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Pseudarthrosis, often associated with neurofibromatosis, usually is present at birth or is the result of pathologic fracture. We present a rare case of a 29-month-old patient with acquired pseudarthrosis in radiographically normal bone.
Neurofibromatosis type 1 (NF1) is a common dominantly inherited disease. More than half of NF1 patients suffer from skeletal manifestations, of which congenital pseudarthrosis of tibia (CPT) is one of the most incapacitating lesions. Two NF1 patients with CPT were operated, and the resected tissues were analyzed using immunohistochemistry and/or in situ hybridization for NF1 protein and mRNA, p-p44/42 MAPK, and S100 protein. Both patients displayed thick-walled arteries and veins with a small lumen within the fibrotic tissue in the vicinity of pseudarthrosis. Endothelial cells were highly positive for p-p44/42 MAPK. A subpopulation of cells surrounding the blood vessels was S100 protein-positive. However, the exact identity of the S100-positive cells remains to be elucidated. Neurofibromin mRNA and protein labeling was detected in both cell types. In conclusion, decreased NF1 function as a RAS-GAP in the endothelium may contribute to vascular thickening in CPT.
The aim of this retrospective study was to evaluate the effectiveness of circular external fixator according with Ilisarov technique for the treatment of diaphyseal pseudarthrosis. The union rate obtained in our serie was 91%. We assessed the complications related to surgery and analysed the reasons for failed technique. Between january 1986 and february 1996, 23 patients were included in this study with a mean follow-up of 65 months. The period of external fixation was 209 days on average. 21 patients had united fractures. The failures were attributed to inadequate interfragmentary contact. The main problem during treatment was pin tract infection. The late complications included axial deformities, re-fractures and joint stiffness. Circular external fixator proved to be useful for the treatment of diaphyseal pseudarthrosis, particularly those complicated by infection or post-traumatic shortening.
Pseudarthrosis in the hand are defined as a non-union of a fracture after 6 month. Reasons might be biological disorders, mechanical instability or infection after fracture treatment. Pseudoarthrotic bone demands stable osteosynthesis and often bone grafting. The presented case is about a dislocated osseous fragment attached to the Aponeurosis dorsalis mimicking clinical and radiological a Pseudarthrosis of the proximal phalanx of the thumb. We would like to draw attention that osseous fragments may present very similarly to a pseudoarthrosis of a phalanx.
We analyzed the clinical and radiographic outcome of 2 cases of congenital pseudarthrosis of both forearm bones managed by free vascularized fibular grafts. The follow-up periods were 17 and 13 years, respectively. The first patient, a 4-year-old girl, had reconstruction of both the radius and ulna by a vascularized fibular graft, restoring pronation/supination to 110 degrees. The second patient, a 17-year-old boy, underwent a 1-bone forearm procedure using a vascularized fibular graft. After surgery, he had a stable forearm that was shortened by approximately 15 cm. In these 2 cases of congenital pseudarthrosis of both forearm bones, bone union was obtained by means of vascularized fibular graft.
Congenital pseudarthrosis of the tibia is a rare disorder of unknown etiology. The free vascularized fibula-pro-tibia-transplant permits correction of the defect and the leg length-discrepancy during one surgical procedure. A 5 year old girl with congenital pseudarthrosis underwent a free vascularized fibular-pro-tibia-transplant. At a follow-up examination 5 years post surgery she had no subjective complaints, she walked without external orthopaedic support, there was no leg length-discrepancy. As stated in the literature the rates of bony unions are much higher than after conventional methods.
The navicular pseudarthrosis is in case of early and appropriate treatment of the navicular fracture relatively seldom. It develops often after a too late diagnosed or insufficiently treated navicular fracture. After an introduction of the pathogenetic causes of the navicular pseudarthrosis we give a survey over the operative methods of treatment represented in literature favourising the method of the implantation of a corticospongious bone-graft after Matti in the modification of Russe, which we prefer in our hospital. We base the long-term results of our treatment on a casuistic of 105 patients, operated after the method Matti-Russe. We performed a follow-up of 68 patients between 3 and 16 years after the operation (8,4 years on average). In our critical examination we put stress on the functional results, on the subjective and objective sucess of the operation, on the professional situation of the patients and its social-medical meaning. At last we give a comparison with the most extensive casuistics of the literature.
Forty patients underwent 47 procedures for repair of a lumbar pseudarthrosis at the University of Minnesota, Twin Cities Scoliosis Center between 1973 and 1986. Forty-three procedures in 36 patients with a minimum follow-up of 2 years were reviewed. Symptoms at the time of surgery included back pain (100%), leg pain (61%), subjective neurologic symptoms (49%), and thigh pain (35%). The diagnosis was made most commonly on the basis of pain radiographs (70%). In 38 cases, posterolateral fusion was performed, using segmental sublaminar wiring in 37%, a variable screw plate in 29%, Harrington compression rods in 16%, and no implant in 18%. Anterior interbody fusion was performed in six cases, including one combined fusion. Follow-up averaged 4.4 years. Solid fusion was achieved in 49% of cases. Eighty-six percent of patients continued to have low-back pain. Clinical outcomes were graded as excellent in 7%, good in 35%, fair in 9%, and failure in 49%. Significantly improved results were seen in patients in whom a solid fusion was obtained (p less than 0.005), in patients who had undergone only one prior surgery on the lumbar spine (p less than 0.01), and in patients in whom the initial fusion had been performed for spondylolisthesis rather than a primarily degenerative disorder (p less than 0.025). A trend toward better results was seen in cases in which the patient did not complain of leg pain preoperatively, in which a Workers' Compensation claim was not involved, and in which a prior attempt at pseudarthrosis repair had not been performed.(ABSTRACT TRUNCATED AT 250 WORDS)
Occut pseudarthrosis is the most likely cause of loss of correction of scoliosis. Prompt detection by serial roentgenograms and treatment of occult pseudarthrosis can prevent deformities which could develop with further spinal growth.
An infant male presented at age 17 months with an established pseudarthrosis in a kyphoscoliotic right tibia. During the ensuing 6 years, three unsuccessful McFarland bypass bone grafts were performed. Then the distal end of the proximal fibula was placed into the medullary cavity of the proximal end of the distal tibia without disturbing the proximal portion of the fibula. This was augmented by autogenous bone graft. Union occurred in one year. The child has been followed for 7 years and the pseudarthrosis remains healed.
The case of a twenty-three-year-old male with a symptomatic pseudarthrosis of the acromion is presented. Open reduction and internal fixation with a plate, screw, and tension band construct supplemented with a bone graft was performed and early range of motion was initiated. Nine months after surgery, the fracture was healed and the patient had excellent function of the shoulder. The literature on pseudarthrosis of the acromion is reviewed.
OBJECTIVES: This study aimed to test the hypothesis that under standardized mechanical and biologic conditions, the process of indirect bone repair in a rodent species could be manipulated to form a reproducible, atrophic, fibrous pseudarthrosis. DESIGN: The model used comprised a mid-diaphyseal, transverse osteotomy in the rat femur, stabilized via a precision miniature external fixator, a constant axial fixation stiffness being defined by a specific frame geometry. MAIN OUTCOME MEASUREMENTS: The repair process for both 0.5-mm and 3.0-mm gap osteotomies was characterized using radiography, dual-energy x-ray absorptiometry, histologic assessment of standardized longitudinal sections, and postmortem mechanical testing. RESULTS: Healing of the defect was highly reproducible, bone union being attained at around 5 weeks postoperatively with a 0.5-mm gap. Increasing the gap width to 3.0 mm resulted consistently in a pseudarthrosis. CONCLUSION: These two reproducible patterns of repair can now be used to elucidate the underlying molecular mechanisms controlling the extent and progression of connective tissue differentiation in indirect bone repair without the additional variable of a nonstandardized mechanical environment.
Successful resolution of a late thoracic outlet syndrome secondary to pseudarthrosis of the clavicle was accomplished by surgical resection of the pseudoarthrosis and mid 3 cm of the clavicle, following conservative therapy which did not alleviate the symptoms. The patient was a 28-year-old woman. Arteriography demonstrated the lesion. A shoulder dislocation preceded the thoracic outlet syndrome; a congenital pseudarthrosis may have been present.
PURPOSE: The use of shock waves in orthopedic diseases was reviewed with special regard to the clinical applications. MATERIALS AND METHODS: Findings in the literature and results from our own studies were analyzed and summarized. RESULTS: Extracorporeal shock waves induced osteoneogenesis in animal models with intact and fractured bones. Based on these findings shock waves were used for the treatment of pseudarthrosis in humans. Most patients had at least 1 unsuccessful operation before shock wave therapy. Complete reunion was noted in 62 to 91% of cases and shock waves are recommended by some as the first choice of treatment for hypertrophic pseudarthrosis. After failed nonoperative therapy shock waves were used for the treatment of patients with various diseases as secondary treatment. The success rate for treatment of tendinopathies, such as tennis elbow, periarthritis humeroscapularis or calcaneal spur, was approximately 80%. For calcific tendinitis shock wave therapy seems to be superior to all other minimal or noninvasive techniques without compromising a potential later operation. CONCLUSIONS: Shock waves have changed medical therapy substantially. Accounting for the epidemiology of the treated diseases, this new change may equal or even surpass the impact of extracorporeal shock wave lithotripsy.
To investigate the relationship of smoking with the rate of pseudarthrosis (surgical nonunion), 50 patients, who were smokers, and 50 patients, who were not, and who had had a two-level laminectomy and fusion during 1977 and 1978 were randomly selected for this study. Most of those participating had sustained job-related injuries whereas the others had no common etiology for their back dysfunction. Most of the patients were from the southeastern United States. Ages ranged from 23 to 62 years, with a mean age of 42.4 years for smokers and 42.7 years for nonsmokers. There was an equal representation of males and females, with minorities represented according to their general percentage in the population. Examination 1 to 2 years after surgery revealed that 40% (20) of the smokers had developed a pseudarthrosis, whereas among nonsmokers, the rate was 8% (4). This finding appears to be independent of age, sex, or race and was statistically significant (chi 2 = 14.035, P = .001). It was hypothesized that the higher incidence of surgical nonunion among smokers may be related to blood gas levels. Nonsmokers showed no significant deficiencies, whereas smokers showed a mean PO2 level of 78.5% (normal = 95-97) and a mean O2 saturation level of 92.9% (normal = 95 or above). Implications and suggestions for further research are also discussed.
The operative treatment of congenital pseudarthrosis of the tibia, especially when associated with neurofibromatosis type I (Recklinghausen's disease), often leads to failure. Frequently, regardless of the type of deformity, multiple operative procedures end in the amputation of the affected limb. Soft tissue coverage of the amputation stump may confront the surgeon with new problems. Secondary perforation of the soft tissue envelope of the stump owing to terminal overgrowth is not a rare complication. A new technique of stump capping is demonstrated in a 10-year-old boy and a 14-year old girl, both with congenital pseudarthrosis of the tibia of the right leg and neurofibromatosis. During this procedure, a radical resection of the pseudarthrotic tissue is performed although all neurovascular structures supplying the calcaneus are carefully maintained (Arteria, vena et nervus tibialis posterior et peronealis). Subsequently, the tibia and fibula are inserted into the calcaneus. This construct is stabilized with two crossed Kirschner wires. Afterwards, the skin of the lower limb and the hindfoot are sutured together covering the neurovascular bundles, which are arranged in a loop-like fashion. The documented active range of motion was similar to that of the unaffected knee joint. Twelve weeks after operation in both patients, full weight bearing was achieved with a lower-leg prosthesis. This new procedure leads to a durable, full weight-bearing stump with complete sensitive innervation without the risk of future soft tissue perforation caused by the growing bone. The stump fits with an end-bearing lower-leg prosthesis.
A patient reported that he sustained a minor fall on the outstretched hand in hyperextension, pronation, and in ulnar deviation. Initial radiographs suggested dorsal transscaphoid-transtriquetral perilunate dislocation. Traditionally, however, this injury is the result of a high-energy impact. A CT scan obtained after closed reduction of the dislocation revealed not only a fresh fracture of the triquetrum but also two corticalized fragments of the scaphoid. A former major fall on this hand and a normal scaphoid of the other hand made pseudarthrosis more likely than scaphoid bipartition. Arthrography revealed intact lunotriquetral and scapholunate ligaments, precluding the possibility of preexisting ligamentous instability. Pseudarthrosis of the scaphoid with a loss of scaphoid function as a mechanical tie-rod of the carpus is most likely responsible for this complex injury. This is the first clinical study that shows that single scaphoid discontinuity without preexisting ligamentous carpal instability may lead to complex perilunar dislocation in minor trauma.
We treated nine patients with congenital pseudarthrosis of the tibia consecutively by a modification of the Ilizarov (circular frame) technique. Seven patients had had several previous operations, and two patients had had none. After resecting of the pseudarthrosis and the surrounding pathologic periosteum, we performed acute shortening and compression at the level of resection, together with simultaneous lengthening of the proximal tibia. Union was achieved in all cases. With this technique, not only the mechanical but also the biologic problems are addressed. As compared with other methods, the circular frame technique also offers the possibility of correcting angulation and limb length discrepancy.