Epdemiology and Treatment of Pseudarthrosis of Long Bones in the Servce D Orthopedics-Traumatology of the University Hospital of Donka ()
1. Introduction
A unanimous definition of pseudarthrosis does not exist [1] [2] . However, in the literature the authors agree on the length of the consolidation; but we retain the definition of Antanova which considers pseudarthrosis as a fracture that does not consolidate without additional surgery, surgical or not, between six (6) and nine (9) months [2] . It is difficult to treat especially if it is associated with bone loss or infection [3] [4] ; and varies according to whether it is hypertrophic or atrophic [5] . Poor surgical indications, infections after osteosynthesis or after an open fracture and the management of patients often by traditional medicine are the main causes. In 2004, Dossim et al. [6] at the Tokin University Hospital (Lomé) treated 24 cases of pseudarthrosis.
The objective of this study was to identify the most common pathological type and to evaluate the results of treatment.
2. Patients and Methods
It was a mixed study of 18 months, retrospective of 12 months (from 1 January to 31 December 2019), and prospective of 6 months (from 1 January to 30 June 2020), covering 30 patients received for pseudarthrosis of the diaphysis of long bones in the Orthopaedic Service-Traumatology of the Donka University Hospital, Conakry Republic of Guinea.
Inclusion criteria: Included all patients aged 16 years and over, treated and followed for pseudarthrosis of the diaphysis of long bones during the study period.
Exclusion criteria: Excluded those under 16 years of age, who did not accept treatment and those lost to sight. Our study variables were epidemiological, diagnostic, therapeutic and evolutionary.
Anatomical lesions were classified according to the Weber-Cech classification (Table 1) [8] . All patients received surgical treatment initially (nails, screw plates and external fixator); for vital pseudarthrosis: osteo-muscular decortication/osteo-muscular decortication + bone grafts; for the avital pseudarthroses, they benefited from bone dissetication + bone grafts systematically and for the septic cases, we carried out the Masquelet technique and realized the second time after obtaining a negative reactive protein C. Patients were assessed according to ASAMI criteria (Table 2 and Table 3) after a mean follow-up of 18 months.
Data sources were patient medical records, hospitalization and consultation records, operating report records.
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Table 1. Distribution of pseudarthrosis by Weber-Cech Classification [7] .
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Table 2. Anatomical distribution according to ASAMI criteria.
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Table 3. Functional distribution according to ASAMI criteria.
Our data was entered with the Word software and our results were analyzed by the Epi info software version 7.2.
3. Results
We recorded 30 patients including 24 men (80%) and 06 women (20%), with a sex ratio of 4. The frequency of pseudarthrosis was 8% compared to other pathologies operated during the study period. The average age was 39.9 years with extremes of 20 and 70 years. The age group most affected was between 20 and 34 years old, or 43.4%. The etiological circumstances were dominated by road accidents with 26 cases (87%. Bone lesions predominated in the tibia with 13 cases (43.5%), followed by the femur with 11 cases (36.6%). The average third was the most frequent location with 15 cases (50%). Oligotrophic pseudarthrosis was the most encountered with 11 cases (37%), according to the Weber-Cech classification.
The initial treatment was dominated by treatment in traditional medicine with 21 cases (70%). Stabilization after the pseudarthrosis cure was the plate screwed in 16 cases (53.4%), followed by the centromedullary confinement in 7 cases (23.3%). After eighteen (18) months of follow-up, our anatomical results were excellent in 19 cases (76%); those functional were excellent in 15 cases (60%) according to ASAMI criteria.
4. Discussion
In 18 months we hospitalized and treated 30 cases of pseudarthrosis of the diaphysis of the long bones, or 8% among the 377 cases of hospitalization. In Burkina Faso, Tall et al. [8] in 2014 recorded 50 patients over 3 years. This high rate can be explained by the cost of treatment, the lack of a community centre and the lack of specialists in other regions; and the first therapist consulted was most often the tradipraticians. AVP represented the main etiology in our series, 26 cases or 87% against 4 cases of falls or 13%. We find the same result in the whole literature.
In the Central African Republic, Tékpa et al. [9] in 2018 found 83.7% of AVPs. Tall et al. [8] in Burkina Faso found 90% of cases. These results would be explained by the increase of two-wheeled machines, and especially the availability of people who do not have the required training, without a driver’s license, and who do not respect the rules of the road and therefore do not care about the personal injury and property that the accident can cause. However, the average age of our patients was 39.9 years with extremes of 20 and 70 years. The age group most affected was 20 to 34 years old, or 43.4%, this is consistent with data from the literature, where there is a predominance of a younger, more active population in society.
We found a male predominance with 80%; with a sex ratio of 4. This same male predominance was found in the series of Tall et al. [8] , which was 76% in favor of men.
These results could be explained by the fact that men are more at risk of fractures than women because of their societal responsibility to arise to the needs of their families.
The tibia was reached 13 times followed by the femur 11 times.
Tibia and femur were the most affected segments with the respective values of 22 times and 14 times in the series of Tall et al. [8] in Burkina Faso in 2014. This result could be explained by the fact that the tibia is the bone most exposed to the slightest impact during the initial trauma especially in drivers of two (02) wheels. The average 1/3 of the shaft of the long bones was the most found seat with 15 cases or 50% and 10 were located at 1/3 lower or 33%.
These results could be explained by the fact that the 1/3 middle diaphysis is less vascularized which would favor the occurrence of pseudarthroses at this level.
In our study, the traditional treatment was found in 21 cases or 70% and 9 cases of surgical and orthopedic treatment.
On the other hand, our results are contradictory to those of the authors, such as SECONDS and GERARD [10] [11] who respectively find surgical treatment as the largest provider of PSA 83.33% and 51.72%.
This would be explained by the fact in developing countries the majority of patients are treated first by the traditional doctor.
In our series, the vital pseudarthroses were the most frequent with 23 cases or 77% with a predominance of oligotrophic pseudarthrosis with 11 cases, or 37% against 7 cases of avital pseudarthrosis with 23% (Table 1).
Tépka et al. [8] in their series reported 69 cases of vital PSA, a rate of 66.3% with a hypertrophic predominance of 35.5%.
This could be justified by the consequence of the mechanical defect related to the initial treatment.
All of our patients received surgery, and the screw plate was the most used implant, in 16 cases or 53.4%; this was due to the type of lesions, the technical platform, the means of the patients but also the need to cause compression at the level of fracture focus. The advantages of surgery are not only to promote stability at the level of the fractured hearth, and osteogenesis but also to dry the infection locally in septic cases; so avoid the infections and recurrent pseudarthroses that have been our main complications. Ali Akhtar [12] and Al Shahrani [13] performed pure compression for simple pseudarthroses especially hypertrophic without shortening and the external fixative was maintained until healing.
The limitations of our work were the poor quality of some X-ray images, with regard to the retrospective study; some patients were lost in the evaluation of the results.
5. Conclusion
Treatment in traditional medicine was the main cause of pseudarthrosis of the diaphysis of long bones and surgical treatment by dissection osteo-muscle with or without bone grafts or the Masquelet technique has resulted in bone consolidation.