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PubMed1988

Treatment of symptomatic flatback after spinal fusion.

Fifty-five patients who had loss of lumbar lordosis after spinal fusion and subsequently had corrective osteotomies were studied. When they were first seen, fifty-two patients (95 per cent) were unable to stand erect and forty-nine (89 per cent) had back pain. The previous use of distraction instrumentation with a hook placed at the level of the lower lumbar spine or the sacrum was the factor that was most frequently identified as leading to the development of the flatback syndrome. Sixty-six extension osteotomies were performed in these fifty-five patients. Nineteen patients (35 per cent) had an associated anterior spinal fusion. Thirty-three patients (60 per cent) had one or more complications, including pseudarthrosis, a dural tear, failure of hardware, neurapraxia, and urinary tract infection. The results of the operation were evaluated at follow-up by review of clinical records, radiographs, and questionnaires. At an average follow-up of six years (range, two to fourteen years), most patients felt that they had benefited from the corrective osteotomies. However, twenty-six patients (47 per cent) continued to lean forward and twenty patients (36 per cent) continued to have moderate or severe back pain. The failure to restore sagittal plane balance led to a higher rate of pseudarthrosis, which was associated with recurrent deformity. Anterior spinal fusion combined with posterior osteotomy resulted in greater maintenance of correction. The prevention of flatback syndrome is important, since its treatment is difficult. When a spinal fusion must be extended to the level of the lower lumbar spine or the sacrum, the use of distraction instrumentation should be avoided in order to prevent this deformity.

Adolescent↗

PubMed1987

Adult idiopathic scoliosis treated by anterior and posterior spinal fusion.

Twenty-six adults, ranging in age from nineteen to fifty-eight years old, were treated for idiopathic scoliosis by two-stage anterior and posterior spinal fusion. The goals of the combined procedure were to increase correction of the curve and decrease the rate of pseudarthrosis. Preoperatively, the major curves measured an average of 83 degrees, and on the best side-bend they averaged 59 degrees, a 29 per cent degree of flexibility. At the time of discharge from the hospital the curves had improved to an average of 44 degrees, a correction of the preoperative curve of 39 degrees or 47 per cent. At an average length of follow-up of forty-nine months, the major curves measured an average of 50 degrees, a 41 per cent correction compared with the initial curves. Twenty-three of the major curves were better than when they were measured on the preoperative radiograph of the best side-bend, by an average of 15 degrees, but eight curves were either the same or worse. No patient had pseudarthrosis or permanent neurological injury. It is our conclusion that a two-stage anterior and posterior fusion is of value for the treatment of the adult who has a rigid curve that requires maximum correction to allow the head, shoulders, and torso to be centered over the pelvis. We do not recommend the use of instrumentation for the anterior fusion as this did not increase the correction of the curve in this series of patients.

Adult↗

PubMed1986

Surgical management of adult scoliosis.

In a retrospective analysis of 62 adult scoliotic patients with an average age of 34 years, 39 patients were treated by single-stage posterior fusions, 19 by Harrington instrumentation, and 20 by Luque instrumentation. Twenty-three patients had staged scoliotic procedures. Overall there was a 47% incidence of complications, with the lowest rate, 20%, found in those patients undergoing single-stage posterior fusion with Luque instrumentation. A 16.7% incidence of pseudarthrosis was found in those patients undergoing posterior fusion with Harrington instrumentation. Pseudarthrosis was not found in patients fused posteriorly with Luque instrumentation or with staged anterior and posterior instrumentation.

Adult↗

PubMedDate not supplied

Technetium-99m-methylenediphosphonate scintimetry after femoral neck fracture. A three-year follow-up study.

Thirty-nine patients with femoral neck fractures were followed up clinically and radiographically by technetium-99m-methylenediphosphonate (99mTc-MDP) scintimetry two to 20 days and four, eight, 12, 24, and 36 months after surgery or until redisplacement, pseudarthrosis, or segmental collapse occurred. The scintimetric data were calculated by selecting regions of interest on the fractured and intact sides over the femoral head, neck, greater trochanter, and shaft; ratios of fractured/intact side were obtained for each region. Bone metabolism after femoral neck fracture was expressed and analyzed numerically. Prognosis regarding the course of healing could be made with precision by studying femoral head isotope activity shortly after surgery, preferably one to three weeks after operation. Intact femoral head uptake (ratio greater than 1.0) was connected with uneventful healing, while defective uptake (ratio less than 1.0) was observed with healing complications. The vast majority of femoral heads with primary uptake defects showed increased uptake (greater than 1.0) after four months, often as early as six to eight weeks, indicating revascularization. Segmental collapse, as well as redisplacement and pseudarthrosis, appear to be related to femoral head vascular injury. Femoral head uptake in patients in whom healing complications developed secondary to avascularity differed significantly from that in patients with normal healing, except at investigations performed four to eight months after operation. 99mTc-MDP uptake in the femoral neck, trochanter, and shaft areas was increased for all femoral neck fractures. Subsequent normalization was considerably slower in patients with healing complications. A significant difference from normal healing did not occur until 12-24 months after operation. For patients with contralateral hip disease affecting the femoral head ratio, the prognosis regarding complications was made with the aid of the femoral head/shaft ratio on the fracture side.

Adolescent↗

PubMed1978

Effects of experimental excision arthroplasty of the hip joint.

The experimental results are reported on a series of sheep in which unilateral hip excision arthroplasty was performed. These sheep were slaughtered at regular postoperative intervals. Radiography and histology were performed on the normal and excised hip joints of the experimental sheep to provide information of the formation of the pseudarthrosis that develops following excision arthroplasty. The efficiency of the false joint that develops is good, judged on a clinical basis. Continuous remodelling of the acetabulum and resected face was noted throughout the experimental period. A sequence of degenerative changes in the acetabular cartilage was observed followed by filling in of the acetabular favity with new bone. New bone also developed on the cemoral component of the pseudarthrosis in the form of osteophytes situated around the perimeter of the resected surface. Growth deformities of the contralateral, nonoperated limb were induced.

Acetabulum↗

PubMedDate not supplied

Intertransverse process fusion with the aid of chemosterilized autolyzed antigen-extracted allogeneic (AAA) bone.

Forty intertransverse process spinal fusions were performed across two to three vertebrae in four cases of fracture-dislocations of the dorsolumbar region and 36 cases of degenerative joint and disk disease, including spinal stenosis and spondylolisthesis of lumbosacral segments. In all cases, arthrodesis was performed with a composite of AAA cortical bone strips and local autologous spongiosa, including lamellar bone chips. The iliac crest was not used as a donor site in any case. The apophyseal joints were erased, packed with autologous bone slivers, and transfixed with AAA bone pegs. In selected cases, AAA cortical bone "H-blocks" were also placed between the spinous process as in a routine posterior lateral arthrodesis. In cases of bilateral total laminectomy for fractures or spinal stenosis, the excised cancellous bone chips were cleaned of soft parts and transplanted across the transverse processes beneath and around the AAA cortical bone implants. In the above-described operations, graded by the Anatomic-Functional Economic (AEF) system, the long-term excellent and good results were: 4/4 in fracture dislocations; 23/28 in degenerative arthritis and spinal stenosis; 5/8 in spondylolisthesis. Overall, there were over 80% excellent and good results; the pseudarthrosis rate was 12%. In a comparable surgical procedure with autologous iliac bone in 58 control cases, reported in the foregoing article in this volume, the minimum pseudarthrosis rate was 8%. Raw band bone, either frozen or freeze-dried, is now either so infrequently considered or unavailable for lumbar spinal operations or unavailable for lumbar spinal operations that further investigations of AAA bone grafts are warranted in a statistically significant number of patients. Although autologous bone is the ideal bone for a graft, the most important incentive for further investigations of AAA bone is the avoidance of complications of excision of massive bone grafts from iliac crests.

Adolescent↗

PubMed1978

Resection and reconstruction for primary neoplasms involving the innominate bone.

Using described criteria for the selection of patients for excision or resection of tumors involving various portions of the innominate bone, as opposed to hemipelvectomy, fifty-seven out of the more than 200 patients evaluated were judged to be candidates for a curative procedure. Of these, twenty-five were selected for hemipelvectomy and thirty-two, for non-amputative procedures. Depending on the location and extent of the lesion as determined by complete preoperative work-ups, three types of procedures were performed singly or in combination:(1) wide excision or radical resection of the iliac wing; (2) periacetabular wide excision or radical resection; or (3) wide excision or radical resection of the pubis. Reconstruction was accomplished when the hip joint was excised by fusion or the creation of a pseudarthrosis either medially in relation to the pubis or laterally in relation to the ilium or wing of the sacrum. The results after follow-ups of one to seventeen years were assessed in terms of the immediate goals of surgery, control of the disease, and function. The findings were as follows: With the preoperative assessment and operative techniques described, an oncologically adequate procedure was performed in two-thirds of the cases. In the remaining cases, the adequacy of the procedure was compromised by poorly planned biopsies, occult microextensions, and surgical errors. The recurrence rate was high after the inadequate procedure (100 per cent) and low (4 per cent) after the adequately accomplished procedures. Function was nearly normal when the hip joint was preserved. If the hip joint was removed and fusion was obtained, the results were good, but fusion was obtained in only 50 percent of the cases in which it was attempted. If the hip joint was removed and pseudarthrosis resulted, the results ranged from good to poor. Sciatic-nerve involvement necessitating resection of the nerve was not a contraindication to a non-amputative procedure.

Acetabulum↗

PubMed1995

[Closed tibial fracture--reamed or unreamed intramedullary nailing. A clinical study].

When comparing the unreamed tibial nail (UTN) with the external fixator in the treatment of open tibial fractures the UTN has shown advantages. Whether we can find these advantages also in the treatment of closed tibial fractures using the UTN instead of a reamed system should be clarified in the following study. We compared 35 UTN treated patients with 35 patients that were treated with a reamed A0-universal tibial nail. Both groups showed no differences in age, sex, etiology and severity of trauma. The fractures were classified by the A0-classification of fractures and the soft tissue damage by the classification of Tscherne and Oestern. The length of mean hospital stay, the time of partial weight bearing and the duration of fracture healing, were shorter using the UTN. 5 of 9 complications using the UTN were immanent to the system (deformation of the locking screws). The other complications were 2 axis shifts, 1 compartment syndrome and 1 pseudarthrosis. The other group showed 1 hematoma, 1 axis shift, 1 compartment syndrome, 2 thromboembolic complications, 2 infections and 3 cases of pseudarthrosis. We think that there is an advantage to use an UTN instead of a reamed nailing system in treatment of closed tibial fractures.

Adult↗

PubMed1994

Robinson anterior cervical fusion comparison of the standard and modified techniques.

In 1990 the authors modified the Robinson anterior cervical interbody fusion technique by burring the endplates to expose subchondral bone. The authors compared 31 patients having the standard technique and 29 patients having the modified technique to evaluate 1) setting of the bone graft, 2) kyphotic angulation, 3) pseudarthrosis rate, and 4) pain outcome. In the standard Robinson fusion technique, the average loss of height across the fused segments was 0.8 mm and the average increase in kyphosis 4.9 degrees. Values for the modified technique were 1.9 mm and 3.1 degrees, respectively. The change in height was statistically significant (P = .01), as was the difference in angulation (P = .028), though the latter was in the opposite direction predicted. The pseudarthrosis rate using the modified technique decreased to 4.4% per level. Pain outcome for the two groups was equivalent. Burring of the endplates for anterior cervical interbody arthrodesis results in a detectable but not clinically important amount of graft settling with a higher success rate for arthrodesis.

Bone Transplantation↗

PubMed1994

Interbody fusion and instrumentation.

Fusion indications in adult degenerative disk disease of the lumbosacral spine include isolated disk resorption, primary and secondary instability, recurrent disk herniation, and pseudarthrosis. Common to these indications are variable proportions of biomechanical insufficiency of the motion segment, instability, deformity, and spinal stenosis. Apart from favorable psychosocial and work related variables, satisfactory outcome is dependent on treatment by a combination of diskectomy, decompression, and deformity correction, in addition to fusion. Isolated intertransverse or interbody fusions show variable fusion rates that are increased by concurrent instrumentation. Persistent pseudarthrosis rates and instrumentation failures have prompted circumferential fusion techniques. Posterior lumbar interbody fusion (PLIF) and segmental pedicle-based plate fixation overcome earlier problems with PLIF by allowing for wide decompression and increased exposure for disk space preparation, minimizing neural injury. Pedicle fixation restores segmental stability and minimizes graft retropulsion. Restoration of anterior column support prolongs instrumentation life, and increases fusion rates irrespective of the number of levels fused. Disk space distraction, with the use of instrumentation as a working tool, permits safer decompression of the intraforaminal zone, a common area of stenosis, and single or multilevel deformity correction to restore coronal, axial, and sagittal alignment and spinal balance. Even though the surgical technique is demanding, fusion rates up to 96% and clinical success up to 86% are achieved.

Adult↗

PubMed1993

Cotrel-Dubousset instrumentation. Results in 52 patients.

Fifty-two posterior spinal fusions were performed for pediatric idiopathic, congenital, and neuromuscular scoliotic curves. Cotrel-Dubousset instrumentation was used in all patients. Nine had prior anterior spinal releases and fusions. The patterns were mixed, with a predominance of right thoracic curvatures. The average preoperative curve measured 60.6 degrees, with correction to 29. Seven patients required revision surgery, and 17 wore orthoses after operation. There were 17 complications in this group, including hook pullout, prominent hardware, infection, pseudarthrosis, and two cases of broken Cotrel-Dubousset instrumentation rods. Fatigue failure of this instrumentation, secondary to pseudarthrosis, has not been reported previously, and these two cases are presented in detail. The operative morbidity and difficulty were increased in the larger idiopathic curves and in neuromuscular and congenital scoliosis. Cotrel-Dubousset instrumentation is an overall excellent tool for the multiplanar correction of scoliosis and is amenable to revision surgery.

Adolescent↗

PubMed1977

[Reaction in bone and cartilage to Judet metal prosthesis over 20 years (author's transl)].

A case in which a vitallium head-prosthesis was implanted 20 years before. Changes in the neck of femur: Vitallium proved even after 20 years very passive. Minor metallosis could be seen only microscopically, no inflammatory or foreign-body reaction, no atrophy but sclerosis of cancellous bone, which is considered to be due to adaptation to changed weightbearing. Losening of the implant caused a kind of "pseudarthrosis" on the surface of the bed, definite secondary changes, in parts osteoarthrotic. The causes of "pseudarthrosis" are discussed.

Aged↗

PubMed1997

[Treatment of spondylolisthesis. Operation in situ or repositioning spondylodesis].

The indication for operative treatment of spondylolisthesis in children and juvenile patients relies mainly on the progressive slipping of the vertebra, with consecutive deformation, on the other hand on neurological disorders, that may be seen as rigid lumbar extension with contractation of hip and knee joints. In the adult patient the main reason for treatment is the painful instability, often accompanied by root pain caused by degenerative changes as a result of repairment. The treatment consists of comlete reduction of the slipping vertebra, and reconstruction of the physiological lumbar lordosis through a postolateral and anterior interbody fusion. In case of additional compression of neurological structures, an extensive decompression must be performed. Today it is possible to reposition nearly ever spondylolisthesis, even ankylosed spondyloloptosis. In some cases it is necessary to performe the reposition step by step in two sessions in order to allow the neurological structures to accomodate. Finally you reach through a complete reposition a physiological curve with correct impact of the biomechanic forces and a harmonic relation between posterior compression and anterior axial force. A complete reposition with an negativ angle in the slipping segment brings the axial force back into physiological position and prevents early degenerative changes in the neighbouring segments. A posterior fusion in situ can not reduce the pathological biomechanics and has to lead to a high rate of pseudarthrosis with an increase of the anterior slipping. Even anterior fusion only is not sufficient, as the posterior inter-articular portion remains divided, the disposition or dysplasia of the facett joints increases the segmentmovement. As a result you see resorption and pseudarthrosis of the anterior fusion. Only in case of undamaged discs and ligaments in juvenile patients without anterior slipping a try with a posterior laminoplastic is allowed.

Adolescent↗

PubMed1998

Anterior cervical plate stabilization in one- and two-level degenerative disease: overtreatment or benefit?

This consecutive case retrospective chart review of 356 patients compares the reoperation rate of one- and two-level anterior cervical discectomies for degenerative disease with and without anterior cervical plate stabilization (ACPS). A total of 210 patients underwent surgery without ACPS (bone alone) and 146 patients underwent surgery with the addition of ACPS. Follow-up ranged from 1 to 9 years. A total of 22 patients with one- or two-level cervical arthrodesis required a second surgical intervention (19 bone alone, 3 with ACPS). Reoperations were performed in the bone-alone group for pseudarthrosis in 12 cases and for progression of degenerative disease in 7 cases. The reoperations in the ACPS group were performed for pseudarthrosis in one case and settling of the graft with screw fracture before fusion in two cases. The log-rank test, which uses all patients and their total follow-up periods, was statistically significant in favoring ACPS (p = 0.05). Furthermore, the reoperation rate after 1 year was also significantly lower when ACPS was utilized compared with bone alone (p = 0.0308, Fisher's exact test, two tailed). These data provide evidence that the addition of ACPS in one- and two-level cervical degenerative disease does not constitute overtreatment but rather supplements the internal stabilization initially provided by the bone graft and yields a lower reoperation rate.

Adult↗

PubMed1998

[Graner operation in therapy of semilunar bone necrosis. Review of the literature and personal results].

Intercarpal arthrodesis with interposition of the capitate osteotomized in Graner's technique is performed in the treatment of stage III Kienböck's disease. Although clinical results are satisfactory, there are complications such as necrosis of the capitate, pseudarthrosis of the capitate, and arthrosis of the radiocarpal joint. From 1992 to 1995, twenty patients were treated for Kienböck's disease by Graner's technique in the Clinic of Hand Surgery II in Bad Neustadt/Saale. Seventeen patients were submitted to follow-up studies. The range of motion (extension/flexion) of the wrist was 55 degree. The grip strength was 67% of the other hand. Four patients continued to complain of pain. Necrosis of the capitate was found in four cases, pseudarthrosis in two cases, and arthrosis of the radiocarpal joint in five cases. Based on the poor X-ray results found in this review, the authors feels there is no indication for Graner's technique. They favor STT arthrodesis in stage III of Kienböck's disease.

Adult↗

PubMed1998

[Results of Kapandji-Sauvé operation after distal radius fractures].

Incongruity of the distal radioulnar joint represents a major problem following malunited fractures of the distal radius. A useful solution is the arthrodesis of the distal radioulnar joint with distal ulnar pseudarthrosis as described by Kapandji-Sauvé. The results of this procedure are presented and the indication compared to alternative treatment options discussed. Between 1991 and 1997, 19 patients were treated with a Kapandji-Sauvé procedure, for rheumatoid arthritis in seven and for a malunited fracture of the distal radius in twelve patients. All of the patients with a malunion of the distal radius were followed up 5 to 70 months postoperatively by clinical and X-ray examination. For evaluation the protocol by Martini for malunited fractures of the distal radius was used. All but one patient agreed that the operation had been beneficial and would choose to undergo the same procedure again necessary. Mean forearm rotation improved from 99 to 166 degrees. Preoperative pain was reduced in eleven patients. Two patients were completely pain-free and seven noticed pain during heavy load only. Grip strength improved postoperatively in three patients, remained unchanged in four and was diminished in three. In two patients preoperative measurements were not available. Evaluation by the Martini protocol gave three very good, four good, four fair, and one poor result. In one patient, regeneration of the ulna across the resected segment occurred necessitating a secondary excision. This resulted in a return of forearm rotation of 140 degree and good patient satisfaction. Arthrodesis of the distal radioulnar joint with distal ulnar pseudarthrosis reliably reduces pain and improves forearm rotation after malunited fractures of the distal radius. However, it cannot influence pain originating from the radiocarpal joint. Therefore, patients with advanced radiocarpal arthrosis are not suitable for the operation. We consider the procedure to be indicated when the distal radioulnar joint is compromised by the fracture itself or by posttraumatic degenerative arthrosis or when instability or subluxation of the distal radioulnar joint occurs that cannot be corrected. We have not observed persisting problems resulting from instability of the proximal ulna.

Adolescent↗

PubMed1998

Vascularised bone graft applications in upper extremity problems.

Between 1990 and 1996, 16 cases of bone defects were treated by vascularised bone grafting by the authors. Free vascularised fibula was used in 10 cases and one free iliac crest graft was used for upper extremity bone defects. Four vascular pedicled first metacarpal bone and one radial styloid bone were used for scaphoid nonunion. Average follow-up was 26 months (6-78 months) and success rate was 94%. We recommend vascularised bone grafts in the upper extremity when there is risk of infection; the defect is greater than five centimeters when the forearm rotation is unlimited. The avascularity of the scaphoid pseudarthrosis must be verified radiologically or through magnetic resonance imaging. This technique should only be used when other reconstructive techniques are unlikely to succeed.

Adolescent↗

PubMed1983

Osteofibrous dysplasia (ossifying fibroma of long bones). A study of 12 cases.

Osteofibrous dysplasia (ossifying fibroma of long bones) is one of the fibro-osseous lesions that affects the tibia and fibula in the first decade of life. A study of 12 patients with this lesion showed the high rate of recurrence after surgical intervention. Most commonly, the lesions are eccentrically located in the diaphysis of the tibia. Pseudarthrosis may develop in cases where the lesion is situated in the distal portion. Roentgenologic and histopathologic features are basically similar to those of monostotic fibrous dysplasia of long bones. However, bony or osteoid trabeculae covered by osteoblasts enable distinction between osteofibrous dysplasia and monostotic fibrous dysplasia, as determined histologically. The current evidence indicates that surgery should not be attempted in patients under 10 years of age.

Bone Neoplasms↗