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 re-fracture. 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 short-term follow-up when treating CPT with intact fibula (Type A).

Keywords: 3-in-1 osteosynthesis; Congenital pseudarthrosis of tibia; Fibula intact.

Fig. 1

Exposure of outer table of the ilium, harvesting a square of cortex measuring 4 × 3 cm

Fig. 2

Holes made in the rectangular cortex using Kirschner wire and absorbable sutures. Cancellous bone curetted from supra-acetabular region

Fig. 3

Proximal osteotomy of the fibula, cylindrical cortex wrapped around the proximal and distal segments of the tibia and fibula, cancellous bone compacted circumferentially between the cortex and the pseudarthrosis site of the tibia, wrapping the bone graft, and securing by tying the sutures

Fig. 4

a Preoperative anteroposterior and lateral radiographs. b X-ray radiograph one week post-operation. c Twenty-three months after the operation, X-ray shows that the cross sectional area of the healed segment was enlarged

Fig. 5

a Preoperative anteroposterior and lateral radiographs. b The X-ray radiograph, 4 days of post-operation. c Forty-eight months after the operation, X-ray shows that the tibia and fibula were well fused

Fig. 6

a Suturing the tibial pseudarthrosis at the ends of the tibia and fibula. b Filling the cancellous bone between the tibia and fibula. c Wrapping the bone graft and securing by tying the sutures

Fig. 7

A schematic diagram of 4-in-1 bone osteosynthesis