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Treatment of pseudarthrosis

Tratment of pseudoarthrosis and bone consolidation

A disease that can be either congenital or can occur as a result of trauma or infection, the word ‘pseudarthrosis’ indicates a bone fracture that, unlike what happens normally, does not consolidate, returning the affected limb to its normal condition.

What is pseudoarthrosis

The word “pseudarthrosis” originates from the Greek words “pseudo” and “arthrosis” which when put together mean “false joint”.

This condition actually presents itself as a joint that connects two bone segments but without, of course, there being any ligament supports required for movement.

Depending on the form that the two bone stumps assume in the final part – in correspondence with the fracture line – it is possible to identify two types of pseudarthrosis:

• atrophic: the tips of the two bone segments are so thin as to avoid contact completely;

• hypertrophic: the final section of bone segments widens into an elephant foot shape. The two stumps are touching, but without having become welded.

The Ilizarov method in the treatment of pseudoarthrosis

Widely used in the treatment of limb deformities following bone infections (osteomyelitis), the Ilizarov method is gaining authoritativeness, even in the treatment of non consolidated fractures such as pseudarthrosis.

The first application of this method is down to the intuition of its designer. Already famous in Russia for having successfully treated several cases of bone deformity, Gavril Ilizarov’s fame also spread beyond his country’s borders, thanks to the results obtained when treating the Italian explorer Carlo Mauri. Following several unsuccessful procedures performed in his own country, Mauri was able to regain the perfect use of his leg – affected by pseudarthrosis – thanks to Ilizarov’s apparatus, which was also to become a technique of reference in the West.

How the Ilizarov apparatus works

The efficacy of the Ilizarov treatment has been the subject of numerous scientific studies, to the point of it becoming a paradigm of reference. It applies the principle that is at the heart of the process of tissue regeneration, eliminating – by stabilizing – the possibility of praeternatural movement. By directing the load on its axis in this way, the function encourages nutrition of the bone and leads to the disappearance of the fibrous and cartilaginous tissue, replaced by the “regenerated” tissue that is packed with vessels. The end result of the process is a perfect fusion between the bone segments, to which a further treatment for elongation can be administered.

Considered a leading expert in orthopaedics and having trained in close contact with Dr. Ilizarov, Dr. Kirienko works with Milan’s most important hospitals, including the San Raffaele the Humanitas Clinical Institute in Rozzano and the Galeazzi Hospital in Bruzzano.

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OSSEUS INFECTIONS

Medical treatment for the elimination of osseus infections

Treatments for osteomyelitis are based on two complementary approaches: medical and surgical.

The medical treatment is paramount for eliminating infected areas. Depending on the degree to which the disease has spread, it will exploit the action of treatments such as:

• Bacterial immunotherapy;

• Hyperbaric oxygen therapy;

• improving the patient’s general condition.

Surgical apporach and the Ilizarov apparatus

The surgical approach is required for the cleaning of necrotic bone tissues and infected soft tissues.

The resection of the infected area and the artholiths lead to a physiological shortening of the limb. The procedure that is universally recognised as being the most effective for restoring normal anatomic function is the one theorised and perfected by Ilizarov.

Thanks to a frame made up of metal rings and secured to the bone, the Ilizarov apparatus is able to carry out the bone transport of separated tissues and encourage their elongation.

The two bone segments in question can thus rely on a fixed support to guide them in the process of recomposition and subsequent recalcification.

Treatment of osseous infection using the Ilizarov method

Classifiable as acute and chronic osteomyelitis, depending on whether the symptoms persist for more than six weeks, or where there is the presence of arthroliths, osteomyelitis is an infection of the osteoarticular apparatus caused by bacteria – the most common being staphylococcus aureus – and more rarely, mycetes or clostridia.

What is osteomyelitis?

Considered the most serious and striking infection that could affect the bone structure, osteomyelitis is a condition that most often occurs in childhood or during a child’s development, but it can also appear in adults following a fracture that has not been treated correctly or through its proximity to an area of infection.

Once a bone has been affected, leukocytes enter into action to combat the disease agents, releasing enzymes that lead to a progressive erosion of the tissue.

The pus that develops after the infection then goes on to create the so-called arthroliths, veritable devitalised areas of tissue that are at the heart of the disease reaching a chronic state, a condition that can lead to osteosclerosis and the onset of severe bone defects such as deformity.

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Elongation of the hand bones

The bones of the hand can be subject to congenital birth defects and conditions, such as osteomyelitis, which require the removal of infected bone tissue ahead of the complete recovery of limb function. Although there are surgical procedures that are based on the transplanting of bones to replace segments that have been removed, the method that is capable of guaranteeing the best outcomes is that devised by Gavril Ilizarov.

The elongation of the bone that can be achieved using the Ilizarov fixator is gradual and occurs without causing any tears and trauma to the soft tissue. Here’s a detailed look at how it works.

How bone developmente and calcification occur

The Ilizarov frame consists of a metal structure made up of rings connected to the bone with metal “wires”. These rings serve to space the bone segments very gradually, so as to stimulate their growth and encourage calcification and complete recovery.

This technique has allowed patients with bone cancer to recover up to 18 cm of bone tissue in the legs. What is more, it has also allowed individuals with deformities in the bones of the hand, that are more delicate and difficult to treat, to regain full functionality of the fingers and bring them to the correct length.

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Arthrodesis of the ankle and other foot joints

What is osteoarhritis of the ankle and what does it result in?

Severe joint trauma, micro-traumas that extend over long periods, or congenital conditions, which compel the foot to assume an incorrect posture, may lead to an ankle beginning to suffer from osteoarthritis. This is a degenerative condition that leads to the gradual deformation of the joint surfaces with reduced local mobility and growing and constant pain. In the absence of rehabilitative therapy and therefore in the presence of a condition of chronic osteoarthritis, one of the most commonly adopted solutions is arthrodesis.

When perform arthodesis on the ankle?

Arthrodesis is a surgical procedure which leads to the total and permanent immobilisation of the joint parts affected by the degeneration process. This technique involves the removal of the joint, that is by now compromised, and the welding of the bone segments, employing techniques that involve the use of screws, synthetic elements or bone grafts.

These methods of intervening, however, are not without risk. Indeed, they could result in complications such as pseudarthrosis, problems with the healing of surgical wounds and neuro-vascular injuries.

Increasingly used because its ability to stimulate osteogenesis, without causing an overload of the damage to soft tissues, the Ilizarov method offers a solution that is capable of guaranteeing a degree of stability.

Advantages of the Ilizarov method in arthodesis of the ankle

The benefits that can be obtained from using the Ilizarov apparatus, instead of resorting to solutions that envisage the use of metal and synthetic grafts, are many:

increased possibility of proceeding with large resections of the limb;

the possibility of limb realignment during treatment;

a much-reduced risk of infection;

a progressive elongation of the bone until it reaches the desired length;

reduced operating trauma;

the possibility of full loading at the end of treatment;

greater stability of the arthrodesis with a very low risk of a corrective procedure, even many years later.

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