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PubMed1998

[Accident-induced pseudarthroses of the dens axis. Etiology, follow-up and therapy].

In a retrospective analysis the significance of internal fixation of unstable and symptomatic non-union of the odontoid was evaluated. In all but one cases a type II fracture of the odontoid was the underlying cause for the pseudarthrosis. The time interval between trauma and definitive diagnosis varied between 6 months and 30 years. All patients asked for medical advice because of acute neck pain; in three cases additional neurological deficits were notified. In all but one case the pseudarthrosis was classified as unstable on flexion-/extension views. The occurrence of neurological deficits showed a positive correlation with the amount of dislocation of the pseudarthrotic odontoid. Nine out of 10 patients underwent internal stabilisation of the non-union. Reoperation because of persistent instability/failure of stabilisation had to be performed in two cases (22.2%). At follow-up all 9 patients were pain-free. The neurological deficits in two patients had improved significantly. According to our experience internal stabilisation in unstable non-union of the odontoid is recommended to achieve significant reduction of the pain level. Also improvement of the neurological deficits can be expected depending on the duration of the symptoms.

Adolescent↗

PubMed2005

[Surgical therapy for spondylolysis and spondylolisthesis].

The therapy for spondylolysis and spondylolisthesis is challenging in view of the large variety of treatment options. A general, standardized therapeutic concept has still not been established. Adequate therapy depends on different parameters and personal experience. Beside direct repair surgery of spondylolysis and low grade spondylolisthesis, dorsal, ventral and combined dorsoventral surgery, with or without instrumentation, are indicated depending on patients age and severity of the slip. Complications such as pseudarthrosis and progression of the slip develop in a given percentage of cases, but these are not significantly correlated with clinical symptoms. Decompression is necessary in high grade slippage with neurologic impairment, especially paresis. Reposition is associated with a higher risk of neurologic complications. Fusion in situ without instrumentation, even in moderate and severe spondylolisthesis, shows good clinical results with high fusion rates and without the increased risk of progression and pseudarthrosis. In many cases, it is an effective, safe and economic therapeutic option.

Adolescent↗

PubMed1997

[Post-traumatic problem cases involving the elbow in children].

In the last 20 years 49 children with gross posttraumatic elbow deformities have been treated in our hospital: 19 patients with an overlooked radial head dislocation, 12 children with a radial condyle deformity and 19 patients with a severe radial head deformity. SECONDARY TREATMENT: In the majority of cases secondary surgical procedures led to unsatisfying results. Only 4 patients with a pseudarthrosis of the radial condyle were treated secondarily. Surgical fixation led to good functional results but was not able to remove the joint deformity. Overlooked radial head dislocations were treated by ulnar osteotomy in 17 cases. We were able to follow up 13 of these: a redislocation had taken place in 8 of them. Functional impairment was found in 6 redislocated cases and in 2 children with a correct position of the radial head. In patients with gross radial head deformities arthrolysis was performed. The radial head had to be taken out in 7 cases. Functional results of pro- and supination were unsatisfactory. INITIAL TREATMENT AND CAUSES: Persistent dislocations of the radial head had been overlooked initially. In 9 out of 12 cases with a radial condyle deformity a conservatively treated dislocated fracture had led to a pseudarthrosis. In the remaining 2 cases the fracture fragments had been fixated in an incorrect position. Radial head deformities were seen after dislocated radial head fractures which had been treated by open reduction, internal fixation, longterm immobilization (6-8 weeks) and excessive physiotherapy. CONCLUSION: In 47 out of 49 cases posttraumatic deformities were either caused by delayed an neglected treatment or traumatic and excessive therapy methods. An adequate initial diagnosis and therapy can prevent more than 90% of severe posttraumatic elbow deformities in children.

Child↗

PubMed1999

Complications of scoliosis surgery in children with myelomeningocele.

The purpose of the present study was to evaluate whether the high incidence of complications in scoliosis surgery in myelomeningocele (MMC) could be attributed to the surgical technique and whether improvements were possible. Between 1984 and 1996, 77 patients with MMC and scoliosis were treated surgically. The clinical and radiological follow-up ranged from 1 to 10 years with a mean follow-up of 3.6 years. The mean age at time of surgery was 12 years 8 months. The average preoperative scoliosis measured 90.20 degrees and was corrected by 47%. The first four patients were stabilized with Harrington rods after anterior correction with a Zielke device (group 1). Twenty-five patients were operated only from posterior, using Cotrel-Dubousset (CD) instrumentation (group 2). In 13 patients an anterior release and discectomy was performed prior to CD posterior instrumentation (group 3). In 26 patients (group 4) this was combined with an anterior instrumentation. The 9 patients of group 5 had congenital vertebral malformations which made a special treatment necessary. Complications could be divided into hardware problems, such as implant failure, dislocation or pseudarthrosis, infections, anesthetic, and neurologic complications. Hardware problems were seen in 29% of all patients. More hardware problems were seen with the Harrington rod (75%) and after solitary posterior instrumentation (30%). The occurrence of pseudarthrosis was dependent on the surgical technique, the extent of posterior spondylodesis, and lumbosacral fusion. Patients with hardware problems had a mean loss of correction of 49% compared to 13% in the other patients. Depending on the different surgical techniques a loss of more than 30% was seen in 12-75% of the cases. Early postoperative shunt failure occurred in four cases; delayed failure - after more than 1 year - in three cases. One patient died within 1 day due to an acute hydrocephalus, another died after 2 1/2 years because of chronic shunt insufficiency with herniation. Wound problems were not dependent on the surgical technique, but on the extent of posterior spondylodesis and the lumbosacral fusion. Based on this analysis we believe our current practice of instrumented anterior and posterior fusion is justified. Further, we are very careful to check shunt function prior to acute correction of spinal deformity.

Adolescent↗

PubMed2002

[Long-term results in the surgical treatment of pilon tibial fractures. A retrospective study].

BACKGROUND: While Pilon fractures of the tibia have been treated for decades by primary open reduction and internal fixation by plate osteosynthesis, during the last 10 years differential treatment was developed: After primary open reduction nowadays patients are treated with (according to type of fracture and tissue damage). As well as primary open reduction and internal fixation a two-step treatment (primary external fixator and delayed ORIF) or consolidation by external fixator combined with minimal invasive osteosynthesis (cannulated screws and K-wires) has been implemented. Furthermore, the significance of primary bone grafting in comminuted fractures to prevent aseptic pseudarthrosis has been acknowledged. METHODS: Of 151 patients with 160 pilon fractures treated from January 1979 to May 1995, 107 patients (113 fractures) were evaluated. Only the results of C2 and C3 fractures could be compared, as only in these groups were all three types of treatment used. RESULTS: Over 75% of the treated fractures were closed fractures, most of them being fractures with a soft tissue damage grade 2 of the Oestern and Tscherne classification. In the open fractures we found mainly grade 3 fractures according to the Gustilo and Anderson classification. In 54.9% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications (25.7%) were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication. Highest infection rate (55.5%) was in the two-step treatment group (primary external fixator and delayed ORIF) and lowest in the primary internal stabilization group, although especially in the C2 and C3 fractures best clinical late results were obtained with the two-step procedure. CONCLUSION: The complication rate in the treatment of pilon fractures depends mainly on the type of fracture, the soft tissue damage and the type of treatment. The results of primary ORIF varied. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the two-step treatment. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires. We consider ORIF of the fibula necessary as stabilization of the second column of the ankle joint.

Adolescent↗

PubMed1992

[Resection of the proximal carpal bones in the sequelae of scaphoid fractures].

Proximal row carpectomy has precise indications in cases of severe sequelae of scaphoid fractures. This procedure may be indicated either as first-line treatment in a case of advanced pseudarthrosis with osteoarthritis, particularly radio-scaphoid, or secondarily after scaphoid pseudarthrosis has been unsuccessfully treated by other methods. It is essential to make sure that the head of the capitatum and the radial surface of the lunate bone have a satisfactory appearance on plain X-rays, MRI and occasionally arthroscopy. The overall results of this operation which retains wrist movements and which also preserves a good grip strength are very encouraging, as demonstrated by the series of 48 cases of sequelae of scAphoid fractures treated by this technique.

Activities of Daily Living↗

PubMed1986

Analysis of twenty-eight recurrent pseudarthroses of the carpal navicular after the Matti-Russe operation.

The authors present a review of 28 cases of failure of consolidation of the carpal navicular after the Matti-Russe operation (multicentric study of 106 cases). The causes of the failures are analysed. Among the non significant factors, we find the delay, the radiographic character of the pseudarthrosis, the donor site of the graft, the time of immobilization and the site of the fracture. The superior polar fractures do not have a bad prognosis in this series. Five causes seem to be in direct relation with the failure of consolidation: the age, the failure of an initial surgery procedure, the presence of radiologic "necrosis", the quality of the technical performance of the Matti-Russe operation, and finally dorsal carpal instability that seems to be a fundamental cause in the failure of bony union. The future of these pseudarthroses is analysed concerning: the functional results (64% of poor results); the evolution towards the pseudarthrosis (30%); the surgical reoperations (12 cases out of 28) with eight repeat Matti-Russe operations that finished in five consolidations.

Adult↗

PubMed2000

[Use of a cannulated 3.0 mm AO screw with an intraosseous support washer in osteosynthesis of the scaphoid: results and analysis of problems in 28 cases].

The cannulated 3.0 mm AO/ASIF screw with threaded washer is a new implant for scaphoid osteosynthesis. After insertion into the distal scaphoid pole, the washer serves as an intraosseous support for the head of the cannulated lag screw. From June 1997 to March 1998 the new implant was used in 28 male patients between 14 and 50 years of age. In fourteen patients, acute scaphoid fractures were operated on, including five transscaphoid perilunate fracture dislocations (Herbert type B2 and B4, respectively). Fourteen patients had scaphoid pseudarthroses, among those two re-pseudarthroses after prior surgery elsewhere. Using a palmar approach, the scaphoid was reduced. In pseudarthroses an iliac cortico-cancellous bone block was inserted, and the implants were inserted in a distal-to-proximal manner. In the fourteen acute fractures, follow-up assessment at a mean of 11 months revealed one pseudarthrosis (7%) and four screw removals (29%) for screw back-out after bony consolidation. In the fourteen pseudarthroses, follow-up assessment at a mean of ten months revealed one re-pseudarthrosis (7%) after a technical fault. It was treated by re-operation using the same implant, and healing was now uneventful. One screw removal became necessary after bony consolidation in another patient (7%). In conclusion, our preliminary results suggest that the new implant is suitable for stabilization of scaphoid pseudarthroses after insertion of an iliac crest bone graft. The complication rate in the treatment of acute fractures was inacceptably high.

Adolescent↗

PubMedDate not supplied

[Pseudoarthrosis in neurofibromatosis type 1].

Neurofibromatosis type 1 (NF1) is the most common neurocutaneous disease. The clinical manifestations are diverse. Some of the skeletal changes are most relevant to the patient. We report on 9 patients with NF1 who presented with typical pseudarthrosis. In 8 of these children the lower extremity was involved. In 2 cases lesions of both tibia and fibula were found, in one case even over long segments with a fully instable leg. One child had a complete pseudarthrosis of the radius and ulna. This report analyses the bony changes, the operations performed and the possible technical improvements to be made. The present study as well as other recent studies suggest that bony lesions should be operated early using microsurgical methods.

Child, Preschool↗

PubMed1988

[3-dimensional computed tomography and multiplanar CT-reformations in lumbar spondylodesis].

Three-dimensional computed tomography (3-D-CT) and multiplanar CT reformations were performed in 42 patients who were clinically suspected of spinal instability following posterior lumbar fusion. Sagittal and coronal CT reformations demonstrated fusion pseudarthrosis more frequently than axial CT or conventional radiography. Three-dimensional CT cuts through the fusion revealed pseudarthrosis in most patients with positive 2-D images. In 5 patients, however, fusion appeared to be artifactually stable or unstable on 3-D cuts contrasting the 2-D images. Three-dimensional surface reconstructions demonstrated the complex anatomy of the fusion and showed superficial breaks. They were helpful in preoperative planning as well as intraoperative localization. 3-D-CT is a clinically useful adjunctive imaging method.

Adult↗

PubMed2002

Mesh cages in idiopathic scoliosis in adolescents.

Since 1995, titanium mesh cages have been used in the thoracolumbar and lumbar spine for instrumented anterior spinal fusions in adolescents with idiopathic scoliosis. One hundred thirty patients had 451 fusion levels with cages. Radiographic results show acceptable coronal correction with maintained or improved thoracolumbar and lumbar lordotic sagittal alignment. The pseudarthrosis rate has been 3% per patient (four of 130 patients) and 0.08% per fusion level with a cage (four of 451 levels). The authors think that the use of titanium mesh cages anteriorly with single or dual rod anterior instrumentation systems provide for adequate lordotic sagittal alignment and an acceptable pseudarthrosis rate.

Adolescent↗

PubMed2002

Anterior column support in surgery for high-grade, isthmic spondylolisthesis.

The literature is confusing as to the need for anterior column fusion in the surgical treatment of patients with high-grade dysplastic spondylolisthesis. The current authors present an analysis of consecutive pediatric patients treated surgically for high-grade spondylolisthesis with and without anterior column structural support with emphasis on fusion rates, segmental kyphosis correction, and functional outcomes. Thirty-seven surgical procedures were done in 31 patients for Meyerding Grade 3 or Grade 4 isthmic dysplastic spondylolisthesis. Patients were separated into two groups based on whether they had structural anterior column support (tricortical autogenous iliac crest) in addition to posterior fusion surgery. Group 1 consisted of 18 patients treated only with posterior surgery without anterior structural support (11 patients were treated with L4-sacrum posterior in situ fusion and seven patients were treated with posterior instrumented reduction with decompression and posterior fusion), and Group 2 consisted of 19 patients who had a reduction and circumferential fusion including anterior structural support. All patients had new radiographs taken at the time of followup (average, 3.1 years, range, 2 years-10 years 1 month) and completed a functional outcome questionnaire. The incidence of pseudarthrosis was 39% (seven of 18 patients) in Group 1 and 0% (0 of 19) in Group 2. All seven patients who had pseudarthrosis achieved solid fusion with a second procedure involving circumferential fusion with anterior column structural grafting. Outcomes regarding pain after treatment, function, and satisfaction were high in those patients who achieved solid fusion regardless of surgical procedure.

Adolescent↗

PubMed2002

Orthopaedic manifestations of neurofibromatosis in children: an update.

Neurofibromatosis is one of the most common genetic disorders affecting mankind. Despite extensive basic science research, the diagnosis still is based largely on well-defined clinical criteria, which often present gradually during childhood. Approximately 50% of patients have significant musculoskeletal manifestations, with scoliosis and congenital pseudarthrosis of the tibia most common. Approximately 20% of children with Type I neurofibromatosis present with scoliosis with or without the classic dystrophic features, such as vertebral scalloping and rib penciling. Dystrophic curves portend rapid progression and require early fusion. Surgical treatment often is challenging because of the common presence of neurofibromas adjacent to the spinal cord, significant multiplanar deformity, and poor bone quality. Congenital pseudarthrosis of the tibia also continues to present significant difficulties. The use of a brace is the mainstay of early treatment, whereas intramedullary rodding commonly is used for operative fixation. Grafting of the free fibula and correction using techniques of distraction and compression histiogenesis with Ilizarov fixators have been reported for refractory cases with varying degrees of success. Multiple heroic, operative attempts may have a tremendous toll on the quality of life of affected children through their early childhood. In addition to these and other distinctive musculoskeletal lesions, affected children often suffer from various medical problems.

Bone and Bones↗

PubMed1984

The role of tomography in the evaluation of the postoperative spinal fusion.

Despite the fact that pseudarthrosis is the most common complication after posterior spinal fusion, no reproducible diagnostic method has been established. This study analyzes the accuracy of the anteroposterior trispiral tomography in evaluating the posterior spinal fusion mass. Tomography was shown to be both sensitive and specific in its ability to detect the presence or absence of a pseudarthrosis. Radiation exposure is not increased when tomography is performed in lieu of less accurate diagnostic studies. Anteroposterior trispiral tomography is a useful adjunct in the routine postoperative evaluation of the patient who has undergone a posterior spinal arthrodesis.

Adult↗

PubMed1989

Low-back pain after lumbar fusion. Surgical and computed tomographic analysis.

Forty-eight patients with persistent pain after lumbar fusion were examined using computed tomography (CT). A total of 157 findings were observed, obviously with greatly varying significance. The main lesions were fragmentation of the fusion mass (16 patients), hair-line pseudarthrosis (9 patients), and spinal stenoses (8 patients). These were also the most frequent indications for reoperation in 20 patients. If the indication for reoperation was fragmentation, hair-line pseudarthrosis, or central spinal stenosis, the results were usually good during a follow-up period that ranged from 6 months to 4 years. At reoperation, 21 of 27 main lesions detected by CT were confirmed; six CT findings were partially or totally incorrect. However, we consider CT to be the best method for examining these problematic patients, but emphasize the choice of relevant CT diagnoses.

Adolescent↗

PubMed1990

The Dwyer procedure in the treatment of idiopathic scoliosis. A 10-year follow-up review of 21 patients.

Despite the well-known Dwyer procedure, developed in 1969, comprehensive reports on its use, with long-term follow-up, are relatively scarce. The purposes of this study were to detect eventual late complications and to compare late results with postoperative angular curve correction. This article reports on 21 children operated on between October 1972 and October 1975 and reviewed with a minimum follow-up of 10 years (10 other patients were lost to follow-up after 5 years). Patients had idiopathic lumbar or thoracolumbar curves (average curve, 56 degrees). Results are discussed with a special reference to longitudinal observation. There is a great correction of the instrumented curve (postoperative, 5 degrees), but a loss of correction of 10 degrees is generally observed, prevented by a complete immediate correction or even hypercorrection. The upper curve, noninstrumented, also shows improvement (mean preoperative, 38 degrees; postoperative, 22 degrees; 10 years, 22 degrees) but re-equilibration cannot be predicted. Pseudarthrosis of one intervertebral space occurs frequently, and may cause failure of the cable with a loss of correction of 10-20 degrees. Kyphosis (or simple loss of lumbar lordosis) is commonly observed but should be balanced with correction of rotation. The following conclusions were made: morbidity is not severe, despite the advanced surgical technique. The technique is difficult and has a direct consequence on the quality of results; pseudarthrosis is a frequent complication, followed by important loss of correction; indications should be discussed carefully in idiopathic lumbar and thoracolumbar curves. It is still too early to advocate either anterior instrumentation of Zielke (VDS) or segmental posterior instrumentation (C. D. Luque) because of short-term follow-up.

Adolescent↗

PubMed1991

The failed posterior lumbar interbody fusion.

The problems presented by unsuccessful posterior lumbar interbody fusion (PLIF) have not been addressed. The cases of 12 patients who presented with failed PLIF were reviewed. Five patients were male and seven female (age range, 24-50 years; mean age, 40 years). All patients underwent at least one PLIF; many had undergone other procedures. A total of 37 procedures had been performed on the 12 patients. Chronic radiculopathy was present in all patients, as detected with electromyographic or nerve conduction velocity examination. At the time of reconstructive surgery, in the 11 patients in whom the canal was explored, all had extensive epidural fibrosis. Nine of the 12 patients had pseudarthrosis of the previous PLIF. Four patients had evidence of motion segment dysfunction at nearby levels: two had positive discograms adjacent to the PLIFs; one developed a facet syndrome at L5-S1, caudal to an L4-5 PLIF; and one demonstrated frank segmental instability at L2-3, cranial to a previous PLIF at L3-4. Twelve patients underwent a total of 22 procedures after referral. Eleven patients initially underwent decompression and fusion, and one patient underwent a sympathectomy. Seven patients underwent an additional 10 procedures, including repeat decompression, repair of pseudarthrosis, and implantation of an epidural analgesic pump system. After all surgical treatment, five patients rated their pain as improved. Seven patients were thought to have a solid fusion. The presence of a solid fusion did not correlate with satisfactory relief of pain (chi-square). Continued extremity pain was the predominant complaint of all the patients. Two shortcomings of the PLIF were evident.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1991

Cotrel-Dubousset pedicle screw system for various spinal disorders. Merits and problems.

Eighty-five consecutive patients with various spinal disorders who underwent surgery using the Cotrel-Dubousset pedicle screw system at Kantoh Rosai Hospital between August 1986 and November 1989 were studied. The group included 52 men and 33 women, ranging in age from 19 to 76 years, with an average age of 53 years. The postoperative follow-up period was from 15 to 54 months, with an average of 33 months. The diagnoses were lumbar degenerative disorders in 69 cases (spondylolisthesis in 32, lumbar degenerative spinal canal stenosis without spondylolisthesis in 21, and "unstable lumbar spine" in 16), spinal trauma in 9, spinal deformities in 5 (scoliosis in 3 and kyphosis in 2), and tumor in 2 (1 spinal cord tumor and 1 vertebral tumor). The Cotrel-Dubousset pedicle screw system proved not only to be useful in fixing an unstable spine from the lower thoracic vertebra to the sacrum, as is the case with the other pedicle screw systems, but also to have great advantages for use in various spinal disorders, including reduction of slipped vertebra, correction of spinal deformity combined with a hook system, and for anterior spinal instrumentation. Postoperative clinical results were good in most of the cases, but pseudarthrosis considerably affected the results in a few cases. Therefore, great care must be taken, both strategically and technically, to prevent pseudarthrosis.

Aged↗