Objective: To explore the long-term effect of combined surgery for the treatment of congenital tibial pseudarthrosis in children. Methods: The clinical data of 44 children with congenital tibial pseudarthrosis who underwent combined surgery (tibial pseudarthrosis tissue resection, intramedullary rod fixation, Ilizarov external fixator fixation, wrapped autologous iliac bone graft) from August 2007 to October 2011 at the Department of Pediatric Orthopedics, Hunan Children's Hospital were collected retrospectively. There were 33 males and 11 females. The age at the time of surgery was (3.7±2.2)years (range:0.6 to 12.4 years), including 25 cases under 3 years old and 19 cases above 3 years old.Among them, 37 cases were complicated with neurofibromatosis type 1.The operation status, postoperative complications and follow-up results were recorded. Results: The follow-up time after surgery was (10.9±0.7)years (range:10 to 11 years).Thirty-nine out of 44 patients (88.6%) achieved initial healing of tibial pseudarthrosis, with an average healing time of (4.3±1.1)months (range:3 to 10months).In the last follow-up, 36 cases (81.8%) had unequal tibial length, 20 cases (45.4%) had refractures, 18 cases (40.9%) had ankle valgus, 9 cases (20.4%) had proximal tibial valgus, and 11 cases (25.0%) had high arched feet.Nine cases (20.4%) developed distal tibial epiphyseal plate bridging.17 cases (38.6%) had abnormal tibial mechanical axis.Seven cases (15.9%) developed needle infection, and one case (2.3%) developed tibial osteomyelitis. 21 patients (47.7%) had excessive growth of the affected femur.Five patients (11.3%) had ankle stiffness, and 34 patients (77.2%) had intramedullary rod displacement that was not in the center of the tibial medullary cavity.Among them, 8 cases (18.1%) protruded the tibial bone cortex and underwent intramedullary rod removal.18 children have reached skeletal maturity, while 26 children have not been followed up until skeletal maturity. Conclusion: Combined surgery for the treatment of congenital pseudarthrosis of the tibia in children has a high initial healing rate, but complications such as unequal tibia length, refracture, and ankle valgus occur during long-term follow-up, requiring multiple surgical treatments.
Male ; Female ; Humans ; Child ; Child, Preschool ; Pseudarthrosis/congenital* ; Follow-Up Studies ; Retrospective Studies ; Tibia/surgery* ; Neurofibromatosis 1 ; Tibial Fractures/surgery*

STUDY DESIGN: A retrospective cohort study. PURPOSE: To compare the clinical and radiological outcomes of patients who underwent anterior cervical discectomy and fusion (ACDF) supplemented with plate fixation using allograft with those who underwent ACDF using tricortical iliac autograft. OVERVIEW OF LITERATURE: As plate fixation is becoming popular, it is reported that ACDF using allograft may have similar outcomes compared with ACDF using autograft. METHODS: Forty-one patients who underwent ACDF supplemented with plate fixation were included in this study. We evaluated 24 patients who used cortical ring allograft filled with demineralized bone matrix (DBM) (group A) and 17 patients who used tricortical iliac autograft (group B). In radiological evaluations, fusion rate, subsidence of grafted material, cervical lordosis, fused segmental lordosis, and radiological adjacent segment degeneration (ASD) were observed and analyzed with preoperative and postoperative plain radiographs. Clinical outcomes were evaluated using the Neck Disability Index score, Odom criteria, and Visual Analog Scale score of neck and upper extremity pain. Radiological union was determined by dynamic radiographs using cutoff values of 1 mm of interspinous motion as the indication of pseudarthrosis. RESULTS: There was no significant difference in the fusion rate, graft subsidence, cervical lordosis, fused segmental lordosis, and ASD incidence between the groups. Operative time was shorter in group A (136 min) than in group B (141 min), but it was not significant (p>0.05). Blood loss was greater in group B (325 mL) than in group A (210 mL, p=0.013). There was no difference in the clinical outcomes before and after surgery. CONCLUSIONS: In ACDF with plate fixation, cortical ring allograft filled with DBM group showed similar radiological and clinical outcomes compared with those of the autograft group. If the metal plate is reinforced, using cortical ring allograft could be a viable alternative to autograft.
Allografts ; Animals ; Autografts ; Bone Matrix ; Cohort Studies ; Diskectomy ; Humans ; Incidence ; Lordosis ; Neck ; Operative Time ; Pseudarthrosis ; Retrospective Studies ; Transplants ; Upper Extremity ; Visual Analog Scale

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is commonly used surgical procedure for cervical degenerative disease. Among the various intervertebral spacers, the use of allografts is increasing due to its advantages such as no harvest site complications and low rate of subsidence. Although subsidence is a rare complication, graft collapse is often observed in the follow-up period. Graft collapse is defined as a significant graft height loss without subsidence, which can lead to clinical deterioration due to foraminal re-stenosis or segmental kyphosis. However, studies about the collapse of allografts are very limited. In this study, we evaluated risk factors associated with graft collapse.METHODS: We retrospectively reviewed 33 patients who underwent two level ACDF with anterior plating using allogenous bone graft from January 2013 to June 2017. Various factors related to cervical sagittal alignment were measured preoperatively (PRE), postoperatively (POST), and last follow-up. The collapse was defined as the ratio of decrement from POST disc height to follow-up disc height. We also defined significant collapses as disc heights that were decreased by 30% or more after surgery. The intraoperative distraction was defined as the ratio of increment from PRE disc height to POST disc height.RESULTS: The subsidence rate was 4.5% and graft collapse rate was 28.8%. The pseudarthrosis rate was 16.7% and there was no association between pseudarthrosis and graft collapse. Among the collapse-related risk factors, pre-operative segmental angle (p=0.047) and intra-operative distraction (p=0.003) were significantly related to allograft collapse. The cut-off value of intraoperative distraction ≥37.3% was significantly associated with collapse (p=0.009; odds ratio, 4.622; 95% confidence interval, 1.470-14.531). The average time of events were as follows: collapse, 5.8±5.7 months; subsidence, 0.99±0.50 months; and instrument failure, 9.13±0.50 months.CONCLUSION: We experienced a higher frequency rate of collapse than subsidence in ACDF using an allograft. Of the various pre-operative factors, intra-operative distraction was the most predictable factor of the allograft collapse. This was especially true when the intraoperative distraction was more than 37%, in which case the occurrence of graft collapse increased 4.6 times. We also found that instrument failure occurs only after the allograft collapse.
Allografts ; Cervical Vertebrae ; Diskectomy ; Female ; Follow-Up Studies ; Humans ; Kyphosis ; Odds Ratio ; Prosthesis Failure ; Pseudarthrosis ; Retrospective Studies ; Risk Assessment ; Risk Factors ; Spinal Fusion ; Transplants

OBJECTIVE: Minimal data exist regarding non-operative management of suspected pseudarthrosis after pedicle subtraction osteotomy (PSO). This study reports radiographic and clinical outcomes of non-operative management for post-PSO pseudarthrosis at a minimum 5 years post-detection.METHODS: Nineteen consecutive patients with implant breakage indicating probable pseudarthrosis after PSO surgery (13 women/six men; mean age at surgery, 58 years) without severe pain and disability were treated with non-operative management (mean follow-up, 5.8 years; range, 5–10 years). Non-operative management included medication, intermittent brace wearing and avoidance of excessive back strain. Radiographic and clinical outcomes analysis was performed.RESULTS: Sagittal vertical axis (SVA), proximal junctional angle, thoracic kyphosis achieved by a PSO were maintained after detection of pseudarthrosis through ultimate follow-up. Lumbar lordosis and PSO angle decreased at final follow-up. There was no significant change in Oswestry Disability Index (ODI) scores and Scoliosis Research Society (SRS) total score, or subscales of pain, self-image, function, satisfaction and mental health between detection of pseudarthrosis and ultimate follow-up. SVA greater than 11 cm showed poorer ODI and SRS total score, as well as the pain, self-image, and function subscales (p<0.05).CONCLUSION: Non-operative management of implant failure of probable pseudarthrosis after PSO offers acceptable outcomes even at 5 years after detection of implant breakage, provided SVA is maintained. As SVA increased, outcome scores decreased in this patient population.
Animals ; Braces ; Follow-Up Studies ; Humans ; Joint Deformities, Acquired ; Kyphosis ; Lordosis ; Male ; Mental Health ; Osteotomy ; Pseudarthrosis ; Scoliosis ; Spine

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare disease that affects the sensory and autonomic nervous system. The patients do not have the ability to sense different sensations, such as pain, which tends to lead to different injuries. In addition, the patients suffer from fluctuations in body temperature due to autonomic involvement. The present case was a five-year-old girl with a neglected distal femur fracture. X-rays taken during the follow-up showed marked callus formation and pseudarthrosis of the distal femur. She had biting injuries of the tongue, auto-amputation of the fingers, some developmental delay and a history of recurrent fever with an unknown origin. The electrodiagnostic study was normal. The quantitative sudomotor axon reflex test revealed markedly reduced postganglionic sudomotor axonal responses at all sites recorded on the left. She was diagnosed with CIPA. As the initial presentation of CIPA involves the musculoskeletal system, orthopedic surgeons should have a high index of suspicion.
Autonomic Nervous System ; Axons ; Body Temperature ; Bony Callus ; Female ; Femur ; Fever ; Fingers ; Follow-Up Studies ; Hereditary Sensory and Autonomic Neuropathies ; Humans ; Musculoskeletal System ; Orthopedics ; Pain Insensitivity, Congenital ; Pseudarthrosis ; Rare Diseases ; Reflex ; Sensation ; Surgeons ; Tongue

Osteonecrosis (ON) is a clinical entity characterized by a pattern of cell death and complex process of bone resorption and formation. Studies related to ON have largely focused on certain anatomical sites; however, the evidence on vertebral body ON (VBON) is largely inconsistent and fragmented. The aim of this study was to clarify the pathophysiology, risk factors, imaging findings, and available treatment modalities for VBON. A systematic review of the relevant articles published in English was performed using PubMed, Embase, Medline, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL databases. A total of 81 articles were included in this study. Three main topics about VBON were identified: (1) pathophysiology and risk factors, (2) diagnosis, and (3) treatment. Forty-five studies were based on the pathophysiology, 52 on diagnosis, and 38 on the treatment options for VBON. The literature on VBON was limited and mainly focused on post-traumatic cases with a considerable overlap with nonunion and pseudoarthrosis.
Bone Resorption ; Cell Death ; Diagnosis ; Osteonecrosis ; Pseudarthrosis ; Risk Factors ; Spine

STUDY DESIGN: Retrospective analysis of prospectively collected data. PURPOSE: To assess the relative advantages of implant constructs with and without pedicle screws in the concave apex for correcting scoliosis. OVERVIEW OF LITERATURE: Concave apical pedicles in scoliosis can be narrow and dysplastic. Neural structures also migrate toward concavity, leaving little room for error while inserting pedicle screws into the concave apex. METHODS: Patients (n=35) undergoing scoliosis surgery from September 2004 to September 2009 with minimum 5-year follow-up period were included. Exclusion criteria were pseudarthrosis, implant failure, infection, anterior release surgery, corrective osteotomies, incomplete data, constructs not involving anchors at the apex of the curve, and kyphoscoliosis. Curves were classified into two groups as follows: group A, with screws alone anchoring the convex apex and the correction performed from the convex side and group B, with screws anchoring the concave apex with or without convex apex purchase and the correction performed from the concave side. RESULTS: Twenty-two of 35 patients were selected. In these patients, 29 individual curves were selected and classified into groups A (n=15) and B (n=14). Both groups were comparable in terms of age, sex, and etiology (idiopathic and nonidiopathic). However, group A had larger (68.53°±26.29°) and more rigid (29.04%±18.22% flexibility) curves than group B (50.14°±16.89° with 49.87%±25.01% flexibility) (two-tailed p<0.05). Despite this, the immediate postoperative correction was comparable between the two groups (A, 57.98%±16.28%; B, 62.76%±13.13%; two-tailed p=0.39). Interestingly, group A showed significantly better results in terms of the gain of instrumented correction over and above preoperative flexibility (A, 28.94%±8.51%; B, 12.89%±23.06%; two-tailed p=0.03). There was no statistically significant difference in the correction percentage of sagittal profile between the two groups and in the loss of correction at follow-up or Scoliosis Research Society-22 scores. CONCLUSIONS: Present study could not demonstrate any advantages associated with use of apical concave pedicle screws.
Follow-Up Studies ; Humans ; Osteotomy ; Pedicle Screws ; Pliability ; Prospective Studies ; Pseudarthrosis ; Retrospective Studies ; Scoliosis ; Spine

Nonunion at the lumbosacral junction is a classic complication of long construct and deformity corrections. Iliac fixations have been extensively studied in the literature and have demonstrated superior biomechanical proprieties and lower complication rates. S2 alar iliac screws address the drawbacks of classical iliac screws but demonstrate similar biomechanical advantage. The main aim of this paper was to describe the S1 alar iliac (S1AI) screw fixation technique while evaluating our early results. S1AI screw fixation technique has the advantage of being able to achieve pelvic fixation without dissection to the S2 pedicle entry and is therefore a viable option for salvage of a failed S1 promontory screw.
Congenital Abnormalities ; Lumbosacral Region ; Pseudarthrosis

STUDY DESIGN: Prospective cohort study. PURPOSE: To study clinicoradiological parameters of zero-profile cage screw used for anterior cervical discectomy and fusion (ACDF). OVERVIEW OF LITERATURE: Radiological parameters of various implants used for ACDF are available, but those for zero-profile cage are sparse. METHODS: Patients with unilateral intractable brachialgia due to single-level cervical disc prolapse between April 1, 2011 and March 31, 2014 were included. Clinical assessment included arm and neck pain using visual analogue score (VAS) and neck disability index (NDI) scores. Radiological assessment included motion segment height, adjacent disc height (upper and lower), segmental and cervical lordosis, implant subsidence, and pseudoarthrosis. Follow-ups were scheduled at 1, 3, 6, 12, and 24 months. RESULTS: Thirty-four patients (26 males, 8 females) aged 30–50 years (mean, 42.2) showed excellent clinical improvement based on VAS scores (7.4–0 for arm and 2.0–0.6 for neck pains). Postoperative disc height improved by 11.33% (p<0.001), but at 2 years, the score deteriorated by 7.03% (p<0.001). Difference in the adjacent segment disc height at 2 years was 0.08% (p=0.8) in upper and 0.16% (p<0.001) in lower disc spaces. Average segmental lordosis achieved was 5.59° (p<0.001) from a preoperative kyphosis of 0.88°; at 2 years, an average loss of 7.05° (p<0.001) occurred, resulting in an average segmental kyphosis of 1.38°. Cervical lordosis improved from 11.59° to 14.88° (p=0.164), and at 2 years, it progressively improved to 22.59° (p<0.001). Three patients showed bone formation and two mild protrusion of the implant at 2 years without pseudoarthrosis/implant failure. CONCLUSIONS: The zero-profile cage screw device provides good fusion and cervical lordosis but is incapable of maintaining the segmental lordosis achieved up to a 2-year follow-up. We also recommend caution when using it in patients with small vertebrae.
Animals ; Arm ; Cohort Studies ; Diskectomy* ; Follow-Up Studies ; Humans ; Kyphosis ; Lordosis* ; Male ; Neck ; Neck Pain ; Osteogenesis ; Prolapse ; Prospective Studies* ; Pseudarthrosis ; Spine

STUDY DESIGN: Literature review. OBJECTIVES: To review the complications of osteoporotic vertebral compression fractures (OCFs) with regard to risk factors and treatment strategies. SUMMARY OF LITERATURE REVIEW: Understanding the complications and treatment methods of OCFs is important given their increasing prevalence. MATERIALS AND METHODS: Review of the literature. RESULTS: The complications of OCFs include kyphotic deformity due to a delayed collapse of the vertebral body and neurologic deficits. The pathophysiologic mechanism of these complications has not been established; however, the most accepted theory is posttraumatic avascular necrosis of the vertebral body. The risk factors for these complications include fracture at the thoracolumbar junction, systemic usage of steroids, severe osteoporosis, and radiological intravertebral vacuum cleft. Most of these complications require surgical treatment, the indications for which include progressing axial back pain, pseudarthrosis, kyphotic deformity, and neurologic deficits. Surgical approaches for treating the complications of OCFs include anterior, posterior, and combined anterior-posterior approaches. Osteotomies should be done when deformity correction is needed. The decision among these various surgical methods should be made considering patient factors and the surgeon's ability to achieve the best outcomes with solid fusion. CONCLUSIONS: complications of OCFs include kyphotic deformity due to delayed collapse of the vertebral body and neurologic deficits. Most of these complications require surgical treatment, in which achieving solid fusion at the fracture site is the ultimate goal. Patient-related factors and the surgeon's ability should be considered prior to making decisions regarding surgery.
Back Pain ; Congenital Abnormalities ; Fractures, Compression* ; Humans ; Necrosis ; Neurologic Manifestations ; Osteoporosis ; Osteotomy ; Prevalence ; Pseudarthrosis ; Risk Factors* ; Steroids ; Vacuum