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Background: The aim of this study was to demonstrate longitudinal radiographic changes at up to five years in patients with pseudarthrosis after posterior lumbar interbody arthrodesis using carbon interbody cages., Methods: From 2003 to 2006, prospective longitudinal radiographic and CT (computed tomography) scan evaluations were made at up to five years after posterior lumbar interbody arthrodesis using carbon interbody cages at one or two levels in 153 consecutive patients. At the one-year evaluation, seventeen patients with early pseudarthrosis at nineteen levels were selected as subjects on the basis of one or more of the following characteristics: complete absence of osseous bridging between the upper and lower vertebrae, angular motion of ≥5°, and/or radiolucent zones surrounding the implant. Angular motion, continuity of osseous bridging, grafted bone quantity, and radiolucent zones around the pedicle screws and cages were observed annually until five years., Results: The mean angular motion of five levels that exhibited ≥5° of motion at one year began to decrease significantly thereafter (p = 0.046), and no level showed movement of ≥5° at five years. The mean grade of the radiolucent zones around the screws on CT showed significant improvements at two years (p = 0.039) and three years (p < 0.01). The radiolucent zones around the screws disappeared at twelve of sixteen levels by five years, and the radiolucent zones around the cages disappeared in eleven of seventeen levels by five years. Of eighteen levels with early pseudarthrosis, seven (39%) were assessed as successfully fused at three years and twelve (67%) at five years. Four (80%) of five patients with a radiolucent zone of >1 mm around the entire cage on CT at one year showed continuing pseudarthrosis at five years, whereas only two (15%) of thirteen patients without this finding did (crude relative risk = 5.2; 95% confidence interval, 1.35 to 20.02). A radiolucent zone of >1 mm around the entire cage on CT at one year could be an early predictor of permanent pseudarthrosis (odds ratio = 123; 95% confidence interval, 1.03 to 14,680)., Conclusions: The interbody arthrodesis site in patients with early pseudarthrosis may begin to change to a successful fusion one or two years after surgery, with two-thirds of such patients exhibiting successful fusion five years after surgery. Final assessment of pseudarthrosis should be performed at least three years after surgery. A radiolucent zone of >1 mm around the entire interbody cage on CT at one year may require early additional surgery., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: While interspinous motion analysis is commonly used to determine the status of an anterior cervical fusion, the accuracy of this technique is unclear. We believed that three questions needed to be answered. What degree of image magnification is ideal? How much motion should be considered "adequate" for making dynamic radiographs? What is the optimal amount of interspinous motion for detecting pseudarthrosis?, Methods: We performed a retrospective study of 125 patients (109 fused segments and 153 pseudarthrotic segments) who had undergone reexploration with confirmation of fusion status. Interspinous motion at each operatively treated level and one superjacent level was measured by two independent investigators twice. Reliabilities of interspinous motion analysis at different magnification rates (25%, 100%, 150%, and 200%) were evaluated for fifty randomly selected segments to determine the optimal magnification, which we used for the remainder of the measurements. Fusion status was also determined on computed tomography (CT) by two other raters. We compared the intraoperative findings with those based on dynamic radiographs (with use of cutoff values of 1 and 2 mm of interspinous motion as the indication of pseudarthrosis) and CT., Results: On radiographs, both 150% and 200% magnification yielded higher interobserver and intraobserver reliabilities compared with 25% and 100% magnification, and the reliabilities at 150% and 200% were similar to each other, so subsequent measurements were made at 150%. The cutoff value of interspinous motion for detecting pseudarthrosis was 0.9 mm as determined with receiver operating characteristic curve analysis. Compared with CT, interspinous motion of ≥ 1 mm showed relatively low sensitivity (79.5%) and negative predictive value (77.1%) and similar specificity (97.0%) and positive predictive value (97.4%). Using interspinous motion of ≥ 2 mm as the cutoff decreased the sensitivity and negative predictive value to 46.6% and 56.8%, respectively. Our evaluation of what constituted adequate dynamic motion for making the radiographs showed that, with use of interspinous motion of ≥ 1 mm as the cutoff for detecting pseudarthrosis, superjacent interspinous motion of ≥ 4 mm increased the sensitivity and negative predictive value (86.3% and 83.4%) compared with those associated with alternative cutoffs of superjacent interspinous motion (≥ 3.5, ≥ 5, and ≥ 6 mm), and the specificity (96.1%) and positive predictive value (96.9%) were reasonable., Conclusions: Use of interspinous motion of ≥ 1 mm as the cutoff for detection of anterior cervical pseudarthrosis on radiographs magnified 150% and made with superjacent interspinous motion of ≥ 4 mm yielded accuracies comparable with those of CT.

Background: Intermediate-term radiographic studies have shown that anterior and circumferential techniques result in high fusion rates in patients with high-grade spondylolisthesis, whereas posterolateral fusion is less successful. We are not aware of any long-term comparative studies in which these three methods have been evaluated with regard to functional outcome, including systematic spinal mobility and trunk strength measurements., Methods: Sixty-nine of eighty-three consecutive patients with high-grade isthmic spondylolisthesis who underwent posterolateral (twenty-one), anterior (twenty-three), or circumferential (twenty-five) uninstrumented spondylodesis between 1977 and 1991 participated in the study. The average duration of follow-up was 17.2 years. Radiographs that were made preoperatively and at the time of the most recent follow-up were assessed with regard to fusion quality and degenerative changes. Outcome was assessed at the time of the most recent follow-up by independent observers on the basis of a physical examination, spinal mobility and nondynamometric trunk strength measurements, and Oswestry Disability Index scores., Results: The mean preoperative vertebral slip was 61% in the posterolateral fusion group, 63% in the anterior fusion group, and 71% in the circumferential fusion group. The final fusion rate was 86% (eighteen of twenty-one) in the posterolateral fusion group, 100% (twenty-three of twenty-three) in the anterior fusion group, and 96% (twenty-four of twenty-five) in the circumferential fusion group. A decrease in lumbar intervertebral disc height at the first mobile level superior to the fusion was noted in five patients in the posterolateral fusion group, seven patients in the anterior fusion group, and one patient in the circumferential fusion group (p = 0.037). The mean Oswestry Disability Index score was 9.7 for the posterolateral fusion group, 8.9 for the anterior fusion group, and 3.0 for the circumferential fusion group (p = 0.035). Nondynamometric trunk strength measurements corresponded with referential values. Abnormally low lumbar flexion affected the posterolateral and circumferential fusion groups more often than the anterior fusion group (p = 0.0015). The percentage of slip showed inverse correlations with lumbar flexion, lumbar extension, and trunk side-bending., Conclusions: As assessed on the basis of patient-based outcomes, circumferential in situ fusion provided slightly better long-term results than did posterolateral or anterior in situ fusion. When the radiographic and functional results were combined with the patient-based outcomes, the overall differences between the three groups were small.

Background: The treatment of congenital pseudarthrosis of the tibia remains difficult and controversial. The purpose of this study was to evaluate the long-term results of a technique consisting of excision of the pseudarthrosis, autologous bone-grafting, and insertion of a Williams intramedullary rod into the tibia., Methods: Twenty-one consecutive patients with congenital pseudarthrosis of the tibia were managed with this technique between 1978 and 1999, and the results were retrospectively reviewed. The mean age of the patients at the time of the latest follow-up was 17.2 years (range, seven to twenty-five years), and the mean duration of postoperative follow-up was 14.2 years (range, three to twenty years)., Results: Initial consolidation occurred in eighteen of the twenty-one patients. Refracture occurred in twelve patients; five fractures healed with closed treatment, five healed after an additional surgical procedure, and two ultimately required amputation. Ten patients had an ankle valgus deformity after tibial union. Eleven patients had a residual limb-length discrepancy of >2 cm; six required a contralateral distal femoral and/or proximal tibial epiphyseodesis, two had a tibial lengthening, and one used a shoe-lift. Five patients had an amputation: two, because of a recalcitrant fracture; two, because of a limb-length discrepancy (6 and 9 cm); and one, because of a chronic lower-extremity deformity., Conclusions: This technique produced a satisfactory long-term functional outcome in sixteen of twenty-one patients and should be considered for the management of congenital pseudarthrosis of the tibia.

Background: Results of the Charnley-Williams method of intramedullary fixation for treatment of congenital pseudarthrosis of the tibia have varied, in part because of variations in surgical technique. The outcomes of three variations of this procedure were compared to determine which technique was the most likely to result in union., Methods: The results in twenty-three consecutive patients with congenital pseudarthrosis of the tibia were reviewed at four to fourteen years following initial surgical treatment with an intramedullary rod. Three types of procedures were performed: type A, which consisted of resection of the tibial pseudarthrosis with shortening, insertion of an intramedullary rod into the tibia, and tibial bone-grafting combined with fibular resection or osteotomy and insertion of an intramedullary rod into the fibula; type B, which was identical to type A except that it did not include fibular fixation; and type C, which consisted of insertion of a tibial rod and bone-grafting but no fibular surgery. The outcome was classified as grade 1 when there was unequivocal union with full weight-bearing function and maintenance of alignment requiring no additional surgical treatment; grade 2 when there was equivocal union with useful function, with the limb protected by a brace, and/or valgus or sagittal bowing for which additional surgery was required or anticipated; and grade 3 when there was persistent nonunion or refracture, requiring full-time external support for pain and/or instability., Results: Eleven patients (48%) ultimately had a grade-1 outcome; nine, a grade-2 outcome; and three, a grade-3 outcome. The final outcome was not associated with either the initial radiographic appearance of the lesion or the age of the patient at the time of the initial surgery. The results following type-A and B operations were better than those after type-C procedures. Surgery on an intact fibula resulted in a lower prevalence of grade-3 outcomes than was found when an intact fibula was not operated on (p = 0.05). Transfixation of the ankle joint by the intramedullary rod did not decrease the prevalence of grade-3 outcomes., Conclusions: There is little justification for a type-C operation, as it either resulted in a persistent nonunion or failed to improve an equivocal outcome in every case. Leaving an intact fibula undisturbed to maintain stability or length also was not successful in this series. In addition, the presence of fibular insufficiency (fracture or a pre-pseudarthrotic lesion) was highly prognostic for subsequent valgus deformity (occurring in ten of twelve cases), whether or not the fibula eventually healed.

Eighty-six patients had a total of eighty-eight primary attempts at repair of a pseudarthrosis that had developed after a localized arthrodesis in the lumbar spine. A follow-up questionnaire was sent to all patients at a mean of fifty-one months (range, twenty-five to seventy-eight months) after the operation; seventy-two patients (84 percent) completed to questionnaire. A solid fusion was ultimately achieved after the treatment of eighty-one (94 percent) of the eighty-six pseudarthroses for which radiographic data were available. With the numbers available, we could find no significant association between a solid fusion and the patient's age, gender, body-mass index, return to work, or outcome score. Despite the high rate of fusion after the index repair and subsequent procedures, only nineteen (26 percent) of the seventy-two patients who completed the questionnaire eventually had a good or excellent outcome. Seven (10 percent) had an excellent result (90 to 100 points), twelve (17 percent) had a good result (70 to 89 points), fourteen (19 percent) had a fair result (50 to 69 points), and thirty-nine (54 percent) had a poor result (less than 50 points). Nevertheless, fifty-one patients (71 percent) reported that the operation led to some improvement, and fifty-five (76 percent) said that they would have the operation again if the circumstances were similar to those before the repair of the pseudarthrosis. Thirty-four of the seventy-two patients were smokers and thirty-eight were non-smokers at the time of the operation. There was a negative linear association between the outcome scores and the number of pack-years (p = 0.02). Cessation of smoking before the operation positively affected the outcome; the patients who had stopped smoking had a mean outcome score of 65 points, compared with 45 points for those who had not stopped (p = 0.03). Patients who had stopped smoking were also more likely to return to work full time (p < 0.001). At the latest follow-up evaluation, twenty of the seventy-two patients had returned to full-time employment. Patients who had been receiving Workers' Compensation at the time of the operation generally did poorly on the outcome questionnaire, but, with the numbers available, they did not have a significantly different rate of solid fusion than patients who had not been receiving Workers' Compensation. Also, the outcome score and the rate of fusion were nor significantly affected by age or by obesity.

Fifty-six patients who had had a fracture of the scaphoid from January 1950 through December 1959 were interviewed, re-examined, and had radiographs made of both hands an average of thirty-six years (range, thirty-one to forty years) later. The average age at the time of the treatment was twenty-eight years (range, fifteen to forty-five years). Fifty-two of the fifty-six patients were treated at the time of the fracture; the other four had a non-union when first seen. The rate of non-union for the fresh fractures at the most recent follow-up examination was 10 per cent (five of fifty-two). Dorsal intercalated-segment instability was found in three of the fifty-six patients; all three had a pseudarthrosis and manifest radiocarpal osteoarthrosis. Marked radiocarpal osteoarthrosis developed in only one (2 per cent) of the forty-seven patients who had a healed fracture; it was far more common in the group that had a pseudarthrosis, in which the prevalence was five of nine patients. Manifest osteoarthrosis also seemed to be associated with pain or weakness: it had developed in only three (6 per cent) of the forty-nine patients who did not have any symptoms at the re-examination, compared with three of the seven who had symptoms.

The use of an intramedullary rod as described by Williams, combined with implantation of an autogenous bone graft, resulted in union of an established congenital pseudarthrosis of the tibia in nine of ten patients. One patient needed additional bone-grafting before union occurred. The average age at the time of the operation was five years and three months. A rod of the appropriate length was inserted at the site of the non-union, antegrade through the distal part of the tibia and the hindfoot and then retrograde through the proximal fragment. This resulted in splinting of the tibia, ankle, and subtalar joints. Solid osseous union occurred an average of six months after the procedure in all ten patients. Five patients had a refracture of the tibia after the initial consolidation. Three of the five needed one or more additional operative procedures; one was managed with a cast; and one patient, who had been followed for four years before the refracture, did not return for treatment of the refracture. As is the plan with this method of treatment, the distal part of the tibia grew off the rod and the distal tip of the rod was located proximal to the foot and ankle, or it was located more proximally than it had been at the operation, in six patients. The rod was removed from three patients. At an average of six years, all ten patients were able to walk without pain.

Sixty-three first, second, or third-time repairs of one or more pseudarthroses were done in fifty-one patients who had had an arthrodesis for idiopathic scoliosis. Forty-five of the patients were female and six were male. The average age was 30.2 years. The indications for the sixty-three repairs were pain (twenty-five repairs), progression of the curve (sixteen), both pain and progression of the curve (twelve), and radiographic changes only (ten). Failure of the implant was identified before 27 per cent of the sixty-three procedures. The pseudarthroses were diagnosed an average of 2.8 years after the initial arthrodeses. Sixty-eight per cent of the defects were visible on plain radiographs preoperatively and 32 per cent were identified at operation. During the time between the original arthrodeses and the repairs of the pseudarthroses, the scolioses increased by a mean of 7 degrees and the kyphoses, by a mean of 10 degrees. Harrington distraction was the most commonly used instrumentation (twenty-six [41 per cent] of the sixty-three procedures), and autogenous iliac bone was the most commonly used material for the graft (thirty-three [52 per cent] of the procedures).

Twenty-two consecutive unselected patients who had severe spondylolisthesis were treated by a first-stage posterior decompression (Gill procedure) and a posterolateral arthrodesis, followed by halo-skeletal traction, and then by a second-stage anterior interbody arthrodesis, followed by immobilization in a cast. Nineteen patients had complete clinical and radiographic evaluation, with an average follow-up of five years (range, two to seven and one-half years). The slip angle averaged 71 degrees preoperatively, was corrected to an average of 31 degrees by reduction, and averaged 28 degrees at follow-up. The average preoperative percentage of slippage (98 per cent) did not change substantially. A pseudarthrosis developed in four patients, all of whom had a reoperation. The neurological deficits that had been present in ten patients preoperatively had completely resolved in all but one at follow-up. One patient had a cauda equina syndrome and two patients had a neuropathy of the root of the fifth lumbar nerve as a result of the reduction; complete recovery occurred in two patients and partial recovery, in one. Alignment in the sagittal plane was restored in seventeen patients, and the back pain and radicular symptoms were relieved in all patients except one who had had those symptoms preoperatively.

Free vascularized fibular bone grafts were used in nineteen children, seen consecutively, who had congenital pseudarthrosis of the tibia. The average age was 5.1 years (range, 1.4 to 11.4 years). Sixteen of the patients had been treated with electrical stimulation for at least one year, and the tibia had not united. All but four patients had had at least one previous operative procedure. At an average follow-up of 6.3 years (range, 2.0 to 11.0 years), eighteen (95 per cent) of the nineteen pseudarthroses had healed. The leg-length discrepancy averaged 1.6 centimeters (range, 0 to 4.0 centimeters), but ten tibiae had residual or progressive valgus or anteroposterior malalignment despite bracing. There was minimum morbidity at the donor site.

Eight patients who had a recurrent pseudarthrosis of the carpal scaphoid were treated by a bone graft from the ulna, vascularized by an ulnar-artery pedicle. The graft was taken from the medial aspect of the distal third of the ulna and inserted into the prepared scaphoid. This technique is advocated only for complex recalcitrant non-union. All of our patients had previously had at least two operations, one of which was conventional non-vascularized bone-grafting. In all eight patients, primary osseous union occurred in an average of 4.6 months; all were able to resume their previous occupational or athletic activities.

We reviewed the cases of 110 patients with paralytic scoliosis due to poliomyelitis who were operated on. In the lumbar region, anterior Dwyer instrumentation with posterior fusion gave excellent correction of scoliosis and pelvic obliquity. In the more rigid thoracic curves, combined anterior Dwyer instrumentation and posterior fusion gave better results than posterior fusion alone, but had more morbidity. Long c-shaped curves benefited more from a combined anterior Dwyer procedure at the apex of the curve and long posterior Harrington instrumentation. Traction was found to be of use only in rigid curves and in those larger than 80 degrees. With combined anterior and posterior fusion, there was a pseudarthrosis rate of 7 per cent in lumbar curves, none in thoracic curves, and 12.5 per cent in long c-shaped curves. The pseudarthrosis rate rose to more than 25 per cent in patients who had a posterior fusion alone.

Eight patients with congenital pseudarthrosis of the tibia had a Syme amputation and were followed for an average of 5.9 years. The average age at amputation was 8.2 years, and an average of 3.8 surgical procedures were performed prior to the amputation in each patient. None of the pseudarthroses healed, but in spite of that the Syme amputation can be recommended when amputation is necessary. With a simple orthosis, the child can then engage in normal activities. The operation provides a longer stump than do conventional amputations, as well as better skin coverage and more potential for further growth of the tibia from the distal epiphysis.

A retrospective study of maintenance of correction as affected by modifications in the management of patients surgically treated for scoliosis showed better results in Group B than in Group A. No supplementary bone was used in the 187 patients in Group A, who were maintained recumbent for three months postoperatively and who wore an underarm body cast for six months. The 177 patients in Group B received autogenous iliac-bone grafts, were allowed to walk seven to ten days postoperatively, and wore an underarm body cast for nine months. By two years postoperatively the patients in Group A had lost an average of 8.3 degrees of correction, and the patients in Group B had lost 4.3 degrees. A pseudarthrosis developed in eight patients in Group A and in one patient in Group B.

Total hip arthroplasty was done in thirty-three patients who had had previous surgical attempts at arthrodesis of the hip. The arthrodesis had failed in nineteen patients, and the other fourteen patients had fused hips with symptoms in the knee and lower back. Thirty-one of the patients had satisfactory functional ability after total hip arthroplasty after one to three and one-half years' follow-up. The two patients in whom the procedure failed had complicating infections.