Pseudarthrosis of the hip: causes, symptoms, treatment and surgery

A false joint of the femoral neck is formed due to improper or incomplete fusion of the bone due to injury. The reason may be inaccurate comparison of fragments (in many cases it is almost impossible to do this using a bloodless method) and fixation in this form, disruption of metabolic processes, insufficient blood supply to the bone area, pinching of the joint capsule by fragments, early activation of the patient. The problem most often occurs after a femoral neck fracture in older people.

The process of the appearance of a false joint is quite long, it begins with smoothing and sclerosis of the ends of the fragments, sometimes a cartilaginous layer and even a certain volume of joint fluid is formed on the surfaces of nearby bone fragments. In other words, the resulting formation is called “pseudoarthrosis.” The femur, left without proper load, undergoes pathological changes: the normal structure of the tissue is disrupted, demineralization occurs, and signs of osteoporosis are visible on the pictures. The surrounding muscles atrophy, metabolic processes slow down even more.

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General information

A false joint is a pathological variant of fusion (consolidation) of bone fragments, which occurs in approximately 5% of patients; it can be detected after twice the average period normally required for the complete formation of a callus , and the features of consolidation are also not detected on x-rays.
Pathology manifests itself in the form of unusual mobility and broken continuity of the bone, up to the “dangling” version. Pseudarthrosis or pseudarthrosis ( ICD 10: M84.1) includes a whole sympathocomplex, manifested by pain and the inability to perform functions of the injured limb. Pathology is most often a complication of a fracture and causes morphological transformations and radiological signs of deterioration of osteoreparation .

Short description

False joint (pseudoarthrosis) is a violation of the integrity of the diaphysis of a tubular bone with the presence of pathological mobility.

Code according to the international classification of diseases ICD-10:

• M84.1 Fracture nonunion [pseudarthrosis]
• M96.0 Pseudarthrosis after fusion or arthrodesis

Frequency - acquired (post-traumatic) account for 2–3% of all fractures. Most often they occur on the tibia, forearm bones, and less often on the femur and humerus. Congenital ones are localized on the lower leg and account for 0.5% of all congenital pathologies of the musculoskeletal system.

Classification • By etiology •• Congenital •• Acquired • By type •• Fibrous pseudarthrosis without loss of bone substance •• Fibrous - synovial pseudarthrosis (true pseudarthrosis) •• Pseudarthrosis with loss of bone substance (bone defect).

Pathogenesis

It is impossible to stop the process of callus formation; it usually obeys all the laws of normal physiology, but at the same time, repair occurs in isolation - at different ends of the fragments without a tendency to fuse them together.

Impaired bone tissue regeneration begins with the development of connective tissue structures in the interfragmental region of varying degrees of differentiation in the false pseudojoint, as well as unevenly distributed groups of collagen fibers. Vascularization develops in this connective tissue, that is, a large number of small blood vessels can be detected in it in the form of a capillary network.

Between bone fragments, connective tissues, fibrous in structure, grow. During movements and stress on the limbs, trauma and corresponding hemorrhage into the interfragmental space may occur. This development option is fraught with disruption of the maturation and formation of callus; even the presence of spongy bone substance in the scar tissue does not lead to complete healing and fusion, although it acquires a more differentiated structure, including powerful parallel collagen bundles, as well as a significantly smaller number of fibroblasts and manifestations vascularization.

In the tissue formation connecting bone fragments, the development of bone crossbars occurs, the shape of which is constantly remodeled, which is associated with the constantly occurring increased activity of osteoclasts.

The structures in the interfragmental zone of the pseudarthrosis usually have different ages with a wide variation in morphological organization, with different contents of immature and mature scar conglomerates in different areas, as well as inclusions of bone tissue of a coarse fibrous structure. The main sources of bone tissue regeneration are represented by osteoblasts and poorly differentiated perivascular cambium cells located around the vessels between the fragment tissues.

Classification

There are many classifications of false joints depending on various factors of their division into types. For example, if the cause of origin is taken into account, the condition may be congenital, pathological and traumatic, resulting from a non-gunshot or gunshot wound. Whereas, depending on the unfolding clinical and radiological manifestations, a false joint occurs:

• forming - that is, occurring after the expiration of the period normally required for healing of an ordinary fracture , characterized by the presence of pain at the fracture sites, as well as during palpation, a distinct “gap” and periosteal callus at the fracture site can be detected on the radiograph;
• “ tight ” or in another way – fibrous – outwardly reminiscent of slit-like, which is characterized by the formation of tissues that are rough and fibrous in nature between the edges of the fragments, while there is no pronounced pathological mobility (no diastasis), and a thin lumen is visible on the x-ray;
• necrotic - develops after gunshot wounds that affected not only the bone, but also its blood supply; also at risk are fractures that are considered predisposed to necrotic processes in the bones - fracture of the femoral neck , transverse fracture of the neck of the supracalcaneal bone, transverse fracture of the middle part of the scaphoid, they may have aseptic necrosis of the edges, freely lying in the middle of the fracture, or necrosis associated with fragments;
• in the form of bone regenerate - more typical for the tibia as a result of insufficiently strong fixation, elongation of segments or excessive stretching;
• true neoarthrosis - most often affects single-bone segments with pathological mobility, the fragments undergo grinding, one becomes spherical in shape, and the second - cup-shaped, between them there is a space that is filled with liquid, a capsule is formed similar to an articular one, since there is a covering of fibrous with islands of hyaline cartilage, the process can occur against the background of a defect in the bone substance.

The false joint may be uncomplicated or have purulent complications , which can be infected , with fistulas , while purulent discharge, the presence of sequesters or foreign bodies that support the purulent process are detected, for example, during injury, fragments of projectiles, metal clamps, etc. can get into the wound .d.

Depending on the degree of osteogenic activity of the pathological process, changes can be normotrophic , atrophic and hypertrophic , when a false pseudojoint is formed as a result of the proliferation of bone tissue at the edges of fragments. It is usually inactive, but the vascular network of the surrounding tissues is preserved. People who have frequent axial loads are at risk. In addition, the process can be avascular - when the blood supply is impaired and poor bone formation occurs against the background of osteoporosis of the fragments.

According to topographic descriptions, pseudarthrosis usually occurs in the bones of the forearm, hips, wrist, foot, jaw, etc.

Congenital pseudarthrosis

In addition to the acquired complication of healing fractures and other injuries, pseudarthrosis can be congenital - in approximately 0.5% of people. Most often it affects long tubular bones, such as the tibia, and manifests itself with mobility along the diaphysis. The pathology is based on a defect in skeletal ossification - fibrous dysplasia .

Congenital pseudarthrosis of the bones of the left leg

The problem can only be solved surgically with the use of bone grafts. It can be identified already at the stage of learning to walk and other movements, since the limb has abnormal mobility and bends in the wrong place.

Pseudarthrosis after femoral neck fracture

A fairly common case among all diagnosed examples of pseudarthrosis is failure of fusion after a femoral neck fracture. It has complex consequences and significantly reduces the quality of life, because symptoms include progression of lameness, shortening of the limb, wasting of soft tissues, and limitation of movements during abduction of the limb. Axial loads cause cephalad displacement of the femur. Ununited fractures and secondary static deformations lead to pelvic distortion, curvature of the spine and equinus position of the foot.

False joint of the forearm

The severe condition of pseudarthrosis of the radius can be complicated by chronic dislocations and displacements of the heads of the bones of the forearm. To solve the problem of the bone apparatus, a consultation of doctors and the development of a step-by-step treatment strategy are usually required. Initially, it is important to align the bone axis and perform distraction, which can be quite painful and require additional anesthesia.

It is important to seek help promptly if you suspect a false joint, because it affects the ability to fully work with your arm and limits movement. Patients may have problems with self-care and work activities.

Neoarthrosis

The most common type is transverse sacral neoarthrosis of the spine. The formation of false joints occurs in pathological conditions occurring between the spinous processes of the lumbar vertebrae or involving the lateral masses of the sacrum. The reasons are the contact of these structures, trauma, their friction, destruction of the soft tissues located between them, including ligaments, dysplastic enlargement against the background of spinal curvature and a significant decrease in the height of the intervertebral discs.

Neoarthrosis of the spine can cause overload conditions and arthrosis . In the case of a bilateral process, they speak of articular sacralization of the transverse processes, but most often the pathological process is unilateral. In this case, patients complain of lower back pain ( lumbodynia or lumboischialgia ), do not tolerate static loads well, it hurts them to turn or bend over, and sometimes even palpation leads to severe discomfort.

Causes of the problem

The reason for the formation of an acquired false joint lies in the failure of bone fusion.
Problems usually arise in the presence of an infectious disease, endocrine system disorders, metabolic or circulatory disorders. Often, a false joint is a consequence of numerous injuries and destruction of the nerve fibers of the affected area. Pathology develops if:

• soft tissue has embedded itself between the fragments;
• the bones are too far apart;
• fixation turned out to be weak;
• the fixing bandage was removed ahead of schedule;
• loaded the damaged area prematurely;
• blood circulation in the area of ​​damage is impaired;
• suppuration began.

The reasons for the formation of congenital pseudarthrosis lie in malnutrition of the fetus, and this also happens when the nerve fibers in a certain area of ​​the arms or legs are destroyed during intrauterine development.

Causes

The causes of pseudarthrosis can be general and local. General etiogenesis is associated with a decrease in the reactivity of the body, metabolic disorders and reparative processes of bone regeneration, these include:

• endocrinopathies;
• intoxication;
• dystrophy;
• vascular diseases;
• tuberculosis;
• tumor cachexia;
• rickets;
• pregnancy;
• multiplicity of combined injuries.

Local causes most often include:

• intrauterine disorders of bone formation and instability of osteosynthesis;
• in approximately 42%, defects occur after surgical interventions, for example, as a result of unstable fixation or resection of fragments during surgical treatment;
• in 32% of cases, malunion occurs due to an error in conservative treatment: when plaster immobilization was not carried out thoroughly, overextension occurred in skeletal traction, interposition of soft tissues occurred, for example, if plaster casts were frequently changed or bone fragments were displaced under them;
• in approximately 18%, the cause of pseudarthrosis is local disturbances in the blood supply in the area of ​​bone fragments and suppuration as a result of inadequate surgical treatment of an open fracture, violations of asepsis , traumatic surgical technique, closing the wound with a skin flap and its excessive tension, ineffective drainage of the wound or non-use of antibiotics ;
• an insignificant percentage - 3.3% is due to the likelihood of postoperative treatment errors in the form of short-term insufficient immobilization for osteosynthesis, repeated, unjustified or untimely attempts to reduce fragments, early removal of the transosseous fixation device, too early loading, etc.

the patients’ obesity, lack of periosteum, insufficient blood supply, diabetes , pregnancy , radiation sickness , general exhaustion, severe anemia , hypoproteinemia and vitamin deficiency .

Pseudoarthrosis or false joint

The percentage of victims of this pathology is quite high - 10% of the total number of limb fractures. Often, the formation of pseudarthrosis occurs in the lower leg, but it happens that it appears on the hips or shoulders.

Pseudarthrosis formation

As a rule, pseudarthrosis is the result of faulty bone healing after a fracture. But such a pathology can also be congenital. If the fetus did not receive enough nutrition to form bone, the result could be the formation of a pseudarthrosis.

Diagnostics

But how to diagnose a false joint? It is enough to take a picture with an X-ray machine - it will show whether there is a hole between the bone fragments and whether there is connective tissue in it. An x-ray is usually taken if the bone has not recovered after two periods of time for healing, and tissue fusion has not occurred. Pseudoarthrosis can be easily distinguished from a simple fracture that has not healed by the presence of a plate of bone blocking the medullary canal. As a result, cartilage tissue is formed, which, in turn, ensures the mobility of the false joint. This joint does not function because the ligaments and muscles do not support it.

Classification of pseudarthrosis

There are several classifications of pseudarthrosis, but the most common is based on its formation:

1. the place where the bones grow together hurts and its mobility is abnormal;
2. a feature of fibrous pseudarthrosis is the proliferation of fibrous tissue;
3. non-ctoric is characterized by circulatory disorders;
4. true. It is very similar to the real one (hence its name), most often affects long bones and is formed due to the appearance of a synovial capsule;
5. hypertrophic (joint mobility is low, bone tissue grows at the ends of the fragments).

Causes

The main cause of pseudarthrosis is a violation of the process of bone fusion after injury. As a rule, bones do not heal properly due to incorrect treatment. The following factors add to the problems and have a strong influence on the formation of a pseudarthrosis:

1. infected fracture;
2. blockage of the bone marrow canal with fragments;
3. the cast was not worn enough;
4. violations of immobilization;
5. lack of a clear logic of treatment or a combination of these methods;
6. destruction and disruption of bone during surgery;
7. penetration of soft tissue or foreign body between fragments;
8. circulatory disorders.

It also happens that damaged bones do not heal properly due to the fact that the body has a certain physiological feature.

Pseudoarthrosis is a disorder that also has some risk factors for its development. For example, metabolic disorders can significantly impair the process of bone fusion, which will lead to the formation of a false joint. In addition, the presence of chronic bone diseases such as osteoporosis or rickets, an unbalanced diet, problems with the endocrine system, chronic infections and cancer can contribute to the development of pseudarthrosis.

As a rule, the most common site of occurrence of a pseudarthrosis is the femoral neck. There are many factors involved, such as old age and osteoporosis, that make this disease common. In addition, this feature can occur in the tibia, radius or shoulder.

How to determine the disease

Any pathology is characterized and described by a number of signs. They are not detected immediately, but after the plaster is removed. These include:

• shortening or deformation of the injured limb;
• physical activity causes pain, while pain is not felt when touched;
• bone mobility is observed in usually immobile places;
• muscles are weakened;
• muscle atrophy due to lack of movement.

Methods for diagnosing pseudarthrosis

After palpation, examination and conversation with the patient, the doctor, as a rule, prescribes an X-ray examination. The picture is taken in two projections; it usually shows the main signs showing pseudarthrosis. These include the absence of callus, the ends of the bones are smooth and sometimes rounded, there is a distance between the bones that is noticeable, and the presence of a depression. Sometimes X-rays are not enough, in which case a computed tomography scan or examination using isotopes is performed.

Treatment of false joints

When treating pseudarthrosis, an individual approach and a method suitable for a particular case are important. The main goal is to restore the bone and correct its deformity. As a rule, surgery comes to the rescue. There are several methods for treating pseudarthrosis, which also depend on the pathology. Atrophic pseudarthrosis is treated with bone grafting - cartilage tissue is removed, due to which doctors achieve maximum convergence of the bone fragments. However, it is only carried out if there is no infection. Hypertrophic pseudarthrosis is treated with stable osteosynthesis. Surgery is not necessary here. There is also a treatment method called compression-distraction osteosynthesis.

An important step is immobilization. The limb is immobilized for more than six months. Of course, this is not enough to restore bone health, so other treatment methods are also used together.

To avoid the occurrence of this disease, you need to follow all the doctor’s recommendations, because it is better to prevent the disease. However, if there is a predisposition and pseudarthrosis does appear, it is important to start treating the joints

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Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

Symptoms

Patients with pseudarthrosis usually experience local symptoms, manifested as:

• pain at the fracture site;
• deformation of the limb and its shortening;
• impairment of supporting ability and other functions;
• decreased muscle strength or complete atrophy ;
• limited mobility in pseudo-joints or vice versa - pathological free painless mobility with neoarthrosis, which cannot be controlled or subordinated to one’s will;
• paresthesia and cyanosis of the skin as a result of impaired circulation and nerve innervation of the limb.

Clear signs can be detected already 2-3 days after the fracture, and this parameter is very important for differentiating the diagnosis from a slowly healing or non-union fracture.

Treatment

Treatment • Conservative (stimulation of repair, osteogenesis) is ineffective • Surgical - preference is given to low-traumatic treatment methods - compression - distraction osteosynthesis • If ineffective - resection of the ends of fragments with subsequent lengthening (bilocal compression - distraction osteosynthesis); bone grafting with a graft on a feeding pedicle using microsurgical techniques • When treating congenital pseudarthrosis, the treatment is complex - medication and physiotherapeutic treatment aimed at improving neural trophism in combination with low-traumatic types of immobilization or bone grafting.

ICD-10 • M84.1 Fracture nonunion [pseudoarthrosis] • M96.0 Pseudoarthrosis after union or arthrodesis

Tests and diagnostics

In addition to a general examination, identifying pain on palpation, listening to the patient’s complaints and studying the medical history, additional serological tests and radiography may be prescribed - always in 2 mutually perpendicular projections.

To assess the intensity of bone formation processes in the area of ​​the pseudarthrosis, it is necessary to conduct a radionuclide study.

The main radiological signs of various types of false joints:

• clear signs of pseudarthrosis - identification of a joint space or line of nonunion (fracture) as a result of delayed consolidation, openness of both bone canals, as well as the absence or weak expression of callus;
• osteosclerosis of the edges of fragments;
• the presence of endplates in the bone marrow cavity;
• during the hypertrophic process, bone growths are detected in places of nonunion or bone fragments become rounded, with smoothed ends and a conical shape;
• the limb has a clear axis curvature;
• fragments may be displaced;
• osteoporosis.

To complete the picture, you may need radiography in an oblique projection, as well as CT and MRI.

Diagnostics

It is possible to detect a false joint of the femoral neck using x-ray examination. There are two options for the development of pseudarthrosis:

• with the hypertrophic type, bone tissue grows strongly around the fragments provided there is normal blood supply. The distance between fragments on x-ray is increased;
• atrophic type false joint develops against the background of metabolic insufficiency. The boundaries of the fragments in the image are clear, surrounded by connective tissue, but it is fragile, so the fracture site remains mobile.

Diet for pseudarthrosis

Diet for osteoporosis

• Efficacy: therapeutic effect, high efficiency
• Terms: 1-3 months
• Cost of food: 2180 - 2260 rubles per week

Complications of bone healing usually occur with endocrine and metabolic disorders, vitamin deficiency and decreased reactivity of the body, so it is very important that nutrition during the rehabilitation period is as healthy and balanced as possible, and can fully provide the body with vitamins, minerals, proteins, fats and carbohydrates. To improve the condition of bones and ligaments, it is advisable to build a diet on such products as:

• eggs, meat, fish;
• cottage cheese, cheese and other dairy products and drinks;
• vegetable oils and seeds, as well as nuts;
• a varied set of vegetables and fruits for every day - at least 300 g;

Avoid too fatty meats, dairy or other products, fried, smoked, empty carbohydrates (synthetic sweets, soda, baked goods, etc.).