gms | German Medical Science

Objectives: Treatment of congenital pseudarthrosis of the tibia (CPT) remains one of the biggest challenges in pediatric orthopedics. Ideal timing and preference of surgical procedures are discussed controversially. Various reconstructive treatment strategies exist, but to date none has proven its superiority. The aim of treatment is to obtain long-term bone union, to prevent refracture, and to correct leg length discrepancies and angular deformities.

Methods: This study retrospectively evaluates the outcome of 3 different reconstructive strategies in treatment of CPT. 26 patients (16 female, 10 male) who had received reconstructive treatment between 1997 and 2019 were included. The study cohort was divided into 3 groups (A, B, and C). Pseudarthrosis excision was performed in all patients in Group A and B, and in two patients of Group C. Group A (6/26 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 (5/26 patients), internal fixation with intramedullary nails was applied. Radiological and clinical evaluation was performed to assess bone union, complication and refracture rates.

Results and Conclusion: Results varied considerably between the study groups. Overall, the primary bone fusion rate was 69%. There were four refractures, all occurring in Group B. The long-term bone union rate without refracture was 54%. The overall complication rate was 54%, and 23% showed persistent pseudarthrosis. Two secondary amputations were performed due to failed bone fusion. Patients with prior surgeries showed higher bone union rates than patients for whom the reconstructive procedure investigated was the index procedure, both in regard of primary as well as long-term bone union.

In reconstructive treatment of CPT, excision of the pseudarthrosis and acute compression followed by extrafocal lengthening and subsequent intramedullary stabilization achieves satisfying results regarding bone union rates and restoration of physiological limb alignment. Bone transport, on the other hand, shows a higher complication rate, but should be preserved for cases of extensive bone defects. Intramedullary stabilization should be applied to maintain bone union, but shows lower bone union rates when used as a stand-alone treatment regimen. Maintenance of long-term bone union without refracture remains difficult and can only be achieved for approximately 50%, regardless the chosen treatment approach. However, accompanying factors such as previous failed surgeries might be less crucial than generally assumed (Figure 1 [Fig. 1]).