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Li Y, Li J, Gan T, Geng Q, Ma X, Yin S, Wu Y, Fang X, Xie H, Zhang H. Ilizarov Distraction for Congenital Pseudoarthrosis of the Tibia in Adults. Orthop Surg 2024. [PMID: 39187975 DOI: 10.1111/os.14189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/24/2024] [Accepted: 07/24/2024] [Indexed: 08/28/2024] Open
Abstract
OBJECTIVE The clinical evidence on the management for congenital pseudoarthrosis of the tibia (CPT) in adults is limited. The aim of this study is to assess the functional and radiological outcomes of Ilizarov distraction for treating CPT in adults. METHODS A retrospective analysis was conducted. Between 2013 and 2022, an Ilizarov distraction technique was performed on 14 adults (14 limbs) with CPT in our limb deformity center. There were seven females and seven males with a mean age of 33.7 (range, 18 ~ 53) years. The diagnosis of NF-1 was confirmed in seven (50.0%) patients. Eight patients had a history of previous surgical failure. The pseudoarthrosis occurred in the middle and lower tibia in all limbs (six left and eight right). The CPT was classified by Crawford classification and Paley classification. The surgical procedures, external fixation time (EFT), and all outcomes and complications were recorded. The Kolmogorov-Smirnov test was performed to test the normality of the data. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score at the preoperative and final follow-up was compared by using the Wilcoxon's signed-rank test. The limb-length discrepancy (LLD) and a self-made exercise capacity score at the preoperative and final follow-up were compared by using the student's t-test. The clinical and radiological outcomes were assessed by the Inan scale. RESULTS The mean EFT of Ilizarov fixator was 19.5 months (range, 7.3 ~ 39.1). At a median follow-up of 26.8 months (IQR, 20.2 ~ 34.3), bone union of the pseudarthrosis and consolidation of the distraction zone were achieved in all patients. The mean LLD was decreased from 11.3 cm (range, 3.4 ~ 17.3) preoperatively to 1.1 cm (range, 0.3 ~ 3.7) (p < 0.05). The mean or median AOFAS ankle-hindfoot score was improved from 53.5 (IQR, 26.5 ~ 60.5) preoperatively to 63.9 (range, 53 to 73) at final follow-up (p < 0.05). The mean score for exercise capacity were improved from 4.9 (range, 1 to 8) preoperatively to 9.6 (range, 7 ~ 12) at final follow-up (p < 0.05). According to the criteria described by Inan et al., the clinical results were classified as good in 10 and fair in 4, while the radiological results were classified as excellent in three, good in 8, and fair in 2. The success rate was 92.9%, as refracture was defined as treatment failure and occurred in one patient. CONCLUSION Ilizarov distraction provided a suitable treatment option for the CPT in adults, as it could achieve a high rate of bone union, a good correction of secondary deformity, a low risk of refracture, and consequently restore a relatively functional limb.
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Affiliation(s)
- Yaxing Li
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jia Li
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Tingjiang Gan
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Qirui Geng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Xikun Ma
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Shijiu Yin
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Ye Wu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Xiang Fang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Huiqi Xie
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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Yi Y, Dong L, Zhang N, Mo S, Xie Y, Hu X. Fast track surgery for children with congenital pseudarthrosis of the tibia: A prospective interventional study. Int J Orthop Trauma Nurs 2024; 53:101051. [PMID: 37858520 DOI: 10.1016/j.ijotn.2023.101051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/11/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE The purpose of this study was to explore the effect of fast-track surgery combined with a clinical nursing pathway on the recovery and complications of congenital pseudarthrosis of tibia. METHODS 82 children with congenital pseudarthrosis of tibia admitted from January 2019 to December 2020 were selected as the study subjects. The control group received routine clinical nursing pathway while the intervention group received a fast-track surgery combined with a clinical nursing pathway. The fasting and water deprivation time were arranged according to the pre operation time, and the accelerated rehabilitation nursing models such as progressive diet management, multi-functional analgesia, and early sequential functional exercise were given after the operation. After collecting data on perioperative diet, postoperative recovery, postoperative complications, and family satisfaction from both groups of patients in a large hospital in China, a comparative analysis was conducted. RESULTS The retention time of negative pressure drainage tube, urinary catheter and hospital stay in the intervention group were shorter than those in the control group (P < 0.05); The incidence of complications in the intervention group (5%) was significantly lower than that in the control group (21.42%) (P = 0.029). The family satisfaction of the intervention group (95.00%) was higher than that of the control group (80.95%). CONCLUSION Strengthening the concept of fast-track surgery nursing in the combined operation of congenital pseudarthrosis of tibia can shorten the hospitalization time of children, reduce the occurrence of postoperative complications and improve their family satisfaction.
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Affiliation(s)
- Yinzhi Yi
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, No.86, Ziyuan Road, Yuhua District, Changsha, Hunan, 410000, China; Hunan Provincial Key Laboratory of Pediatric Orthopedics, Hunan Children's Hospital, No.86, Ziyuan Road, Yuhua District, Changsha, Hunan, 410000, China.
| | - Lin Dong
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, No.86, Ziyuan Road, Yuhua District, Changsha, Hunan, 410000, China.
| | - Ni Zhang
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, No.86, Ziyuan Road, Yuhua District, Changsha, Hunan, 410000, China.
| | - Shasha Mo
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, No.86, Ziyuan Road, Yuhua District, Changsha, Hunan, 410000, China.
| | - Yonghong Xie
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, No.86, Ziyuan Road, Yuhua District, Changsha, Hunan, 410000, China.
| | - Xiongke Hu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, No.86, Ziyuan Road, Yuhua District, Changsha, Hunan, 410000, China; Hunan Provincial Key Laboratory of Pediatric Orthopedics, Hunan Children's Hospital, No.86, Ziyuan Road, Yuhua District, Changsha, Hunan, 410000, China.
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Yu H, Li Z, Tan Q, Liu K, Zhu G, Mei H, Yang G. Association between preoperative concurrent fibular pseudarthrosis and risk of postoperative ankle valgus in patients with congenital pseudarthrosis of the tibia. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001763. [PMID: 36863762 PMCID: PMC9972442 DOI: 10.1136/bmjpo-2022-001763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/07/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND This study evaluated the correlation of preoperative concurrent fibular pseudarthrosis with the risk of ankle valgus deformity in patients with congenital pseudarthrosis of the tibia (CPT) who underwent successful surgical treatment. METHOD The children with CPT who were treated at our institution between 1 January 2013 and 31 December 2020 were retrospectively reviewed. The independent variable was preoperative concurrent fibular pseudarthrosis, and the dependent variable was postoperative ankle valgus. Multivariable logistic regression analysis was performed after adjusting for variables that might affect the risk of ankle valgus. Subgroup analyses with stratified multivariable logistic regression models were used to assess this association. RESULTS Of the 319 children who underwent successful surgical treatment, 140 (43.89%) developed ankle valgus deformity. Moreover, 104 (50.24%) of 207 patients with preoperative concurrent fibular pseudarthrosis developed an ankle valgus deformity compared with 36 (32.14%) of 112 patients without preoperative concurrent fibular pseudarthrosis (p=0.002). After adjusting for sex, body mass index, fracture age, age of patient undergoing surgery, surgery method, type 1 neurofibromatosis (NF-1), limb-length discrepancy (LLD), CPT location and fibular cystic change, patients with concurrent fibular pseudarthrosis presented a higher risk of ankle valgus than those without concurrent fibular pseudarthrosis (OR 2.326, 95% CI 1.345 to 4.022). This risk further increased with CPT location at the distal one-third of the tibia (OR 2.195, 95% CI 1.154 to 4.175), age <3 years of patient undergoing surgery (OR 2.485, 95% CI 1.188 to 5.200), LLD <2 cm (OR 2.478, 95% CI 1.225 to 5.015) and occurrence of NF-1 disorder (OR 2.836, 95% CI 1.517 to 5.303). CONCLUSION Our results indicate that patients with CPT and preoperative concurrent fibular pseudarthrosis have a significantly increased risk of ankle valgus compared with those without preoperative concurrent fibular pseudarthrosis, particularly in those with CPT location at the distal third, age <3 years at surgery, LLD <2 cm and NF-1 disorder.
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Affiliation(s)
- Hui Yu
- Department of Orthopedic Surgery, Hunan Children's Hospital, Changsha, Hunan, China.,Department of Orthopedic Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhuoyang Li
- Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qian Tan
- Department of Orthopedic Surgery, Hunan Children's Hospital, Changsha, Hunan, China
| | - Kun Liu
- Department of Orthopedic Surgery, Hunan Children's Hospital, Changsha, Hunan, China
| | - Guanghui Zhu
- Department of Orthopedic Surgery, Hunan Children's Hospital, Changsha, Hunan, China
| | - Haibo Mei
- Department of Orthopedic Surgery, Hunan Children's Hospital, Changsha, Hunan, China
| | - Ge Yang
- Department of Orthopedic Surgery, Hunan Children's Hospital, Changsha, Hunan, China
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Hu X, Li A, Liu K, Wu J, Mei H. Design of a New "U"-shaped Staple and Its Clinical Application in Postoperative Ankle Valgus of Congenital Pseudarthrosis of the Tibia in Children. Orthop Surg 2022; 14:1981-1988. [PMID: 35856419 PMCID: PMC9483067 DOI: 10.1111/os.13381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Objective There has been a lack of suitable epiphysis blocking materials due to the characteristics of less tissue coverage and narrow epiphysis in children's distal tibial medial malleolus. Therefore, this study is to investigate the clinical efficacy and safety of a new “U”‐shaped staple in the treatment of postoperative ankle valgus of congenital pseudarthrosis of the tibia (CPT). Method According to the inclusion and exclusion criteria, 33 patients with postoperative ankle valgus of CPT were treated with new “U”‐shaped staples from May 2013 to September 2019. The deformity of ankle valgus was gradually corrected by implanting a new “U”‐shaped staple on the medial side of the distal tibia. Clinical indexes such as the operation time, intraoperative bleeding and hospital stay were observed. Tibiotalar angle was selected as the evaluation index of ankle valgus. American Orthopedic Foot & Ankle Society (AOFAS) scale was used for clinical evaluation of ankle function. The tibiotalar angle, deformity correction rate and complications were evaluated by preoperative, postoperative and last follow‐up imaging data. Student's t‐test was used for statistical analysis. Results Thirty‐three patients, including 12 males and 21 females were included. All the patients were followed up for at least 14 months, with an average of 35 months. The average operation time was 23 (15–40) min, the average amount of intraoperative bleeding was 7.5 (4–10) mL, and the average hospital stay was 4.2 (3–6) days. The intraoperative tibiotalar angles of all patients were 74.2° ± 4.6°, the tibiotalar angle were 86.8° ± 4.9° when internal fixation was removed, and the tibiotalar angles at the last follow‐up were 84.3° ± 5.9°. The average orthopedic rate was 0.68° per month. No patients suffered from serious complications such as screw prolapse, osteomyelitis, wound infection, etc. Postoperative wound pain complications occurred in two patients, which were relieved after conservative treatment. The AOFAS score improved from 46.2 ± 9.4 before the operation to 74.6 ± 5.7 at the last follow‐up (P < 0.01). The ankle movement was good without joint stiffness. There was no epiphyseal plate injury after the removal of internal fixation. Conclusion The new “U”‐shaped staple is characterized by simple implantation, low notch, lower risk of fixation failure and close fitting with cortical bone. It is a safe and effective internal fixation system for the treatment of ankle valgus in children.
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Affiliation(s)
- Xiongke Hu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha, Hunan, China
| | - Anping Li
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha, Hunan, China
| | - Kun Liu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha, Hunan, China
| | - Jiangyan Wu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha, Hunan, China
| | - Haibo Mei
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha, Hunan, China
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Xie JH, Mei HB, Liu K, Zhu GH, Ouyang YQ, Huang Y, Hou ST, Wang LY, Yi YZ. Analysis of related factors of behavioral problems in children with congenital pseudarthrosis of tibia. Rev Assoc Med Bras (1992) 2022; 68:893-897. [PMID: 35946764 PMCID: PMC9574966 DOI: 10.1590/1806-9282.20211197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: This study aimed to investigate the factors associated with behavioral problems in children with congenital pseudarthrosis of the tibia. METHODS: Random sampling is utilized to obtain a sample of 90 patients. The behavioral problems of the patients are detected by Achenbach Children's Behavior Scale. Parental emotional problems are investigated by the Self-Rating Depression Scale and Self-Rating Anxiety Scale. RESULTS: The results demonstrate that the detection rate of behavioral problems in children with congenital pseudarthrosis of the tibia is 53.3% (48/90). Among these behavioral problems, an abnormal rate is higher in the four dimensions: thinking, violation of discipline, social interaction, and aggression. The anxiety and depression scores of caregivers are statistically higher in the abnormal group than in the normal group. The results of the multivariate analysis show that the anxiety degree of the parents had a significant impact on the behavior of the children. CONCLUSIONS: Children with congenital pseudarthrosis of the tibia are facing the issues of high rates of behavioral problems. Parents of children with congenital pseudarthrosis of the tibia had higher levels of anxiety and depression than parents of normal children. The anxiety and depressive state of mind of parents or caregivers had a significant impact on the behavior of children with congenital pseudarthrosis of the tibia.
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Affiliation(s)
- Jian-Hui Xie
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
| | - Hai-Bo Mei
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
| | - Kun Liu
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
| | - Guang-Hui Zhu
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
| | - Ya-Qi Ouyang
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
| | - Yuan Huang
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
| | - Shu-Ting Hou
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
| | - Lan-Ying Wang
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
| | - Ying-Zhi Yi
- Hunan Children's Hospital, Department of Orthopedics - Changsha, China
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Li Z, Yu H, Huang Y, Liu Y, Zhu G, Tan Q, Mei H, Yang G. Analysis of risk factors affecting union and refracture after combined surgery for congenital pseudarthrosis of the tibia: a retrospective study of 255 cases. Orphanet J Rare Dis 2022; 17:245. [PMID: 35739599 PMCID: PMC9229079 DOI: 10.1186/s13023-022-02375-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Congenital pseudarthrosis of the tibia (CPT) is a rare disease occurring in children. The aim of this study is to identify the factors affecting bone union and re-fracture after surgery for CPT and to provide reliable evidence for clinics. Methods We collected the detailed information of 255 cases with Crawford IV CPT treated by combined surgery in our hospital from 2013 to 2020. Basic characteristics were recorded. Univariate variance and logistic regression analysis were used to compare the correlations between factors and outcomes. Results 92.5% of patients achieved primary union, 7.5% of patients had non-union and 13.3% of patients had re-fracture. Logistic regression analysis showed that age at index surgery (Coef. = 0.171, 95%CI 0.015–0.327, P = 0.032), and CPT location (Coef. = − 1.337, 95%CI − 2.218–0.456, P = 0.003) had statistical differences, while no factors had significant correlation with re-fracture. Furthermore, ROC curve showed that the optimal age threshold for first surgery was 2.37 years old. Conclusions For patients with Crawford IV CPT treated by combined surgery, the younger the age at index surgery and the closer the CPT location to the distal end, the easier to achieve bone union.
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Affiliation(s)
- Zhuoyang Li
- Department of Orthopedics, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hui Yu
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong, China
| | - Yiyong Huang
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Yaoxi Liu
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Guanghui Zhu
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Qian Tan
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Haibo Mei
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China.
| | - Ge Yang
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China.
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Yalikun A, Yushan M, Hamiti Y, Lu C, Yusufu A. Combination of the Ilizarov Method and Intramedullary Fixation for the Treatment of Congenital Pseudarthrosis of the Tibia in Children: A Retrospective Observational Study. Front Surg 2022; 9:901262. [PMID: 35656087 PMCID: PMC9152179 DOI: 10.3389/fsurg.2022.901262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/20/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Congenital pseudoarthrosis of the tibia (CPT) is a rare disease in children, and its treatment remains a challenge for orthopedic surgeons. The purpose of this study was to evaluate treatment outcomes of patients with CPT treated by using the Ilizarov method combined with intramedullary fixation. Method Eighteen patients evaluated retrospectively from January 2009 to January 2020 were treated using the Ilizarov method combined with intramedullary fixation. Demographic data, clinical characteristics, and complications were all recorded and investigated during the period of follow-up. Ankle function was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores at the last follow-up. Result The average follow-up was 39.2 months (25–85 months) for all 18 patients. The mean age was 6.2 years (3.5–11.2 years). Fourteen (77.8%) patients had a primary bone union at the site of pseudarthrosis, while four obtained union after secondary surgical intervention. The mean duration of the Ilizarov method was 8.1 months (4.2–13.5 months). Eight (44.4%) patients had a pin-tract infection during treatment. Four (22.2%) patients had proximal tibial valgus with a mean angle of 12.1° (5–25°), while seven (38.9%) patients had ankle valgus deformities with a mean of 10.3° (5–20°). Eleven (61.1%) patients had an average 1.4 cm of limb length discrepancy (LLD) (0.6–3.1 cm) postoperatively. Five (27.8%) patients had refracture and recovered after a secondary surgery. At the last follow-up, the average postoperative AOFAS score was 72 (55–84). Conclusion The Ilizarov method combined with intramedullary fixation is an effective method for the treatment of CPT, which can facilitate bony union and help to prevent refracture. Management of fibular pseudarthrosis is associated with functional outcomes. It is necessary to follow up until skeletal maturity and evaluate long-term clinical outcomes.
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Hu X, Li A, Liu K, Mei H. Efficacy Comparison of 3 Kinds of Distal Tibial Hemiepiphyseal Implants in the Treatment of Postoperative Ankle Valgus of Congenital Pseudarthrosis of the Tibia. J Pediatr Orthop 2022; 42:e441-e447. [PMID: 35200210 PMCID: PMC9005098 DOI: 10.1097/bpo.0000000000002101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Congenital pseudarthrosis of the tibia (CPT) is a complex and serious disease in orthopaedics which often requires multiple operations for treatment. Postoperative ankle valgus deformity is easily seen after the operation of CPT. The aim of this study is to retrospectively evaluate the effectiveness of three different implants for treating postoperative ankle valgus after CPT. METHODS A total of 41 patients with postoperative ankle valgus after CPT from December 2010 to July 2019 were selected. Of these 41 patients, 23 patients were treated with "U"-shaped staple, 10 patients were treated with hollow screw and 8 patients were treated with cortical bone screw. The evaluation index was tibiotalar angle. The general data, preoperative, postoperative, and final follow-up imaging data were recorded, and the deformity correction rate and complications were compared. RESULTS All the patients were performed with postoperative follow-up visit for at least 12 months (31 mo on average). In the "U"-shaped staple group, the preoperative tibiotalar angle was 74.8±4.8 degrees, the tibiotalar angle was 85.8±4.5 degrees when the internal fixation was removed; in the hollow screw group, the average preoperative tibiotalar angle was 72.2±6.1 degrees, the average tibiotalar angle was 88.4±5.1 degrees when the internal fixation was removed; in the cortical bone screw group, the average preoperative tibiotalar angle was 75.1±4.2 degrees, the average tibiotalar angle was 88.4±5.1 degrees when the internal fixation was removed. The correction rate of the "U"-shaped staple group was 0.71 degrees/month, with that of in the hollow screw group and cortical bone screw group being 0.64 degrees/month and 0.61 degrees/month, respectively. There was no significant difference in the correction rate between the 3 groups. One case of internal fixation complication was reported in the hollow screw group; 2 cases of missing correction effect were reported, 1 in cortical bone screw group and 1 in hollow screw group; and 2 cases showing symptom of wound pain were reported in the "U"-shaped staple group. CONCLUSION Ankle valgus is a common postoperative complication of congenital tibial pseudarthrosis. Temporary hemiepiphysiodesis with "U"-shaped staple or screws is an effective treatment for postoperative ankle valgus deformity of CPT in children. LEVEL OF EVIDENCE Level IV-retrospective study.
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Xu S, Liu Y, Zhu G, Liu K, Tang J, Wu J, Yan A, Jiang F, Mo S, Mei H. Evaluation of the efficacy of ipsilateral fibular transfer for reconstruction of large tibial defects in children: a retrospective study. J Orthop Surg Res 2022; 17:142. [PMID: 35248095 PMCID: PMC8898503 DOI: 10.1186/s13018-022-03021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background Reconstruction of large tibial defects is often a major challenge in limb salvage. This study aimed to evaluate initial follow-up results of ipsilateral fibula transfer for the treatment of large tibial defects in children.
Methods A retrospective study was performed between September 2014 and April 2021. Ten children were identified as having large tibial defects. The children underwent ipsilateral fibula transfer. We then evaluated initial healing, tibial length discrepancy, ankle varus/valgus, fibular position, refracture, infection, and function. Results Five boys and five girls, with an average age of 7.2 years, were evaluated. The transferred fibula was united in the patients. The mean follow-up period after fibular transposition was 43 months. The patients achieved primary bone union; the mean time to union was 8.4 months (range, 4–18 months). Complications included refracture (30%), infection (40%), tibia malunion (30%), ankle varus (30%), sensory loss of toes (10%), and ankle valgus (10%). No other major complications were observed. All 10 patients were able to perform activities of daily living and return to their normal activities. Conclusion Ipsilateral fibula transfer is a salvage surgery for the treatment of large tibial defects in children with congenital pseudoarthrosis of the tibia, traumatic nonunion of the tibia, and/or tibial defect after chronic osteomyelitis. However, long-term results still need to be followed up.
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Surgical treatment options for congenital pseudarthrosis of tibia in children: cross-union versus other options: a systematic review. J Pediatr Orthop B 2022; 31:139-149. [PMID: 35102104 DOI: 10.1097/bpb.0000000000000924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The systematic review aimed to provide a comprehensive update on various surgical treatment options for congenital pseudarthrosis of tibia (CPT) in children and the outcome achieved in terms of union, union time and complications of non-union and refracture. A literature search was performed in PubMed (including Medline) database for broad keywords: 'Congenital pseudarthrosis of tibia and children'. Studies selected included full-text articles on surgical treatments of CPT following: intra-medullary rod (IMR)/Ilizarov/combined IMR with Ilizarov/vascularized fibular graft (VFG) and cross-union. Out of 719 studies, 57(1227 CPT patients/1235 tibias) were included for review. Cross-union group had 100% union rate with no non-unions, least refracture rate (22.5%) and minimal time to primary union (4.5 months). For IMR, Ilizarov, combined IMR with Ilizarov and VFG, the respective results were as follows: primary union rates - 67.7, 84.2, 83.7 and 65.3%; final union - 76.5, 81.5, 92.4 and 87.1%; primary union time - 12.6, 9.3, 5.3 and 9.5 months; non-union rates - 17.0, 13.6, 6.0 and 7.9%; refracture rates - 48.1, 47.7, 33.7 and 34.6%. The success probability was lowest for IMR (35.2%), 44% for Ilizarov, 55.5% for combined IMR with Ilizarov, 42.7% for VFG and highest 77.5% for cross-union group. Outcomes of the more recent cross-union technique fare better than other surgical methods. However, studies on cross-union are few and longer follow-up is lacking. Combined IMR with Ilizarov and VFG have better results compared to IMR or Ilizarov alone.
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Zhou Y, Tan Q, Liu K, Liu Y, Zhu G, Mei H, Yang G. Epidemiological and clinical characteristics of congenital pseudarthrosis of the tibia in China. Front Pediatr 2022; 10:943917. [PMID: 36090554 PMCID: PMC9452726 DOI: 10.3389/fped.2022.943917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Congenital pseudarthrosis of the tibia (CPT) is a refractory and rare disease. Because of its extremely low incidence, little is known about its clinical features. In this retrospective study, we aim to analyze the clinical characteristics of patients with CPT. MATERIALS AND METHODS This is a retrospective study of children with CPT identified by the radiological review. Investigations of CPT included general conditions, the characteristics of CPT, treatment methods, and surgical complications. RESULTS We collected 514 CPT cases from March 1999 to March 2020 in our hospital, such as 317 (61.67%) boys, 197 (38.33%) girls; 330 (62.86%) in Crawford IV; 510 (97.14%) in mid and distal 1/3 tibia; 481 (93.58%) in less than 3 years at onset age; 297 (57.78%) in less than 3 years at the first outpatient visit. The most common post-operative complication was ankle valgus (101, 39.60%), followed by limb length discrepancy (91, 35.69%), refracture (38, 14.90%), osteomyelitis (15, 5.88%), and removal of internal fixation (10, 3.93%). CONCLUSIONS CPT with a higher incidence of Crawford IV frequently occurs in boys and the middle or distal part of the tibia; most patients have the onset age and first outpatient visit before 3 years; the major surgical complications are ankle valgus and limb length discrepancy.
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Affiliation(s)
- Yijun Zhou
- The First Affiliated Hospital of Ji'nan University (Guangzhou Overseas of Chinese Hospital), Guangzhou, China.,The First People's Hospital of Changde, Guangde Clinical Institute of Xiangya Medical College of South Central University, Changde, China
| | - Qian Tan
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Kun Liu
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Yaoxi Liu
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Guanghui Zhu
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Haibo Mei
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Ge Yang
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
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12
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Deng H, Mei H, Wang E, Li Q, Zhang L, Canavese F, Li L. The association between fibular status and frontal plane tibial alignment post-union in congenital pseudarthrosis of the tibia. J Child Orthop 2021; 15:261-269. [PMID: 34211603 PMCID: PMC8223089 DOI: 10.1302/1863-2548.15.200255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Controversy exists regarding fibular status related to tibial alignment after congenital pseudarthrosis of the tibia (CPT) achieves union. We aimed to determine whether fibular status affected frontal plane tibial alignment post-CPT union. METHODS Between January 2010 and December 2013, we followed 36 patients treated using a combined surgical technique (mean 6.6 years (2.2 to 9.4)). Outcome measures comprised medial proximal tibial angle, tibial diaphyseal angulation, lateral distal tibial angle (LDTA), relative intramedullary rod length and relative fibula length discrepancy. RESULTS The frequency of proximal tibial valgus deformity and ankle valgus deformity were significantly lower in the fibular integrity group than in the fibular un-integrity group (proximal tibial valgus deformity: 2/17 versus 11/19; p = 0.006; ankle valgus deformity: 10/17 versus 18/19; p = 0.016). The mean LDTA was notably higher in the fibular integrity group than in the fibular un-integrity group (81.2° (sd 6.7°) versus 71.3° (sd 6.6°); p < 0.001). A statistically significant difference was observed in relative fibula length discrepancy between patients with fibular integrity (0.06 (0 to 0.11); Malhotra grade 0, n = 6; Malhotra grade I, n = 11) and those without (0.24 (0.01 to 0.36); Malhotra grade 2, n = 2; Malhotra grade 3, n = 17; p < 0.001). Ankle valgus deformity had a significant positive correlation with proximal tibial valgus deformity (r = 0.402; p = 0.015). Patients with an intact and normal length fibula had a lower frequency of ankle valgus deformity than those with an intact but shortening fibula (1/6 versus 9/11; p = 0.035). CONCLUSION Shortening or pseudarthrosis of the fibula was associated with ankle valgus and proximal tibial valgus deformities post-CPT union. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Huajun Deng
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Haibo Mei
- Department of Pediatric Orthopaedics, Hunan Children’s Hospital, The Pediatric Academy of University of South China, Changsha, Hunan Province, China,Correspondence should be sent to: Haibo Mei, Department of Pediatric Orthopaedics, Hunan Children’s Hospital, The Pediatric Academy of University of South China, Changsha City 410007, Hunan Province, China, E-mail:
| | - Enbo Wang
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Qiwei Li
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Lijun Zhang
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Federico Canavese
- Lille University Center, Jeanne de Flandres Hospital, Department of Pediatric Orthopedics, Lille, France
| | - Lianyong Li
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China,Lianyong Li, Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang City 110004, Liaoning Province, China. E-mail:
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Wang X, Shi L, Zhang R, Wang W, Wang F, Wang M, Xu Z, Zuo R, Xu J, Kang Q. Efficacy of the "Eiffel tower" double titanium elastic nailing in combined management of congenital pseudarthrosis of the tibia: preliminary outcomes of 17 cases with review of literature. BMC Musculoskelet Disord 2021; 22:490. [PMID: 34049518 PMCID: PMC8162002 DOI: 10.1186/s12891-021-04382-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 05/18/2021] [Indexed: 01/03/2023] Open
Abstract
Background Difficulty in obtaining union, recurrent fractures, and residual deformities remain the problems challenging the management of congenital pseudarthrosis of the tibia (CPT). We applied the “Eiffel Tower” double titanium elastic nails (TENs) in the existing combined approach, which takes advantages of TEN’s mechanical stability with the protection against refracture, Ilizarov’s high fusion rate with alignment control and the biologic environment provided by bone grafting for bony union. The results of this procedure are presented and discussed. Methods Seventeen patients with CPT treated by combined surgery including pseudarthrosis resection, the “Eiffel Tower” double TENs technique, autogenous iliac bone grafting, and Ilizarov fixation between 2013 and 2019 were retrospectively investigated. Signs of bone union, limb length discrepancy (LLD), rate of refracture, and degree of residual deformities were reviewed. The AOFAS Ankle Hindfoot scale and measurement of ankle motion were used to evaluate ankle function. The mean follow-up time was 40.5 (11 to 91) months. Results The mean age at index surgery was 6.2 (2.5 to 15) years. Union of the pseudarthrosis was achieved in 100% of cases. Among them, 15 (88.2%) patients obtained union of the pseudarthrosis on the first attempt (primary union). The average time to primary union was 3.8 (2 to 6) months. The rest 2 cases achieved union after additional surgeries (secondary union). In terms of complications, refracture occurred in 2 patients (11.8%) and 4 patients (23.5%) developed pin infection. The mean limb length discrepancy at the final follow up was 33.4 (6–141) mm. The average AOFAS score improved from 38.2 (27 to 51) pre-operatively to 77 (63 to 87) post-operatively (p < 0.01). Conclusions The “Eiffel Tower” double TENs technique is an ideal intramedullary fixation method in the surgical treatment of CPT. The combination of TENs technique with bone grafting and Ilizarov fixation has the advantages of early bone union, less injury on metaphysis, and early functional recovery. Level of evidence Level IV.
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Affiliation(s)
- Xiaoyu Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Li Shi
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Rui Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Wenbo Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Feng Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Mengwei Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Ze Xu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Rongtai Zuo
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Jia Xu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Qinglin Kang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
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Reconstructive Approaches in Surgical Management of Congenital Pseudarthrosis of the Tibia. J Clin Med 2020; 9:jcm9124132. [PMID: 33371504 PMCID: PMC7767548 DOI: 10.3390/jcm9124132] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/14/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022] Open
Abstract
Treatment of congenital pseudarthrosis of the tibia remains a major challenge in pediatric orthopedics. Ideal timing and preference of surgical procedures are discussed controversially. A variety of reconstructive treatment strategies have been described in literature, but so far none has proven its superiority. The aim of treatment is to obtain long-term bone union, to prevent refracture, and to correct angular deformities and leg length discrepancies. This study retrospectively evaluates the outcome of different reconstructive strategies. Sixty-nine patients were identified who presented to our outpatient department between 1997 and 2019. Twenty-six of these patients underwent reconstructive surgical treatment and were included in this study. The study cohort was divided into three groups. Excision of the pseudarthrosis was performed in all patients in Group A and B, and in two patients of Group C. Group A (six/26 patients) received subsequent bone transport through external fixation maintaining original length. In Group B (15/26 patients), patients underwent either previous, simultaneous, or subsequent extrafocal lengthening through external fixation to reconstitute length. In Group C (five/26 patients), internal fixation with intramedullary nails was applied. Radiological and clinical evaluation was performed to assess bone union and complication rates. Results varied considerably between the study groups. Overall, the primary bone fusion rate was 69.2%. There were four refractures, all occurring in Group B. The long-term bone union rate without refracture was 53.8%. The overall complication rate was 53.8% and 23.1% showed persistent pseudarthrosis. Two secondary amputations were performed due to failed bone fusion. In conclusion, excision of the pseudarthrosis and extrafocal lengthening achieves a satisfying bone union rate and limb reconstruction, while bone transport does not offer significant advantages but shows higher complication rates. Intramedullary stabilization should be applied to maintain bone union, but shows lower bone union rates when used as a stand-alone treatment regimen. Regardless of the primary bone fusion rates, the probability of long-term bone union remains unpredictable.
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Zhong H, Ma S, Cen Y, Ma L, Li D, Liang B, Chen J, Zhang Y. A case report of early unilateral external fixation by 3D printing and computer-assisted and secondary bone graft internal fixation in pseudarthrosis of the tibia surgery. J Int Med Res 2020; 48:300060520945518. [PMID: 32972273 PMCID: PMC7522843 DOI: 10.1177/0300060520945518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Congenital pseudarthrosis of the tibia (CPT) is a rare congenital malformation. It is characterized by a tibial anterior bowing deformity or specific types of non-union, which typically result from abnormal development of the tibia, leading to the formation of local pseudarthrosis. The treatment of CPT is very challenging. The advent of 3D printing and computer-assisted techniques in recent years has provided a new ancillary technique for treatment planning and implementation. This case report describes the successful surgical treatment of a 14-year-old male that presented with a shortened limb deformity. Ahead of elective surgery, 3D printing and computer-assisted techniques were used to provide a 1:1 model of his left tibia, fibula and ankle joint to precisely determine the surgical procedure. The first surgery did not result in complete calcification of the tibial extension area, so a second proximal tibia iliac bone graft and internal fixation surgery was undertaken. Following regular follow-up and rehabilitation, by the 18-month follow-up, the proximal tibial bone graft had healed and the patient had resumed walking with a normal gait. This case report describes in detail the successful use of unilateral external fixation using the Ilizarov technique, 3D printing and computer-assisted orthopaedic surgery in the planning of treatment for CPT.
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Affiliation(s)
- Hua Zhong
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Sushuang Ma
- Department of Traumatology, The Zhanjiang Central People's Hospital, Zhanjiang, Guangdong Province, China
| | - Yibiao Cen
- Department of Orthopaedics, Lianjiang People's Hospital, Zhanjiang, Guangdong Province, China
| | - Limin Ma
- Department of Orthopaedics, Guangdong General Hospital, Guangdong Academy of Medical Sciences, South China University of Technology, Guangzhou, Guangdong Province, China
| | - Deqiang Li
- Department of Traumatology, The Zhanjiang Central People's Hospital, Zhanjiang, Guangdong Province, China
| | - Bo Liang
- Department of Traumatology, The Zhanjiang Central People's Hospital, Zhanjiang, Guangdong Province, China
| | - Jin Chen
- Department of Traumatology, The Zhanjiang Central People's Hospital, Zhanjiang, Guangdong Province, China
| | - Yu Zhang
- Department of Orthopaedics, Guangdong General Hospital, Guangdong Academy of Medical Sciences, South China University of Technology, Guangzhou, Guangdong Province, China
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16
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Kocaoğlu M, Eralp L, Bilen FE, Civan M. Congenital pseudarthrosis of the tibia: Results of circular external fixation treatment with intramedullary rodding and periosteal grafting technique. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:245-254. [PMID: 32442122 DOI: 10.5152/j.aott.2020.03.26] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE This study investigated the clinical and functional results of treating congenital pseudarthrosis of the tibia (CPT) using the combined techniques of hamartoma resection, periosteal grafting, circular external fixator application, and intramedullary rodding. METHODS The clinical and radiological data of 17 patients (mean age at the treatment time: 7.6 months (range: 4.6-9.7 months) with CPT, treated by a single surgeon between 1997 and 2017, were retrospectively analyzed. All data regarding surgical interventions, complications, deformity analysis parameters, limb length discrepancy (LLD), ankle joint range of motion, and residual deformities were reviewed. All the patients were followed up at least two years after the last surgical intervention. The mean follow-up time was 8.5 years (range: 2.2 to 15.7 years). RESULTS Union was achieved with the index treatment in 15 of the 17 cases (88.2%). The mean age of the patients at the last follow-up visit was 14.2 years (range: 7.6 to 22.1). The mean LLD was 2.1 cm. Nine patients had radiological ankle valgus at the last follow-up. In the entire series, eight patients did not display any complications, four cases reported minor complications, and five cases were complicated by refractures. CONCLUSION Circular external fixator application combined with periosteal grafting is a superior method of CPT treatment. This method provides a healthy biological healing environment while correcting the mechanical problems. The combination of periosteal and cancellous bone grafts with intramedullary rods and an external fixator addresses issues that complicate obtaining and maintaining a union during the CPT treatment. LEVEL OF EVIDENCE Level IV, Therapeutic study.
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Affiliation(s)
| | - Levent Eralp
- Department of Orthopaedics and Traumatology, İstanbul University, İstanbul School of Medicine, İstanbul, Turkey
| | - Fikri Erkal Bilen
- Department of Orthopaedics and Traumatology, Yeni Yüzyıl University, School of Medicine, İstanbul, Turkey
| | - Melih Civan
- Department of Orthopaedics and Traumatology, Gaziosmanpaşa Training and Research Hospital, İstanbul, Turkey
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Liu Y, Yang G, Liu K, Wu J, Zhu G, Tang J, Zheng Y, Mei H. Combined surgery with 3-in-1 osteosynthesis in congenital pseudarthrosis of the tibia with intact fibula. Orphanet J Rare Dis 2020; 15:62. [PMID: 32122367 PMCID: PMC7053109 DOI: 10.1186/s13023-020-1330-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/07/2020] [Indexed: 02/07/2023] Open
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).
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Affiliation(s)
- Yaoxi Liu
- Department of pediatric orthopaedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 ziyuan road, yuhua district, Changsha City, Hunan Province, 410007, People's Republic of China
| | - Ge Yang
- Department of pediatric orthopaedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 ziyuan road, yuhua district, Changsha City, Hunan Province, 410007, People's Republic of China
| | - Kun Liu
- Department of pediatric orthopaedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 ziyuan road, yuhua district, Changsha City, Hunan Province, 410007, People's Republic of China
| | - Jiangyan Wu
- Department of pediatric orthopaedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 ziyuan road, yuhua district, Changsha City, Hunan Province, 410007, People's Republic of China
| | - Guanghui Zhu
- Department of pediatric orthopaedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 ziyuan road, yuhua district, Changsha City, Hunan Province, 410007, People's Republic of China
| | - Jin Tang
- Department of pediatric orthopaedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 ziyuan road, yuhua district, Changsha City, Hunan Province, 410007, People's Republic of China
| | - Yu Zheng
- Department of pediatric orthopaedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 ziyuan road, yuhua district, Changsha City, Hunan Province, 410007, People's Republic of China
| | - Haibo Mei
- Department of pediatric orthopaedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 ziyuan road, yuhua district, Changsha City, Hunan Province, 410007, People's Republic of China.
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Abstract
PURPOSE OF REVIEW Congenital pseudoarthrosis of the tibia and fibula are rare conditions that share common treatment strategies. The purpose of this review is to provide an overview of the recent developments in treatments for both conditions. RECENT FINDINGS Recent literature has focused on the use of BMP and on gait analysis as a tool for measuring long-term functional outcomes. Recent study has indicated rhBMP-2 may shorten the time to initial healing of pseudoarthroses, but not guarantee bony union. Children with initial fractures before the age of four have been shown to have long-term gait outcomes that may be ultimately comparable to children with prostheses. Both congenital pseudoarthrosis of the tibia and fibula are challenging conditions to treat, which require comprehensive approaches to account for both the biological and mechanical components of the conditions.
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Affiliation(s)
- Katherine A Eisenberg
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Carley B Vuillermin
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
- Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA.
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Paley D. Congenital pseudarthrosis of the tibia: biological and biomechanical considerations to achieve union and prevent refracture. J Child Orthop 2019; 13:120-133. [PMID: 30996736 PMCID: PMC6442511 DOI: 10.1302/1863-2548.13.180147] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED Congenital pseudarthrosis of the tibia (CPT) is likely to be a primary periosteal disease and secondary bone disease. The primary goal of treatment is to obtain union, correct the diaphyseal deformity, correct any proximal fibular migration and prevent refracture. The pathobiology demonstrates increased osteoclasis by the surrounding fibrous hamartoma and reduced osteogenesis and bone morphogenic protein production by the bone. This leads to a loss of remodelling potential and gradual bowing and atrophy of the bone with eventual fracture of the tibia and or fibula. This recommends the synergistic use of bisphosphonates and bone morphogenic protein. The pathomechanics of CPT implicate the anterolateral bowing, narrow diameter of the atrophic bone ends and proximal fibular migration. These biomechanical factors can be addressed by means of straightening of the deformity, intramedullary support of both bones, stable fixation and reduction of proximal migration of the fibula. A summary of the literature on CPT shows that the mean probability of achieving primary union without refracture, by most treatments is 50% (12% to 80%). Two recent studies have shown a much higher success rate approaching 100%, by creating a cross-union between the tibia and fibula. The cross-union with intramedullary reinforcement of the bone makes refracture unlikely due to the cross-sectional area of union with its two-bar linkage. A new classification to guide such treatment is also proposed. LEVEL OF EVIDENCE V - expert opinion.
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Affiliation(s)
- D. Paley
- Paley Orthopedic and Spine Institute, West Palm Beach, Florida, United States, Correspondence should be sent to Dr. Dror Paley, Paley Orthopedic and Spine Institute, 901 45th St. Kimmel Building, West Palm Beach, Florida 33407, United States. E-mail:
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20
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Vaidya SV, Aroojis A, Mehta R, Agashe MV, Dhawale A, Bansal AV, Sarathy K. Short Term Results of a New Comprehensive Protocol for the Management of Congenital Pseudarthrosis of the Tibia. Indian J Orthop 2019; 53:736-744. [PMID: 31673175 PMCID: PMC6804390 DOI: 10.4103/ortho.ijortho_155_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment of Congenital Psuedarthrosis of Tibia (CPT) often poses significant challenges due to difficulty in achieving union and subsequent complications like refractures, implant failures, etc. Our new comprehensive protocol is aimed at achieving crossunion between the tibia and fibula. AIMS AND OBJECTIVES The aim of the present study is to evaluate the short-term results of our new protocol and to compare the results with our previously used techniques. MATERIALS AND METHODS 10 patients with mean age 2.35 years (1 to 6.5 years) who were treated by our new comprehensive protocol were included in Group A, and 11 patients with mean age 2 years (1 to 5.5 years) who primarily underwent intramedullary rodding with bone graft were included in Group B. The new comprehensive protocol consisted of pre-operative Zolendronate infusion, surgery consisting of intramedullary fixation of tibia supplemented with Ilizarov ring fixator and bone grafting aimed at achieving tibia-fibula cross-union. Retrospective evaluation of serial radiographs was performed and outcomes with respect to union and subsequent complications were analysed. RESULTS 10/10 (100%) patients in Group A united, whereas union was achieved in only 8/11 (72%) patients in Group B. The index surgery was successful in achieving union in all 10 patients in Group A, whereas in Group B 2.25 (1 to 4) surgeries were needed to achieve union. The time to union was significantly shorter in Group A (4.68 months) as compared to Group B (30.88 months). The cross sectional area of union was significantly greater in Group A (3.82 cm2) as compared to Group B (1.18 cm2). One patient in Group A needed a subsequent corrective osteotomy for tibial valgus, and one patient underwent tibia lengthening; whereas in Group B, two patients needed corrective osteotomes for residual malaligments. CONCLUSION Our study demonstrates that the new comprehensive protocol is extremely effective for achieving sound union in Congenital Pseudarthrosis of Tibia.
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Affiliation(s)
- Sandeep Vijaykumar Vaidya
- Department of Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India,Address for correspondence: Dr. Sandeep Vijaykumar Vaidya, Pinnacle Orthocentre Hospital, 1st/2nd Floor, Blue Nile Commercial Complex, Chandanwadi Signal, Junction of LBS Marg and Almeida Road, Thane West, Thane - 400 602, Maharashtra, India. E-mail:
| | - Alaric Aroojis
- Department of Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Rujuta Mehta
- Department of Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Mandar Vikas Agashe
- Department of Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Arjun Dhawale
- Department of Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Ankita Vijay Bansal
- Department of Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Kailash Sarathy
- Department of Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
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21
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Abstract
Currently, the timing of surgery for congenital pseudarthrosis of the tibia (CPT) remains controversial. The aim of this study was to investigate the results of treatment of pseudarthrosis of the tibia in children younger than 3 years of age. A retrospective study was carried out to explore the relationship between postoperative complications and the age of surgery in children with CPT. The analysis was carried out on 42 patients with Crawford type IV CPT treated with a combined surgical technique between 2008 and 2012. Patients were divided into two groups according to their age: group A (<3 years) and group B (>3 years). The incidence rates of refracture, ankle valgus, tibial valgus, and limb-length discrepancy of the two groups were evaluated. Primary bone union was achieved in 28 out of 29 (97%) patients in group A and 12 out of 13 (92%) patients in group B (P>0.05). In group A, six (21%) patients developed a refracture; 14 (48%) patients had ankle valgus with a mean degree of 11° (range: 5°-25°); 11 (38%) patients had tibial valgus with a mean tibial valgus deformity of 8.6° (range: 5°-20°); and 12 (41%) patients had limb-length discrepancy with a mean limb length of 2.9 cm (range: 0.5-4 cm). In group B, five (38%) patients developed refracture; seven (54%) patients had ankle valgus with a mean degree of 14° (range: 5°-30°); seven (54%) patients had tibial valgus with a mean tibial valgus deformity of 10.7° (range: 5°-20°); and 10 (77%) patients had limb-length discrepancy with a mean limb length of 2.8 cm (range: 1.5-3 cm). Groups A and B were significantly different in limb-length discrepancy (P=0.033). This study suggests that there is no need to defer surgery for pseudarthrosis of the tibia until the child is older than 3 years of age.
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