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The essence of this modification is the curved structure of the cavity in the scaphoid bone and of the bone graft which fits into the cavity. The indication for the Matti-Russe method extends to those cases in which the direction of the line of pseudarthrosis is unfavourable and the proximal fragment is relatively small. The mechanical stability increases, because the wall of the cavity on all sides remains equally thick.
We evaluated the results of 85 patients having L4-L5 disc excision (52 having disc excision alone, and 33 having disc excision and fusion) using the Smiley-Webster scale at an average follow-up of 7.3 years. Both groups (fusion and nonfusion) were comparable except that the nonfusion group had a significantly higher percentage of patients with a history of chronic back pain and degenerative changes on their initial radiographs. The fusion group had significantly better results compared with the nonfusion group (85% satisfactory results versus 39% satisfactory results). The most common cause of unsatisfactory results in the fusion group was pseudarthrosis (two) while progressive degenerative disc disease (18) and recurrent disc prolapse (eight) were the most common cause of unsatisfactory results in the nonfusion group. The overall reoperation rate was 9.4% (13.5% in the nonfusion group, and 3% in the fusion group.
Specific problems in the treatment of the segmental fracture of the tibial shaft. The management, the postoperative problems and the functional results of 40 patients with 41 segmental fractures of the tibial shaft were reviewed. 63.4% of the fractures were open and 75% of the patients had one or more associated lesions. All fractures were treated operatively: 23 (56.1%) with a single or double plate osteosynthesis and 18 (43.9%) with an external fixator. 37 fractures could be followed-up until bony consolidation. The postoperative problems of each stabilization method are discussed. A pseudarthrosis is seen in 18.9% and a deep infection in 10.8% of the patients. A good functional result could be obtained in 78.4%. The segmental fracture of the tibial shaft is connected with specific biomechanical and fracture healing problems. The vascularization of the intermediate fragment is severely disturbed by the trauma itself and may surely not be endangered secondarily by the operative procedure.
After years of experience in the treatment of fresh diaphyseal fractures of the tibia and humerus using functional braces, we began to use them in cases of delayed union and pseudarthrosis. This decision was encouraged by the excellent results obtained in fresh fractures and by the favourable effects of function on the repair process. The 15 cases reviewed, 13 in the tibia and 2 in the humerus, had previously been treated by various traditional methods. Treatment by functional bracing consisted of removing any plates or other devices, sometimes in association with "minimal" surgery such as fibular osteotomy, prior to the application of the functional brace. Total weightbearing was allowed ab initio until there was complete radiographic healing. All the cases resulted in complete healing over a period ranging from two to five months, with total functional recovery of the limb involved.
The principles underlying the use of isoelastic shoulder prostheses are discussed and the results obtained in 8 patients are reported. Two operations were for pseudarthrosis of the humeral neck and 6 for osteolytic neoplasms. The results were assessed after an average follow-up of 4 years. Full movement was never recovered; there was partial recovery in 6 cases, and no significant recovery in 2. The extent of the surgical resection was determined by the type of lesion; in more conservative resections which allowed for the reconstruction of tendinous insertions, the functional results were better than in wide resections. The difficulty of recovering good movement was related to the limited possibilities of reconstructing the insertions of the external rotator muscles.
There is a need for a specifically designed plate for anterior fixation of the vertebral bodies, contoured to fit closely around the lateral aspect of the spine and wide enough to allow multiple options for placement of at least three screws in each vertebra. The large-diameter cancellous screws should penetrate the opposite cortex. Existing bone plates are inadequate, because they are too narrow and do not allow positioning of more than two screws in each vertebra. The Biomedical Engineering Department of the National Research Council of Canada designed and tested the plate described in this article, with particular attention to providing smooth surfaces to prevent vascular complications. Three lengths of plates have been developed and are used in the area from T11 to L5, with a specific tapered plate for the L5 area to prevent contact with the overlying iliac vessels. This device should be used for stabilization following corpectomy for tumor, decompression of burst fractures, severe disc degeneration, pseudarthrosis, and the multiply operated back.
The long-term results of 19 perilunate dislocations of the carpus (including 9 transscapho-perilunate dislocations) were: good, 7 cases; fair, 8; poor, 4. The 9 transscapho-perilunate dislocations gave worse results than simple dislocations, with pseudarthrosis in 5 cases. Arthrosis was found in more than half the cases, more frequently in transscapho-perilunate dislocations and in cases associated with a fracture of the radial styloid. Radiographic signs of instability were observed in 8 wrists. The unstable wrists had a high incidence of arthrosis and showed decidedly worse clinical results compared to stable wrists (good, 1; fair, 4; poor, 3, as compared to good, 6 and fair 4). In all the unstable wrists we therefore believe that the results may be improved if the radiographic signs of instability are specifically looked for immediately after reduction so that abnormal anatomical relationships in the carpus can be corrected early.
Twelve patients who had undergone osteosynthesis with a metal plate combined with a frozen homoplastic bone graft for the treatment of fractures or pseudarthrosis were subjected to bone scintigraphy with 99 Tc MDP. This investigation showed the graft to be a site of early and specific accumulation of the tracer. This finding supports early colonization of the graft by vascular structures and osteoblastic cells. In view of the small number of cases studied and our incomplete knowledge of the metabolic processes involved these considerations must remain hypotheses but given the excellent clinical results obtained, the relationships between homoplastic bone and host bone merit further investigation.
Sclerotic bone ends and failure of union have quite often resulted from scaphoid fractures due to relatively insufficient blood supply to the proximal fragment. Clearly manifest scaphoid pseudarthrosis can be repaired only by surgery. Transplantation of cancellous or corticocancellous bone in combination with freshening of the sclerotic bone ends are priorities on which emphasis is laid in such surgical intervention. 38 patients with scaphoid pseudoarthrosis received surgical treatment in the casualty ward of Linz, between 1976 and 1982. The shortest follow-up interval for 30 patients was twelve months. 4 surgical methods were used, the technique of Streli in 16 cases, that of Matti-Russe in 9 instances, the Matti technique in 3 cases, and the Russe-II approach in 2 cases. Bony union was achieved in 90 per cent of the above patients. The technique of Streli was used in most cases for postoperative immobilisation, that is forearm cast for six weeks, which differed from other methods in which axilla to palm cast is applied up to twelve weeks. This paper has been prepared, with the view to describing results obtainable from various surgical approaches to scaphoid pseudoarthrosis.
Nonunion is a potential complication of anterior cervical discectomy and fusion (ACDF). There are reports that cite the prevalence of nonunion for two-level ACDF with various fusion techniques, but they do not recommend treatment alternatives. Pseudarthrosis after a two-level ACDF occurred in a 69-year-old man. Posterior cervical wiring and autograft resulted in a successful fusion anteriorly and posteriorly. Posterior fusion augments stability, enhances the potential for eventual anterior fusion, avoids the risks of an additional anterior procedure, and is an excellent therapeutic alternative to a second anterior attempt at stabilization.
Sixteen patients who had Grade-IV or V spondylolisthesis underwent a staged reconstruction for the salvage of a failed result of previous procedures. The indications for operation were incapacitating pain, radicular pain, pseudoclaudication, or the inability to stand upright. All patients had shown progression of the deformity after the previous surgery. At an average length of follow-up of fifty-two months, all patients had resumed normal activities and were free of the pain and symptoms of spinal stenosis. The complications included delayed union in six patients and a traumatic pseudarthrosis in one patient. In all of these patients a solid fusion was obtained after additional surgery. In five patients, neuropathy of the fifth lumbar-nerve root developed after surgery; it resolved in three patients. From this work, it is concluded that staged reconstructive surgery is feasible in patients who have Grade-IV or V spondylolisthesis with incapacitating pain and deformity that interfere with normal function. The benefits outweighed the risks in this very select group of patients.
We reviewed the cases of fifty patients who underwent anterior lumbar-spine fusion with autogenous fibular and iliac-bone grafts and were followed for two to fifteen years. Their diagnoses were instability of the spine, degenerative disc disease, pseudarthrosis, and spondylolisthesis. Fifty-six per cent had union and 44 per cent, non-union. Those who had iliac grafts healed in an average of 2.5 years and those who had fibular grafts, in 5.2 years. The clinical result was successful in twenty-six patients (52 per cent) and unsuccessful in twenty-four patients (48 per cent). Paradoxically, about one-half of the patients with clinical successes had a non-union and one-half of the failures had union. Retrograde ejaculation (sterility) did not develop in any of the men, and a survey of world authorities on anterior spine fusion revealed only sixteen patients with the sequela of retrograde ejaculation. The incidence of that complication has been exaggerated.
A group of 63 patients with non-union of the scaphoid diagnosed by chance during 1971 until 1977 was compared with a second group of 112 patients from the period of 1953 to 1970. They were similar in age, the occasion which gave rise to detection and diagnosis, and localisation of the pseudarthrosis. Marked differences were found in the interval between the time of accident and diagnosis and the extent of arthrotic changes.
Microsurgical transfers are discussed for pterygium syndrome, congenital pseudarthrosis, aplasia cutis congenita, and transverse absence of the digits. Also reviewed are general considerations for the performance of microsurgical procedures in infants.
The indications and techniques for internal fixation of the lumbar spine in degenerative conditions have changed drastically since internal fixation was first applied to the spine almost 100 years ago. Anterior instrumentation and fusion may be used for repair of pseudarthrosis after posterolateral fusion; symptomatic lumbar scoliosis associated with degenerative disc disease; late pain secondary to posttraumatic kyphosis; postlaminectomy instability; and lumbar pain secondary to thoracolumbar kyphosis. Posterior instrumentation and fusion has been performed with Luque instrumentation over 3-4 levels in cases of multilevel instability. Combined anterior and posterior instrumentation and fusion are required for lumbosacral fusion in lumbar scoliosis with degenerative disease, and surgical correction of postsurgical lumbar kyphosis (flat-back syndrome). The techniques are demanding but with attention to detail can be performed with acceptably low-complication rates.
Twenty-four patients with lumbar pseudarthroses following attempted fusion were investigated by preoperative discography. The pseudarthroses were confirmed at surgical exploration. In 19 patients, discography at the level of a pseudarthrosis reproduced typical back pain, and in two patients the level above the fusion reproduced typical pain. Discography is not indicated when the major symptoms are leg or buttock pain. Technical errors included injection into the annulus fibrosis and impingement of the needle into the vertebral endplate. The latter may produce a false-positive result. Previous posterior fusions and very narrow disc spaces prevented insertion of the needle in some patients. Not all lumbar pseudarthroses were symptomatic, and two frequently occurred in the same patient. Discography is a useful adjunct to the traditional investigation of lumbar pseudarthroses.
A 20 year old man was treated with cefoperazone for 25 days because of a local infection after an open fracture complicated by pseudarthrosis. Severe liver damage was noted on 25th day of cefoperazone treatment. There was extreme elevation of transaminases and alkaline phosphatasis as well as jaundice and prolonged prothrombin time. Upper GI bleeding, fever and acute renal failure developed. All symptoms disappeared after cessation of cefoperazone. A causal relationship between the drug and liver damage seems likely because of a positive lymphocyte stimulation test, the time relation between cefoperazone therapy and change in liver function as well as the development of eosinophilia. Other causes of liver damage could be excluded. The pathogenesis of liver damage, upper GI bleeding and acute renal failure is discussed.
The monofixateur opens up avenues in external skeleton fixation. Proceeding from Lambotte's groundwork and from the given anatomical conditions and biomechanical requirements, a system has been developed that ensures maximum effectiveness with a minimum of mechanical means and operative procedure. Of particular importance is the dual-application feature of the monofixateur system: it is equally indicated for static as well as dynamic fixation, and is quickly and easily adapted from one function to the other at any time as called for by the treatment process. This system provides for dynamic function when applied without fixation clamping jaws on one of the major bone fragments. It allows for functional axial compression to be exerted through muscle contraction and pressure, while simultaneously excluding the possibility of bending and rotation, thus effectively promoting the healing process. The monofixateur is indicated for treatment of closed, open and infected fractures, pseudarthrosis, osteotomy adaption, arthrodesis and joint transfixations. In brief, the advantages of external fixation by the monofixateur may be summarized as follows: Simple mechanical design affording precise function. High stability with small number of fixation components. Unilateral assembly of device in position biomechanically favorable. Static or dynamic fixation. Little patient impairment.