What is the treatment for pseudoarthrosis?

From the Guidelines

The treatment for pseudoarthrosis, specifically congenital pseudarthrosis of the tibia (CPT) in children, should involve surgical management with complete excision of the pseudarthrosis site, sufficient autogenous bone graft, and proper method of fixation, such as combining external fixation with intramedullary fixation, as recommended by the CPAM-LRC consensus panel 1.

Key Considerations

• The primary approach is surgical revision with internal fixation, which may include bone grafting to stimulate new bone formation.
• Autologous bone grafts are considered the gold standard as they provide osteogenic cells, osteoinductive factors, and an osteoconductive scaffold.
• The surgical procedure often involves removing any fibrous tissue at the non-union site, stabilizing the fracture with plates, screws, rods, or external fixators, and placing bone graft material.
• Combining external fixation with intramedullary fixation can be used for treatment of CPT, as it prevents refractures and axial deformities, with a consensus agreement of 84% among experts 1.

Surgical Techniques

• The use of intramedullary rods (IMR) alone is generally associated with high complication rates and low success rates, ranging from 54% to 90% 1.
• The use of Fassier-Duval rods (FDR) has improved the primary union rate (85.7%) and no refracture has been reported based on recent studies 1.
• The Ilizarov method can be used alone as a fixation device for CPT, offering the advantage of simultaneously correcting deformities and addressing limb length discrepancies (LLD), with a consensus agreement of 21% among experts 1.

Adjunctive Treatments

• There is no consensus on the use of rhBMP7 and 2, bisphosphonates, electric stimulation, pulsed electromagnetic stimulation, and low-intensity pulsed ultrasound stimulation due to the inconclusive benefits of these adjuvants 1.
• These adjuvants are generally regarded as complementary to primary surgical procedures rather than substitutes or alternatives.

Important Considerations

• The management of CPT currently relies on surgical interventions, with the primary goals of achieving and maintaining bone union, correcting deformities, addressing secondary ankle issues, preventing refracture, and equalizing limb length 1.
• Long-term follow-up for CPT patients is crucial, as refracture has been reported up to 18 years after fusion, indicating that normal bone quality cannot be reached, even after remodeling and acquired skeletal maturity 1.

From the Research

Definition of Pseudoarthrosis

• Pseudoarthrosis is a disorder of fracture healing after conservative or operative treatment of fractures that are older than 6 months 2
• It can also be defined as the result of failed attempted spinal fusion, typically manifesting with axial or radicular pain months to years after the index operation 3

Treatment of Pseudoarthrosis

• The treatment of pseudoarthrosis involves a targeted therapy that differentiates between aseptic and septic or atrophic, oligotrophic or hypertrophic pseudoarthrosis 2
• Operative principles include revitalization of atrophic bone fragments, stabilizing reosteosynthesis for instability, and the treatment of infection by transformation of a septic into a stabilized or aseptic pseudoarthrosis 2
• In the case of spinal pseudoarthrosis, treatment involves a second attempt at fusion and may require an approach different from that of the index surgery, as well as the use of additional instrumentation, bone graft, and osteobiologic agents 3
• The wave plate technique is a treatment option for femoral pseudoarthrosis, which seeks to solve the problem of implant breakdown and osteosynthesis failure by transferring the support to the cortex under the plate or creating the resistance of a leaf spring 4

Factors Influencing Treatment

• Metabolic factors, patient factors, use and choice of instrumentation, fusion material, and surgical technique have all been shown to influence the rate of successful fusion 3
• The type of pseudoarthrosis, such as avascular or vascular, and the location of cortical bone failure, can also affect the treatment outcome 4