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PubMed1989

Surgical treatment of scaphoid nonunion. Review of the literature and recommendations for treatment.

The management of scaphoid pseudarthrosis is still controversial. The numerous methods that have been proposed can be roughly classified according to their aim - relief of pain or healing of bone. Following a review of the literature, and guided by personal experience with the Matti-Russe technique and McLaughlin internal fixation, the authors present recommendations for treatment according to clinical presentation of the condition.

Carpal Bones↗

PubMed1980

Triple arthrodesis and Lambrinudi arthrodesis. Literature review and follow-up study.

A literature review is presented about triple arthrodesis and Lambrinudi arthrodesis including indications, techniques, complications, and a more extensive review of some specific indications. Forty-eight patients were operated on between 1961 and 1977, 25 of whom were reviewed at follow-up. Our follow-up study shows a rather high rate of pseudarthrosis, with however a normal failure rate. According to these findings transfixation of the bones with K-wires is to be considered.

Adolescent↗

PubMed1996

Direct anterior fixation of odontoid fractures with a hollow spreading screw system.

Direct fixation of odontoid fractures has the advantage of preserving rotation in the atlanto-axial motion segment. Early mobilisation of patients and minor intra-operative trauma increase the value of this technique. The original screw method of Nakanishi, Magerl, and Böhler, was improved by Knöringer who designed a double-threaded screw for direct fixation of dens axis fractures. He stated that double screwing is absolutely necessary in order to prevent rotation of fragments against each other. The purpose of the present study was to describe a new single screw for direct fixation of odontoid fractures, which is easy to place into the limited space of the dens axis and which offers enough rotational stability and sufficient compression of fracture fragments. The so-called hollow spreading screw system (HSS) consists of an outer hollow screw, a spreading insert, a toothed washer, an hexagonal nut, and a protective nut. Thirty-five patients with traumatic and arthritic odontoid fractures were treated using direct internal fixation with the HSS system. In 30 cases, there was a type-II-fracture, in 3 a shallow type-III-fracture, and in 2 a type-II-fracture with pseudarthrosis formation. Pre-operative neurological deficits were seen in 16 cases. No additional neurological deficits were caused by the surgical procedure. The bony fusion rate of fresh fractures in the presented series was 100%. With the HSS system, ca. 12% postoperative complications, such as slight reduction of head rotation or neck pain, were found. These results are virtually equal to the results of the double-screw technique. Since a relatively simple technical procedure is required for placement of the screw, the HSS system can be recommended in all cases of odontoid fractures suitable for direct anterior fixation.

Adolescent↗

PubMed1994

Upper tibial corticocancellous flap anatomy study (19.2.93).

A cortico-cancellous flap from the anterolateral aspect of the upper third of the tibia was presented. Sixty lower limbs of "fresh" cadavers were dissected. The vascular bundle includes the anterior tibial artery and its recurrent collateral branches and recurrent and musculoperiosteal arteries. The flap is harvested with the interosseous membrane and can be used either free or predicled. We used this flap for two patients suffering from pseudarthrosis. Long range clinical and radiological results are good.

Adult↗

PubMed1982

[Long-term results of compression-osteosynthesis with three AO-screws for spongiosa in fractures of the femur-neck (author's transl)].

Between 1969 and 1978 in 42 patients fractures of the femur-neck were treated with three AO-screws for spongiosa (screws with a short thread). Late results in these patients are reported. The interval between operation and follow-up was in average 90 months. In no case pseudarthrosis had developed; the rate of necrosis of the femur head was 23.8%. The method is suitable in selected cases of medial fractures of the femur-neck, type I and II, and in lateral fractures, preferably in younger patients. The results in fractures of type III according to Pauwels show, that in advanced age these fractures should be treated with a partial or total prosthesis, because the rate of necrosis of the femur-head cannot be lowered.

Aged↗

PubMed1985

[Quantitative determination of the effect of induced alternating currents on the integration of autologous spongiosa transplants].

In a right-left experiment on the ulna of beagles, the authors investigate the influence of induced alternating current on the number of healed-in autologeous spongiosa grafts taken from the same side of the body. At first an atrophic pseudarthrosis is produced in both ulnae of twenty animals by bone resection and electrocoagulation over six months. Following to spongiosa transplantation and plate osteosynthesis, the ulnae are stimulated during eight weeks with a sinusoidal current of 38 cps and an electromagnetically induced alternating-current voltage of 600 mV on an average. The blindfold evaluation of the X-ray picture is performed by four experts and shows significantly better results in the stimulated side. By variance analysis of the results of electronic planimetry of serial layers in the region of transplantation represented by microradiography, it is demonstrated that the greater bone density of the stimulated grafts compared to the control grafts is statistically significant. It has to be considered that these results refer strictly to the electric data and treatment times applied by the authors. Particularly the results are not valid for the unique application of electromagnetic fields without alternating-current component.

Animals↗

PubMed1980

[Antibodies against staphylococci in patients of a department for orthopedic surgery (author's transl)].

Sera from different groups of patients in a department of traumatic surgery were examined for staphylococcal alpha-antitoxin-titres. In comparison to a group of normal controls the following changes were found: 1. Patients, had significantly raised titres, if they had undergone surgery because of closed fractures, pseudarthrosis and luxations and even if the postoperative course was uneventful. This can be explained through the wide-spread occurrence of staphylococci in hospitals, which can invade the organisms through an incision, the skin or mucous membranes. These findings should be kept in mind while estimating staphylococcal antitoxin-titres in patients hospitalized over a long period. 2. Patients suffering from surgical infections and also paraplegics showed still more significantly raised antitoxin-titres in comparison to the normal controls or to patients, who had undergone aseptic surgery. Increased titres were found even in the sera of patients, whose wounds did not drain staphylococcus aureus. Patients suffering from chronic staphylococcal osteomyelitis showed the highest mean values of antitoxin-titres; these patients, however, had also the greatest variations with high and low levels. The question arouse whether a high or a low level corresponds to the severity of the disease. It was found that it is necessary to titrate different antibodies against staphylococcal toxins. In a second paper the results of the simultaneous determination of alpha-antitoxin and anti-PV-leucocidin in patients with posttraumatic bone infections will be presented.

Antibodies, Bacterial↗

PubMed1981

[The connecting osteosynthesis and its problems in unstable pertrochanteric fractures of the femur (author's transl)].

In unstable pertrochanteric fractures of the femur a high bending strain and much load lies on the medial part of the bone. The connecting osteosynthesis takes off this load and immediately guarantees a high stability. Clinical experiences with 44 cases of connecting osteosynthesis - among them 35 per-and subtrochanteric fractures of the femur-show, that in 11 cases complications due to the fractures occurred (breaking of the implant, pseudarthrosis etc.) These complications are probably due to a delayed healing caused by bone cement penetrating into the area of the fracture. It is recommended to use an autologous cancellous bone graft. Indications for the compound osteosynthesis are only unstable pertrochanteric fractures in old patients in poor general condition and a short life-expectancy, and fractures in patients with diffuse metastases.

Aged↗

PubMed1999

[Nonunion of the humeral diaphysis - operative and nonoperative treatment].

Operative treatment of acute humeral shaft fractures represents a major source of nonunions. The analysis of the biomechanical and biological causes of diaphyseal nonunions of the humerus is a prerequisite for the successful treatment of ununited humeral shaft fractures. Biologically active nonunions heal after debridement and correction of deformities with an improvement of mechanical stability, preferably by fixation with a compression plate. In atrophic nonunions, the restoration of the biologic capacity to restore osteogenesis by bone grafting is additionally necessary. The treatment of synovial pseudarthrosis and infected nonunion requires removal of bone and debridement of synovial and infected avascular tissues, respectively. Intramedullary nails to improve mechanical stability and nonoperative treatment with extracorporeal shock waves should only be used in a few special cases which do not have any severe deformities.

Biomechanical Phenomena↗

PubMed1999

[Operative versus non operative treatment of odontoid non unions. How dangerous is it not to stabilize a non union of the dens?].

INTRODUCTION: Injuries precede the vast majority of all odontoid pseudarthroses. Because of specific anatomic conditions type II injuries lead more often than other types to non unions. For its development insufficient internal or external fixation and a persisting fracture gap are crucial. METHODS AND RESULTS: In 71 patients after operative stabilization of odontoid fractures with two anterior lag-screws we detected 8 non unions. In 3 patients the interval between accident and operation amounted to more than 5 weeks, seven times we did not succeed in closing the fracture gap. Technical mistakes like insufficient reduction (n = 1) or screw misplacement (n = 3) were additional reasons. According to the literature and own observations an os odontoideum must be considered in most instances as a pseudarthrosis after a lesion of the subdental synchondrosis in childhood. The most important diagnostic tool in odontoid non unions is a dynamic examination of the upper cervical spine under fluoroscopic control in maximum flexion and extension. We propose a classification of posttraumatic dens non unions into 4 types. Type I corresponds to a stable "non union" in approximate anatomical position of the dens and without signs of instability in the former fracture zone. Type II describes a relatively stable grossly displaced non union that is not to be reduced by simple, closed means. Type III means an unstable non union and Type IV a posttraumatic os odontoideum. CONCLUSIONS: Therapeutical recommendations need to be differentiated. Unstable non unions are most often responsible for persistent pain, may result in acute or chronic myelopathy++ and therefore - as well as ossa odontoidea - need operative fixation. In considerably displaced non unions a closed reduction manoeuver with long term traction should be tried. The operative treatment of choice is the posterior transarticular screw fixation C1/C2 desirably in a percutaneous technique. Tight, "stable" pseudarthroses in the sense of a persisting fracture gap in painfree patients should first be controlled radiologically. If the odontoid position remains unchanged, non operative treatment may be continued.

Bone Screws↗

PubMed2002

[Clinical evaluation of the distal femoral nail].

METHOD: The clinical results after DFN-osteosynthesis of n=56 AO-classification 33A-fractures (32%), 33C-fractures (43%), 32X-fractures (21%) and pseudarthrosis treatment (4%) are presented. RESULTS: Follow up was available for 54 fractures (96%) after a mean of 1.2 years (range 0.2-2.8 years). 95% of patients showed full-weight-bearing with a knee flexion of 120 (60-140) degrees. Extension-deficit >10 degrees was observed in 5.4%. All fractures were consolidated. One soft-tissue infection, one partial loss of reduction and one implant failure were observed. A significant axial malalignment was found radiologically in 17%, a loosened spiralblade or locking screw in 7.4%. In 91% of cases the result was judged as good to excellent by patients and surgeons. CONCLUSION: The mechanical stability of the implant allows a save osteosynthesis of unstable supracondylar and complete articular femoral fractures without additional bone grafting. Mechanical stability and minimal invasive operative technique permit a safe bone healing without major complications.

Adolescent↗

PubMed2005

[ Intramedullary nailing (ESIN) in clavicular pseudoarthroses. Results of a prospective clinical trial].

This prospective clinical trial was performed to assess healing, clinical outcome and complications after intramedullary nailing of midshaft clavicular nonunions. Over 2.5 years, 14 patients were included. Exclusion criteria were pathological fractures, bony defects, previous operative therapy, atrophic and infection pseudarthrosis and the patient's age: <18 years or >70 years. Results were evaluated after 3, 6, 12 and 18 months. Beginning 3 months after the operation, pain (VAS), subjective satisfaction, Constant score and DASH score were significantly better than preoperatively during the follow-up period (p<0.001). There were no infections, no implant displacements or refractures.Intramedullary fixation of midshaft clavicular nonunions with an elastic titanium nail is a safe, minimally invasive surgical technique, producing excellent functional and cosmetic results without additional bone grafting.

Adult↗

PubMed1997

[Extracorporeal shockwave treatment of delayed bone healing. A critical assessment].

Since the late 1980s, experiments have been performed to influence physiologic and disturbed healing of bone. However, the mainly negative results of animal studies, cannot be applied to the human nonunion situation as long as there is no adequate animal pseudarthrosis model. Prospective clinical studies in various centres have resulted in success rates of more than 50%, although the majority of patients had been treated repeatedly and ineffectively with the gold standard of re-osteosynthesis and grafting. Since the mechanisms are not yet understood, only such desperate conditions are an indication for the application of high-energy extracorporal shock waves.

Adolescent↗

PubMed1997

[Shock waves in orthopedics].

Extracorporeal shock waves have revolutionized urological stone treatment. Nowadays shock waves are widely used in orthopedics, too. This article reviews the applications of extracorporeal shock waves on bone and adjacent soft tissue. The osteoneogenetic effect of extracorporeal shock waves has been proven and can be used to treat pseudarthrosis with a success rate of around 75%. Shock waves have a positive effect in tennis and golfer's elbow, calcaneal spur, and the complex called "periarthritis humero-scapularis." The mechanism for this is not yet known, and results from large prospective and randomized studies are still lacking. However, the treatment has been performed many thousands of times. In patients in whom conservative treatment has failed surgery used to be the only choice, but its success rate barely exceeds that of shock wave therapy and surgery can still be done if shock wave therapy fails. Extracorporeal shock waves will have an impact on orthopedics comparable to its effect in urology. Scientific evaluations, professional certifications, quality assurance and reimbursement issues present great challenges.

Bone Diseases↗

PubMed2003

[Stress fractures of the tarsal navicular bone. Causality, diagnosis, therapy, prophylaxis].

Stress fractures of the tarsal navicular bone are a challenge in diagnosis and therapy. First and foremost you have to think about this fracture. The origin of the injury can be detected in a wrong or too heavy strain of the bone especially in long distance runners and recruits. The MRI is the diagnostic tool of first choice. Therapy of displaced or comminuted fractures as well as pseudarthrosis is best done with surgical procedures like direct screw fixation or interposition of autologous bone depending on the circumstances and the age of injury. Conservative treatment with a plaster of Paris is useful in non-displaced and non-comminuted fractures. Prophylaxis with technical aids and a changing habits is recommended.

Bone Screws↗

PubMed1996

[Spinal pseudarthroses].

Pseudarthroses of the spine are classified into congenital, acquired non-traumatic, posttraumatic and postoperative (iatrogenic) pseudarthroses. The various types of non-unions of the spine are described according to their clinical and radiological appearance. In line with their clinical importance, special attention with respect to the operative treatment is given to non-union of the axis of C2 and to spondylolysis. For the pseudarthrosis of the dens a posterior fusion according to Gallie-Brooks is recommended, in spondylolysis without marked slipping a "direct repair" should be considered in young patients.

Child↗

PubMed1997

[Extracorporeal shock-wave therapy. Experimental basis, clinical application].

The purpose of our studies was to investigate experimentally the dose-dependent effects of extracorporeal shock waves on tendon and bone and to unveil therapeutic possibilities in tendinopathies and pseudarthroses. In animal experiments, both positive and negative influences were exerted by shock waves, depending on the initial situation and on the power of the applied shock waves. In prospective clinical trials positive effects were found in the treatment of persistent tennis elbow, plantar fasciitis, calcifying tendinitis, and pseudarthrosis. Our data show that extracorporeal shock waves may provide analgesic, resorptive and osteo-inductive reactions with nearly no side effects. However, the high cost of apparatus and staff prevents a routine application. Extracorporeal shock waves thus remain a last alternative before the indication is made for an operative procedure.

Achilles Tendon↗

PubMed2000

[Deviations in the axes of the lower extremities].

Deviations in the axes can be physiological or pathological. During growth, the axes of the lower extremities undergo significant changes. The femoral neck-shaft-angle decreases from 150 degrees on average at birth to 120 degrees on average at the end of growth. The lower leg is bowed in a varus direction at birth. After a child begins to walk, the knee axis deviates to a slight valgus. This goes back to normal before the age of ten. Pathologic deviations of the axis are rare. They occur in congenital deformations, after trauma or infection, or as a result of metabolic diseases. In association with coxa vara pseudarthrosis of the femoral neck usually develops. Therefore this deformation has to be treated. Correction is best made with a Y-shaped osteotomy according to Pauwels. At the lower leg, a deviation of 15 degrees from the normal axis is usually an indication for operative treatment. In children and adolescents, corrections are best made with (monolateral) external fixators. They allow early weight bearing, which is especially desirable in bilateral corrections.

Adolescent↗