Metabolic and Endocrine Disorders in Pseudarthrosis.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: Establish 1-year patient-reported outcomes after spine surgery for symptomatic pseudarthrosis compared with other indications. In the subgroup of pseudarthrosis patients, describe preexisting metabolic and endocrine-related disorders, and identify any new diagnoses or treatments initiated by an endocrine specialist. SUMMARY OF BACKGROUND: Despite surgical advances in recent decades, pseudarthrosis remains among the most common complications and indications for revision after fusion spine surgery. A better understanding of the outcomes after revision surgery for pseudarthrosis and risk factors for pseudarthrosis are needed. METHODS: Using data from our institutional spine registry, we retrospectively reviewed patients undergoing elective spine surgery between October 2010 and November 2016. Patients were stratified by surgical indication (pseudarthrosis vs. not pseudarthrosis), and 1-year outcomes for satisfaction, disability, quality of life, and pain were compared. In a descriptive subgroup analysis of pseudarthrosis patients, we identified preexisting endocrine-related disorders, frequency of endocrinology referral, and any new diagnoses and treatments initiated through the referral. RESULTS: Of 2721 patients included, 169 patients underwent surgery for pseudarthrosis. No significant difference was found in 1-year satisfaction between pseudarthrosis and nonpseudarthrosis groups (77.5% vs. 83.6%, respectively). A preexisting endocrine-related disorder was identified in 82% of pseudarthrosis patients. Endocrinology referral resulted in a new diagnosis or treatment modification in 58 of 59 patients referred. The most common diagnoses identified included osteoporosis, vitamin D deficiency, diabetes, hyperlipidemia, sex-hormone deficiency, and hypothyroidism. The most common treatments initiated through endocrinology were anabolic agents (teriparatide and abaloparatide), calcium, and vitamin D supplementation. CONCLUSIONS: Patients undergoing revision spine surgery for pseudarthrosis had similar 1-year satisfaction rates to other surgical indications. In conjunction with a bone metabolic specialist, our descriptive analysis of endocrine-related disorders among patients with a pseudarthrosis can guide protocols for workup, indications for endocrine referral, and guide prospective studies in this field.

Distal tibial fracture repair in a neurofibromatosis type 1-deficient mouse treated with recombinant bone morphogenetic protein and a bisphosphonate.

Congenital pseudarthrosis of the tibia is an uncommon manifestation of neurofibromatosis type 1 (NF1), but one that remains difficult to treat due to anabolic deficiency and catabolic excess. Bone grafting and more recently recombinant human bone morphogenetic proteins (rhBMPs) have been identified as pro-anabolic stimuli with the potential to improve the outcome after surgery. As an additional pharmaceutical intervention, we describe the combined use of rhBMP-2 and the bisphosphonate zoledronic acid in a mouse model of NF1-deficient fracture repair. Fractures were generated in the distal tibiae of neurofibromatosis type 1-deficient (Nf1(+/-)) mice and control mice. Fractures were open and featured periosteal stripping. All mice received 10 µg rhBMP-2 delivered in a carboxymethylcellulose carrier around the fracture as an anabolic stimulus. Bisphosphonate-treated mice also received five doses of 0.02 mg/kg zoledronic acid given by intraperitoneal injection. When only rhBMP but no zoledronic acid was used to promote repair, 75% of fractures in Nf1(+/-) mice remained ununited at three weeks compared with 7% of controls (p < 0.001). Systemic post-operative administration of zoledronic acid halved the rate of ununited fractures to 37.5% (p < 0.07). These data support the concept that preventing bone loss in combination with anabolic stimulation may improve the outcome following surgical treatment for children with congenital pseudarthosis of the tibia and NF1.

Tratamiento de la pseudoartrosis séptica y recalcitrante de la diáfisis humeral mediante impactación intramedular / Treatment of the septic and recalcitrant humeral shaft nounion by means intramedullary impactation

Se presenta un caso de una fractura de la diáfisis humeral complicada con una pseudoartrosis recalcitrante, infección y parálisis radial. Se propone una alternativa de tratamiento que, por su sencillez y aplicabilidad, puede incluirse en el arsenal terapéutico para solucionar esta grave patología (AU)

We present a case of humeral shaft fracture complicated with recalcitrant nonunion, infection and radial nerve paralisys. A treatment alternative sets out that, by its simplicity and applicability, deserves to have it in account within the therapeutic arsenal which we arrange to the solution of this serious pathology (AU)

The use of implantable direct current stimulation in multilevel spinal fusion without instrumentation. A prospective clinical and radiographic evaluation with long-term follow-up.

STUDY DESIGN: A prospective study with long-term follow-up of 143 patients who underwent spinal fusion with direct current stimulation and no instrumentation. OBJECTIVES: To assess the effects of direct current stimulation on fusion success, clinical outcome, and return to work in multilevel lumbar spinal fusion procedures. SUMMARY OF BACKGROUND DATA: Efforts to ensure higher fusion success rates in multilevel procedures have resulted in the use of surgical adjuncts, such as spinal instrumentation systems and electrical stimulation. METHODS: Patients were assessed 3, 6, 12, 18, and 24 or more months after surgery (long-term follow-up). Fusion was determined by anteroposterior and lateral radiographs and lateral bending films and was considered successful if there was evidence of bony fusion and the absence of motion between the operated vertebrae. Surgical technique included either a posterior facet or posterolateral fusion. RESULTS: There were no significant differences (P > 0.05) in fusion success between 12-month results and the long-term results. The median length of the long-term follow-up period was 5.0 years (range, 2-9 years) Nineteen patients were lost to follow-up; five were unwilling to return for assessment, and one patient died. Fusion success among the remaining 118 patients was 91.5%. Two-level procedures (90) had a fusion rate of 93%. Three-level procedures (22) had a fusion rate of 91%. Eighty-five patients (72%) had no pain; 27 patients (23%) had mild pain occasionally, and six patients (5%) had some degree of moderate pain. One hundred patients (85%) returned to work; 12 (10%) retired; five (4%) were not working before the surgery, and one patient (1%) was unable to return to work. There were no worker's compensation patients, and there were no major surgical complications in this series. CONCLUSIONS: Multilevel fusion in this series with long-term follow-up evaluation of direct current stimulated patients without instrumentation showed clinical and radiographic success higher than in recent studies without instrumentation and comparable with recent studies using instrumentation.

Treatment of pseudarthroses with electrodynamic potentials of low frequency range.

In 319 patients suffering from septic and noninfected pseudarthroses, bone consolidation has been achieved in 93.6% by a cancellous bone graft plus a semi-invasive method of electrostimulation of nonunion using low frequency A.C. potentials, i.e., the electrodynamic procedure. By inductively coupled electromagnetic fields, the potentials are produced in inductable implants. There are no contraindications for the procedure and no side effects.

Asymmetrical slow-pulsating direct current.

Treatment with asymmetrical pulsating direct current in combination with external fixation on pseudarthroses offers encouraging results. Using a fully automatic stimulator continuously for six months appears to eliminate previous electrode problems. Since pseudarthrosis is not a well-defined condition and as the above treatment is multilateral, no conclusion can be stated as to the effect of electrostimulation. However, the noninvasive stimulator is reliable and the results appear promising.

A multicenter study of the treatment of non-union with constant direct current.

A clinical study was initiated at the University of Pennsylvania in 1970 to evaluate the use of constant direct current in treating acquired non-union. In 1977 the study was expanded to include twelve participating investigators throughout the United States. The results indicate that, given proper electrical parameters and proper cast immobilization, a rate of bone union comparable to that seen with bone-graft surgery was achieved. Experience dictated that four cathodes, each delivering twenty microamperes of constant direct current for twelve weeks, were required to heal a non-union of a long bone. Of 178 non-union in 175 patients treated with adequate electricity in the University of Pennsylvania series, 149 (83.7 per cent) achieved solid bone union. Patients with a history of osteomyelitis had a healing rate of 74.4 per cent. The presence of previously inserted metallic fixation devices did not affect the end-result healing rate. Of eighty non-unions in seventy-nine patients treated with electricity in the participating investigators' series, fifty-eight (72.5 per cent) achieved solid bone union. Review of the non-unions treated unsuccessfully with constant direct current suggested that inadequate electricity, the presence of synovial pseudarthrosis or infection, and dislodgment of the electrodes are causes for failure with the procedure. Complications of the electrical treatment were minor and there was no deep infection resulting from this procedure in patients without previous osteomyelitis. We concluded that the practicing orthopaedic surgeon utilizing constant direct current to treat non-union should, by adhering to proper fracture management and by following the biophysical principles described herein, be able to achieve a rate of union comparable to that of bone-graft surgery, with a lower associated risk.

[Electromagnetic stimulation of infected experimental pseudarthrosis in a left-right study of beagles]. / Elektromagnetische Stimulation infizierter Defektpseudarthrosen im Rechts-Links-Versuch am Beagle.

Electromagnetic AC-stimulation according to the method of KRAUS was applied in 9 infected ununited ulnar fractures in the beagle. New cortical bone formation, bridging of the bone defect and the number of blood vessels in bone and soft tissue was assessed. Electromagnetic stimulation had no significant influence on bone healing or on the number of vessels.