Treating pseudarthrosis (unhealed bone fractures)

Bone healing is multifactorial and depends on:

• Intact blood supply
• Vital bone cells: bone formation
• Sufficient stability following fractures

Definition and example of pseudarthrosis

The x-rays show a break as the expression of an unhealed bone fracture = pseudarthrosis (formation of false joint) just above the upper ankle joint.

Case study

In general, there is an increased risk of developing pseudarthrosis following an open fracture.

The following injuries cause interruptions to the blood supply:

• Open fracture
• Severe soft tissue damage

There are additional risk factors that may promote the development of pseudarthrosis

• Nicotine
• Alcohol
• Diabetes mellitus
• Systemic circulatory disorders (e.g. peripheral arteriosclerosis, vascular calcification)
• Thyroid diseases
• Metabolic disorders (vitamin D deficiency, calcium deficiency)
• Medications:
  • cortisone
  • painkillers (e.g. Diclofenac)

Unstable osteosynthesis – a risk factor for the development of pseudarthrosis

Case studies

Plate broken and pulled away from the clavicle

Symptoms typical of pseudarthrosis are often present

• Stress-related pain
• Swelling
• False joint mobility

X-ray diagnostics

Case study

Conventional x-rays do not always provide clear information facilitating the diagnosis of pseudarthrosis!

Additional diagnostic procedures with computed tomography images of the pseudarthrosis region show findings typical of pseudarthrosis

The CT images show a broken screw and a gap in the bone

The following therapeutic principles are applied when treating pseudarthrosis

• Increased stability:
  • nail filling the medullary cavity
  • fixed-angle bridge plate
• Correction of bone malpositioning
• Biological activation

Implants to stabilise the bone: modern fixed-angle bridge plate

Case studies of the surgical treatment of pseudarthrosis

1. X-ray analysis of humeral shaft pseudarthrosis following plate osteosynthesis shows the following:

• The plate and screws have become loose
• The fracture has not healed
• The bone is unstable

Operation:

• Removal of the loose plate
• Resection of the scar tissue which is preventing the formation of new bone
• Substitution of long fixed-angle bridging plate
• Grafting of autologous bone and application of bone growth factor BMP-2

2. X-ray analysis of tibial pseudarthrosis following insertion of intramedullary nail shows the following

• The fracture has not healed
• The intramedullary nail is unstable and the distal locking screw has been removed

The standard surgical treatment for pseudarthrosis of the lower leg entails replacing the intramedullary nail:

• Reaming and thus “refreshing” the bone marrow cavity
• Implantation of a stable intramedullary nail
• Compression of the pseudarthrosis zone
• Stability increased by inserting locking screws in distal region
• The image shows complete bone regeneration in the former pseudarthrosis zone after a period of 3 months

The image on the right shows the removal of the metal after approx. 1 year

The following procedures are used for the biological activation of the pseudarthrosis region

• Grafting of bone from the iliac crest
• Application of bone growth factors
• Blood collection from the iliac crest

The RIA system is another way of harvesting autologous bone

• Harvesting cancellous bone from the osseous canal, e.g. in the thigh

Summary: modern treatment of pseudarthrosis (unhealed bone fractures)

• Early surgical treatment of pseudarthrosis is recommended
  • Axial correction
  • Stabilisation with
    • state-of-the-art intramedullary nails
    • fixed-angle plates

• Biological activation of the pseudarthrosis zone using
  • autologous bone
  • Bone growth factors promote the successful healing of pseudarthrosis
• Adjuvant treatment of pseudarthrosis,
  • e.g. with high-energy shock wave therapy, can be considered in individual cases