Pseudoarthrosis after lumbar spine fusion: nonoperative salvage with pulsed electromagnetic fields.

Simmons JW Jr, Mooney V, Thacker I.

UTMB, Galveston, Texas, USA.

We studied 100 patients in whom symptomatic pseudarthrosis had been established at more than 9 months after lumbar spine fusion. All patients were treated with a pulsed electromagnetic field device worn consistently 2 hours a day for at least 90 days. Solid fusion was achieved in 67% of patients. Effectiveness was not statistically significantly different for patients with risk factors such as smoking, use of allograft, absence of fixation, or multilevel fusions. Treatment was equally effective for posterolateral fusions (66%) as with interbody fusions (69%). For patients with symptomatic pseudarthrosis after lumbar spine fusion, pulsed electromagnetic field stimulation is an effective nonoperative salvage approach to achieving fusion.

A case of congenital pseudoarthrosis of the tibia treated with pulsing electromagnetic fields.  17-year follow-up.

Ito H, Shirai Y, Gembun Y.

Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan.

Congenital pseudarthrosis of the tibia presents surgeons with one of the most challenging of all orthopedic problems. Various surgical treatments have succeeded only rarely. We report long-term follow-up of a patient with congenital pseudarthrosis of the tibia treated with pulsed electromagnetic fields (PEMF) and bone grafting. In this severe case, Bassett type III and Boyd type II, encouraging results were achieved with Boyd’s dual onlay grafts and PEMF. Seven years after surgery, skeletal maturity was complete and an unacceptable degree of leg shortening had been avoided.

Treatment of an adult with neglected congenital pseudoarthrosis of the tibia with acute fracture: a case report.

Shih HN, Chuang DC, Hsu RW.

Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan, R.O.C.

Treatment of congenital pseudoarthrosis of the tibia is very difficult. Numerous surgical procedures have been used including bone grafting, fixation, pulsed electromagnetic field, vascularized fibular bone grafting and lengthening devices. Previous studies, often reporting unsatisfactory results, are limited to children and adolescents. In adults, the following factors need to be considered: leg length discrepancy, leg deformity, soft tissue problems, lack of potential for growth and difficulties in healing. We reported a case of untreated congenital pseudoarthrosis of the tibia with fracture in a 32-year-old man. Conventional treatments used included excision of the pseudoarthrosis, correction of the deformity, intramedullary fixation, bone grafting and soft tissue transplantation for lengthening and coverage. These procedures led to good bony union and a satisfactory outcome.

Long-term pulsed electromagnetic field (PEMF) results in congenital pseudoarthrosis.

Bassett CA, Schink-Ascani M.

Bioelectric Research Center, Riverdale, New York 10463.

Ninety-one patients with congenital pseudarthrosis of the tibia have been treated with pulsed electromagnetic fields (PEMFs) since 1973 and all except 4 followed to puberty. Lesions were stratified by roentgenographic appearance. Type I and type II had gaps less than 5 mm in width. Type III were atrophic, spindled, and had gaps in excess of 5 mm. Overall success in type I and II lesions was 43 of 60 (72%). Of those 28 patients seen before operative repair had been attempted, 7 of 8 type I lesions healed (88%), whereas 16 of 20 type II lesions healed (80%) on PEMFs and immobilization alone. Only 19% (6 of 31) type III lesions united, only one of which did not require surgery. Sixteen of 91 limbs (18%) were ultimately amputed, most before treatment principles were fully defined in 1980. Fourteen of these 16 patients (88%) had type III lesions. Refracture occurred in 22 patients, most as the result of significant trauma, in the absence of external brace support. Twelve of the 19 refractures, retreated with PEMFs and casts, healed on this regime. Episodic use of PEMFs proved effective in controlling stress fractures in several patients until they reached puberty. PEMFs, which are associated with no known risk, appear to be an effective, conservative adjunct in the management of this therapeutically challenging, congenital lesions.

Treatment of congenital and infantile pseudoarthrosis of the tibia with pulsing electromagnetic fields.

Sharrard WJ.

The management of congenital and infantile pseudarthrosis of the tibia poses difficult problems because of the variability in the type and prognosis of the lesion and varied response to surgical treatment. Whatever the severity of the lesion, the use of pulsed electromagnetic fields can be expected to improve the prognosis for union by a factor of at least 20 per cent. In a very few patients, usually those with pseudarthrosis presenting later in life, pulsed electromagnetic fields alone together with plaster immobilization may be sufficient to produce union. In some, partially successful previous surgery may be made completely successful by subsequent application of pulsed electromagnetic fields. In patients with a fair or good prognosis as regards the type of lesion, a combination of surgery and pulsed electromagnetic treatment, some period of which may also be given before surgical treatment, gives a moderately high rate of success. In the three groups already described, the overall success rate is likely to be more than 70 per cent. In lesions with a poor prognosis, or after multiple surgical procedures in an older child, a combination of very adequate further surgery and pulsed electromagnetic fields can produce union in perhaps 30 per cent of cases, but it is unwise to commence any treatment if the limb is already unacceptably short, if there is gross wasting of the limb with evidence of inadequate vascular supply, and/or if the joints of the foot and ankle are stiff and associated with deformity. In such cases, the procedure of choice is amputation.