What does false joint mean? Pseudarthrosis as an outcome of femoral neck fracture

A false joint or pseudarthrosis develops due to improper fusion of bone fragments during a fracture. Under normal circumstances, after a fracture, bones heal by forming pliable, shapeless bone tissue. It helps to fuse 2 bone fragments and restore its integrity.

In medicine, many special treatment techniques are used, for example, applying plaster, connecting bone fragments using metal plates, performing skeletal traction and other manipulations for proper fusion of bones during a fracture. But if the bone fragments, due to some reason, do not heal properly, after some time the edges of the bones that are in contact with each other are rubbed in and smoothed. This is how a false joint is formed. Sometimes there is the development of a thin layer of cartilaginous tissue on the surface of the fragments that are in contact, or the accumulation of fluid. The formation of a certain articular capsule around the pathological fusion is often observed.

Such abnormal fusions are divided into several categories: congenital, traumatic and pathological. Based on the clinical and radiological picture, we can distinguish:

A false joint that is forming. It develops after a period of bone fusion. The features of this pathology are: pain in the fracture site, pain on palpation and during physical activity. Fluoroscopy shows the specific fracture lumen and periosteal callus.
Fibrous false joint - dense fibrous tissue appears between the bone fragments, the joints move normally, but the x-ray shows a narrow gap after the fracture.
A necrotic false joint occurs with gunshot injuries. This disrupts blood circulation. Or it can occur after a fracture, if there is a predisposition of the bones to the formation of necrosis.
A false joint of bone regenerate is an abnormal formation that appears as a result of osteotomy due to excessive stretching or improper fixation during medical procedures to lengthen segments.
A true pseudarthrosis is formed mainly on single-bone segments in places of pathological mobility. The bone fragments are polished, soon they are covered on top with fibrous cartilage tissue, and a gap appears between them, in which fluid accumulates. A cavity with defective contents is formed near the ends of the fragments.

According to the presence of infections and pus, uncomplicated false joints are divided into infected pathological formations.

Based on the stages of osteogenic activity, they divide:

Hypertrophic formations - with this type, bone tissue grows at the ends of the fragments. This phenomenon occurs in people with constant pressure on the limb or with reduced motor activity of bone fragments.
Avascular false formations - with this form, blood circulation in the joints is impaired, a violation in bone formation is visualized, and osteoporosis of the fragments is formed.

Why does it form?

The main causes of pseudarthrosis, which provoke the appearance of pathological fusion, are diseases accompanied by disruptions in metabolism (diseases of the endocrine system, oncological diseases), complications after surgery (weak fixation), improper management of postoperative therapy (early loads on the limb, early removal of fixators). Other factors in the development of pathology are errors in drug therapy and purulent formations. The reasons for the formation of pathology are as follows:

impaired blood circulation in the area of fragments;
increased clearance between fragments;
getting into the gap between fragments of soft tissue;
incorrect location of fragments after matching bones touching each other.

There are other reasons for the appearance of pseudarthrosis:

osteoporosis;
damage to bone tissue during surgical treatment;
lack of formation of a blood clot between fragments;
the body's reaction to metal fixation devices;
the presence of a foreign body between the fragments;
excessive number of fragments;
reaction to taking certain medications after a fracture (hormones, anticoagulants);
the presence of any other tissue injuries (burns).

Symptoms of the disease

The main symptoms and signs of the onset of pathology are excessive mobility of some joints, which during normal development should not move this way. This phenomenon can be almost invisible, or, on the contrary, intensely expressed. For example, there are cases in medical practice when a sick person was able to rotate a limb 360 degrees in those areas where pseudarthrosis had formed. Changes in the muscle strength of the joint are observed, and shortening of the limb up to several centimeters is diagnosed.

Normal motor activity of the affected limb is disrupted. This phenomenon can be observed especially clearly with anomalies in the lower limb - the leg turns under, the person loses the ability to stand on it. The patient needs support with a cane or crutches.

Therapy methods

The main stages of therapy after a fracture include restoring bone continuity. Getting rid of the resulting deformities makes it possible to restore the normal functioning of the limb. Treatment is carried out by a doctor according to the degree of damage. In addition to the basic methods (fixators, special devices, bone grafting), physiotherapy, general strengthening of the body, massage, and normalization of blood circulation are performed.

– this is a pathological condition accompanied by a violation of the continuity of the tubular bone and the occurrence of mobility in parts unusual for it. It often has an asymptomatic course and is manifested by the presence of mobility in an unusual place and pain when supporting the affected limb. Diagnosed based on the results of an objective examination and X-ray data. Treatment is mainly surgical. An osteosynthesis operation is performed, and if it is insufficiently effective, bone grafting is performed.

General information

A false joint is a pathological condition accompanied by a violation of the continuity of the tubular bone and the occurrence of mobility in parts unusual for it. Post-traumatic (acquired) pseudarthrosis develops after 2-3% of fractures; most often they form on the tibia, radius and ulna, less often on the humerus and femur. Congenital pseudarthrosis is localized on the bones of the leg and accounts for 0.5% of all congenital anomalies of the musculoskeletal system.

Causes

Acquired pseudarthrosis is a complication after a bone fracture caused by a violation of the process of fusion of fragments. The likelihood of developing pathology increases with the introduction of soft tissue between fragments, a significant distance between bone fragments, insufficient or early stopped immobilization, premature loading, local disruption of blood supply and suppuration in the fracture area.

The risk of pathology increases with metabolic disorders, endocrine and infectious diseases, circulatory disorders due to shock or blood loss, multiple fractures, severe combined trauma, and innervation disorders in the fracture zone. The cause of the development of congenital false joints is a violation of nutrition and innervation of the corresponding limb segment in the prenatal period.

Pathanatomy

With acquired false joints, the gap between the bone fragments is filled with connective tissue. The structure of long-existing false joints is gradually changing. The ends of the fragments become covered with cartilage and become more mobile. In the area of the gap, an articular cavity is formed, covered with a capsule and filled with synovial fluid. With congenital pathology, the affected area is filled with incompletely formed bone tissue, which cannot withstand the load on the limb.

Classification

By etiology:

acquired;
congenital.

By type:

fibrous pseudarthrosis without bone loss;
true (fibrous-synovial);
false joints with bone defect (loss of bone substance).

By type of formation:

normotrophic;
atrophic;
hypertrophic.

Symptoms of pseudarthrosis

The acquired variant of the pathology occurs at the site of the fracture and is accompanied by more or less pronounced mobility of the bone in an unusual place. If the pseudarthrosis forms on one of the two bones of a limb segment (for example, on the radius when the ulna is intact), symptoms may be absent or mild. Palpation is usually painless; significant load (for example, resting on the false joint of the lower limb) is usually accompanied by pain. Congenital pseudarthrosis is characterized by more pronounced mobility. The pathology is detected when the child learns to walk.

Diagnostics

The diagnosis is made by an orthopedic traumatologist based on the medical history, clinical and radiological picture, as well as the time that has passed since the injury. If the average time required for healing of this type of fracture has passed, they speak of delayed consolidation. In cases where the average period of fusion is exceeded by two or more times, a false joint is diagnosed. This division in traumatology and orthopedics is quite arbitrary, but at the same time it is of great importance when choosing treatment tactics. With delayed consolidation, there is still a chance for fusion. When a false joint forms, independent fusion is impossible.

To confirm the diagnosis, radiography is performed in two (direct and lateral) projections. In some cases, radiographs are taken in additional (oblique) projections. The images reveal the absence of callus, smoothing and rounding of the ends of the bone fragments, and the appearance of an endplate at the ends of the fragments (closing the cavity in the center of the tubular bone). An x-ray of an atrophic pseudarthrosis shows a conical narrowing of the ends of the bone fragments; a radiograph of a hypertrophic pseudarthrosis shows thickening of the ends of the fragments and uneven contours of the gap. With a true pseudarthrosis, the end of one fragment becomes convex and the other concave.

Treatment of pseudarthrosis

Conservative therapy is ineffective. The operation of choice is low-traumatic compression-distraction osteosynthesis (application of the Ilizarov apparatus). If there is no result, bone grafting or resection of the ends of bone fragments with their subsequent lengthening is performed. Treatment of congenital pseudarthrosis is complex and includes surgery in combination with physical and drug therapy aimed at improving tissue nutrition in the affected area.

Pain in the affected area

Deformation of the affected segment

Impaired limb mobility

Gait disturbance

Inability to stand on your feet

Unnatural bend of the limb

Limitation of joint mobility

Swelling in the affected area

Pathological limb mobility

Decreased muscle tone

Increased range of motion

Limb shortening

Pseudarthrosis is considered a fairly common disorder, against the background of which there is a violation of the structural integrity of the bone and the appearance of its abnormal mobility in unintended sections. Since the pathology can be either primary or secondary, the predisposing factors of formation will differ. In the first case, this is caused by a malnutrition of one or another segment of the bone at the stage of intrauterine development of the fetus, in the second, improperly healed fractures act as a provocateur.

This disease very often occurs without any clinical manifestations, but most often patients complain of pain, deformation of the affected segment and unhealthy mobility.

Pseudarthrosis is diagnosed by conducting a thorough physical examination and palpation, as well as an instrumental procedure such as x-ray examination.

The treatment tactics in the vast majority of situations are surgical in nature and consist of excision of the pathological formation followed by plastic surgery.

The International Classification of Diseases, Tenth Revision, identifies several codes for such a disease. The ICD-10 code for pseudarthrosis against the background of a non-healing fracture is M84.1, and the pseudarthrosis formed after fusion is M96.0.

Etiology

The main reason for the development of the congenital form of the disease is a disruption in the process of nutrition and innervation of a particular bone segment during the period of intrauterine development of the fetus. In such situations, the bone is filled with incompletely formed tissue, which makes it impossible to withstand the load on the limb.

Acquired pseudarthrosis has a much wider range of predisposing factors. Among them it is worth highlighting:

the course of diseases characterized by an abnormal process of metabolism and complete restoration of bone tissue. This category includes severe and pathologies due to which the organs of the endocrine system suffer;
inadequate implementation of bone surgery;
inadequate postoperative recovery, for example, if the limb was loaded too early;
development of suppuration, which acts as a complication of a fracture or surgery;
incorrect position of fragments after comparison of the bone;
penetration of soft tissue into the gap located between bone fragments;
presence in medical history or;
injury to the periosteum during surgical treatment;
obstruction of the medullary canal;
the body’s reaction to metal systems and other orthopedic structures used for bone fusion;
uncontrolled use of certain medications, namely anticoagulants or steroid hormones;
susceptibility of affected tissues to concomitant damage - this includes extensive burns or irradiation;
the presence of an oncological process in the body;
period of bearing a child;
secondary infection of a wound received after an open fracture;
profuse internal hemorrhage;
maxillofacial injuries are the main cause affecting the appearance of a false joint of the lower jaw.

Regardless of the root cause, the pathogenesis of a false joint after a fracture is that the bone gap is filled with connective tissue, causing the fragments to be covered with cartilage - it is because of this that they become abnormally mobile.

Classification

Dividing the disease by time of occurrence implies the existence of:

congenital pseudarthrosis- in all cases localized in the lower leg. The diagnosis frequency is only 0.5% of the total number of primary developing ailments affecting the skeletal system;
secondary developing pseudarthrosis- form after approximately 3% of fractures and most often affect the tibia and ulna, as well as the forearm. It is several times less common in the femur and shoulder.

According to the nature of the formation of pseudarthrosis, it can be:

normotrophic- no growth is observed;
atrophic- often there is insufficient blood supply and bone formation;
hypertrophic- bone tissue can grow only at the ends of the affected segment.

Classification by type includes the following variants of the course of the disease:

fibrous pseudarthrosis- not accompanied by loss of bone substance;
true pseudarthrosis;
false joint, complementary loss of bone substance.

There are also the following types of disease:

emerging- formed at the very end of the period necessary for adequate bone fusion;
fibrous;
necrotic- often develops after gunshot wounds. The most commonly diagnosed pseudarthrosis is the scaphoid, neck of the talus, or femur;
neoarthrosis;
bone regenerate- in such situations, a false joint of the femoral neck occurs.

In addition, the disease can be complicated (infected) and proceeds without any consequences.

Symptoms

The false joint of the clavicle or any other location has a pronounced and rather specific clinical picture. The main symptoms are considered to be:

pain of varying severity at the site of injury;
deformation of the affected segment;
gait disturbance;
inability to stand on your feet without assistance;
decreased muscle tone of the affected limb;
limited mobility of the joint located above and below the injury;
significant swelling of the damaged area;
reduction in the length of the injured arm or leg by no more than 10 centimeters;
uncharacteristic increase in range of motion;
impaired functioning of the limb;
bending an arm or leg in an unnatural position;
pathological mobility in the area where it should not normally exist;
muscle atrophy developing against the background of limited motor function;
absence of pain on palpation of the pseudarthrosis after a fracture of the clavicle, hip, hand or any other bone.

Congenital pathology is often discovered when the baby learns to walk and is completely asymptomatic.

Diagnostics

An orthopedic or traumatologist knows what a pseudarthrosis is, how to correctly diagnose, differentiate and treat it. Despite the presence of characteristic symptoms, the diagnostic process involves the implementation of a whole range of measures.

Thus, the initial diagnosis after a fracture of the femoral neck or other bone includes:

familiarizing the clinician with the medical history - this is necessary to search for a pathological etiological factor that increases the likelihood of developing such a disease;
collection and analysis of life history - this includes information regarding medication use, injuries received, burns and radiation;
thorough examination and palpation of the affected segment;
a detailed survey of the patient - to determine the severity of symptoms and compile a complete symptomatic picture.

The main instrumental procedure to confirm the diagnosis is an x-ray examination performed in several projections. The following data may indicate the formation of a pseudarthrosis:

absence of callus intended to connect fragments;
rounding and smoothing of bone fragments;
overgrowth of the strip of bone located at the ends of the fragments and the appearance of end plates;
the formation of a gap between the joint parts;
one of the fragments looks like a hemisphere.

To clarify the type and nature of pseudarthrosis, a radioisotope study is performed.

Laboratory diagnostic procedures are not carried out because they have no diagnostic value.

Treatment

Elimination of a false joint that appears after a fracture of the hip, collarbone, forearm and other area is often based on surgical treatment methods.

Clinicians highlight some principles of surgical treatment of pseudarthrosis:

implementation of the intervention 6-12 months after wound healing;
excision of scars and skin grafting;
comparison of fragments;
refreshing bone ends;
restoration of channels.

Most often, in order to eliminate the defect of a broken bone, the following methods are used:

“Russian castle” type intervention;
Chaklin's operation;
osteosynthesis with grafts.

In addition, you may need to wear an Ilizarov apparatus - the duration of such treatment is at least 8 months. The treated limb is allowed to be loaded 2 months after completion of therapy.

In situations where there is no need for medical intervention, therapy is limited to wearing specially designed orthoses.

In any case, getting rid of a false joint of the clavicle or other bone should take a comprehensive approach. After surgery, patients are often prescribed:

therapeutic massage course;
physiotherapy;

Taking medications and using folk remedies in this case is unsuccessful.

Prevention and prognosis

There are no specific preventive measures to prevent the formation of congenital pseudarthrosis of the tibia, since the pathological process develops during the period of intrauterine development of the fetus.

As for the acquired defect, to reduce the likelihood of its formation the following is indicated:

prevention of gunshot or any other injury to bones;
regular visits to a specialist who will monitor the healing process of the fracture;
high-quality immobilization of the affected limb;
adequate treatment of diseases that negatively affect the skeletal system and musculoskeletal system;
compliance with all medical recommendations after removal of the cast;
annual complete preventive examination at a medical institution.

The prognosis of both the primary and secondary forms of the disease directly depends on the time of treatment and the etiological factor. Often, with the help of surgical intervention, it is possible to achieve complete restoration of activity and motor function of an arm or leg. A favorable outcome is observed in approximately 72% of patients. However, a complete refusal of qualified assistance can result in disability for the patient. The incidence of complications reaches 3%.

A “callus” is formed, which is a shapeless and loose mass, thanks to which bone tissue is restored between the fragments. For more accurate fusion of bones, various techniques are used: applying plaster, stretching the bones of the skeleton, connecting fragments with metal plates, knitting needles, etc. However, under the influence of various factors, in some cases the tubular bone does not heal. After some time, its touching and rubbing edges smooth out and form a false joint (or pseudarthrosis) - one of the complications in the treatment of fractures. Sometimes a thin layer of cartilage and fluid forms on the edges of the bones of such a formation, and a capsule similar to a joint capsule appears around it.

The first attempts to treat such complications of fractures were made by Hippocrates. They were not successful, because for these purposes only conservative methods were used - tapping the damaged area with a wooden hammer and administering medications to activate the growth of callus. Later, surgical operations began to be performed to eliminate false joints (according to Back, Yazykov, Khakhutova, etc.).

According to some statistics, such a complication in the treatment of closed fractures is observed in 5-11% of cases, and in open ones - in 8-35%. Pseudoarthrosis often occurs after damage to the radius and femoral neck, and in case of congenital pathology - on the lower leg (at the border of the lower and middle third of the tibia). In this article we will introduce you to the causes, types, main symptoms and methods of treating pseudarthrosis.

Causes

The cause of the formation of a false joint may be improper immobilization of the limb after a fracture and displacement of bone fragments.

The appearance of congenital pseudarthrosis is provoked by intrauterine pathologies. They are more often unilateral and appear on the tibia. The frequency of their development is on average 1 case per 190 thousand children. The appearance can be caused by the following intrauterine pathologies:

amniotic band;
fibrous dysplasia;
underdevelopment of blood vessels due to their embryonic defect;

The development of acquired false joints can be caused by the following internal or external reasons:

improper treatment of fractures - displacement of bone fragments under plaster, improper immobilization of the limb with a plaster cast, frequent replacement of plaster, overextension during skeletal traction, insufficient immobilization of the limb after osteosynthesis, early and excessive loads on the broken limb, premature removal of the apparatus for fixing fragments;
consequences of surgical interventions - resection of fragments, unstable fixation;
diseases leading to disruption of normal bone regeneration and metabolism (for example, endocrine pathologies, tumor cachexia, general intoxication);
purulent complications.

The following cases can cause the appearance of acquired pseudarthrosis:

penetration of soft tissue or foreign bodies into the gap between the ends of a broken bone;
excessive number of fragments;
incorrect alignment of the ends of the broken bone;
insufficient blood circulation in the area of fragments;
large distance between the ends of the broken bone;
absence of hematoma between the ends of the broken bone;
trauma to the periosteum during surgical procedures;
reaction during metal osteosynthesis to metal devices (plates, bolts, nails);
clogging and closure of the bone marrow canal in fragments with a plate;
additional tissue damage (burns, radiation);
taking or steroids.

Types of false joints

Depending on the cause of pseudarthrosis, there are:

congenital;
acquired: pathological and traumatic.

Depending on the nature of the damage, pseudarthrosis can be:

non-gunshot;
firearms.

Depending on the clinical manifestations detected during x-rays, false joints are of the following types:

Emerging. Appears during the completion of the period necessary for normal bone fusion. The x-ray reveals clear boundaries of the fracture “gap” and bone callus. The patient feels pain in the damaged area and when trying to palpate it.
Fibrous. Fibrous tissue is revealed between the ends of the bone and a narrow “gap” is visible on the image. Mobility in the joint is sharply limited.
Necrotic. Appears after gunshot wounds or during fractures that are predisposed to the development of bone necrosis. Such pseudarthrosis is more often observed with injuries to the neck of the talus and femur or the middle part of the scaphoid.
Pseudoarthrosis of bone regenerate. Appears when osteotomy of the tibia is incorrect, due to its excessive stretching or insufficiently strong fixation to the apparatus for lengthening the segments.
True (or neoarthrosis). In most cases, it develops on single-bone segments with excessive mobility. With such pseudarthrosis, fibrous cartilaginous tissue with areas of hyaline cartilage appears at the edges of the fragments. A formation appears around the debris, similar to a periarticular bursa, which contains fluid.

Depending on the method of formation and intensity of bone formation, pseudarthrosis can be:

hypertrophic – bone growths appear at the ends of a broken bone;
normotrophic - there are no bone growths on the fragments;
atrophic (or avascular) - in such joints blood circulation is impaired, bone formation is poor or is often accompanied by osteoporosis of a broken bone.

According to their course, pseudarthrosis can be:

uncomplicated - not accompanied by infection and the appearance of pus;
infected - the addition of a purulent infection leads to the formation of fistulas and sequestra (cavities) localized in the bone, from which pus is released; such joints may contain fragments of projectiles or metal clamps.

Symptoms

With a pseudarthrosis, the following main symptoms are observed:

atypical, subtle or extremely pronounced mobility of those parts of the body in which movements do not normally occur;
uncharacteristic increase in the direction or amplitude of movements;
reducing the length of an arm or leg to 10 cm;
swelling below the fracture site;
decreased muscle strength in a limb with pseudarthrosis;
dysfunction of a broken limb;
changes in the functions of nearby joints.

Diagnostics

In addition to examining and analyzing the patient’s complaints, an X-ray examination is performed to diagnose pseudarthrosis. For a more detailed examination of structural changes in bones, x-rays should be taken in two perpendicular projections. In some difficult cases, the patient is prescribed tomography.

When studying x-rays with pseudarthrosis, the following changes are revealed:

there is no callus connecting the fragments;
fragments of a broken bone become rounded and smoothed (sometimes they become conical due to the lack of bone tissue formation during atrophic pseudarthrosis);
at the ends of the fragments, the bone cavities are overgrown and endplates appear on them, stopping regeneration in the bone marrow tissues;
a gap is revealed between the “articular surfaces” in both projections;
sometimes one of the fragments has the shape of a hemisphere, resembling the articular head, and the other has a concave surface and resembles the articular cavity.

X-rays can reveal a false joint. To determine the intensity of bone formation and clarify the form of pseudarthrosis - hypertrophic or atrophic - a radioisotope study is carried out.

Treatment

The main method of eliminating false joints is surgery. Conservative therapy aimed at eliminating pseudarthrosis and consisting in the use of drugs for fusion of fragments and physical procedures does not give the expected effect.

The main goal of treatment is to restore continuity to the broken bone. After this, measures are taken to eliminate the deformities causing the impairment of the affected limb. The treatment plan is drawn up depending on the clinical case and individual characteristics of the patient.

To eliminate false joints, general and local measures are used.

General therapeutic measures

Patients with pseudarthrosis are recommended to take measures aimed at increasing muscle tone, stabilizing blood circulation in pseudarthrosis, preserving and restoring the functions of the affected leg or arm. For this purpose, patients are prescribed physiotherapeutic procedures, massage and a set of physical therapy exercises.

Local treatment

Local treatment of pseudarthrosis involves an operation aimed at creating favorable conditions for proper fusion of fragments. To do this, their ends are brought closer together and immobilized. During the intervention, the surgeon pays attention not only to bringing the fragments closer together, but also creates conditions for adequate blood circulation in the fracture area. In addition, infection prevention or treatment of purulent complications is carried out.

Local treatment can be carried out using the following methods:

compression-distraction osteosynthesis;
stable osteosynthesis;
bone grafting.

Local treatment tactics are selected depending on the type of pseudarthrosis. In its hypertrophic form, the operation can be extrafocal - a compression-distraction device is applied to the limb. And with atrophic pseudarthrosis, in order to restore the integrity of the broken bone, it is first necessary to perform its plastic surgery.

When choosing a surgical procedure, the location of the pseudarthrosis is also taken into account:

for periarticular localization, compression-distraction osteosynthesis is performed;
if localized on the upper or middle third of the thigh, intramedullary osteosynthesis is performed;
when localized on the radius (with the development of clubhandedness), first hardware distraction is performed, and then bone grafting;
when localized on the humerus or tibia, compression-distraction osteosynthesis is performed.

Compression-distraction osteosynthesis

This method of treatment is performed using special devices that provide comparison of fragments. In this case, the broken arm or leg must be completely motionless. The device allows for maximum approximation and mutual compression of the ends of the broken bone. In addition, this method makes it possible to eliminate shortening or deformation of the limbs. To ensure immobilization, Kalnberz, Ilizarov, etc. devices are used. The essence of the method is to remove the sections of bone that form the false joint, bring them closer together and press them against each other. After the formation of a callus, the fragments begin to gradually move away from each other, restoring the length of the limb and the integrity of the bone.

Sustainable osteosynthesis

To perform this method of treatment, special fixators (plates, rods) are used, which provide the contact and immobility of damaged bone fragments necessary for healing. To apply them, damaged areas of the bone are exposed during surgery. In hypertrophic pseudarthrosis, bone fusion with the help of stable osteosynthesis occurs without performing bone plastic surgery, but in atrophic pseudarthrosis, this preliminary intervention must be performed.

Bone grafting

This surgical method is used infrequently, but only in cases where it is necessary to stimulate osteogenesis in atrophic pseudarthrosis. Before carrying out such operations, it is necessary to eliminate purulent processes, perform excision of scar changes and skin plastic surgery. At least 8-12 months must pass from the completion of treatment for purulent complications to the date of bone grafting surgery.

Rehabilitation and results

Regular physical therapy exercises help to recover from illness.

The duration of immobilization of the affected limb in case of false joints is 2-3 times longer than in the treatment of a conventional fracture of the same bone. After its completion, the patient is assigned a rehabilitation program.

Normally, bone fractures heal due to the formation of “callus” - that is, loose and shapeless bone tissue that promotes healing of two bone fragments and allows the restoration of bone integrity.

In order for the bones to heal even better, many special therapeutic techniques are used: a cast is applied, bone fragments are connected using metal plates (this manipulation is called metal osteosynthesis), skeletal traction is done, and much more.

If for some reason the bone fragments do not heal, then after some time the edges of the bone that touch each other will rub in, smooth out, and a false joint will form in their place. In some cases, you can observe the appearance of a thin layer of cartilage tissue on the surface of the contacting fragments, as well as a small amount of fluid, just like in real joints. Quite often, a kind of joint capsule is formed around the false joint. Pseudarthrosis in medicine has another name - pseudarthrosis.

Classification of false joints

All false joints can be divided into several groups:

1.According to the etiology, false joints can be:

congenital;
traumatic;
pathological.

2.According to the nature of the damage, we can distinguish:

firearm origin;
non-gunshot origin.

3.According to the clinical and radiological picture, the following types of pathology occur:

Forming false joint - usually appears after the period during which bone tissue normally fuses. Its distinctive features include the presence of painful sensations in the fracture zone, pain when palpating and moving the affected joint; X-ray images can reveal a clear “gap” of the fracture, as well as periosteal callus.
Tight (or fibrous, slit-like) pseudarthrosis - this form is characterized by the appearance of rough fibrous tissue between bone fragments, the mobility of the joint is not significantly reduced (in the absence of diastasis), the appearance of a narrow gap can be observed on X-ray photographs.
Necrotic pseudarthrosis - appears in the case of gunshot wounds, when normal blood circulation is disrupted, as well as in fractures that are predisposed to the development of bone necrosis (the body of the talus is most susceptible to this phenomenon due to a transverse fracture of the neck of the talus, the head of the femur due to fractures of the femoral neck , as well as the medial part of the scaphoid due to a transverse fracture).
False joint of bone regenerate – this pathology occurs as a result of osteotomy of the tibia due to too much distraction (stretching) or weak hardware fixation when lengthening the segments.
True pseudarthrosis (otherwise called nonarthrosis) - appears mostly on single-bone segments where pathological mobility is present. The fragments are polished and then covered with fibrous cartilage with areas of hyaline cartilage. A space forms between them, in which fluid accumulates, and around the ends of the fragments a capsule appears, the same as in a real joint, but with a defect in the main substance in it.

4. According to the degree of osteogenic activity, they are distinguished:

Hypertrophic pseudarthrosis is a type of pseudarthrosis in which bone tissue grows at the ends of the fragments. Usually occurs in people who carry out axial load on the limb, in case of low mobility of fragments, and also when the vascular network of the surrounding tissues is completely preserved.
Avascular false joints are joints in which blood circulation is impaired and poor bone formation is observed; often here the pathology is accompanied by osteoporosis of the fragments.

5. According to the presence of purulent complications, they differ:

uncomplicated pseudarthrosis;
infected.

Complicated by a purulent infection - the latter are distinguished by the appearance of a fistula with purulent discharge, sequesters located in the bone and supporting the purulent process, as well as the presence of foreign bodies (for example, metal clamps, fragments of wounding projectiles).

Causes of pseudarthrosis

A number of reasons can lead to the development of this pathology, which we will give below:

the presence of diseases in which metabolic disorders occur in the body, as well as normal bone tissue regeneration (for example, such pathologies include diseases of the endocrine system, general intoxication, rickets, tumor cachexia);
consequences of surgery (resection of fragments during chemical treatment, unstable fixation);
errors in postoperative treatment (insufficient immobilization of the patient after osteosynthesis, too early load on the limb, early removal of the bone fixation apparatus);
errors in drug treatment (excessively frequent replacement of the plaster cast, inadequate immobilization with plaster, displacement of fragments under the bandage, overextension of fragments during skeletal traction);
presence of suppuration.

You can also identify the following reasons for the development of this pathology:

when the fragments are incorrectly positioned relative to each other after matching the bones;
penetration of soft tissue into the gap between bone fragments;
too large a distance between the fragments;
insufficient blood circulation in the area of fragments;
presence of osteoprosis;
trauma to the periosteum during surgery;
blockage of the bone marrow canal in bone fragments;
absence of a blood clot between the fragments;
reaction to nails and metal plates when performing metal osteosynthesis;
foreign body between bone fragments;
too many fragments;
the use of a number of medications, for example, steroid hormones or anticoagulants;
associated tissue damage, for example, burns, radiation.

Symptoms and signs

Pseudoarthrosis usually has several clinical symptoms, which include:

Increased mobility in those places of the human body where, as a rule, there should be no movements at all; this also includes an increased amplitude and directions of movements that are atypical for a healthy person. Pathological mobility can be almost imperceptible, or, on the contrary, it can be extremely strong. So, for example, in medicine there are cases when the patient could rotate the lower or upper limbs up to 360 degrees in the area of the false joint.
Shortening of the affected limb by up to 10 centimeters may also be observed.
The muscle strength of the limb decreases as a result of the formation of a false joint.
There is a dysfunction of the affected arm or leg: the false joint does not have the bone restraints that real joints have, and it is not fixed by muscles, ligaments or tendons. Particularly prominent in this case are the pseudo joints of the lower extremities. In the case of physical activity, pseudarthrosis can lead to twisting of the legs, loss of the ability to move independently, as well as to stand or lean on the affected limb. For this, the patient has to use crutches, a cane, or a special orthopedic device.
Due to the reduced load on the real joints, disturbances in their functioning are observed.

Diagnosis of pathology

The diagnosis of pseudarthrosis can be established based on anemnesis, as well as the clinical symptoms described above. But all these signs do not necessarily accompany the appearance of a pseudarthrosis; in a certain percentage of patients they are absent. This is often typical for fibrous hypertrophic false joints, that is, for joints with low mobility of fragments, for example, with pseudarthrosis of the tibia or fibula.

The most accurate diagnostic method that allows you to establish this pathology is an x-ray examination. X-rays are necessarily taken in two perpendicular projections (this helps to more accurately and in detail examine the structural features of the bones). In some cases, tomography may be performed.

The following main radiological signs observed with pseudarthrosis can be identified:

There is no callus that connects the ends of the fragments.
You can see the smoothing and rounding of the ends of the fragments; in some cases they have a conical shape, which develops due to bone resorption and the absence of bone formation processes (occurs in atrophic pseudarthrosis).
The bone marrow cavity at the ends of the fragments is overgrown, and an endplate develops (this indicates the cessation of restoration processes in the bone marrow).
Quite often one can note the hemispherical shape of the end of one of the fragments; its appearance is very similar to the articular head. The end of the other fragment in this case is concave like a glenoid cavity. Also, on x-ray images in both projections, the gap between the “joints” is clearly visible.

Using X-ray diagnostics, it is possible to distinguish between manifestations of a pseudarthrosis with a slow progression of the fracture. How intense the processes of bone formation in the area of the pseudarthrosis are can be judged based on radioisotope data. These data will differ in atrophic or hypertrophic forms of pseudarthrosis.

Treatment

The process of treating a pseudarthrosis includes, first of all, restoration of bone continuity, and then the subsequent elimination of developed deformities, which will normalize the functions of the affected limb. The treatment plan is developed by the attending physician based on all existing symptoms, as well as other personal data of the patient.

Treatment of pseudarthrosis is divided into general and local measures. Next we will look at them in more detail.

General therapeutic measures help strengthen the body, increase muscle tone, maintain or restore impaired functions of the diseased limb, and normalize hemodynamics in the area of the pseudarthrosis. This group of methods includes regular performance of special therapeutic exercises, massage sessions, as well as physiotherapeutic manipulations.
Local treatment consists of creating certain conditions for normal regeneration by bringing together and immobilizing fragments (in some cases it is necessary to carry out stimulation), normalizing blood circulation in the affected area, as well as in the prevention and proper treatment of purulent complications. These principles are fully met by three main groups of treatment methods, namely: stable osteosynthesis, compression-distraction osteosynthesis and bone grafting.

Compression-distraction osteosynthesis - with the help of this manipulation it is possible to achieve rapprochement and mutual compression of bone fragments, as well as eliminate deformities and shortening of the limb. This treatment is carried out using special devices and always in conditions of immobility of the affected arm or leg.
Stable osteosynthesis is done with the help of special clamps; it can also be used to obtain close contact, contact and immobility of fragments, but in this case, surgical exposure of the fragments is necessary, which significantly limits the use of this method. In the case of hypertrophic pseudarthrosis, stable osteosynthesis helps to achieve complete bone fusion and restoration of its integrity without bone grafting. The latter cannot be avoided in case of atrophic false joints.
Bone grafting - this technique is used much less frequently in the treatment of pseudarthrosis. In the case of atrophic pseudarthrosis, it helps stimulate osteogenesis. A mandatory condition for its implementation is the elimination of purulent complications, preliminary excision of scars with skin grafting. Enough time must also pass after the infection has cleared (approximately 8 months to one year).

Based on this, we can say that the treatment of pseudarthrosis directly depends on its type: hypertrophic or atrophic. For example, if in the case of hypertrophic pseudarthrosis the osteogenetic abilities of the tissues are preserved and extrafocal intervention is sufficient for treatment, that is, the application of a compression-distraction device, then in the atrophic form, in addition to extrafocal operations, it will be necessary to perform bone grafting.

The location of the pseudarthrosis is also taken into account in treatment:

Thus, for pseudarthrosis of the tibia or humerus, the best effect will be achieved by performing compression-distraction osteosynthesis in a closed manner;
on the forearm, in case of damage to the radius and the formation of clubhand, you must first apply hardware distraction, and then perform bone grafting;
on the thigh in the upper and middle thirds, intramedullary osteosynthesis brings the best results;
in the case of periarticular localization, compression-distraction osteosynthesis is indicated.

Which doctor treats

If one or more signs indicating pseudarthrosis appear, you need to contact a rheumatologist, who will treat this pathology. Since the treatment is complex, in addition to the rheumatologist, the following specialists are also involved in the process: physiotherapist, massage therapist, arthroscopist, surgeon.