Introduction

Between 1969 and 1973 both authors were members of Hardi Weber′s team in St. Gallen, Switzerland. This period was only interrupted by a 6-month stay with Maurice Müller in Bern. Although the AO techniques had become popular, the principles were not always applied as developed and taught by the AO Founders. St. Gallen and Bern were the orthopaedic centers for referrals of failed internal fixations, leading to all possible types of nonunions.

Oldrich Čech came from Praha, Czech Republic, and worked with Hardi Weber and his team at regular intervals. He was trained in the classical, internationally well-known orthopaedic university center in Praha. Čech was an excellent communicator and teacher and brought his ideas to St. Gallen. René Marti shared an office and had many discussions with him. Under his guidance Marti assisted and later operated mainly corrections of nonunions. During this time, Weber and Čech analyzed 700 cases of nonunion and finally published the treatment principles in the book “Pseudarthroses: pathophysiology, biomechanics, therapy results” (in German) in 1973 [1].

Many times, after a rather heroic decortication, Marti asked himself if this method was constructive or destructive. Čech′s answer was: “Nature is powerful”. And he was right. He was able to combine mechanical and biological thinking in a perfect way.

By the time Marti took over the Orthopaedic Department of the University of Amsterdam, Netherlands in 1973 he was well-prepared. The method of treating nonunions learned from Weber, Müller, and Čech (Fig 1.1-1) immediately became one of the highlights of his early orthopaedic work in Amsterdam. The Amsterdam hyperbaric oxygen chamber known worldwide saved many gas gangrene limbs from amputation, but produced as many infected defect nonunions of the tibia suitable for reconstructive surgery.

It was logical for René Marti′s farewell congress in 2004 in Amsterdam to focus on the treatment of nonunions and osteotomies of posttraumatic deformities. Unfortunately, Weber could not participate—his untimely death in August 2002 shocked all of us.

Čech, still an active orthopaedic surgeon, opened the congress with a historical overview of the treatment of nonunions. Trained in a center of classical orthopaedic interventions in Praha, he made his experience with so-called “old-fashioned” techniques based on biology and combined these nonunion treatment modalities with the newly developed, more mechanical fixation techniques. His main contribution, together with Weber, was certainly the classification of nonunion based on the vascularity of the bone ends. In 1969 they could demonstrate that even defect nonunions are not necessarily atrophic and heal just by rigid mechanical fixation. Nowadays, resection of so-called “worthless pseudarthrosis” is the exception.

The techniques described in “Pseudarthroses: pathophysiology, biomechanics, therapy, results” [1] for nonunion treatment can still be applied nowadays.

In the present book by René Marti and Peter Kloen (“Concepts and Cases in Nonunion Treatment”), besides presenting the fragment transport (Ilizarov) technique, additional modifications based on their combined experience gathered in the last 35 years are highlighted.

History of pseudarthrosis/nonunion treatment

In the 5th edition of Astley Cooper′s “A treatise on dislocations and fractures of the joints” (1842) [2], observations were reported that are still valid today. On the development of “nonunion” and of “false joints” he wrote the following: “There is no difficulty, for example, in understanding that the materials effused for the consolidation of a fracture can never be converted into a bony callus, if subjected to frequent motion and disturbance”. He recommends the following to the surgeon engaged in healing a nonunion “…to ensure all the mechanical conditions which are essential for the consolidation of callus, comprising perfect rest and immobility, and contact and pressure of the broken surfaces against each other”. We should, however, not be underwriting the next therapeutic recommendation when he goes on to say “… or, if a false joint appears to have formed, he may cut down on the broken ends, and shave them off”.

Resection of pseudarthroses/nonunions had already been introduced much earlier by White [3] in 1770. In 1886, Ollier [4] wrote on resection in pseudarthroses of the tibia. In 1886, Bruns reported 440 resections of pseudarthroses in his “Textbook of fractures” [5]. Nine years before the discovery of the x-rays named for Wilhelm Conrad Röntgen, Bruns recommended the following differentiating classification of disturbed fracture union:

1. 
   

   Delayed consolidation (delayed callus formation, delayed ossification of the callus)

   
   
2. 
   

   Pseudarthrosis

   
   
   
   
   1. 
      

      Isolated scanning of the ends of the fragments

      
      
   2. 
      

      Fibrous union of the ends (taut or lax)

      
      
   3. 
      

      Nearthrosis formation

Experience gathered in World War I by Hohmann [6] lead to the description of a further type in 1921, called defective pseudarthrosis. But this type was already known to Nussbaum [7] in 1875 and to Hahn [8] in 1884. Nussbaum successfully treated two cases of this condition in the ulna with a reversed graft and Hahn one case in the tibia by transferring the fibula into the proximal fragment of the tibia.

Lexer considered that the fibrous tissue in the gap of a pseudarthrosis had lost the potential to ossify. He based his therapy on this conception: resection of the “worthless pseudarthrosis”, opening up the medullary canal and stimulation of osteogenesis by a cortical graft. This classical form of management, developed by Albee [9] in 1921 and Lexer [10] in 1922, even today remains the method of choice in many instances.

One of the personalities who influenced the historical development of pseudarthrosis treatment was Zahradníček (Fig 1.1-2a), co-founder of the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT), who significantly contributed to the development of surgical orthopaedics. In addition to the treatment of dysplasia of the hip in children—derotational intertrochanteric osteotomy—Zahradníček dealt with the treatment of fractures, including pseudarthroses.

At the SICOT congress in Berlin, Germany, in 1939, Zahradníček planned to present the introductory lecture on “Pseudarthrosis treatment”. However, due to the outbreak of World War II, the congress was cancelled and the lecture instead was published (Fig 1.1-2b) [11].

Zahradníček presented the results of the treatment of 145 pseudarthroses (Fig 1.1-3) together with their classification:

• 
  

  I Fibrous pseudarthrosis “Elephant′s foot”

  
  
• 
  

  II Pseudarthrosis with minimal callus—“limb” pseudarthrosis

  
  
• 
  

  III Nearthrosis

  
  
• 
  

  IV Atrophic pseudarthrosis

In addition, he introduced the surgical technique of pseudarthrosis treatment by a cortical bone graft (Fig 1.1-4a–d) and the technique of cortical bone grafting used for a large bone defect (Fig 1.1-4e–h).

After World War II, Max Lange (Fig 1.1-5a) published the “Orthopedic-surgery textbook” (1951) [12] where he described his surgical technique. Another monograph was published by his student Alfred N Witt, who presented his extensive experience in this field. “The Treatment of pseudarthroses” by Witt (1952) [13] differentiates between taut, lax, and defective pseudarthroses. Witt recommends autogenous bone transplantation as an operation that promises the greatest success in the treatment of pseudarthrosis (Fig 1.1-5b, Fig 1.1-6).

Friedrich Pauwels’ concepts (1935, 1940) [14, 15], however, are of quite a different kind. He stated that “pseudarthrosis results from unfavorable mechanical demands on the fracture”. Citing examples of pseudarthroses of the neck of the femur but also of the tibia, Pauwels proved that by improving the biomechanical setup, disturbing forces can be eliminated and pseudarthroses can be induced to unite (Fig 1.1-7). At first Pauwels’ ideas remained unnoticed.

Another manner to influence the biomechanics of pseudarthroses became available by the advent of the stable osteosynthesis:

• 
  

  Compression plate: Danis (1949) [16], Razemon (1955) [17], Decoulx and Razemon (1956) [18], and the first AO course taught in Davos by Müller (1960).

  
  
• 
  

  Medullary nail: Küntscher (1949) [19]

  
  
• 
  

  External fixator with compression: Greifensteiner, Klarmann, Wustmann (1948) [20], Müller, Allgöwer (1958) [21], Judet (1960, 1962) [22, 23].

Employing these methods, conditions could be created that correspond to the requirement of mechanical rest in a pseudarthrosis. The results, at first achieved empirically by the clinicians, have proven that pseudarthrosis tissue is not biologically inferior but it can, on the contrary, react and ossify as soon as an osteosynthesis produces mechanical rest.

This empirically observed behavior of pseudarthroses under stable conditions was elaborated in the following fundamental works:

• 
  

  Judet (1960) “Anatomically and radiologically it is possible to compare avascular pseudarthrosis of inert or atrophic limbs with hypervascular pseudarthrosis with its hyper-ostotic affliction construct, which finds its maximal expression in the elephant′s foot” [23] (French).

  
  
• 
  

  Schenk, Willenegger, Müller (1958) “Growing-in of vessels throughout the pseudarthrosis as soon as mechanical rest is secured” [24].

  
  
• 
  

  Segmüller, Čech, Bekier (1969) “Scintimetric and scintigraphic proof that biologically inactive pseudarthroses are extremely rare and that the so-called atrophic pseudarthroses which are poor in callus have, in the majority of cases, a good blood supply and biological activity” [25].

With the results gained from about 700 cases from St. Gallen and Praha in mind, Weber and Čech felt that the time had come to analyze and publish this experience. The authors’ observations concentrated on pseudarthroses of the long bones; pseudarthroses of the bones of the hand and foot were not included. In 1973, their monograph “Pseudarthroses” (in German) [1] was published. This monograph offered a new concept of the pathophysiology of pseudarthrosis and introduced clear therapeutic guidelines into clinical practice:

• 
  

  Vital pseudarthroses—therapy: stable osteosynthesis

  
  
• 
  

  Avital pseudarthroses—therapy:

  
  
  
  
  • 
    

    stable osteosynthesis

    
    
  • 
    

    biological stimulation (cancellous bone grafting, decortication)

These methods and procedures have been verified over a period of 35 years. Now the authors face the following questions: what is still valid, what is the contribution of Ilizarov′s school, and what has to be changed; what kinds of pseudarthroses do we have to treat today and what are their causes; what are the new techniques and what is their contribution?

To answer these questions is the goal of this book, prepared by a number of specialists from all over the world who met at René Marti′s farewell congress in Amsterdam in 2004.

Biological activity of pseudarthroses/nonunions of long bones

According to previous authors (Albee (1921) [26], Hohmann (1921) [6], Lexer (1922) [10]) a pseudarthrosis does not possess sufficient power to bring about union. Witt (1952) [13] still considered a pseudarthrosis to be the end product, and that for union to occur a biological stimulus is necessary. This stimulation was ascribed to cortical bone grafting, a type of plastic surgery, which was carried out many times. Also of interest are the efforts to achieve mechanical stability using such “bioactive” grafts (by “bolting”). In 1918, Matti [27] already knew about the importance of true fixation and recommended Albin Lambotte′s “Fixateur Externe” for the treatment of certain fractures and pseudarthroses.

In complete contrast to the supposition that the inferiority of pseudarthrosis tissues is responsible for the failure of bony union is Pauwels’ view who—as published in 1935 [14] for cases of femoral neck fractures and in 1940 [15] for cases of shaft fractures—held mechanical factors responsible for the development of a pseudarthrosis. By improving the mechanical preconditions Pauwels was able to achieve union in pseudarthroses where seemingly a biologically fully finalized process had existed. Without even touching the pseudarthrosis, let alone resecting it, union occurred as soon as mechanically disturbing forces were eliminated and only pure pressure forces were allowed to act upon the pseudarthrosis. In this way Pauwels created the basis of a biomechanical concept for the treatment of pseudarthroses.

From 1939 on Danis treated recent fractures and pseudarthroses by means of his “coapteur”, a compression plate, to achieve union [16]. In 1949, Küntscher [19] reported his successful method of treating pseudarthroses by the medullary nail. Greifensteiner and Wustmann stabilized pseudarthroses by the double-wire clamp used like an external fixator as early as 1953.

From 1958 on Müller and Allgöwer [21] used the equipment of Sir John Charnley for the same purpose. Müller (1961) [29]—and with him the members of the AO—used compression osteosynthesis (lag screw, tension band fixation, “compression plate”, external fixator), and medullary nailing in the treatment of pseudarthroses.

In 1962, R and J Judet followed with the development of their own external fixator. Common to all these “mechanical” methods is the concept that by producing mechanical rest at the level of the pseudarthrosis, union is sure to occur. Alongside the development of treatment of pseudar throses by the above “mechanical” methods, a change occured in the biological management of pseudarthroses.

In 1958, R and J Judet and Roy-Camille [30] shed a completely new light on the problem of the biology of pseudarthroses; their publication “Vascularization of long bones based on a clinical and experimental study” (French) refutes the traditional concept of the biological inferiority of pseudarthroses. On the contrary, the radiologically apparent bone sclerosis is histologically based on hyperplasia with hyper-vascularization. In 1960, the Judet brothers differentiated two biologically totally diverse types of pseudarthrosis on the basis of further studies [31]:

• 
  

  Avascular pseudarthrosis with necrotic fragment ends

  
  
• 
  

  Hypervascular pseudarthrosis with hyperostotic fragment ends, which condition finds its strongest expression in an elephant-foot pseudarthrosis

The results of the experimental and clinical work of the brothers Judet and their colleagues were convincingly supported by further work by Rhinelander et al (1968) [32], and Schenk, Müller, and Willenegger (1968) [33] (Fig 1.1-8).

Scintiscan of pseudarthrosis/nonunion

As the experiments on the model and scintimetry on the tibial nonunions have shown, mediconuclear examination enables the surgeon to judge how far a pseudarthrosis is capable of reacting biodynamically. By scintiscan a “hot zone”, its location, and activity is directly delineated by image and color.

Out of a larger number of examinations, four clinically typical pseudarthroses and their scintiscans will now be described in order to show that “bioactivity” differs from case to case (Figs 1.1-9, 1.1-10, 1.1-11, 1.1-12).

1. 
   

   Double fracture

   
   
2. 
   

   Elephant-foot pseudarthrosis

   
   
3. 
   

   Pseudarthrosis without callus

   
   
4. 
   

   Defective pseudarthrosis

Related posts:

Principles: Nonoperative treatment Autogenous bone grafting in the treatment of nonunions Infected nonunion of the clavicle Anteroinferior plating of midshaft clavicular nonunions Midshaft clavicular nonunion Nonunion of the clavicle—introduction

Stay updated, free articles. Join our Telegram channel

Join