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Congenital pseudarthrosis of the tibia is nearly always the result of a congenital bowing of the tibia when it is unilateral and with an antero-external angle. There is no possible spontaneous consolidation and there may be several associated sequellae (shortening and trophic disorders of the limb). The etiological and therapeutic aspects of the affection are reviewed.
The authors demonstrate a case of a scaphoid pseudarthrosis leading to an attrition rupture of the flexor pollicis longus tendon, tenosynovitis and haemorrhage into the carpal tunnel causing recurrent symptoms of an acute carpal tunnel syndrome. Every acute carpal tunnel syndrome is an emergency requiring instant decompression of the carpal tunnel. If success with conservative treatment of acute carpal tunnel syndrome is questionable, early operative relief of the median nerve is the safest procedure.
Fractures of the elbow may result in deformity, pseudarthrosis and arthritis, which lead to painful and restricted use of the joint. The operative treatment of these late complications includes osteotomies, surface reconstruction, arthrolysis, arthroplasty, alloarthroplasty and arthrodesis. Indications, operative techniques and results are described and discussed.
Eight patients who had a recurrent pseudarthrosis of the carpal scaphoid were treated by a bone graft from the ulna, vascularized by an ulnar-artery pedicle. The graft was taken from the medial aspect of the distal third of the ulna and inserted into the prepared scaphoid. This technique is advocated only for complex recalcitrant non-union. All of our patients had previously had at least two operations, one of which was conventional non-vascularized bone-grafting. In all eight patients, primary osseous union occurred in an average of 4.6 months; all were able to resume their previous occupational or athletic activities.
Personal experience of 4 years with the use of Ilizarov's apparatus is reported. The apparatus has been utilised on a routine basis in the treatment of complex fractures, in pseudarthrosis and in hypometrias. On the whole, the results obtained were positive, confirming the value of the apparatus and its ductility in the treatment of complex lesions of the skeleton.
Twenty-two consecutive unselected patients who had severe spondylolisthesis were treated by a first-stage posterior decompression (Gill procedure) and a posterolateral arthrodesis, followed by halo-skeletal traction, and then by a second-stage anterior interbody arthrodesis, followed by immobilization in a cast. Nineteen patients had complete clinical and radiographic evaluation, with an average follow-up of five years (range, two to seven and one-half years). The slip angle averaged 71 degrees preoperatively, was corrected to an average of 31 degrees by reduction, and averaged 28 degrees at follow-up. The average preoperative percentage of slippage (98 per cent) did not change substantially. A pseudarthrosis developed in four patients, all of whom had a reoperation. The neurological deficits that had been present in ten patients preoperatively had completely resolved in all but one at follow-up. One patient had a cauda equina syndrome and two patients had a neuropathy of the root of the fifth lumbar nerve as a result of the reduction; complete recovery occurred in two patients and partial recovery, in one. Alignment in the sagittal plane was restored in seventeen patients, and the back pain and radicular symptoms were relieved in all patients except one who had had those symptoms preoperatively.
A report on surgical treatment of 75 pseudarthroses of the tibia, 64 cases of which could be followed up for assessing the treatment results. The majority of these were pseudarthroses due to infection or associated with atrophy, that is to say, cases that were difficult to treat. Stabilization was usually effected by osteosynthesis with autocompression plates; in the majority of cases autologous bone grafts were performed additionally. In 82.8% of the cases cure of the pseudarthrosis was achieved, in 68.8% already by first surgery. 7.8% of the patients refused further surgical treatment. 9.4% are still under treatment at the time of writing.
Authors describe a case of consolidation of a congenital pseudarthrosis. The difficulties of the treatment of this disease are known. Very few procedures can secure the internal fixation and the induction of osteogenesis in the same time. Authors used beside internal fixation the distraction method that led to a surprisingly quick consolidation.
Post-traumatic axial malalignment of the lower limbs causes osteoarthrosis of the adjacent joints. Whether or not correction osteotomy is indicated depends upon the degree and the location of the deformity. Malalignment of the proximal femur should be corrected if the axis of the leg does not pass through the knee joint. If the axis is outside the central half of the tibial head, the indication for correction osteotomy is a relative one: varus deformities are more difficult to compensate and it is more urgent that these be corrected. Of 103 patients who underwent osteotomies of the proximal femur during the period 1973-1981, there were 73 in whom it was possible to follow up an average of 7 years after the realignment procedure. In nearly two-thirds of these patients the clinical symptoms noted before surgery had improved. In 10 cases of pseudarthrosis of the femoral neck, necrosis of the femoral head could not be avoided in spite of the surgical correction; nonetheless, the prognosis is better if the correction is done within the first 3 months after the trauma.
Restoration of a loadable mandible after extensive resections, defects or comminuted fractures, serious osteomyelitis and pseudarthrosis will be successful only if sufficiently stable fixation of the fragments and immobilization beyond the physiological period of bone healing are guaranteed. By means of various types of plates and extroral appliances for osteosynthesis the conventional methods have been improved, but failures and complications are still frequent. The treatment itself is a great strain for the patient. The titanium mesh implant system developed by Ph. Boyne and his group for reconstruction in mandibular defects means, in our opinion, an important therapeutical step forward. Its technical advantages and our own clinical experience advocate application of this system.
Forty-six patients who had a neuromuscular spinal deformity were treated with arthrodesis and Luque segmental spinal instrumentation and were followed for an average of three years. Twenty-two patients had cerebral palsy and twenty-four had another neuromuscular disease. In thirty-nine patients, the arthrodesis was extended to the sacrum. Eleven patients who had severe scoliosis as well as pelvic obliquity and decompensation of the torso had a combined anterior and posterior arthrodesis; the other thirty-five patients had a one-stage posterior procedure. Preoperatively, the average scoliosis was 74 degrees; this was corrected to 39 degrees at follow-up. Final corrections were similar for scoliosis and were better for pelvic obliquity and decompensation of the torso in patients who had combined anterior and posterior arthrodesis. The results for scoliosis and pelvic obliquity in patients who had a spastic deformity were similar to the results in patients who had a flaccid deformity. Correction of decompensation of the torso was better in patients who had a spastic deformity. Postoperatively, a brace was used in half of the patients in each group; this did not appear to affect the amount of correction in either group, although the result may have been influenced by the selection process. The rate of complications was 48 per cent. Pseudarthrosis occurred in three patients (6.5 per cent). There were no major neurological deficits related to the correction or to the use of sublaminar wires. Three patients died, one in the immediate postoperative period and the other two at eighteen months and four years after the original procedure, due to causes unrelated to the operation.
The article analyses experience in the treatment of 125 patients with ununited fractures and pseudarthrosis of the humeral diaphysis by osteosynthesis with massive compressing metal plates. The possibility of creating the necessary reserve of mechanical stability at the expense of the massive plates and strained fixation allows immobilization in a plaster cast to be avoided in most cases and early motor rehabilitation of the patients to be undertaken. The results were positive in 96.8% of cases, which makes it possible to consider the method to be sufficiently effective in the management of fractures of the humeral diaphysis and their sequelae.
We reviewed the results of spinal arthrodesis that was performed, with sublaminar wires that were attached to either double L-shaped Luque rods or to a Harrington rod, in forty-two adults who had idiopathic scoliosis. The minimum length of follow-up was two years; the maximum, five years; and the average, three years. The average scoliosis measured 67 degrees preoperatively, was corrected to 37 degrees at operation, and was 44 degrees at the time of follow-up. The final correction averaged 34 per cent. A single Harrington rod and multiple sublaminar wires were used in thirty-one patients. Eighteen of the thirty-one patients had a posterior arthrodesis only and thirteen, a preliminary anterior arthrodesis followed by a posterior arthrodesis. Eleven patients had instrumentation with double L-shaped Luque rods; six of them had posterior arthrodesis only and five, a preliminary anterior arthrodesis followed by a posterior arthrodesis. One patient had neurological deficit that was related to the operation. Three patients had a pseudarthrosis, which was in the lumbar area in all of them. All three patients had had only a posterior operation. No statistically significant difference in the amount of final correction was demonstrated between the subgroups.
A series of 38 patients with 38 fractures of the tibial shaft, primarily treated with an external fixator, is presented. In all of them, a second osteosynthesis is performed. More than 80% of these fractures were open and more than 80% were of the type B or C of the AO-classification. A pseudarthrosis was responsible for the reosteosynthesis in 24 fractures and a deep infection in 10. The day before the second intervention averaged 8.4 months. In 22 patients a plate osteosynthesis, in 11 an intramedullary nailing and in 4 a second external fixation was carried out. In one patient a transposition of a free osteomyocutaneous flap was performed. The functional end results were excellent or good in 75% of the patients. In fractures with a high risk of bone healing problems, a changing of procedure should be planned from the beginning of the treatment. The second procedure significantly shortens the time of fracture healing. The most appropriate stabilization should be performed secondarily, depending on the fracture form and the situation of the soft tissues of the lower leg.
Twenty-five patients aged 19-62 years were treated for tibial nonunions (22 atrophic, three hypertrophic) with bone loss (1-23 cm, mean 6.2 cm) by the Ilizarov technique and fixator. Thirteen had chronic osteomyelitis, 19 had a limb-length discrepancy (2-11 cm), 12 had a bony defect (1-16 cm), and 13 had a deformity. Six had a bone defect with no shortening, 13 had shortening with no defect, and six had both a bone defect and shortening. Nonunion, bone defects, limb shortening, and deformity can all be addressed simultaneously with the Ilizarov apparatus. Bone defects were closed from within without bone grafts by the Ilizarov bone transport technique of sliding a bone fragment internally, producing distraction osteogenesis behind it until the defect is bridged (internal lengthening). Length was reestablished by distraction of a percutaneous corticotomy or through compression and subsequent distraction of the pseudarthrosis site (external lengthening). Distraction osteogenesis resulting from both processes obviated the need for a bone graft in every case. Deformity was corrected by means of hinges on the apparatus. Infection was treated by radical resection of the necrotic bone and internal lengthening to regenerate the excised bone. Union was achieved in all cases. The mean time to union was 13.6 months, but it was only 10.6 months if the time taken for unsuccessful compression-distraction of the nonunion is eliminated from the calculation. The bone results were excellent in 18 cases, good in five, and fair in two based on union in all cases, persistent infection in three, deformity in four, and limb shortening in one. The functional results were excellent in 16 cases, good in seven, fair in one, and poor in one based on return to work and daily activities in all cases, limp in four cases, equinus deformity in five cases, dystrophy in four cases, pain in four cases, and voluntary amputation for neurogenic pain in one case.
Reimplantation after subtotal section of the right lower limb under the Scarpa triangle was been attempted and was successful. Section and contusion of the femoral artery and vein required 2 end-to-end saphenous bypass grafts. The use of the lower limb is correct, after to a follow up of 4 years. The risks, inherent to all proximal section, with important muscular masses, in a small child, are described. Functional prognosis depends on three aspects: bone, vessels, and nerves. A tibial pseudarthrosis had to be operated secondarily with significant lengthening. A partial stenosis of the graft was demonstrated arteriographically. Pes equinus, a result of paralysis, has been fitted with an orthesis. This observation is almost an experimental one: what can be the future of a reimplanted lower limb in the child.
The effects of pregnancy on patients who have idiopathic scoliosis were investigated in terms of increased risk of progression of the curve. The charts, radiographs, and other pertinent data on 355 affected women who had reached skeletal maturity (Risser Grade 4) before 1975 were reviewed and analyzed. One hundred and seventy-five patients had had at least one pregnancy each (Group A) and 180 patients had never been pregnant (Group B). The groups were comparable with regard to the treatments that they had received. After skeletal maturity was reached, the curve progressed more than 5 degrees in 25 per cent and more than 10 degrees in 10 per cent of the patients in each group. The age of the patient at the time of the first pregnancy did not influence the risk of progression, and the stability of the curve before pregnancy did not decrease the risk of its progression during pregnancy. In patients who had had a spinal fusion, progression in the unfused portion of the spine was negligible in both Group A and Group B. The presence of a pseudarthrosis did not result in progression of the curve during pregnancy. The effects of scoliosis on pregnancy and delivery were evaluated in the 175 women in Group A. No specific problems that were directly related to the scoliosis were noted except for four patients, in whom delivery posed difficulties. The incidence of cesarean section was one-half of the national average, and no sections were directly related to the mother's scoliosis.(ABSTRACT TRUNCATED AT 250 WORDS)
UNLABELLED: The following specific characteristics of injury cause the problems that occur in scaphoid bone fractures: 1. Mechanisms of accident: There are only a few typical circumstances that cause the injury: as there are false winding of a shrankshaft handle or a fall on the extended hand. In all the other cases the accident is neither realized by the injured person himself or by the physician. As a consequence the possibility of injury of the scaphoid bone is not taken into consideration. 2. SYMPTOMS: In a stable fracture the symptoms do not appear directly but may be clearly delayed or they may disappear very quickly after a short period of intensity, so that the accident is no longer taken any notice of. 3. Radiodiagnostics: Because of the anatomic position of the scaphoid bone any X-raying from a lateral view is difficult because the scaphoid is covered by other carpal bones. In case of an undisplaced fracture you often only see very fine fracture lines, which are only to be seen from a direct orthograde view. It is necessary to X-ray the carpus in different positions. 4. THERAPY: If there is the slightest chance of a scaphoid bone fracture an intensive therapy must be directly started. An immobilisation for a too short period may lead to a delayed union and end in a pseudarthrosis. This is also the case if you start the therapy too late. Then the fracture line is already filled up by fibrous tissue. The latest period of time to begin a conservative treatment is six to eight weeks after the day of the accident.(ABSTRACT TRUNCATED AT 250 WORDS)