Video-Assisted Thoracoscopic Lateral Interbody Fusion for Symptomatic Pseudarthrosis in Neurofibromatosis 1-Associated Spinal Deformity

BACKGROUND

The treatment of symptomatic pseudarthrosis via posterior-only approaches in the setting of neurofibromatosis 1 (NF1) is challenging due to dural ectasias, resulting in erosion of the posterior elements. The purpose of this report is to illustrate a minimally invasive method for performing anterior thoracic fusion for pseudarthrosis in a patient with NF1-associated scoliosis and dysplastic posterior elements. To the best of our knowledge, this is the first documented case of using video-assisted thoracoscopic lateral interbody fusion to treat pseudarthrosis for NF1-associated spinal deformity.

CASE DESCRIPTION

The patient underwent video-assisted thoracoscopic anterior spinal fusion via a direct lateral interbody approach with interbody cage placement at T10-T11 and T11-T12, followed by revision of his posterior spinal fusion and instrumentation. The patient had an uneventful postoperative course. At 6 months of follow-up, the patient had complete resolution of his preoperative symptoms and had returned to full-time work with no complaints. At 3 years postoperatively, the patient reported being satisfied with the operation and had continued to work full-time without restrictions.

CONCLUSIONS

To the best of our knowledge, this is the first report of pseudarthrosis in the setting of NF1-associated scoliosis treated via minimally invasive anterior thoracic fusion facilitated by video-assisted thoracoscopic surgery. This is a powerful technique that allows for safe access for anterior thoracic fusion in the setting of dysplastic posterior anatomy and poor posterior bone stock.

Modified "SUPERhip2" to Reconstruct Postinfectious Femoral Neck Pseudoarthrosis (Hunka Type 3): A Case Report

CASE

We report a case of a 3-year-old girl who developed a post-infectious femoral neck pseudoarthrosis after a proximal hematogenous femoral osteomyelitis (type 3 according to Hunka classification of the sequelae of the septic hip in children). The patient was treated by a modified "SUPERhip 2" procedure (a reconstructive procedure described to reconstruct congenital femoral neck pseudoarthrosis). This report describes the surgical technique in details and discusses the advantages, pitfalls, and complications and possible complications.

CONCLUSION

Our modification simplifies the "SUPERhip 2" procedure. Postinfectious neck pseudoarthrosis was successfully treated, and we believe this modification is applicable for the treatment of congenital femoral neck pseudoarthrosis as well.

The Effects of Preoperative Epidural Steroid Injection on Pseudarthrosis Following Lumbar Fusion: A Retrospective Cohort Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The goal of this study is to evaluate the effects of preoperative lumbar epidural steroid injection on the rate of pseudarthrosis following lumbar spine fusion surgery.

SUMMARY OF BACKGROUND DATA

Epidural corticosteroids help to reduce nerve root edema and suppress proinflammatory cytokines in patients with radiculopathy. Corticosteroids may inhibit bone formation and reduce bone matrix synthesis rates. Thus, there is concern that corticosteroids may reduce lumbar fusion capability, potentially resulting in increased rates of symptomatic pseudarthrosis.

MATERIALS AND METHODS

We identified all patients who underwent 1-level or 2-level lumbar fusion surgery between 2018 and 2022. Patients were categorized into one of 3 groups: no preoperative epidural steroid injection (ESI) history (group 0), preoperative ESI within 90 days of surgery (group 1), or most recent ESI >90 days before surgery (group 2). The primary outcome of this study was pseudarthrosis. Binominal regression analyses were performed to determine the relationships between potential risk factors (sex, age, body mass index, smoking history, diabetes status, history of systemic steroid use, preoperative ESI, perioperative intravenous steroid administration, type of surgery, and postoperative ESI within 6 mo) and the development of postoperative pseudarthrosis.

RESULTS

A total of 446 patients were included in this study. Of those, 106 patients (23.7%) did not have a preoperative ESI (group 0), 132 patients (29.5%) had an ESI within 90 days of surgery (group 1), and 208 patients (46.6%) had their most recent ESI >90 days before surgery (group 2). The overall incidence of pseudarthrosis following lumbar fusion was 8.7% (39 of 446). Although the incidence of pseudarthrosis following ESI at any time point was higher than in our control cohort (group 0), this difference was not statistically significant.

CONCLUSIONS

This study found no increased risk of postoperative pseudarthrosis in patients who underwent 1-level or 2-level lumbar fusions after preoperative ESI.

LEVEL OF EVIDENCE

Level III.

Low-Density Lipoprotein Cholesterol and Statin Usage Are Associated With Rates of Pseudarthrosis Following Single-Level Posterior Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the relationships of low-density lipoprotein cholesterol and statin usage with pseudarthrosis following single-level posterior or transforaminal lumbar interbody fusion (PLIF/TLIF).

SUMMARY OF BACKGROUND DATA

Hypercholesterolemia can lead to atherosclerosis of the segmental arteries, which branch into vertebral bone through intervertebral foramina. According to the vascular hypothesis of disc disease, this can lead to ischemia of the lumbar discs and contribute to lumbar degenerative disease. Yet, little has been reported regarding the effects of cholesterol and statins on the outcomes of lumbar fusion surgery.

MATERIALS AND METHODS

TriNetX, a global federated research network, was retrospectively queried to identify 52,140 PLIF/TLIF patients between 2002 and 2021. Of these patients, 2137 had high cholesterol (≥130 mg/dL) and 906 had low cholesterol (≤55 mg/dL). Perioperatively, 18,275 patients used statins, while 33,415 patients did not. One-to-one propensity score matching for age, sex, race, and comorbidities was conducted to balance the analyzed cohorts. The incidence of pseudarthrosis was then assessed in the matched cohorts within the six-month, one-year, and two-year postoperative periods.

RESULTS

After propensity score matching, high-cholesterol patients had greater odds of developing pseudarthrosis six months [odds ratio (OR): 1.73, 95% confidence interval (CI): 1.28-2.33], one year (OR: 1.59, 95% confidence interval (CI): 1.20-2.10), and two years (OR: 1.57, 95% CI: 1.20-2.05) following a PLIF/TLIF procedure. Patients with statin usage had significantly lower odds of developing pseudarthrosis six months (OR: 0.74, 95% CI: 0.69-0.79), one year (OR: 0.76, 95% CI: 0.71-0.81), and two years (OR: 0.77, 95% CI: 0.72-0.81) following single-level PLIF/TLIF.

CONCLUSIONS

The findings suggest that patients with hypercholesterolemia have an increased risk of developing pseudarthrosis following PLIF/TLIF while statin use is associated with a decreased risk. The data presented may underscore an overlooked opportunity for perioperative optimization in lumbar fusion patients, warranting further investigation in this area.

Cannabis Use is Associated With Higher Rates of Pseudarthrosis Following TLIF: A Multi-Institutional Matched-Cohort Study

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

To compare the rates of pseudarthrosis in patients undergoing 1 to 3 level transforaminal lumbar interbody fusion (TLIF) procedures between cannabis users and noncannabis users.

SUMMARY OF BACKGROUND DATA

Recreational use of cannabis is common, though it remains poorly studied and legally ambiguous in the United States. Patients with back pain may turn to adjunctive use of cannabis to manage their pain. However, the implications of cannabis use on the achievement of bony fusion are not well-characterized.

METHODS

Patients who underwent 1 to 3 level TLIF for degenerative disc disease or degenerative spondylolisthesis between 2010 and 2022 were identified using the PearlDiver Mariner all-claims insurance database. Cannabis users were identified with ICD 10 code F12.90. Patients undergoing surgery for nondegenerative pathologies such as tumors, trauma, or infection were excluded. 1:1 exact matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with pseudarthrosis in a linear regression model. The primary outcome measure was development of pseudarthrosis within 24 months after 1 to 3 level TLIF. The secondary outcomes were the development of all-cause surgical complications as well as all-cause medical complications.

RESULTS

A 1:1 exact matching resulted in two equal groups of 1593 patients who did or did not use cannabis and underwent 1 to 3 level TLIF. Patients who used cannabis were 80% more likely to experience pseudarthrosis compared with patients who do not [relative risk (RR): 1.816, 95% CI: 1.291-2.556, P <0.001]. Similarly, cannabis use was associated with significantly higher rates of all-cause surgical complications (RR: 2.350, 95% CI: 1.399-3.947, P =0.001) and all-cause medical complications (RR: 1.934, 95% CI: 1.516-2.467, P <0.001).

CONCLUSION

After 1:1 exact matching to control for confounding variables, the findings of this study suggest that cannabis use is associated with higher rates of pseudarthrosis, as well as higher rates of all-cause surgical and all-cause medical complications. Further studies are needed to corroborate our findings.

Ehlers-Danlos Syndrome is Associated with Increased Rates of Adjacent Segment Disease Following TLIF: A Propensity Matched Study

BACKGROUND

Ehlers-Danlos syndrome (EDS) is a collection of connective tissue disorders which are often associated with tissue laxity and disc degeneration. However, the implications of EDS on the risk of adjacent segment disease (ASD) after transforaminal lumbar interbody fusion (TLIF) are not well described. The objective of this study is to compare the rates of ASD among patients with EDS and those without EDS.

METHODS

Patients who underwent 1-3 level TLIF for degenerative disc disease between 2010-2022 were identified using the PearlDiver Mariner all-claims insurance database. Patients with all types of EDS were included. Patients undergoing surgery for tumors, trauma, or infection were excluded. 1:1 propensity matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with ASD in a linear regression model. The primary outcome measure was the development of ASD. The secondary outcomes were the development of pseudoarthrosis, medical complications, and surgical complications.

RESULTS

Propensity matching resulted in 2 equal groups of 85 patients who did or did not have EDS and underwent 1-3 level TLIF. Patients without EDS were less likely to experience ASD (RR 0.18, 95% CI 0.09-0.35, P < 0.001). There was no significant difference between the 2 patient groups with regards to a diagnosis of pseudoarthrosis, and there was no significant difference for all-cause medical and surgical complications between the 2 patient groups.

CONCLUSIONS

After propensity matching to control for confounding variables, the findings of this study suggest that EDS may be associated with an increased risk of ASD following TLIF. Future studies are needed to corroborate these findings.

The incidence of reoperation for pseudarthrosis after cervical spine surgery

INTRODUCTION

Pseudarthrosis after cervical spine surgery represents an underreported and challenging complication. Using a large multi-center surgical database, we sought to: (1) report the incidence of cervical pseudarthrosis, (2) evaluate changes in rates of cervical pseudarthrosis, and (3) describe risk factors for suboptimal outcomes after cervical pseudarthrosis surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019 was used. The primary outcome was occurrence of a cervical fusion procedure with a prior diagnosis of pseudarthrosis. Fusion for pseudarthrosis was divided into anterior and posterior approaches. Post-operative complications were classified as major or minor. Prolonged LOS was defined as exceeding the 75th percentile for total hospital stay.

RESULTS

A total of 780 patients underwent cervical fusion for pseudarthrosis, and a significant increase in rates of surgery for pseudarthrosis was seen (0.25-1.2%, p < 0.001). The majority of cervical pseudarthrosis was treated with a posterior approach (66.5%). Postoperatively, 38 (4.9%) patients suffered a complication and 247 (31.7%) had a prolonged LOS. The three strongest risk factors for complications and extended LOS were > 10% weight loss preoperatively, congestive heart failure, and pre-operative bleeding disorder.

CONCLUSION

Results from a large multi-center national database revealed that surgery to treat cervical pseudarthrosis has increased from 2012 to 2019. Most pseudarthrosis was treated with a posterior approach. Reoperation to treat cervical pseudarthrosis carried risk, with 5% having complications and 32% having an extended LOS. These results lay the groundwork for a future prospective study to discern the true incidence of cervical pseudarthrosis and how to best avoid its occurrence.

Postoperative CT imaging to characterize fusion in pediatric and adolescent vertebral column resection

BACKGROUND

Vertebral column resection (VCR) is a powerful corrective technique for the management severe, rigid spinal deformities but does carry a relatively high complications rate. One of the feared complications is pseudarthrosis which places the patient at risk for implant failure. We present a single-center experience with post-operative computed tomography (CT) imaging at the osteotomy site to screen for impending pseudarthrosis.

METHODS

A retrospective review of a single surgeon series of posterior-only VCR performed for severe pediatric and adolescent spinal deformities was performed. Demographic, radiographic, and clinical data were collected. Patients underwent postoperative CT imaging at the osteotomy site 6-9 months following VCR with grading of the osteotomy fusion. Patients with impending pseudarthrosis were recommended for prophylactic revision surgery.

RESULTS

Thirty-three patients were included (mean age 11.6 ± 4.9 years, 54.5% female), undergoing a mean 1.9 level VCR. Kyphoscoliosis accounted for 75.7% (N = 25/33) of cases with 45.5% of all cases being congenital etiology and 60.6% having at least 1 previous surgery. Postoperative CT imaging was performed in 22 patients at a mean of 7.8 months following VCR. Two patients were identified as having impending pseudarthrosis with one undergoing revision surgery to enhance the posterior fusion, with addition of a third rod while one patient refusing surgery who subsequently developed broken hardware requiring revision surgery. No patient with a stable fusion on CT imaging developed a clinically significant pseudarthrosis.

DISCUSSION

Postoperative CT imaging of the osteotomy is useful in screening for impending pseudarthrosis and can aide in decision making for clearance to return to activity or the need for prophylactic intervention following VCR in pediatric and adolescent patients. We advocate that obtaining routine CT imaging of the osteotomy site at 6-9 months may identify potential complications earlier and allow for prophylactic intervention.

Repeat surgical interventions following "definitive" instrumentation and fusion for idiopathic scoliosis: a 30-year update

PURPOSE

Although spinal fusion (SF) is considered "definitive" treatment in juvenile/adolescent idiopathic scoliosis (JIS/AIS), complications requiring reoperation continue to occur. The purpose of this study was to characterize the evolving rates of reoperation following SF in JIS/AIS.

METHODS

Single-center retrospective review of patients who underwent SF for JIS/AIS as their index surgical treatment between 2013 and 2019. Patient data were collected to identify complications requiring reoperation and factors associated with reoperation. Complication rates from 2013 to 2019 were compared to patients from 1988 to 2012 at the same institution.

RESULTS

This study analyzed 934 patients (81.7% female, mean age at surgery 14.5 ± 2.1). Thirty-eight patients (4.1%) required a total of 47 reoperations, a > 50% decrease in overall complication rate from the 2008-2012 population (4.1% vs 9.6%, respectively, p < 0.001). The decrease stemmed mainly from decreases in rates of infection (1.1% vs 4.1%, p < 0.001) and symptomatic implants (0.4% vs 2.1%, p = 0.004). There were, however, non-significant increases in implant failures (0.6% vs 0.2%, p = 0.4367) and pseudoarthrosis (1.0% vs 0.4%, p = 0.5202). Both of these complications were associated with patients with a higher mean weight (implant failure: 70.4 kg ± 21.1 vs 56.1 kg ± 14.9, p = 0.002; pseudoarthrosis: 85.8 kg ± 27.9 vs 55.9 ± 14.5, p = 0.001).

CONCLUSIONS

Reoperation following SF for JIS/AIS has decreased over the past 7 years when compared to 25 years of historical controls. The changing landscape of reoperation demands further research into the risk factors for those reoperations that have become more common.

Trans-sacral interbody fixation in long fusions to the sacrum for adult spinal deformity: complications and fusion rates at minimum two years follow-up

PURPOSE

This study aims to investigate the fusion rate and complications associated with trans-sacral interbody fusion (TSIF) in long fusions to the sacrum for adult spinal deformity (ASD) over a two year follow-up period. Potential predictor variables associated with pseudarthrosis were also examined.

METHODS

A retrospective clinical review was conducted on a consecutive series of ASD patients who underwent long fusions to the sacrum, with TSIF performed as a same-day or staged procedure. Patient demographics, bone mineral density, operative details, perioperative and late complications, and fusion rates were reviewed. Univariate analysis was used to identify the risk factors associated with pseudarthrosis.

RESULTS

The study included 43 patients with an average age of 55.3 ± 8.9 years. The perioperative complication rate was 28%, with 12% of the complications directly related to TSIF. The late complication rate was 33%, with 16% related to TSIF. The most common complications were pseudarthrosis (14%) and postoperative ileus (7%). The overall radiographic fusion rate at two years was 86%. Univariate analysis revealed that revision surgery was significantly associated with pseudarthrosis (p = 0.027). Over the follow-up period, patients who underwent TSIF during long posterior fusions to the sacrum showed improvement in overall SRS scores, ODI scores, and SF-36 physical health and mental health (p < 0.05).

CONCLUSION

TSIF is a relatively safe and minimally invasive method for achieving interbody fusion at the lumbosacral junction in the treatment of ASD, with acceptable fusion rates and a low complication rate. However, TSIF is not recommended for revision reconstruction in ASD.

Long-term outcomes in patients treated with tissue-sparing posterior cervical fusion to revise a 1-level pseudarthrosis following ACDF

STUDY DESIGN

Observational Study BACKGROUND: Symptomatic pseudarthrosis is one long-term complication in patients treated with anterior discectomy and fusion (ACDF). When revising a pseudarthrosis, a surgeon must decide to intervene posteriorly and/or anteriorly. Open posterior cervical fusion (PCF) is attractive for high rates of arthrodesis, however this technique introduces risks of added complications resulting from extensive soft tissue dissection. The purpose of this study was to assess long-term outcomes in patients undergoing tissue-sparing PCF with facet instrumentation to treat a single level pseudarthrosis.

METHODS

Forty-five subjects were recruited from six participating sites. All subjects had a history of ACDF that was subsequently revised with tissue-sparing PCF to treat symptomatic pseudarthrosis at one level. Long-term radiographic assessments included flexion and extension X-ray and multi-planar CT. Subjects additionally completed a patient satisfaction questionnaire. Radiographs were assessed by investigators and an independent core imaging lab to diagnose implant integrity and arthrodesis at the revised levels.

RESULTS

The revision procedure required a median 49 min to complete with an estimated blood loss of 10 cc. Subjects were discharged a median 1 day following treatment. There were no instances of hospital re-admission nor subsequent surgical interventions. Study follow-up assessments were performed a median 39 months from revision. Surgeons diagnosed complete fusion in 91 % of cases. The core imaging lab identified bridging bone across the revised segment in 80 % of cases. Range of motion was < 2° in 93 % of cases. Seventy-four percent of subjects reported being satisfied with their outcomes.

CONCLUSIONS

This study summarizes long-term radiographic outcomes in a cohort of patients receiving tissue-sparing PCF for the treatment of pseudarthrosis. Assessed years after revision, patients achieved rates of arthrodesis similar to open PCF without the soft tissue dissection responsible for perioperative morbidity and long-term soft tissue pain.

Fate of pseudarthrosis detected 2 years after anterior cervical discectomy and fusion: results of a minimum 5-year follow-up

BACKGROUND CONTEXT

Prior study has shown that 70% of cervical pseudarthrosis after anterior cervical discectomy and fusion (ACDF) detected at 1 year will go on to fusion by 2 year. Pseudarthrosis detected 2 years after ACDF may have different bone healing potential compared to nonunion detected 1 year after surgery. Therefore, it might have a different clinical significance.

PURPOSE

To examine the radiographic and clinical prognosis of pseudarthrosis detected 2 years after ACDF with a minimum follow-up of 5 years.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENTS SAMPLE

A total of 249 patients who completed a 5-year follow-up after ACDF.

OUTCOMES MEASURES

Clinical outcomes such as neck pain visual analogue scale (VAS), arm pain VAS, and neck disability index (NDI) and radiographic assessment such as X-ray, computed tomography (CT) scan.

METHODS

A total of 249 patients who completed a 5-year follow-up after ACDF were retrospectively reviewed. Patients who were diagnosed with pseudarthrosis at 2 years postoperatively were included. Fusion, neck pain VAS, arm pain VAS, and NDI were assessed. The results were compared between the union group (patients who achieved union), and the nonunion group (patients with pseudarthrosis) at 5 years postoperatively.

RESULTS

Among the patients who had pseudarthrosis at 2 years postoperatively, the fusion rate at 5 years was 32.6% (14/43). While the union group showed continued improvements in neck pain VAS, arm pain VAS, and NDI until 5 years, the nonunion group showed significant worsening of arm pain VAS and NDI at 5 years, with the values of neck pain VAS, arm pain VAS, and NDI being significantly worse than those of the union group at 5 years.

CONCLUSION

The incidence of pseudarthrosis detected at 2 years postoperatively after ACDF was 67.4%, and it remained unfused at 5 years postoperatively. Nonunion identified 2 years after ACDF may be considered a poor prognostic factor because it has less potential to achieve fusion with further follow-up and a higher chance of worsening clinical symptoms. Therefore, the presence of fusion at the 2-year follow-up can be considered an indicator of the success of the surgery.

Comparative analysis of cancellous graft and cortico-cancellous graft in osteosynthesis of scaphoid pseudoarthrosis with plate

INTRODUCTION

Scaphoid is the most fractured carpal bone, with a 5-10% nonunion rate. Treatment challenges include choosing the implant and graft that best corrects humpback deformity and carpal malalignment with higher chances of bony healing.

OBJECTIVE

Compare cortico-cancellous and cancellous grafts between two groups of patients treating scaphoid nonunion with locking plates using autologous bone graft and evaluate bone healing rates and radiographic, tomographic, and functional parameters before and after surgery.

METHODS

Non-randomized prospective study including 20 cases of scaphoid nonunion. Groups were divided into Group A (ten patients treated with cortico-cancellous iliac graft) and Group B (ten patients treated with cancellous iliac graft). Patients underwent pre- and postoperative radiographs, computed tomography, and functional evaluation.

RESULTS

In postoperative analysis, Group A showed a statistically significant difference in intrascaphoid angle (p = 0.002) and scapholunate angle (p = 0.011) correction when comparing the pre- and postoperative periods. Group B showed a statistically significant difference in intrascaphoid angle (p = 0.002) and scapholunate angle correction (p = 0.0018), grip strength (p = 0.002), and tip pinch strength (p = 0.001) when comparing the pre- and postoperative periods. By comparing both groups, Group B showed a statistically significant difference in intrascaphoid angle correction (p = 0.002), grip strength (p = 0.002), tip pinch strength (p = 0.002), and radial deviation (p = 0.0003). There was no statistical difference when comparing bony healing between groups.

CONCLUSION

Scaphoid nonunion treatment with a locking plate was effective, showing a high bony healing rate and improved carpal alignment in imaging tests for both graft types. However, results for intrascaphoid angle correction, grip strength, tip pinch strength, and radial deviation were better in Group B.

LEVEL OF EVIDENCE

IV, case series.

Impact of the adjacent bone on pseudarthrosis in mandibular reconstruction with fibula free flaps

BACKGROUND

Mechanical and morphological factors have both been described to influence the rate of pseudarthrosis in mandibular reconstruction. By minimizing mechanical confounders, the present study aims to evaluate the impact of bone origin at the intersegmental gap on osseous union.

METHODS

Patients were screened retrospectively for undergoing multi-segment fibula free flap reconstruction of the mandible including the anterior part of the mandible and osteosynthesis using patient-specific 3D-printed titanium reconstruction plates. Percentage changes in bone volume and width at the bone interface between the fibula/fibula and fibula/mandible at the anterior intersegmental gaps within the same patient were determined using cone-beam computed tomography (CBCT). Additionally, representative samples of the intersegmental zones were assessed histologically and using micro-computed tomography (µCT).

RESULTS

The bone interface (p = 0.223) did not significantly impact the change in bone volume at the intersegmental gap. Radiotherapy (p < 0.001), time between CBCT scans (p = 0.006) and wound healing disorders (p = 0.005) were independent risk factors for osseous non-union. Preliminary analysis of the microstructure of the intersegmental bone did not indicate morphological differences between fibula-fibula and fibula-mandible intersegmental bones.

CONCLUSIONS

The bone interface at the intersegmental gap in mandibular reconstruction did not influence long-term bone healing significantly. Mechanical and clinical properties seem to be more relevant for surgical success.

Retrospective Analysis of Bone Substitute Material for Traumatic Long Bone Fractures: Sex-Specific Outcomes

Male patients often experience increased bone and muscle loss after traumatic fractures. This study aims to compare the treatment outcomes of male and female patients with large bone defects. A total of 345 trauma patients underwent surgery, with participants divided into two groups: one receiving bone substitute material (BSM) for augmented defects (n = 192) and the other without augmentation (empty defects = ED, n = 153). Outcome parameters were assessed among female (n = 184) and male (n = 161) patients. Descriptive statistics revealed no significant differences between male and female patients. Approximately one-half of the fractures resulted from high-energy trauma (n = 187). The BSM group experienced fewer complications (p = 0.004), including pseudarthrosis (BSM: n = 1, ED: n = 7; p = 0.02). Among female patients over 65, the incidence of pseudarthrosis was lower in the BSM group (p = 0.01), while younger females showed no significant differences (p = 0.4). Radiologically, we observed premature bone healing with subsequent harmonization. Post hoc power analysis demonstrated a power of 0.99. Augmenting bone defects, especially with bone substitute material, may reduce complications, including pseudarthrosis, in female patients. Additionally, this material accelerates bone healing. Further prospective studies are necessary for confirmation.

Pseudoarthrosis after anterior cervical discectomy and fusion: rate of occult infections and outcome of anterior revision surgery

BACKGROUND

Pseudoarthrosis after anterior cervical discectomy and fusion (ACDF) is relatively common and can result in revision surgery. The aim of the study was to analyze the outcome of patients who underwent anterior revision surgery for pseudoarthrosis after ACDF.

METHODS

From 99 patients with cervical revision surgery, ten patients (median age: 48, range 37-74; female: 5, male: 5) who underwent anterior revision surgery for pseudoarthrosis after ACDF with a minimal follow up of one year were included in the study. Microbiological investigations were performed in all patients. Computed tomography (CT) scans were used to evaluate the radiological success of revision surgery one year postoperatively. Clinical outcome was quantified with the Neck Disability Index (NDI), the Visual Analog Scale (VAS) for neck and arm pain, and the North American Spine Society Patient Satisfaction Scale (NASS) 12 months (12-60) after index ACDF surgery. The achievement of the minimum clinically important difference (MCID) one year postoperatively was documented.

RESULTS

Occult infection was present in 40% of patients. Fusion was achieved in 80%. The median NDI was the same one year postoperatively as preoperatively (median 23.5 (range 5-41) versus 23.5 (7-40)), respectively. The MCID for the NDI was achieved 30%. VAS-neck pain was reduced by a median of 1.5 points one year postoperatively from 8 (3-8) to 6.5 (1-8); the MCID for VAS-neck pain was achieved in only 10%. Median VAS-arm pain increased slightly to 3.5 (0-8) one year postoperatively compared with the preoperative value of 1 (0-6); the MCID for VAS-arm pain was achieved in 14%. The NASS patient satisfaction scale could identify 20% of responders, all other patients failed to reach the expected benefit from anterior ACDF revision surgery. 60% of patients would undergo the revision surgery again in retrospect.

CONCLUSION

Occult infections occur in 40% of patients who undergo anterior revision surgery for ACDF pseudoarthrosis. Albeit in a small cohort of patients, this study shows that anterior revision surgery may not result in relevant clinical improvements for patients, despite achieving fusion in 80% of cases.

LEVEL OF EVIDENCE

Retrospective study, level III.

Postoperative cage migration and subsidence following TLIF surgery is not associated with bony fusion

Pseudarthrosis following transforaminal interbody fusion (TLIF) is not infrequent. Although cage migration and subsidence are commonly regarded as evidence of the absence of solid fusion, there is still no evidence of the influence of cage migration and subsidence on fusion. This study aimed to evaluate cage migration and subsidence using computed tomography (CT) DICOM data following lumbar interbody fusion. The effects of cage migration and subsidence on fusion and clinical outcomes were also assessed. A postoperative CT data set of 67 patients treated with monosegmental TLIF was analyzed in terms of cage position. To assess the effects of cage migration and subsidence on fusion, 12-month postoperative CT scans were used to assess fusion status. Clinical evaluation included the visual analog scale for pain and the Oswestry Disability Index. Postoperative cage migration occurred in 85.1% of all patients, and cage subsidence was observed in 58.2%. Radiological signs of pseudarthrosis was observed in 7.5% of the patients Neither cage migration nor subsidence affected the clinical or radiographic outcomes. No correlation was found between clinical and radiographic outcomes. The incidence of cage migration was considerable. However, as cage migration and subsidence were not associated with bony fusion, their clinical significance was considered limited.

Association Between the Bone Density of Posterior Fusion Mass and Mechanical Complications After Thoracolumbar Three-Column Osteotomy for Adult Spinal Deformity

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

To assess the relationship of fusion mass bone density on computed tomography (CT) and the development of rod fractures (RFs) and proximal junctional kyphosis (PJK).

SUMMARY OF BACKGROUND DATA

Few studies have evaluated the relationship of fusion mass bone density to mechanical complications.

MATERIALS AND METHODS

A retrospective review of adult spinal deformity patients who underwent thoracolumbar three-column osteotomy from 2007 to 2017 was performed. All patients underwent routine 1-year CT imaging and had at least 24 months follow-up. Posterior fusion mass bone density was evaluated by measuring hounsfield unit (HU) on CT in three different regions [upper instrumented vertebra (UIV), lower instrumented vertebra, and osteotomy site], and were compared between patients with and without mechanical complications.

RESULTS

A total of 165 patients (63.2 years, 33.5% male) were included. Overall PJK rate was 18.8%, and 35.5% of these underwent PJK revision. There was significantly lower density of posterior fusion mass at the UIV in patients who experienced PJK compared with patients without PJK (431.5HU vs. 537.4HU, P =0.026). Overall RF rate was 34.5% and 61.4% of these underwent revision for RFs. Among 57 patients with RFs, 71.9% had pseudarthrosis. Fusion mass density did not differ between patients with or without RFs. However, in RF patients with pseudarthrosis, there was significantly higher bone mass density near the osteotomy compared with those without pseudarthrosis (515.7HU vs. 354.2HU, P =0.012). There were no differences in radiographic sagittal measures between the patients with and without RF or PJK.

CONCLUSIONS

Patients with PJK tend to have less dense posterior fusion mass at the UIV. Fusion mass density does not correlate with RF, but greater bone density near the osteotomy was correlated with accompanying pseudarthrosis in patients with RFs. Assessing density of posterior fusion mass on CT may be helpful in assessing risk for PJK and provide insight as to the causes of RFs.

Incidence, mechanism, and protective strategies for 2-year pelvic fixation failure after adult spinal deformity surgery with a minimum six-level fusion

OBJECTIVE

The purpose of this study was to determine the incidence, mechanism, and potential protective strategies for pelvic fixation failure (PFF) within 2 years after adult spinal deformity (ASD) surgery.

METHODS

Data for ASD patients (age ≥ 18 years, minimum of six instrumented levels) with pelvic fixation (S2-alar-iliac [S2AI] and/or iliac screws) with a minimum 2-year follow-up were consecutively collected (2015-2019). Patients with prior pelvic fixation were excluded. PFF was defined as any revision to pelvic screws, which may include broken rods across the lumbosacral junction requiring revision to pelvic screws, pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws, a broken or loose pelvic screw, or sacral/iliac fracture. Patient information including demographic data and health history (age, sex, BMI, smoking status, American Society of Anesthesiologists score, osteoporosis), operative (total instrumented levels [TIL], three-column osteotomy [3CO], interbody fusion), screw (iliac, S2AI, length, diameter), rod (diameter, kickstand), rod pattern (number crossing lumbopelvic junction, lowest instrumented vertebra [LIV] of accessory rod[s], lateral connectors, dual-headed screws), and pre- and postradiographic (lumbar lordosis, pelvic incidence, pelvic tilt, major Cobb angle, lumbosacral fractional curve, C7 coronal vertical axis [CVA], T1 pelvic angle, C7 sagittal vertical axis) parameters was collected. All rods across the lumbosacral junction were cobalt-chrome. All iliac and S2AI screws were closed-headed tulips. Both univariate and multivariate analyses were performed to determine risk factors for PFF.

RESULTS

Of 253 patients (mean age 58.9 years, mean TIL 13.6, 3CO 15.8%, L5-S1 interbody 74.7%, mean pelvic screw diameter/length 8.6/87 mm), the 2-year failure rate was 4.3% (n = 11). The mechanisms of failure included broken rods across the lumbosacral junction (n = 4), pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws (n = 3), broken pelvic screw (n = 1), loose pelvic screw (n = 1), sacral/iliac fracture (n = 1), and painful/prominent pelvic screw (n = 1). A higher number of rods crossing the lumbopelvic junction (mean 3.8 no failure vs 2.9 failure, p = 0.009) and accessory rod LIV to S2/ilium (no failure 54.2% vs failure 18.2%, p = 0.003) were protective for failure. Multivariate analysis demonstrated that accessory rod LIV to S2/ilium versus S1 (OR 0.2, p = 0.004) and number of rods crossing the lumbar to pelvis (OR 0.15, p = 0.002) were protective, while worse postoperative CVA (OR 1.5, p = 0.028) was an independent risk factor for failure.

CONCLUSIONS

The 2-year PFF rate was low relative to what is reported in the literature, despite patients undergoing long fusion constructs for ASD. The number of rods crossing the lumbopelvic junction and accessory rod LIV to S2/ilium relative to S1 alone likely increase construct stiffness. Residual postoperative coronal malalignment should be avoided to reduce PFF.

Increased rate of pseudarthrosis in the anterior intersegmental gap after mandibular reconstruction with fibula free flaps: a volumetric analysis

OBJECTIVES

Pseudarthrosis after mandibular reconstruction leads to chronic overload of the osteosynthesis and impedes dental rehabilitation. This study evaluates the impact of gap site on osseous union in mandible reconstruction using a new volumetric analysis method with repeated cone-beam computed tomography (CBCT).

METHODS

The degree of bone regeneration was evaluated in 16 patients after mandible reconstruction with a fibula free flap and patient-specific reconstruction plates. Percentual bone volume and width changes in intersegmental gaps were retrospectively analyzed using a baseline CBCT in comparison to a follow-up CBCT. Patients' characteristics, plate-related complications, and gap sites (anterior/posterior) were analyzed. Detailed assessments of both gap sites (buccal/lingual/superior/inferior) were additionally performed.

RESULTS

Intersegmental gap width (p = 0.002) and site (p < 0.001) significantly influence bone volume change over two consecutive CBCTs. An initial larger gap width resulted in a lower bone volume change. In addition, anterior gaps showed significantly less bone volume changes. Initial gap width was larger at posterior segmental gaps (2.97 vs 1.65 mm, p = 0.017).

CONCLUSIONS

A methodology framework has been developed that allows to quantify pseuarthrosis in reconstructed mandibles using CBCT imaging. The study identifies the anterior segmental gap as a further risk factor for pseudarthrosis in reconstructions with CAD/CAM reconstruction plates. Future research should evaluate whether this outcome is related to the biomechanics induced at this site.

Assessing Postoperative Pseudarthrosis in Anterior Cervical Discectomy and Fusion (ACDF) on Dynamic Radiographs Using Novel Angular Measurements

STUDY DESIGN

A retrospective review of operative patients at a single institution.

OBJECTIVE

The aim was to validate a novel method of detecting pseudarthrosis on dynamic radiographs.

SUMMARY OF BACKGROUND DATA

A common complication after anterior cervical discectomy and fusion is pseudarthrosis. A previously published method for detecting pseudarthrosis identifies a 1 mm difference in interspinous motion (ISM), which requires calibration of images and relies on anatomic landmarks difficult to visualize. An alternative is to use angles between spinous processes, which does not require calibration and relies on more visible landmarks.

MATERIALS AND METHODS

ISM was measured on dynamic radiographs using the previously published linear method and new angular method. Angles were defined by lines from screw heads to dorsal points of spinous processes. Angular cutoff for fusion was calculated using a regression equation correlating linear and angular measures, based on the 1 mm linear cutoff. Pseudarthrosis was assessed with both cutoffs. Sensitivity, specificity, inter-reliability and intrareliability of angular and linear measures used postoperative computed tomography (CT) as the reference.

RESULTS

A total of 242 fused levels (81 allograft, 84 polyetheretherketone, 40 titanium, 37 standalone cages) were measured in 143 patients (mean age 52.0±11.5, 42%F). 36 patients (66 levels) had 1-year postoperative CTs; 13 patients (13 levels) had confirmed pseudarthrosis. Linear and angular measurements closely correlated ( R =0.872), with 2.3° corresponding to 1 mm linear ISM. Potential pseudarthroses was found in 28.0% and 18.5% levels using linear and angular cutoffs, respectively. Linear cutoff had 85% sensitivity, 87% specificity; angular cutoff had 85% sensitivity, 96% specificity for detecting CT-validated pseudarthrosis. Interclass correlation coefficients were 0.974 and 0.986 (both P <0.001); intrarater reliability averaged 0.953 and 0.974 ( P <0.001 for all) for linear and angular methods, respectively.

CONCLUSIONS

The angular measure for assessing potential pseudarthrosis is as sensitive as and more specific than published linear methods, has high interobserver reliability, and can be used without image calibration.

LEVEL OF EVIDENCE

3.

[Predictive Factors and Treatment of Aseptic Pseudoarthrosis of the Humeral Shaft]

PURPOSE OF THE STUDY Aseptic pseudoarthrosis (nonunion, PSA) of the humeral shaft is one of the serious complications in the treatment of fractures in this area. In a retrospective study, the authors described different methods of treating patients with this complication using predictive factors. MATERIAL AND METHODS Based on the definition of nonunion and the criteria, 14 patients (N=14) with the mean age of 56 years (32-78), namely 8 men and 6 women were included in the study. All patients were followed up clinically and radiologically at 1, 3, 6, 9, 12 months and every 3 months until the condition stabilized. The follow-up period was 11-72 months, with the average of 22 months. According to the AO classification, the fractures were classified as: 4-A1, 1-A2, 4-A3, 1-B1, 3-B2 and 1-C2. Based on the Weber-Čech classification, 2 cases of pseudoarthrosis were hypertrophic, 4 oligotrophic and 8 atrophic. According to the Non-Union Scoring System (NUSS), 5 patients reached the score under 25 points, 3 patients received 25-50 points, 4 patients 51-75 points and two patients over 76 points. In five cases, the fracture displacement index (FDI) was above 100%. In 11 patients, PSA was in the proximal and middle third and in three patients in the distal third of the humerus. METHODS Of the whole group (N=14), the nail was used in 5 cases (36%) - in 3 cases NUSS of up to 50 points and in 2 cases over 76 points. The plate was used in 9 cases (64%). In patients with NUSS of up to 50 points - in 1 case after conservative treatment, in 1 case for augmentation of nail, in 3 cases for augmentation of Prévot nails. In 4 cases with NUSS of 51-75 points a plate was replaced. Osteosynthesis was always supplemented by Judet's decortication or resection of atrophic bone and spongioplasty by autologous graft. RESULTS Shoulder function measured by the Constant Murley score (C-M) improved from 53 to 89 points (from the range of 36-76 points to the range of 75-100 points). The function of the elbow joint also improved, namely from the Mayo Elbow Performance Score (MEPS) of 65 points to 90 points (from the range of 45-70 points to the range of 80-100 points). In 11 cases (79%) the nonunion was healed and in 3 cases (21%) the failure to heal was reported. In the group with unhealed nonunions, in one case with NUSS of 51-75 points a thermoplastic casting was used and in two patients with NUSS above 76 points a palliative surgery was performed using a 12mm interlocking intramedullary nail. DISCUSSION The results of our study focused on the treatment of aseptic nonunion of the humeral shaft confirm the conclusions arrived at by other authors. As to the osteosynthesis materials, the plate remains the gold standard and provides sufficient stability for bone healing. For unhealed treatment-resistant PSA, we offer a stable intramedullary nail instead of prosthetic replacement or amputation, which provides good stability required for limb function. CONCLUSIONS When planning the treatment of aseptic pseudoarthrosis of the humeral shaft, it is necessary to have a thorough knowledge of etiopathogenesis with all predictive factors. The NUSS classification provides good guidance in treating this complication. Key words: aseptic nonunion, NUSS classification, predictive factors.

Congenital pseudarthrosis of the forearm as a single manifestation of neurofibromatosis type 1 at birth: A case report

Congenital pseudoarthrosis of the forearm is an extremely rare condition. It is most commonly associated with neurofibromatosis type I (NF1). Patients with NF1-associated pseudoarthrosis have complex medical management and often require surgical intervention due to higher failure rates of union. In this case report, we present a unique case of a newborn baby with congenital pseudoarthrosis of both the radius and ulna that was manifested at birth and shortly thereafter, was diagnosed with NF type 1.

Elastic stable intramedullary nailing for treatment of pediatric forearm fractures: A 15-year single centre retrospective study of 173 cases

OBJECTIVE

The aim of this study was to analyze the outcomes and complications in children treated with elastic stable intramedullary nailing (ESIN) for forearm fracture.

METHODS

The study included 173 patients (126 men and 47 women; median age: 11 years (range: 3-17 years) treated with ESIN for forearm fracture between May 2002 and May 2018. Immobilization was not performed after the surgery. The median follow-up was 68 months (range: 3-161 months). The etiology, healing time, and complications were recorded.

RESULTS

All patients achieved complete radiographic healing at a median of 6.8 weeks (range: 4-11 weeks). The most common injuries were sport related (n=65) and by falling from standing height (n=57), followed by injuries from bicycle riding, motorbike accidents, road traffic accidents, and fights. Fifteen (8.76%) postoperative complications were recorded: eight entry-site skin irritations, two cases of skin infection, two refractures, and one case each of nail migration, injury of ulnar nerve, and pseudoarthrosis. All complications, except cases of refractures and pseudoarthrosis, were treated conservatively, with no long-term consequences for the patients. Patients with refractures and pseudoarthrosis were reoperated, and complete function of the extremities was fully restored.

CONCLUSION

ESIN for treatment of forearm fractures in children shows good functional and cosmetic results. This is a minimally invasive, cast-free, simple, and reproducible technique, with a low complication rate. Owing to these excellent objective and subjective results, surgical stabilization of the forearm fracture using ESIN is recommended in children and adolescents.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Is There a Correlation Between Preoperative or Postoperative Vitamin D Levels with Pseudarthrosis, Hardware Failure, and Revisions After Lumbar Spine Fusion?

BACKGROUND

Vitamin D deficiency is a well-known cause of postoperative complications in patients undergoing orthopedic surgery. Orthopedic complications seen in vitamin D deficiency include nonunion, pseudarthrosis, and hardware failure. We seek to investigate the relationship between vitamin D deficiency and outcomes after lumbar spinal fusions.

METHODS

A retrospective patient chart review was conducted at a single center for all patients who underwent lumbar spinal fusions from January 2015 to September 2017 with preoperative or postoperative vitamin D laboratory values. We recorded demographics, social history, medications, pre-existing medical conditions, bone density (dual-energy x-ray absorptiometry) T-scores, procedural details, 1-year postoperative Visual Analog Score (VAS), documented pseudarthrosis, revisions, and hardware failure. A total of 150 patients were initially included in the cohort for analysis.

RESULTS

Overall, preoperative and postoperative vitamin D levels were not significantly associated with a vast majority of the patient characteristics studied, including comorbidities, medications, or surgical diagnoses (P > 0.05). Age at surgery was significantly associated with vitamin D levels; older patients had higher serum levels of vitamin D both preoperatively (P = 0.03) and postoperatively (P = 0.01). Those with a higher average body mass index had lower vitamin D in both groups (P = 0.02). Vitamin D levels were not significantly associated with rates of postoperative pseudarthrosis, revision, or hardware complications (P > 0.05). VAS pain score at 1 year and smoking status preoperatively or postoperatively were not associated with vitamin D levels (P > 0.05).

CONCLUSIONS

Both preoperative and postoperative vitamin D levels were not significantly associated with an increased or decreased risk of pseudarthrosis, revision surgery, hardware failure, or 1-year VAS pain score after lumbar spine fusion surgery.

[Vertebrobasilar territory embolisms due to the ununited fracture of the right clavicle from 35 years ago]

A 61-year-old man, with a history of right clavicular fracture 35 years prior, visited our hospital due to the sudden onset of vertigo and tinnitus following weakness and numbness in his left arm and leg. He also had a 6-month history of right arm pain with overuse. Brain MRI showed acute brain infarcts in the right posterior cerebral artery territory. Intravenous alteplase was administered 188 minutes after onset. Although heparin infusion was commenced on day 2, he had vertigo again on day 9, and MRI showed a recurrent brain infarct in the right posterior inferior cerebellar artery territory. Ultrasound examination revealed occlusion of his right subclavian artery beneath the old right clavicular fracture as well as mobile thrombus in the proximal portion of the right subclavian artery. We speculated that a pseudarthrosis at the site of the old right clavicular fracture had repetitively pressed the right subclavian artery. Subsequently, we considered thrombi, which had developed in the proximal portion of the right subclavian artery, migrated into the right vertebral artery, causing recurrent emboli in the vertebrobasilar artery territory.

Posterior column reconstruction improves fusion rates at the level of osteotomy in three-column posterior-based osteotomies

PURPOSE

To determine the incidence of pseudarthrosis at the osteotomy site after three-column spinal osteotomies (3-COs) with posterior column reconstruction.

METHODS

82 consecutive adult 3-COs (66 patients) with a minimum of 2-year follow-up were retrospectively reviewed. All cases underwent posterior 3-COs with two-rod constructs. The inferior facets of the proximal level were reduced to the superior facets of the distal level. If that was not possible, a structural piece of bone graft either from the local resection or a local rib was slotted in the posterior column defect to re-establish continual structural posterior bone across the lateral margins of the resection. No interbody cages were used at the level of the osteotomy.

RESULTS

There were 34 thoracic osteotomies, 47 lumbar osteotomies and one sacral osteotomy with a mean follow-up of 52 (24-126) months. All cases underwent posterior column reconstructions described above and the addition of interbody support or additional posterior rods was not performed for fusion at the osteotomy level. Among them, 29 patients underwent one or more revision surgeries. There were three definite cases of pseudarthrosis at the osteotomy site (4%). Six revisions were also performed for pseudarthrosis at other levels.

CONCLUSION

Restoration of the structural integrity of the posterior column in three-column posterior-based osteotomies was associated with > 95% fusion rate at the level of the osteotomy. Pseudarthrosis at other levels was the second most common reason for revision following adjacent segment disease in the long-term follow-up.

Amniotic band syndrome with pseudoarthrosis of tibia and fibula: A case report

Constriction of the lower limb by congenital amniotic band has been proposed to explain the development of pseudoarthrosis of tibia and fibula. We report a case of amniotic band syndrome in a preterm infant with pseudoarthrosis of tibia and fibula. Simple release of constriction band with Z-plasty resulted in the growth of mature bone, replacing the pseudoarthrosis and hence did not require surgical amputation. Our case confirms the potential for bone growth in ABS, once the constricting band is released. Early limb preserving surgery with release of the constricting band with an intention to salvage the limb appears appropriate.

Recidivism Rates After Smoking Cessation Before Spinal Fusion

Tobacco use has documented negative effects on perioperative complications and clinical outcomes. Smoking cessation before spinal surgery may improve clinical outcomes. The goal of this study was to determine the recidivism rate after smoking cessation before spinal fusion. A prospective observational study was performed at the University of Kansas Medical Center between 2006 and 2011. All patients with serum-confirmed nicotine cessation before spinal fusion surgery were eligible. Smoking status was determined with questionnaires at 3 months, 6 months, and 1 year postoperatively. All reported nonsmokers had confirmatory serum nicotine and cotinine tests. Two-tailed Pearson chi-square and independent t tests were conducted, and significance was set at α=0.05. A total of 42 subjects (21 women, 21 men) with confirmed preoperative serum-negative test results were prospectively enrolled over a period of 3.9 years. Of these patients, 1 opted out at 6 months and 1 died of unknown cause. The findings showed a recidivism rate (response rate) of 60% (40 of 41) at 3 months, 61% (33 of 41) at 6 months, and 68% (25 of 40) at 1 year. One case of asymptomatic pseudarthrosis occurred 1 year postoperatively in a confirmed nonsmoker. No correlation was found between smoking status at 3 months and sex, primary vs revision surgery, or complications (P>.05). Smokers who relapsed at 3 months were older than nonsmokers (55.2 vs 44.2 years, respectively; P=.03). Some patients are willing to cease smoking before spinal fusion for optimal clinical outcomes; however, the rate of recidivism is high (60%) within the first 3 months post-operatively.

Is a Persistent Vacuum Phenomenon a Sign of Pseudarthrosis After Posterolateral Spinal Fusion?

The purpose of this study is to evaluate whether the vacuum phenomenon (VP) resolves after posterolateral lumbar fusion, and whether persistence of VP is indicative of failed fusion. We retrospectively reviewed patients with degenerative lumbar spinal stenosis with instability with a positive VP on preoperative computed tomography (CT) who underwent posterolateral lumbar spinal fusion. Lumbar CT and radiographs were evaluated for the presence of VP and fusion at each level. Thirty-six positive VP levels were identified on the preoperative lumbar CT at the levels in the fusion in 18 patients. The mean age at surgery was 67.6 ± 9.4 years and mean follow-up was 1.6 ± 0.86 years. Fusion was seen at 32 levels (88.9%). Of the 15 levels where VP persisted, evidence of fusion was seen in 13 levels and pseudarthrosis was seen at 2. Of the 21 levels where VP disappeared, fusion was seen at 19 levels and pseudarthrosis was seen at 2 .There was no significant difference between the 2 groups (P > .05). We did not find an association between persistence of VP and pseudarthrosis. Persistence of VP after spinal fusion may not be an indicator of pseudarthrosis, and should not be misinterpreted as an indication for additional surgery.

Grafting of Expanded Mesenchymal Stem Cells without Associated Procedure in a Healed Case of Ulna Pseudarthrosis: A Case Report

BACKGROUND

The surgical management of pseudoarthrosis is often a challenge. The use of mesenchymal multipotent cells expanded and manipulated in the laboratory is an interesting treatment of pseudoarthrosis, because they can lead to differentiation into osteocytes and thus the formation of bone tissue.

CASE DESCRIPTION

We present a case of a 47-years-old man with isolate ulna fracture, treated with plate and screws and evolved in non-union. The patient underwent an expanded stem cells graft on the site of non-union with a small incision of approximately 3cm, without changing the synthesis system. After one year, the X-ray showed a complete fracture consolidation.

DISCUSSION

In our opinion, this case is interesting because it highlights the cellular action that is the only healing factor; it is an important demonstration of the biological action of expanded mesenchymal stem cells (MSCs).

CONCLUSION

To validate the use of MSCs, it is necessary to perform comparative studies for age, sex, general condition, location, and mechanism of injury as a further clinical validation of the efficiency of this cell line.

Scaffold-free Three-dimensional Graft From Autologous Adipose-derived Stem Cells for Large Bone Defect Reconstruction: Clinical Proof of Concept

Long bone nonunion in the context of congenital pseudarthrosis or carcinologic resection (with intercalary bone allograft implantation) is one of the most challenging pathologies in pediatric orthopedics. Autologous cancellous bone remains the gold standard in this context of long bone nonunion reconstruction, but with several clinical limitations. We then assessed the feasibility and safety of human autologous scaffold-free osteogenic 3-dimensional (3D) graft (derived from autologous adipose-derived stem cells [ASCs]) to cure a bone nonunion in extreme clinical and pathophysiological conditions. Human ASCs (obtained from subcutaneous adipose tissue of 6 patients and expanded up to passage 4) were incubated in osteogenic media and supplemented with demineralized bone matrix to obtain the scaffold-free 3D osteogenic structure as confirmed in vitro by histomorphometry for osteogenesis and mineralization. The 3D "bone-like" structure was finally transplanted for 3 patients with bone tumor and 3 patients with bone pseudarthrosis (2 congenital, 1 acquired) to assess the clinical feasibility, safety, and efficacy. Although minor clones with structural aberrations (aneuploidies, such as tri or tetraploidies or clonal trisomy 7 in 6%-20% of cells) were detected in the undifferentiated ASCs at passage 4, the osteogenic differentiation significantly reduced these clonal anomalies. The final osteogenic product was stable, did not rupture with forceps manipulation, did not induce donor site morbidity, and was easily implanted directly into the bone defect. No acute (<3 mo) side effects, such as impaired wound healing, pain, inflammatory reaction, and infection, or long-term side effects, such as tumor development, were associated with the graft up to 4 years after transplantation. We report for the first time that autologous ASC can be fully differentiated into a 3D osteogenic-like implant without any scaffold. We demonstrated that this engineered tissue can safely promote osteogenesis in extreme conditions of bone nonunions with minor donor site morbidity and no oncological side effects.

Pseudarthrosis after lumbar spinal fusion: the role of ¹⁸F-fluoride PET/CT

Purpose

Painful pseudarthrosis is one of the most important indications for (revision) surgery after spinal fusion procedures. If pseudarthrosis is the source of recurrent pain it may require revision surgery. It is therefore of great clinical importance to ascertain if it is the source of such pain. The correlation between findings on conventional imaging (plain radiography and CT) and clinical well-being has been shown to be moderate. The goal of this study was to determine the possible role of ¹⁸F-fluoride PET in patients after lumbar spinal interbody fusion by investigating the relationship between PET/CT findings and clinical function and pain.

Methods

A cohort of 36 patients was retrospectively included in the study after ¹⁸F-fluoride PET/CT for either persistent or recurrent low back pain (18 patients) or during routine postoperative investigation (18 patients) between 9 and 76 months and 11 and 14 months after posterior lumbar interbody fusion, respectively. Sixty minutes after intravenous injection of 156 – 263 MBq (mean 199 MBq, median 196 MBq) ¹⁸F-fluoride, PET and CT images were acquired using an integrated PET/CT scanner, followed by a diagnostic CT scan. Two observers independently scored the images. The number of bony bridges between vertebrae was scored on the CT images to quantify interbody fusion (0, 1 or 2). Vertebral endplate and intervertebral disc space uptake were evaluated visually as well as semiquantitatively following ¹⁸F-fluoride PET. Findings on PET and CT were correlated with clinical wellbeing as measured by validated questionnaires concerning general daily functioning (Oswestry Disability Index), pain (visual analogue scale) and general health status (EuroQol). Patients were divided into three categories based on these questionnaire scores.

Results

No correlation was found between symptom severity and fusion status. However, ¹⁸F-fluoride activity in the vertebral endplates was significantly higher in patients in the lowest Oswestry Disability Index category (i.e. with the worst clinical performance) than in patients in higher categories (p = 0.01 between categories 1 and 2 and 1 and 3). The visual analogue scale and EuroQol results were similar although less pronounced, with only SUV_max between category 1 and 2 being significantly different (p = 0.04).

Conclusion

We hypothesize that ¹⁸F-fluoride PET/CT may be able to provide support for the diagnosis of painful pseudarthrosis and could serve as a tool to discriminate between symptomatic and asymptomatic pseudarthrosis for revision surgery, as CT defines the consolidation status and PET pinpoints the ‘stress reaction’ at the vertebral endplates which significantly correlates with Oswestry Disability Index score.

Interobserver agreement using computed tomography to assess radiographic fusion criteria with a unique titanium interbody device

The accuracy of using computed tomography (CT) to assess interbody fusion in patients with titanium implants has been questioned in the past. Radiologists have reported difficulty assessing fusion bone quality because of metal artifact and small graft windows. A new titanium interbody implant with a large footprint and a wide graft aperture has been developed. We conducted a study to determine the interobserver reliability of using CT to assess radiographic fusion variables with the new titanium interbody device. Patients underwent anterior lumbar interbody fusion with the same titanium interbody implant. Reconstructed CT images were obtained randomly at 6, 9, or 12 months. Two independent radiologists reviewed the scans. Interobserver reliability was calculated using the κ statistic. Fifty-six spinal fusion levels (33 patients) were analyzed. The radiologists agreed on 345 of the 392 fusion data points reviewed (κ = .88). Agreement for solid fusion formation was 0.77. This interbody device demonstrated minimal artifact and minimal subsidence, and trabecular bone was easily identified throughout the implant in the vast majority of cases reviewed. High interobserver agreement was noted across all radiographic variables assessed.

[Bisegmental anterior interbody spondylodesis, using rigid plates, in surgical treatment of cervical vertebral column traumas and diseases]

Results of surgical treatment of 34 patients, suffering cervical vertebral column traumas and diseases, are analyzed. In all the patients bisegmental anterior interbody spondylodesis was conducted, using cervical rigid plates and vertical cylindrical net implants. The existing and newly obtained information about changes in the radiological indices dynamics while the method application by its authors is presented. The interbody synostosis was achieved in 82.4% patients in 1 yr after the operation. The complications rate while the implants application have constituted 23.3%, and the total rate of complications--29.1%.

Pseudoarthrosis of the hand in neurofibromatosis type 1: a case report

Neurofibromatosis (NF) is a disorder with a wide spectrum of clinical manifestations. Here, we describe a 16-year-old boy with NF1 who had pseudoarthrosis of the 4th and 5th fingers of the left hand. He had specific cutaneous lesions and Lisch nodules in the iris. Because NF1 affects multiple organ systems, patients are likely to benefit most from a multidisciplinary treatment strategy.

[Clinical observation and evaluation of reasons for pseudarthrosis after anterior cervical fusion]

OBJECTIVE

To explore the causes of pseudarthrosis and evaluate the clinical neurological function and neck subaxial symptoms after anterior cervical fusion.

METHODS

A total of 412 patients were followed up with an average of 5.4 years. The bone mineral density, bone graft trimming and placement, management of endplate, smoking and neck support fixation time were observed. Japanese Orthopedic Association (JOA) score was used to evaluate the changes of neurological functions and clinical outcomes. Visual analog scale (VAS) score was used to evaluate the neck subaxial symptoms. And pseudarthrosis was examined by flexion-extension radiography. SPSS statistical software 13.0 was used to evaluate the differences of JOA and VAS scores between pseudarthrosis and control groups.

RESULTS

Among them, 37 cases of pseudarthrosis were observed. There were osteoporosis (n = 30 vs n = 119), cartilage end-plate punctuate hemorrhage (n = 18 vs n = 340), 25 and 43 cases with ineffective cervical external fixation (n = 25 vs n = 43) and smoking (n = 26 vs n = 87) in pseudarthrosis and fusion groups respectively. Significant differences existed in the above-mentioned indices between two groups. However, no significant difference existed in bone graft shape between two groups. There were significant differences in JOA and VAS scores between two groups.

CONCLUSION

The causes of pseudarthrosis included decreased bone density, osteoporosis, over-curette of endplate, shortness of neck support fixation time and smoking. And pseudarthrosis may influence the long-term recovery of neurological functions or it is correlated significantly with neck symptoms.

[Formation of vascularized bone grafts and their use for treatment of pseudoarthroses and bone defects]

An analysis of 135 transplant surgeries of vascularised bone grafts in treatment of pseudoarthroses and defects of the clavicle, humerous, ulnar, radial, metacarpal,wrist and fingers bones was made. The fusion was noticed in 130 operated patients. The earlier removal of immobilization (in 2), the repeated trauma (in 2) and osteomyelitis of the transplanted graft, which required its removal in 1 patient, were the causes of failure in 5 (3.7%) patients.

Upper and lower limb length equalization: diagnosis, limb lengthening and curtailment, epiphysiodesis

INTRODUCTION

This article contains notions and guidelines derived from the current therapeutic approach used in the Pediatric Orthopedics Clinic of "M.S. Curie" Hospital, Bucharest. The purpose of this work is to illustrate the clinic's experience theoretically and by means of images.

METHODS

This article is based on 25 years of clinical experience (1986-2011), gained at Mangalia Regional Hospital and the Pediatric Orthopedics Clinic of "M.S. Curie" Hospital in Bucharest, having treated more than 250 such cases. In post-traumatic shortenings with associated soft tissue injuries we used double leveled corticotomies and lengthening. The lengthening rarely exceeded 10 cm, especially for congenital deformities and repeated lengthening. From 2001 onwards, all lengthening operations included the intramedullary implantation of one or two TEN rods, with the purpose of reducing the time to fixator removal and to shrink the healing index. In the last five years we frequently used minimally invasive osteotomies after the placement of TEN implants, achieving the separation of a small fragment that sites itself between the major fragments. The lengthening rate was 1 mm per day, broken down in four steps (0.25 mm every 6 hours). For difficult cases, such as congenital pseudarthroses or the presence of scar tissue around the osteotomy site, we recommended 0.75 mm of lengthening per day (0.25 mm every 8 hours). For congenital pseudarthroses we used controlled epiphysiolysis and bone transport. For inequalities ranging 3 to 5 cm we used temporary epiphysiodesis, initially with staples, and subsequently with "8", "H" and "I" plates. Limb shortening followed by locked intramedullary fixation was reserved for those patients who did not follow through with the evaluation program and who could not benefit from temporary epiphysiodesis.

RESULTS

The amount of lengthening per segment varied between 3 and 17 cm. The longest staged lengthening measured 20 cm, in two stages, and the greatest overall lengthening was 25 cm for an entire lower limb. An appropriate stabilization, followed by the adequate choice of osteotomy site and the postoperative weight loading of the limb ensured a quick and qualitative healing process.

COMPLICATIONS

Less than half of the patients suffered complications, most of them being minor ones. Pseudarthroses have been treated by compaction of the site, followed by distraction, and/or the injection of BMP (Bone Morphogenic Protein). We saw no complications after epiphysiodesis or limb shortening.

CONCLUSIONS

Limb lengthening procedures up to 5 cm lead to rapid consolidation and minimal complications. Lengthenings exceeding 5 cm require a good psychological preparation and careful monitoring. In lengthenings more than 10 cm, a faster rate of consolidation requires a double corticotomy, the use of intramedullary fixation and the immobilization of adjacent joints. In Lobstein's disease, good results can be obtained by the use of an Ilizarov external fixator. Restoring limb length equality by temporary epiphysiodesis, around the age of 10-12, is the least aggressive method and is very effective. Limb shortening by segmental resection should become obsolete.

[Therapy-resistant, atrophic and septic femoral pseudarthrosis]

Non-union is a common and serious complication in orthopaedic surgery with high socioeconomic importance. In addition to conventional methods for the treatment of non-unions bone morphogenetic protein (BMP)-7 for the induction of bone tissue is available. The case report demonstrates successful treatment of a septic and atrophic femoral non-union by combination therapy with BMP-7 and autologous spongiosa graft after multiple revision surgeries.

[Non-vascularized fibular graft as salvage technique for forearm reconstruction]

Authors report a case of a reconstruction of a large bone defect in the forearm with a free fibular graft occurring a good incorporation of the graft. Authors discuss the interest of fibula graft in reconstruction of large bone defect of the forearm.

Comparative study of the use of electromagnetic fields in patients with pseudoarthrosis of tibia treated by intramedullary nailing

We made a comparative cohort study in patients suffering from tibial pseudoarthrosis, all of whom were treated by intramedullary nailing. We divided patients into two groups: one treated by intramedullary nailing only (control group) and the other by intramedullary nailing combined with pulsed electromagnetic fields (PEMFs). The study included 57 cases of tibial pseudoarthrosis in 57 patients from February 1987 to February 2002. Pseudoarthrosis was treated surgically in all cases (Grosse-Kempf dynamic intramedullary nailing). This was combined with PEMFs in 22 cases. The average age was 38.3 years (range 14-89 years) and the average duration of follow-up was 27.2 months (range 12-48 months). Forty-nine fractures (86%) healed and eight (14%) did not. Of the group treated with PEMFs, 20 (91%) healed and two (9%) did not; from the group that did not receive PEMF (35), 29 (83%) healed compared to six (17%) that did not. The relationship between union and use of PEMFs, and between time to union and use of PEMFs was clinically relevant. PEMFs are useful when treating tibial pseudoarthrosis. Its noninvasive nature means that there are more complication-free unions.

A neglected case of congenital pseudarthrosis of tibia

Congenital pseudarthrosis of the tibia (CPT) is a rare malformation. It was first described by Hatzoecher in 1708. Treatment options of the congenital pseudarthrosis of tibia are variable and challenging. Various forms of bone grafts such as autologous iliac bone graft or free vascularised fibular graft, bracing, electrical stimulation, external fixators including Ilizarov technique and internal fixation with rods and plates are used. Here we represent a case of congenital pseudarthrosis of the tibia (CPT) of a 15 year-old boy, a shopkeeper hailing from Barhatta, Netrokona and diagnosed by history, clinical examination and x-ray. He was treated by Ilizarov technique and follow up was done for a period of 1 year. Complete union was achieved with correction of angulation and shortening.

Isolated congenital anterolateral bowing of the fibula: a case report with 24 years follow-up

Only very few cases of congenital anterolateral bowing of the fibula have been described in literature. We report a girl with congenital anterolateral bowing of the fibula with a 24 year follow-up. Asymptomatic bowing of her left leg below the knee was noted at the age of three years. Radiographs showed an isolated anterolateral bowing of the fibula with a normal ipsilateral tibia. Supervised neglect was advised. A spontaneous fracture occurred one year later. A shortening osteotomy resulted in solid consolidation of the fracture. At the age of 27 years the deformity had progressed into a two-level fracture of the fibular diaphysis with pseudoarthrosis. The segment in-between the fractures was resected. Following this, the patient returned to a normal level of activities in just a matter of weeks. She could even participate in recreational tennis six weeks after surgery and was then discharged from the outpatient clinic. Isolated congenital anterolateral bowing of the fibula is a very rare condition and there is no consensus on its treatment. In this case, removal of the painful pseudarthrotic fragment of the fibula led to a good result.

Bone loss treatment, pseudoarthrosis, arthrodesis and benign tumors using xenoimplant: clinical study

BACKGROUND

Bone loss as a result of arthrodesis, pseudarthrosis, benign tumors and bone defects was treated using a xenoimplant (Nukbone).

METHODS

The effectiveness of the material was evaluated through a longitudinal and observational study at the Hospital Regional "General Ignacio Zaragoza" (HRGIZ) ISSSTE. The Mexican xenoimplant is a patent of the National Autonomous University of Mexico (UNAM).

RESULTS

Fifty two patients were considered regardless of age or gender. Of these patients, 28 were male and 24 female. Average age of the patients was 47.7 years (9-84 years). Twenty eight patients had arthrodesis, 16 were treated with pseudarthrosis, three patients had benign tumors and five patients presented bone defects, which were implanted with Nukbone at the site and was the correct treatment for the problem. The xenoimplant is fully integrated during a period of 3-18 months, depending on the size of the pathology and the region where it was placed. Fracture healing was evaluated radiographically according to the classification of Montoya. No patient had clinical signs of rejection.

CONCLUSIONS

In Mexico, bony xenoimplants (osseous) have been used, all of foreign origin due to the high degree of technological dependence in this country. In this study we describe the use, for the first time, of a Mexican xenoimplant with a patent from the Universidad Nacional Autónoma de México (UNAM). The Mexican xenoimplant is biocompatible and can be adapted to treat pathologies where bony (osseous) material is needed.

Salvage procedures for pseudarthrosis after transforaminal lumbar interbody fusion (TLIF)-anterior-only versus anterior-posterior surgery: a clinical and radiological outcome study

A retrospective review was performed to analyze the radiographic and functional outcomes of two different surgeries to repair a pseudarthrosis following a transforaminal lumbar interbody fusion (TLIF) procedure. Although there are several published reports on the results of the TLIF procedure, there are no reports on how to salvage a failed TLIF. A total of 38 consecutive patients with failed TLIF procedures (at 50 levels) were repaired by either a direct anterior approach only (21 patients) or by a combined direct anterior approach coupled with a posterior exploration and pseudarthrosis repair (17 patients). The minimum follow-up after revision was 24 months. Clinical outcome was measured by Oswestry Disability Index, Roland Morris Questionnaire, SF-36, and the authors' own centers' satisfaction questionnaire in 17 of the 38 patients. The fusion rate for the anterior-alone group was 81% (17/21) and 88% (15/17) for the anterior-posterior group, not a statistically significant difference. The Oswestry scores averaged 56.4 for the anterior lumbar interbody fusion (ALIF) group and 51.4 for the anterior-posterior fusion (APF) group. The Roland-Morris scores averaged 18.9 for the ALIF group and 20.0 for the APF group. The SF-36 showed similar outcomes in both groups. The authors' center's satisfaction questionnaire also showed similar results. The outcomes, both radiologic and functional, were equal in both groups. There was very little improvement in functional outcomes comparing prerepair to postrepair based on the authors' questionnaire.