Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital

BACKGROUND

Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team.

METHODS

The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up.

RESULTS

The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months.

CONCLUSION

Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

[The frequency of endothelial dysfunction in patients with pseudarthrosis of long bones with hyperhomocysteinemia and associated metabolic disorder]

In article described research of frequency of endothelial dysfunction in 153 patients with pseudarthrosis of long bones and in individuals with consolidated fractures. The reparative regeneration are associated by structural and functional disorders of the central and peripheral vessels as endothelial dysfunction, thickening of the intima-media, prevails at hypoplastic and atrophic types bone nonunion, neurotrofic syndrome and refractures. Endothelial function was significantly dependent on the levels of homocysteine, total cholesterol and interleukin-6 in serum.

Alternative technique of cement augmentation of loosened pedicle screws -- technical note and presentation of two cases

An alternative cement augmentation technique for pedicle screws is described, which was applied in two patients with mono- and bisegmental non-union after preceding multisegmental lumbar fusion. The correctly placed pedicle screws in S1 with diameters of 6 and 8.5 mm had severely enlarged the screw cavities due to segmental instability. Revision screws with 10 mm diameter demonstrated sufficient purchase only on the left side. Therefore, cement augmentation was performed for the right sided screws. After verification of intact pedicle borders, the cavity was filled up with PMMA bone cement. Afterwards, a Kirschner wire was positioned centrally, the hardening of the cement was awaited, the cement was gradually drilled and the screw was placed. In both patients, sufficient purchase of the cemented pedicle screws was documented. Screw insertion after awaiting the hardening of the bone cement in pedicles and vertebral bodies with huge defect situations seems to be an alternative to previous cement augmentation techniques of pedicle screws with the advantage, that the screws could be more easily unscrewed, if necessary.

Treatment of pseudoarthrosis of the upper limb using expanded mesenchymal stem cells: a pilot study

BACKGROUND

In orthopedic field is growing interest in the use of stem cells: this mesenchymal multipotent line (MSCs) can lead to differentiation into osteocytes and thus the formation of bone tissue. In literature applications of this line are described in injuries of tendons and ligaments, small bony avulsions, nonunion fractures and cartilage defects.

AIM

Utilize MSCs expanded in laboratory in case of atrophic pseudoarthrosis of the upper limb.

MATERIALS AND METHODS

We obtain the amount of cell necessary for the implant by the collaboration with the UO Haematological Department. For the procedure we make a blood sample from the iliac crest bone marrow and a subsequent phase of selection and cultivation of mesenchymal line for 3 weeks, to get a sufficient amount of tissue to be used, which is presented at the time of surgery on a scaffold made by autologous plasma gel and CaCl(2). We reassessed our experience in 8 different types of upper limb fractures result in pseudarthrosis and delayed of consolidation: 4 women and 4 men, average 44 years old followed with a follow-up of 50.3 months. In all cases the site of non-union has been revitalized (by microfractures and drilling) and a synthesis was performed with a rigid plate. So we fill the bone gap with autologous bone and mesenchymal stem cells expanded in the laboratory.

RESULTS

We have a radiographic healing in 8 cases and no adverse events were highlighted.

CONCLUSIONS

Using this cells line we obtained encouraging but certainly not conclusive impressions, according to the limited number of cases and lack of adequate comparative studies. In tissue engineering are also certainly needed further investigations and developments.

Vascularized bone grafts for the management of skeletal defects in orthopaedic trauma and reconstructive surgery

Bone loss from trauma, neoplasia, reconstructive surgery and congenital defects remains a major health problem. The long-term clinical goal is to reconstruct bony tissue in an anatomically functional three-dimensional morphology. In the extremities, bone grafts are used for the treatment of non-unions and necrotic lesions, for skeletal structural support and for the reconstruction of defects resulting from trauma, tumor excision, osteomyelitis, congenital pseudarthrosis, or radiation necrosis. In all cases their use is successful provided that the host bed has adequate vascularization. In cases of decreased blood supply, a vascularized bone graft should be applied. The intrinsic blood supply of the vascularized bone grafts leads to higher success rates and to acceleration of the repair process in the reconstruction of defects and necrotic lesions of the skeleton.

[TGF-beta1 as a pathophysiological factor in fracture healing]

AIM

TGF-beta1 is an important local and systemic regulatory molecule during fracture healing. Various authors have shown differences in the systemic levels of TGF-beta1 over the time taken for bone healing in distraction osteogenesis and osteotomies. Previous studies have shown characteristic differences in the physiological levels of growth factors between normal fracture healing and delayed fracture union. The aim of the present study was to evaluate possible differences in sera levels of patients with normal and delayed union fracture healing.

METHODS

Patients with long bone shaft fractures were recruited prospectively. Peripheral blood samples were collected over a period of 1 year using a standardized time schedule. At the end of the individual's investigation period, TGF-beta1 levels were determined. To achieve a homogeneous collective of patients, only those with a maximum of two fractures were included in the study. After matching for four criteria, we compared patients with normal fracture healing to patients with delayed unions. The fact of delayed union was accepted in case of failed consolidation 4 months after trauma.

RESULTS

During a prospective study period of 1 year, 15 patients with normal fracture healing could be compared to 15 patients suffering from delayed union. By determining the absolute sera levels we found a typical increase of TGF-beta1 up to 2 weeks after fracture in both groups, with a subsequent decrease up to the sixth week after fracture. However, a decline in serum concentration occurred earlier in patients with delayed union, causing significantly lower TGF-beta1 levels in the non-union group 4 weeks after trauma (P=0.00006).

CONCLUSION

Even with a relatively small number of patients, we could show a significant difference in serum concentrations of TGF-beta1 between the investigated groups. If these results can be verified within a larger collective, TGF-beta1 could be used as a predictive cytokine for delayed fracture healing.

rhBMP-2 (ACS and CRM formulations) overcomes pseudarthrosis in a New Zealand white rabbit posterolateral fusion model

STUDY DESIGN

The study design consisted of a New Zealand white rabbit model of pseudarthrosis repair. Study groups consisting of no graft, autograft, or recombinant human bone morphogenetic protein-2 (rhBMP-2) with absorbable collagen sponge (ACS) or compression resistant matrix (CRM) were evaluated.

OBJECTIVE

To evaluate the relative efficacy of bone graft materials (autograft, ACS, and CRM).

SUMMARY OF BACKGROUND DATA

rhBMP-2 has been shown to have a 100% fusion rate in a primary rabbit fusion model, even in the presence of nicotine, which is known to inhibit fusion.

METHODS

Seventy-two New Zealand white rabbits underwent posterolateral lumbar fusion with iliac crest autograft. To establish pseudarthroses, nicotine was administered to all animals. At 5 weeks, the spines were explored and all pseudarthroses were redecorticated and implanted with no graft, autograft, rhBMP-2/ACS, or rhBMP-2/CRM. At 10 weeks, fusions were assessed by manual palpation and histology.

RESULTS

Eight rabbits (11%) were lost to complications. At 5 weeks, 66 (97%) had pseudarthroses. At 10 weeks, attempted pseudarthrosis repairs were fused in 1 of 16 of no graft rabbits (6%), 5 of 17 autograft rabbits (29%), and 31 of 31 rhBMP-2 rabbits (with ACS or CRM) (100%). Histologic analysis demonstrated more mature bone formation in the rhBMP-2 groups.

CONCLUSIONS

The 2 rhBMP-2 formulations led to significantly higher fusion rates and histologic bone formation than no graft and autograft controls in this pseudarthrosis repair model.

Prediction of biomechanical stability after callus distraction by high resolution scanning acoustic microscopy

Accurate clinical prediction of the resistance to fracture after callus distraction requires a detailed understanding of structural and elastic properties of the newly formed bone. We investigated 26 sheep that underwent middiaphyseal callus distraction at a rate of 0.5 mm every 12 h for 30 d using a standard unilateral fixator system. The sample population included four groups undergoing different treatments to improve bone healing, including bone grafting and the local application of growth factors. All animals were sacrificed eight weeks after the end of distraction. The fracture forces of the lengthened tibia and the contralateral control tibia from each animal were evaluated by biomechanical (four-point bending) testing. The microstructure and anisotropic acoustic impedance distributions were assessed by quantitative 50-MHz scanning acoustic microscopy. The relationships between resistance to fracture, structural properties and acoustic impedance of the newly formed callus tissue and adjacent cortical tissue were investigated. A significant linear multivariate regression model was developed that predicts the fracture force with a high accuracy (RMSE = 248 N, R(2) = 0.86, p < 0.0001).

Short Form–36 outcomes following focal 1- and 2-level cervical laminectomy with multilevel instrumented fusion

BACKGROUND

Multilevel laminectomy with instrumented fusion addresses diffuse dorsal cord compression with an adequately preserved cervical lordosis. However, for patients with only 1 to 2 laminar impingement, more "focal" laminectomy and fusion may suffice, the shortened laminectomy allowing for a more simple spinous process fusion skipping the 1 or 2 lamina that have been removed.

METHODS

Fourteen patients presented with severe spastic myeloradiculopathy (Nurick grade IV) attributed to magnetic resonance imaging- and CT-documented 1- to 2-level laminar compression, stenosis, and ossification of the yellow ligament. Magnetic resonance images also revealed 1- to 2-level hyperintense signals within the cord at the levels of maximal compromise. Surgical procedures included 1- to 2-level laminectomies and average 6.4-level posterior fusions. Dynamic x-ray/CT studies, which were obtained 3, 6, and up to 12 months postoperatively, followed progression toward fusion. Outcomes were assessed using Nurick grades (0-V) and SF-36 questionnaires assessed preoperatively and up to 12 months postoperatively.

RESULTS

Patients improved on all 8 SF-36 Health Scales within the first postoperative year. Maximal improvement was observed on 5 Health Scales within the first 6 postoperative months (physical function, mental health, vitality, general health, role physical). The preoperative average Nurick grade (3.8) improved postoperatively (0.7 at 6 months, 0.5 at 1 year). Dynamic x-ray and CT studies documented fusion for all 14 patients by the sixth postoperative month.

CONCLUSIONS

One- and two-level cervical laminectomies with multilevel-instrumented fusion effectively decompressed "focal" cord compression, whereas fusion maintained the cervical lordotic curvature and provided stability to avert future disease progression.

Paraparesis due to exacerbation of preexisting spinal pseudoarthrosis following infliximab therapy for advanced ankylosing spondylitis

BACKGROUND CONTEXT

Recent reports have described the long-term efficacy and safety of infliximab as a treatment for ankylosing spondylitis (AS). The most important adverse effects of infliximab are infections, malignancies, autoimmunities, and hypersensitivity reactions. There has never been a reported case of paraparesis after infliximab therapy for AS.

PURPOSE

To describe a case with paraparesis caused by rapid exacerbation of preexisting spinal pseudoarthrosis after infliximab therapy for advanced AS.

STUDY DESIGN/SETTING

Case report/Osaka University Graduate School of Medicine, Suita, Japan.

PATIENT SAMPLE

A 55-year-old man with a 27-year history of AS.

OUTCOME MEASURES

Case report.

METHODS

A 55-year-old man with a 27-year history of AS was treated with infliximab, which provided considerable pain relief and improvement of activities of daily living. However, as the patient resumed vigorous daily activity, he felt back pain and subsequently developed paraparesis. Radiographs showed rapid exacerbation of preexisting spinal pseudoarthrosis at the T11-T12 level after infliximab therapy.

RESULTS

After laminectomy and posterolateral fusion, the back pain and paraparesis improved sufficiently to allow independent walking, but moderate bladder dysfunction persisted.

CONCLUSIONS

Although this patient could have certainly become myelopathic over time without undergoing infliximab therapy, the patient's history and radiographic course suggest that suppression of inflammation by infliximab improved his activities of daily living, which paradoxically exacerbated preexisting spinal pseudoarthrosis and quickened the onset of subsequent myelopathy.

Electrical stimulation therapies for spinal fusions: current concepts

Electrical stimulation therapies have been used for more than 30 years to enhance spinal fusions. Although their positive effects on spinal fusions have been widely reported, the mechanisms of action of the technologies were only recently identified. Three types of technologies are available clinically: direct current, capacitive coupling, and inductive coupling. The latter is the basis of pulsed electromagnetic fields and combined magnetic fields. This review summarizes the current concepts on the mechanisms of action, animal and clinical studies, and cost justification for the use of electrical stimulation for spinal fusions. Scientific studies support the validity of electrical stimulation treatments. The mechanisms of action of each of the three electrical stimulation therapies are different. New data demonstrates that the upregulation of several growth factors may be responsible for the clinical success seen with the use of such technologies.

Pseudoarthrosis of vertebral fracture: radiographic and characteristic clinical features and natural history

BACKGROUND

We examined mobility based on radiographic appearance, clinical appearance, and the natural course of osteoporotic vertebral pseudoarthrosis (VPA) in a prospective study in 34 consecutive cases of VPA in 27 patients with osteoporosis.

METHODS

Conventional lateral, lateral flexion, and extension stress radiography (XP) and supine cross-table lateral XP were performed. Anterior vertebral body height and vertebral kyphotic angle were measured to assess vertebral mobility. If vertebral cleft or vertebral instability, which means a difference in vertebral body height between conventional and supine cross-table lateral XP, was present, VPA was diagnosed. Back pain was classified into five grades.

RESULTS

The average anterior vertebral height was 9.9 +/- 5.6 mm on conventional lateral XP; it increased to 11.4 +/- 6.5 mm on extension stress XP (not significant) and 18.3 +/- 5.7 mm on cross-table lateral XP (significant). The vertebral kyphotic angle was 24.1 degrees +/- 9.7 degrees on conventional lateral XP; it decreased to 21.6 degrees +/- 9.8 degrees on extension stress XP (not significant) and 11.8 degrees +/- 8.5 degrees on cross-table lateral XP (significant). Intravertebral clefts were detected by conventional lateral XP, extension stress XP, and supine cross-table XP in 3 of 34 (8.8%), 7 of 21 (33.3%), and 28 of 34 (82.4%) vertebral compression fractures (VCFs), respectively. Surgical treatment was performed in seven patients (two because of severe pain and five because of neurological deficits) and in one patient who died. Except in these eight patients, back pain decreased by at least one grade with time in 18 of 19 patients (95%) in whom the clinical course was analyzed. Radiographic follow-up using supine cross-table XP was performed in 15 of 19 patients. Although 11 of these 15 patients (73%) showed vertebral instability on supine cross-table lateral XP, 10 of 11 patients (91%) did not complain of intolerable back pain during daily activity at the final follow-up.

CONCLUSIONS

VPA is often detected on supine cross-table lateral XP but not usually on extension stress XP. Despite the presence of vertebral instability, many patients did not complain of intolerable back pain during their daily activity. Surgical treatment to alleviate back pain should be performed for painful VPA after conservative treatment for about 4 months.

Allograft bone in spinal fusion for adolescent idiopathic scoliosis

OBJECTIVE

The purpose of this long-term study was to determine the efficacy of allograft bone for spinal fusion for adolescent idiopathic scoliosis. Prior studies comparing allograft and autograft have been short term.

METHODS

This multicenter retrospective study was carried out on 111 patients with 132 total curves fused for adolescent idiopathic scoliosis. Minimum follow-up was 5 years (average 72 months). A variety of segmental instrumentation was used, with most being dual-rod, multiple-hook constructs.

RESULTS

Average preoperative curve was 59 degrees with immediate correction to 29 degrees (51%) and final follow-up of 32.24 degrees (45.4%). Average loss of correction was 3.5 degrees (5.9%). There were three pseudarthroses, one infection, and no rod breakage.

CONCLUSION

Pseudarthrosis rate of 2.7% and loss of correction of 5.9% are comparable with or better than those in previous reports using autogenous bone graft and either segmental or nonsegmental instrumentation.

Étude rétrospective des résultats du traitement chirurgical de 21 pseudarthroses de l'humérus

INTRODUCTION

The morbidity of surgery for non-union of the humerus is not insignificant: the aims of this retrospective study were to study the results of these rather difficult procedures and to make some logical suggestions regarding surgical technique.

PATIENTS AND METHODS

Between 1996 and 2000, 21 patients had a surgical procedure for non-union of the humeral shaft. At follow-up, the mean age was 40 years. The causes of the initial trauma were: 12 road accidents, seven standing height falls, one fall from a window, one farm machine accident. The commonest fracture site was the middle third. In 17 procedures, we performed plate osteosyntesis. Three patients were treated by external fixator because of infection. In one patient we used a nail. For the follow-up evaluation, we used the score of the Western Orthopaedic Society.

RESULTS

According to the "WOS" score evaluation, we noted: ten very good results, five good results, three poor results and one bad result. The bad result corresponded to the patient in whom consolidation was not obtained.

DISCUSSION AND CONCLUSION

Management of non-union of the humerus should be by immediate surgery. The best treatment of non-union of the humerus is its prevention by correct management of the initial fracture.

Funktionelle Ergebnisse nach Entfernung der proximalen Handwurzelreihe bei SNAC- und SLAC-Wrist Stadium II

The proximal row carpectomy (PRC) is a motion preserving procedure which creates a new joint without arthrosis. It is a frequently used procedure in stage II of a posttraumatic degenerative arthrosis of the wrist after scaphoid nonunion or scapholunate ligament instability (SNAC-/SLAC-wrist). In this retrospective analysis the functional postoperative results of this operation are compared in light of a homogenous indication (SNAC-/SLAC-wrist stage II). In 38 patients PRC was performed for a stage II SNAC- (n = 29) or SLAC-wrist (n = 9) between June 1994 and March 2002. Postoperative examination included range of motion and grip strength. Pain was assessed using a visual analogue scale (VAS 0 - 100). The DASH questionnaire (disability of the arm, shoulder and hand) was used to evaluate the disabilities in activities of daily living (ADL). Thirty patients (79 %) with a mean age of 39 years (23 - 59) were evaluated with a mean follow-up of 27 months (6 - 100). Mean extension and flexion of the wrist reached 75 degree which was 57 % of the contralateral hand. Mean radial and ulnar deviation was 33 degree corresponding with 52 % of the contralateral hand. The average grip strength was 50 % of the unaffected side. The postoperative DASH score was 27.4. Pain with strenuous activity was reduced by 40 %, resting pain by 77 %. Three patients showed radiological signs of a radiocapitate arthrosis, one patient needed conversion into a complete wrist arthrodesis. Our results are in concordance with the literature. However, our follow-up time is relatively short and we cannot make any conclusion about the long-term outcome. PRC is a technically straightforward procedure for treatment of carpal collapse. For stage II of the SNAC-/SLAC-wrist we consider the resection of the proximal carpal row an alternative procedure to the midcarpal arthrodesis particularly in patients who require less grip strength and when a shorter postoperative immobilization is reasonable.

Defining pseudoarthrosis in the cervical spine with differing motion thresholds

STUDY DESIGN

Calculate the apparent pseudarthrosis rate for anteriorly plated cervical spine fusions using different threshold levels of intervertebral rotation.

OBJECTIVES

Determine whether the apparent pseudarthrosis rate depends on the amount of intervertebral rotation used to characterize a fusion as a pseudarthrosis.

SUMMARY OF BACKGROUND DATA

Intervertebral motion at a spine fusion site is an important outcome measure in most spine fusion research studies. Intervertebral motion measures are used to determine if a device can be sold for use in spine fusion surgery. There is no consensus on how much motion is too much motion at a spine fusion site, and the intervertebral motion threshold that is used to define a pseudarthrosis is arbitrary. There are only limited data on the dependence of the pseudarthrosis rate on the threshold used to define a pseudarthrosis.

METHODS

Intervertebral motion at the fusion site was measured from flexion extension radiographs taken 1 year after cervical spine fusion using anterior plates and allograft in 200 patients. The number of cases where intervertebral motion at the fusion site exceeded thresholds between 1 degrees and 4 degrees were calculated. RESULTS.: The apparent pseudarthrosis rate varied from 6% when the intervertebral motion threshold was 4 degrees to 44% when the intervertebral motion threshold was 1 degrees .

CONCLUSIONS

The apparent pseudarthrosis rate was highly dependent on the threshold of motion used to define a pseudarthrosis.

Long-term outcomes of clavicular pseudoarthrosis therapy

BACKGROUND

Clavicular pseudoarthrosis is a rare condition, the management of which should not be underestimated because it requires re-operations and causes serious morbidity or even a lifelong handicap.

PATIENTS AND METHODS

We reviewed a series of 13 patients with non-union of a clavicular fracture who underwent a surgical treatment from the year 1993 to 2002. Twelve fractures were a result of trauma and one was a result of osteomyelitis. Twelve non-unions were located in the middle third of the clavicle, while only one was in the lateral third. Seven non-unions were atrophic and six were hypertrophic. The average age of patients was 33 years (range: 14-52 years). Average post-operative follow-up time was 4.7 years (range: 1-11 years). In the study, we used intramedullar osteosynthesis such as Kirschner wire, different kinds of plates and screws, followed by autogeneous or heterogeneous bone grafting. Constant scoring system was used to evaluate mobility and strength of the upper extremity.

RESULTS AND CONCLUSION

A single operation was adequate in seven cases; two operations were adequate in four cases and three operations were adequate in one case. Fractures healed properly in 11 cases, but in some cases mild-to-moderate symptoms still persisted post-operatively. The results of 13 patients who underwent various surgical procedures show that a reconstruction plate should be the first choice of osteosynthesis, followed by a dynamic-compression plate, and a semitubular plate should be the last choice. To conclude, with this kind of treatment of clavicular pseudoarthrosis, we achieved a high degree of patient satisfaction, as well as objective improvements in status reports.

Atrophic nonunions of the proximal ulna

Ten consecutive patients were treated by one surgeon for an atrophic nonunion of the proximal ulna. There were six men and four women with an average age of 47 years. Nine of the initial injuries were fracture-dislocations (seven posterior Monteggia lesions and two transolecranon fracture-dislocations) and one was a fracture of the proximal ulnar and radial diaphysis. The nonunion was associated with failed operative fixation in nine patients and occurred after treatment in cast in one patient. Three patients had synovial pseudarthroses and eight had bony defects. Debridement of the nonunion, autogenous cancellous bone grafting, and contoured limited-contact plate fixation were done at an average of 36 months after the original injury. The patients were followed up for an average of 39 months. Union was achieved in all 10 patients. The average arc of ulnohumeral motion was 105 degrees and the average arc of forearm rotation was 130 degrees. According to the system of Broberg and Morrey five patients had an excellent result, four had a good result, and one had a fair result. The fair result was attributable to proximal radioulnar synostosis and severe ulnohumeral arthrosis. Atrophic nonunion of fractures of the proximal ulna usually follow a complex injury treated with inadequate fixation. Stable plate fixation and autogenous bone graft predictably lead to union, but the functional result may be limited by associated problems.

[Comparison between fixation with Herbert screws and Kirschner wires in the treatment of scaphoid pseudoarthrosis]

OBJECTIVES

To compare the treatment results of patients with scaphoid pseudoarthrosis, who were treated by autogenous cancellous bone grafting followed by fixation with Herbert screws or Kirschner wires.

METHODS

The study included 19 men (mean age 28 years, range 20 to 41 years) who were treated for scaphoid pseudoarthrosis and had a minimum follow-up of 12 months. Treatment was comprised of autogenous cancellous bone grafting and fixation with Herbert screws (n=10) or Kirschner wires (n=9). Fifteen right and four left hands were affected. The mean duration between the traumatic event and surgery was 20 months (range 3 to 72 months). Fractures were localized in the proximal pole (n=4, 21%), waist (n=13, 68%), and in the distal pole (n=2, 11%). The mean follow-up was 16 months for Herbert screws, and 21 months for Kirschner wires.

RESULTS

None of the patients exhibited a loss in range of motion of 10 degrees or more. The mean time to union was six months (range 3 to 20 months) with Herbert screws and eight months (range 4 to 22 months) with Kirschner wires. All patients had union with Kirschner wires, whereas non-union occurred in three patients with Herbert screws, two of whom had had proximal pole fractures. Radiologic outcome was significantly different between the two groups (p<0.01).

CONCLUSION

Because of good vascularity and union potential, scaphoid pseudoarthrosis can be successfully treated by an appropriate surgical technique using autogenous cancellous grafting independent of fixation materials.

Isolated congenital pseudoarthrosis of the fibula

Congenital pseudarthrosis of the limb most commonly involves the tibia, although various combinations of bones including fibula, radius, ulna, clavicle and humerus have all been described. Isolated congenital pseudarthrosis of the fibula is a very rare entity with only 12 cases reported in the English literature. We report three cases of this condition treated in our institution. The first child had a varus ankle deformity at the age of 4 months. The other two children presented with valgus ankle deformity after they started to walk. Two patients were treated conservatively while the third had a distal tibio-fibular fusion in view of severe valgus deformity. All three patients showed good early results after 1 to 2 years. We advocate early distal tibio-fibular fusion to prevent valgus deformity in these children.

The role of neurofibromin and melatonin in pathogenesis of pseudarthrosis after spinal fusion for neurofibromatous scoliosis

We might hypothesize that the high rate of pseudarthrosis after spinal fusion for neurofibromatous scoliosis is related to two factors: the absence of neurofibromin and melatonin deficiency. Loss of the up-regulation of neurofibromin during the healing process might abolish the bone-forming effects mediated through platelet-derived growth factor (PDGF) and transforming growth factor (TGF) beta1. The absence of neurofibromin might cause an increase in the Ras activity that increases the mitogen-activated protein kinase (MAPK) with resultant disturbance of the regulatory mechanism of core binding transcription factor (Cbfa 1) and increase of osteocalcin. These effects might inhibit bone formation. Melatonin deficiency might cause defective bone formation and favour excess fibrous tissue formation.

Prospective radiographic and clinical outcomes and complications of single solid rod instrumented anterior spinal fusion in adolescent idiopathic scoliosis

STUDY DESIGN

Prospective clinical cases series.

OBJECTIVES

To prospectively evaluate outcomes and critically review radiographic results and complications associated with single solid rod anterior spinal fusions in adolescent idiopathic scoliosis with 2-year minimum follow-up (range, 2-6 years).

METHODS

Ninety consecutive patients at a single institution with thoracic (n = 43) or thoracolumbar/lumbar (n = 47) adolescent idiopathic scoliosis were treated by one of two surgeons with a similar anterior surgical technique using rib autograft, intradiscal structural (Harms) cages placed below T12, and anterior single solid rod convex compressive instrumentation. The patients were evaluated prospectively with the Scoliosis Research Society outcome instrument and upright radiographs before surgery and minimum 2-year follow-up. RESULTS (RADIOGRAPHIC): The average coronal correction of thoracic curves was from 55 degrees to 29 degrees (47%). The average correction of thoracolumbar/lumbar curves was from 50 degrees to 15 degrees (70%). In the sagittal plane, kyphosis was improved in thoracic fusions from 23 degrees to 30 degrees (T5-T12) and lordosis maintained in thoracolumbar/lumbar fusions at -58 degrees (T12-sacrum). Five patients (5.5%) developed a pseudarthrosis, four with implant failure. Three of five required a posterior fusion for a reoperation rate of 3.3%. The fourth and fifth patients were asymptomatic and appeared fused at the 2-year follow-up, with minimal loss of correction. Common risk factors for pseudarthrosis were smoking (4 of 5), weight >70 kg (4 of 5), and for thoracic pseudarthrosis, hyperkyphosis >40 degrees T5-T12 (2 of 3). RESULTS (CLINICAL OUTCOME): Scoliosis Research Society domain average scores were improved for function, pain, and self-image (P < 0.01). With the Scoliosis Research Society satisfaction domain, 88% responded that they were satisfied with their results and 89% would undergo the same treatment again. Four of five patients with pseudarthrosis did not have statistically significant lower final Scoliosis Research Society scores than those with solid fusions (93 vs. 97, P = 0.18).

CONCLUSION

Anterior instrumented fusions for adolescent idiopathic scoliosis using a single solid rod had good radiographic and clinical outcomes. Consideration should be given to alternate techniques in larger adolescents (>70 kg) with thoracic hyperkyphosis (>40 degrees ), and smoking should be avoided. Poor radiographic outcomes did not correlate with final Scoliosis Research Society scores.

Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws

STUDY DESIGN

An analysis of lumbosacral fusions for high-grade spondylolisthesis fusions with reduction and long fusions to the sacrum in ambulatory adults.

OBJECTIVE

To assess the clinical and radiographic results of lumbosacral fusions using bilateral S1 and iliac screws.

SUMMARY OF BACKGROUND DATA

S1 screws often fail with lumbosacral fusions, whereas L5-S1 pseudarthrosis is common in patients with deformity.

MATERIALS AND METHODS

A total of 81 patients (38 revision, 43 primary) with minimum 2-year follow-up (average, 4.2 years; range, 2.0-7.1 years) underwent L5-S1 fusion using S1 and iliac screws (158 screws). Forty-nine of 81 constructs (61%) included an anterior load-sharing/fixation device. Group 1 included isthmic spondylolisthesis (n = 42), whereas Group 2 included long fusions (> or =3 levels) to the sacrum (n = 39). In Group 2, 15 patients (Group 2A) were fused from L1, L2, or L3 to the sacrum (3-5 levels, average 3.3 levels) and 24 patients (Group 2B) were fused from the thoracic spine to the sacrum (6-17 levels, average 11.5 levels). Twelve patients had pseudarthrosis at L5-S1. A patient questionnaire was completed.

RESULTS

A total of 36 of the 38 revision patients had previous iliac crest harvesting, yet iliac screws were placed in 34 of 36 patients. Overall, 78 of 80 patients had iliac crest harvesting (one not attempted). None had loss of screw fixation or iliac crest fracture after harvesting. Four of the 81 patients (4.9%) had pseudarthrosis at L5-S1 after reconstruction. This included solid fusion in 10 of 12 patients presenting with L5-S1 pseudarthrosis. Fourteen percent of patients experienced some discomfort over the iliac screws; however, only one patient required screw removal.

CONCLUSIONS

Bilateral iliac screws coupled with bilateral S1 screws provide excellent distal fixation for lumbosacral fusions with a high fusion rate (95.1%) in high-grade spondylolisthesis and long fusions to the sacrum. Previous iliac crest harvesting does not prevent ipsilateral screw placement (34 of 36 patients) or additional iliac harvesting (78 of 80 patients).

[Vascularized peroneal reconstruction after bloc resection of tumors or congenital malformations of the upper limb in children]

Limb salvage surgery is the standard care for most malignant tumor affecting the extremities in the child, and a vascularized fibula transfer is probably the most popular microsurgical option to reconstruct long-bone defects. Between 1994 and 1999, nine children with intractable diseases of the upper limb were treated using free vascularized fibula grafts (one patient had resection in 1983 and initially prosthetic reconstruction, then fibula transplant in 1996). There were 6 boys and 3 girls. Mean age was 10 years (between 6 and 16). Eight patients had defects after sarcoma resection, one had an aggressive enchondroma. The reconstructed sites were the humerus (= 6), the radius (n = 3). The length of the bone defect ranged from 8 to 19 cm (mean: 14.4 cm). The fibula head with the cartilage and the growth plate was used in 3 children. One girl, 4.5 years old with congenital pseudoarthrosis of radius and cubitus had a resection and reconstruction with a U shaped fibula transplant. One patient died from lung and brain metastasis, two years after the reconstruction. There were no local recurrences. The complications were numerous but usually benign; fracture of the grafted fibula n = 7, necessity of additional bone grafts (n = 4) malunion (n = 1) needed reoperation, pseudoarthrosis (n = 2) with reoperation, ankle valgus (n = 1) required reoperation, necrosis of the fibula head (n = 1), radial inclination (n = 1). The ten patients had bone union. The mean period required to obtain radiographic bone union was 5 months. The functional results of the remaining patients were evaluated according to the scale of ENNEKING. The results ranged from 21 to 30 points. Our results were satisfactory with regard to pain, emotional acceptance, manual dexterity. The vascularized fibula graft is indicated in children with large bone defects, more than 8 cm in the humerus, radius and ulna.

Lumbar posterolateral fusion alone or with transpedicular instrumentation in L4--L5 degenerative spondylolisthesis

We retrospectively reviewed 57 patients with L4--L5 degenerative spondylolisthesis (L4--L5 DS) who underwent posterior decompression and posterolateral fusion of L4--L5 without (Group A) or with (Group B) transpedicular screw instrumentation at least 2 years earlier. The clinical results and fusion rate were similar between Groups A and B, that is, a 72.4% satisfactory outcome with a fusion rate of 82.8% in Group A versus 82.1% satisfactory outcome with a 92.8% fusion rate in Group B. Screw instrumentation reduced postoperative low back pain and resulted in a lordotic slip angle of L4--L5. However, in patients with radiologically excessive segmental motion showing a translational motion of 3 mm or more, flexion angulation of -5 degrees or less, and a slip angle of -5 degrees or less at the site of spondylolisthesis (L4--L5), the kyphotic slip angle (L4--L5) tended to increase after surgery. In the future, in patients with radiologically excessive segmental motion, this point should be considered, and surgical techniques should be evaluated. Our results suggest that the validity of the general addition of screw instrumentation to L4--L5 fusion for L4--L5 degenerative spondylolisthesis is low.

Fibula pseudarthrosis revisited treatment with Ilizarov apparatus: case report and review of the literature

A case of isolated congenital fibula pseudarthrosis with progressive valgus ankle deformity is reported. Valgus deformity can be corrected early by Ilizarov apparatus. Bone grafting is an essential part of treatment for union of the pseudarthrosis site. Internal splinting may be helpful in preventing further valgus deformity by maintaining continuity of fibula. Age of presentation has an important bearing on the choice of treatment.

Increased fusion rates with cervical plating for three-level anterior cervical discectomy and fusion

STUDY DESIGN

A retrospective review of all patients surgically treated by a single surgeon with a three-level anterior cervical discectomy and fusion with and without anterior plate fixation.

OBJECTIVES

To compare the clinical and radiographic success of anterior three-level discectomy and fusion performed with and without anterior cervical plate fixation.

SUMMARY OF BACKGROUND DATA

Previous studies of multilevel cervical discectomies and fusions have shown fusion rates to decrease as the number of surgical levels increases. Anterior cervical plate stabilization can provide more stability and may increase fusion rates for multilevel fusions.

METHODS

Over a 7-year period, 59 patients were treated surgically with a three-level anterior cervical discectomy and fusion by the senior author. Forty patients had cervical plates, whereas 19 had fusions with no plates. These patients were observed for an average of 3.2 years. Clinical and radiographic follow-up data were obtained.

RESULTS

Of the 59 patients, 14 had a pseudarthrosis (7 in each group). The pseudarthrosis rates were 18% (7 of 40) for patients with plating and 37% (7 of 19) for patients with no plating. Although the nonunion rate for unplated fusions was double that of plated fusions, this difference was not statistically significant. There was no statistically significant correlation between pseudarthrosis and gender, age, level of surgery, history of tobacco use, or previous anterior surgery. The fusion rates were improved with the use of a cervical plate. Inferior clinical results were demonstrated in patients with a pseudarthrosis, regardless of the use of a cervical plate.

CONCLUSIONS

The addition of plate fixation for three-level anterior cervical discectomy and fusion is a safe procedure and does not result in higher complication rates. In this study, the pseudarthrosis rate was lower for patients with a cervical plate. However, this difference was not statistically significant. Patients treated with cervical plating had overall better results when compared with those of patients treated without cervical plates. Although the use of cervical plates decreased the pseudarthrosis rate, a three-level procedure is still associated with a high nonunion rate, and other strategies to increase fusion rates should be explored.

[Intramedullary osteosynthesis for treatment of pseudarthrosis]

The main causes of long bone fractures healing complications are: insufficient vascularisation of the bone fragments and excessive movement in the fracture site. Intramedullary osteosynthesis preceded by intramedullary reaming (internal decortication) ensure refreshing of the bone ends and a good mechanical stabilisation in cases with pseudoarthroses. Long bone fractures healing complications occurring during either conservative or operative treatment can be treated using this method. Intramedullary nailing with reaming usually suffices in the treatment of pseudoarthroses of the lower extremity. Weight bearing stimulates metaplasia of connective tissue into bone. Lack of dynamic compression in the upper extremity requires intramedullary nailing to be supplemented by interlocking of the nail and open external decortication of the fracture site. Several cases of pseudoarthoses treated with intramedullary osteosynthesis are presented.

[A adaptive proximal scaphoid implant]

INTRODUCTION

In this study, the insertion of a pyrocarbon implant (APSI) has been described, which is shaped to allow adaptive mobility during carpal movement in the first row of carpals. This implant replaces the proximal part of the scaphoid; it is designed to treat styloscaphoid arthritis, and to prevent further deterioration and carpal collapse by restoring the first carpal row to its original height, i.e., 'SNAC wrist' after scaphoid pseudoarthritis, and 'SLAC wrist' following scapho-lunate dissociation.

MATERIALS AND METHOD

This retrospective series included 25 cases which were examined and analyzed at an average of six years post-surgery (between three and ten years) by an independent observer using the EVAL expert database system: 1) 14 cases involved pseudoarthritis, which developed from the scaphoid ('SNAC wrist'); 2) ten cases were connected with scapho-lunate nonunion ('SLAC wrist'); 3) one case involved carpal collapse with siliconite, which had previously been inserted as a scaphoid silicone partial implant for the treatment of pseudoarthritis involving a stage II fracture.

RESULT

In all cases, the reason for the preoperative-consultation for degenerative arthritis was the presence of pain, which post-surgery was no longer apparent in 60% of cases, and only persisted during effort in 28% of cases. Thus 88% of the patients were satisfied with the results, and were able to resume their normal professional and sports activities at the same level as before. Strength connected with digitopalmar grip and pinch force were found to have increased compared to the function in the healthy hand. No implant dislocation was detected by radiological investigation. Dynamic X-rays of the implant in flexion, extension, and frontal inclination confirmed this adaptive mobility. Carpal height was in all cases maintained. The radio-lunate angle remained unchanged in 15 cases, was improved in six cases, and was worse in four cases. Two poor results were connected with severe ligament lesions prior to surgery.

CONCLUSION

The preliminary results regarding the APSI implant seem to be promising for cases of polar pseudoarthritis in which curative treatment is no longer possible. This technique avoids further deterioration and carpal collapse ('SNAC wrist'). However, in cases of scapho-lunate nonunion ('SLAC wrist') where ligament lesions are severe, this method does not resolve the problem of ligament destabilization, which requires further treatment.

[Deviations in the axes of the lower extremities]

Deviations in the axes can be physiological or pathological. During growth, the axes of the lower extremities undergo significant changes. The femoral neck-shaft-angle decreases from 150 degrees on average at birth to 120 degrees on average at the end of growth. The lower leg is bowed in a varus direction at birth. After a child begins to walk, the knee axis deviates to a slight valgus. This goes back to normal before the age of ten. Pathologic deviations of the axis are rare. They occur in congenital deformations, after trauma or infection, or as a result of metabolic diseases. In association with coxa vara pseudarthrosis of the femoral neck usually develops. Therefore this deformation has to be treated. Correction is best made with a Y-shaped osteotomy according to Pauwels. At the lower leg, a deviation of 15 degrees from the normal axis is usually an indication for operative treatment. In children and adolescents, corrections are best made with (monolateral) external fixators. They allow early weight bearing, which is especially desirable in bilateral corrections.

[Treatment of pseudarthrosis of the carpal scaphoid bone by percutaneous pinning. Apropos of 74 cases]

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

Functional results at the end of skeletal growth in 30 patients affected by congenital pseudoarthrosis of the tibia

From a multicentric study on Congenital Pseudoarthrosis of the tibia (CPT) conducted on 340 patients, we evaluated the functional results on a group of thirty patients who were at the end of skeletal growth (age < or = 16 years). The prognosis of CPT is very much related to the radiologic classification. Crawford type 2 and Crawford type 4 pseudoarthrosis have a worse prognosis, with a lower percentage of fusion at the site of pseudoarthrosis. Crawford 4 patients have the worst functional results. Most of them showed a severe leg length discrepancy, needed a permanent brace, with an ankle joint function fair or poor. The presence of fibula pseudoarthrosis seems to be responsible for most of the worst functional results. The level of deformity caused by either the natural course of the disease or its treatment, is decisive in the evaluation of the functional results.

[Pseudarthrosis]

Understanding the pathophysiology of non-union is a prerequisite for successful treatment of this disorder. Fracture healing may be impeded by mechanical or biological factors as well as a combination of these. A thorough evaluation of each individual case before surgery is necessary to prevent either undertreatment or overtreatment. The whole spectrum of methods of internal fixation may be utilized for stabilization. To optimize the biological component, classic methods such as decortication and cancellous autograft may be employed. It is too early yet to determine if alternative techniques (e.g. ultrasound) will successfully replace these long-standing options. In any case, these newer modalities cannot supplant the need for skeletal stabilization. For infected pseudarthroses the first step is eradication of infection, after which measures can be taken to unite the fracture. Callus distraction has opened new and safe ways to treat large bone defects.

[Pertrochanteric pseudarthrosis. Implant failure - technical error - destiny?]

Pain is not always the leading symptom of a failed union. High primary stability often allows full weight bearing in spite of fracture instability. The difficult diagnosis of a pseudarthrosis is a reason for late intervention. Implant failure and implant breakage are typical signs of surgical underestimation. Finally, the diagnosis "pseudarthrosis" is a fluent one and is defined as a failed fracture healing despite implant stability. Recognition of biological and biomechanical failure, this demands correct evaluation of the global situation and extensive experience in revision surgery on the part of the surgeon.

[The biological reaction in atrophic and hypertrophic pseudarthrosis of diaphysis of long bone. Causes and forms of appearance]

The grading of long-tubular-bone pseudarthrosis depends on the biological reaction or lack of reaction in pseudarthrosis or non-unions. Hypertrophic and oligotrophic pseudarthrosis belongs to biologically reacting non-unions, whereas non-reacting non-unions are necrotic pseudarthrosis and defective non-unions with partial decline or complete destruction of cortical substance. Pseudarthrosis is a serious disturbance or disorder within the regulation cycle in fracture healing, which consists of osteoregeneration, osteovascularization and stabilization. The causes and underlying reasons for disturbance of this regulation cycle are primarily massive destruction of the biological and functional very important unity of periost, cortical substance and medullary space. This can occur from trauma, but it happens more often from surgical procedures that do not take the biological principles of bone-healing into account. Surgical strategies and interventions that respect the importance of periosteal tissue, cortical tissue and medullary space do fill the biological principles of fracture-healing and fracture union.

[A system for assessing the stability of the osteosynthesis in femoral neck fractures]

Results of experimental investigation of different biomechanical parameters of the system "bone-fixative" and bony fixatives are analyzed in relation to different types of fractures of the femur neck. The data obtained are compared with clinical results of osteosynthesis. On this basis an index system is recommended for choosing the method of treatment of fractures and the particular type of the fixative.

[Pseudarthrosis of an occult fracture in zone III of the sacrum]

Fractures in the midline of the sacrum are rare, a pseudarthrosis has not been described previously. We report about a 53-year-old woman with a midline fracture of the sacrum which has not been recognized, although there were indirect fracture signs on the native x-rays and a CT was performed. The surgical treatment with sacral compression bars was successful and pseudarthrosis healing resulted but the patient continued to have mild low back pain. The case reported here confirms that low back pain may caused by pathologic changes of the posterior part of the pelvis. The unusual fracture location could be caused by a bifid spinous process.

Retarded mineralization cascade in an experimental nonunion--a sequential polyfluorochrome labeling study in rats

BACKGROUND AND AIMS

Although the early phases of the healing seem to occur normally, the persistent rotational instability between the fracture fragments combined to periosteal manipulation at the fracture site cause a failure in the restoration process of bone; i.e. the bridging event of the fracture ends does not occur and the tissue in the interfragmentary area is not mineralized. A nonunion with a soft tissue connection between the fragments is formed without restoration of the biomechanical characteristics of the bone.

MATERIAL AND METHODS

A nonunion model of the rat femur was employed to study the mineralization process of developing pseudoarthrosis using the sequential polychrome labeling and conventional histological hard tissue staining with Masson-Goldner trichrome method.

RESULTS AND CONCLUSIONS

The same results of this study are in accordance with previous studies using the same nonunion model and suggest that if sufficient mechanical stability between the fracture fragments has not been achieved within optimal time period, the chondral phase of the callus is extended and the mineralization process of the hypertrophied chondrocytes is retarded and finally extinguished and the fracture gap is filled with non-mineralizing connective tissue.

Major fibrillar collagens and fibronectin in an experimental nonunion: an immunohistochemical study

We studied in a rat pseudoarthrosis model the time sequence of expression and distribution of fibronectin and collagens I, II, III and V. Collagens and fibronectin were immunolocalized at the light microscopic level. The major difference from the normal healing pattern was the extension of collagen II and cartilage into the interfragmentary area and at the circumference of the periosteal callus, without any bridging chondral or bony elements in the fracture gap. The formation of a fibrous bond, consisting mostly of collagen III and fibronectin, was observed. This speaks in favor of the failure of the multipotentional mesenchymal stem cells to change the fracture-healing process towards fibroblast proliferation and the production of tissue unable to mineralize. The decisive zone for mineralization of the callus appeared to be the area of the hypertrophied chondrocytes near the periosteal ossification front.

Comparison of the results of the Girdlestone pseudarthrosis with reimplantation of a total hip replacement

A Girdlestone pseudarthrosis of the hip (resection arthroplasty) is nowadays mainly carried out for failed hip replacements. A decision may have to be made whether to reimplant a new hip prosthesis or to accept the result of a pseudarthrosis. We followed 2 groups of patients: 32 patients had a long standing pseudarthrosis; in the other group of 16 patients, a total hip replacement was reimplanted at an average of 3 years after a pseudarthrosis. The improvement in hip function after the reimplantation was marginal and the results were comparable to a good functioning pseudarthrosis. However, personal satisfaction and the activities of daily living were better in the reimplantation group, and their Harris hip score was 64 compared to 58 in those with a pseudarthrosis. The Girdlestone procedure still seems to be a reasonable salvage operation for some complications following hip surgery, but when there are the correct indications, reimplantation of a total hip prosthesis is recommended.

Proximal row carpectomy through a palmar approach

From 1990 to 1994, nine proximal row carpectomies were done through a palmar approach. With an average follow-up of 20 months, seven of the nine patients were completely painfree. Average range of wrist flexion/extension remained unchanged, and average radial/ulnar deviation increased from 25 degrees to 46 degrees . All the patients demonstrated an increase in grip strength in the operated hand. Four cases showed a slight reduction in articular space and subchondral sclerosis in the radiocapitate articulation, in spite of good function. Dynamic studies demonstrated no sign of radiocarpal instability. All the patients were very satisfied with the results and returned to their previous work within 2 months, on average.

Gait analysis and muscle strength in children with congenital pseudarthrosis of the tibia: the effect of treatment

Twelve patients with healed congenital pseudarthrosis of the tibia underwent gait analysis and muscle strength testing to determine the functional result of treatment. Six children younger than 4 years of age presented with pseudarthroses (early onset), and six children first fractured at older than 4 years of age (delayed onset). Four children with amputations as final treatment for congenital pseudarthrosis were studied for comparison. The early-onset group had undergone an average of 4.2 surgeries and all required transankle fixation. The delayed-onset group had undergone an average of 1.5 surgeries, with one child requiring fixation across the ankle. Lack of ankle push-off and foot drop occurred in the early-onset group. Terminal stance phase ankle power generation was greatly diminished in the early-onset group. Total mechanical work performed by the affected limb, when compared to the uninvolved contralateral limb, was symmetric in delayed-onset patients and reduced by 68% in early-onset patients and by 85% in amputees. Gastrocsoleus strength was reduced by 40%. Gait and muscle strength of patients with "healed" congenital pseudarthrosis of the tibia are markedly disturbed. Early onset of disease, early surgery, and transankle fixation lead to an inefficient gait comparable to that of amputees.

Reversing the inhibitory effect of nicotine on spinal fusion using an osteoinductive protein extract

STUDY DESIGN

The effect on spinal fusion of an osteoinductive bone protein extract in the presence of a known inhibitor of spinal fusion (systemic nicotine) was studied prospectively in an animal model of posterolateral lumbar fusion.

OBJECTIVES

To evaluate the ability of a bovine-derived osteoinductive bone protein extract to overcome the inhibitory effect of nicotine in a rabbit spine fusion model.

SUMMARY OF BACKGROUND DATA

Multiple studies have demonstrated the ability of a variety of osteoinductive growth factors to serve as a bone graft substitute for lumbar spinal fusion under "normal" healing conditions.

METHODS

Forty-eight adult female New Zealand white rabbits underwent spine arthrodesis at L5-L6 while receiving systemic nicotine through a subcutaneous miniosmotic pump. Arthrodesis was performed using one of the following three graft materials: 1) autogenous iliac crest, 2) osteoinductive bone protein delivered in an allogeneic demineralized bone matrix/ collagen carrier, or 3) osteoinductive bone protein delivered with autogenous iliac crest. Fusions were assessed by blinded manual palpation, radiography, and biomechanical testing.

RESULTS

Of the 44 rabbits manually tested by blinded observers, all 14 in the osteoinductive bone protein plus autogenous iliac crest bone group had solid fusions (14 of 14), whereas the fusion rate was less in the osteoinductive bone protein plus demineralized bone matrix group (nine of 14, 64%; P = 0.02), and there were no fusions in the autogenous iliac crest only group (0 of 16, 0%; P = 0.000001). The use of osteoinductive bone protein with autogenous bone produced stronger and stiffer fusions compared with those using autogenous bone alone or osteoinductive bone protein with allograft bone.

CONCLUSIONS

Cigarette smoking and nicotine are inhibitory factors in the healing of fractures and spine fusions. This study shows that the inhibitory effect of nicotine can be overcome with an osteoinductive bone growth factor in an animal model.

[Extracorporeal shockwave treatment of delayed bone healing. A critical assessment]

Since the late 1980s, experiments have been performed to influence physiologic and disturbed healing of bone. However, the mainly negative results of animal studies, cannot be applied to the human nonunion situation as long as there is no adequate animal pseudarthrosis model. Prospective clinical studies in various centres have resulted in success rates of more than 50%, although the majority of patients had been treated repeatedly and ineffectively with the gold standard of re-osteosynthesis and grafting. Since the mechanisms are not yet understood, only such desperate conditions are an indication for the application of high-energy extracorporal shock waves.

Relevancy of radiographic features in elbow fractures

PURPOSE

To correlate radiographic and clinical findings of elbow fractures.

MATERIAL AND METHODS

A retrospective study was made of 110 consecutive adult elbow fractures of various types involving the humerus, the ulna, and the radius.

RESULTS

Twenty-seven fractures with radiographically conspicuous distortions healed. Of these only 15 had clinical sequelae. Five had clinical sequelae without showing conspicuous radiographic distortions after healing.

CONCLUSION

For radiographic evaluation and classification purposes, it would seem to be important to note the status of the capitellum, the capitellum-trochlear plane, and the combination of a distal humerus and a proximal ulna fracture. The outcome of common olecranon fractures and injuries to the radial head would seem to depend less on a detailed radiographic description.

[Bone marrow in patients with pseudarthrosis. A study of progenitor cells by in vitro cloning]

PURPOSE OF THE STUDY

The recent observations that osteoblasts develop from a stem cell found in the medullary stroma suggest that, as already suspected in classical histological studies, many consolidation mechanisms are based on bone marrow. Since cells characteristics can now be studied in tissue culture, it has become possible to investigate the activity of the bone marrow in non union. The working hypothesis for this study was: if the bone marrow plays a part in bony callus formation, bone marrow from non union site should manifest anomalous activity whatever the origin of the focus sampled. Therefore, the aim of this study was to seek in vitro, using cell cloning techniques, anomalies of bone marrow from non union site.

MATERIALS

The study characterizes the bone marrow from 35 non union sites, not only with respect to the medullary stroma but also the hematopoietic compartment. In this study, we look for systemic anomalies which could explain susceptibility to non union, we also compare in vitro activity of bone marrow taken from non union with others samples taken from the iliac crest of the same patient.

METHODS

The cell density in the bone marrow in these sites was studied in vitro with material taken from the non union site. Samples were taken by aspiration with a trocar located by image intensification. Assays of CFU-GM were chosen to quantify the hematopoietic activity of the marrow, and of CFU-F to quantify stroma cells activity. Cell densities in the non union site were compared to those in patients' own iliac crests, and also to iliac crests densities of a control population of bone marrow donors.

RESULTS

The bone marrow of non union site contained low levels of progenitor cells. Especially surprising was that progenitors were also sparse in the bone marrow of the iliac crest of patients with non union, compared with control bone marrow donors. In several cases, certain general factors are probably responsible for the abnormally low levels of progenitor cells, not only in the non union site, but also in the iliac crest.