Role of Huntington procedure as a limb salvage surgery for complex gap nonunion of tibia in children

Abstract

Back ground: Complex gap nonunion of tibia following open fractures and osteomyelitis with pathological fractures in children is a treatment challenge with unpredictable outcome. Treatment options available are bone transport, bone grafting, induced membrane technique, allograft reconstruction and Huntington procedure (ipsilateral transposition of vascularized fibula). There is no consensus in the literature about which technique is optimal in the given situation. The purpose of the present study is to evaluate the role of Huntington procedure in the management of complex gap nonunion of tibia in paediatric patients.

Material and method: Eighteen patients (11 males and 7 females) with a mean age of 8.4 years (range 3-12 years) having complex gap nonunion of tibia with an average bone defect of 6.6 cm (range 5-17 cm) were treated with Huntington procedure between June 2008 to December 2016. The mean follow-up was 4.3years (range 3.5-6 years).

Result: Union was seen in all except one, with an average time to union being 11.5 weeks and13.8 weeks at proximal and distal tibio-fibular synostosis respectively. Revision plating was done in one patient with nonunion. Hypertrophy of fibula was seen in all patients. One patient developed 15° ankle varus and required corrective osteotomy. Ankle was fixed in equinus in three patients with a mean value of 13.3° (range 5°-25°). Lambrinaudi procedure was done to correct 25° fixed ankle equinus in one patient. Fixed flexion deformity of knee was seen in nine patients with a mean value of 9.7° (range 5°-20°). Two patients had iatrogenic foot drop; one recovered completely and one had only partial recovery. Shortening was seen in eight patients with a mean value of 3.5 cm (range 1-5 cm). At final evaluation 9 patients were very satisfied, 8 satisfied and 1 was dissatisfied.

Conclusion: Huntington procedure is a useful limb salvage surgery for complex gap nonunion of tibia in children. However; further improvements in the surgical technique are needed to increase the patient satisfaction by reducing the risk of complications.

Keywords: Children; Gap nonunion; Huntington surgery; Osteomyelitis; Tibia; Trauma.

Fig. 1

a. Radiographs of a 12 years female with chronic osteomyelitis complicated by pathological fracture. Following serial debridement and sequestrectomy the resultant bone gap was 17 cm This patient was managed by two stage Huntington Procedure. b. Follow up radiographs of same patient at 3.5 years showing consolidation at proximal and distal radioulnar synostosis. Hypertrophy of fibula is also evident. The cross union at proximal and distal ends is helpful to prevent coronal plane mal alignment to some extent.