Complications in medical procedures: Pseudoartrosis and delayed bone consolidation

Why do some fractures behave well and others poorly?

Our body and each structure are nourished by blood and oxygen. When there's a fracture, not only the bone is affected but all the surrounding tissues. To heal, it requires blood and oxygen, which are interrupted when broken. This is a complex process with many factors to consider, but the ultimate goal is to optimize the conditions of your injury and body for recovery.

What happens during bone consolidation?

There are two types: primary and secondary

We understand primary bone consolidation as the healing of the fracture without callus formation and with the support of materials like plates, screws, or nails to fix and stabilize the fracture position.

On the other hand, in secondary consolidation, all fractures subjected to an immobilization process with materials (such as casts) that don't require surgical stabilization tend to heal through callus formation.

It develops in three phases: Inflammatory, reparative, and remodeling

The first occurs within the first 24 to 48 hours, initiating an inflammatory process where cell activation and migration to the injury site occurs, forming a clot between the tissues and affected bone.

In the reparative phase or soft callus, the callus begins to form, creating bridges from both ends of the broken bone, resulting in the restoration of medullary circulation. This occurs over a period of two weeks and is influenced by mechanical and humoral causes. Following this is the formation of the hard callus, where calcification and progressive ossification can already be seen on X-rays.

In the last phase, the remodeling phase occurs over a period of 3 to 5 months. It consists of the formation of immature bone like cartilage that gradually remodels thanks to osteoclasts, the cells responsible for repairing bones and returning them to their original state.

Consolidation disorders

Consolidation delay:
In which there is an evolutionary alteration of the fracture that is well reduced and immobilized, however, after a time it stops consolidating and no complete bone union is perceived, and the fracture continues to be visible on X-rays.

Pseudoartrosis:
Which is the absolute absence of fracture consolidation, appearing as a false joint in the part of the epiphysis, metaphysis or diaphysis, the latter being the most frequent. Pseudoartrosis also presents sclerosis of the fracture edges and periosteal pseudocapsule, and particularly strange mobility, but without pain in the fracture area.

Causes

There are different factors, among them may be:

• High-impact trauma, multi-segmented fractures, open fractures that have become infected.
• Age
• Bad habits like heavy smoking.
• Systemic diseases like diabetes, lupus, hypothyroidism, and disqualifying osteopathy.
• Vicious consolidation, which occurs due to poor fracture reduction technique.

Treatment for consolidation delay

It will be essential to correct the cause that provokes or maintains it, for example, correcting poor immobilization, treating infection, stimulating the limb, and removing foreign bodies.

Treatment for Pseudoartrosis

The approach will depend on the types of pseudoartrosis. For example, hypertrophic pseudoartrosis where stability must be ensured, an infected pseudoartrosis will need to be treated with antibiotics, and atrophic pseudoartrosis will require removal of fibrous tissue from the fracture height to healthy bone. Some approaches may include:

Grafts

Grafts are the most suitable option as they don't present immunological reactions or infections. These can be iliac crest autografts: the area with the greatest osteoinductive capacity. Vascularized grafts: provide mechanical and vascular support used for complex cases.

Osteosynthesis

One of the advantages of fixation in cases of pseudoartrosis is the vascularization of the bone and tissues, allowing them to regenerate more quickly.

Intramedullary nails: They allow load stability and micromobility ideal for pseudoartrosis of long bones.

There are multiple individualized approaches that take into account all the present factors of consolidation disorders and pseudoartrosis to achieve the goal and reintegrate the patient to their quality and dignified life again. Talking about complications in procedures is a topic that is sometimes not discussed much. A complication is an unwanted event that can occur despite adequate treatment, ranging from infections, side effects with medications, and as we saw today, delayed consolidation and pseudoartrosis. Any procedure, no matter how minimal, can bring a complication. Although the percentage of the event may be very low, it's never zero. What we do as specialist physicians in traumatology and orthopedics to minimize the percentage of any complication is to optimize you as a patient and take specific measures for what may increase the risk and treat it to reduce it as much as possible.

It is extremely important as your specialist physician to always be fair with your medical condition and not provide expectations that don't correspond. Ask, talk, and know everything about your condition it's your right as a patient.

If you have any questions, send me a message or schedule your appointment to begin. I'm close to you in Tijuana.