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PubMed2006

Three-level anterior cervical discectomy and fusion with plate fixation: radiographic and clinical results.

STUDY DESIGN: Retrospective review of patients with cervical spondylosis treated with 3-level anterior cervical discectomy and fusion with plate fixation. OBJECTIVE: To assess the radiographic and clinical outcome of 3-level instrumented anterior cervical discectomy. SUMMARY OF BACKGROUND DATA: Three-level cervical discectomy without plate fixation has shown high rates of pseudarthrosis and poor outcomes. The addition of internal fixation may improve these parameters. METHODS: A total of 46 patients were observed for an average of 17.6 months (range, 6-51 months). All had 3-level anterior cervical discectomy and fusion with tricortical iliac crest autograft (4 cases), fibular ring allograft (38 cases), or titanium cage (4 cases). Allografts and cages were filled with iliac crest autograft. All patients had semirigid plating. Clinical and radiographic follow-up data were obtained. Clinical outcomes were measured as described by Robinson and with the Nurick scale. RESULTS: Forty-four patients achieved solid fusion. Two patients had additional surgery for junctional disease, and in 1 of them pseudarthrosis repair was also performed. One asymptomatic pseudarthrosis was noted. With a successful result defined as an excellent or good outcome accompanied by significant pain relief, 38 patients had a successful result (83%). Radiographic adjacent level disease was diagnosed in 11 patients after surgery and was symptomatic in 5. CONCLUSION: Three-level anterior cervical discectomy with plate fixation has a high rate of fusion, a low complication rate, and acceptable outcome in the treatment of multilevel cervical spondylosis.

Adult↗

PubMed2006

Repeat surgical interventions following "definitive" instrumentation and fusion for idiopathic scoliosis.

STUDY DESIGN: A retrospective chart review was performed on all idiopathic scoliosis patients treated with instrumented spinal fusion over a 15-year period. OBJECTIVES: To provide an experience from a single institution over a prolonged time period. The goal was to determine the frequency of repeat surgical interventions following the "definitive" spinal fusion surgery and identify the factors responsible for these reoperations. SUMMARY OF BACKGROUND DATA: Instrumented spinal fusion remains the standard of care in the surgical management of idiopathic scoliosis. This surgery is considered a "definitive" procedure where, barring a complication, no additional surgical procedures are planned. Although many studies have reported the frequency of specific complications following spinal fusion, little information currently exists regarding the cumulative average of these repeat surgical interventions that occur following these "definitive" procedures. METHODS: Surgical logs were reviewed on all patients who had an instrumented spinal fusion for idiopathic scoliosis from January 1988 through December 2002. All subsequent surgical interventions on these patients were then identified from the logs through December 2004. Pertinent information was gleaned from surgical logs and patient charts to provide details for these reoperations. RESULTS: A total of 1,046 patients underwent an instrumented spinal fusion for idiopathic scoliosis: 809 had a posterior-only fusion, 228 had an anterior-only fusion, and 9 had a combined anterior/posterior spinal fusion. A total of 172 repeat surgical interventions were performed in 135 patients (12.9%). Of these 135 patients, 29 patients (21.5%) had two or more separate procedures performed. The most common reasons for reoperation were infection, symptomatic implant, and pseudarthrosis. Patients who had posterior fusions had a significantly higher rate of reoperation than patients who had anterior fusions (14.0% vs. 9.3%). Reoperations due to infections and symptomatic implants occurred with significantly higher frequency in the posterior spine fusion group compared with those with anterior spinal fusion. No differences in rates of reoperation for pseudarthrosis were noted between posterior and anterior fusion groups. CONCLUSIONS: Repeat surgical interventions are relatively common following these supposedly definitive surgical procedures. The most common reasons for return to surgery are infection, symptomatic implant, and pseudarthrosis.

Adolescent↗

PubMed1998

Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up.

We reviewed the cases of 108 patients with cervical spondylotic myelopathy who had been managed with anterior decompression and arthrodesis at our institution. Operative treatment consisted of anterior discectomy, partial corpectomy, or subtotal corpectomy at one level or more, followed by placement of autogenous bone graft from the iliac crest or the fibula. At the latest follow-up examination, thirty-eight of the eighty-two patients who had had a preoperative gait abnormality had a normal gait, thirty-three had an improvement in gait, six had no change, four had improvement and later deterioration, and one had a worse gait abnormality. Of the eighty-seven patients who had had a preoperative motor deficit, fifty-four had complete recovery; twenty-six, partial recovery; six, no change; and one had a worse deficit. The average grade according to the system of Nurick improved from 2.4 preoperatively to 1.2 (range, 0.0 to 5.0) postoperatively. A pseudarthrosis developed in sixteen patients, thirteen of whom had had a multilevel discectomy. Only one of thirty-eight arthrodeses that had been performed with use of a fibular strut graft was followed by a non-union. An unsatisfactory outcome with respect to pain was significantly associated with pseudarthrosis (p < 0.001). The development of complications other than non-union was associated with a history of one previous operative procedure or more (p = 0.005). Recurrent myelopathy was rare, but when it occurred it was associated with a pseudarthrosis or stenosis at a new level. The strongest predictive factor for recovery from myelopathy was the severity of the myelopathy before the operative intervention--that is, better preoperative neurological function was associated with a better neurological outcome. Anterior decompression and arthrodesis with autogenous bone-grafting can be performed safely, and is associated with a high rate of neurological recovery, functional improvement, and pain relief, in patients who have cervical spondylotic myelopathy.

Adult↗

PubMed2003

Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance.

BACKGROUND: Fixed sagittal imbalance (a syndrome in which the patient is only able to stand with the weight-bearing line in front of the sacrum) has many etiologies. The most commonly reported technique for correction is the Smith-Petersen osteotomy. Few reports on pedicle subtraction procedures (resection of the posterior elements, pedicles, and vertebral body through a posterior approach) are available in the peer-reviewed literature. We are aware of no report involving a substantial number of patients with coexistent scoliosis who underwent pedicle/vertebral body subtraction for the treatment of fixed sagittal imbalance. METHODS: Twenty-seven consecutive patients in whom sagittal imbalance was treated with lumbar pedicle subtraction osteotomy at one institution were analyzed. Radiographic analysis included assessment of thoracic kyphosis, lumbar lordosis, lordosis through the pedicle subtraction osteotomy site, and the C7 sagittal plumb line. Outcomes analysis was performed with use of a before-and-after pain scale, items from the Oswestry questionnaire, and the Scoliosis Research Society (SRS) questionnaire after a minimum duration of follow-up of two years. Complications and radiographic findings were also analyzed for the entire group. RESULTS: Overall, the average increase in lordosis was 34.1 degrees and the average improvement in the sagittal plumb line was 13.5 cm. One patient had development of a lumbar pseudarthrosis through the area of pedicle subtraction osteotomy, and six patients had development of a thoracic pseudarthrosis. Two patients had development of increased kyphosis at L5/S1, caudad to the fusion, resulting in some loss of sagittal correction. There were significant improvements in the overall Oswestry score (p < 0.0001) and the pain-scale score (p = 0.0002). Most patients reported improvement in terms of pain and self-image as well as overall satisfaction with the procedure. CONCLUSIONS: Pedicle subtraction osteotomy is a useful procedure for patients with fixed sagittal imbalance. A worse clinical result is associated with increasing patient comorbidities, pseudarthrosis in the thoracic spine, and subsequent breakdown caudad to the fusion. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Adult↗

PubMed2004

Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. Surgical technique.

Humans↗

PubMed2006

Comparison of CD HORIZON SPIRE spinous process plate stabilization and pedicle screw fixation after anterior lumbar interbody fusion. Invited submission from the Joint Section Meeting On Disorders of the Spine and Peripheral Nerves, March 2005.

OBJECT: The authors present the early clinical results obtained in patients who underwent SPIRE spinous process plate fixation following anterior lumbar interbody fusion (ALIF). METHODS: Between May 2003 and January 2005, 32 patients underwent titanium cage and bone morphogenetic protein-augmented ALIF and subsequent SPIRE (21 cases) or bilateral pedicle screw (BPS; 11 cases) fixation. Pedicle screws were implanted using either the open approach (three cases) or using a tubular retractor (eight cases). Patients' charts were reviewed for operative time, estimated blood loss (EBL), hospital length of stay (LOS), and evidence of pseudarthrosis or hardware failure. In SPIRE plate-treated patients, the median EBL (75 ml) was lower than in BPS-treated patients (open BPS [150 ml]; tubular BPS [125 ml]). The median operative time in SPIRE plate-treated patients was also shorter (164 minutes compared with 239 and 250 minutes in the open and tubular BPS, respectively). The median LOS was 3 days for both the SPIRE and tubular BPS groups, but 4 days in the open BPS group. There were no instances of major surgery-induced complication, pseudarthrosis, or hardware failure during mean follow-up periods of 5.5, 7.2, and 4.9 months in the SPIRE, open PS, and tubular BPS groups, respectively. CONCLUSIONS: The SPIRE plate is easy to implant and is associated with minimal operative risk. Compared with BPS/rod constructs, SPIRE plate fixation leads to less EBL and shorter operative time, without an increase in the rate of pseudarthrosis. Hospital LOS was also shorter in SPIRE plate-treated patients, which is consistent with the goals of minimal access spinal technologies.

Adult↗

PubMed1976

Osteofibrous dysplasia of long bones a new clinical entity.

A new clinico-pathologic entity is described. It is defined as osteofibrous dysplasia of long bones, and is based on twenty two personal observations to which are added seventeen cases from the literature. This dysplasic congenital lesion is clearly differentiated from fibrous dysplasia by clinical, radiographic and histological characteristics and by its clinical course. These features may be summarised as follows: 1) Slight predominance of the male sex. 2) Very early age of onset either at birth or in the first years of life. 3) Site almost exclusively tibial, sometimes also in the fibula. Localisation predominantly in the middle third of the tibial diaphysis, but sometimes in the distal or proximal third. In the fibula, it is always at the distal third. 4) The lesion is painless and generally causes bony enlargement. There is often slight anterior bowling and more rarely, slight varus of valgus bowing. Pathological fracture may occur; rarely there is a pseudarthrosis. 5) The radiographic appearances are very characteristic, with enlargement of the bone, intracortical osteolytic lesions with thinning or disappearance of the external cortex, sclerotic reaction on the medullary aspect, and narrowing of the medullary canal. 6) The histological features are also typical, consisting of fibrous tissue enclosing bone trabeculae lined by osteoblasts and a "zonal" architectural pattern. 7) Sometimes the lesion tends to heal spontaneously in the very early years of life; in other cases it is moderatley progressive. It relapses frequently after curettage, but such recurrences are generally non-progressive. In some cases slight anterior bowing persists permanently. 8) Surgery should be restricted to patients over the age of five in whom the lesion is extensive, with imminent or actual pathological fracture, and to the rare cases of pseudarthrosis. The results are good even in cases of relapse or pseudarthrosis. The correction of residual bowing, if indicated, can safely be carried out with one or more osteotomies at the age of ten to twelve years.

Adult↗

PubMed1999

[Free muscle transplantation after complex fractures of the lower leg and ankle: results from 32 patients].

OBJECTIVE: To describe the results of free vascularized muscle transfer for treatment of complications of severe open fractures of the distal tibia and ankle region. DESIGN: Retrospective. METHODS: In 1994-1998, 32 patients underwent free muscle transfer for soft tissue reconstruction after high energy injury to the distal tibia and ankle region. In six patients reconstruction took place within one week after the injury (group 1); 13 patients underwent free muscle transfer in combination with (re)osteosynthesis and cancellous bone grafting for treatment of infected (defect) pseudarthrosis (group 2); chronic posttraumatic osteitis existed for an average of 12 years in six patients (group 3); in seven patients the indication was determined by unstable scar tissue, cosmetic reasons, or as preparation for corrective osteotomy (group 4). RESULTS: Three haematomas and two thrombembolic complications were encountered. Amputation could not be avoided in three patients. Consolidation of the fracture, pseudarthrosis or arthrodesis and/or eradication of infection was accomplished in all remaining 29 patients. An average of 2.2 (range: 0-7) reinterventions were additionally needed in groups 1-3, including reosteosynthesis, sequestrectomy, cancellous bone grafting and/or arthrodesis. CONCLUSION: In case of severe open fracture of the distal tibia and/or ankle region, free vascularized muscle transfer provided cover of the fracture or pseudarthrosis region, thereby improving local vascularisation. This treatment protects the underlying bone, enhances osteogenesis and improves resistance to infection.

Adult↗

PubMed1999

The effect of cervical plating on single-level anterior cervical discectomy and fusion.

The use of anterior plates for single-level cervical fusions is controversial. Previous studies that evaluated single and multiple-level fusions have shown increased and decreased fusion rates when cervical plates are used. The purpose of this study was to compare the clinical and radiographic success of single-level discectomy performed with and without anterior cervical plate fixation. During a 6-year period, 80 patients were surgically treated with a single-level anterior cervical discectomy. Forty-four patients had cervical plates, whereas 36 had fusions without plates (average follow-up, 2.3 years). The pseudarthrosis rates were 4.5% (2 of 44) for patients with plating and 8.3% (3 of 36) without plating. This difference was not significant (p = 0.653). There was no correlation of pseudarthrosis with sex, age, level of surgery, history of tobacco use, or the presence of previous anterior surgery. The amount of graft collapse for patients with plating was 0.75 mm compared with 1.5 mm for those without a plate (p = 0.026). The amount of kyphotic deformity of the fused segment was 1.2 degrees with plating compared with 1.9 degrees for patients without plating (p = 0.079). Ninety-one percent of the patients with plating had good or excellent results compared with 88% in the group without cervical plates, based on Odom's criteria. The addition of plate fixation for single-level anterior cervical discectomy and fusion is safe and not associated with a significant increase in complication rates. The pseudarthrosis rates are not significantly different when a cervical plate is used.

Adult↗

PubMed2003

Treatment of nonunions following anterior cervical discectomy and fusion with interspinous wiring and bone grafting.

Between 1979 and 2000, 25 posterior arthrodeses were performed for repair of symptomatic nonunions following anterior discectomy and fusion. The surgical technique in all cases was an interspinous wiring with an autogenous bone graft in 20 and morselized allograft bone in five. The average follow-up was 5 years (range, 1-14 years). In all patients, the anterior pseudarthrosis progressed to a solid union as judged by an independent musculoskeletal radiologist. In 17 patients, their preoperative pain was relieved; however, of these, six developed recurrent pain caused by degeneration at an adjacent level on an average of 5 years (range, 1-14 years) after their posterior surgery. The authors propose that posterior interspinous wiring with a bone graft is a safe and efficacious method of repair of an anterior pseudarthrosis. However, patients must be cautioned that even though the pseudarthrosis can be predictably repaired by a posterior procedure, preoperative pain may not be relieved.

Bone Transplantation↗

PubMed1994

[Anterior instability of the shoulder associated with fracture of the coracoid process. Apropos of 3 cases].

PURPOSE OF THE STUDY: The aim of this paper is to present an unusual lesion associating anterior instability of the shoulder with a fracture of the horizontal part of the coracoid process. It emphasizes surgical treatment using the Latarjet procedure. MATERIAL AND METHODS: Three cases are presented: One case was a recurrent anterior dislocation of the shoulder associated with a fracture of the horizontal part of the coracoid process; an other case was a painful shoulder associated with pseudarthrosis of the coracoid process and a fracture of the anterior and inferior edge of the glenoid. In the last case there was a recurrent dislocation of the shoulder associated with a pseudarthrosis of the coracoid process detected intra-operatively. All the patients were operated on using the Latarjet's procedure using the fractured coracoid process. RESULTS: The three cases had a good result. DISCUSSION: The association of an anterior dislocation of the shoulder and a fracture of the coracoid process is very unusual. It is often unrecognized because of poor knowledge of this lesion or a poor quality of the radiograms performed in the emergency room. The most likely mechanism is a direct impact of the humeral head against the coracoid process during the dislocation. The fracture is located (as in our 3 cases) at the horizontal part of the coracoid process near its elbow and they are often associated lesions at the anterior and inferior edge of the glenoid. The diagnosis requires good quality radiograms and a Garth's view systematically performed after reducing the dislocation. When the shoulder is painful or unstable, surgical treatment is performed and the Latarjet's procedure takes care of the pseudarthrosis and the instability of the shoulder. CONCLUSION: Isolated fractures of the coracoid process are probably uncommon. When there is a fracture of the horizontal part of the coracoid process anterior instability of the shoulder should be suspected. This is the case when the shoulder has never been dislocated and when the standard radiograms are "normal" without "crossing lesions" at the anterior and inferior edge of the glenoid or at the humeral head (Hill-Sach lesion).

Adolescent↗

PubMed1993

[The dynamic hip screw in medial fractures of the femoral neck: results in 51 patients].

Femoral neck fractures are common in the elderly, especially in female patients. Pseudarthrosis and femoral head necrosis were complications with a high incidence in earlier days, when the femoral neck fracture was treated by obsolete osteosynthesis techniques. Replacement of the femoral head by an endoprosthesis was introduced in the seventies because of these complications. This hemiarthroplasty also causes many postoperative complications. With the development of the dynamic hip screw for trochanteric and subtrochanteric fractures a new technique for stabilising femoral neck fractures has been introduced. In a retrospective study (average follow-up: 3.4 years; 3 months-6 years; median: 3.6 years) of 51 patients with a femoral neck fracture who were treated with a DHS the short- and long-term postoperative complications (femoral head necrosis and pseudarthrosis) were determined. The most frequent short-term complications were bleeding (10 patients), the need for blood transfusion (10), decubitus (6), wound infection (5), urinary tract infection (5). Femoral head necrosis was seen in two patients more than 30 days after the operation. Pseudarthrosis was not observed. Because of the low complication rate, we can conclude that DHS osteosynthesis, on a correct indication, can be used as first choice in femoral neck fractures.

Adult↗

PubMed1975

[Infected tibial shaft pseudarthroses, treatment and results (author's transl)].

In a follow up study of 47 patients with infected pseudarthrosis of tibia therapy and results are declared. The most important matter in therapy is the osteosyntesis with compression of the pseudarthrosis. In the majority of cases externe stabilisation is used; seldom compression plate or medullary nailing is indicated. Such cases require much experience in the therapy of bone infection, although if the stabilisation with the fibula is tryed. Flush drainage, suction drainage, antibiotic therapy and cancellous bone grafting are necessary for localisation and decreasing of infection and for induction and acceleration of bone union. In some cases amutation can't be prevented. With correct judgement and consequent treatment in the majority of cases bone union will be obtained.

Bone Nails↗

PubMed1982

85Sr-scintimetry in femoral neck fracture.

In 40 patients with fracture of the femoral neck 85Sr scintimetry was performed at the time of nailing and 4 months postoperatively. The fractures were radiographed repeatedly for 5 years; thirteen fractures healed without complications, 22 developed necrosis of the femoral head, and 5 pseudarthrosis. The early isotope measurement did not distinguish between normal and necrosis cases even with detailed analysis. The 4 months activities were high in osteonecrosis and low pseudarthrosis. The latter observation is interpreted as evidence that non-union of a femoral neck fracture is due to severe permanent vascular damage.

Adult↗

PubMed1984

[Errors and dangers in the treatment of fractures and pseudarthroses of the clavicle].

The rate of pseudarthrosis in 726 conservatively treated fractures of the clavicula was 0.69%. The danger of hyperporoses lies in neurovascular compression. Errors in treatment pertain to wrong operative indications and inadequate osteosyntheses. Surgery should be performed only in 2nd and 3rd degree open fractures and/or concomitant neurovascular lesions (2.06%), in distal fracture dislocations with instability of the AC-joint (1.6%) and in cases of painful pseudarthrosis (n = 46). The implant of choice is the 3.5 DCP. Six cortical contacts must be achieved in each fragment.

Clavicle↗

PubMed2000

[Diaphyseal femur pseudarthroses--only a technical problem?].

Between 1981 and 1994 at the Bergmannsheil Ruhr University Hospital in Bochum, Germany, we treated 145 patients with femoral diaphyseal nonunions following initial operative treatment. Of these patients, 138 received this initial operative treatment at an outside institution. The primary reconstructions for the fractures utilized plates in 112 cases, reamed nails in 24 cases and external fixators in 9 cases. The average age of the patients was 35 years and the mean time from the initial operative treatment was 2 years. Twenty-seven patients (19%) presented with a hypertrophic nonunion and 118 (81%) with an atrophic nonunion. There was a significant correlation between primary "classic" plating and development of an atrophic nonunion (chi 2-test: P < 0.01). We observed 34 wound infections (23%) with no significant correlation to the type of primary osteosynthesis. We determined that 73 of the pseudarthroses were due to improper osteosynthesis techniques. Of these cases, 41% involved the use of plates, 83% involved the use of reamed nails, and 78% involved the use of external fixators. Fracture location near the diaphyseal-metaphyseal junctions was common in this problematic group. Ninety-two percent of all plates led to atrophic nonunions. There were 21 open fractures and of these 90% (n = 19) developed an atrophic pseudarthrosis and 29% (n = 6) developed a wound infection. Fifty-seven (39%) of all patients had additional injuries, but we found that did not increase the risk of disturbed bone healing. Our revision operations focused on the elimination of wound infections, refreshment of bone healing, and improvement in fragment stability. Only 28% of all "classic" plates and 11% of all external fixators were changed to an intramedullary implant at the time of the first revision surgery. Hypertrophic nonunions required a mean of 1.3 revision operations to achieve bone healing whereas a mean of 2 revision operations were necessary to fuse atrophic bone ends (P < 0.05). In cases of diaphyseal pseudarthrosis healing time was not affected by the type of osteosynthesis used for primary reconstructions. Since lack of fracture healing can often already be observed directly from postoperative X-rays, we recommend that revision procedures be performed early. The prolonged length of time to care for femoral nonunions underlines the importance of appropriate primary fracture treatment. That takes into consideration both the biomechanical and the biological aspects of bone healing.

Adolescent↗

PubMed2007

[Corrective osteotomy of post-traumatic malunions and pseudarthroses in the femur using a fork plate: a prospective analysis of 23 consecutive cases].

INTRODUCTION: The fork plate is a further development of the AO fixed-angle blade plate, which facilitates the seeding of the angle blade. In a prospective study we evaluated the applicability of the fork plate for the correction of post-traumatic malunions and pseudarthroses in the femur. MATERIAL AND METHODS: Between 01/1993 and 12/2003 a consecutive series of 23 patients were operated due to post-traumatic malunion or pseudarthrosis of the femur with an average age of 46 years at the time of surgery. The operative procedure is analogous to the one using angle blade plates. The most important surgical step, the placement of the fork instead of the blade, is more precise thanks to stepwise control with the image intensifier. RESULTS: All preexisting malunions and pseudarthroses were corrected with the fork plate as preoperatively planned. Complications not related to the implant were found in 13%, all of which resolved without sequelae. In 87% we found a bony union of the osteotomy after 3 months, and the three remaining femora healed within an additional 2-12 months without loss of the correction achieved. CONCLUSION: In all of the cases analyzed, the fork plate proved to be of value for correction of femoral malunion and pseudarthrosis. In relation to the angle blade plate, the fork plate features a modified surgical technique with the same possible indications. As a consequence this modification provides a high level of therapeutic safety even with a small number of annual operations performed.

Adult↗

PubMed1998

[Fracture of the radial condyle of the humerus in the growth period].

In an overview the clinical and academic problems of this kind of fractures are described and their treatment is discussed. The most important problem is the pseudarthrosis that can happen in the framework of a conservative treatment of displaced fractures, rarely after operative treatment with K-wires. A rather academic problem is the obligatory growth disturbance of a partial stimulation of the lateral part of the growth plate. This leads to radial overgrowth and thus to a more or less distinct varus deformity. The extent of varus deformity is dependent on the time till consolidation, which is longest in conservatively treated fractures and shortest in those treated with compression screw osteosynthesis. An additional academic problem is the so-called fishtail deformity that becomes radiological visible at the end of growth. This deformity has no clinical significance. Pseudarthrosis, varus and fishtail deformity are a result of increasing instability of primarily or secondarily displaced fractures. All three problems can be avoided by metaphyseal compression osteosynthesis with an AO small-fragment screw with an additional axial K wire in the trochlea. Our own long-term results are shown and compared with the results of other procedures in the literature.

Adolescent↗