Combined surgery with 3-in-1 osteosynthesis in congenital pseudarthrosis of the tibia with intact fibula

Abstract

Background: Re-fracture is the most serious complication in congenital pseudarthrosis of the tibia (CPT). There are reports that children with small cross-sectional areas in the sections of the pseudarthrosis are more prone to refracture. Presently, preventing complications is a challenge. Increasing the cross-sectional area in healed segments may reduce the incidence of re-fracture. Purpose: To elucidate the indications, surgical technique, and outcomes of combined surgery and 3-in-1 osteosynthesis in CPT with intact fibula. Methods: We retrospectively assessed 17 patients with Crawford Type IV CPT with intact fibula (Type A) who were treated with combined surgical technique and 3-in-1 osteosynthesis between March 2014 and August 2015. The average age of the patients at the time of surgery was 3 years. Incidence of re-fracture, ankle valgus, proximal tibial valgus, and limb length discrepancy (LLD) were investigated over an average follow-up time of 47 months. Results: Primary union was achieved in all patients. The average time for primary union was 4.9 months. Fifteen (88%) cases showed LLD with an average limb length of 1.6 cm; 6 (35%) cases exhibited tibial valgus with an average tibial valgus deformity of 7.8°; 2 cases had ankle valgus, wherein the ankle valgus deformity was 12°in one and 17°in another; and the cross-sectional area of the bone graft was enlarged to 1.74 times that of the tibia shaft. No case had re-fracture during the follow-up period. Movement of the ankle joint was restored in 16 patients with an average dorsiflexion of 22°and an average plantar flexion of 41°; the function of the ankle joint was normal. One patient had plantar flexion of 20°but did not have dorsiflexion. Conclusion: Combined surgical technique with 3-in-1 osteosynthesis, which is primarily considered for bone union with a large cross-sectional area, results in a high primary union rate. This can provide satisfactory results in shortterm follow-up when treating CPT with intact fibula (Type A).

Application of multiple wrapped cancellous bone graft methods for treatment of segmental bone defects

“…Harvesting methods of autologous cancellous bone have also made great progress. Studies have also shown that more cancellous bone can be obtained from the posterior iliac crest than from the anterior iliac crest, therefore the former is the first choice [7, 16]. The proximal tibia is also considered a rich source of cancellous bone, with few complications [5, 6, 14, 16].…”

“…They reported clinical healing of bone 6 months postoperatively. Liu Yao-xi [7] reported congenital tibial pseudarthrosis in 12 pediatric patients with bone defects (4–11 cm) treated with a line suturing cortical bone wrapped cancellous bone graft and achieved 100% healing. In the present study, the average bone defect length was 5.9 cm, the longest tibia defect was 9 cm, and the longest humerus defect was 7 cm.…”

“…A more suitable choice in such cases is Ilizarov technique. Second, the infection must be controlled and keep a normal state in erythrocyte sedimentation rate and C-reactive protein level for more than 3 months before the bone graft [6, 7]. Third, complications of harvesting large amount of graft materials from the iliac crest remain an unsolved problem.…”

“…In the same year, Cobb et al [6] reported a wrapped bone graft using titanium mesh in the treatment of large segmental bone defects. Later, Tian Wen et al [7] adopted a line mesh and line suture or line-binding cancellous bone graft to treat segmental long bone defects and obtained satisfactory effects. All the aforementioned methods employ cancellous bone wrapped in a mechanical device, thereby overcoming the shortcomings of traditional cancellous bone grafts [7].…”

“…Later, Tian Wen et al [7] adopted a line mesh and line suture or line-binding cancellous bone graft to treat segmental long bone defects and obtained satisfactory effects. All the aforementioned methods employ cancellous bone wrapped in a mechanical device, thereby overcoming the shortcomings of traditional cancellous bone grafts [7]. These improved free bone graft methods change the traditional view of the unsuitability of free bone graft as a treatment for large segmental one defects [5, 6, 8–10].…”