Pseudarthrosis (failure of bone fractures to heal) Therapy

Bone healing is multifactorial and dependent on:

• Maintained blood circulation
• Vital bone cells: New bone formation
• Sufficient stability after bone fractures

Definition of pseudarthrosis and example of pseudarthrosis

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

Case study

In principle, there is a high risk of pseudarthrosis developing after an open fracture.

This is due to an injury-related circulatory disorder:

• Open fracture
• Severe soft tissue injury

There are other risk factors for the development of pseudarthrosis

• Nicotine
• Alcohol
• Diabetes mellitus
• Systemic circulatory disorders (e.g. peripheral arteriosclerosis – vascular calcification)
• Thyroid diseases
• Metabolic disorders (lack of vitamin D, calcium)
• Medication:
  • Cortisone
  • Painkillers (e.g. Diclofenac)

Risk factor instability of the osteosynthesis for the development of pseudarthrosis

Case studies

Avulsion and fracture of a plate osteosynthesis on the collarbone

A typical symptom of pseudarthrosis is often present

• Exercise-induced pain
• Swelling
• False joint mobility

X-ray diagnostics

Case study

Conventional X-ray diagnostics for the detection of pseudarthrosis is not always clear!

X-ray images of the lower leg. Has the bone healed?

Extended diagnostics with tomographic imaging of the pseudarthrosis region using computer tomography shows findings typical of pseudarthrosis

The CT images show a bone gap and a screw fracture

The following therapy principles are used to treat pseudarthrosis

• Increased stability:
  • nail filling the medullary canal
  • Angle-stable, bridging plate
• Correction of bone misalignment
• Biological activation

Implants to stabilize the bone: Modern angular stable, bridging plate

Case studies for the surgical treatment of pseudarthrosis

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

• Plate and screws are loose
• The broken bone has not healed
• The bone is unstable

Operation:

• Removal of the loosened plate
• Resection of scarred connective tissue that prevents new bone formation
• Change to stable-angle, long-span, bridging plate osteosynthesis
• Accumulation of autologous bone and bone growth factor BMP-2

2. The X-ray analysis of a tibial pseudarthrosis after intramedullary nailing shows the following findings

• The broken bone has not healed
• The inserted intramedullary nail is unstable and the locking screws remote from the body have been removed

A standardized surgical treatment for lower leg pseudarthrosis consists of changing the intramedullary nail:

• Drilling out and thus “freshening up” the medullary cavity
• Implantation of a stable intramedullary nail
• Compression of the pseudarthrosis zone
• Locking screws inserted away from the body increase stability
• The picture already shows the complete bony healing of the former pseudarthrosis after 3 months

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

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

• Transplantation of bone from the iliac crest
• Accumulation of bone growth factors
• Blood collection from the iliac crest

Another option for harvesting autologous bone is the so-called RIA system

• Removal of bone cancellous bone from the bone canal, e.g. on the thigh

Summary: Modern treatment of pseudarthrosis (failure of bone fractures to heal)

• Early surgical treatment of pseudarthrosis is recommended
  • Axle correction
  • Stabilization with
    • Most modern intramedullary nails
    • angle-stable plates

• Biological activation of the pseudarthrosis zone with
  • Autologous bone
  • Bone growth factors support the successful healing of pseudarthrosis
• A supportive therapy for pseudarthrosis
  • e.g. with high-energy shock waves can be considered in individual cases