Congenital pseudarthrosis of the tibia: the outcome of a pathology-oriented classification system and treatment protocol.

Congenital pseudarthrosis of the tibia is defined as a non-union of a tibial fracture that develops in a dysplastic bone segment of the tibial diaphysis. Pathologically, a fibrous hamartoma surrounds the bone at the congenital pseudarthrosis of the tibia site. The cases of 25 children, who have congenital pseudarthrosis of the tibia, were included in this study. Their ages ranged from 15 months to 15 years at the time of treatment. Neurofibromatosis-1 was present in 24 children. They were managed according to our classification system and treatment protocol. The treatment for mobile pseudarthrosis (types 1 and 2) included complete excision of the pathological periosteum, insertion of autogenous iliac crest bone graft, and combined fixation using intramedullary rod and Ilizarov external fixator. For type 3 pseudarthrosis (stiff pseudarthrosis), a pre-constructed Ilizarov fixator was applied for simultaneous distraction of the pseudarthrosis and deformity correction without open surgery. Evaluation of results was mainly radiological and included achievement of union, leg length equalization, deformity correction and prevention of refracture. Consolidation of the pseudarthrosis and osteotomies was achieved in all cases (100%). Refracture occurred in one case (4%) at the site of previous pseudarthrosis. Residual limb length discrepancy more than 2.5 cm occurred in two cases (8%). Valgus deformity of the ankle was present in 12 cases (48%) and was treated by supramalleolar osteotomy. Follow-up ranged from 24 to 48 months (average 36.9 months) after fixator removal. The results of our treatment protocol, based on our classification system, have been consistently good and predictable in all cases of congenital pseudarthrosis of the tibia. Mobility of the pseudarthrosis is an important factor in choosing the type of interference.

[The sterno-vertebral instability - a new classification and therapeutic options]. / Die sternovertebrale Instabilität - Klassifikation und Behandlungsalgorithmus.

INTRODUCTION: Sternal fractures in the context of high velocity trauma are commonly referred to as impact injuries. In general, these are considered to be treated conservatively. In the literature, there are only a few studies and a small number of cases. We know that not only high velocity accidents cause combined trauma of sternum and spine, but also low velocity traumas in the elderly are relatively common. How should such combinations of injuries be treated? MATERIAL AND METHOD: Based on 11 patients from the years 2005 to 2013 with different combinations of sternal and spinal injuries, we distinguish the therapeutic approach of ventral, dorsal or combined stabilisation, with the help of a four-column classification of these injuries. RESULTS: We classify sternovertebral injury into 4 types. First the descendant type with an injury from C I to C VII and sternum, second the horizontal type (T I to T XII and sternum), third the ascendant type (L I to L V and sternum) and fourth a dissociative type. The recommended therapy of the descendant type is dorsoventral stabilisation of the spinal column plus stabilisation of the sternum. The horizontal type should be treated with dorsal stabilisation of the spine and stabilisation of the sternum. The ascendant type should be supplied with dorsoventral stabilisation of the spinal column and conservative therapy of the sternum. In case of the dissociative type one should supply each injury independently. CONCLUSION: The literature on sternal injuries and their treatment is low. Combinations of sternum and spine injuries have not yet been processed systematically in literature. Thus, there is no concerted standard of therapeutic options. The very rare occurrence of this injury combination often leads to this injury type being forgotten in the primary evaluation of casualties.

[Pseudarthrosis of the long bones]. / Pseudarthroses aseptiques des os longs.

5 to 10% of all fractures present with a delayed union, whereas 1 to 5% progress to a nonunion, which can be defined as a fracture older than 6 months and lacks any potential to heal without any further intervention. Different fracture and patient related risk factors exist, and the management of a nonunion needs a thorough clinical, radiological and biological workup to classify them in one of the two main categories, the viable nonunions that need essentially more stability, usually by a more rigid fixation, and the non-viable nonunions that need essentially a biological stimulation by decortication and bone grafting. This treatment still remains the first choice with bony healing obtained in 85 to 95% of cases, but it also comes along with certain risks, and some valuable alternatives exist if chosen on the basis of rigid criteria.

Isolated congenital pseudoarthrosis of the fibula: a comparison of fibular osteosynthesis with distal tibiofibular synostosis.

BACKGROUND: Isolated congenital pseudoarthrosis of the fibula is associated with progressive ankle valgus and rare subsequent tibial involvement. Two operative techniques were compared: (1) osteosynthesis with intercalary grafting and (2) distal tibiofibular synostosis. Hemiepiphysiodesis or osteotomy supplemented the primary procedure when necessary. METHODS: A retrospective review of isolated congenital pseudoarthrosis of the fibula-Dooley types 2 (without ankle valgus) and 3 (with ankle valgus); cases with tibial involvement (Dooley types 1 and 4) were excluded. Nine patients were identified (mean age, 7.6 years, follow-up, 6.6 years). One is under observation without bracing (type 2). Five patients (one type 2 and four type 3) were treated with osteosynthesis. Three were treated with distal tibiofibular synostosis (one type 2 and two type 3). One patient in each group also underwent concomitant medial distal tibia hemiepiphysiodesis; 1 patient in the synostosis group underwent distal tibia varus osteotomy with the primary procedure. RESULTS: In the osteosynthesis group (5 patients), mean lateral distal tibial angle (LDTA) improved from 75.6 to 86.6 degrees. Union was achieved in 4; 1 had early graft resorption requiring revision. Four of the 5 had neutral ankle alignment at the final follow-up. Among the 3 patients with primary union and no deformity correction, mean LDTA improved from 81 to 88 degrees over 9.8 years of follow-up. One patient had mild residual valgus (LDTA, 79 degrees) after temporary screw hemiepiphysiodesis. Complications were as follows: nonunion (n = 1), compartment syndrome with mild residual plantar flexion weakness (n = 1), and fibular stress fracture, which healed with immobilization (n = 1).In the synostosis group (3 patients), the mean LDTA improved from 64.3 to 80.0 degrees. One achieved union with distal tibia medial hemiepiphysiodesis (final LDTA, 86 degrees). Two had failure: one synostosis nonunion underwent repeat varus osteotomy (final LDTA, 81 degrees), and the other (Dooley type 2) had crossunion; however, persistent fibular pseudoarthrosis proximal and distal to the synostosis, progressive valgus developed (final LDTA, 73 degrees). CONCLUSIONS: Osteosynthesis with intercalary grafting achieved primary union in 4 of 5 patients; mild residual ankle valgus was present in 1 patient at final follow-up. Synostosis failure with residual ankle valgus at maturity occurred in 2 of 3 patients. Progression to tibial pseudoarthrosis was not observed in either group. In this series, osteosynthesis eliminated fibular discontinuity, allowing correction of ankle valgus. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

[Treatment of non-unions of the carpal scaphoid using a nonvascularised corticocancellous bone graft: a retrospective series of 47 cases]. / Traitement des pseudarthroses du scaphoïde carpien par greffe corticospongieuse non vascularisée: étude rétrospective de 47 cas.

OBJECTIVES: The authors report their results on the treatment of scaphoid non-unions without osteoarthritis or necrosis, by anterior nonvascularized bone graft. PATIENTS AND METHODS: Forty-seven patients treated between 1988 and 2003 were analysed with a mean follow-up of 74 months. There were 19 non-unions without carpal instability (IIA) and 28 with carpal instability (IIB). All patients were treated by an anterior approach with corticocancellous bone graft and osteosynthesis using two pins. Clinical results were analysed on pain, strength and mobility. Radiographic analysis was of union, correction of instability and occurrence of osteoarthritis. RESULTS: These were divided into stages IIA and IIB: 1) stage IIA: all cases proceeded to bony union; ten results were excellent and nine good and no instability; there was one case of osteoarthritis; 2) stage IIB: 78% of patients proceeded to bony union; one result was excellent, 17 good, four moderate and six cases remained un-united. There were 12 cases of osteoarthritis. Most of them occurred in patients with residual instability after the initial surgical procedure. CONCLUSION: Corticocancellous nonvascularized bone graft by a palmar approach is an excellent technique for treatment of scaphoid non-unions without osteoarthritis and necrosis. The presence of instability is a poor prognostic factor; its correction during the operation allows the surgeon to decrease the risk of osteoarthritis.

Evaluación, con una nueva escala de severidad, de la eficacia del tratamiento de las pseudoartrosis mediante campos electromagnéticos pulsátiles / Evaluation of the efficacy of treating pseudoarthrosis by pulsed electromagnetic fields with a new scale of fracture severity

Ciento cuarenta y seis fracturas con signos clínicos y radiológicos de falta de consolidación, tratadas mediante campos electromagnéticos pulsátiles han sido revisadas retrospectivamente. El objetivo de este estudio es conocer la influencia de la severidad de la fractura inicial y las características de la pseudoartrosis en la eficacia de este tratamiento. Para ello los autores han desarrollado una nueva escala cuantitativa que puntua diferentes variables clínicas y radiológicas previas al tratamiento. El resultado del tratamiento, la consolidación de la pseudoartrosis fue considerado al final del mismo. El éxito global del tratamiento con campos electromagnéticos pulsátiles fue del 71,2 %. El tiempo de evolución medio hasta el comienzo del tratamiento fue de 38,1 semanas. La severidad de la fractura inicial media según la escala fue de 11,64 puntos (5- 15 puntos). Las características de la pseudoartrosis puntuaron de media 11,1 puntos (6-18 puntos). Algunas características de la pseudoartrosis tienen influencia significativa en el resultado del tratamiento, mientras que la severidad incial de las fracturas no ha influido en los resultados. De acuerdo con nuestra escala los pacientes con pseudoartrosis que presentan puntuaciones inferiores a 10 puntos presentan un alto índice de curación con el tratamiento estudiado. Esto significa que en pacientes con pseudoartrosis estables e hipertróficas se debe considerar el tratamiento mediante campos electromagnéticos pulsátiles

One hundred forty-six fractures with clinical and radiologic signs of nonunion, treated by pulsed electromagnetic fields were studied retrospectively. The objective of the study is to know the influence of initial fracture severity and nonunion features in the efficacy of this treatment. The evaluation was based on our quantitative scale to evaluate and to quantify the severity of the initial fracture and the features of delayed union and nonunions before the treatment. The results were studied at the end of treatment considering the clinical and radiologic patterns of fracture healing. The average time from the initial fracture to the beginning of treatment was 38.1 weeks. The mean severity score was 11.64 points (range, 5 - 15 points) and the average of nonunion features was 11.1 points (range, 6 - 18 points). We found that some nonunion characteristics have a significant influence on the result of treatment, while the initial fracture severity does not. According to our scale, patients with nonunion who had scores of 10 points or less were prone to achieve healing. The overall success of treatment was 71.2%. In patients with stable and hypertrophic nonunions, pulsed electomagnetic fields must be one of the first treatment methods to consider

[Clinical trial with the distal femoral nail]. / Klinische Erprobung des distalen Femurnagels.

METHODS: The clinical results after DFN-osteosynthesis of n = 56 AO-classification 33A-fractures (32%), 33C-fractures (43%), 32X-fractures (21%) and treatment of non-union (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. 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.

Valoración ecográfica de la seudoartrosis postraumática del escafoides carpiano / Ultrasound assessment of posttraumatic pseudoarthrosis of the carpal scaphoid

Objetivos: Evaluar la utilidad de la ecografía en el diagnóstico de la seudoartrosis postraumática del escafoides carpiano. Describir los hallazgos ecográficos observados en estos pacientes. Material y métodos: Se han estudiado 11 pacientes diagnosticados de seudoartrosis de escafoides carpiano. El estudio se realizó con sonda de 7,5 MHz. Los signos valorados fueron la irregularidad de la superficie cortical, existencia de solución de continuidad o 'brecha', aumento de partes blandas periescafoidea y su vascularización mediante método Doppler color. Este estudio se hizo de manera comparativa respecto a la mano contralateral. Resultados: En todos los pacientes se observó irregularidad cortical y en seis de ellos 'brecha' en la cortical ósea de la superficie palmar del escafoides. En 10 pacientes se detectó aumento de partes blandas con aumento de la vascularización. Un paciente con fractura no consolidada no presentó brecha ni aumento de partes blandas demostrando la cirugía integridad de la cortical ósea (fractura en 'cacahuete').Conclusiones: La ecografía es un método útil en el diagnóstico de la seudoartrosis de escafoides carpiano. La existencia de un aumento de partes blandas periescafoidea, con vascularización incrementada, en pacientes con antecedente de fractura de escafoides superior a seis a ocho semanas sugiere fallo en la consolidación ósea (AU)

[Treatment of pseudarthrosis of the carpal scaphoid bone by percutaneous pinning. Apropos of 74 cases]. / Traitement des pseudarthroses du scaphoïde carpien par enclouage percutané. A propos de 74 cas.

From 1985 to 1997, 74 patients was operated of scaphoid non union at the Kassab Institute by a percutaneous pinning as described by Galluccio. The average age is 30 years with an extreme from 17 to 48 years. Union was obtained after an average of two years and six months. In 12 cases the delay was superior than three years. Functionally, pain is a constant cause of consultations and the majority of patients presented a reduction of the mobility sector (80%) and the strength of grasp (70%). Anatomically, it is particularly a pseudarthrosis stage II a of Alnot, and type I b of our classification. An immobilisation post-operative during one month is the rule. The analysis of results at an average of four years, revealed 91% of clinical recovery. Radiographically, the union is obtained in 89% of cases. Our fails (11%), are explained by an inadequate mounting and particularly by the length of pseudarthrosis. Compared to other means of synthesis, the percutaneous pinning of Galluccio, is an inexpensive technique, easily and rapid, which permit to obtain an interesting results particularly in the recent pseudarthrosis (evolution delay below three years).

The treatment of pseudoarthrosis of the scaphoid by bone grafting and three methods of internal fixation.

OBJECTIVES: To measure the rate of union in patients with pseudoarthosis of the scaphoid, treated with trapezoidal bone grafting as outlined by Fernandez and 1 of 3 methods of internal fixation and to compare unions versus nonunions and potential predictors of union to determine if associations exist. DESIGN: A retrospective radiologic study of scaphoid pseudoarthroses. SETTING: Division of Orthopedic Surgery, Ottawa Hospital, General Site, a tertiary care facility. PATIENTS: Thirty-four patients with nonunion of scaphoid fractures, treated between 1990 and 1997, with an average follow-up of 19.8 months. INTERVENTIONS: Trapezoidal bone grafting and internal fixation with Kirschner (K) wires, an AO cannulated screw or a Herbert screw. OUTCOME MEASURES: The time to union of scaphoid pseudoarthroses and predictors of union, including the classification, location of pseudoarthrosis, type of internal fixation and length of bone graft. RESULTS: The results showed a correlation between the classification and location of the fracture as determined radiologically, and the outcome. There was no correlation between the type of internal fixation used and the outcome, or between the length of the bone graft and the outcome. Twenty-three patients had radiologically demonstrated union after a mean time of 8.2 months; 16 of 24 patients achieved successful union when treated with K-wire implants, after a mean time of 7.2 months. CONCLUSIONS: Trapezoidal bone grafting and internal fixation with K wires is a practical technique, classification and location of the fracture notwithstanding. Time to union is long, and the results may be unpredictable. Use of K wires for internal fixation presents the clinician with an alternative to fixation with either the AO cannulated screw or the Herbert screw, and has the advantages of cost, ease of insertion and accessibility. This method may therefore be the treatment of choice in developing countries. Resection of the area of pseudoarthrosis must include all fibrous tissue and sclerotic bone. The length of graft, within the parameters of this study, did not affect the outcome.

Congenital pseudarthrosis of the tibia: history, etiology, classification, and epidemiologic data.

Congenital pseudarthrosis of the tibia is a rare disease with a variable history. The pseudarthrosis is usually not present at birth (and therefore is not truly congenital) but occurs during the first decade of life. Paget in 1891 was the first to describe a case. The etiology is unknown. Neurofibromatosis plays a role in approximately 50% of patients. In the others, hereditary and mechanical factors are debated. Various (morphologic) classification systems have been proposed (Andersen, Boyd, Crawford). Because the appearance changes during the course of the disease, all classification systems have limited value: the determining factor is the stage of the disease at which it was classified. Because of the rarity of the disease and the variability of its history, the European Pediatric Orthopaedic Society decided to carry out a multicenter study on this disease. This paper presents the epidemiologic data on the patients involved. Data have been gathered on 340 patients from 13 countries. Two hundred patients were male (58.8%), 140 were female (41.2%). The right side was affected in 165 patients (48.5%) and the left side in 172 (50.6%); 3 patients had bilateral disease. Symptoms of neurofibromatosis were present in 54.7%. Histologic examinations in 192 patients showed a nonspecific appearance in 45.3%; in 15.6% the ultrastructure resembled fibrous dysplasia, and in 39% there was histologic evidence of neurofibromatosis. Most of the lesions were initially localized in the middle or distal third of the tibia. In 29% the localization changed during the course of the disease.

[Operative versus non operative treatment of odontoid non unions. How dangerous is it not to stabilize a non union of the dens?]. / Operative oder konservative Behandlung der Pseudarthrose des Dens axis. Wie gefährlich ist es, eine Denspseudarthrose nicht zu stabilisieren?

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.

Congenital pseudarthrosis of the tibia: a retrospective review.

Treatment of congenital pseudarthrosis of the tibia has been notoriously very difficult. This retrospective review of 36 cases (33 patients) seen at the Shriners Hospital (Springfield, Massachusetts Unit), from 1927 to the present evaluates the different forms of treatment and their long-term results. Adequate information was obtained from 30 patients (33 cases) to include them in this study. Twenty-nine patients (32 cases) underwent 154 surgical procedures, of which 138 were to achieve union of the pseudarthrosis (4.3 per case), and one parent could not recall how many surgeries were performed on her son. Sixteen surgeries were performed to correct leg-length discrepancy. Four cases healed with bracing alone. Of the 30 patients (33 cases), 14 patients (15 cases) required amputation. These patients had undergone multiple attempts at union (average, 4.7 procedures). Patients who went on to union averaged 2.8 surgical procedures. Even with newer techniques available to the trained pediatric orthopaedist, treatment of congenital pseudarthrosis of the tibia remains an elusive problem.

[Post-traumatic carpal collapse (SLAC- and SNAC-wrist)--stage classification and therapeutic possibilities]. / Der posttraumatische karpale Kollaps (SLAC- und SNAC-wrist)--Stadieneinteilung und therapeutische Möglichkeiten.

Longstanding scaphoid nonunion or scapholunate ligament injuries can lead to carpal collapse. SLAC-wrist (scapholunate advanced collapse) following scapholunate dissociation and SNAC-wrist (scaphoid nonunion advanced collapse) after missed fusion of scaphoid fracture should be differentiated. Severity of degenerative changes is classified by three stages. In stage I where arthrosis is limited to the radial styloid reconstructive procedures of the scaphoid or scapholunate ligament are the treatment of choice. In stage II including arthrosis of the radioscaphoid joint and stage III with additional arthrosis in the midcarpal joint these procedures are excluded. Salvage procedures preserving wrist mobility like midcarpal fusion or proximal row carpectomy are preferable to total wrist fusion which represents the last line of defence.

Classificaçäo radiográfica das pseudoartroses do escafóide carpiano / Radiographic classification of carpal scaphoid pseudoarthrosis

Os autores propöem uma classificaçäo radiográfica das pseudartroses do escafóide carpiano. Sugerem uma sistematizaçäo do tratamento baseado nesta classificaçäo.

Resultados en el tratamiento de la seudoartrosis / Results in the treatment of pseudoarthrosis

Se presenta un estudio retrospectivo de 53 pacientes atendidosa por seudoartrosis diafisarias en un período de 5 años, en el que se dan a conocer los diversos trazos de la lesión primaria, su topografía, la clasificación, el número de operaciones previas y la que logró su solución; finalmente se presentan algunos casos representativos. Se dan conclusiones, donde se destacan, entre ellas, la evolución favorable que ha tenido su tratamiento, de acuerdo con las nuevas técnicas introducidas en la especialidad