Congenital pseudarthrosis of the tibia: Rate of and time to bone union following contralateral vascularized periosteal tibial graft transplantation

Abstract

Introduction: Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging orthopedic disorders. The use of a vascularized tibial periosteal grafts has been recently reported as a powerful tool to obtain bone union. We report its use in CPT.Patients and Methods: Retrospective short-term study of 29 children (18 male/11 female, 15 right-sided/14 left-sided) of mean age 45 months (range 11-144 months), operated upon after October 2014.Nonunion site was debrided, and the periosteum of the involved limb was excised. A vascularized tibial periosteal graft (mean length 10.7 cm (range 9-15 cm) with a monitoring skin island (mean length 4.1 cm (range 3-5 cm) and based on the anterior tibial vessels, was obtained from the contralateral tibia. Anterior tibial vessels were always the recipient vessels. Most cases were stabilized with an LCP plate.The rate of and time to bone union were analyzed. Charts only were evaluated through the first 3 months after bone union was achieved. Results:The flap survived and bone union was obtained in all cases, through a periosteal callus, in a mean time of 5.1 weeks (range 3-6 weeks). Mean follow-up was 8.3 months (range 7-19 months). No union failures occurred 3 months after resuming unprotected weight bearing.Conclusions: Our novel technique produced a consistent, rapid capacity for CPT union, superior to previously-reported techniques. However, it cannot be recommended as a standard method of treatment until consistent, long-term, refracture-free follow-up is documented.

Anterolateral congenital tibial bowing: case report

“…We are all confident and hopeful for the other existing surgical trends that are all showing excellent outcomes for CPT and its complications, achieving bone union, reducing re-fracture and the morbidity of multiple surgical procedures, and not least the decreasing of the percentage of amputation rate ( 15 , 19 , 20 ).…”

“…Several recent studies on the surgical treatment for CPT are now available in the literature that are showing encouraging results, such as: “Congenital pseudarthrosis of the tibia: Rate of and time to bone union following contralateral vascularized periosteal tibial graft transplantation” ( 15 ); the “Cross-Union Technique” ( 8 ); “Distal Tibial Guided Growth for Anterolateral Bowing of the Tibia: Fracture may be prevented” ( 21 ); and “Does An Osteotomy Performed in Congentital Pseudarthrosis of the Tibia Heal?” ( 19 ).…”

“…Thus, periosteal replacement addresses the pathogenesis of this disorder. As early as 1906, Codivilla proposed the concept of periosteal substitution ( 14 , 15 ).…”

“…Together, these approaches have resulted in an amputation rate of 50% due to failure to achieve union in 20%–50% of cases and the occurrence of re-fractures in 30% of patients ( 18 ). The reported rate of bone union using several surgical techniques was 20%–50%, while bone union has been achieved in 100% of the cases treated with contralateral vascularized periosteal tibial graft transplantation ( 15 ). Longer follow-up for a refracture-free rate is needed to consider it safe enough to recommend it as a standard approach.…”

“…Vascularized fibular grafting and induced membrane techniques can be successful but at the cost of numerous surgical procedures. Growth modulation is a promising new approach to preventing fractures altogether, though further study with larger patient series is necessary ( 15 – 22 ).…”