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PubMed1982

[Indication, technic and results using the external fixator in infected fractures and infected pseudarthrosis].

Infected pseudo-arthrosis is the dreaded combination of chronic osteomyelitis and instability at the fracture site. Treatment consists in radical removal of sequestered bone and alloplastic implants, temporary implantation of Septopal chains for high-dose local antibiotic therapy and re-osteosynthesis with external fixator. The external fixator of Raoul Hoffmann is preferred because of its unlimited versatility. A total of 131 patients were treated in accordance with the method described. In 90.1% of the cases bone consolidation was achieved, and in 89.3% chronic osteomyelitis subsided.

Adolescent↗
PubMed1999

[Scaphoid fracture and scaphoid pseudarthrosis].

Careful diagnostic and early therapy are especially important in cases of scaphoid fractures. This is due to the patients being mostly young and the high number of non-unions of these carpal bones. Conservative and various operative treatments are therapeutical options. Out of the patients who underwent surgery from January 1993 to February 1999 42 patients with a scaphoid fracture and 88 patients with a scaphoid non-union were, in addition to standard X-ray examination, examined clinically and by MRI pre- and post-operatively. Fractures of the scaphoid were treated by Herbert screw fixation. The operative treatment of non-unions of the scaphoid included the transplantation of an iliac crest graft and Herbert screw fixation. Post-operatively a cast-immobilisation was done. Subjective statements of the patients and clinical results were assessed. The classification of Herbert and Fisher (1984)/Filan and Herbert (1996) for X-rays was used. The signal intensities of the MRI in the fragments of the scaphoid were determined qualitatively and quantitatively by computer calculation, comparing the pre- and post-operative results with one another. Post-operative results of the scaphoid fractures were in most cases good and excellent. 67 patients with a scaphoid non-union and 11 with a scaphoid fracture showed a pre-operative diminishing of the signal in the proximal fragment. For these patients, the fusion rate was lower than in patients without pre-operative signal reduction. The examination shows that in most cases bony fusions with good clinical results could be achieved by Herbert screw fixation. The MRI seems to be able to complete the radiological classification of the fractures regarding a prognosis.

Bone Screws↗
PubMed1999

[Pseudarthrosis].

Understanding the pathophysiology of non-union is a prerequisite for successful treatment of this disorder. Fracture healing may be impeded by mechanical or biological factors as well as a combination of these. A thorough evaluation of each individual case before surgery is necessary to prevent either undertreatment or overtreatment. The whole spectrum of methods of internal fixation may be utilized for stabilization. To optimize the biological component, classic methods such as decortication and cancellous autograft may be employed. It is too early yet to determine if alternative techniques (e.g. ultrasound) will successfully replace these long-standing options. In any case, these newer modalities cannot supplant the need for skeletal stabilization. For infected pseudarthroses the first step is eradication of infection, after which measures can be taken to unite the fracture. Callus distraction has opened new and safe ways to treat large bone defects.

Biomechanical Phenomena↗
PubMed1996

[Infected pseudarthrosis].

Sequestrectomy, fragment fixation, wound treatment and bone grafting are the old principles of infected non union surgery. Today these principles are the frame, which contents a more aggressive treatment. Sequestrectomy is a radical excision of the complete infected bone-soft-tissue-scar, the resulting defects are covered by one of the various techniques (skin-traction, flap surgery, bone shifting, etc.). Out of 71 infected non unions, treated by radical resection and bone segment transport, healing rate without recurrence of infection was 94%, in 3 additional patients (4%) amputation was performed. For bone fragment fixation, a non devastating implant, like external fixateur, is preferred. To close the wound, the law of avoiding a dead space is used. Defects are closed by muscle flaps, by fragment shortening or by a antibiotic spacer temporarily. The skin is closed by skin-traction techniques or with flap surgery. After soft tissue healing, small bone defects are filled by autografts, defects of more than 3-4 cm with transported segments. Previous limb shortening to close bone defects, with a lengthening later in a "healthy" region, is also possible. Local antibiotic wound treatment cases a significant reduction of the contamination rate, improved dressing techniques support wound healing free of infection. This therapeutic techniques are comparable to open fracture treatment, where by similar surgery a very low infection rate can be achieved.

Amputation, Surgical↗
PubMed2000

[Calcaneus pseudarthrosis: a clinical rarity].

The calcaneus pseudoathrosis is rarely seen in clinical workday and we couldn't find any case be reported. In two cases the authors present the diagnosis and therapy of a non-union after a calcaneus fracture. The authors point especially at anatomical characteristics and biomechanical reasons and their meaning for aetiology of pseudoathrosis after a calcaneus fracture.

Adolescent↗
PubMed1996

[Pseudarthrosis].

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Fracture Healing↗
PubMed1996

[Ilizarov procedure in pseudarthrosis].

The treatment of nonunions has made an important development through the work of Ilizarov describing the principles of compression and distraction by using the ring-fixator. While local compression is sufficient in hypertrophic nonunions, the treatment of choice for atrophic infected nonunions with bony defects is a corticotomy followed by a segmental transport, especially in case of an osseous defect larger than 3 cm. Primary shortening poses a better starting point both for soft-tissue reconstruction and for early docking. External fixation systems are the ring-fixator, the unilateral fixator and hybrid systems combining both fixation methods. The use of a ring-fixator makes a shorter time of osseous consolidation possible when compared to a unilateral system (25,8 d/cm - 35,8 d/cm). Soft-tissue reconstruction before initiation of transport also shortens the time of osseous consolidation compared to later soft-tissue coverage. A docking-region in the metaphyseal area is supported by minimal internal fixation and cancellous bone graft. Segmental transport is complicated by local infection, regenerate failure (4.3% and regenerate fracture (2.9%).

Adult↗
PubMed1996

[Pseudarthrosis of the proximal femur].

Mechanical and biological factors are responsible for non-unions of the proximal femur. We analyse the causal treatment-possibilities of the different localisations. Fifty-five patients with non-unions of the femoral neck (average age 53 years) with or without preexistent femoral head necrosis (44%) were treated by abduction osteotomy and followed up at regular intervals. In 15% of cases a second operation was necessary after an average of 9.3 years, including the early complications. At the latest control 90% of the patients were satisfied, with an average Harris hip score (HHS) of 91. The survivorship analysis with end point total hip replacement is favourable. In the same period 22 patients were treated with a total hip replacement. The 11 survivors had a clearly worse HHS of 65. The low-risk, technically demanding valgization osteotomy should be the first step in the treatment of femoral neck non-unions, even in the presence of femoral head necrosis; secondary operations are not compromised. Pertrochanteric non-unions are rare. The pertrochanteric fragment very often heals, leaving a lateral femoral neck non-union which can be treated with valgization osteotomy. Depending on the type of non-union and the age of the patient, anatomical reduction, medial displacement and valgization osteotomy can be employed. With the angulated plates of the ASIF (95 degrees, 120 degrees, 130 degrees) 23 of the 24 non-unions could be healed in one operation. Fourteen patients underwent total hip replacement. In the subtrochanteric area mechanical and vascular instability leads to implant failure or fatigue fracture. Rigid compression-re-osteosynthesis is the therapy of choice, the 95 degrees condylar plate the implant. Twenty-three of our documented 24 subtrochanteric non-unions healed, 4 in the presence of an infection. Multiple operations have been necessary in 2 of the 4 non-unions following a pathological fracture.

Adult↗
PubMed1996

[Pseudarthrosis of the proximal ankle joint].

Nonunion of the ankle malleoli is extremely rare these days. This is probably due to the fact that primary osteosynthesis is performed in ankle fractures instead of the conservative treatment given up to 20 years ago. Today nonunions of the malleoli are seen, if at all, is infected cases after surgical procedures. Noninfected, stable and painless nonunions usually do not need any surgical correction. In painful cases, small fragments, especially of the medial malleolus, should be resected; larger fragments should be stabilized with two 3.5-mm cancellous screws. Alternatively, the tension banding technique, especially after Weber A fracture, produces high compression in the area of nonunion. In cases of additional bony defects, a local upside down cortical-cancellous bone graft should be performed in addition. In summary, the therapeutic approach requires exact remodeling, bone-grafting and stabilization. Infected nonunions with loss of bone mass should be treated according to the guidelines for osteitis therapy.

Adult↗
PubMed1996

[Infected pseudarthrosis].

In open fractures the rate of infected non-union defects has in recent years decreased due to the increased primary application of external fixation. In spite of this positive state of affairs the condition is still encountered often enough to warrant specific treatment strategies and techniques. In the treatment of infected pseudarthroses the general principles of osteitis treatment are applied. This includes radical excision of infected pseudarthrotic bone and of the diseased surrounding soft tissue, provides mechanical stability in the non-union area and requires effective local treatment of the infection in combination with systemic, target-specific and temporary well-defined antibiotic therapy as well as procedures to improve local circulation. The incorporation of autogenous bone transplants in defects appears to depend on close contact between the transplant and the vascularized receiving site and on the quantity of the transplanted osseous material. A promising alternative method of dealing with extensive bone defects is osteogenesis produced by callus distraction; therefore special attention is given to Ilizarov's ring fixation system. Unstable scar formation demands local muscular flaps or microvascularized free flap transfer, which seems to be superior to other methods.

Anti-Bacterial Agents↗