Congenital pseudarthrosis of the radius treated with gradual distraction and free vascularized fibular graft: case report

Free fibula flap to achieve bone union after congenital pseudoarthrosis of the forearm in neurofibromatosis: Technical report based on 3 cases, and literature review

Congenital pseudarthrosis of the forearm bones (CPFBs) is rare, with only 106 reported cases, and is frequently associated with neurofibromatosis (NF). Approximately 5% of patients with NF develop pseudarthrosis, and 50% of patients with pseudarthrosis have NF. Achieving bone union is difficult in congenital pseudarthrosis. Many methods have been attempted, including casting, internal fixation with or without grafting, and electrical stimulation, but failure is frequent. Free vascularized fibular flaps (FVFs) have been used to bridge long bone defects since 1975 and in tibial pseudarthrosis since 1979. In CPFB, FVF is more successful than other methods in achieving union and is the current treatment of choice. Here, we presented three cases of forearm pseudarthrosis treated with FVF, reviewed the literature on CPFB, and discussed some technical aspects of FVF treatment. Three cases of congenital pseudoarthrosis were treated with free fibula flaps, diagnosed at ages of 7 years (ulna), 15 months (radius), and 9 years (radius and ulna). Two flaps were stabilized with intramedullary wires and latterly, one with compression plates. One persistent nonunion received revision nonvascularized bone grafting and plating. All patients achieved union by 11 months after index surgery. Reconstruction with vascularized fibula is the treatment of choice because it offers the highest published union rates and good functional results. Complete resection of the affected bone and stable fixation, latterly with compression plates are critical to success. Surgery is technically demanding, and complications are common. Secondary surgery may be required, but outcomes are favorable. LEVEL OF EVIDENCE: IV.

Reconstruction of congenital pseudarthrosis of the radius with a vascularized tibial periosteal transplant: A case report

Congenital pseudarthrosis of the forearm poses a considerable challenge because of its rarity. The objective of this report is to introduce a novel surgical technique for its treatment. Here, we document a case of congenital pseudarthrosis of the radius in a 3-year-old boy diagnosed with type-1 neurofibromatosis. The surgical treatment involved the excision of approximately 9 cm of native radial periosteum and a bifocal radius osteotomy, which was supplemented with a vascularized tibial periosteal transplant to facilitate bone healing. Anastomosis between the anterior tibial vessels and radial vessels was performed. No immediate or late postoperative complications were observed. After 3 weeks, a robust callus formation was observed, and during a follow-up examination 3 years and 4 months later, a wide range of active forearm rotation was noted. This report suggests that vascularized periosteal flaps show promise as a viable treatment option for congenital pseudarthrosis of the forearm. They offer an alternative to vascularized fibular grafts or single-bone forearm constructs.

Vascularized Growth Plate Transfer in Paediatric Ulna Non-Union: Operative Technique and Review of the Literature

Congenital pseudarthrosis of forearm fractures is rare and is strongly associated with neurofibromatosis type 1 (NF1). Our case report illustrates the progression of a non-union of the ulna after minor trauma in a twelve-year-old boy, newly diagnosed with NF1, and presents the technique of microsurgical bone reconstruction, including the growth plate. More than seven years after the first operation, follow-up presents a favorable outcome with a pain-free patient and unrestricted function of the forearm after a secondary correction of the remaining radial bowing. This treatment is discussed with a comprehensive review of the current literature on ulnar congenital pseudarthrosis in PubMed and Google Scholar and free fibular growth plate transfer in PubMed and Google Scholar. Nine publications reporting on 20 cases of congenital ulnar non-unions were identified. With this reconstructive option, favorable outcomes were achieved in all cases with the union after primary surgery and complications requiring further surgeries in nine cases. The benefit of vascularized growth plate bone transfer in congenital ulna non-union seems to be significant compared to other therapies such as open reduction internal fixation (ORIF), non-vascularized bone grafts, or one-bone-forearms and beneficial when growth reconstruction is needed. Other techniques might be necessary to improve insufficient long-term results.

Traumatic Radius Pseudoarthrosis in Neurofibromatosis Type 1: All Treatment Options in One Patient

Although congenital pseudoarthrosis of the radius is a rare case, it has been reported many times in the literature in the past and it has been shown that it can be associated with neurofibromatosis type 1. However, traumatic radius pseudoarthrosis has never been reported before. In this case report, all treatment options were applied to the same patient over a four-year period and the results were reported. A two-year-old boy had a left radius diaphysis fracture after a simple fall, and bone union could not be achieved despite the application of cast immobilization, internal fixation grafting, and electrical stimulation in an external center. He was admitted to our hospital when he was six years old. A plain X-ray image and computed tomography scan showed that he had radius pseudoarthrosis and also he was diagnosed with neurofibromatosis type 1 on genetic analysis. The patient underwent wide resection of the segment with pseudoarthrosis and free vascularized fibula grafting. Bone union was achieved in the third postoperative month.

Treatment of Recalcitrant Nonunion of the Radius With Posterior Interosseous Bone Flap in Children

BACKGROUND

Forearm nonunion is a rare condition in children, and its treatment is usually successful. However, nontraumatic nonunion can be resistant to treatment. Although the vascularized fibular bone graft has been frequently used for complex forearm nonunion, there is no consensus on the best treatment method. In this study, we aimed to investigate the outcome of the antegrade posterior interosseous bone flap (PIBF) in treating children with complex radius nonunion.

METHODS

The participants consisted of 3 girls and 1 boy ranging from 31 months to 9 years of age. They were treated with PIBF surgery, and the nonunion of the radius was fixed with a plate or an external fixator. The nonunion was due to congenital pseudoarthrosis, osteogenesis imperfecta, or infantile osteomyelitis. All patients were evaluated for a clinical and radiologic union.

RESULTS

The radiologic union was achieved 2 to 3 months after the surgery in all cases. The functional recovery of the elbow, forearm, and wrist was satisfactory except for 1 patient who experienced donor site fracture, and finally radioulnar synostosis accompanied by radial head dislocation.

CONCLUSION

Because of the simplicity of its technique and short duration of surgery, PIBF can be a reliable and less-demanding alternative to vascularized fibular bone graft in the treatment of complex forearm nonunion in children.

LEVEL OF EVIDENCE

Level IV.

Congenital pseudoarthrosis of the radius in Neurofibromatosis Type 1: An entity not to be missed!

Congenital pseudoarthrosis of the radius is exceedingly rare. We report an isolated pseudoarthrosis of the radius in a five-year-old girl child with Neurofibromatosis type-I (NF-I). She underwent excision of the pseudoarthrosis tissue, ulna osteotomy, iliac crest cortico-cancellous bone grafting, and K wire fixation of both bones. A sound union of the radius and the ulna was achieved after 4 months. At two-year follow-up, mild shortening of the forearm persisted with maintenance of sound union of both bones. Accurate diagnosis of the condition is central in avoiding complications and the need for complex surgical procedures.

Congenital Forearm Pseudarthrosis, a Systematic Review for a Treatment Algorithm on a Rare Condition

BACKGROUND

A congenital forearm pseudarthrosis is a rare condition and is strongly associated with neurofibromatosis type 1. Several surgical techniques are described in the literature, but the most optimal treatment strategy remains unclear. This systematic review aims to develop a treatment algorithm that may aid in clinical decision making.

METHODS

The PROSPERO registration number for this study was CRD42018099602 and adheres to the PRISMA guidelines for systematic reviews. Embase, MEDLINE, Cochrane Central, Web of Science, and Google Scholar databases were searched for published studies reporting on congenital forearm pseudarthrosis not related to other underlying pathologies like bacterial infection or fibrous dysplasia. Results were not restricted by date or study type, only English literature was allowed. Studies were assessed for quality using the critical appraisal checklist for case reports from the Joanna Briggs Institute. Patient characteristics, underlying disease, type of surgery, union rate, and functional outcome were extracted from included studies.

RESULTS

Of 829 studies identified, 47 were included in this review (17 case series and 30 case reports, a total of 84 cases). A one-bone forearm procedure showed highest union rates (92%), however, it results in loss of forearm rotation. Free vascularized fibula grafting showed high union rates (87%) and was related to good functional outcome of elbow flexion and forearm rotations. Other procedures showed disappointing outcomes.

CONCLUSIONS

Congenital forearm pseudarthrosis is best treated with a free vascularized fibula grafting, a one-bone forearm procedure should be used as a salvage procedure. Evidence extracted from the case reports was sufficient to generate a treatment algorithm to be used in clinical pediatric practice.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Peripheral nerve sheath tumors of the upper extremity and hand in patients with neurofibromatosis type 1: topography of tumors and evaluation of surgical treatment in 62 patients

Objective: Neurofibromatosis type 1 (NF1) is an autosomal dominant tumor predisposition syndrome with a tendency to develop peripheral nerve sheath tumors (PNST). Plexiform neurofibromas (PNF) are detected in a high proportion of affected patients. The tumors can lead to severe disfigurement and are classified as precancerous. This study examines the surgical procedures that have been performed on large PNST of the upper limb and hand, and investigates whether a specific distribution pattern of the tumors can be detected in surgically treated cases.

Methods: Surgical procedures on the upper extremity and hand performed on patients with NF1 were evaluated at an interval of 25 years (1992–2016). Topography of the tumors was classified according to dermatomes. The number of interventions per patient, duration of operations, and complications of the interventions were registered. An overview of the surgical treatment of PNST of the upper limb and hand was obtained from the literature, with special consideration of the genetic background of treated tumors.

Results: One hundred and sixty-three surgical interventions on the upper limb and hand were performed in 62 patients with NF1 for the treatment of large PNST, predominantly PNF (age: mean value: 27.33 years, male: 33, female: 29; right side: 25, left side: 26, bilateral: 7). Surgical procedures lasted an average of 72.47 minutes. In approximately half of the patients, one surgical procedure was sufficient. Duration of stay in hospital was on average 7–11 days. Neurological complications were rarely noted and occurred only temporarily. There were no dermatomes affected by PNF with particular frequency. However, some dermatomes were more often simultaneously affected by a PNF at the same time as others.

Conclusion: Although the distribution pattern shows some accumulation of tumor localization, tumors are distributed evenly and show very variable size and extent in individual cases. Surgical treatment of PNF of the upper limb and hand helps alleviate the physical discomfort that these patients have from their disfiguring disease. Repeated interventions are necessary relatively often in order to adapt the tumorous region to the outline of the limb and to improve its function.

Diagnosis and treatment of osteopenic fractures in children

Osteopenic fractures occur in children every day. At times the osteopenic nature of these fractures is painfully obvious, as in neurofibromatosis and osteogenesis imperfecta, while in many other situations overt osteopenia does not declare itself, such as in normal and obese children. Normal pediatric bone growth commonly involves periods of relative bone weakness. Childhood obesity creates a situation where bone is unable to fully adapt to the stresses placed upon it. Conditions like neurofibromatosis and osteogenesis imperfecta place pediatric bone at a distinct genetic disadvantage. This review will highlight recent research in these areas and provide radiographic examples of the treatment of osteopenic fractures in children.

Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction

Successful free vascularized bone transfers have revolutionized the limb salvage and musculoskeletal reconstruction. The free vascularized fibula remains the mainstay in bone reconstruction combines the benefits of blood supply, biological potential, and callus formation with its unique biomechanical characteristics offering a supreme candidate for various dissolvable issues. Especially in conditions where there was lack of other applicable method and the free vascularized fibular graft was introduced as the only alternative. Extensive traumatic bone loss, tumor resection, femoral head osteonecrosis and congenital defects have been managed with exceptional results beyond expectations. The present manuscript updates several issues in application of free vascularized fibular graft in extremity and trunk reconstruction. It also highlights tips and pearls of surgical technique in some crucial steps of harvesting the vascularized fibular graft in order to offer a vascularized bone with safety and low donor site morbidity.