Association of Ilizarov's technique and intramedullary rodding in the treatment of congenital pseudarthrosis of the tibia

Abstract

Purpose Many surgical techniques have been published on how to treat congenital pseudoarthrosis of the tibia (CPT). We combined Ilizarov's fixator with intramedullary nailing of the tibia and developed a procedure which combines the advantages of both methods: Ilizarov's high fusion rate with alignment control and the protection against refracture provided by the intramedullary nail. The results of this approach are presented and discussed. Material and methods Seven boys and three girls aged 3-14 years (mean age 8 years 2 months) were treated using our combined technique. In six cases, the CPT was associated with neurofibromatosis. Two strategies were adopted: in six cases, a compression was applied on the bone defect, and in four cases, segmental bone transportation was performed before the compression procedure. The final follow-up (1.2-6.6 years) included a clinical and radiological examination. Results Tibial union was achieved in nine cases without bone grafting. In one case, tibial union still remains uncertain, despite intertibiofibular bone grafting and additional compression procedures. Thirteen overall complications were noted, including three valgus deformity of the ankle. Bone transportation failed to achieve complete limb lengthening in three cases. One deep infection occurred 4 years after removal of the external fixator. The treatment for this included nail removal and antibiotic therapy for 3 months. Despite a permanent protection of orthosis, a refracture occurred 2 years after nail removal, reverting to the initial level of pseudarthrosis. Another surgical attempt using the same method was then performed with a satisfactory result. Conclusions The association of Ilizarov's technique and intramedullary nailing achieved and maintained tibial union in nine of ten patients at final follow-up. It also allowed correction of axial deformities and prevented refracture. Despite the short duration of the follow-up and a high rate of complications in our series, this method can be useful in many cases of CPT in which healing has failed to occur despite many previous surgeries.

Induced membrane technique for the treatment of congenital pseudarthrosis of the tibia: Preliminary results of five cases

“…A valgus ankle deformity was found in 25 % of the cases because of persistent fibular pseudarthrosis or a distal tibial epiphyseal growth defect. Associating internal fixation with pins or telescopic nails with the external fixation has been proposed because of the high rate of recurrent fracture and axial deformities [15]. External fixators may be difficult to use in small children because of the size and difficulties fixing small osteoporotic bony fragments, especially in distally located dystrophic lesions [16].…”

Distal tibial fracture repair in a neurofibromatosis type 1-deficient mouse treated with recombinant bone morphogenetic protein and a bisphosphonate

“…14,28 In addition, there is no universally accepted method of fixation with both Ilizarov ring fixators and several designs of intramedullary nail being described. [6][7][8][9][10][11] Most agree that all tissue should be resected from the pseudarthrosis at operation and a strong anabolic stimulus applied to promote healing. It seems logical to use BMPs to boost the potential for bone healing in these patients.…”

“…intramedullary nailing 9,10 ) alone or in combination. 11 In terms of the timing of surgery, bracing is increasingly used, particularly before three years of age, in order to delay surgery. 12 A combination of bracing and a cortical bypass allograft has recently been reported with a good outcome in ten patients at a mean follow-up of 6.5 years.…”

Controversies in the management of congenital pseudarthrosis of the tibia and fibula

“…57 Circular external fixators are widely used to treat CPT. [57][58][59][60][61][62] The biggest advantage of this approach is that while the tibial fragments are being compressed to achieve union, lengthening of the tibia and correction of angular deformities can be undertaken concomitantly. The ring fixator may be combined with intramedullary fixation with retention of the nail after removal of the fixator to avoid re-fracture.…”