Causes and Morphology of Long Bone Pseudoarthrosis in Own Material

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1 ORIGINAL PAPERS Adv Clin Exp Med 2006, 15, 5, ISSN X Copyright by Silesian Piasts University of Medicine in Wrocław PAWEŁ REICHERT 1, ROMAN RUTOWSKI 1, 2, KRZYSZTOF ZIMMER 1, JERZY GOSK 1, TOMASZ GRECZNER 1, MACIEJ URBAN 1 Causes and Morphology of Long Bone Pseudoarthrosis in Own Material Przyczyny powstawania i morfologia stawów rzekomych kości długich w materiale własnym 1 Chair and Clinic of Traumatology and Hand Surgery in Silesian Piasts University of Medicine in Wrocław, Poland 2 Chair and Department of Medicine of Sport in Wrocław University of Physical Education, Poland Abstract Background. Disturbances in fractured bone union connected with the increased incidence of trauma have become an ever more serious problem in the contemporary traumatology of motor organs. The etiological diversity of such trauma makes the problem of treating complications complex. Knowledge of the causes leading to the formation of pseudoarthrosis allows avoiding this complication in certain cases and knowledge of morphology is essential to planning a correct treatment process. Objectives. A retrospective analysis of the causes leading to pseudoarthrosis after long bone fractures and defin ing the morphology of long bone pseudoarthrosis were the purposes of the study. Material and Methods. In , 80 patients were treated for pseudoarthrosis of long bone shafts in this clin ic. In the study group, men constituted the majority (66%). Pseudoarthrosis of the humerus was treated most often (29%), followed by the femur (20%), radius (20%), ulna (19%), and the tibia (9%). The time from fracture to decor tication was from 6 to 48 months. Examination of the patients consisted of subjective examination and additional examinations (radiological, arteriographic, and scintiscanning). Intrasurgical examination was documented with photographs. Pseudoarthrosis was classified according to the Weber and Cech division. Results. Dysplastic pseudoarthrosis was observed most often (38 patients, 44%), followed by oligotrophic (27 patients, 31%), aplastic (17 patients, 20%), and hypertrophic (4 patients, 5%). Conclusions. Avital forms (dysplastic, aplastic) of pseudoarthrosis after fracture of long bones appear more often than vital forms (hypertrophic, oligotrophic). The latter are usually complications after nonsurgical treatment of a long bone, while the former appear more often in fractures requiring surgical treatment. Complications in the form of pseudoarthrosis appear most often after surgery of osteosynthesis with use of a metal plate adhering direct ly to the bone and, most seldom, after intramedullar osteosynthesis with arthrorisis. Avital pseudoarthroses, par ticularly aplastic, appear most often in fractures complicated by infection, impairment of blood supply, and injury to nerves (Adv Clin Exp Med 2006, 15, 5, ). Key words: pseudoarthrosis, nonunion, failure of osteosynthesis, ostitis. Streszczenie Wprowadzenie. Zaburzenia zrostu złamań kości w związku ze wzrostem urazowości stają się coraz poważniej szym problemem współczesnej traumatologii narządu ruchu. Różnorodność etiologiczna sprawia, że problem le czenia powikłań jest złożony. Istotną kwestią są nie tylko trudności medyczne w wyleczeniu, ale również czas, w jakim to nastąpi, a co za tym idzie koszty leczenia. Wiedza o przyczynach prowadzących do wytworzenia sta wów rzekomych pozwala w określonych przypadkach uniknąć tego powikłania, a znajomość morfologii jest nie zbędna do zaplanowania prawidłowego procesu leczenia. Cel pracy. Retrospektywna analiza przyczyn prowadzących do wytworzenia stawów rzekomych po złamaniach trzonów kości długich oraz określenie morfologii stawów rzekomych kości długich. Materiał i metody. Do badań włączono 80 chorych z 86 stawami rzekomymi trzonów kości długich, leczonych w Klinice Chirurgii Urazowej i Chirurgii Ręki Akademii Medycznej we Wrocławiu w latach Staty stycznie przeważali mężczyźni (66%) głównie w 2., 3. i 4. dekadzie życia. Najwięcej leczono chorych ze stawami rzekomymi kości ramiennej, następnie kości udowej, promieniowej i łokciowej. Czas od złamania do operacji sta

2 834 P. REICHERT et al. wu rzekomego wynosił 6 48 miesięcy. Badanie chorych składało się z badania podmiotowego, przedmiotowego i dodatkowych badań: radiologicznego, arteriograficznego i scyntygraficznego. Badanie śródoperacyjne dokumen towano zdjęciami fotograficznymi. Do klasyfikacji stawów rzekomych użyto klasyfikacji Webera i Cecha. Wyniki. Najwięcej stwierdzono stawów rzekomych dysplastycznych (44%), następnie oligotroficznych (31%), aplastycznych (20%) i hipertroficznych (5%). Przyczyną powstania stawów rzekomych w 38 przypadkach był brak warunków mechanicznych do uzyskania zrostu, u 14 chorych zaburzenia ukrwienia i unerwienia, w 8 przypadkach pourazowe zapalenie kości, u 16 chorych brakowało jednoznacznej przyczyny. Wnioski. Awitalne postacie (dysplastyczne, aplastyczne) stawów rzekomych po złamaniu kości długich występu ją częściej niż postacie witalne (hipertroficzne, oligotroficzne). Stawy rzekome hipertroficzne i oligotroficzne są zwykle powikłaniem po nieoperacyjnym leczeniu złamań kości długich, a stawy rzekome awitalne dysplastycz ne i aplastyczne występują częściej w złamaniach wymagających leczenia operacyjnego. Powikłanie w postaci stawu rzekomego występuje najczęściej po operacji osteosyntezy z użyciem płyty metalowej przylegającej bezpo średnio do kości, a najrzadziej po osteosyntezie śródszpikowej z zaryglowaniem. Stawy rzekome awitalne zwłasz cza aplastyczne występują najczęściej w złamaniach powikłanych zakażeniem, upośledzeniem ukrwienia oraz uszkodzeniem nerwów (Adv Clin Exp Med 2006, 15, 5, ). Słowa kluczowe: staw rzekomy, brak zrostu, powikłania osteosyntezy, zapalenie kości. Disturbances in the union of fractured bones connected with the increased incidence of trauma have become an ever more serious problem in the contemporary traumatology of the motor organs. The etiological diversity of the traumas makes the problem of treating complications complex. Not only the medical difficulties in healing, but also the time in which it takes place and, of course, the costs of treatment are essential matters. Knowledge of the causes leading to the formation of pseudoarthrosis allows one in certain cases to avoid this complication, and knowledge of morphology is essential to planning a correct treatment process. Permanent discontinuity of the bone filled with fibrous tissue, sometimes with cartilaginous meta plasia at the bone ends, and pathological mobility causing insufficient function of the extremity is called pseudoarthrosis. There are no precise data about the incidence of pseudoarthrosis in Poland, but the fact that annually about % of the population (i.e. about 1.2 million people a year) suffer injuries to a motor organ, including such that lead to fractures, of which 5 15% include distur bances in fractured bone union in the form of delayed union, pseudoarthrosis, or bone inflamma tion, demonstrates the scope of the problem [1 8]. The first report about the percentage of fail ures in treating long bone fractures is the statisti cal list of Bruns mentioned by Bohler [9], where the percentage for pseudoarthrosis was 0.5%. Scudler and Hey Groves [9] presented further studies where the amount for pseudoarthrosis was, respectively, 2 3% and 4 5%. Bado [9] and Watson Jones [10] mention pseudoarthrosis as the most serious failure, but they do not present fig ures. The first large study presented 135 cases of pseudoarthrosis of long bones treated in the Clinic of Orthopedics in Iowa in [9]. The process of bone union is a biological process, and ensuring the proper conditions for its formation is a sufficient procedure leading to frac ture healing. The motor organ is physiologically equipped with mechanisms which carry out repair, and disturbances in union are a sign of their defi ciency or dysfunction. Ensuring a proper blood supply and the immobilization of bone fragments are among the most important factors influencing the course of bone union. Systemic metabolic disturbances, among which diabetes is the most important, constitute important factors complicating bone union. Another factor negatively influencing bone union is primary or secondary infection of the fracture by bacteria. An open fracture is a factor predisposing to inflamma tion of bone tissue and marrow with pathogens entering via the injured skin both from the external environment and from the patient s own skin. Osteoporosis is another essential factor influencing disturbances in bone union [1]. Anti inflammatory drugs, antibiotics, and antiallergic and antineoplas tic drugs are also among the factors which can unfa vorably influence bone union [1]. Lately there have also appeared reports about the unfavorable influ ence of antiresorption preparations and bifosonians widely used in osteoporosis treatment, which can also disturb bone union. Among the existing divisions of pseudoarthro sis (radiologically into vital and avital, biological ly into synovial and fibrous, and clinically into infected an uninfected), the division according to Weber and Cech is the most often accepted [11]. The radiological features differentiating pseudo arthrosis are presented in Table 2. A retrospective analysis of the causes leading to the formation of pseudoarthrosis after long bone fractures and defining the morphology of long bone pseudoarthrosis were the purpose of the study. Material and Methods From 1995 to 2005, 80 patients were treated for pseudoarthrosis of long bone shafts in this clin

3 Causes and Morphology of Long Bone Pseudoarthrosis 835 ic. In six patients the pseudoarthrosis involved two bones. Most of the patients (87%) had initially been treated outside this clinic. In the tested group, men constituted the majority (66%) and the ages of the operated patients were from 18 to 83 years (average: 41 years). Most of the male patients were in their 20 s, 30 s, and 40 s, and most of the female patients were in their 20 s, 30 s, and 70 s (Fig. 1). Pseudoarthrosis of the humerus was treated most often (29%), followed by the femur (20%), radius (20%), ulna (19%), and tibia (9%) (Fig. 2). The time from fracture to decortication was from 6 to 48 months (Table 1). Examination of the patients consisted of subjective examination and additional examinations, i.e. radiological, arterio graphic, and scintiscanning (Fig. 3). In studying the histories we paid particular attention to the kind of fracture, discontinuation of cutaneous integuments, the initial mode of treatment, and accompanying nerve injuries. Radiological exami nation was based on the evaluation of radiological images of the fracture, then of the pseudoarthrosis which formed. Intrasurgical examination was doc umented by photographs. Pseudoarthrosis was classified according to Weber and Cech division (Table 2) [11]. Results Dysplastic pseudoarthrosis was observed most often (38 patients, 44%), followed by oligotrophic (27 patients, 31%), aplastic (17 patients, 20%), and hypertrophic (4 patients, 5%) (Fig. 4). In the major ity of cases of surgical treatment, an AO plate was used (49%), followed by intramedullar anastomo sis (30%), stabilizer (9%), and bone suture (12%) humeral ramienna ulnar łokciowa 17 8 radial promieniowa metacarpus śródręcza Fig. 2. Disposition of treated bones Ryc. 2. Rozkład leczonych kości femoral udowa tibial piszczelowa men mężczyźni women kobiety a b age (wiek) Fig. 1. Division of patients according to age and sex Ryc. 1. Podział chorych ze względu na wiek i płeć c Fig. 3. Patient J. W., age 28, disease history no. 3110/05, dysplastic pseudoarthrosis. a radiological picture, b intrasurgical picture, c bone scintiscan ning, d arteriography Ryc. 3. Chory J. W., l. 28, hist. chor. nr 3110/05, staw dysplastyczny. a zdjęcie radiologiczne, b zdjęcie śródoperacyjne, c scyntygrafia kości, d arteriografia d Table 1. Time from fracture to decortication Tabela 1. Czas od złamania do zabiegu dekortykacji Time from fracture to surgery months > 24 (Czas od złamania do operacji miesiące) Number of patients (Liczba chorych)

4 836 P. REICHERT et al. The etiopathogenesis of pseudoarthrosis was ana lyzed in four groups (Fig. 5) and the particular causes are presented in Table 3. We observed a relation between the kind of fracture and the pseudoarthrosis which appeared. The significant statistical difference at the level of p = shows that hypertrophic and oligotroph ic joints appeared most often in cases of closed fractures, while dysplastic and aplastic joints were usually the consequences of open fractures (Figs 6 and 7, Table 4). There was a connection between the kind of treatment and the pseudoarthrosis which formed. The significant statistical differ ence at the level of p = shows that hyper trophic and oligotrophic joints appeared more often after conservative treatment, while dysplas tic and aplastic joints were mainly complications of surgical treatment (Figs 8 and 9, Table 5). Discussion The analysis of the causes of pseudoarthrosis demonstrates the complexity of the problem and its etiological diversity. In our material, the cause was lack of mechanical conditions to achieve union in 50%, inadequate blood supply was responsible for failure in 18%, bone inflammation in 11%, and unknown cause in 21% of cases. Similar causes of Table 2. Radiological features differentiating pseudoarthrosis Tabela 2. Cechy radiologiczne różnicujące stawy rzekome Kind of Biologically active vital Biologically inactive avital pseudoarthrosis (Biologicznie czynne) (Biologicznie nieczynne) (Rodzaj stawu rzekomego) hypertrophic oligotrophic dysplastic aplastic Fracture line deformed, distinct deformed, distinct lack a little blurred, (Linia złamania) often unchanged Fracture surface irregular, plicated irregular, plicated lack blurred (Powierzchnia złamania) Fracture fissure extended extended very extended a little extended (Szczelina złamania) Fragments contours thickened with rounded thinned sometimes blurred, (Kontury odłamów) periosteal growth often unchanged Marrow cavity closed closed closed open (Jama szpikowa) Fragments calcification excessive correct or excessive largely decreased correct (Uwapnienie odłamów) Inne (Others) pictures: numerous bone cysts, icicle shape of in sclerotic form: elephant s foot cystoid form fragments ends increased saturation horse s hoof of fragments ends bird s beak 20% 5% hypertrophic hipertroficzny oligotrophic oligotroficzny dysplastic dysplastyczny aplastic aplastyczny 31% 21% lack of mechanical conditions brak warunków mechanicznych do uzyskania zrostu disturbances of blood and nerve supply zaburzenia ukrwienia i unerwienia reason difficult to define przyczyna trudna do ustalenia inflammation pourazowe zapalenie kości 11% 44% Fig. 4. Kinds of pseudoarthrosis Ryc. 4. Rodzaje stawów rzekomych 50% 18% Fig. 5. Causes of pseudoarthrosis Ryc. 5. Przyczyny powstawania stawów rzekomych

5 Causes and Morphology of Long Bone Pseudoarthrosis 837 Table 3. Particular causes of pseudoarthrosis Tabela 3. Poszczególne przyczyny stawów rzekomych Cause of formation Number of patients (Przyczyna powstania) (Liczba pacjentów) I Lack of mechanical conditions to achieve union (Brak warunków mechanicznych do uzyskania zrostu) 1. External immobilization not giving full stabilization of fragments a) non anatomical position of fragments 1 b) too short immobilization with plaster dressing 1 c) incorrect immobilization lack of immobilization of two neighboring joints 1 2. Factors leading to formation of pseudoarthrosis a) lack or too short a period of immobilization after surgical treatment despite unstable 9 osteosynthesis (Fig. 10) b) use of wrong plate (Figs. 11, 12) 4 c) introducing bolts into the fissure of fracture (Figs. 13, 14) 2 d) stabilization without contact of fragments (Fig. 15) 5 e) too early removal of stabilization 2 f) osteolysis around the bolts (Fig. 16) 4 3. Muscular interposition (Fig. 17) 1 4. Break of connectors (Figs. 18, 19) 8 Total (Razem) 38 II Disturbances of blood and nerve supply (Zaburzenia ukrwienia i unerwienia) a) exeresis of spinal nerve roots 4 b) discontinuity of radial nerve fibers 4 c) impairment of blood supply 6 Total (Razem) 14 III Posttraumatic inflammation of bone 8 (Pourazowe zapalenie kości) IV Cause difficult to define 16 (Przyczyna trudna do ustalenia) hypertrophic hipertroficzny oligotrophic oligotroficzny dysplastic dysplastyczny aplastic aplastyczny hypertrophic hipertroficzny oligotrophic oligotroficzny dysplastic dysplastyczny aplastic aplastyczny 43% 0% 10% 12% 6% 47% Fig. 6. Morphology of pseudoarthrosis in open fractures Ryc. 6. Morfologia stawu rzekomego w złamaniach otwartych 43% 39% Fig. 7. Morphology of pseudoarthrosis in closed fractures Ryc. 7. Morfologia stawu rzekomego w złamaniach zamkniętych failure can be found in other authors. According to Frost and Niedźwiedzki [5, 12 14, 17], technical faultiness is the cause of 70 80% of union distur bances. In the first group observed in the analyzed material, non anatomical positioning of bone frag ments, too short or incorrect immobilization, and incorrect osteosynthesis were among the obvious technical defects which did not ensure proper mechanical conditions for fracture healing. In the second group, nerve and vessel injuries were con nected mainly with the extent of injury. These cases involved mainly the upper extremity. In the

6 838 P. REICHERT et al. Table 4. Morphology of pseudoarthrosis depending on the picture of the fracture Tabela 4. Morfologia stawu rzekomego w zależności od obrazu złamania Kind of fracture Morphology of pseudoarthrosis Total (Rodzaj złamania) (Morfologia stawu rzekomego) (Razem) vital avital Open % % 21 (Otwarte) Closed % % 65 (Zamknięte) Total (Razem) p = 0.004; p level of statistical significance. p = 0,004; p poziom istotności statystycznej. hypertrophic hipertroficzny oligotrophic oligotroficzny dysplastic dysplastyczny aplastic aplastyczny hypertrophic hipertroficzny oligotrophic oligotroficzny dysplastic dysplastyczny aplastic aplastyczny 30% 0% 10% 22% 4% 28% 60% Fig. 8. Morphology of pseudoarthrosis in patients trea ted conservatively Ryc. 8. Morfologia stawu rzekomego u chorych leczo nych zachowawczo 46% Fig. 9. Morphology of pseudoarthrosis in patients treated surgically Ryc. 9. Morfologia stawu rzekomego u chorych leczo nych operacyjnie Table 5. Morphology of pseudoarthrosis depending on the way of treatment Tabela 5. Morfologia stawu rzekomego w zależności od sposobu leczenia Kind of treatment Morphology of pseudoarthrosis Total (Rodzaj leczenia) (Morfologia stawu rzekomego) (Razem) vital avital Conservative (Zachowawcze) % % 10 Surgical (Operacyjne) % % 76 Total (Razem) p = 0.03; p level of statistical significance. p = 0,03; p poziom istotności statystycznej. third group the main factor causing pseudoarthrosis was posttraumatic bone inflammation [1 4, 15, 16]. All the patients had originally had open frac tures treated surgically, connected in five cases with general therapy with antibiotics and in three cases use of Septopal (gentamycin preparation). In four cases, sequesters were observed during surgery. Inflammation is mentioned by all authors

7 Causes and Morphology of Long Bone Pseudoarthrosis 839 Fig. 12. Patient M.C., age 26, disease histo ry no. 3454/04 Ryc. 12. Chora M.C., l. 26, hist. chor. nr 3454/04 Fig. 10. Patient E.B., age 41, disease history no. 6258/03 Ryc. 10. Chora E.B., l. 41, hist. chor. nr 6258/03 Fig. 11. Patient G.K., age 33, disease histo ry no. 782/05 Ryc. 11. Chory G.K., l. 33, hist. chor. nr 782/05 Fig 13. Patient M.K., age 20, disease history no. 7044/03. Bolt in fissure of pseudo arthrosis Ryc. 13. Chory M.K., l. 20, hist. chor. nr 7044/03. Śruba w szparze stawu rzekomego as a risk factor of pseudoarthrosis. In the fourth group no observable cause was found. Brashear [18] emphasizes that not all factors causing pseudoarthrosis depend on the doctor. The location of the fracture, the degree of displacement of bone fragments, and injuries to vessels and nerves do not depend on the doctor. Additionally, there are places particularly unfavorable for union, such as the bor der of the medial and distal third part of the tibia s shaft, which was confirmed in the results of the present studies. It seems that the large number of pseudoarthroses after anastomosis with an AO plate is connected with mechanical defects of osteosynthesis, e.g. destabilization of fractures through slackening of the metal elements and breakage of connectors, and also with the technol ogy of surgery, damaging the blood supply. Osteosynthesis with an AO plate and bolts is often performed with large damage to the periosteum Fig. 14. Patient M.K., age 20, disease history no. 7044/03. Intrasurgical picture of fissure of pseudoarth rosis after removal of connector Ryc. 14. Chory M.K., l. 20, hist. chor. nr 7044/03. Obraz śródoperacyjny szpary stawu rzekomego po usunięciu łącznika

8 840 P. REICHERT et al. Fig. 15. Patient M.S., age 48, disease histo ry no. 1623/04 Ryc. 15. Chory M.S., l. 48, hist. chor. nr 1623/04 Fig. 17. Patient J.J., age 52, disease history no. 561/05. Metal seen after withdrawal of displaced muscle Ryc. 17. Chory J.J., l. 52, hist. chor. nr: 561/05 wi doczny metal po odsunięciu interponowanego mięśnia Fig. 16. Patient A.M., age 80, disease history no. 1552/99. Osteolysis around bolts Ryc. 16. Chora A.M., l. 80, hist. chor. nr 1552/99. Osteoliza wokół śrub (detachment) and also with damage to soft tissue, which can influence the deterioration of the blood supply of the bone in the fracture to a large extent. This was confirmed in the present observations, where avital pseudoarthrosis was found after treat ment with a plate in 67% of patients. Analysis of the relationships between particu lar causes and morphology of pseudoarthrosis also seems very essential. Open fracture and the possi bility of infection are essential risk factors for pseudoarthrosis. It appears that extensive injury to soft tissues, particularly to blood vessels connect ed with a complicated fracture, appearing most often as a result of direct injury with great force with injury to soft tissues and infection by microorganisms, has an influence, which is con firmed by Niedźwiedzki and others [2 4, 6, 13, 14, 18 20]. In the presented material the present authors observed that in the group of patients initially treated conservatively, oligotrophic joints domi nated and there were no atrophic joints, while of those treated surgically, dysplastic and aplastic joints were the most numerous. The above results can be connected with injury to the blood supply related to the complexity of the fracture and the extent of injury to soft tissues and also with addi tional surgical injury. The obtained results agree with the reports of the authors of AO methods who confirm that about 90% of pseudoarthrosis of the vital hypertrophic type are the consequence of conservative treatment and the wider use of methods of surgical treatment causes an increase in the number of pseudoarthros es of the atrophic avascular type [5, 6]. The question is whether the surgery itself causes pseudoarthrosis or whether the initial pic ture of the fracture and the accompanying injuries impose a surgical procedure which influences the treatment result. It seems that reports concerning the increased number of atrophic pseudoarthroses after surgical treatment are connected both with the picture of fracture as well as with the correct ness of performing osteosynthesis and the compli cations after surgical treatment.

9 Causes and Morphology of Long Bone Pseudoarthrosis 841 a b Fig. 18. Patient M.J., age 21, disease history no. 3085/04: break of connectors, a) radiological picture, b) intrasurgi cal picture Ryc. 18. Chory M.J., l. 21, hist. chor. nr 3085/04: złamanie łączników zespalających, a) zdjęcie radiologiczne, b) zdjęcie śródoperacyjne References [1] Górecki A: Growth factors and bone tissue [Czynniki wzrostu i tkanka kostna]. Oficyna Wydawnicza 2004, ASPRA JR. [2] Karpina B, Marciniak W (promoter): An evaluation of treatment results with the Judet Forbes method of dis turbances in the union of long bone fractures [Ocena wyników leczenia sposobem Judet a Forbes a zaburzeń zros tu złamań kości długich]. Doctoral thesis, AM Poznań [3] Ramotowski W, ed.: Complications in bone union [Leczenie powikłań zrostu kostnego]. PZWL [4] Szojlew D: Treatment results of disturbances in union after long bone shaft fractures using modified bone mus cle decortication (Wyniki leczenia zaburzeń zrostu po złamaniach trzonów kości długich zmodyfikowaną dekor tykacją kostno mięśniową). Chir Narz Ruchu Ortop Pol 1972, 37, [5] Tylman D, Dziak A: Traumatology of the motor organ [Traumatologia narządu ruchu]. Wydawnictwo Lekarskie PZWL [6] Tylman D: Bone fracture mending: the biological aspects and the influence of physical factors [Gojenie się złama nia kości aspekty biologiczne i wpływ czynników fizycznych]. Chir Narz Ruchu Ortop Pol 1986, 51, [7] Velde E, van der Werken C: Plate osteosynthesis for pseudoarthrosis of the humeral shaft. Injury, Int J Care Injured 2001, 32, [8] Verbruggen J, Stapert J: Failure of reamed nailing in humeral non union: an analysis of 26 patients. Injury, Int. J Care Injured 2005, 36, [9] Blumenfeld J: Pseudoarthrosis of the Long Bones. J Bone Joint Surg 1947, 29, [10] Watson Jones R: Fractures and Joint Injures. Williams and Wilkins Co. Baltimore [11] Weber BG, Cech O: Pseudoarthrosis, Pathophysiology, Biomechanics, Therapy, Results. New York San Francisco London. Grune and Stratton. Jovanovich Publishers [12] Frost HM: The biology of fracture healing. An overview for clinicians. Clin Orthop 1989, 248, [13] Niedźwiecki T, Dąbrowski Z, Bonczar M: Treatment of pseudoarthrosis of long bones by stable unification of fragments and grafting of bone marrow stroma cells cultured in vitro [Leczenie stawów rzekomych kości długich stabilnym zespoleniem odłamów i przeszczepianiem komórek podścieliska szpikowego z hodowli in vitro]. Chir Narz Ruchu Ortop Pol 2000, 65, [14] Niedźwiecki T: The influence of bone marrow on fracture healing, delays in union, and pseudoarthroses in long bones [Wpływ szpiku kostnego na gojenie złamań, zrostów opóźnionych i stawów rzekomych kości długich]. Chir Narz Ruchu Ortop Pol 1993, 58, supl 3, [15] Deja W, Lipiński J, Lasek J, Romanowicz G, Marks W, Witkowski Z: Inflammatory complications during the treatment of injuries of the motor organ: selected diagnostic and treatment issues [Powikłania zapalne w przebiegu leczenia obrażeń narządu ruchu wybrane zagadnienia diagnostyczne i lecznicze]. Nowiny Lekarskie 2001, 4, [16] Martinez A, Herrera A, Cuenca J: Marchetti nailing with decortication and bone graft in non unions of the two upper thirds of the humerus. Chirurgie de la Main 2002, 21, [17] Miligram JW: Nonunion and pseudoarthrosis of fracture healing. A histopathologic study of 95 human speci mens. Clin Orthop 1991, 268, [18] Brashear R: Diagnosis and prevention of non union. J Bone Joint Surg 1964, 47 A, [19] Rodriguez Merchan EC, Forriol F: Nonunion: general principles and experimental data. Clin Orthop Relat Res 2004, 419, [20] Chapman MW, Woo S: Principles of fracture healing. Operative Orthopaedics, J. B. Lippincott Company, Philadelphia 1998, 1,

10 842 P. REICHERT et al. Address for correspondence: Paweł Reichert Klinika Chirurgii Urazowej i Chirurgii Ręki AM ul. Traugutta 57/ Wrocław Poland fax: tel.: , tel.: e mail: chiruraz@churaz.am.wroc.pl Conflict of interest: None declared Received: Revised: Accepted: Praca wpłynęła do Redakcji: r. Po recenzji: r. Zaakceptowano do druku: r.