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Introduction: Although osteoporosis and low bone mineral density is thought to lead to poor fusion outcomes, few studies have adequately addressed the correlation, and they were limited by small sample size at a single institution., Methods: We completed a secondary analysis of 182 patients enrolled at 26 spine centers across the United States in the EXO-SPINE FDA-approved clinical trial with 12-month CT-based fusion status determined by two independent, blinded radiologists. Using previously described CT-based techniques, we measured local and global Hounsfield units (HU) and examined the relationship with radiographic and clinical outcomes., Results: CT scans were available for review from 95 patients, with a mean age of 56.2 years and mean global density of 153.0 HU. No relationship was observed between HU and radiographic fusion status or clinical outcomes. Although 12% of patients had lumbar vertebral body HU measurements consistent with osteoporosis, this classification had no relation with fusion or clinical outcomes. Patients with pseudarthrosis had higher Oswestry Disability Index (22.2 vs. 16.6, P = 0.037) and back pain visual analog scale (7.0 vs. 4.9, P = 0.014) scores than patients with at least unilateral fusion at the 12-month follow-up., Discussion: In this large, multicenter study, lower vertebral body HU was not associated with worse fusion status after single-level instrumented posterolateral lumbar fusion using only local autologous bone graft. However, there was an association between radiographic fusion status and clinical outcomes, validating the importance of determining predictors of successful fusion. Assessment of fusion status with CT scans yielded a much lower fusion success rate with local bone graft than previously reported and may warrant additional investigation., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

The diagnosis and treatment of non-unions still represents an interdisciplinary challenge. Therefore, prevention, early detection and specific treatment are of great importance. Non-unions of the upper extremities, although less common than that of the lower extremities, requires special attention for successful treatment due to the central role of the shoulder girdle and arm in day to day activities. Successful treatment of non-unions requires a comprehensive evaluation of the patient's medical history, a thorough clinical examination and in particular radiological imaging. In order to effectively treat the pseudarthrosis it is crucial to distinguish between pseudarthroses that are suspected to be due to infections and those that are not. This article presents a treatment algorithm for managing both pseudarthrosis due to infection and pseudarthrosis without infection in the upper extremities., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Anterior chest wall instability as a result of sternocostal non-union is a rare complication but can give rise to invalidating pain and cardiac arrhythmias. A woman in her 40s was referred to us with anterior chest wall pain and instability after a modified Ravitch procedure. Sternocostal pseudoarthrosis was seen for which multiple operations were performed which were complicated by low-grade infections. A patient-specific three-dimensional modelled and printed prostheses was used in an operation to both lift the sternum for pectus correction and to reconnect the sternum and the sternal costal junction to regain anterior chest wall stability., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Case: We report a case of a 3-year-old girl who developed a post-infectious femoral neck pseudoarthrosis after a proximal hematogenous femoral osteomyelitis (type 3 according to Hunka classification of the sequelae of the septic hip in children). The patient was treated by a modified "SUPERhip 2" procedure (a reconstructive procedure described to reconstruct congenital femoral neck pseudoarthrosis). This report describes the surgical technique in details and discusses the advantages, pitfalls, and complications and possible complications., Conclusion: Our modification simplifies the "SUPERhip 2" procedure. Postinfectious neck pseudoarthrosis was successfully treated, and we believe this modification is applicable for the treatment of congenital femoral neck pseudoarthrosis as well., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C353)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: We describe the surgical management of a girl with dwarfism and congenital spondyloepiphyseal dysplasia, who presented in adolescence with coxa vara and bilateral pseudarthrosis between the femoral neck and the diaphysis, with asymmetric distal migration at both sites and leg length discrepancy. The patient at 16 years underwent valgus osteotomy in situ and femoral neck fixation in the left hip. The right hip was operated 19 months later., Conclusion: Hip dysplasia is common in spondyloepiphyseal dysplasia, but a debilitating nontraumatic bilateral pseudarthrosis at the base of the femoral neck has not been previously reported. Valgus corrective osteotomies of the femur in situ led to union and allowed the patient to walk., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C319)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Vertebral column resection (VCR) is a powerful corrective technique for the management severe, rigid spinal deformities but does carry a relatively high complications rate. One of the feared complications is pseudarthrosis which places the patient at risk for implant failure. We present a single-center experience with post-operative computed tomography (CT) imaging at the osteotomy site to screen for impending pseudarthrosis., Methods: A retrospective review of a single surgeon series of posterior-only VCR performed for severe pediatric and adolescent spinal deformities was performed. Demographic, radiographic, and clinical data were collected. Patients underwent postoperative CT imaging at the osteotomy site 6-9 months following VCR with grading of the osteotomy fusion. Patients with impending pseudarthrosis were recommended for prophylactic revision surgery., Results: Thirty-three patients were included (mean age 11.6 ± 4.9 years, 54.5% female), undergoing a mean 1.9 level VCR. Kyphoscoliosis accounted for 75.7% (N = 25/33) of cases with 45.5% of all cases being congenital etiology and 60.6% having at least 1 previous surgery. Postoperative CT imaging was performed in 22 patients at a mean of 7.8 months following VCR. Two patients were identified as having impending pseudarthrosis with one undergoing revision surgery to enhance the posterior fusion, with addition of a third rod while one patient refusing surgery who subsequently developed broken hardware requiring revision surgery. No patient with a stable fusion on CT imaging developed a clinically significant pseudarthrosis., Discussion: Postoperative CT imaging of the osteotomy is useful in screening for impending pseudarthrosis and can aide in decision making for clearance to return to activity or the need for prophylactic intervention following VCR in pediatric and adolescent patients. We advocate that obtaining routine CT imaging of the osteotomy site at 6-9 months may identify potential complications earlier and allow for prophylactic intervention., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Objective: The objective of this study was to evaluate the surgical effectiveness of posterior procedure with long segment stabilization for treating thoracolumbar pseudarthrosis associated with ankylosing spinal disorders (ASDs) without anterior fusion or osteotomy., Methods: Twelve patients with thoracolumbar pseudarthrosis in ASD were enrolled. All patients underwent posterior long-segment stabilization procedures. In some patients, the percutaneous technique or the aid of a robot or O-arm navigation was utilized for pedicle screw implantation. The clinical results were evaluated by means of the visual analog scale and Oswestry Disability Index. Radiological outcomes were evaluated for bone fusion, anterior column defect, local kyphotic correction, and position of the pedicle screws., Results: All patients experienced effective bone fusion at the sites of pseudarthrosis. The mean operative time was 161.7 ± 57.1 minutes, and the average amount of blood loss was 305.8 ± 293.2 mL. For 6 patients who underwent surgery with the assistance of a robot or O-arm navigation, there was no statistically significant difference observed in terms of operative time and mean blood loss compared to those who used the freehand technique (P > 0.05). The visual analog scale score, Oswestry Disability Index value, and mean local kyphotic angle showed significant improvements at the final follow-up (P < 0.05). The accuracy of pedicle screw placement was 96%., Conclusions: Posterior surgery with long-segment fixation, without anterior fusion or osteotomy, can achieve satisfactory outcomes in ASD patients with thoracolumbar pseudarthrosis. The application of percutaneous techniques, as well as the assistance of robots or navigation technique may be a good choice for the treatment of pseudarthrosis in ASD patients., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Design: Observational Study BACKGROUND: Symptomatic pseudarthrosis is one long-term complication in patients treated with anterior discectomy and fusion (ACDF). When revising a pseudarthrosis, a surgeon must decide to intervene posteriorly and/or anteriorly. Open posterior cervical fusion (PCF) is attractive for high rates of arthrodesis, however this technique introduces risks of added complications resulting from extensive soft tissue dissection. The purpose of this study was to assess long-term outcomes in patients undergoing tissue-sparing PCF with facet instrumentation to treat a single level pseudarthrosis., Methods: Forty-five subjects were recruited from six participating sites. All subjects had a history of ACDF that was subsequently revised with tissue-sparing PCF to treat symptomatic pseudarthrosis at one level. Long-term radiographic assessments included flexion and extension X-ray and multi-planar CT. Subjects additionally completed a patient satisfaction questionnaire. Radiographs were assessed by investigators and an independent core imaging lab to diagnose implant integrity and arthrodesis at the revised levels., Results: The revision procedure required a median 49 min to complete with an estimated blood loss of 10 cc. Subjects were discharged a median 1 day following treatment. There were no instances of hospital re-admission nor subsequent surgical interventions. Study follow-up assessments were performed a median 39 months from revision. Surgeons diagnosed complete fusion in 91 % of cases. The core imaging lab identified bridging bone across the revised segment in 80 % of cases. Range of motion was < 2° in 93 % of cases. Seventy-four percent of subjects reported being satisfied with their outcomes., Conclusions: This study summarizes long-term radiographic outcomes in a cohort of patients receiving tissue-sparing PCF for the treatment of pseudarthrosis. Assessed years after revision, patients achieved rates of arthrodesis similar to open PCF without the soft tissue dissection responsible for perioperative morbidity and long-term soft tissue pain., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This study was funded by Providence Medical technology (PMT). Dr. McCormack has a financial interest in PMT. Dr. Summerside is an employee of PMT. Drs Haglund, Williams, and Lemons have no financial interested that would be impacted by outcomes reported in this study., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aim: To compare 1 and 2 level posterior lumbar interbody fusion (PLIF) to transforaminal lumbar interbody fusion (TLIF) techniques in an effort to elucidate trends in overall radiological and clinical outcome, rate of complications, operation time, length of hospital stay, reoperation rate, pseudoarthrosis or failure rate, and estimated blood loss., Material and Methods: Online databases including Scopus, Science Direct, Clinical key, Ovid, Embase, and PubMed/ Medline were queried over the period encompassing January 2000 to August 2021 for suitable studies. Search criteria consisted of ("TLIF" AND "PLIF") OR ("Transforaminal Lumbar interbody fusion" AND "Posterior lumbar interbody fusion") AND ("comparative" OR "comparison") OR ("fusion" OR "outcome" Or "reoperation" OR "Failure rate" OR "Failure" OR "Complication rate" OR "Complication")., Results: Fourteen eligible studies were selected. Neurological deficits were considerably higher in the PLIF group (24%vs.10%). The mean operation time and estimated blood loss for PLIF and TLIF were 178.5 min and 515 ml; and 160 min and 405 ml, respectively. No significant difference was found regarding the fusion rate. The reoperation rate was greater in PLIF (2%) than TLIF (0%). No clear difference was found regarding the length of stay (LOS) and surgical site infection (SSI)., Conclusion: The superiority of TLIF over PLIF may be evidenced by the lower rate of neurologic deficit, surgical technical aspects, less blood loss and shorter operation time. Cage migration, screw displacement, infection, and pseudoarthrosis may be influenced by a variety of factors, including the facility, the surgeon, and the instrumentation/ graft used, and do not appear to be different. Multicenter non-randomized prospective trials are recommended to determine the possible superiority of one method over the other.

Background Context: Prior study has shown that 70% of cervical pseudarthrosis after anterior cervical discectomy and fusion (ACDF) detected at 1 year will go on to fusion by 2 year. Pseudarthrosis detected 2 years after ACDF may have different bone healing potential compared to nonunion detected 1 year after surgery. Therefore, it might have a different clinical significance., Purpose: To examine the radiographic and clinical prognosis of pseudarthrosis detected 2 years after ACDF with a minimum follow-up of 5 years., Study Design/setting: Retrospective cohort study., Patients Sample: A total of 249 patients who completed a 5-year follow-up after ACDF., Outcomes Measures: Clinical outcomes such as neck pain visual analogue scale (VAS), arm pain VAS, and neck disability index (NDI) and radiographic assessment such as X-ray, computed tomography (CT) scan., Methods: A total of 249 patients who completed a 5-year follow-up after ACDF were retrospectively reviewed. Patients who were diagnosed with pseudarthrosis at 2 years postoperatively were included. Fusion, neck pain VAS, arm pain VAS, and NDI were assessed. The results were compared between the union group (patients who achieved union), and the nonunion group (patients with pseudarthrosis) at 5 years postoperatively., Results: Among the patients who had pseudarthrosis at 2 years postoperatively, the fusion rate at 5 years was 32.6% (14/43). While the union group showed continued improvements in neck pain VAS, arm pain VAS, and NDI until 5 years, the nonunion group showed significant worsening of arm pain VAS and NDI at 5 years, with the values of neck pain VAS, arm pain VAS, and NDI being significantly worse than those of the union group at 5 years., Conclusion: The incidence of pseudarthrosis detected at 2 years postoperatively after ACDF was 67.4%, and it remained unfused at 5 years postoperatively. Nonunion identified 2 years after ACDF may be considered a poor prognostic factor because it has less potential to achieve fusion with further follow-up and a higher chance of worsening clinical symptoms. Therefore, the presence of fusion at the 2-year follow-up can be considered an indicator of the success of the surgery., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: This case study evaluates the diagnosis and treatment of a 12 year old Caucasian male gymnast who had several diagnoses including an isolated first rib fracture, resultant pseudoarthrosis of the first rib, and the development of symptomatic thoracic outlet syndrome. We discuss the causes, prevalence, and suggestions for prompt diagnosis and treatment of these conditions in pediatric patients. Although all three conditions are rare in a child, this case highlights the importance of having a high clinical index of suspicion in recurrent pain in pre-pubertal athletes., Case Presentation: A 12 year old Caucasian male underwent several years of conservative treatment with physical therapy and rest without resolution of his left shoulder pain. He was subsequently diagnosed with pseudoarthrosis of the first rib and thoracic outlet syndrome, which was curative by surgical removal of the first rib, and allowed him to return to his baseline activity level., Conclusions: Since each of these diagnoses are rare, especially in the pediatric population, we aim to educate the medical community on the prompt diagnosis and treatment of these conditions., (© 2023. The Author(s).)

Isolated congenital pseudarthrosis of the fibula is a rare entity with a limited number of cases reported in the literature. Treatment is challenging because of recalcitrant nonunion and because no consensus about the best treatment plan exists. We report a case of isolated congenital fibular pseudarthrosis with valgus deformity of the ankle. The patient had a history of two failed operations. We used a novel surgical plan that combined tibiofibular synostosis with fibular segment transfer through a unilateral external fixator. The patient showed good early results with fibular union. We advocate the combination of tibiofibular synostosis and fibular segment transfer to restore the integrity and stability of the ankle in recalcitrant isolated congenital fibular pseudarthrosis cases with a history of failed surgery.

Background: Mechanical and morphological factors have both been described to influence the rate of pseudarthrosis in mandibular reconstruction. By minimizing mechanical confounders, the present study aims to evaluate the impact of bone origin at the intersegmental gap on osseous union., Methods: Patients were screened retrospectively for undergoing multi-segment fibula free flap reconstruction of the mandible including the anterior part of the mandible and osteosynthesis using patient-specific 3D-printed titanium reconstruction plates. Percentage changes in bone volume and width at the bone interface between the fibula/fibula and fibula/mandible at the anterior intersegmental gaps within the same patient were determined using cone-beam computed tomography (CBCT). Additionally, representative samples of the intersegmental zones were assessed histologically and using micro-computed tomography (µCT)., Results: The bone interface (p = 0.223) did not significantly impact the change in bone volume at the intersegmental gap. Radiotherapy (p < 0.001), time between CBCT scans (p = 0.006) and wound healing disorders (p = 0.005) were independent risk factors for osseous non-union. Preliminary analysis of the microstructure of the intersegmental bone did not indicate morphological differences between fibula-fibula and fibula-mandible intersegmental bones., Conclusions: The bone interface at the intersegmental gap in mandibular reconstruction did not influence long-term bone healing significantly. Mechanical and clinical properties seem to be more relevant for surgical success., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: Patient-specific osteosynthesis for pseudarthrosis of the acromion., Indications: Symptomatic pseudarthrosis of the acromion at the level of a meta/mesacromion., Contraindications: Infection; patient noncompliance regarding postoperative treatment protocol., Surgical Technique: Preoperatively, a patient-specific three-dimensional model of the scapula is printed. A locking compression plate (LCP) is individually adapted to this model. Via a dorsal surgical approach over the scapular spine, the pseudarthrosis is refreshed and autologous cancellous bone from the iliac crest is embedded in the fracture zone. This is followed by fixed-angle osteosynthesis with the individualized plate. In addition, tension banding with tapes is performed to reduce the tensile and shear forces on the fracture caused by the muscle., Postoperative Management: Consistent wearing of a shoulder-arm brace for 6 weeks postoperatively, active-assisted increase in range of motion for an additional 3 weeks, then gradual increase in weight-bearing and initiation of daily activities without additional weights until 12 weeks postoperatively., Results: Treatment with the presented technique resulted in radiographic consolidation of the fracture and significant improvement in range of motion and pain at the 1‑year follow-up., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The purpose of this study was to investigate the initial efficacy of a new telescopic rod in the treatment of congenital pseudarthrosis of tibia (CPT) in children. A new type of telescopic rod for children was designed and its clinical results were evaluated. There were nine cases of CPT on the right and six cases on the left; there were six females and nine males. The average age at operation was 35.5 months. There were 12 cases with neurofibromatosis type 1 and 4 cases with proximal tibial dysplasia. The initial healing of tibial pseudarthrosis, proximal tibial valgus deformity, tibial length, ankle valgus, ankle function, and intramedullary rod displacement were evaluated during follow-up. All 15 cases were followed up for an average of 18.2 months, 14 cases achieved initial healing, with an average healing time of 4.3 months. Ten cases had unequal lengths of the tibia, with an average of 0.9 cm. Proximal tibial valgus occurred in seven cases and ankle valgus occurred in one child. The average range of motion of the ankle joint was 23° and the average plantar flexion was 42°. The average extension of the new telescopic rod was 1.6 cm. The displacement of the telescopic rod occurred in seven cases, there was no epiphyseal plate tethering and re-fracture. The new children's telescopic rod has a reasonable design and can extend with the growth of tibia. There are no complications of epiphyseal plate tethering and re-fracture. It provides a new choice of intramedullary fixation for the treatment of CPT., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Fusion rates and long-term outcomes are well established for anterior cervical discectomy and fusion (ACDF) of 3 levels or fewer, but there is a paucity of similar data on 4-level fusions. The authors evaluated long-term fusion rates and clinical outcomes after 4-level ACDF without supplemental posterior instrumentation., Methods: The authors retrospectively reviewed patients who underwent 4-level ACDF at a single institution with at least 1-year of radiological follow-up. Fusion was determined by measuring change in interspinous distance at each segment on dynamic radiographs or by the presence of bridging bone on CT scans at minimum 1-year follow-up. Clinical outcomes were assessed using Neck Disability Index and Short Form-36., Results: A total of 63 patients (252 levels) met the inclusion criteria for the study, with a mean follow-up of 2.6 years. Complete radiographic fusion at all 4 levels was observed in 26 patients (41.3%). Of the 37 patients (58.7%) with radiographic pseudarthrosis, there was a mean of 1.35 nonfused levels. The fusion rate per level, however, was 80.2% (202/252 levels). The most common level demonstrating nonunion was the distal segment (C6-7), showing pseudarthrosis in 29 patients (46.8%), followed by the most proximal segment (C3-4) demonstrating nonunion in 9 patients (14.5%). The mean improvement in Neck Disability Index and Short Form-36 was 15.7 (p < 0.01) and 5.8 (p = 0.14), respectively, with improvement in both scores surpassing the minimum clinically important difference. One patient (1.6%) required revision surgery for symptomatic pseudarthrosis, and 5 patients (7.9%) underwent revision for symptomatic adjacent-segment disease. Patient-reported outcomes results are limited by the low rate of 1-year follow-up (50.8%), whereas reoperation data were available for all 63 patients., Conclusions: More than half of patients undergoing 4-level ACDF without posterior fixation demonstrated pseudarthrosis of at least 1 level-most commonly the distal C6-7 level. One patient required revision for symptomatic pseudarthrosis. Patient-reported outcomes showed significant improvements at 1-year follow-up, but clinical follow-up was limited. This is the largest series to date to evaluate fusion outcomes in 4-level ACDF.

Case: Distal phalangeal fractures are often treated conservatively. However, some patients experience residual pain. We report 2 cases of patients who underwent low-intensity pulsed ultrasound (LIPUS) therapy for pseudarthrosis after fracture of the distal phalanx of the fifth toe with symphalangism. Both patients (female, 63 and 33-year-old, respectively) underwent conservative treatment with buddy-taping fixation; however, bone union failed, and LIPUS therapy was initiated. In both cases, bone union was achieved and pain resolved after 3 months., Conclusion: Bone union occasionally fails after conservative treatment of distal phalangeal fractures. LIPUS is a useful treatment of symptomatic pseudarthrosis after such fractures., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C187)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Pseudoarthrosis after anterior cervical discectomy and fusion (ACDF) is relatively common and can result in revision surgery. The aim of the study was to analyze the outcome of patients who underwent anterior revision surgery for pseudoarthrosis after ACDF., Methods: From 99 patients with cervical revision surgery, ten patients (median age: 48, range 37-74; female: 5, male: 5) who underwent anterior revision surgery for pseudoarthrosis after ACDF with a minimal follow up of one year were included in the study. Microbiological investigations were performed in all patients. Computed tomography (CT) scans were used to evaluate the radiological success of revision surgery one year postoperatively. Clinical outcome was quantified with the Neck Disability Index (NDI), the Visual Analog Scale (VAS) for neck and arm pain, and the North American Spine Society Patient Satisfaction Scale (NASS) 12 months (12-60) after index ACDF surgery. The achievement of the minimum clinically important difference (MCID) one year postoperatively was documented., Results: Occult infection was present in 40% of patients. Fusion was achieved in 80%. The median NDI was the same one year postoperatively as preoperatively (median 23.5 (range 5-41) versus 23.5 (7-40)), respectively. The MCID for the NDI was achieved 30%. VAS-neck pain was reduced by a median of 1.5 points one year postoperatively from 8 (3-8) to 6.5 (1-8); the MCID for VAS-neck pain was achieved in only 10%. Median VAS-arm pain increased slightly to 3.5 (0-8) one year postoperatively compared with the preoperative value of 1 (0-6); the MCID for VAS-arm pain was achieved in 14%. The NASS patient satisfaction scale could identify 20% of responders, all other patients failed to reach the expected benefit from anterior ACDF revision surgery. 60% of patients would undergo the revision surgery again in retrospect., Conclusion: Occult infections occur in 40% of patients who undergo anterior revision surgery for ACDF pseudoarthrosis. Albeit in a small cohort of patients, this study shows that anterior revision surgery may not result in relevant clinical improvements for patients, despite achieving fusion in 80% of cases., Level of Evidence: Retrospective study, level III., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Pseudarthrosis following transforaminal interbody fusion (TLIF) is not infrequent. Although cage migration and subsidence are commonly regarded as evidence of the absence of solid fusion, there is still no evidence of the influence of cage migration and subsidence on fusion. This study aimed to evaluate cage migration and subsidence using computed tomography (CT) DICOM data following lumbar interbody fusion. The effects of cage migration and subsidence on fusion and clinical outcomes were also assessed. A postoperative CT data set of 67 patients treated with monosegmental TLIF was analyzed in terms of cage position. To assess the effects of cage migration and subsidence on fusion, 12-month postoperative CT scans were used to assess fusion status. Clinical evaluation included the visual analog scale for pain and the Oswestry Disability Index. Postoperative cage migration occurred in 85.1% of all patients, and cage subsidence was observed in 58.2%. Radiological signs of pseudarthrosis was observed in 7.5% of the patients Neither cage migration nor subsidence affected the clinical or radiographic outcomes. No correlation was found between clinical and radiographic outcomes. The incidence of cage migration was considerable. However, as cage migration and subsidence were not associated with bony fusion, their clinical significance was considered limited., (© 2023. Springer Nature Limited.)

Case: An 18-year-old woman with a history of congenital pseudarthrosis of the clavicle (CPC) presented with episodes of right upper extremity ischemia. Vascular studies demonstrated an extensive thrombus with complete occlusion of the brachial artery. She underwent urgent thrombectomy. Subsequently, she underwent first rib resection and scalenectomy as well as pseudarthrosis takedown and fixation. Postoperatively, she returned to Division I collegiate soccer with complete symptomatic resolution., Conclusion: We report a case of arterial thoracic outlet syndrome secondary to CPC., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B968)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Retrospective comparative study., Objective: To assess the relationship of fusion mass bone density on computed tomography (CT) and the development of rod fractures (RFs) and proximal junctional kyphosis (PJK)., Summary of Background Data: Few studies have evaluated the relationship of fusion mass bone density to mechanical complications., Materials and Methods: A retrospective review of adult spinal deformity patients who underwent thoracolumbar three-column osteotomy from 2007 to 2017 was performed. All patients underwent routine 1-year CT imaging and had at least 24 months follow-up. Posterior fusion mass bone density was evaluated by measuring hounsfield unit (HU) on CT in three different regions [upper instrumented vertebra (UIV), lower instrumented vertebra, and osteotomy site], and were compared between patients with and without mechanical complications., Results: A total of 165 patients (63.2 years, 33.5% male) were included. Overall PJK rate was 18.8%, and 35.5% of these underwent PJK revision. There was significantly lower density of posterior fusion mass at the UIV in patients who experienced PJK compared with patients without PJK (431.5HU vs. 537.4HU, P =0.026). Overall RF rate was 34.5% and 61.4% of these underwent revision for RFs. Among 57 patients with RFs, 71.9% had pseudarthrosis. Fusion mass density did not differ between patients with or without RFs. However, in RF patients with pseudarthrosis, there was significantly higher bone mass density near the osteotomy compared with those without pseudarthrosis (515.7HU vs. 354.2HU, P =0.012). There were no differences in radiographic sagittal measures between the patients with and without RF or PJK., Conclusions: Patients with PJK tend to have less dense posterior fusion mass at the UIV. Fusion mass density does not correlate with RF, but greater bone density near the osteotomy was correlated with accompanying pseudarthrosis in patients with RFs. Assessing density of posterior fusion mass on CT may be helpful in assessing risk for PJK and provide insight as to the causes of RFs., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The aim of this study was to identify the hitherto unknown incidence of congenital pseudarthrosis of the clavicle (CPC), based on a cohort of continuous livebirths born in our hospital, to review the literature and investigate if there is evidence supporting the published association between left-sided CPC and dextrocardia. From our electronic medical record and radiology databases, we identified all live births and patients with the diagnosis of CPC born from 2000 to 2016. We reviewed the imaging which included one or both clavicles to search for unrecorded CPC cases and reviewed all retrievable CPC publications listed in PubMed and publications quoted within these publications going back to 1910. We identified 87 407 livebirths of which 41 800 had radiological studies done, 14 885 showing one or both clavicles. We found five cases of CPC, two from the electronic database and three from our imaging review, giving an incidence of 1 of 17 481 livebirths. We identified 138 publications reporting paediatric and adult CPC cases and 12 review articles, including 429 patients (187 female; 159 male; 83 unknown) with 456 CPCs and a minimum of 24 additional patients from case reports for which we could not retrieve details. Two publications reported one case of left-sided CPC with dextrocardia, either not showing left/right marking or only showing the CPC with the aortic knob on the same side. We report the first CPC incidence of 0.0057%, provide the by far most inclusive CPC epidemiology based on 429 patients and could not find reliable proof that there has ever been a patient with left-sided CPC which was associated with dextrocardia., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The purpose this study was to precisely characterize patterns of allograft subsidence following anterior cervical discectomy and fusion (ACDF) utilizing computed tomography scans, determine risk factors for cervical allograft subsidence, and investigate the impact of subsidence on pseudarthrosis rates., Methods: We performed a retrospective review of patients undergoing 1-to 3-level ACDF utilizing allograft interbodies with anterior plating between 2011 and 2019. Subsidence measurements were performed by 2 independent reviewers on computed tomography scans obtained 6 months postoperatively. Subsidence was then classified as mild if subsidence into the inferior and superior endplates were both ≤2 mm, moderate if the worst subsidence into the inferior- or superior endplate was between 2 and 4 mm, or severe if the worst subsidence into the inferior- or superior endplate was ≥4 mm. Multivariate analysis was performed to identify risk factors for the development of subsidence., Results: We identified 98 patients (152 levels) for inclusion. A total of 73 levels demonstrated mild subsidence (≤2 mm), 61 demonstrated moderate subsidence (2-4 mm), and 18 demonstrated severe subsidence (≥4 mm). On multivariate analysis, risk factors for severe subsidence included excessive vertebral endplate resection and lower screw tip to vertebral body height ratio. Severe subsidence was associated with an increased rate of pseudarthrosis (94.1% vs. 13.6%) without an associated increase in reoperation rate., Conclusions: Following ACDF with allograft interbodies, 50% of interbodies will subside >2 mm and 10% of interbodies will subside >4 mm. Risk factors for severe subsidence should be mitigated to decrease the risk of pseudarthrosis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Study Design: This is a retrospective study., Objective: Implant nonfusion is an important prognostic factor for patients after anterior cervical discectomy and fusion (ACDF). This study aimed to investigate endplate-specific pseudarthrosis after ACDF, to determine if the rate of fusion is inferior in the lower endplate, and to identify any differences in clinical and radiological results. Research comparing each endplate on which the endplate affects nonfusion is limited., Methods: We analyzed 71 patients with 142 total spinal levels who underwent double-level ACDF (C4-5-6 and C5-6-7) with an allograft and plate at our hospital between January 2012 and December 2018. Fusion grades were assessed using computed tomography and the Bridwell fusion grade system at 1 year postoperatively. Radiological parameters were obtained from lateral cervical radiographs collected preoperatively and at 1 month and 1 year after surgery., Results: There was no difference in fusion between the C4-5-6 and C5-6-7 ACDF procedures, but the fusion rate and Bridwell fusion grade at the caudal surgery level were lower than those at the cranial surgery level (93 vs. 79%, p < 0.001). The lower endplate of the caudal fusion level showed the most common pseudarthrosis (18 of 71 [25%]). There was no difference in radiological parameters and clinical outcomes between the fusion and pseudarthrosis groups., Conclusion: In double-level ACDF procedures, the nonfusion rate was higher at the caudal fusion levels, especially at the lower endplates of the caudal fusion levels., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Although most osteoporotic vertebral fractures (OVFs) heal conservatively, the most crucial undesirable outcome of conservative treatment is the failure to unite. There is paucity of literature on prevalence and risk factors of pseudarthrosis., Methods: A prospective study involving patients (aged ≥50 years) undergoing conservative treatment of osteoporotic thoracic/lumbar fractures without neurodeficits was performed. Patients were followed for a minimum of 6 months and classified into 3 groups based on fracture healing: group 1, healing without collapse; group 2, healing with collapse; and group 3, pseudarthrosis. An assessment of all clinicoradiologic parameters at the time of injury and at each follow-up was performed and compared among patients belonging to the groups., Results: A total of 77 patients (90 fractures) were studied. Sixty-six (73.3%), 16 (17.8%), and 28 (8.9%) fractures were classified under groups 1, 2, and 3, respectively. Mean ages in groups 1, 2, and 3 were 67.9 ± 9.1, 70.4 ± 7.6 and 72.3 ± 7.9 years (P = 0.08). Sex distribution was 62:15 (female/male). Seventy-three fractures (81.1%) occurred at the thoracolumbar junction. Stiff spine, ambulatory status, comorbidities, bone mineral density, and injury level were not associated with pseudarthrosis/collapse (P > 0.05). Male sex was associated with pseudarthrosis (P = 0.03). Based on regression analysis, initial vertebral height loss (radiography; P = 0.028), segmental Cobb (radiography; P = 0.019), vertebral comminution (computed tomography; P = 0.032), posterior ligamentous complex injury (magnetic resonance imaging; P = 0.048), and marrow change pattern (T2-weighted magnetic resonance imaging, Kanchiku classification; P = 0.037) were correlated with poorer outcome. Patients with pseudarthrosis had higher visual analog scale score (P = 0.04; final follow-up)., Conclusions: Of OVFs, 8.9% developed pseudarthrosis. Male sex, severity of postinjury vertebral deformation (vertebral loss, kyphosis, comminution, and marrow changes) and presence of posterior ligamentous complex injury are risk factors for pseudarthrosis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to determine the incidence, mechanism, and potential protective strategies for pelvic fixation failure (PFF) within 2 years after adult spinal deformity (ASD) surgery., Methods: Data for ASD patients (age ≥ 18 years, minimum of six instrumented levels) with pelvic fixation (S2-alar-iliac [S2AI] and/or iliac screws) with a minimum 2-year follow-up were consecutively collected (2015-2019). Patients with prior pelvic fixation were excluded. PFF was defined as any revision to pelvic screws, which may include broken rods across the lumbosacral junction requiring revision to pelvic screws, pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws, a broken or loose pelvic screw, or sacral/iliac fracture. Patient information including demographic data and health history (age, sex, BMI, smoking status, American Society of Anesthesiologists score, osteoporosis), operative (total instrumented levels [TIL], three-column osteotomy [3CO], interbody fusion), screw (iliac, S2AI, length, diameter), rod (diameter, kickstand), rod pattern (number crossing lumbopelvic junction, lowest instrumented vertebra [LIV] of accessory rod[s], lateral connectors, dual-headed screws), and pre- and postradiographic (lumbar lordosis, pelvic incidence, pelvic tilt, major Cobb angle, lumbosacral fractional curve, C7 coronal vertical axis [CVA], T1 pelvic angle, C7 sagittal vertical axis) parameters was collected. All rods across the lumbosacral junction were cobalt-chrome. All iliac and S2AI screws were closed-headed tulips. Both univariate and multivariate analyses were performed to determine risk factors for PFF., Results: Of 253 patients (mean age 58.9 years, mean TIL 13.6, 3CO 15.8%, L5-S1 interbody 74.7%, mean pelvic screw diameter/length 8.6/87 mm), the 2-year failure rate was 4.3% (n = 11). The mechanisms of failure included broken rods across the lumbosacral junction (n = 4), pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws (n = 3), broken pelvic screw (n = 1), loose pelvic screw (n = 1), sacral/iliac fracture (n = 1), and painful/prominent pelvic screw (n = 1). A higher number of rods crossing the lumbopelvic junction (mean 3.8 no failure vs 2.9 failure, p = 0.009) and accessory rod LIV to S2/ilium (no failure 54.2% vs failure 18.2%, p = 0.003) were protective for failure. Multivariate analysis demonstrated that accessory rod LIV to S2/ilium versus S1 (OR 0.2, p = 0.004) and number of rods crossing the lumbar to pelvis (OR 0.15, p = 0.002) were protective, while worse postoperative CVA (OR 1.5, p = 0.028) was an independent risk factor for failure., Conclusions: The 2-year PFF rate was low relative to what is reported in the literature, despite patients undergoing long fusion constructs for ASD. The number of rods crossing the lumbopelvic junction and accessory rod LIV to S2/ilium relative to S1 alone likely increase construct stiffness. Residual postoperative coronal malalignment should be avoided to reduce PFF.

Background Context: Postoperative dynamic radiographs are used to assess fusion status after anterior cervical discectomy and fusion (ACDF) with comparable accuracy to computed tomography (CT) scans., Purpose: To (1) determine if dynamic radiographs accurately predict pseudarthrosis revision in a cohort of largely asymptomatic patients who underwent ACDF, (2) determine how adjacent segment motion is affected by fusion status, and (3) analyze how clinical outcomes differ between patients with symptomatic and asymptomatic pseudarthrosis., Study Design: Retrospective cohort study., Patient Sample: Patients ≥ 18 years who underwent primary one- to four-level ACDF at a single institution over a 10-year period., Outcome Measures: Interspinous motion on preoperative and postoperative flexion-extension radiographs and preoperative and postoperative Visual Analogue Scale for Neck Pain (VAS Neck) and Arm Pain (VAS Arm), Neck Disability Index (NDI), Modified Japanese Orthopaedic Association scale (mJOA), Mental and Physical Component Scores of the Short-Form 12 (SF-12) Health Survey (MCS-12 and PCS-12) METHODS: The difference in spinous process motion between flexion and extension radiographs was used to determine motion at each level of the ACDF construct. Pseudarthrosis was defined as ≥ 1 mm spinous process motion on dynamic radiographs. A receiver operating characteristic (ROC) curve was generated to predict the probability of surgical revision for pseudarthrosis based on millimeters of interspinous motion at each instrumented level. Patient reported outcome measures (PROMs) were used to assess the effect of pseudarthrosis on clinical outcomes. Alpha was set at p<.05., Results: A total of 597 patients met inclusion criteria including 1,203 ACDF levels. Of those, 215 patients (36.0%) were diagnosed with a pseudarthrosis on dynamic radiographs with 29 patients (4.9%) requiring pseudarthrosis revision. ROC analysis identified a "cutoff" value of 1.00 mm of interspinous process motion for generating an optimal area under the curve (AUC). The negative predictive value (NPV) was 99.6%, whereas the positive predictive value (PPV) was 13.7%. When analyzing adjacent segment motion, the Δ supra-adjacent interspinous process motion (ISM) was significantly lower for patients with a superior construct pseudarthrosis (-1.06 mm vs. 1.80 mm, p<.001), whereas the Δ infra-adjacent level ISM was significantly lower for patients with an inferior construct pseudarthrosis (-1.21 mm vs. 2.15 mm, p<.001). Patients with a pseudarthrosis not requiring revision had worse postoperative NDI (29.3 vs. 23.4, p=.027), VAS Neck (3.40 vs. 2.63, p=.012), and VAS Arm (3.09 vs. 1.85, p=.001) scores at 3 months, but not 1-year, compared with patients who were fused. Patients requiring pseudarthrosis revision had higher 1-year postoperative NDI (38.0 vs. 23.7, p=.047) and lower 1-year postoperative Δ VAS Arm (-0.22 vs. -2.97, p=.016) scores., Conclusions: One-year postoperative dynamic radiographs have a greater than 99% negative predictive value for identifying patients requiring pseudarthrosis revision, but they have a low positive predictive value. Most patients with a pseudarthrosis remain asymptomatic with similar 1-year postoperative patient-reported outcomes compared with patients without a pseudarthrosis., Competing Interests: Declarations of competing interests The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. There are no relevant disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Congenital pseudarthrosis of the tibia (CPT) is a challenging problem in orthopedic practice, with high rates of non-union, refracture, and residual deformities. After union, long-term follow-up is required to manage late post-union complications. This study aimed to assess the outcomes of the Ilizarov technique in the management of CPT., Materials and Methods: This retrospective study included patients with CPT treated with the Ilizarov method between 2005 and 2018. Intramedullary rods were used in 9 cases and iliac bone graft was used in 12 cases. An orthosis was applied till the end of follow-up in all cases. The American Orthopaedic Foot and Ankle Society (AOFAS) scale was used for the evaluation of the functional outcomes., Results: This study included 16 patients, 11 males and 5 females, with an average age of 5.4 ± 2.8 years. Seven cases had multiple previous surgeries. Six patients had neurofibromatosis. The mean follow-up period was 5.8 ± 3.4 years. The average AOFAS score improved significantly from 47.5 ± 7.6 preoperatively to 78.9 ± 8.9 at the latest follow-up. Union was achieved in 15 cases, and persistent non-union occurred in one case. The clinical results were excellent in one patient, good in seven cases, fair in 6, and poor in 2 cases. The radiological results were excellent in one patient, good in seven cases, fair in seven, and poor in one case., Conclusions: The Ilizarov technique combined with intramedullary rod and primary or secondary bone graft provides a high union rate of CPT and can achieve simultaneous effective management of problems related to pseudarthrosis, including non-union, deformity, limb shortening, and adjacent joint contracture and subluxation. Level of evidence Level IV., (© 2022. The Author(s).)

Purpose: Following spinal instrumentation and fusion, differentiating between successful arthrodesis and pseudoarthrosis on imaging can be challenging. Interpretation of such examinations requires understanding both the expected evolution of postoperative findings and the subtle indicators of pseudoarthrosis across multiple imaging modalities. Due to this level of intricacy, many clinicians lack familiarity with the subject beyond the more rudimentary concepts., Methods: This review provides an in-depth overview of the imaging of the post-operative spine, with particular emphasis on differentiating between pseudoarthrosis and arthrodesis., Results: A comprehensive overview of imaging of the post-operative spine is given, including the most common imaging modalities utilized, the expected post-operative findings, imaging findings in pseudoarthrosis, and imaging definitions of fusion., Conclusion: Differentiating between pseudoarthrosis and arthrodesis in the postoperative spine is complex, and requires a robust understanding of various findings across many different modalities., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Abstract: Orthognathic surgery to treat dentofacial discrepancies has become an increasingly common elective procedure in sur-gical practices. Despite its numerous advantages such as improved aesthetics and masticatory and respiratory function, some complications and unfavorable results can be observed. Pseudoarthrosis after orthognathic surgery is a rare complication and is little reported in the literature. Pseudoarthrosis is characterized by an increasing occlusal worsening associated with bone mobility and pain. Due to the low incidence of pseudoarthrosis, it is necessary to study its involvement to elucidate its etiology and treatment. The aim of this work was to report a clinical case of bilateral mandibular pseudoarthrosis after orthognathic surgery, where multiple interventions and prolonged treatment time were necessary until the case was concluded. The precise diagnosis associated with the choice of the most effective treatment based on the literature proved to be essential for the management of this complication., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Objectives: Pseudarthrosis after mandibular reconstruction leads to chronic overload of the osteosynthesis and impedes dental rehabilitation. This study evaluates the impact of gap site on osseous union in mandible reconstruction using a new volumetric analysis method with repeated cone-beam computed tomography (CBCT)., Methods: The degree of bone regeneration was evaluated in 16 patients after mandible reconstruction with a fibula free flap and patient-specific reconstruction plates. Percentual bone volume and width changes in intersegmental gaps were retrospectively analyzed using a baseline CBCT in comparison to a follow-up CBCT. Patients' characteristics, plate-related complications, and gap sites (anterior/posterior) were analyzed. Detailed assessments of both gap sites (buccal/lingual/superior/inferior) were additionally performed., Results: Intersegmental gap width ( p = 0.002) and site ( p < 0.001) significantly influence bone volume change over two consecutive CBCTs. An initial larger gap width resulted in a lower bone volume change. In addition, anterior gaps showed significantly less bone volume changes. Initial gap width was larger at posterior segmental gaps (2.97 vs 1.65 mm, p = 0.017)., Conclusions: A methodology framework has been developed that allows to quantify pseuarthrosis in reconstructed mandibles using CBCT imaging. The study identifies the anterior segmental gap as a further risk factor for pseudarthrosis in reconstructions with CAD/CAM reconstruction plates. Future research should evaluate whether this outcome is related to the biomechanics induced at this site.

Study Design: A retrospective review of operative patients at a single institution., Objective: The aim was to validate a novel method of detecting pseudarthrosis on dynamic radiographs., Summary of Background Data: A common complication after anterior cervical discectomy and fusion is pseudarthrosis. A previously published method for detecting pseudarthrosis identifies a 1 mm difference in interspinous motion (ISM), which requires calibration of images and relies on anatomic landmarks difficult to visualize. An alternative is to use angles between spinous processes, which does not require calibration and relies on more visible landmarks., Materials and Methods: ISM was measured on dynamic radiographs using the previously published linear method and new angular method. Angles were defined by lines from screw heads to dorsal points of spinous processes. Angular cutoff for fusion was calculated using a regression equation correlating linear and angular measures, based on the 1 mm linear cutoff. Pseudarthrosis was assessed with both cutoffs. Sensitivity, specificity, inter-reliability and intrareliability of angular and linear measures used postoperative computed tomography (CT) as the reference., Results: A total of 242 fused levels (81 allograft, 84 polyetheretherketone, 40 titanium, 37 standalone cages) were measured in 143 patients (mean age 52.0±11.5, 42%F). 36 patients (66 levels) had 1-year postoperative CTs; 13 patients (13 levels) had confirmed pseudarthrosis. Linear and angular measurements closely correlated ( R =0.872), with 2.3° corresponding to 1 mm linear ISM. Potential pseudarthroses was found in 28.0% and 18.5% levels using linear and angular cutoffs, respectively. Linear cutoff had 85% sensitivity, 87% specificity; angular cutoff had 85% sensitivity, 96% specificity for detecting CT-validated pseudarthrosis. Interclass correlation coefficients were 0.974 and 0.986 (both P <0.001); intrarater reliability averaged 0.953 and 0.974 ( P <0.001 for all) for linear and angular methods, respectively., Conclusions: The angular measure for assessing potential pseudarthrosis is as sensitive as and more specific than published linear methods, has high interobserver reliability, and can be used without image calibration., Level of Evidence: 3., Competing Interests: T.S.P. is a paid consultant at Globus Medical, Stryker K2M, NuVasive, Medtronic; is receiving royalties from Altus and stock options from SpineAlign. A.J.B. is a paid consultant at Medtronic Sofamor Danek, Nuvasive, and Stryker; and is receiving IP royalties from Nuvasive. The remaining authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Pseudarthrosis of the cervical spine represents a common and challenging problem for spine surgeons. Rates vary greatly from as low as 0%-20% to >60% and depend heavily on patient factors, approach, and number of levels. While some patients remain asymptomatic from pseudarthrosis, many require revision surgery due to instability, continued neck pain, or radiculopathy/myelopathy. We aimed to provide a practical, narrative review of cervical pseudarthrosis to address the following areas: (1) definitions, (2) incidence, (3) risk factors, (4) presentation and workup, (5) treatment decision-making, and (6) postoperative care. It is our hope the current review provides a concise summary for how to diagnose and treat challenging cervical nonunions., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Constriction band syndrome (CBS) may be rarely associated with pseudarthrosis of tibia. Published literature includes only case reports. We evaluated the outcome of children with frank pseudarthrosis of the tibia with CBS and compared our results with other reported cases. We aimed to formulate a clinical classification of tibial involvement in CBS on the basis of the treatment guidelines. Seven patients with the presence of one or more constriction bands and radiological signs of tibial pseudarthrosis were included in the study. Eight reported cases of CBS with tibial involvement with management and follow-up details were reviewed. Only two tibial pseudarthrosis united spontaneously after the release of the constriction band. Two patients underwent simultaneous correction of tibial deformity and nailing with band release, one of which needed bone grafting for the pseudarthrosis union. Three patients subsequently needed an excision of tibial pseudarthrosis with nailing to achieve tibial union, two of them had autologous bone grafting along with nailing. Additional procedures were required for the correction of foot deformity and limb length discrepancy. Our findings were similar to the reported cases. The pseudarthrosis of the tibia with CBS does not always heal following band release. Additional surgeries may be required for persistent pseudarthrosis, limb length discrepancy and residual foot deformities. A functional and radiological classification is proposed for the treatment of tibial pseudarthrosis with CBS., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim: Determine the changes in bone density that occur in the cortical layer of the tibia in patients with CPT after surgical treatment due to radiography data., Patients and Methods: Materials and methods: The study was performed on X-rays of the tibia of three patients with CPT, aged 5 to 7 years. X-rays were taken before surgery and 1 year after surgery. The optical density of the cortical layer of both tibia bones was determined, for which they were conditionally divided into 7 zones., Results: Results: In all patients with CPT before treatment, there is significant decrease in the optical density of cortical bone tissue of the damaged tibia compared with contralateral. One year after surgery, there was an increase in the optical density of the cortical layer of both tibia of the studied patients. The increase in the density of the nonoperated tibia can be attributed to the active growth of patients. On the operated limb, the increase in the density of the cortical layer became statistically significant in all studied areas, which can be attributed not only to the growth of patients, but also to the possibility of active loading of the operated limb., Conclusion: Conclusions: In all patients with CPT before treatment, a statistically significant decrease in the density of cortical bone tissue of the damaged tibia was observed. As a result of the treatment there is an approximation of the bone density of the operated limb to the indicators of intact contralateral bone.

Congenital pseudarthrosis of the tibia (CPT) is characterized by anterolateral tibial bowing and hamartomatous periosteum that predisposes it to fracture. Fassier-Duval telescopic rods can improve the structural integrity of bone segments after reconstruction. We present our experience treating CPT with the Fassier-Duval rod and a novel technique for Fassier-Duval exchange that was developed after extraction failed in one patient. Patients were identified who underwent treatment with Fassier-Duval rods for CPT between 2007 and 2016 and had undergone their first rod exchange. Medical records were reviewed, and complications were classified using the system of Cherkashin. Four patients had an average age at the initial insertion of 6 years 4 months (4-9 years). The average follow-up duration after initial Fassier-Duval implantation was 5.4 years (2.7-8.1 years). Seven Category 2 complications were associated with the Fassier-Duval rod: interlocking K-wire migration (2), lengthening failure (2), explant failure (1), distal migration of female rod through physis (1) and male rod portion proximally migrating through physis (1). Three patients underwent one rod exchange [average 3.2 years after implantation (range, 2.7-3.9 years)]. One patient underwent two rod exchanges (2.9 and 6.9 years after initial implantation). The second attempt at exchange failed; this failure prompted the development of custom trephines to remove the hard bone that can encase the distal male segment. The use of custom trephines was made necessary by dense sclerotic bone at the previous pseudarthrosis site. We recommend that custom trephines be available during Fassier-Duval rod extraction to avoid failed retrieval. Level of evidence: Level IV (Case series)., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective case-control study., Objective: The aim of this study was to evaluate the prevalence of pseudarthrosis following antepsoas (ATP) lumbar and lumbosacral fusions., Summary of Background Data: Pseudarthrosis is a feared complication following spinal fusions and may affect their clinical outcomes. To date there are no sufficient data on the fusion rate following ATP lumbar and lumbosacral arthrodesis., Methods: This is a retrospective review of 220 patients who underwent lumbar minimally invasive antepsoas (MIS-ATP) fusions between January 2008 and February 2019 who have at least 1-year postoperative computed tomography (CT) follow-up scans. Fusion was graded using CT scans imaging and adopting a 1-4 grading scale (1, definitely fused; 2, likely fused; 3, likely not fused; 4, definitely not fused/nonunion). Grades 3 or 4 indicate pseudarthrosis., Results: A total of 220 patients (average age: 66 years, 82 males (37.2%), and 127 (57.7%) smokers) were included. Eight patients (3.6%) developed pseudarthrosis. A total of 693 discs were addressed using the ATP approach. Of those, 681 (98.3%) were considered fused (641 levels [92.5%] were "definitely fused" and 40 levels [5.8%] were "Likely fused") and 12 discs (1.7%) developed pseudarthrosis (seven levels [1.0%] were "likely not fused" and five levels (0.7%) were "definitely not fused"). The highest rate of pseudarthrosis was found at L5-S1 (4.8%) compared to the L1-L5 discs (0-2%). Of 127 smokers, six developed pseudarthrosis (odds ratio = 2.3, P = 0.3). The fusion rates were 95.3% and 97.8% for smokers and nonsmokers, respectively. Of the eight patients who developed pseudarthrosis, only four (50%) were symptomatic, of whom two (25%) required revision surgery. Both of these patients were smokers. The overall revision rate due to pseudarthrosis was 0.9% (two of 220 patients)., Conclusion: The MIS-ATP technique results in a high fusion rate (96.4% of patients; 98.3% of levels). Pseudarthrosis was noted mostly at the L5-S1 discs and in smokers.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Case: Although congenital nonunion of the clavicle is a well-known pathology in children, posttraumatic nonunion is a rare entity. Nonunion after open reduction and internal fixation of a clavicle fracture is exceptional in the pediatric population. We report on a patient presenting posttraumatic pseudarthrosis of the clavicle after surgical treatment. Pseudarthrosis was resected, and the defect was bridged with an iliac crest autograft, supplemented with bone morphogenetic protein, and fixed with an elastic stable intramedullary nail., Conclusion: This procedure offered enough stability for achieving fracture consolidation and is a safe alternative to plating in clavicle nonunion., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B714)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: We describe a case of 2 individually rare diseases existing comorbidly in the form of congenital pseudarthrosis of the tibia (CPT) coincident with cleidocranial dysostosis and provide a review of the literature, including the sole preexisting documented coincidence., Conclusion: Understanding, treatment, and surgical protocol of CPT have changed considerably since this comorbidity was last reported. Updates include synostosis, periosteal grafting, the use of bone morphogenetic protein, and bisphosphonates. Our case varies from the previous in associated disorder and family history. The relationship between CBFA1 and RUNX2 genes may hold the key, but further study is needed., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B712)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Congenital pseudoarthrosis of the forearm is an extremely rare condition. It is most commonly associated with neurofibromatosis type I (NF1). Patients with NF1-associated pseudoarthrosis have complex medical management and often require surgical intervention due to higher failure rates of union. In this case report, we present a unique case of a newborn baby with congenital pseudoarthrosis of both the radius and ulna that was manifested at birth and shortly thereafter, was diagnosed with NF type 1., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: The aim of this study was to investigate the prognosis of symptomatic pseudarthrosis observed at 1 year after lateral lumbar interbody fusion (LLIF) surgery and to analyze the risk factors for persistent pseudarthrosis for 2 years postoperatively., Summary of Background Data: Few articles have evaluated the prognosis of symptomatic pseudarthrosis following LLIF surgery., Methods: One hundred fifty-two patients with a minimum follow-up of 2 years were screened. Fusion status was assessed at 1 year postoperatively, and unfused segments were reevaluated at 2 years postoperatively. Dynamic x-rays and computed tomography images were acquired to evaluate the fusion status. Demographic data were evaluated to identify the risk factors associated with persistent pseudarthrosis. Clinical outcomes, including the visual analog scale (VAS) for back/leg pain and the Oswestry disability index (ODI), were evaluated preoperatively and at 1 and 2 years postoperatively., Results: Symptomatic pseudarthrosis was detected in 42 patients at 1 year postoperatively. Among them, 23 patients (54.8%) exhibited solid bony fusion 2 years postoperatively without further intervention. Fourteen patients (33.3%) showed asymptomatic pseudarthrosis, and the remaining five patients (11.9%) showed symptomatic pseudarthrosis. Multivariable analysis showed that diabetes (adjusted odds ratio [OR]: 2.817, P = 0.007), smoking (adjusted OR: 6.497, P = 0.008), and fusion at more than three levels (adjusted OR: 2.525, P = 0.031) were risk factors for persistent pseudarthrosis. Improvements in the VAS scores for back pain and ODI scores were significantly lower in the persistent pseudarthrosis group than in the final solid fusion group at 2 years postoperatively., Conclusion: It is not necessary to intervene for all patients in whom symptomatic pseudarthrosis is detected at 1 year postoperatively because only 11.9% of them will show persistent symptomatic pseudarthrosis. However, early revision surgery should be considered when severe symptomatic pseudarthrosis associated with diabetes, smoking, and fusion at more than three levels is present.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Congenital pseudarthrosis of the tibia (CPT) is a rare disease that has challenged trauma and orthopedic surgeons for a long time. Clinically CPT mostly presents with progressive varus and antecurvation malformation of the tibia in infancy and childhood. In many cases CPT is associated with neurofibromatosis or fibrous dysplasia. Without knowledge of the clinical picture a discontinuity of the tibia and/or fibula visible on an X‑ray can be misinterpreted as a simple fracture. Histopathological investigations have revealed that a pathological alteration of the periosteum in the region of the pseudarthrosis, a hamartoma, may be essentially responsible for this disorder. Consequently, to treat the CPT a resection of the hamartoma must also be carried out. Multimodal treatment approaches combining pharmacological and surgical treatment, such as the cross-union technique of Paley, seem to have improved the prognosis of CPT., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: The current surgical treatment of choice is the combination surgical technique, involving tibial intramedullary fixation to maintain the mechanical axis and mechanical stability of tibial pseudarthrosis. In traditional combined surgery, the Williams rod is often used. Long-term intramedullary fixation of the foot and ankle will affect the ankle joint function of children. The intramedullary rod is relatively shorter due to the growth of the distal tibia. In addition, there are some complications such as epiphyseal bone bridge and high-arched foot. The use of a telescopic intramedullary rod may avoid these complications., Purposes: To investigate the initial effect of the "telescopic rod" in a combined surgical technique for the treatment of congenital pseudarthrosis of the tibia in children., Methods: A retrospective study including 15 patients with Crawford type IV CPT who were treated using a combined surgical technique and the telescopic rod from January 2017 to May 2018. The average age at the time of surgery was 43.3 months (16-126 months). Of the 15 patients, 7 had proximal tibia dysplasia and 12 exhibited neurofibromatosis type 1. The combined surgical technique using the telescopic rod included the excision of pseudarthrosis, intramedullary rod insertion, installation of Ilizarov's fixator, tibia-fibular cross union, and wrapping autogenic iliac bone graft. The incidence of refracture, ankle valgus, tibial valgus, and limb length discrepancy (LLD) in patients were investigated., Results: All patients achieved primary union with an average follow-up time of 37.3 months (26-42 months). The mean primary union time was 4.5 months (4.0-5.6 months). Nine cases showed LLD (60%), with an average limb length of 1.1 cm (0.5-2.0 cm). Ankle valgus, proximal tibial valgus, telescopic rod displacement, and epiphyseal plate tethering occurred in 1 case (6.6%) (18°), 3 cases (20%) (10°, 5°, and 6°, respectively), 6 cases (40%), and 2 cases (13%), respectively. There were no refractures during the follow-up periods., Conclusion: Although there are complications such as intramedullary rod displacement while using the telescopic rod in a combined surgery, the primary healing rate of congenital pseudarthrosis of the tibia in children is high., (© 2021. The Author(s).)

Case: A 15-year-old right-hand-dominant adolescent girl presented with a nondisplaced first rib fracture and evidence of mesoacromion. She reported radiating numbness, pain, temperature change, and paresthesia in her left arm. An MRI revealed a first rib fracture along with brachial plexus and scalene musculature inflammation. Follow-up radiographs demonstrated bilateral rib anomalies during routine comparison views., Conclusion: Congenital pseudarthrosis of the first rib occurs but is not well documented in the literature. This case report describes a case of congenital bilateral first rib pseudarthrosis with associated thoracic outlet syndrome symptoms in a competitive female softball athlete., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B478)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: In the pathogenesis of femoral pseudoarthrosis, the arched shape of the bone is important when determining traction force on the anterolateral plane and posteromedial compression. In plate osteosynthesis, flexion forces affect the implant and can determine its breakdown and osteosynthesis failure. The wave plate seeks to solve the problem by transferring the support to the cortex under the plate or creating the resistance of a leaf spring., Objectives: To evaluate the bone healing pattern of femoral pseudoarthrosis treated with wave plate and its effectiveness in consolidation., Materials and Methods: We retrospectively evaluated 18 patients with femoral pseudoarthrosis treated with wave plate., Results: Three months after surgery, one patient presented healing of pseudoarthrosis, six months after surgery, 16 patients presented healing of pseudoarthrosis and at 12 months, all patients had complete bone healing. Regarding the type of pseudoarthrosis, nine patients had avascular and nine vascular pseudoarthrosis. Fifteen patients had medial cortical failure and three, lateral cortical failure. In all cases, consolidation started where there was bone failure, be it medial or lateral., Discussion: The wave plate technique is well indicated for the existence of cortical bone failure, both in fractures and in pseudoarthrosis. Objective is to stabilize the fragments by transferring and allowing contact between them. The formation of the bone callus occurred in our sample from the region of the bone defect to the region of bone contact, using either a tricortical or cancellous bone graft. The elastic force of the wave and the eccentric distribution of loads in the femur favored the formation of a callus where it was distracted (bone failure) and the location with concentration of movement (proximity between the fragments) was the end of bone healing., Conclusion: The wave plate technique was effective in bone healing of femoral pseudoarthrosis, promoting consolidation from the cortical failure to the bone contact zone., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2021. Published by Elsevier Ltd.)

Purpose: This study aims to evaluate the effect of lengthening speed on the quality of callus and complications during distraction osteogenesis and describe an optimal lengthening speed in patients with congenital pseudarthrosis of tibia (CPT)., Methods: Twenty-seven patients with CPT with a minimum follow-up of 36 months who underwent limb lengthening surgery between 1997 and 2016 with external fixator only were included in this study. All patients underwent lengthening procedures after achieving complete bone union in this study. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction period. Complications were noted in post-operative follow-up period. Receiver operator characteristics (ROC) curve analysis was performed to obtain optimal lengthening speed for these patients., Result: The mean age at the time of surgery was 5.74 years. The mean lengthening speed was 0.596 mm/day. Follow-up period of 136.14 months with a mean lengthening period of 92.4 days. Mean amount of lengthening was 5.44 cm for patients with CPT. Total rate of callus with good morphological quality was calculated as 66%. According to ROC analysis, optimal cut-off values of lengthening speed for the obtaining good morphological quality callus was 0.564 mm/day for tibial lengthening in CPT. There was a significantly positive correlation between complication rate and lengthening speed for each group., Conclusion: We recommend a mean lengthening rate of 0.56mm/day for the lengthening procedures with external fixator in patients with CPT who had complete bone union at the area of pseudarthrosis.

Background: Difficulty in obtaining union, recurrent fractures, and residual deformities remain the problems challenging the management of congenital pseudarthrosis of the tibia (CPT). We applied the "Eiffel Tower" double titanium elastic nails (TENs) in the existing combined approach, which takes advantages of TEN's mechanical stability with the protection against refracture, Ilizarov's high fusion rate with alignment control and the biologic environment provided by bone grafting for bony union. The results of this procedure are presented and discussed., Methods: Seventeen patients with CPT treated by combined surgery including pseudarthrosis resection, the "Eiffel Tower" double TENs technique, autogenous iliac bone grafting, and Ilizarov fixation between 2013 and 2019 were retrospectively investigated. Signs of bone union, limb length discrepancy (LLD), rate of refracture, and degree of residual deformities were reviewed. The AOFAS Ankle Hindfoot scale and measurement of ankle motion were used to evaluate ankle function. The mean follow-up time was 40.5 (11 to 91) months., Results: The mean age at index surgery was 6.2 (2.5 to 15) years. Union of the pseudarthrosis was achieved in 100% of cases. Among them, 15 (88.2%) patients obtained union of the pseudarthrosis on the first attempt (primary union). The average time to primary union was 3.8 (2 to 6) months. The rest 2 cases achieved union after additional surgeries (secondary union). In terms of complications, refracture occurred in 2 patients (11.8%) and 4 patients (23.5%) developed pin infection. The mean limb length discrepancy at the final follow up was 33.4 (6-141) mm. The average AOFAS score improved from 38.2 (27 to 51) pre-operatively to 77 (63 to 87) post-operatively (p < 0.01)., Conclusions: The "Eiffel Tower" double TENs technique is an ideal intramedullary fixation method in the surgical treatment of CPT. The combination of TENs technique with bone grafting and Ilizarov fixation has the advantages of early bone union, less injury on metaphysis, and early functional recovery., Level of Evidence: Level IV.