Treatment of Pseudarthrosis
The treatment of pseudarthrosis requires surgical intervention with complete excision of the pseudarthrosis site, sufficient autogenous bone grafting, and appropriate fixation methods, with the specific approach varying by anatomical location. 1
General Principles of Pseudarthrosis Management
- Pseudarthrosis (non-union) should be investigated when suspected, as there may be an association between successful fusion (arthrodesis) and improved clinical outcomes 1
- Surgical management of pseudarthrosis is generally effective with success rates ranging from 75% to 100%, though multiple treatments may be required in some cases 2
- The current gold standard for stimulating bone regeneration is revision surgery with application of autologous bone grafts 2
- Treatment approach depends on whether the pseudarthrosis is infected versus uninfected, and atrophic versus hypertrophic 2, 3
Anatomical Site-Specific Treatment Approaches
Congenital Pseudarthrosis of the Tibia (CPT)
- CPT should be managed operatively in patients over 2 years old (100% expert consensus) 1
- Surgical management requires complete excision of the pseudarthrosis site, sufficient autogenous bone grafting, and proper fixation methods (100% expert consensus) 1
- Combined external fixation with intramedullary fixation is recommended (84% expert consensus), as it prevents refractures and axial deformities 1
- Single fixation methods are generally not recommended:
- The Ilizarov method alone has mixed support (21% agree, 37% neutral, 26% disagree) but may be beneficial as a secondary option when other methods fail, or in patients with angulation, impending refractures, or shortening exceeding 5 cm 1
Cervical Spine Pseudarthrosis
- Revision of a symptomatic cervical pseudarthrosis should be considered as arthrodesis is associated with improved clinical outcomes 1
- Both posterior and anterior surgical approaches have proven successful for correction of anterior pseudarthrosis 1
- Posterior approaches may be associated with higher fusion rates following repair of an anterior pseudarthrosis 1
- Common symptoms of cervical pseudarthrosis include persistent or recurrent axial neck pain, radiculopathy, and myelopathy 1
Scaphoid Pseudarthrosis
- Trapezoidal bone grafting with internal fixation is an effective treatment approach 4
- Multiple fixation options exist including Kirschner wires, AO cannulated screws, or Herbert screws 4
- The classification and location of the fracture correlate with outcomes, while the type of internal fixation used does not significantly affect outcomes 4
- Complete resection of fibrous tissue and sclerotic bone is essential for successful treatment 4
Adjunctive Therapies
- Several approaches have been described to enhance bone regeneration, including:
Common Pitfalls and Considerations
- Metabolic factors, patient factors, choice of instrumentation, fusion material, and surgical technique all influence the rate of successful fusion 6
- In congenital pseudarthrosis, even after achieving union, the repaired bone is often biologically and mechanically inferior 1
- Refracture has been reported up to 18 years after fusion in CPT cases, indicating that normal bone quality may not be achieved even after remodeling and skeletal maturity 1
- Long-term follow-up for pseudarthrosis patients is essential, particularly in congenital cases 1
- For spinal pseudarthrosis, diagnosis should be based on clinical presentation and imaging studies, after ruling out other causes of persistent pain 6
Diagnostic Approach
- Thin-cut CT scans may be more reliable than radiographs in demonstrating fusion in spinal cases 6
- The degree of motion seen on flexion-extension radiographs that indicates failed fusion remains controversial 6
- Pseudarthrosis is typically defined as a disorder of fracture healing that persists longer than 6 months after conservative or operative treatment 3