Atrophic Pseudarthrosis Research Articles

Atrophic pseudarthrosis of humeral diaphyseal fractures: medico-legal implications and methodological analysis of the evaluation.

Humeral shaft fractures account for 1- 3% of all fractures and about 20-27% of those involving the humerus. In the past they were often conservatively treated, with an acceptable consolidation rate. Open reduction and internal fixation (ORIF) is the best choice in polytrauma patients, in complex or pathological fractures and in those associated with vascular injuries. Regardless the type of fixation used, these fractures can evolve into delayed union or pseudarthrosis (PSA). It should be noted that the humeral shaft itself has a high intrinsic healing potential, due to the blood supply provided by the surrounding muscles. The aim of this work is to evaluate whether the causes that led to the development of atrophic pseudarthrosis in a humeral diaphyseal fracture are attributable to inadequate management of this fearful complication and to highlight the possible medico-legal repercussions. We will try to verify whether the currently used forensic evaluation parameters of permanent disability are appropriate and adequate in relation to the complexity of such injuries. This complexity also includes the repercussions on the ergonomic efficiency of the entire limb, the relative possible postural alterations, the inevitable extension of the period of traumatic illness and the relative repercussions on the overall compromised structure of the subject. (www.actabiomedica.it)

Surgical treatment of congenital pseudoarthrosis of the clavicle: Our 22-year, single-center experience.

Objectives This study reports the surgical outcomes in a patient cohort with congenital pseudarthrosis of the clavicle (CPC).Patients and methods A total of nine pediatric patients (5 males, 4 females; mean age: 4.43 years; range, 2 to 12 years) who were diagnosed with CPC and treated surgically with a minimum one-year follow-up between January 1996 and December 2018 were retrospectively analyzed. The patients were divided into two groups according to the fixation method as the Kirschner wire (K-wire; Group A, n=2) or stabilization with a plate (Group B, n=7). The physical function and symptoms were evaluated using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scale.Results The mean age at the time of diagnosis was 2.95 (range, 0 to 12) years. Six cases were atrophic pseudarthrosis and three cases were hypertrophic. Radiographic consolidation occurred in all cases with a mean duration of 103.8±39.1 days, indicating no significant difference between the groups (p>0.05). Complications registered were a K-wire breakage in a patient in Group A and an internal fixation plate loosening in a patient in Group B. The mean postoperative follow-up was 2.98±1.82 years. The QuickDASH score was 0 points in all patients.Conclusion The early surgical indication based on refreshment of the pseudarthrosis focus, with bone autograft interposition when a failure exists to restore adequate clavicular length, and fixation are reliable alternatives with favorable clinical and radiological results in the mid- and long-term with fewer complications.

Enfekte psödoartrozda antibiyotikli polimetilmetakrilat çimento kaplı intramedüler çivi ile fiksasyon tekniğinin etkinliği

Objective: Non-union accompanied by infection requires both the treatment of infection and stabilization of the fracture. This study examined the efficacy of a fixation technique using antibiotic impregnated polymethylmethacrylate (PMMA) cement-coated intramedullary nail in patients with infected pseudarthrosis of the femur or tibia. Material and Methods: Fourteen patients with Cierny-Mader stage 4 infected non-union of the femur or tibia were included. Patients were treated with local debridement, antibiotic containing PMMA cement-coated intramedullary nail application and systemic antibiotics. They were followed-up for union and recovery of infection. Results: Femoral and tibial pseudarthrosis were present in 3 and 11 patients, respectively. Eleven patients had hypertrophic and three patients had atrophic infected non-union. The mean duration of follow-up was 24.7 months (range: 8-37 months). During follow-up, infection improved in 85.7% of the cases (12 patients). Union was achieved in 10 (71.4%) patients during follow-up. Ten over 11 patients (90.9%) with hypertrophic pseudarthrosis achieved union. On the other hand, none of the patients with atrophic pseudarthrosis achieved union. Conclusion: Considering the high-dose local antibiotic effect and the advantage of stabilization with intramedullary nail, antibiotic impregnated PMMA cement-coated locked intramedullary nail application may be recommended in the treatment of hypertrophic pseudarthrosis. However, regarding the treatment of atrophic pseudarthrosis, it seems to be effective for the treatment of infection but ineffective for bone union. Larger trials are warranted.

Hypotrophic pseudoarthrosis: methodological problems of the impact interpretation of compensatory effects

Input: The humanitarian trauma use methods of mesenchymal stimulation (curettage, tunnelization) widely and bring positive results. On this basis, the aim of this study was: treatment technology of animal with hypotrophic pseudarthrosis development. To achieve this aim we have identified the following tasks: study histological changes in the hypotrophic pseudarthrosis area, develop the tunneling zone of pseudarthrosis technology, evaluate the effectiveness of tunnelization under hypotrophic pseudarthrosis on the basis of clinic-morphological and radiographic changes (patent RU 2117997, 2240602, 2240603, 22464304, 22464305, 2271139, 2271140, 2303436, 2323694, 2323695). Objectives: The objects of the study were dogs with emerging complications (hypotrophic pseudarthrosis) after osteosynthesis of 57 goals. Methods: clinical, biochemical , hematological, radiographic, histological. Results and discussion: On the basis of histological changes (absence of the periosteum, the abundance of coarse fiber connective tissue, the presence of hondroida, isolated fragments of a full cartilage resorption of trabecular bone) indicates the presence of hypotrophic pseudarthrosis. Using of the term “atrophic pseudarthrosis” is not entirely competent, as nutrition of the periosteum was carried out, but not properly. Accordingly, the term “hypotrophic pseudarthrosis” should be used when referring to this process. Treatment technology of patients with hypotrophic pseudoarthrosis proposes tunnelization of pseudoarthrosis zone that provokes vascularization of pseudoarthrosis area. Changes in hematological and main biochemical indicators of sick animals within the reference quantities shows, firstly, that the basis of hypotrophic pseudarthrosis is trophicity breaking of the bone fragments, secondly, tunnelization method is invasive and less traumatic. That indicates by reduction of C-reactive protein from 2,8±0,7 before operation to 1,9±0,3 30 days later, and to 0,4±0,05 on 120 day. Radiologically, hypotrophic pseudarthrosis characterized by thinning of cortical and erosion of cortical layers of proximal and distal bone fragments, optical density and diameter of the bone regenerate decrease, appearance in the zone of diastase radiographically weakly visible tissues (fibrous).

Methods of Reconstructive Surgical Treatment for Patients with Defects and Pseudarthroses of Femur

Treatment results of 59 patients with femoral bone defects and diaphyseal pseudarthroses were analyzed. To substitute bone defects of more than 6 cm permeable porous endoprostheses were used. In patients with normotrophic and hypertrophic pseudarthrosis stable osteosynthesis with interfragmental compression of bone fragments by shape-memory-effect tightening bows was performed. In patients with atrophic pseudarthrosis bone plasty with autograft was applied. In all patients the weight-bearing ability of the affected limb was restored. Total restoration of function was achieved in 75.6% of patients.

Nuestra experiencia clínica en el uso de BMP-7

ObjectiveTo analyze the clinical efficacy of BMP-7 in the treatment of pseudarthrosis of the long bones in three hospital centers. Patients and methodsWe performed a multicenter study (Hospital Ramón y Cajal, in Madrid, Hospital La Fe, in Valencia, Hospital Universitario La Paz, in Madrid) with 31 patients with atrophic pseudarthrosis of the long bones. ResultsAlthough the sample was highly heterogeneous in terms of the patients’ origins and diseases, favorable results, defined as consolidation of pseudarthrosis, were obtained in a high percentage of patients (77.8%).

The behavior of natural coral in a context of diaphyseal atrophic pseudarthrosis

Natural coral and metal plate stabilization were used to obtain bone consolidation in a context of posttraumatic atrophic pseudarthrosis of a femoral shaft with nonunion. Bone substitute bioresorption was the result of dual, interdependent biological and mechanical processes. The process was exponential (natural logarithm). The coral beads were arranged in adjacent columns along the long axis of the femoral shaft parallel to the femoral shaft cortex. This demonstrates the role of natural stresses, which acted in the same manner as on a fracture-free bone. The resorption of the columns aligned in the same wall occurred in a definite order. The subperiosteal column was resorbed before that adjacent to the medullary canal. This shows the role played by the double vascularization of long bones in biomaterial resorption and callus formation.

Diaphyseal femur pseudarthroses--only a technical problem?

Between 1981 and 1994 at the Bergmannsheil Ruhr University Hospital in Bochum, Germany, we treated 145 patients with femoral diaphyseal nonunions following initial operative treatment. Of these patients, 138 received this initial operative treatment at an outside institution. The primary reconstructions for the fractures utilized plates in 112 cases, reamed nails in 24 cases and external fixators in 9 cases. The average age of the patients was 35 years and the mean time from the initial operative treatment was 2 years. Twenty-seven patients (19%) presented with a hypertrophic nonunion and 118 (81%) with an atrophic nonunion. There was a significant correlation between primary "classic" plating and development of an atrophic nonunion (chi 2-test: P < 0.01). We observed 34 wound infections (23%) with no significant correlation to the type of primary osteosynthesis. We determined that 73 of the pseudarthroses were due to improper osteosynthesis techniques. Of these cases, 41% involved the use of plates, 83% involved the use of reamed nails, and 78% involved the use of external fixators. Fracture location near the diaphyseal-metaphyseal junctions was common in this problematic group. Ninety-two percent of all plates led to atrophic nonunions. There were 21 open fractures and of these 90% (n = 19) developed an atrophic pseudarthrosis and 29% (n = 6) developed a wound infection. Fifty-seven (39%) of all patients had additional injuries, but we found that did not increase the risk of disturbed bone healing. Our revision operations focused on the elimination of wound infections, refreshment of bone healing, and improvement in fragment stability. Only 28% of all "classic" plates and 11% of all external fixators were changed to an intramedullary implant at the time of the first revision surgery. Hypertrophic nonunions required a mean of 1.3 revision operations to achieve bone healing whereas a mean of 2 revision operations were necessary to fuse atrophic bone ends (P < 0.05). In cases of diaphyseal pseudarthrosis healing time was not affected by the type of osteosynthesis used for primary reconstructions. Since lack of fracture healing can often already be observed directly from postoperative X-rays, we recommend that revision procedures be performed early. The prolonged length of time to care for femoral nonunions underlines the importance of appropriate primary fracture treatment. That takes into consideration both the biomechanical and the biological aspects of bone healing.

Classification of Pseudarthroses of the Lumbar Spine

Imaging studies and operative records of 55 patients who had undergone lumbar pseudarthrosis repair were studied, providing a total of 85 surgically documented pseudarthroses. Preoperative imaging studies were carefully analyzed for the anatomic characteristics of the involved levels and the morphology of the fusion mass. The pseudarthroses were found to fall into four distinct morphologic categories: atrophic, transverse, shingle, and complex. The atrophic pseudarthrosis type was noted to be strongly associated with the presence of intact facet joints or spinal hardware. This retrospective analysis indicates that stress shielding provided by intact facet joints or spinal implants may contribute to graft atrophy in certain patients. The classification scheme proposed may be useful in future analyses of different fusion techniques in determining the various causes of this surgical complication.

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.