Treatment of posttraumatic clavicular pseudarthrosis.

Six patients with posttraumatic pseudarthrosis of the clavicle were treated during 1973 and 1974 with an operative technique consisting of trimming of the bone ends, placement of a cortical bone transplant posteriorly and metal plate anteriorly, and fixation of the plates with screws. At examination 10-23 months postoperatively complete healing had been achieved in all cases.     

Surgical treatment of congenital clavicular pseudarthrosis]

INTRODUCTION: Congenital pseudarthrosis of the clavicle is an extremely rare disease of unknown histogenesis. The method of treatment is still discussed controversely. CASES: Two cases of a congenital pseudarthrosis of the right clavicle were presented, revealing the typical clinical, radiologic and histopathologic features. Surgical treatment was performed at the age of 4 and 7 years, consisting of a partial resection of the bony ends of both segments of the clavicle, partial excision of the dense fibrous tissue lying within the defective area in the middle third of the clavicles by forming a continuous sleeve for interposing autogeneous spongiosa from the iliac crest and internal fixation with a Kirschner wire. Both cases showed a successful solid bone union in X-ray controls after 8 weeks. CONCLUSIONS: According to the histopathological findings we assume an abnormal ineffective chondral instead of an endesmal ossification resulting from a damage during embryogenesis as the underlying pathogenetic mechanism of congenital pseudarthrosis of the clavicle. Since chondral ossification proves to be ineffective also after birth, spontaneous bony union cannot be expected. Therefore, reconstructive surgery is the treatment of choice.     

Results of the treatment of clavicular pseudarthrosis

The problems encountered with pseudarthrosis of the clavicle reviewed with reference to 28 patients. Non-union was posttraumatic in 25 cases, due to osteotomy in 2, and postradiation in 1. The preceding treatment had been conservative in 16 cases and surgical in 12. In 26 cases ORIF was performed, with additional bone grafting in 21 cases. Symptoms leading to operation were pain and weakness of the shoulder. In addition, plexus irritation was present in 3 and a thoracic outlet syndrome in 2 cases. At follow-up, bony healing had been achieved in 24 of the 26 cases. No symptoms were present in 23 patients, and these all had a normal ROM of the shoulder. In 1 patient - who had undergone multiple previous operations and local irradiation - slight pain and limited motion were observed despite bony union. In 2 cases non-union is still present, with persistent symptoms.     

Congenital pseudarthrosis of the tibia

Congenital pseudarthrosis of the tibia is characterized by anterolateral deformity of the tibia and shortening of the limb. Its etiology remains unclear. Although several classification systems have been proposed, none provides specific guidelines for management. Treatment remains challenging. The goal is to obtain and maintain union while minimizing deformity. The basic biologic considerations with surgical intervention include resection of the pseudarthrosis and bridging of the defect with stable fixation. Intramedullary stabilization, free vascularized fibula, and Ilizarov external fixation are among the most frequently used methods of treatment. In addition, bone morphogenetic protein recently has shown promise. Nevertheless, despite improvements in healing rates with congenital pseudarthrosis of the tibia, the potential for amputation in failed cases persists.     

Congenital pseudarthrosis of the fibula

Three cases of congenital pseudarthrosis of the fibula are reported, all with prepseudarthrotic involvement of the omolateral tibia. In patients with this condition, correction of valgus deformity should be deferred until puberty, and the occurrence of tibial fractures should be prevented by means of leg splints.     

Congenital pseudarthrosis of the forearm

Congenital pseudarthrosis of the forearm is a rare condition in which traditional treatment methods have proven unsatisfactory. We report a case of congenital pseudarthrosis of the radius and ulna successfully treated by resection of the distal ulna and excision of the radial pseudarthrosis with replacement by an interpositional free vascularized fibular graft.     

Congenital pseudarthrosis of the ulna

We report a case of congenital pseudarthrosis of the ulna along with generalized neurofibromatosis (type I). The patient had a good clinical outcome after single-bone forearm reconstruction. In the setting of radial head dislocation following long-standing congenital pseudarthrosis of the ulna, single-bone forearm reconstruction is a viable option. It prevents the loss of hand function by the effective shortening of flexor tendons and spares movements of the humeroulnar and radiocarpal joints.     

Congenital pseudarthrosis of the forearm

Early treatment of congenital pseudarthrosis of the forearm is necessary to prevent permanent angulation and shortening of the forearm with resulting loss of function. Total replacement of defective bone and complete excision of the destructive, abnormal fibrous tissue seem to be essential if an effective treatment is to be accomplished.     

Congenital unilateral pseudarthrosis of the olecranon

Congenital pseudarthrosis of the olecranon is a rare condition. Three isolated cases with bilateral presentation, different treatment modalities and variable outcome were reported in the orthopaedic literature. In this presented case a pseudarthrosis of the right olecranon in a 13-year-old boy was treated by pseudarthrosis resection, bone graft interposition and tension band osteosynthesis. Hardware removal was performed nine months after the initial procedure. At 6-year follow-up at the end of growth, the patient has no pain and a free range of motion of his dominant right elbow. This (to our knowledge) first case of unilateral pseudarthrosis of the olecranon had an excellent clinical result with stable fixation and support of bone healing by a bone graft interposition.