Functional and radiological outcomes after treatment of congenital pseudarthrosis of the tibia using the Ilizarov technique: a retrospective single-center study

BACKGROUND

Congenital pseudarthrosis of the tibia (CPT) is a challenging problem in orthopedic practice, with high rates of non-union, refracture, and residual deformities. After union, long-term follow-up is required to manage late post-union complications. This study aimed to assess the outcomes of the Ilizarov technique in the management of CPT.

MATERIALS AND METHODS

This retrospective study included patients with CPT treated with the Ilizarov method between 2005 and 2018. Intramedullary rods were used in 9 cases and iliac bone graft was used in 12 cases. An orthosis was applied till the end of follow-up in all cases. The American Orthopaedic Foot and Ankle Society (AOFAS) scale was used for the evaluation of the functional outcomes.

RESULTS

This study included 16 patients, 11 males and 5 females, with an average age of 5.4 ± 2.8 years. Seven cases had multiple previous surgeries. Six patients had neurofibromatosis. The mean follow-up period was 5.8 ± 3.4 years. The average AOFAS score improved significantly from 47.5 ± 7.6 preoperatively to 78.9 ± 8.9 at the latest follow-up. Union was achieved in 15 cases, and persistent non-union occurred in one case. The clinical results were excellent in one patient, good in seven cases, fair in 6, and poor in 2 cases. The radiological results were excellent in one patient, good in seven cases, fair in seven, and poor in one case.

CONCLUSIONS

The Ilizarov technique combined with intramedullary rod and primary or secondary bone graft provides a high union rate of CPT and can achieve simultaneous effective management of problems related to pseudarthrosis, including non-union, deformity, limb shortening, and adjacent joint contracture and subluxation. Level of evidence Level IV.

Congenital pseudarthrosis of the clavicle: a systematic review

PURPOSE

There is no consensus on the type of surgical treatment of congenital pseudarthrosis of the clavicle due to its rarity. The purpose of this study is to provide evidence in favor of a surgical technique and to explore factors correlated with bone consolidation.

METHODS

Systematic review of the literature and an analysis of the data for each subject, including all available subjects from the published series and clinical cases since 1990. Fisher's exact tests or T-tests were used to evaluate the effect of independent variables (age at surgery and type of treatment) on bone healing.

RESULTS

The literature search provides 305 articles; 30 were selected, reporting 191 patients and 194 clavicles. One hundred and fifty-one clavicles were operated on at a mean age of nine years and four months (from 8 months to 21 years). Thirteen clavicles (8, 6%) had not consolidated at the last follow-up. Concerning the type of fixation, the rate of healing was similar for plates and pins (p = 0.27). The rate of consolidation was higher with autograft than with allograft, xenograft, or no graft (p = 0.00001), and was 100% for vascularized graft. The mean age at surgery was higher for patients who healed at the last follow-up (118 vs. 61 months, p = 0.001).

CONCLUSION

In the event of surgical indication for congenital pseudarthrosis of the clavicle, it is recommended to perform autograft and stable fixation (level 4) after seven years old (level 4).

Salvage of congenital pseudarthrosis of the tibia by the induced membrane technique followed by a motorised lengthening nail

An 18-year-old male with neurofibromatosis type I was treated for congenital pseudarthrosis of the tibia using the Masquelet induced-membrane technique with internal fixation by retrograde implantation of a transplantar intramedullary nail. Bone healing was obtained at the expense of malunion with external rotation and 5.5cm of lower limb shortening. A motorised intramedullary-lengthening nail (Fitbone^®, Wittenstein, Igersheim, Germany) was implanted. This treatment was successful in correcting the rotational malalignment and limb length discrepancy. The motorised nail Fitbone^® may be a valid option for treating complex cases of limb length discrepancy, including those combined with limb deformities.

Surgical technique and indications of the induced membrane procedure in children

The induced membrane technique is now quite adaptable to segmental bone reconstruction in children. This technique is much the same as the technique used in adults. A cement spacer is interposed, and in a second operating phase, occurring 6 weeks after the interposition of the spacer, the cement is removed and a morselized corticocancellous graft is installed in the induced membrane that had formed around the cement. Graft expansion using allograft chips should not exceed 30% of the total volume. An additional autograft strut is useful in the reconstruction of long femoral or metaphyseal-diaphyseal tibial defects. Despite the apparent simplicity of this technique, it requires rigorous technique during cement sleeving and to stabilize the defect to prevent nonunion, stabilization device loosening, or resorption of the graft, the main complications. This technique is now becoming the gold standard for bone reconstruction in trauma and septic bone surgery. In pediatrics, the Masquelet technique is now mainly used in the context of cancer surgery reconstructions. Constraints related to chemotherapy have led to deferral of the graft, which is therefore empirically performed 8 weeks after the last course of chemotherapy. Congenital anomalies, including congenital pseudarthrosis, may now be treated using this technique, replacing long and difficult conventional treatment. A longer follow-up would be necessary to assess and confirm the superiority of this pediatric reconstruction technique.

Masquelet's procedure and bone morphogenetic protein in congenital pseudarthrosis of the tibia in children: a case series and meta-analysis

PURPOSE

A type 2 recombinant human bone morphogenetic protein (rhBMP2) and Masquelet's procedure were used in three children presenting with congenital pseudarthrosis of the tibia (CPT). Recent studies on CPT suggested the presence in situ of pathologic tissues promoting pseudarthrosis. The authors hypothesized that large segmental resection of pseudarthrosis could improve prognosis of the CPT. Masquelet's procedure and rhBMP2 have been advocated for the treatment of long bone defect.

METHOD

The authors report three cases of CPT in children treated with Masquelet's procedure and application of rhBMP2. They analyzed all published cases of CPT similarly treated.

RESULTS

In the present study, Masquelet's procedure did not improve the results in the treatment of CPT, but segmental bone reconstruction was possible. Bone healing was obtained in three out of the five applications of rhBMP2. In one case, the patient's parents asked for leg amputation. Analysis of the 33 published cases with the application of BMP in CPT points to a 62 % healing rate in this pathology.

CONCLUSION

The authors confirmed that segmental bone reconstruction is possible in CPT using Masquelet's procedure. In the literature, the success rate of the application of rhBMP in CPT appears to be lower than the healing rate usually reported without BMP. Nevertheless, the strict selection of patients, limited number of cases, and their heterogeneity make interpreting the results difficult. However, the theoretical risk which the children are exposed to during the use of BMP makes rigorous selection of the indications necessary. Finally, the interest of rhBMP2 application in Masquelet's procedure remained to be proven.