Congenital Pseudoarthrosis Of The Tibia Research Articles

Osteogenic organoid for bone regeneration: Healing of bone defect in congenital pseudoarthrosis of the tibia.

Congenital pseudoarthrosis of the tibia (CPT) is an uncommon disease associated with failure to achieve bone union and recurrent fractures. There is evidence showing that CPT is associated with decreased osteogenesis. Based on the capacity of mesenchymal stromal cells (MSCs) to induce osteogenesis, we develop an osteogenic organoid (OstO) constituted by these cells, and other components of the bone niche, for inducing bone formation in a child diagnosed with CPT. To evaluate the capacity of an OstO to induce bone formation in a patient with CPT. The OstO was fabricated with allogeneic bone marrow MSCs from a healthy donor, collagen microbeads (CM) and PRP clot. The CM and PRP function as extracellular matrix and scaffolds for MSC. The OstO was placed at the site of non-union. Internal and external fixation was placed in the tibia. Radiological evaluation was performed after MSCs transplantation. After 4 months of MSCs transplantation, radiographic imaging showed evidence of osteogenesis at the site of CPT lesion. The tibia showed bone consolidation and complete healing of the non-union CPT lesion after 6 months. Functional improvement was observed after 1 year of MSC transplantation. The OstO is a bone-like niche which promote osteogenesis in patients with failure in bone formation, such as CPT. To our knowledge, these results provide the first evidence showing CPT healing induced by an OstO constituted by allogeneic MSCs. Future studies incorporating a larger number of patients may confirm these results.

Treatment of Refractory Congenital Pseudoarthrosis of Tibia with Contralateral Vascularized Fibular Bone Graft and Anatomic Distal Tibial Locking Plate: A Case Series and Literature Review

Congenital pseudoarthrosis of the tibia (CPT) remains a challenge for physicians. Several treatment options have been proposed, but the standard of care remains inconclusive. In this study, we present three patients for whom the failure of prior treatments was managed with a contralateral vascularized fibular bone graft (VFG) and an anatomic distal tibial locking plate. Between 2017 and 2021, three patients were referred for failed treatment of CPT. All patients had undergone multiple prior surgeries, including tumor excision and fixation with ring external fixators, plates, and screws. We performed radical tumor resection and reconstruction of bone defects with a VFG. The construct was fixed with an anatomic locking plate, and the patients were followed up for a mean of 45.7 months. All three patients were able to obtain graft union at 19.3 weeks. At the final follow-up, all grafts achieved bony hypertrophy without evidence of bone resorption or local tumor recurrence. There was a mean leg length difference of 8.5 cm preoperatively, compared with 6.3 cm postoperatively. The average lower leg angulation was 7.4 degrees and the average ankle range of motion was 58.3 degrees. The mean VAS score was 0 and the mean AOFAS score was 88.3. No significant complications were noted. Implantation of a VFG and an anatomic distal tibia locking plate can be considered an option for treatment-refractory CPT. Patients can expect to achieve bone consolidation, ambulate as tolerated, and have a low complication rate.

Congenital pseudoarthrosis of the tibia and fibula is managed with plate osteosynthesis and the Ilizarov method

Pseudo means false, and arthrosis means joint formation. Congenital pseudoarthrosis (C.P.T.) of the tibia is a rare congenital anomaly. The incidence of it is one in 190,000 live births. Although rare, C.P.T. of the tibia poses one of the most challenging management problems in pediatric orthopaedics. It is characterized by de-ossification, bending, and pathological fracture, followed by the inability to form a normal callus at the fracture site. Fifty-five percent of cases of pseudoarthrosis are associated with neurofibromatosis-1 (NF-1), and 6% of patients with NF-1 develop pseudoarthrosis of the tibia. A 9-year-old male came to the orthopaedic outpatient department with a deformity over his right leg since birth. There were multiple café au lait spots on the front and back of the trunk. The right leg had a bony deformity in the lower third with anterior convexity, with typical features of pseudarthrosis tibia and fibula, along with gross abnormal mobility and 2 cm shortening. The left leg was normal. There is no evidence of any new bone formation at the non-union sites. The patient was managed with refreshing the bone ends to produce bleeding bone ends with good contact and open removal of aberrant fibrous tissue from the region of the tibia´s pseudoarthrosis. Bone fragments were reduced and fixed with a locking plate. Corticotomy was done at the proximal end of the tibia to improve the limb length discrepancy via the distraction osteogenesis method, and an Ilizarov ring fixator was applied. Postoperatively, distraction was done at 1 mm per day.

Management of congenital pseudoarthrosis using Ilizarov Device-Delsuth, oghara experience.

Congenital pseudoarthrosis of the tibia (CPT) is a rare and very difficult pediatric orthopedic condition to manage. It occurs spontaneously or from a trivial trauma. It results from a dysplastic periosteum that is more osteoclastic and less osteoblastic in nature. Successful treatment targets excision of the dysplastic periosteum and replacement with viable one and bone graft ± bone morphogenic proteins to aid union. Stabilization of the union site with intramedullary implants is advised to prevent refracture. To highlight the outcome of treatment of CPT with the Ilizarov procedure, bone graft, and use of bisphosphonate (sodium alendronate). This is a retrospective study of five patients treated for CPT using the Ilizarov procedure, bone graft, and use of bisphosphonate in the Delta State University Teaching Hospital, Oghara in Delta State, Nigeria. Inclusion criteria were patients that had a fracture of the tibia ± fibula spontaneously or from minor trauma. Exclusion criteria were patients that had pathological fractures or fractures from significant trauma. The outcome was graded into good, fair and poor. Five patients were seen in this study. The male/female ratio was 2:3. The age was 6-18 years (mean = 11.5 years). The limb length discrepancy was 6-12 cm (mean = 7.2 cm) pre-operation and zero after completion of distraction. There was the loss of some regeneration in two patients at the end of consolidation. Two patients had hypertrophic CPT, while three patients had atrophic. Union was good in four and fair in one. Complications seen were ankle stiffness bending of the regenerate and loss of length of regenerate. CPT is a rare condition worldwide that is associated with non-union and complicated by post-operation refracture or non-union has been successfully treated with a procedure that entails use of Ilizarov technique, bone graft bisphosphonate and support with intramedullary nails.

Congenital Pseudoarthrosis of the Tibia: A Narrative Review.

Congenital pseudoarthrosis of the tibia, also known as CPT, is a rare bone disease mostly occurring in the pediatric age group of 10. The case generally represents anterolateral bowing of the tibia with refractures. This condition is quite rare and has very few cases per year. CPT is still a challenging concern in orthopedics. Bone reunion often requires repeated surgical measurements. With advancements, we have new treatment plans that include induced membrane techniques and bone marrow stromal cell grafts of various induced and morphogenetic protein, which still requires confirmation. Different treatment strategies based on surgical, mechanical, and biological concepts have been shown with varying success rates. Ilizarov technique and vascularised fibular grafts have vastly increased the effectiveness in treating CPT of the tibia. Constant and recurrent refracture, residual deformities, and difficulty obtaining bone union remain the challenges in managing CPT. Hence, phasing CPT as bowing the tibia in an anterolateral fashion is more appropriate because it's a heterogeneous entity with varying prognoses.

Експериментальне дослідження щільності кісткової тканини у хворих з уродженим псевдоартрозом кісток гомілки до та після операції за даними комп’ютерної томографії

Surgical treatment of congenital pseudarthrosis of the tibia bones is accompanied by a significant percentage of complications and refractions. One of the main reasons for the unsatisfactory results of treatment is the violation of the quality of bone tissue in the area of pseudoarthrosis, which is an obstacle to the normal process of fusion of the shin bones. Рurpose - use computed tomography to examine bone density in patients with congenital pseudoarthrosis of the tibia before and after surgery. Materials and methods. CT scans of the tibia of three patients with congenital pseudoarthrosis of the tibia, aged 5 to 7 years. The density in the Hounsfield units of the cortical layer above and below the nonunion zone was determined. Results. Prior to treatment, a significant decrease (p=0.001) in the density of the cortical layer of the tibia of the injured limb along its entire length was determined. One year after surgery, a statistically significant difference in the density of the cortical layer of the tibia remains. The optical density of the cortical layer of the damaged tibia is statistically significantly less than healthy (p=0.001). One year after surgical treatment by osteosynthesis with an intramedullary rod with axial mobility, the difference in the density of the cortical layer of the tibia of the healthy and operated limbs remains statistically significant (p=0.001) less than the bone density of the healthy limb. On the unoperated limb, a significant (p<0.05) increase in optical density of bones was observed in all studied areas. Conclusions. As a result of surgical treatment of congenital pseudoarthrosis of the tibia, there is a statistically significant increase in the density of the cortical layer. The density of the cortical layer of the bones of the operated shin a year after surgery is close to the density of the bones of a healthy limb. The increase in bone density of the operated limb is due not only to the growth of patients, but also occurs due to the possibility of loading the operated limb. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Anterolateral Tibial Bowing and Congenital Pseudoarthrosis of the Tibia: Current Concept Review and Future Directions.

Congenital pseudarthrosis of the tibia (CPT) is a rare condition closely associated with neurofibromatosis type I. Affected children are born with anterolateral bowing of the tibia which progresses to pathologic fracture, pseudarthrosis, and high risk of refracture even after initial union has been attained. There is currently no consensus on the classification of this disease or consensus on its treatment. The purpose of this review is to (1) review the clinical presentation, etiology, epidemiology, classification, and natural history of congenital pseudarthrosis of the tibia and (2) review the existing trends in treatment of congenital pseudarthrosis of the tibia and its associated complications. Current treatment protocols focus primarily on combining intramedullary fixation with external or internal fixation to achieve union rates between 74 and 100%. Intramedullary devices should be retained as long as possible to prevent refracture. Cross-union techniques, though technically difficult, have a reported union rate of 100% and no refractures at mid- to long-term follow-up. Vascularized fibular grafting and induced membrane technique can be successful, but at the cost of numerous surgical procedures. Growth modulation is a promising new approach to preventing fracture altogether, though further study with larger patient series is necessary. The primary consideration in treatment of CPT is expected union rate and refracture risk. Combined intramedullary and external or internal fixation, especially with cross-union techniques, show most promise. Perhaps most exciting is further research on preventing fracture through guided growth, which may reduce the morbidity of multiple surgical procedures which have been the mainstay of treatment for CPT thus far.

Особенности ортопедической патологии у больных нейрофиброматозом I типа

Introduction Neurofibromatosis type 1 (NF1) is one of the most common hereditary tumor syndromes. The average incidence of NF1 in the world is 1:3000 of the population. The characteristic signs of the disease are neurofibromas and café-au-lait macules on the skin. 60 % of patients with NF1 develop specific skeletal anomalies: scoliosis, chest deformity, pseudarthrosis, requiring surgical treatment and long-term rehabilitation. It is necessary to develop prognostic criteria for the development of severe skeletal anomalies in NF1 and take early measures to prevent their progression. Congenital pseudarthrosis of the tibia is diagnosed in 5 % of children with NF1, accounting for 80 % of all cases of this pathology in the general population. Spinal scoliosis is detected in 60 %, osteoporosis in 50 %, chest deformity in 37.6 %, microgenia in 53 %, increased head circumference in 25 %, sphenoid wing dysplasia in 12 %, facial asymmetry in 10 % of patients with NF1. The aim of the review is to focus on the pathogenesis of skeletal anomalies development in NF1 that result in disorders of the musculoskeletal system in NF1 in order to take early measures for the prevention and treatment of the disease. Materials and method The review is based on numerous studies found in the databases: PubMed, Scopus, Web of Science, published mainly over the past 5 years. The suitable studies were searched by keywords and their combinations «neurofibromatosis type 1» with the words «skeletal abnormalities», «musculoskeletal system», «pseudarthrosis», «scoliosis», «pathogenesis», «deformation», «treatment», «frequency», «prevalence», «genotype-phenotype correlation», « modifier genes». Results and discussion The pathogenesis of skeletal anomalies is due to both the loss of heterozygosity of the NF1 gene in pseudoarthrosis and the effect of neurofibromin deficiency on the development of connective tissue. Currently, the only effective drugs for the treatment of tumor syndrome in NF1 are inhibitors of mitogen-activated kinase (MEK), which suppress the increased activity of Ras oncogenes. A promising issue is the study of the effect of MEK inhibitors on the progression of skeletal anomalies in patients with NF1 in the treatment of tumor syndrome. Therefore, dynamic observation by an orthopedic surgeon with an objective assessment of the observed changes is of great importance in the management of patients. It is necessary to widely introduce molecular genetics methods for confirming the diagnosis of NF1 in the clinic in cases of a combination of skeletal anomalies with individual signs of the disease, since the manifestations of NF1 are steadily progressing with age, even in the presence of erased and atypical forms of the disease. Since the analysis of scientific literature has shown the possible influence of modifier genes on the pathogenesis of NF1, the search for mutations in these genes is promising. Conclusion Most patients with NF1 develop orthopedic pathology, which is associated with the role of the NF1 gene in the development of connective tissue. The increased mutability of this gene causes the loss of heterozygosity in the development of congenital pseudoarthrosis of the tibia. At the same time, NF1 driver mutations are detected in 10 % of sporadic malignant neoplasms. Therefore, the role of somatic mutations in the NF1 gene in the development of skeletal anomalies in the general population is probable. The methods of NF1 therapy that are under investigation may become the basis for the complex treatment of oncological and orthopedic patients.

Evaluation of the efficacy of ipsilateral fibular transfer for reconstruction of large tibial defects in children: a retrospective study

BackgroundReconstruction of large tibial defects is often a major challenge in limb salvage. This study aimed to evaluate initial follow-up results of ipsilateral fibula transfer for the treatment of large tibial defects in children.MethodsA retrospective study was performed between September 2014 and April 2021. Ten children were identified as having large tibial defects. The children underwent ipsilateral fibula transfer. We then evaluated initial healing, tibial length discrepancy, ankle varus/valgus, fibular position, refracture, infection, and function.ResultsFive boys and five girls, with an average age of 7.2 years, were evaluated. The transferred fibula was united in the patients. The mean follow-up period after fibular transposition was 43 months. The patients achieved primary bone union; the mean time to union was 8.4 months (range, 4–18 months). Complications included refracture (30%), infection (40%), tibia malunion (30%), ankle varus (30%), sensory loss of toes (10%), and ankle valgus (10%). No other major complications were observed. All 10 patients were able to perform activities of daily living and return to their normal activities.ConclusionIpsilateral fibula transfer is a salvage surgery for the treatment of large tibial defects in children with congenital pseudoarthrosis of the tibia, traumatic nonunion of the tibia, and/or tibial defect after chronic osteomyelitis. However, long-term results still need to be followed up.

Cross-Union Surgery for Congenital Pseudarthrosis of the Tibia.

Congenital Pseudoarthrosis of the Tibia (CPT) is a rare condition with a reputation for recurrent fractures and failure to achieve union. A large variety of surgical procedures have been attempted for the treatment of fractured cases of CPT with an average rate of union without refracture of only 50%. Intentional cross-union between the tibia and fibula has been reported to improve these results to 100% union with no refractures. This is a retrospective study of 39 cases of CPT in 36 patients treated by the Paley cross-union protocol with internal fixation, bone grafting, zoledronic acid infusion and bone morphogenic protein 2 (BMP2) insertion. All 39 cases of CPT united at the tibia and developed a cross-union to the fibula. Two patients had a persistent fibular pseudarthrosis, one that was later treated at the time of planned rod exchange and one that has remained asymptomatic. There were few postoperative complications. There were no refractures during the up to 7-year follow-up period. The most common problem was the Fassier-Duval (FD) rod pulling through the proximal or distal physis into the metaphysis (66.7%). This did not negatively affect the results and was remedied at the time of the planned rod exchange. The Paley Cross-Union Protocol is very technically demanding, but the results have radically changed the prognosis of this once sinister disease.

Management of Congenital Pseudoarthrosis of the Tibia and Fibula.

Congenital pseudoarthrosis of the tibia and fibula are rare conditions that share common treatment strategies. The purpose of this review is to provide an overview of the recent developments in treatments for both conditions. Recent literature has focused on the use of BMP and on gait analysis as a tool for measuring long-term functional outcomes. Recent study has indicated rhBMP-2 may shorten the time to initial healing of pseudoarthroses, but not guarantee bony union. Children with initial fractures before the age of four have been shown to have long-term gait outcomes that may be ultimately comparable to children with prostheses. Both congenital pseudoarthrosis of the tibia and fibula are challenging conditions to treat, which require comprehensive approaches to account for both the biological and mechanical components of the conditions.

Evaluation of bone marrow-derived mesenchymal stem cell quality from patients with congenital pseudoarthrosis of the tibia

BackgroundThe treatment of congenital pseudoarthrosis of the tibia (CPT) remains challenging in pediatric orthopedics due to the difficulties in bone union, continuous angulation, joint stiffness, and severe limb length discrepancy. Mesenchymal stem cells (MSCs) therapy offers a complementary approach to improve the conventional surgical treatments. Although the autologous MSC treatment shows a promising strategy to promote bone healing in CPT patients, the quality of MSCs from CPT patients has not been well studied. The purpose of this study is to investigate the quality of MSCs isolated from patients with CPT.MethodsThe bone marrow-derived MSCs from the fracture site and iliac crest of six CPT patients were isolated and compared. The cumulative population doubling level (cPDL), phenotype characteristics, and trilineage differentiation potency were observed to assess the quality of both MSCs.ResultsThere were no significant differences of the MSCs derived from the fracture site and the MSCs from the iliac crest of the subjects, in terms of cPDL, phenotype characteristics, and trilineage differentiation potency (all p > 0.05). However, MSCs from the fracture site had a higher senescence tendency than those from the iliac crest.ConclusionMSC quality is not the main reason for delayed bone regeneration in those with CPT. Thus, autologous MSC is a promising source for treating CPT patients

Congenital pseudoarthrosis of the tibia: role of the fibula

Objective Congenital pseudoarthrosis of the tibia is still a mystery and a great challenge to pediatric orthopedic surgeon. Owing to the different morphology of congenital pseudoarthrosis of the tibia, there are many treatment options with many debatable points. The fibula is a main strut that protects the tibial union and has implications on the orientation of the ankle. Patients and methods Nine patients had congenital pesudoarthrosis of the tibia, and their average age at the time of operation was 3.8 years; four of these nine patients had intact fibula (group 1), whereas five had associated pseudoarthrosis of the fibula (group 2). The treatment method was decided depending on the condition of the fibula, whether it was intact or affected by pseudoarthrosis. In cases with intact fibula, tibiofibular fusion was done. However, in cases with associated fibular pseudoarthrosis, the pathologic pseudoarthrotic tissues were resected and the tibia and fibula were fixed with intramedullary wires and Ilizarov ring fixator. Results A union rate of 100% was achieved without a refracture till the last follow-up. Good tibial alignment was achieved in all cases, and wide cross-sectional area at the pseudoarthrosis site was obtained in all cases. One case with fibula plus +1 position was complicated with a varus deformity of the ankle. Conclusion Addressing the fibular problem safeguards against refracture and protects against ankle joint deformity. Achieving tibial union with wide regenerate or wide fusion mass, good tibial alignment and fibular union is mandatory for preventing refracture. The article was level of evidence IV.

Versatility of the microvascular fibular flap in limb reconstruction

Abstract Background The structural characteristics of the fibula, strength, shape, length and limited donor site morbidity make it more suitable for reconstructing long bone defects larger than 6 cm in the limbs. Material and methods A descriptive study was conducted using a non-probabilistic sample of consecutive cases undergoing on limb reconstruction with free fibular flap in the period from January 2010 to January 2015 in the Mexican Institute of Social Security No. 21, Monterrey, Nuevo Leon. Results The mean age of the ten cases included was 25 years, with the most common diagnosis being trauma in 4 patients, osteosarcoma in 2, followed by one congenital pseudoarthrosis of the tibia, one non-union fracture, and one gunshot wounds, respectively. The most common location was tibia, followed by humerus, radius, ulna and femur. Conclusions This study has shown that the fibular free flap can be an excellent option for management of long bone defects, regardless of cause of the injury. One or more skin islands can be added for coverage in exposure of deep tissue and osteosynthesis material, thus preserving the septocutaneous perforators.

Plating following gradual realignment with the Taylor spatial frame for refractory congenital pseudarthrosis of the tibia: A novel technique

Congenital pseudoarthrosis of the tibia (CPT) is an intractable pediatric orthopedic disease. This study aims to report short-term outcomes of our staged surgery: Gradual realignment with Taylor Spatial Frame (TSF) and conversion to a locking plate for Boyd classification type II CPT. Three males (mean age, 10.3 years) who had undergone past surgeries (average, 3.7) were included. The pseudoarthrosis was atrophic and mobile in all cases. The distal bone fragment was translocated to the proximal anterior direction, resulting in shortening of the leg. In the first surgery, TSF was applied spanning the pseudoarthrosis. A foot ring was placed on the foot, and the distal fragment of the tibia was fixed together with the foot. The deformity correction was initiated a day after surgery. TSF was converted to a locking plate after scheduled alignment was achieved, and cancellous bone of iliac crest was grafted. Bony union was achieved at a mean of 3 months, and patients walked independently after mean 56-month follow-up, without any complications. Although the treatment outcome after the vascularized fibular graft and the Ilizarov method is relatively successful, several issues require long-term relief, and the surgical procedure requires specialized techniques. The present method shortens the duration of external fixation, uses only simple surgical maneuvers, and prevents re-fracture by anatomical alignment and indwelling of the plate.

Versatilidad del colgajo microvascular de peroné en reconstrucción de extremidades

BackgroundThe structural characteristics of the fibula, strength, shape, length and limited donor site morbidity make it more suitable for reconstructing long bone defects larger than 6cm in the limbs. Material and methodsA descriptive study was conducted using a non-probabilistic sample of consecutive cases undergoing on limb reconstruction with free fibular flap in the period from January 2010 to January 2015 in the Mexican Institute of Social Security No. 21, Monterrey Nuevo Leon. ResultsThe mean age of the ten cases included was 25 years, with the most common diagnosis being trauma in 4 patients, osteosarcoma in 2, followed by one congenital pseudoarthrosis of the tibia, one non-union fracture, and one gunshot wounds, respectively. The most common location was tibia, followed by humerus, radius, ulna and femur. ConclusionsThis study has shown that the fibular free flap can be an excellent option for management of long bone defects, regardless of cause of the injury. One or more skin islands can be added for coverage in exposure of deep tissue and osteosynthesis material, thus preserving the septocutaneous perforators.

Congenital pseudoarthrosis of tibia: A rare case report

Congenital pseudoarthrosis (CPT) of the tibia is rare congenital anomaly occurring 1 in 190,000 live births. It is one of the rare causes of limb shortening. A 8-year-old male child born of consanguious marriage came to orthopedic OutPatient Department with history of significant shortening of left leg since birth so much, so that patient cannot use his left leg for walking. His right leg was normal. Family history of neurofibromatosis-I (NF-1) is present. History, photographs and X-rays were taken and patient was diagnosed as a case of CPT of the tibia. Significant association between CPT of tibia and NF-I has been found. The case is of significance to orthopedicians and pediatrician from the management point of view.

Effectiveness of recombinant human bone morphogenetic protein-7 in the management of congenital pseudoarthrosis of the tibia: a randomised controlled trial.

Despite the popularity and an increased use of bone morphogenetic protein to improve bone healing in patients with congenital pseudoarthrosis of the tibia (CPT), no previous study has compared its efficacy against any other procedure. We randomised 20 consecutive patients (mean age 4.1 years) with CPT (Crawford type IV) associated with neurofibromatosis type 1(NF1) and no previous history of surgery into two groups. Group 1 received recombinant human bone morphogenetic protein-7 (rhBMP-7) along with intramedullary Kirschner (K)-wire fixation and autologous bone grafting; group 2 received only K wire and grafting. Outcome measures were time to achieve union, Johnston grade, tibial length and the American Orthopaedic Foot and Ankle Society (AOFAS) score, which were evaluated preoperatively and at five year follow-up. Study results showed that patients in group 1 achieved primary bone union at a mean of 14.5 months [standard error (SE) 5.2], whereas group 2 took a mean of 17.11 months (SE 5.0). However, the log-rank test showed no difference in healing times between groups at all time points (P = 0.636). There was a statistically significant pre- to post operative improvement (P < 0.05) within groups for the other outcome measures. In a five year follow-up, these results suggest that rh-BMP-7 and autologous bone grafting is no better than autologous grafting alone.

Congenital pseudoarthrosis of the tibia

This preliminary report is on two patients with congenital pseudoarthrosis of the tibia who had a persistent nonunion following intramedullary rodding and bone grafting. We do not advocate repeated surgery to achieve union. When limb length discrepancy becomes greater than 5 cm, we proceeded with an Ilizarov procedure with the primary aim of equalizing limb length rather than achieving union. Healing of the pseudoarthrosis occurred in both patients after lengthening over the intramedullary rod without compression of the nonunion site. We believe that union occurs because of hyperaemia during the lengthening. This approach minimizes the repeated surgeries that are usually needed and thus ensures a more normal childhood without frequent hospitalizations.

Congenital pseudarthrosis of the tibia treated with a combination of Ilizarov’s technique and intramedullary rodding

Background and purpose Ilizarov’s technique and intramedullary rodding have often been used individually in congenital pseudarthrosis of the tibia. In this series, we attempted to combine the advantages of both methods while minimizing the complications.Methods We reviewed 15 cases of congenital pseudoarthrosis of the tibia (CPT) who were treated with a combination of Ilizarov’s apparatus and antegrade intramedullary nailing between 2003 and 2008. The mean age at surgery was 7.5 (3–12) years and the mean limb length discrepancy was 2.5 (1.5–5) cm. At a mean follow-up time of 4.5 (1.6–7.2) years after the index surgery, the patients were evaluated clinically and radiographically for ankle function (AOFAS score) and for malalignment, signs of union, limb length discrepancy, and complications.Results 14 patients achieved union, in 6 patients primary union and in 8 patients after secondary procedures. The AOFAS score improved from a preoperative mean of 40 (20–57) to 64 (47–75). The main complication was refracture in 1 patient, and non-union in 1 patient.Interpretation The combination of the Ilizarov technique and conventional antegrade intramedullary nailing was successful in achieving union with few complications, though this should be shown in long-term studies lasting until skeletal maturity.