion was achieved in 22 of 24 patients (92%) at 12 months and in 23 patients (96%) at 24 months. One patient (4%) with a pseudarthrosis underwent successful revision by augmentation of the posterolateral fusion mass through a standard open midline approach.

There were no severe adverse events associated with presacral ALIF, which in this series demonstrated clinical outcomes and fusion rates comparable with those of reports of other methods of interbody fusion.

Between 1993 and 2008, 41 patients underwent total coccygectomy for coccydynia which had failed to respond to six months of conservative management. Of these, 40 patients were available for clinical review and 39 completed a questionnaire giving their evaluation of the effect of the operation. Excellent or good results were obtained in 33 of the 41 patients, comprising 18 of the 21 patients with coccydynia due to trauma, five of the eight patients with symptoms following childbirth and ten of 12 idiopathic onset. In eight patients the results were moderate or poor, although none described worse pain after the operation. The only post-operative complication was superficial wound infection which occurred in five patients and which settled fully with antibiotic treatment. One patient required re-operation for excision of the distal cornua of the sacrum.

Total coccygectomy offered satisfactory relief of pain in the majority of patients regardless of the cause of their symptoms.

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive.

At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side.

Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.

There are few reports on the treatment of pyogenic lumbar spondylodiscitis through the posterior approach using a single incision. Between October 1999 and March 2003 we operated on 18 patients with pyogenic lumbar spondylodiscitis. All underwent posterior lumbar interbody fusion using an autogenous bone graft from the iliac crest and pedicle screws via a posterior approach. The clinical outcome was assessed using the Frankel neurological classification and the criteria of Kirkaldy-Willis. Under the Frankel classification, two patients improved by two grades (C to E), 11 by one grade, and five showed no change. The Kirkaldy-Willis functional outcome was excellent in five patients, good in ten and fair in three. Bony union was confirmed six months after surgery in 17 patients, but in one patient this was not achieved until two years after operation. The mean lordotic angle before operation was 20° (−2° to 42°) and the mean lordotic angle at the final follow-up was 32.5° (17° to 44°). Two patients had a superficial wound infection and two a transient root injury. Posterior lumbar interbody fusion with an autogenous iliac crest bone graft and pedicle screw fixation via a posterior approach can provide satisfactory results in pyogenic spondylodiscitis.

Intertrochanteric osteotomy may postpone the need for total hip replacement (THR). In young patients with an acquired deformity of the femoral head and secondary osteoarthritis, a valgus intertrochanteric osteotomy may allow better congruency but the acetabular cover may become insufficient because of subluxation of the femoral head. In patients with a spherical femoral head and acetabular dysplasia, cover can still remain insufficient after varus displacement osteotomy. We present the long-term results of intertrochanteric osteotomy combined with an acetabular shelfplasty in both these circumstances.

Sixteen hips (15 patients) with a deformed femoral head, and ten (seven patients) with a spherical femoral head, underwent an intertrochanteric osteotomy and acetabular shelfplasty. The mean age at the time of surgery was 30 and 37 years and the mean final follow-up was 15 and 19 years, respectively. Six patients in the deformed group, but only one in the spherical group, had required a THR by the time of their final follow-up. In both groups, those who had not undergone a THR had a good result.

Acetabular shelfplasty is an excellent addition to an intertrochanteric osteotomy and gives full cover of the femoral head in patients with a deformity of the head and secondary osteoarthritis.

We have prospectively studied the outcome of infections associated with implants which were retained and treated using a standardised antimicrobial protocol. Over a period of four years, we studied 24 consecutive patients who had symptoms of infection for less than one year, a stable implant, no sinus tract and a known pathogen which was susceptible to recommended antimicrobial agents. The infections involved hip prostheses (14), knee prostheses (5), an internal fixation device (4), and an ankle prosthesis (1).

Twenty patients had a successful outcome at a median follow-up of 3.7 years (1.8 to 4.7); four had failure of the implant after a median follow-up of 1.2 years (0.3 to 2.5). The probability of survival without failure of treatment was 96% at one year (95% confidence interval (CI) 88 to 100), 92% at two years (95% CI 80 to 100) and 86% at three years (95% CI 72 to 100).

Patients with a short-term infection but with a stable implant, no sinus tract and a known pathogen may be successfully treated by retention of the implant and the use of a standardised regimen of antimicrobial treatment.

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha’s technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique.

The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6° (0 to 45) to 34° (5 to 90) at the last review. The mean forward flexion increased from 12° (0 to 85) to 30° (5 to 90).

Abduction (41°) and especially forward flexion (43°) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42° of abduction and 56° of forward flexion. Active abduction (28°) and forward flexion (19°) were much less in completely flail shoulders (n = 34).

Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished.

The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.