Congenital pseudarthrosis of the tibia treated with a combination of Ilizarov’s technique and intramedullary rodding

Figures & data

Table 1. Demographics of the patients with congenital pseudoarthrosis of the tibia who were treated with combination of Ilizarov apparatus and intramedullary nailing

A	B	C	D	E	F	G	H	I	J	K	L	M
1	L	M	5	6	5	50	I	N	40	65	1.5	1
2	R	F	5	7	8	75	II	N	57	70	2	1
3	L	M	7	7	3	38	I	Y	30	65	4	3.2
4	R	M	3.5	5	4.5	40	I	N	48	60	2	1
5	R	F	7.5	7.5	3.5	44	I	Y	44	70	5	3
6	R	M	12	12	5	65	II	Y	20	60	2.5	2
7	R	M	3	5	6	50	I	N	54	65	1.5	1.5
8	L	M	4.5	8	9.5	72	I	N	30	65	2	2
9	R	F	6	9	4	18	I	Y	30	58	2	1
10	R	M	5	9	8	50	I	N	44	66	2	1.6
11	L	M	7	7	3	40	II	Y	35	65	2.5	1.5
12	R	F	7.5	9	8.5	88	I	Y	30	55	2	2
13	L	M	4.5	4.5	3.5	46	I	Y	44	75	2.5	2
14	R	F	6	8	6	50	I	Y	38	47	2.5	1.9
15	R	M	5	6	5	54	I	N	56	75	1.5	1.5

A No

B Side

C Sex

D Age at presentation (years)

E Age at surgery (years)

F Follow-up from presentation (years)

G Follow-up from index surgery (months)

H Boyd classification

I Previous surgery

J AOFAS score preoperatively

K AOFAS score postoperatively

L Pre-op LLD (cm)

M LLD at final follow-up (cm)

Table 2. Patient-related data in the two groups. In group I, no surgery had been performed prior to index surgery and in group II one or more operations had been performed before the index surgery

	Group I	Group II
Previous surgery	No	Yes
No. of patients	7	8
Boyd classification
type I	6	6
type II	1	2
Average age at presentation, years	4.4	7.2
Average age at index surgery, years	6.5	8.0
Average age at final follow-up, years	11	12
Average follow-up, months	55	47
Union
primary	6	0
secondary	1	7
non-union	0	1
AOFAS score preoperatively	47	34
AOFAS score postoperatively	67	62

Figure 1. A. Anteroposterior and lateral radiographs from a 6-year-old boy with Boyd type-I congenital pseudoarthrosis of the tibia.

B. Anteroposterior and lateral radiograph of the same patient who was operated elsewhere with attempted four-in-one fusion. At presentation, the child had minimal discharge of pus over the lateral fibular non-union, and had abnormal mobility at the distal third of the tibia. [OK???] Radiographs showed persistent non-union and 40° valgus deformity.

C. Anteroposterior and lateral radiographs of the child after excision of sclerotic bone ends, antegrade nailing, and application of the Ilizarov method. D. Anteroposterior and lateral radiographs of the child 2 years after surgery, showing well-united tibia with acceptable axial alignment.

D. Anteroposterior and lateral radiographs of the child 2 years after surgery, showing well-united tibia with acceptable axial alignment.

Table 3. Complications and results for patients with congenital pseudoarthrosis of the tibia who were treated with Ilizarov technique and intramedullary nailing

No	Minor complication	Treatment	Major complication	Treatment	Final outcome	Clinical grade
1	Pin-tract infection	Non-operative	–	–	Primary union	Good
	Ankle stiffness	Non-operative	–	–	–	–
2	Pin-tract infection	Non-operative	Delayed consolidation	Corrective osteotomy	Secondary union	Fair
	Equinus	Non-operative	Valgus malalignment	with bone graft	–	–
3	Pin-tract infection	Wire change	Delayed consolidation	–	Secondary union	Fair
4	Pin-tract infection	Non-operative	–	–	Primary union	Good
5	Pin-tract infection	Wire change	Delayed consolidation	Supramalleolar osteotomy	Secondary union with	Fair
	Knee flexion contracture	Non-operative	Valgus malalignment	with bone graft	good alignment
6	Pin-tract infection	Non-operative	–		Primary union	Good
7	Pin-tract infection	Non-operative	Delayed consolidation	DBM application	Secondary union	Fair
	Ankle stiffness	Non-operative	–	–	–	–
8	Pin-tract infection	Non-operative	–	–	Primary union	Good
9	Pin-tract infection	Wire change	Delayed consolidation	Bone grafting with refixation	Secondary union	Fair
	Knee flexion contracture	Non-operative	–	–	–	–
	Equinus	Non-operative	–	–	–	–
10	Pin-tract infection	Non-operative	–			Fair
11	Pin-tract infection	Non-operative	Delayed consolidation (bone transport)	Bone grafting with plating	Secondary union	Fair
12	Pin-tract infection	Wire change	Delayed consolidation	Bone grafting with plating	Secondary union	Fair
	Ankle stiffness	Non-operative	Refracture
13	Pin-tract infection	Non-operative	–	–	Primary union	Good
14	Pin-tract infection	Removal of apparatus	Non-union	Amputation advised	Non-union	Poor
15	Pin-tract infection	Non-operative	–	–	Primary union	Good

Figure 2. A. Anteroposterior and lateral radiographs from an 8-year-old boy with Boyd type-I congenital pseudoarthrosis of the tibia who was operated multiple times with Ilizarov apparatus and attempted four-in-one fusion. At presentation, the child had frank non-union with sclerotic bone ends with 2.5 cm shortening.

B. Anteroposterior and lateral radiographs from the child after attempted Ilizarov fixation with intramedullary rodding. The intramedullary rod had to be removed due to infection, and there was severe ankle valgus.

Table 4. Comparison of the present series with other series

Author (year)	No. of patients	Method used	Follow-up, years	Delayed/ non-union	Refracture	Malalignment	Amputation
Dobbs et al. (2004)	21	Intramedullary nailing, bone grafting	14.2	3	12	–	5
Cho et al. (2008)	43	Ilizarov	9.2	1	19	–	–
Shah et al. (2011)	11	Retrograde IM nailing, bone grafting	15.2	2	6	8	–
Mathieu et al. (2008)	10	Ilizarov + ante/retrograde nailing	4.0	2	1	3	–
Present series (2012)	15	Ilizarov + antegrade nailing + plating
		in some cases	4.5	8	1	2	1 advised