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Objective: To investigate the clinical and radiologic characteristics of children with congenital pseudarthrosis of the tibia (CPT) in a single center. Methods: This is a retrospective case series study. According to inclusion and exclusion criteria, clinical data of 497 children(507 limbs) with CPT who were treated at Department of Orthopedics, the Children's Hospital Affiliated to Xiangya School of Medicine, Central South University from January 2011 to December 2020 were collected. Baseline data included gender, age at initial visit, age at onset of symptoms, accompanying symptoms, domicile, whether first treated at our hospital, and treatment-related information such as surgical or conservative treatment, surgical complications, etc., were extracted and analyzed using the health information system. Imaging data of the children, including Crawford classification, bilateral leg lengths, presence of fibular pseudarthrosis, and location of pseudarthrosis along the tibia segment, were analyzed using the Picture Archiving and Communication System. Data were compared using independent sample t test or χ 2 tests. Results: Among 497 children with CPT, there were 305 males (61.4%) and 192 females (38.6%). The age at initial visit was (3.6±3.2) years (range: 0.1 to 16.2 years). Neurofibromatosis type 1 (NF1) symptoms were positive in 340 children (68.4%), and negative in 157 children (31.6%). Among NF1-positive children, those with symptoms onset before 1 year of age were significantly more than NF1-negative children (74.1%(252/340) vs . 66.2%(104/157); χ 2 =9.24, P =0.001), and the proportion of fractures (92.9%,316/340) was significantly higher than that in the NF1-negative group (84.7%,133/157) ( χ 2 =8.33, P =0.004). According to imaging data, Crawford type Ⅳ was the most common type, with 321 limbs (63.3%), followed by type Ⅱ in 100 limbs (19.7%), type Ⅲ in 54 limbs (10.7%) and type Ⅰ in 32 limbs (6.3%). Pseudarthrosis occurred in the proximal third of the tibia in 14 limbs (2.8%), in the middle third in 185 limbs (36.5%), and in the distal third in 308 limbs (60.8%). Seventy-four children (14.9 %) had associated fibular pseudarthrosis. The lateral proximal tibial angle was 86.91°±5.21°(range: 72.17° to 102.08°), and the lateral distal tibial angle was 87.27°±10.73°(range: 51.07° to 128.17°). A total of 421 children (84.7%) underwent surgical treatment with (3.1±2.4) surgeries performed per child (range:0 to 12 surgeries); 76 children (15.3%) received conservative treatment. Postoperative complications mainly included ankle valgus (77 cases), leg length discrepancy (71 cases),refracture (48 cases), osteomyelitis (11 cases), and hardware failure (10 cases). NF1-positive children underwent more surgeries than NF1-negative children ((5.1±2.2)times vs .(2.1±1.8)times; t =14.93, P <0.01). Conclusions: Crawford type Ⅳ is the most common type of CPT in children in this study. CPT predominantly occurs in the middle or distal third of the tibia. The majority of children with CPT experienced symptoms and were seen at outpatient clinics before the age of 3 years. The main surgical complications currently associated with CPT treatment are ankle valgus and leg length discrepancy. Compared with CPT without NF1, children with NF1-positive CPT tend to have earlier symptom onset and may require more frequent treatments.

Up to 84% of patients with congenital pseudarthrosis of the tibia (CPT) present with neurofibromatosis type 1 (NF1) (NF1-CPT). However, the etiology of CPT not fulfilling the NIH diagnostic criteria for NF1 (non-NF1-CPT) is not well understood. Here, we collected the periosteum tissue from the pseudarthrosis (PA) site of 43 non-NF1-CPT patients and six patients with NF1-CPT, together with the blood or oral specimen of trios (probands and unaffected parents). Whole-exome plus copy number variation sequencing, multiplex ligation-dependent probe amplification (MLPA), ultra-high amplicon sequencing, and Sanger sequencing were employed to identify pathogenic variants. The result showed that nine tissues of 43 non-NF1-CPT patients (21%) had somatic mono-allelic NF1 inactivation, and five of six NF1-CPT patients (83.3%) had bi-allelic NF1 inactivation in tissues. However, previous literature involving genetic testing did not reveal somatic mosaicism in non-NF1-CPT patients so far. In NF1-CPT patients, when the results from earlier reports and the present study were combined, 66.7% of them showed somatic NF1 inactivation in PA tissues other than germline inactivation. Furthermore, no diagnostic variants from other known genes (GNAS, AKT1, PDGFRB, and NOTCH3) related to skeletal dysplasia were identified in the nine NF1 positive non-NF1-CPT patients and six NF1-CPT patients. In conclusion, we detected evident somatic mono-allelic NF1 inactivation in the non-NF1-CPT. Thus, for pediatric patients without NF1 diagnosis, somatic mutations in NF1 are important., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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

Background: Interbody fusion at the caudal levels of long constructs for adult spinal deformity (ASD) surgery is used to promote fusion and secure a solid foundation for maintenance of deformity correction. We sought to evaluate long-term pseudarthrosis, rod fracture, and revision rates for TLIF performed at the base of a long construct for ASD., Methods: We reviewed 316 patients who underwent TLIF as a component of ASD surgery for medical comorbidities, surgical characteristics, and rate of unplanned reoperation for pseudarthrosis or instrumentation failure at the TLIF level. Fusion grading was assessed after revision surgery for pseudarthrosis at the TLIF level., Results: Rate of pseudarthrosis at the TLIF level was 9.8% (31/316), and rate of rod fractures was 7.9% (25/316). The rate of revision surgery at the TLIF level was 8.9% (28/316), and surgery was performed at a mean of 20.4 ± 16 months from the index procedure. Current smoking status (odds ratio 3.34, P = 0.037) was predictive of pseudarthrosis at the TLIF site. At a mean follow-up of 43 ± 12 months after revision surgery, all patients had achieved bony union at the TLIF site., Conclusions: At 3-year follow-up, the rate of pseudarthrosis after TLIF performed at the base of a long fusion for ASD was 9.8%, and the rate of revision surgery to address pseudarthrosis and/or rod fracture was 8.9%. All patients were successfully treated with revision interbody fusion or posterior augmentation of the fusion mass, without need for further revision procedures at the TLIF level., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Patients with osteopenia or osteoporosis who require surgery for symptomatic degenerative spondylolisthesis may have higher rates of postoperative pseudarthrosis and need for revision surgery than patients with normal bone mineral densities (BMDs). To this end, the authors compared rates of postoperative pseudarthrosis and need for revision surgery following single-level lumbar fusion in patients with normal BMD with those in patients with osteopenia or osteoporosis. The secondary outcome was to investigate the effects of pretreatment with medications that prevent bone loss (e.g., teriparatide, bisphosphonates, and denosumab) on these adverse outcomes in this patient cohort., Methods: Patients undergoing single-level lumbar fusion between 2007 and 2017 were identified. Based on 1:1 propensity matching for baseline demographic characteristics and comorbidities, 3 patient groups were created: osteopenia (n = 1723, 33.3%), osteoporosis (n = 1723, 33.3%), and normal BMD (n = 1723, 33.3%). The rates of postoperative pseudarthrosis and revision surgery were compared between groups., Results: The matched populations analyzed in this study included a total of 5169 patients in 3 groups balanced at baseline, with equal numbers (n = 1723, 33.3%) in each group: patients with a history of osteopenia, those with a history of osteoporosis, and a control group of patients with no history of osteopenia or osteoporosis and with normal BMD. A total of 597 complications were recorded within a 2-year follow-up period, with pseudarthrosis (n = 321, 6.2%) being slightly more common than revision surgery (n = 276, 5.3%). The odds of pseudarthrosis and revision surgery in patients with osteopenia were almost 2-fold (OR 1.7, 95% CI 1.26-2.30) and 3-fold (OR 2.73, 95% CI 1.89-3.94) higher, respectively, than those in patients in the control group. Similarly, the odds of pseudarthrosis and revision surgery in patients with osteoporosis were almost 2-fold (OR 1.92, 95% CI 1.43-2.59) and > 3-fold (OR 3.25, 95% CI 2.27-4.65) higher, respectively, than those in patients in the control group. Pretreatment with medications to prevent bone loss prior to surgery was associated with lower pseudarthrosis and revision surgery rates, although the differences did not reach statistical significance., Conclusions: Postoperative pseudarthrosis and revision surgery rates following single-level lumbar spinal fusion are significantly higher in patients with osteopenia and osteoporosis than in patients with normal BMD. Pretreatment with medications to prevent bone loss prior to surgery decreased these complication rates, although the observed differences did not reach statistical significance.

Congenital pseudarthrosis of the tibia is defined as a non-union of a tibial fracture that develops in a dysplastic bone segment of the tibial diaphysis. Pathologically, a fibrous hamartoma surrounds the bone at the congenital pseudarthrosis of the tibia site. The cases of 25 children, who have congenital pseudarthrosis of the tibia, were included in this study. Their ages ranged from 15 months to 15 years at the time of treatment. Neurofibromatosis-1 was present in 24 children. They were managed according to our classification system and treatment protocol. The treatment for mobile pseudarthrosis (types 1 and 2) included complete excision of the pathological periosteum, insertion of autogenous iliac crest bone graft, and combined fixation using intramedullary rod and Ilizarov external fixator. For type 3 pseudarthrosis (stiff pseudarthrosis), a pre-constructed Ilizarov fixator was applied for simultaneous distraction of the pseudarthrosis and deformity correction without open surgery. Evaluation of results was mainly radiological and included achievement of union, leg length equalization, deformity correction and prevention of refracture. Consolidation of the pseudarthrosis and osteotomies was achieved in all cases (100%). Refracture occurred in one case (4%) at the site of previous pseudarthrosis. Residual limb length discrepancy more than 2.5 cm occurred in two cases (8%). Valgus deformity of the ankle was present in 12 cases (48%) and was treated by supramalleolar osteotomy. Follow-up ranged from 24 to 48 months (average 36.9 months) after fixator removal. The results of our treatment protocol, based on our classification system, have been consistently good and predictable in all cases of congenital pseudarthrosis of the tibia. Mobility of the pseudarthrosis is an important factor in choosing the type of interference.

Objective: This study investigated the clinical and functional results of treating congenital pseudarthrosis of the tibia (CPT) using the combined techniques of hamartoma resection, periosteal grafting, circular external fixator application, and intramedullary rodding., Methods: The clinical and radiological data of 17 patients (mean age at the treatment time: 7.6 months (range: 4.6-9.7 months) with CPT, treated by a single surgeon between 1997 and 2017, were retrospectively analyzed. All data regarding surgical interventions, complications, deformity analysis parameters, limb length discrepancy (LLD), ankle joint range of motion, and residual deformities were reviewed. All the patients were followed up at least two years after the last surgical intervention. The mean follow-up time was 8.5 years (range: 2.2 to 15.7 years)., Results: Union was achieved with the index treatment in 15 of the 17 cases (88.2%). The mean age of the patients at the last follow-up visit was 14.2 years (range: 7.6 to 22.1). The mean LLD was 2.1 cm. Nine patients had radiological ankle valgus at the last follow-up. In the entire series, eight patients did not display any complications, four cases reported minor complications, and five cases were complicated by refractures., Conclusion: Circular external fixator application combined with periosteal grafting is a superior method of CPT treatment. This method provides a healthy biological healing environment while correcting the mechanical problems. The combination of periosteal and cancellous bone grafts with intramedullary rods and an external fixator addresses issues that complicate obtaining and maintaining a union during the CPT treatment., Level of Evidence: Level IV, Therapeutic study.

Fractures of the acromion are uncommon clinical entities, and stress fractures are even more rare, with few cases reported. Due to their rarity, stress fractures are often misdiagnosed. Here, we report a case of an elderly patient with an acromion stress fracture, which was overlooked, resulting in nonunion followed by the displacement of the distal portion of the acromion. The purpose of this report was to discuss this rare fracture, highlighting the importance of an accurate evaluation of radiological imaging as well as clinical data. (www.actabiomedica.it).

Purpose: Ochronotic spondyloarthropathy is an uncommon disease, and its association to sagittal malalignment in the context of a pseudarthrosis has never been described., Methods: We present the case of a 56-year-old female, who underwent previously L4L5 laminectomy for central canal stenosis and started later on to complain of progressively severe low back pain with a significant forward imbalance while walking. X-rays showed non-compensated sagittal malalignment due to thoracolumbar kyphosis, CT scan revealed multilevel central intradiscal calcifications with important vacuum disc at L4L5, and MRI showed T1 and T2 hypointensity signal at the same level with bone marrow oedema. Alkaptonuric ochronosis was suspected and confirmed by the presence of homogentisic acid in the urine, and the diagnosis of L4L5 pseudarthrosis with associated severe sagittal malalignment in the context of ochronotic spondyloarthropathy was established., Results: The patient underwent surgery with a posterior-only approach with a long-segment pedicle screw construct from T10 to the pelvis with a 360° fusion with a cage at L4L5. Samples taken from the disc and ligaments confirmed the diagnosis of ochronotic spondyloarthropathy macroscopically and microscopically. She could walk on day 2 with a satisfactory clinical and radiological result at 2 years., Conclusion: This is the first case in the literature to describe a post-laminectomy pseudarthrosis leading to a significant sagittal malalignment in a patient with ochronotic spondyloarthropathy. Management of such a case is challenging as the spine is partially ankylosed; therefore, a long construct is advisable to avoid ankylosing disorders related complications.

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder affecting approximately 1 in 2,000 newborns. Up to 5% of NF1 patients suffer from pseudarthrosis of a long bone (NF1-PA). Current treatments are often unsatisfactory, potentially leading to amputation. To gain more insight into the pathogenesis we cultured cells from PA tissue and normal-appearing periosteum of the affected bone for NF1 mutation analysis. PA cells were available from 13 individuals with NF1. Biallelic NF1 inactivation was identified in all investigated PA cells obtained during the first surgery. Three of five cases sampled during a later intervention showed biallelic NF1 inactivation. Also, in three individuals, we examined periosteum-derived cells from normal-appearing periosteum proximal and distal to the PA. We identified the same biallelic NF1 inactivation in the periosteal cells outside the PA region. These results indicate that NF1 inactivation is required but not sufficient for the development of NF1-PA. We observed that late-onset NF1-PA occurs and is not always preceded by congenital bowing. Furthermore, the failure to identify biallelic inactivation in two of five later interventions and one reintervention with a known somatic mutation indicates that NF1-PA can persist after the removal of most NF1 negative cells., (© 2019 Wiley Periodicals, Inc.)

Background: Congenital pseudarthrosis of the tibia (CPT) is a rare disease. Some patients present neurofibromatosis type 1 (NF1), while some others do not manifest NF1 (non-NF1). The etiology of CPT, particularly non-NF1 CPT, is not well understood. Here we screened germline variants of 75 CPT cases, including 55 NF1 and 20 non-NF1. Clinical data were classified and analyzed based on NF1 gene variations to investigate the genotype-phenotype relations of the two types of patients., Results: Using whole-exome sequencing and Multiplex Ligation-Dependent Probe Amplification, 44 out of 55 NF1 CPT patients (80.0%) were identified as carrying pathogenic variants of the NF1 gene. Twenty-five variants were novel; 53.5% of variants were de novo, and a higher proportion of their carriers presented bone fractures compared to inherited variant carriers. No NF1 pathogenic variants were found in all 20 non-NF1 patients. Clinical features comparing NF1 CPT to non-NF1 CPT did not show significant differences in bowing or fracture onset, lateralization, tissue pathogenical results, abnormality of the proximal tibial epiphysis, and follow-up tibial union after surgery. A considerably higher proportion of non-NF1 patients have cystic lesion (Crawford type III) and used braces after surgery., Conclusions: We analyzed a large cohort of non-NF1 and NF1 CPT patients and provided a new perspective for genotype-phenotype features related to germline NF1 variants. Non-NF1 CPT in general had similar clinical features of the tibia as NF1 CPT. Germline NF1 pathogenic variants could differentiate NF1 from non-NF1 CPT but could not explain the CPT heterogeneity of NF1 patients. Our results suggested that non-NF1 CPT was probably not caused by germline NF1 pathogenic variants. In addition to NF1, other genetic variants could also contribute to CPT pathogenesis. Our findings would facilitate the interpretation of NF1 pathogenic variants in CPT genetic counseling.

Purpose: To examine the efficacy, safety, and clinical outcomes of distraction osteogenesis through the physis (PDO) or through subphyseal osteotomy (SPDO) in patients with atrophic-type congenital pseudarthrosis of tibia with proximal tibial dysplasia., Methods: To validate the efficacy and safety of PDO and SPDO, radiographic and clinical parameters were compared between 5 patients who underwent proximal tibial metaphyseal or metadiaphyseal lengthening as a control (group 1) and 7 patients who underwent PDO or SPDO (group 2). Postoperative complication was also compared between the groups., Results: A significant difference in terms of healing index (group 1, 83.3±24.7 d/cm; group 2, 35.0±11.1 d/cm; P=0.001) and percentage increase (11.0%±3.7% vs. 23.1%±10.5%, P=0.034) was observed between the 2 groups. According to the Paley classification, group 1 included 1 "problems" case and 3 "obstacles" cases, whereas group 2 included 2 "problems" cases and 1 "obstacles" case. According to the Lascombes classification, group 1 included 2 grade IIIb cases and 3 grade IV cases, whereas group 2 included 6 grade I cases and 1 grade IIa case. Severe complications were significantly higher in group 1 compared with the group 2 (P=0.007)., Conclusions: This study demonstrated that PDO or SPDO can be effectively and safely performed for tibial lengthening in atrophic-type congenital pseudarthrosis of tibia patients with proximal tibial dysplasia., Level of Evidence: Level III.

We conducted a systematic review with meta-analysis and qualitative synthesis. This study aims to characterize pseudarthrosis after long-segment fusion in spinal deformity by identifying incidence rates by etiology, risk factors for its development, and common features. Pseudarthrosis can be a painful and debilitating complication of spinal fusion that may require reoperation. It is poorly characterized in the setting of spinal deformity. The MEDLINE, EMBASE, and Cochrane databases were searched for clinical research including spinal deformity patients treated with long-segment fusions reporting pseudarthrosis as a complication. Meta-analysis was performed on etiologic subsets of the studies to calculate incidence rates for pseudarthrosis. Qualitative synthesis was performed to identify characteristics of and risk factors for pseudarthrosis. The review found 162 articles reporting outcomes for 16,938 patients which met inclusion criteria. In general, the included studies were of medium to low quality according to recommended reporting standards and study design. Meta-analysis calculated an incidence of 1.4% (95% CI 0.9-1.8%) for pseudarthrosis in adolescent idiopathic scoliosis, 2.2% (95% CI 1.3-3.2%) in neuromuscular scoliosis, and 6.3% (95% CI 4.3-8.2%) in adult spinal deformity. Risk factors for pseudarthrosis include age over 55, construct length greater than 12 segments, smoking, thoracolumbar kyphosis greater than 20°, and fusion to the sacrum. Choice of graft material, pre-operative coronal alignment, post-operative analgesics, and sex have no significant impact on fusion rates. Older patients with greater deformity requiring more extensive instrumentation are at higher risk for pseudarthrosis. Overall incidence of pseudarthrosis requiring reoperation is low in adult populations and very low in adolescent populations.

Background: Recurrent peripheral facial paresis is a rare symptom that may be caused by multiple pathologic conditions., Methods: We report a case of recurrent peripheral facial palsies caused by an ipsilateral enlarged styloid process. A surgical excision of the process was performed., Results: The treatment was well tolerated. Postoperatively, no further recurrent paresis was observed., Conclusion: To the best of our knowledge, this is the first case study of an enlarged styloid process with facial paresis. A detailed workup, including imaging, should be performed in cases with recurrent facial paresis and/or cases with a history of trauma and facial paresis and, of course, to exclude a neoplastic etiology., (© 2018 Wiley Periodicals, Inc.)

Congenital pseudoarthrosis of the clavicle is a rare entity that can be confused for a traumatic injury. We present 4 cases of congenital clavicular pseudoarthrosis and discuss its imaging findings that can help differentiate it from the more common clavicular facture. We also reviewed its epidemiology, embryology, and management based on available and most recent literature.

To compare the current treatments for congenital pseudarthrosis of tibia, a total of 33 studies were reviewed. Vascularized fibular graft with external fixation or combined fixation had the fastest time till initial union (P<0.05). Bone morphogenetic protein had no advantage in terms of initial union, time till union, and refracture rates. This meta-analysis supports that fixation methods with corticocancellous bone autograft utilizing the combined technique of Ilizarov external fixation and intramedullary rod stabilization ensure a statistically significant reduction in the number of refractures compared with standalone fixation methods and would be the preferred method for preventing long-term complications in patients with congenital pseudarthrosis of tibia.

Metatarsal fractures make up the greatest portion of foot fractures in children. Most of them are treated with closed reduction and non-weightbearing cast immobilization.Usually, these fractures heal uneventfully and delay union and pseudoarthrosis are rare. We report a case of a 10-year-old child with non-union of the second metatarsal following a traumatic fracture, caused by an accident 10 months before, and treated successfully by osteosynthesis with plate and screws. Good clinical outcome was achieved at 2 years follow-up.

Neurofibromatosis 1 has various complications. To elucidate the frequency of neurofibromatosis 1-related major complications requiring medical intervention, a nationwide retrospective study was conducted of 3,530 patients with neurofibromatosis 1 registered from 2001 to 2014 in Japan. The ratio of certified patients requiring medical intervention (>stage 3) was 82%. Patients classified in the most severe grade experienced dermatological complications (71.8% of patients), neurological complications (38.1%) and bone complications (33.3%). In patients with dermatological manifestations, medical treatment was needed for cutaneous neurofibromas (58%), diffuse plexiform neurofibromas (31%) and malignant peripheral nerve sheath tumours (10%). Patients with neurological manifestations needed medical treatment mainly for brain tumours (53%) and intellectual disability (26%). Patients with bone manifestations needed medical treatment for pseudoarthrosis (9%), scoliosis (55%) and bone defects (16%). It is necessary for physicians to be aware of neurofibromatosis 1-related complications requiring medical intervention in order to provide appropriate care for patients with neurofibromatosis 1.

Scedosporium apiospermum is a ubiquitous filamentous fungus, commonly found in soil, sewage and polluted waters. It is rarely pathogenic but can cause a broad spectrum of clinical diseases, which can be localised or disseminate to distant organs. The disseminated form of the disease is mostly seen among immunocompromised patients. However, some rare cases of disseminated disease have been reported in immunocompetent individuals. Treatment of these infections is challenging because of their natural resistance to many antifungal agents. Here, we report the case of a 57-year-old immunocompetent patient diagnosed with femoral pseudarthrosis due to S. apiospermum, despite having no obvious clinical sign of infection. Previously, the patient had undergone four iterative femoral surgeries following a road traffic accident which occurred 20 years before. During its last surgery for pseudarthrosis, no clinical or biological signs of infection were present. Per operative samples tested positive for S. apiospermum. The patient was successfully treated with oral voriconazole during 6 months with an excellent tolerance. We also provide a review of literature on bone and joint infections due to Scedosporium spp. (S. apiospermum, Scedosporium boydii and Scedosporium aurantiacum), discussing the evolution of their management and outcome which seems to improve since the use of voriconazole., (© 2017 Blackwell Verlag GmbH.)

BACKGROUND Congenital pseudoarthrosis of the tibia is one of the most difficult orthopedic diseases to treat. Many authors consider osteotomy of the bowed non-broken tibia a contraindication. However, leaving the patient with a deformed, bowed leg is intolerable and is associated with deformity progression and increased risk of fracture. CASE REPORT A 12-year-old boy presented with a bowed leg. X-ray tibia showed partially healed congenital pseudoarthrosis of the tibia and 30 degrees of flexion deformity. Deformity was successfully treated by percutaneous osteotomy made through the site of congenital pseudoarthrosis and gradual correction using a computer-assisted external fixator, the Taylor spatial frame (TSF; Smith and Nephew, Memphis, TN). At the end of the correction, a telescopic Fassier-Duval intramedullary nail was used prophylactically to prevent re-fracture. After 2 years of follow-up, X-ray images show bone-healing without any bowing. CONCLUSIONS Closed percutaneous osteotomy, without excision of the pseudoarthrosis, and gradual correction then insertion of Fassier-Duval telescopic nail may serve as a treatment to correct deformed bone in congenital pseudoarthrosis of the tibia.

We present the case of a delayed pseudoarthrosis resulting from a fracture at the site of a radiographically confirmed anterior cervical fusion following plate removal. In this case, an anterior cervical plate was removed to allow for further surgery at a supra-adjacent level. A modicum of literature exists describing delayed fractures following hardware removal in thoracolumbar fusion constructs. The development of a fracture/pseudoarthrosis following hardware removal at the site of a radiographically confirmed anterior cervical fusion has not been previously reported. We describe the clinical presentation and operative management in the case of this rare and unexpected complication., (Copyright © 2017. Published by Elsevier Ltd.)

Congenital pseudarthrosis of the clavicle (CPC) is a very rare pathology of which over 200 cases have been reported. Usually discovered during the first months of life, CPC is characterised by a definitive bone defect in the middle third of the clavicle. Generally asymptomatic, the pseudarthrosis of the clavicle can cause aesthetic issues and functional symptoms indicating a surgical repair. Different reconstruction techniques have been reported with various complications. We present a 14-year-old boy diagnosed with CPC and concerned about the cosmetic aspect of a swelling of his right clavicle. We performed a two-stage surgical repair using the induced membrane technique described by Masquelet. A complete bone union has been obtained, and patient is satisfied with the cosmetic appearance. In our opinion, the Masquelet technique is a safe and reproducible procedure to treat CPC in high-risk older patients with long gap allowing a rapid and lasting bone union., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Study Design: A case report and literature review., Objective: To report a late dislocation of the vertebra caused by progressive dural ectasia combined with type-1 neurofibromatosis (NF-1) and the clinical results of pseudarthrosis repairs using autologous cultured osteoblasts., Summary of Background Data: NF-1 is a well-known genetic disorder that is commonly characterized by spinal deformities including kyphoscoliosis. Late dislocation of the vertebra resulting from progressive dural ectasia after surgical correction of NF-1 scoliosis is a very rare occurrence, and pseudarthrosis frequently develops after surgical intervention for this complex spinal deformity., Methods: A 32-year-old female patient with NF-1 scoliosis underwent surgical correction with posterior instrumented fusion. Seventeen years later, dislocation of the lumbar spine with implant failure resulting from massive progressive dural ectasia was observed. She underwent anterior interbody fusion three times and posterior instrumented fusion four times for pseudarthrosis followed by surgical deformity correction. For the last operation, autologous cultured osteoblasts were used as a therapeutic approach to repair the pseudarthrosis, and a three-dimensional printing technique was used to understand the surgical anatomy of the dislocated lumbar spine in detail., Results: After the final operation, bone union was achieved and confirmed by clinical and radiological examination., Conclusion: Spine surgeons should be knowledgeable about the possibility of late destabilization of the spine, due to pulsatile dural ectasia, and a high rate of pseudarthrosis in neurofibromatosis. Autologous cultured osteoblasts may prove to be a modality that can be applied pseudarthrosis repair to treat complex spinal deformity., Level of Evidence: 5.

Congenital pseudarthrosis of the clavicle is a rare malformation in which the aetiology is still unclear. Bilateral involvement is exceptional. Although it is a congenital malformation, it may not be diagnosed until late childhood, with patients presenting with a painless deformity of the middle third of the clavicle in the absence of prior trauma. The treatment is controversial, and may be surgical, depending on the functional impact and aesthetics. A case of bilateral involvement is presented, together with a review of the relevant literature., (Copyright © 2014 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

The diagnosis of implant-associated infections is challenging as chronic low-grade infections often only manifest as subtle clinical symptoms. Clinical evaluation, patient history, imaging, histopathological and microbiological examinations build the cornerstones of the diagnostics for implant-associated infections. New onset of pain at rest, local symptoms at the surgical site and early loosening of the prosthesis or pseudarthrosis should raise suspicion for an infection and prompt further evaluation. Percutaneous sinus tracts, purulent wound secretions and skin erosions with exposure of the implant are certain signs of implant-associated infections. Elevated C‑reactive protein levels in blood support the diagnosis of infection but are neither sufficient sensitive nor specific to confirm or exclude infection. Preoperative antibiotic therapy interferes with the diagnostic evaluation and should be avoided. In periprosthetic joint infections, joint aspiration with determination of the leukocyte count and microbiological examination is a crucial first diagnostic step. Through microbiological and histopathological examinations of intraoperative tissue samples, as well as sonication of explanted implants, the causative pathogen can be identified in most cases. In osteosynthesis-associated infections imaging plays a key role to detect non-union, infection callus, sequester, peri-implant osteolysis and extraosseous and intramedullary pathologies. In prosthetic joint infections imaging provides information about the position and stability of the prosthesis. In case of hematogenic infection seeding from a distant focus, blood cultures should be sampled, followed by a meticulous investigation of potential primary focus of infection, depending on the causative agent.

Study Design: Single-center, retrospective study of consecutive surgeries., Objective: This study aimed to evaluate the reliability of previously published anterior fusion grading systems and assess the ability of health-related quality-of-life (HRQOL) outcomes to predict pseudarthrosis (PSAR)., Summary of Background Data: Despite existing radiographic indicators, PSAR may still go unidentified on biplanar radiographs, and little data is available on the reliability of such grading systems in adult spinal deformity patients. As such, there is a need for a practical, noninvasive tool to help identify PSAR., Methods: This study included consecutive primary surgical patients with idiopathic or degenerative scoliosis undergoing anterior and posterior correction with instrumentation to the sacrum or pelvis and minimum 2-year follow-up. Patients were grouped into fused (no radiographic or clinical signs of PSAR) and PSAR (known PSAR diagnosed by surgical exploration or thin-cut computed tomography scan at least 1 year after surgery) cohorts. Two-year radiographs were graded by an independent blinded orthopedic deformity surgeon and a neuroradiologist. HRQOL scores [22-item Scoliosis Research Society questionnaire (SRS-22) and the Oswestry Disability Index (ODI)] at 1-year follow-up were analyzed as potential predictors of future PSAR., Results: Thirty-four patients with average follow-up of 2.2 years (2-2.5 y) were evaluated. Eight (23.5%) patients had known PSAR consisting of 40 (24.8%) anterior levels. Analysis by independent reviewers incorrectly identified 2 levels as unfused and failed to identify any PSAR levels. The PSAR group had lower average SRS scores in all domains and lower average ODI scores at 1-year postoperatively relative to fused patients. The PSAR group also showed no significant improvement in SRS or ODI scores relative to baseline. In comparison, the fused group showed significant improvement in all domains., Conclusions: Standard radiographs are insufficient for identifying PSAR in adult spinal deformity patients. Failure to achieve significant improvement in SRS and ODI should lead the surgeon to suspect PSAR and consider additional investigation.

Herein we report two cases of infections caused by Tissierella praeacuta and a review of the literature. The first case was a septic pseudarthrosis of the left femur after multiple fractures. Two per-operative samples were positive with T. praeacuta. The patient was successfully treated by piperacillin - tazobactam and metronidazole. The second case was a bacteremia in a patient suffering from pyonephrosis and a hepatic abscess. The treatment was meropenem. No relapses were observed in both cases. Identification of the strains using MALDI-TOF coupled to mass spectrometry (MS) (Beckman coulter, France) was inconclusive in the two cases. Identification by 16S rRNA sequencing was then performed. This bacterium was susceptible to beta-lactams, chloramphenicol, rifampicine and metronidazole., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: This study sought to evaluate the long-term osteosynthesis results for AO/OTA 31.A1-A2 pertrochanteric fractures treated with the percutaneous compression plate (PCCP)., Materials and Methods: This investigation was a retrospective observational descriptive study of 335 patients, with a minimum follow-up of 2 years and a maximum follow-up of 8 years (2004-2011)., Results: The average post-operative hospital stay was 6.2 days, and the average decrease in haemoglobin levels after the intervention was 2.7 mg/dL, with transfusion required for one-third of the patients. Complications related to the implant were observed in 4.2 % of patients; the most notable complication was cut-out (2.4 % of patients), and 3 cases involved pseudarthrosis with breakage of the implant (0.9 % of patients)., Conclusions: From the results obtained in this study and an analysis of previously published work, we believe that the PCCP may be the implant of choice for AO/OTA 31.A1-A2 fractures.

A fracture is defined as pathological when it arises in a bone tissue that has been modified and reshaped by a local or systemic pathological process. In children, pathological fractures can be secondary to several conditions, ranging from metabolic diseases to tumors, infections or neuromuscular pathologies. History, clinical examination and radiologic assessment are essential to making a diagnosis, to identifying the underlying cause and to planning the right treatment of a pathological fracture. Treatment must be tailored to both the fracture and the underlying cause. The objective of this work is to present the diagnostic approach and the course to follow when a child presents with a pathological fracture. The most common causes of pathological fractures, as well as their characteristics, will be described. Pathological fractures occurring in osteogenesis imperfecta and in abused children as well as stress fractures will not be discussed., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

The work is based on an analysis of treatment results of 47 patients with congenital pseudarthrosis of the tibia. The Ilizarov technique of unfree osteoplasty was applied on these patients. The authors considered an application of combined variants of exterior and external osteosynthesis as very perspective in rehabilitation of the patients with congenital pseudarthrosis.

The percentage of delayed or non-unions after fractures of long bones depends on the individual risk profile at approximately 10 %. The current definition states that a non-union is a fracture that will not consolidate without any further intervention - independent from the treatment time. At the early stage of a non-union a conservative treatment is possible in case of an adequately stable situation. The operative treatment depends on the type of the non-union. There are one-step or two-step procedures, all according to the principles of the "diamond concept". This means improvement of the mechanical situation - in most cases by means of a reosteosynthesis - and vascularization, local application of osteoconductive carriers e.g. tricalciumphosphate, vital cells from autologous bone and osteoinductive substances like bone morphogenetic proteins (BMP-2 or BMP-7). Hypertrophic and atrophic non-unions without large defect gaps or signs of infection can be treated with a one-step procedure. For treating infected non-unions or non-unions with large defect gaps the Masquelet technique is recommended., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Painful pseudarthrosis is one of the most important indications for (revision) surgery after spinal fusion procedures. If pseudarthrosis is the source of recurrent pain it may require revision surgery. It is therefore of great clinical importance to ascertain if it is the source of such pain. The correlation between findings on conventional imaging (plain radiography and CT) and clinical well-being has been shown to be moderate. The goal of this study was to determine the possible role of (18)F-fluoride PET in patients after lumbar spinal interbody fusion by investigating the relationship between PET/CT findings and clinical function and pain., Methods: A cohort of 36 patients was retrospectively included in the study after (18)F-fluoride PET/CT for either persistent or recurrent low back pain (18 patients) or during routine postoperative investigation (18 patients) between 9 and 76 months and 11 and 14 months after posterior lumbar interbody fusion, respectively. Sixty minutes after intravenous injection of 156 - 263 MBq (mean 199 MBq, median 196 MBq) (18)F-fluoride, PET and CT images were acquired using an integrated PET/CT scanner, followed by a diagnostic CT scan. Two observers independently scored the images. The number of bony bridges between vertebrae was scored on the CT images to quantify interbody fusion (0, 1 or 2). Vertebral endplate and intervertebral disc space uptake were evaluated visually as well as semiquantitatively following (18)F-fluoride PET. Findings on PET and CT were correlated with clinical wellbeing as measured by validated questionnaires concerning general daily functioning (Oswestry Disability Index), pain (visual analogue scale) and general health status (EuroQol). Patients were divided into three categories based on these questionnaire scores., Results: No correlation was found between symptom severity and fusion status. However, (18)F-fluoride activity in the vertebral endplates was significantly higher in patients in the lowest Oswestry Disability Index category (i.e. with the worst clinical performance) than in patients in higher categories (p = 0.01 between categories 1 and 2 and 1 and 3). The visual analogue scale and EuroQol results were similar although less pronounced, with only SUVmax between category 1 and 2 being significantly different (p = 0.04)., Conclusion: We hypothesize that (18)F-fluoride PET/CT may be able to provide support for the diagnosis of painful pseudarthrosis and could serve as a tool to discriminate between symptomatic and asymptomatic pseudarthrosis for revision surgery, as CT defines the consolidation status and PET pinpoints the 'stress reaction' at the vertebral endplates which significantly correlates with Oswestry Disability Index score.

OBJECT Failed solid bony fusion, or pseudarthrosis, is a well-known complication of lumbar arthrodesis. Recent advances in radiographic technology, biologics, instrumentation, surgical technique, and understanding of the local biology have all aided in the prevention and treatment of pseudarthrosis. Here, the current literature on the diagnosis and management of lumbar pseudarthroses is reviewed. METHODS A systematic literature review was conducted using the MEDLINE and Embase databases in order to search for the current radiographie diagnosis and surgical treatment methods published in the literature (1985 to present). Inclusion criteria included: 1) published in English; 2) level of evidence I-III; 3) diagnosis of degenerative lumbar spine conditions and/or history of lumbar spine fusion surgery; and 4) comparative studies of 2 different surgical techniques or comparative studies of imaging modality versus surgical exploration. RESULTS Seven studies met the inclusion criteria for current radiographie imaging used to diagnose lumbar pseudarthrosis. Plain radiographs and thin-cut CT scans were the most common method for radiographie diagnosis. PET has been shown to be a valid imaging modality for monitoring in vivo active bone formation. Eight studies compared the surgical techniques for managing and preventing failed lumbar fusion. The success rates for the treatment of pseudarthrosis are enhanced with the use of rigid instrumentation. CONCLUSIONS Spinal fusion rates have improved secondary to advances in biologies, instrumentation, surgical techniques, and understanding of local biology. Treatment of lumbar pseudarthrosis includes a variety of surgical options such as replacing loose instrumentation, use of more potent biologies, and interbody fusion techniques. Prevention and recognition are important tenets in the algorithm for the management of spinal pseudarthrosis.

Background: About 2,000 patients annually incur a fractured scaphoid in Norway. Assessment and diagnosis can be difficult, and fractures are overlooked. Scaphoid fractures have traditionally been cast-immobilised, but for the last decade screw fixing has been used increasingly, and offers hope of a higher healing frequency and improved function. Some scaphoid fractures are not diagnosed in the acute phase and some do not heal after treatment. Patients may then end up with painful pseudarthrosis. The purpose of this article is to provide an overview of the assessment, treatment and outcomes of scaphoid fractures., Method: The article is based on literature searches in PubMed and the authors' own clinical experience., Results: Primary diagnosis of scaphoid fractures and subsequent plaster cast immobilisation yield very good clinical results. Surgery should be limited to displaced fractures, fractures forming part of more extensive wrist injuries and exceptional other cases. Results comparable a quality equivalent to cast immobilisation are achieved by experienced surgeons in this area. Untreated scaphoid fractures often result in painful pseudarthrosis with subsequent abnormal position of the carpal bones and secondary arthrosis. This outcome can be counteracted by surgery on old fractures with bone grafting, internal fixation and cast immobilisation., Interpretation: Norwegian procedures for treating scaphoid fractures/pseudarthrosis are consistent with internationally documented good practice. Assessment of wrist pain following falls can be improved by conducting clinical tests for scaphoid fracture and radiology with four wrist projections. In the event of clinical suspicion, but no X-ray findings, the patient should be referred for a CT or MRI scan.

Purpose: The purpose of this study was to correlate the pre-operative imaging, vascularity of the proximal pole, and histology of the proximal pole bone of established scaphoid fracture non-union., Methods: This was a prospective non-controlled experimental study. Patients were evaluated pre-operatively for necrosis of the proximal scaphoid fragment by radiography, computed tomography (CT) and magnetic resonance imaging (MRI). Vascular status of the proximal scaphoid was determined intra-operatively, demonstrating the presence or absence of puncate bone bleeding. Samples were harvested from the proximal scaphoid fragment and sent for pathological examination. We determined the association between the imaging and intra-operative examination and histological findings., Results: We evaluated 19 male patients diagnosed with scaphoid nonunion. CT evaluation showed no correlation to scaphoid proximal fragment necrosis. MRI showed marked low signal intensity on T1-weighted images that confirmed the histological diagnosis of necrosis in the proximal scaphoid fragment in all patients. Intra-operative assessment showed that 90% of bones had absence of intra-operative puncate bone bleeding, which was confirmed necrosis by microscopic examination., Conclusions: In scaphoid nonunion MRI images with marked low signal intensity on T1-weighted images and the absence of intra-operative puncate bone bleeding are strong indicatives of osteonecrosis of the proximal fragment.

Background: Treatment of tibial nonunion with bone loss is extremely difficult. A variety of techniques have been described, but each has shortcomings, in particular prolonged external fixation time as well as serious complications such as nonunion and infection. Accordingly, we developed a technique that seeks to reduce these complications by using a circular external fixator in addition to an intramedullary nail to achieve union, limb lengthening, and stability of the regenerated segment., Description of Technique: First, the pseudoarthrosis area is resected, and acute compression is continued until bone contact at the docking site was achieved. Then primary grafting is applied to the docking site using a graft harvested from the patient's iliac bone, and the predrilled nail holes localized on the middle segment of the tibia are locked with a free-hand technique. Finally, lengthening is performed to overcome the leg-length discrepancy with an external fixator., Methods: Between 2008 and 2011, this technique was used to treat five patients with tibial nonunion with bone loss. All patients were available for a minimum of a 14-month followup (mean, 30 months; range, 14-58 months). General indications for the procedure were age older than 16 years, tibial nonunion with bone loss, and the absence of any psychiatric disorder. We evaluated external fixation time, external fixation index (defined as the duration of external fixation in months divided by the total amount of bone transported and/or the amount of lengthening in centimeters), and time to union on plain radiographs, clinical results using the Paley bone and functional assessment scores, and postoperative complications from chart review., Results: The external fixation time was 4 months (range, 3-5 months), and the average external fixation index was 0.4 months/cm. The mean time to bone union was 4.6 months (range, 3.5-5.5 months). All angles were determined to be in the normal range. No patients developed refracture or malalignment either on the docking site or the osteotomy site. Paley bone evaluation results were excellent in all five patients, and Paley functional results were excellent in four and good in one. We observed 10 pin-site infections as minor complications, and one patient was left with a residual equinus deformity of 5° as a major complication according to the Paley classification., Conclusions: Our technique combining acute shortening and distraction osteogenesis had promising results for the treatment of tibial nonunion with bone loss in a small group of patients. However, future studies directly comparing available approaches to this difficult problem are required. Because this problem is uncommon, these studies will almost certainly require the cooperation of multiple large participating centers., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Study Design: Retrospective study., Objective: To study the impact of smoking status on postoperative complications and pseudarthrosis in adult patients undergoing posterolateral fusion (PLF) of the lumbar spine., Summary of Background Data: Results of studies analyzing the impact of smoking on complication and pseudarthrosis rates after spine surgery are conflicting., Methods: A retrospective medical record review was performed to identify all adult patients who underwent single- and 2-level instrumented PLF without interbody devices for degenerative spine disease in a 21-year period at a single institution. Patients were divided into smokers and nonsmokers. The main outcome variables were development of at least one postoperative complication and development of pseudarthrosis., Results: A total of 281 patients underwent single- or 2-level PLF in the 21-year period. Of these, 231 (82.21%) patients were nonsmokers and 50 (17.9%) were smokers. For patients undergoing single-level PLF, complication rates in nonsmokers (3.57%) versus smokers (7.69%) were not significantly different (P = 0.353); pseudarthrosis in nonsmokers occurred in 9.82% of cases compared with 7.69% in the smokers group (P = 0.738). Nonsmokers undergoing 2-level PLF had complication rates of 6.72%, compared with 4.17% in smokers (P = 0.638), but pseudarthrosis rates were significantly higher in the smokers group than in the nonsmokers group (29.17% vs. 10.92%; P = 0.019). Patients were followed up for an average of 53.5 months., Conclusion: The findings in this study suggest that smoking has a significant impact on pseudarthrosis rates after 2-level PLF of the lumbar spine, but not necessarily on single-level PLF., Level of Evidence: 4.

Study Design: Retrospective review of pedicle subtraction osteotomy (PSO) cases., Objective: To report our results, radiographic and clinical outcomes at a minimum 5 years following revision surgery for pseudarthrosis after a PSO., Summary of Background Data: To our knowledge, there is no report on the results of revision surgery for pseudarthrosis after a PSO., Methods: Eighteen consecutive patients with pseudarthrosis after PSO (16 females/2 males; average age at surgery, 49.8 yr) treated with revision surgery at one institution were analyzed (average follow-up, 6.5 yr; range, 5-12 yr). Radiographic and clinical outcomes analysis was performed., Results: Sagittal vertical axis (SVA) and lumbar lordosis (LL) improved significantly after revision surgery (SVA, P = 0.000; LL, P = 0.024) and were maintained until ultimate post-revision follow-up (SVA, P = 0.170; LL, P = 0.729). Proximal junctional angle (P = 0.828), thoracic kyphosis (P = 0.828), and PSO angle (P = 0.717) achieved by the primary surgery were also maintained until ultimate post-revision. We increased the number of rods and/or changed them to 6.35-mm diameter in all patients. There were significant improvements post-revision in Oswestry Disability Index (45 vs. 37.9, P = 0.041) and Scoliosis Research Society pain subscale (2.6 vs. 3.1, P = 0.047) but not in Scoliosis Research Society total score or other subscales. Pelvic incidence greater than 60° demonstrated a trend toward poorer Oswestry Disability Index and Scoliosis Research Society scores (P > 0.05), but there were no significant differences between SVA greater or less than 11 cm., Conclusion: Revision surgery for pseudarthrosis after PSO can provide acceptable radiographic and clinical outcomes at a minimum 5 years post-revision. Successful surgical outcomes may be achieved by using an increased number or size of implants and ample bone graft for complete fusion after revision surgery., Level of Evidence: 4.

Study Design: Retrospective review of prospectively collected data., Objective: To assess the prevalence, risk factors, and clinical outcomes for pseudarthrosis after a lumbar pedicle subtraction osteotomy (PSO)., Summary of Background Data: There exists no large series that examines pseudarthrosis rates of PSOs., Methods: Data of 171 consecutive patients with adult deformity who underwent a lumbar PSO by 2 surgeons at a single institution with a minimum 2-year follow-up were analyzed. Pseudarthrosis diagnosed through sagittal malalignment and instrumentation failure noted on radiograph was confirmed intraoperatively., Results: Eighteen (10.5%) of 171 patients developed pseudarthrosis after a PSO. Eleven of the 18 patients (6.4% of all patients, 61.1% of the 18 patients with pseudarthrosis) had pseudarthrosis at the PSO site, L3 being the most common; other locations included the lumbosacral junction (4/18), thoracolumbar junction (2/18), and upper thoracic spine (1/18). Preoperative pseudarthrosis level was a predictor of the postoperative level of pseudarthrosis (93%). Fifteen of the 18 patients (83%) had no interbody fusion directly above or below the PSO site, 16 (88%) had a history of pseudarthrosis at the time of PSO surgery and 2 of 3 patients who had prior radiation to the lumbar region developed pseudarthrosis. Most pseudarthroses occurred within the first 2 years (n = 13/18), between 2 and 5 years (n = 3/18), and more than 5 years (n = 2/18) postoperatively. Prior pseudarthrosis (P < 0.0001), pseudarthrosis at the PSO site (P < 0.0001), prior decompression in the lumbar region (P = 0.0037), prior radiation to the lumbar region (P < 0.0001), and presence of inflammatory/neurological disorders (P < 0.0036) were identified as risk factors. All 18 patients with pseudarthroses required revision surgery (posterior-only surgery, n = 12; anteroposterior surgery, n = 6) due to loss of sagittal alignment and pain. The mean pre-revision Scoliosis Research Society score was 85, post-revision score was 95 (P = 0.0166), and the mean pre-revision Oswestry Disability Index score was 42.5, post-revision score was 34.5 (P = 0.0203)., Conclusion: The overall prevalence of pseudarthrosis was 10.5% of which 61% occurred at the actual PSO site and Scoliosis Research Society and Oswestry Disability Index scores improved significantly after pseudarthrosis repair., Level of Evidence: 4.

Spinal fractures are commonly encountered in ankylosing spondylitis (AS) patients. This study compares the outcome of early surgical treatment with initial conservative treatment for thoracolumbar fractures in patients with AS. From 1996 to 2008, 28 patients with AS were treated either operatively or conservatively for thoracolumbar fractures; however, only 25 patients met the inclusion criteria with a minimum follow-up of 2 years. For surgically treated patients, posterior spinal instrumentation was performed using a transpedicle screw system. Nonsurgically treated patients wore a fracture brace. The demographic data, diagnosis, mechanism of injury, and neurological status were recorded, and fracture healing was assessed radiographically. The mean age was 54.2 ± 13.8 years (range 30-80 years). Six patients (Group A) received surgical intervention within 1 month. All of these fractures healed, and two of five patients showed neurologic improvement after surgery. Eight patients (Group B) had fractures that were missed. The delay in diagnosis resulted in pseudoarthrosis in all cases, and progressive neurologic deficits were identified in four cases. Eleven patients (Group C) received conservative treatment with bracing. Fracture union was achieved in three cases, and pseudoarthrosis occurred in eight cases. Operative treatment can achieve solid fusion and improve the neurological status, while conservative treatment may result in pseudoarthrosis and progressive neurologic deficit. The results suggest that AS patients with unstable spinal fractures should receive early surgical management to prevent further sequelae.

There are only 2 documented cases of vertebral compression fractures occurring within a solid lumbar fusion mass: one within the fusion mass after hardware removal and the other within the levels of the existing instrumentation 1 year postoperatively. The authors report a case of fracture occurring in a chronic (> 30 years) solid instrumented fusion mass in a patient who underwent kyphoplasty. The pain did not improve after the kyphoplasty procedure, and the patient developed a posterior cleft in the fusion mass postoperatively. The patient, a 46-year-old woman, had undergone a T4-L4 instrumented fusion with placement of a Harrington rod when she was 12 years old. Adjacent-segment breakdown developed, and her fusion was extended to the pelvis, with pedicle screws placed up to L-3 to capture the existing fusion mass. Almost 2 years after fusion extension, she fell down the stairs and suffered an L-2 compression fracture, which is when kyphoplasty was performed without pain relief, and she then developed a cleft in the posterior fusion mass that was previously intact. She refused further surgical options. This case report is meant to alert surgeons of this possibility and allow them to consider the rare occurrence of fracture within the fusion mass when planning extension of chronic spinal fusions.

Introduced in 1911, spinal fusion is now widely used to stabilize the cervical, thoracic, and lumbar spine. Despite advancements in surgical techniques, including the use of instrumentation and optimizing bone graft options, pseudarthrosis remains one of the most significant causes of clinical failure following attempted fusion. Diagnosis of this common complication is based on a focused clinical assessment and imaging studies. Pseudarthrosis classically presents with the onset of or return of axial or radicular symptoms during the first postoperative year. However, this diagnosis is complicated because other diagnoses can mimic these symptoms (such as infection or adjacent segment degeneration) and because many cases of pseudarthrosis are asymptomatic. Computed tomography and assessment of motion on flexion/extension radiographs are the two preferred imaging modalities for establishing the diagnosis of pseudarthrosis. The purpose of this article was to review the current status of imaging and clinical practices for assessing fusion following spinal arthrodesis., (Copyright © 2014 Elsevier Inc. All rights reserved.)