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PubMed2001

Mechanobiology of initial pseudarthrosis formation with oblique fractures.

Mechanical stresses play an important role in regulating tissue differentiation in a variety of contexts during skeletal development and regeneration. It has been shown that some intermittent loading at a fracture site can accelerate secondary fracture healing. However, it has not been shown how the stress and strain histories resulting from mechanical loading of a fracture might, in some cases, inhibit normal fracture healing and induce pseudarthrosis formation. In this study, finite element analysis is used to calculate hydrostatic stress and maximum principal tensile strain patterns in regenerating tissue around the site of an oblique fracture. Using a mechanobiologic view on tissue differentiation, we compared calculated stress and strain patterns within the fracture callus to the histomorphology of a typical oblique pseudarthrosis. Tissue differentiation predictions were consistent with the characteristic histomorphology of oblique pseudarthrosis: in the interfragmentary gap. tensile strains led to "cleavage" of the callus; at the ends of both fracture fragments, hydrostatic pressure and tensile strain caused fibrocartilage formation, and, at discrete locations of the periosteum at the oblique fracture ends, mild hydrostatic tension caused bone formation. We also found that discrete regions of high hydrostatic pressure correlated with locations of periosteal bone resorption. When previous findings with distraction osteogenesis are considered with these observations, it appears that low levels of hydrostatic pressure may be conducive to periosteal cartilage formation but high hydrostatic pressure may induce periosteal bone resorption during bone healing. We concluded that tissue differentiation in pseudarthrosis formation is consistent with concepts previously presented for understanding fracture healing, distraction osteogenesis, and joint formation.

Biomechanical Phenomena↗

PubMed1999

Congenital pseudarthrosis of the forearm treated by free vascularized fibular graft: a report of three cases and a review of the literature.

Congenital pseudarthrosis of the forearm is a rare condition; approximately 60 cases have been reported in the English literature. We report 3 patients treated by wide excision of the pseudarthrosis and free vascularized fibular grafting. The pseudarthrosis involved the radius in 1 patient and the ulna in 2. Neurofibromatosis was present in 2 patients. The technical problems encountered during the procedures included preservation of the distal epiphysis and attaining stable fixation of the fibular graft without damaging its vascular supply. A review of 15 previously reported patients treated by free vascularized fibular grafting showed that this procedure is excellent in the treatment of congenital pseudarthrosis of the forearm and that the result is consistently reproducible.

Child, Preschool↗

PubMedDate not supplied

[Clavicular pseudarthrosis in childhood: differential diagnosis, clinical aspects, therapy and results].

AIM: Both congenital as well as post-traumatic pseudarthroses of the clavicle are very rare diagnoses in childhood. This study evaluates operative and non-operative therapy in relation to diagnosis, clinical appearance, and results. METHODS: A retrospective study was performed on all patients with pseudarthrosis of the clavicle in childhood. The data were obtained from medical records. Follow-ups were performed on patients who had undergone surgery. RESULTS: A total of 15 patients with 16 pseudarthroses were included, of these five patients had congenital and nine patients had post-traumatic pseudarthroses. One patient with a bilateral defect was diagnosed as having cleidocranial dysostosis. Concerning the patients with congenital pseudarthrosis, cosmetic appearance was the leading complaint while patients with post-traumatic pseudarthrosis suffered from pain and impaired function of the shoulder joint. Nine patients underwent surgery, including two patients with congenital, and seven with post-traumatie lesions. CONCLUSION: While patients with congenital pseudarthrosis mostly achieve good functional results by means of conservative therapy, surgery is optional in relation to the severity of cosmetic damage. However, the majority of post-traumatic lesions require operative therapy due to associated pain and restricted function.

Adolescent↗

PubMed2005

Surgical treatment of congenital pseudarthrosis of the clavicle: a report of three cases and review of the literature.

Congenital pseudarthrosis of the clavicle is a rare entity of unknown aetiology with predominance of the right side. Our therapeutic concept is discussed with special reference to surgical therapy, histopathological findings and the most recent literature. Two girls and one boy, aged 4, 6, and 8 years, presenting with congenital pseudarthrosis of the clavicle were surgically treated between 1994 and 2000. A resection of the pseudarthrosis and internal fixation with a small reconstruction plate was performed. A bone graft from the iliac crest was used for restoration of clavicular length. Histological examination revealed a false joint with the ends of the clavicle covered by hyaline cartilage. The patients showed radiographic healing after 12 weeks. At follow-up (mean 44 months), all patients showed excellent clinical and radiological results without functional impairment. The clinical features and histological examination of the resected pseudarthroses clearly proved the diagnosis of a true congenital pseudarthrosis of the clavicle. According to our clinical and radiological results and considering the recent literature, we recommend surgical therapy with resection, bone grafting, and osteosynthesis with a reconstruction plate around the age of 4 - 6 years.

Bone Transplantation↗

PubMedDate not supplied

[Transaxial spongiosa-plasty and ventral, temporary atlanto-axial fixation for therapy of dens pseudarthrosis].

PURPOSE: According to literature there is a pseudarthrosis rate of about 1% up to 64% depending on the treatment of the dens fracture (16). Generally the treatment of dens pseudarthrosis consists of the fusion of the joint C1/C2 with or without dens resection. Now, a method is presented whereby, on the one hand the pseudarthrosis is treated, while on the other hand the anatomical structures and physiological function of the joint C1/ C2 are restored. METHOD: The operation consists of a gradual outboring of the base of the dens and the dens axis and filling with autologous cancellous bone. Then follows a lateral, temporary transarticular screw fixation of C1/C2 which guarantees an immobilisation of the filled out dens. A halo-body-jacket is then applied. The removal of the screws of the temporary fixation follows three months post operatively after X-ray control. Then physiotherapy of the cervical spine follows. RESULTS: During 7/93 and 7/97 this operation was carried out on 11 patients. In 9 cases compression screw osteosynthesis was primarily conducted and in 2 cases conservative therapy had preceded. The X-ray follow ups showed on an average of 14 month a stable bony fusion in 10 patients, the clinical follow up examinations on an average of 14 month a normal function. CONCLUSION: The operation presented is indicated in case of dens pseudarthrosis because this accomplished a definite bony fusion without disturbance of the function of the joint C1/C2 in patients not older than 60 years. Disadvantages are to be found in the intraoperatively high X-ray radiation and the 3 month immobilisation.

Adolescent↗

PubMedDate not supplied

[Diagnostic and therapeutic problems of congenital pseudarthrosis of the lower leg in children].

So-called pseudarthrosis of the lower leg is a rare condition whose treatment entails major therapeutic problems. The first symptoms of this disease are structural changes thinning, and sclerosis of the tibia and fibula, as well as varus and antecurvation malposition? of the axis. In all of the authors' patients the pseudarthrosis occurred as a secondary phenomenon, three times in attempts to correct the lower leg axis surgically; in two children spontaneous fractures occurred due to fatigue and in two others after stumbling. In all seven of the surgically treated children and in three of the six in the outpatient group café-au-lait spots were seen. The neurofibromatosis was also confirmed by histological examinations in all of the surgically treated children. Not only the views concerning etiology, but also therapy have changed. Our present treatment method is undoubtedly a success as compared to that used on our first patients. On the basis of our surgical experience so far we can recommend the following method: resection of the pseudarthrosis with removal of all pathologically changed tissue (also by fraising), insertion of Küntscher nails from the heel to the tibia, adequate covering of the pseudarthrosis location with spongiosa grafts from the pelvic ridge. If necessary, the intervention should be repeated.

Bone Neoplasms↗

PubMedDate not supplied

Ilizarov technique in the treatment of congenital pseudarthrosis of the tibia.

This study analyzes the risks and benefits of Ilizarov's technique in congenital pseudarthrosis of the tibia (CPT). This was a retrospective review of 14 patients treated between 1985 and 1993 for CPT, by using Ilizarov's technique. In 12 cases, this technique was used after failure of previous surgical treatment. Realignment, end-to-end compression, and leg lengthening were undertaken in all the cases, without excision of the pseudarthrosis site. The mean fixation duration was 7.8 months. Union was achieved with the initial treatment in seven cases. Bone grafting was used in six of the seven remaining cases and achieved bone healing in three of them. Refracture occurred in one case, and ended with nonunion. At 3.5-year average follow-up, the tibia was united in nine cases. We found that the best indications for Ilizarov's technique in CPT were the normotrophic and hypertrophic types of pseudarthrosis (Apoil II), after the age of 5 years. Secondary massive bone grafting is to be considered in some cases. The major disadvantage of this method is the lack of excision of the pseudarthrosis site. Even after healing is achieved, the bone remains dystrophic and fragile and necessitates a permanent protective orthosis, until the end of bone growth.

Adolescent↗

PubMed1988

Three-dimensional computed tomography and multiplanar reformations in the assessment of pseudarthrosis in posterior lumbar fusion patients.

Three-dimensional (3-D) surface reconstructions and multiplanar computed tomography (CT) reformations were obtained in 30 patients with clinically suspected spinal fusion pseudarthrosis. The imaging studies were blind-reviewed and the results were compared with the clinical and surgical findings. Sagittal, planar, and curved coronal two-dimensional (2-D) reformations were more useful in the detection of bony nonunion than were axial CT scans, as the latter required more extensive analysis. Three-dimensional surface "cuts" adequately demonstrated pseudarthrosis in most cases. In some instances, however, segmentation artifacts created artifactual clefts or implied solidity, which contrasted with the interpretation of the 2-D images. Sagittal 3-D cuts were helpful in demonstrating bony central and lateral stenosis. Three-dimensional surface reconstructions demonstrated superficial clefts and outlined the complex anatomy of the spinal fusions, thus facilitating pre- and intraoperative planning. The amount of bone stock available for pseudarthrosis repair at the fusion site and the need for additional harvesting of bone from the iliac crest also could be assessed easily. 3-D CT proved to be useful as an adjunctive imaging method in the evaluation of posterior lumbar fusion patients suspected of pseudarthrosis.

Adult↗

PubMed1990

Metabolic bone disease in lumbar pseudarthrosis.

Pseudarthrosis occurs in many patients who undergo lumbar spine fusion and it has been suggested that abnormalities of bone metabolism contribute to it. The authors evaluated 47 patients with pseudarthrosis for metabolic bone disease. Symptomatic patients with pseudarthrosis underwent metabolic bone evaluation. Abnormal results of laboratory tests were found in 7 patients (14.9%): 3 low or borderline 1,25 dihydroxy vitamin D3, 2 elevated 24-hour urine calcium, and 2 low serum testosterone. None of these abnormalities correlated with other clinical findings. Bone density was low in 14 of 24 patients in whom it was measured. Low values did not correlate with smoking or abnormal laboratory values. Metabolic bone abnormalities do not appear to play a frequent or significant role in pseudarthrosis after attempted lumbar spine fusion.

Adult↗

PubMed1996

Cervical pseudarthrosis in ankylosing spondylitis. A case report.

STUDY DESIGN: This report illustrates two different cases of cervical pseudarthrosis in ankylosing spondylitis. OBJECTIVES: To point out the extreme rarity of this condition at cervical level, to discuss the pathogenesis, and to stress the necessity of surgical management. SUMMARY AND BACKGROUND DATA: Pathogenesis of pseudarthrosis in ankylosing spondylitis is discussed. Several factors are involved: trauma, which may be major or minor and undetected; stress fracture; and inflammatory changes. Major trauma was the cause of pseudarthrosis in the first patient, whereas stress fracture and inflammatory changes were the probable causes in patient 2. In patient 1 there were signs and symptoms of cord compression. Patient 2 was referred because of functional disability resulting from kyphosis and because of potential neurologic risk. METHODS: Cervical fusion was performed in both patients. Patient 1 underwent posterior fusion; patient 2 had combined fusion. Patient 1 also underwent a lamineotomy. RESULTS: The course of the disorder after surgery was uneventful in both patients. Neurologic symptoms subsided in patient 1; kyphosis was corrected in patient 2. Both patients resumed their preoperative activities. Follow-up evaluation was done 6 years after surgery in patient 1 and 2 years after surgery in patient 2. CONCLUSIONS: Pseudarthrosis of the cervical spine in ankylosing spondylitis is extremely rare. Presentation of the two patients was different in terms of pathogenesis and signs and symptoms. Surgical treatment is advocated for this disorder.

Cervical Vertebrae↗

PubMed1998

Pseudarthrosis of the lumbar spine. Outcome after circumferential fusion.

STUDY DESIGN: Twenty-five patients with a pseudarthrosis after previous spinal fusion surgery were reviewed after a circumferential fusion was performed. OBJECTIVES: To determine the fusion rate and its relation to outcome, i.e., pain reduction and return to work, and associated complications. SUMMARY OF BACKGROUND DATA: Circumferential fusion has become a common procedure with more patients undergoing multiple operations. This operation is thought to improve the fusion rate with a low complication rate. However, the procedure has not been evaluated specifically for the management of pseudarthrosis. METHODS: Twenty-five patients were reviewed regarding age, gender, smoking status, previous back surgeries, extent of leg and back pain, occupation, levels of surgery, type of instrumentation, blood loss, and complications. A minimum follow-up period of 2 years included evaluation of radiographs, pain levels, medication, and return to work. RESULTS: Twenty percent of patients were heavy smokers. An average of 2.2 previous procedures had been performed, and the average follow-up period was 2.7 years. Eighty percent of patients underwent multiple-level fusions. A solid fusion was achieved in 100%. Complications included two painful instrumentation devices requiring removal, one retroperitoneal hematoma, one anterior abdominal wall dehiscence, and one case of pneumonia. Pain scores improved from 7.4 to 4.7 for back pain, and 5.4 to 2.8 for leg pain, respectively. Both improvements were statistically significant (P < 0.01 and 0.003, respectively). However, only 52% of patients reduced their pain by a full category. Forty-one percent were still taking narcotics intermittently or consistently, and 53% returned to work or were actively seeking employment. DISCUSSION: A fusion rate of 100% was noted in the face of factors often placing patients at high risk for developing a pseudarthrosis, namely multiple levels of previous spinal surgery, including previous pseudarthrosis, and a habit of heavy smoking. Complications were few. However, the satisfactory outcome rate was only somewhat better than 50%, based on a lack of substantial pain improvement and return to work.

Bone Screws↗

PubMed2006

Osteogenic protein-1 induced gene expression: evaluation in a posterolateral spinal pseudarthrosis model.

STUDY DESIGN: Molecular study of gene expression in rabbit lumbar pseudarthrosis repairs using reverse transcriptase polymerase chain reaction. OBJECTIVE: To evaluate differential gene expression of no graft, autograft, and osteogenic protein-1 treated pseudarthroses. SUMMARY OF BACKGROUND DATA: Osteogenic protein-1 is a potential bone graft alternative that has achieved high fusion rates in a rabbit lumbar fusion model, including in the repair of nicotine-induced pseudarthroses. A previous study established a correlation between osteogenic protein-1 fusion outcomes and an enhanced level of cytokine gene expression. The expression of such cytokines is known to be decreased in nicotine-exposed rabbit fusion masses. METHODS: Messenger ribonucleic acid was isolated from nicotine-exposed New Zealand white rabbit lumbar pseudarthroses following attempted no graft, autograft, and osteogenic protein-1 pseudarthrosis repairs. Reverse transcriptase polymerase chain reaction was used to assess the expression of angiogenin, angiopoietin, intercellular adhesion molecule, platelet-derived growth factor-beta, vascular endothelial growth factor, bone morphogenetic proteins 2 and 7, type I collagen, and osteonectin. Glyceraldehyde-3-phosphate dehydrogenase was used as a constitutively expressed control. RESULTS: Levels of gene expression in the osteogenic protein-1 group were higher than those of the autograft group, which were higher than the no graft group for the majority of the genes studied. CONCLUSIONS: In the rabbit pseudarthrosis model, gene expression data supported the hypothesis that successful pseudarthrosis repair is related to the induction of osteogenic and angiogenic cytokines by osteogenic protein-1.

Animals↗

PubMed2000

Pathology of bone lesions associated with congenital pseudarthrosis of the leg.

Congenital pseudarthrosis of the leg remains one of the most controversial pediatric entities in terms of etiopathogenesis, pathology, treatment, and prognosis. The authors reviewed the pathologic material of 24 patients with congenital pseudarthrosis of the leg along with clinical and radiographic data. The tibia was affected in 22 patients; in two patients the disease was limited to the fibula. Fifteen patients were male and nine were female. Age at surgery ranged from 1 to 26 years. Nineteen patients were classified as having dysplastic type, one cystic, and four mixed. Clinical evidence of neurofibromatosis type I (NF-I) was found in 17 patients. The main histopathologic change observed was the growth of a highly cellular, fibromatosis-like tissue. In the dysplastic type, such tissue was associated with the periosteum. In the cystic type, a closely similar tissue occupied the lytic area. In case classified as of mixed type, the coexistence of endosteal/medullary and periosteal involvement by the fibromatosis-like tissue was observed. In the cystic lesion, evidence of de novo bone formation within the lesional tissue was obvious. Overall, the histologic features of the cystic lesion were similar to those of osteofibrous dysplasia. In the dysplastic type, the proliferation of the fibrovascular tissue was associated with active osteoclastic resorption of the cortex, which remodeled into a trabecular rather than a compact type of structure. Histologic comparison of the pathologic samples of patients with and without NF-I revealed no significant differences. The pseudarthrosis gap was continuous with periosteal soft tissues and filled by fibrous tissue, fibrocartilage, and hyaline cartilage with features of enchondral ossification. The authors suggest that the clinical diversity of congenital pseudarthrosis of the leg results from the diverse location of a single pathologic process--namely the growth of an abnormal, fibromatosis-like tissue either within the periosteum or within the endosteal/marrow tissues. It is tempting to suggest that such an "osteofibromatosis" represent a skeletal expression of neurofibromatosis, either within the fully expressed syndrome (patients with known neurofibromatosis) or as isolated lesion (patients with unknown/cryptic neurofibromatosis).

Adolescent↗

PubMed2004

Congenital pseudarthrosis of the clavicle: a histopathological study in five patients.

Congenital pseudarthrosis of the clavicle is usually situated on the right clavicle. Pathological data on pseudarthrosis are scant. The histological analysis of five cases treated by 'en bloc' surgical resection are reported. Enchondral ossification was observed on both sides of the resected pseudarthrosis in two cases. Less characteristic enchondral features were noted in three cases. These findings confirm that the pseudarthrosis is due to the failure of coalescence of the two primary ossification centers of the clavicle.

Adolescent↗

PubMed2004

Use of an intramedullary rod for treatment of congenital pseudarthrosis of the tibia. A long-term follow-up study.

BACKGROUND: The treatment of congenital pseudarthrosis of the tibia remains difficult and controversial. The purpose of this study was to evaluate the long-term results of a technique consisting of excision of the pseudarthrosis, autologous bone-grafting, and insertion of a Williams intramedullary rod into the tibia. METHODS: Twenty-one consecutive patients with congenital pseudarthrosis of the tibia were managed with this technique between 1978 and 1999, and the results were retrospectively reviewed. The mean age of the patients at the time of the latest follow-up was 17.2 years (range, seven to twenty-five years), and the mean duration of postoperative follow-up was 14.2 years (range, three to twenty years). RESULTS: Initial consolidation occurred in eighteen of the twenty-one patients. Refracture occurred in twelve patients; five fractures healed with closed treatment, five healed after an additional surgical procedure, and two ultimately required amputation. Ten patients had an ankle valgus deformity after tibial union. Eleven patients had a residual limb-length discrepancy of >2 cm; six required a contralateral distal femoral and/or proximal tibial epiphyseodesis, two had a tibial lengthening, and one used a shoe-lift. Five patients had an amputation: two, because of a recalcitrant fracture; two, because of a limb-length discrepancy (6 and 9 cm); and one, because of a chronic lower-extremity deformity. CONCLUSIONS: This technique produced a satisfactory long-term functional outcome in sixteen of twenty-one patients and should be considered for the management of congenital pseudarthrosis of the tibia.

Adolescent↗

PubMed2005

Use of an intramedullary rod for the treatment of congenital pseudarthrosis of the tibia. Surgical technique.

Bone Nails↗

PubMed2003

Revision strategies for lumbar pseudarthrosis.

Management and avoidance of lumbar pseudarthrosis are among the most common and challenging tasks faced by reconstructive spine surgeons. The risks of pseudarthrosis can be broadly divided into two categories: those within a surgeon's control and those not within his/her control. These include biological factors, graft choices, site preparation, and surgical design. The authors review the biological factors that affect fusion and how they can be manipulated to avoid or manage lumbar pseudarthrosis. Surgical planning and construct design to prevent or treat pseudarthrosis will also be discussed. Additionally, the importance of restoring sagittal balance will be reviewed.

Adrenal Cortex Hormones↗

PubMed1998

[Immunohistochemical investigations of congenital pseudarthrosis of the tibia].

OBJECTIVE: To investigate the etiology and pathology of congenital pseudarthrosis. METHOD: Sixty-three specimens were taken from 21 CPT patients. The antibodies, which were used for immunohistochemical studies, were produced against (1) NF-200 or S-100 protein; (2) type I or III collagen; (3) PCNA. The control specimens were taken from neurofibromatosis and traumatic pseudarthrosis. SABC staining was performed. RESULT: Low positive expression of NF-200 (3.2%) and S-100 (4.8%) was noted in the CPT lesion, whereas high expression of NF-200 (85.2%) and S-100 (88.9%) in the lesion of neurofibromatosis. The soft tissues in CPT had a higher ratio of type III to I collagens in comparison with traumatic pseudarthrosis. Positive expression of PCNA (95.2%) was significantly higher in the soft tissues than that (2.5%) in traumatic pseudarthrosis. CONCLUSION: CPT is a disease of non-neuro origin. Its occurrence has no direct relation with neurofibromatosis. CPT has its characteristic pathology in the periosteum rather than in the bone. The pathological fracture or non-union of CPT is caused by fibromatosis, which has a strong activity of cellular proliferation and corrosion. CPT has its pathological property similar to a tumor.

Adolescent↗