Treatment of congenital pseudarthrosis of the tibia with vascularized fibular periosteal transplant

The vascularized fibular periosteal flap has been recently described and showed solid angio and osteogenic features. We report the use of a free vascularized fibular periosteal transplant in the treatment of a El-Rosasy-Paley Type III congenital pseudarthrosis of the tibia in a 7-year-old boy, with a prior unsuccessful surgery at the age of three. The contralateral fibular periosteum was used to replace two-thirds of the hamartomatous tibial periosteum. We did not proceed to debriding the focus of the pseudarthrosis nor addressed the tibial recurvatum or revised the previous tibial rod. Consolidation was achieved radiologically at 3 months, allowing for the tibial rod to be removed. One year postoperatively, the patient ambulated without the use of a protective orthesis and resumed his sports practice. This novel pathogenesis-based technique showed promising results and a prompt healing of such a difficult orthopedic condition.     

Long-term follow-up on the use of vascularized fibular graft for the treatment of congenital pseudarthrosis of the tibia

Background  

Congenital pseudoarthrosis of the tibia (CPT) is one of the most difficult conditions to treat.     

Congenital pseudarthrosis of the tibia: treatment with free vascularized fibular grafts

We used free vascularized fibula transfers to treat 12 patients with congenital pseudarthrosis of the tibia. The mean age at surgery was 6.5 years, and the average follow-up was 3.4 years. Only one patient had persistent nonunion at the time of last follow-up, but he had 2.2 operations after the initial vascularized procedure. Problems included delayed union at the distal anastomosis and refracture. Union can be achieved in most patients, but attention to technical detail is very important. All angulation must be corrected and, at the first sign of delayed union, the site should be regrafted and intramedullary fixation should be used.     

Free vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia

Five patients with congenital pseudarthrosis of the tibia treated by a free vascularized fibular graft are described. Follow-up evaluation ranged from 15 to 81 months, with a mean of 40 months. Bony union was attained in three of five cases as determined roentgenographically. The remaining two cases failed to attain bony union. All cases except one, who was treated with a below-knee amputation, subsequently attained bony union. However, four cases had five fractures after bony union. We discussed unsolved problems regarding the free vascularized fibular graft and fracture after bony union.     

Vascularised fibular graft for congenital pseudarthrosis of the tibia. Long-term results

Five children with congenital pseudarthrosis of the tibia treated by free vascularised fibular grafts were followed up until skeletal maturity. The ipsilateral fibula was used in four cases, the contralateral fibula in one. All our cases achieved bone union, but leg length discrepancy, atrophy of the foot and ankle stiffness were frequent complications, due perhaps to the many previous operations. Vascularised fibular grafting might achieve better results if it were done as the primary procedure.     

Free vascularised fibular graft in the treatment of congenital pseudarthrosis of the tibia

Five cases of congenital pseudarthrosis of the tibia successfully treated by a free vascularised fibular graft are described. Follow-up ranged from 5 to 34 months with a mean of 17.5 months. The technique, which includes radical excision of abnormal bone and soft tissue around the pseudarthrosis, also permits primary bone lengthening, and correction of deformity. The early results indicate that satisfactory bony union is achieved in a relatively short period of time.     

Treatment of congenital pseudoarthrosis of the tibia by a free vascularized fibular graft: Case report

A free vascularized fibular graft was used to treat a case of congenital pseudoarthrosis of the tibia in a 5-year-old girl. Four weeks after the surgery, x- ray films revealed remarkable callus formation at the proximal junction of the graft and tibia. Seventeen months passed before union at this junction was complete. Union at the distal junction, on the other hand, took only 12 weeks. It was noted that the fibular graft enlarged in diameter rapidly, and at 17 months was the same size as the recipient tibia.     

Use of free vascularized fibular graft for congenital ulnar pseudarthrosis: surgical decision making in the growing child

Congenital pseudarthrosis of the ulna may cause growth disturbance and progressive forearm deformity, leading to functional compromise of the upper extremity. Treatment is challenging, and surgical decision making must take into account three goals of treatment: bony healing, distal radioulnar joint (DRUJ) stability, and continued skeletal growth. Four cases of congenital ulnar pseudarthrosis treated with free vascularized fibular graft are presented here. In two cases, the vascularized fibular graft included the proximal fibular epiphysis to reconstruct the DRUJ and ulnocarpal joints. Average age of the four patients at time of vascularized fibular grafting was 10 years (range 3-16 years). Patients had undergone up to three previous failed operations. A step-cut osteotomy technique with rigid internal fixation was used in all patients. Donor-site distal tibiofibular arthrodesis was performed in skeletally immature patients when appropriate. At average follow-up of 60 months (range 33-83 months), all patients achieved bony union with full wrist range of motion compared with the contralateral extremity. The DRUJ was stable in all patients. Two skeletally immature patients with concomitant epiphyseal transfer showed continued skeletal growth. Two patients nearing skeletal maturity achieved revascularization of the distal ulna. Free vascularized fibular grafting is a successful option in the treatment of congenital ulnar pseudarthrosis. Reconstruction of the distal radioulnar and ulnocarpal joints using concomitant proximal fibular epiphyseal transfer should be considered in the skeletally immature patient with distal ulnar involvement.     

Hip resurfacing after failed free vascularized fibular graft

Metal-on-metal resurfacing of the hip is a bone sparing arthroplasty that may be an option when a head-sparing nonarthroplasty option fails. We present the first published report of 5 cases of failed free vascularized fibular graft treated with modern hip resurfacing arthroplasty. This selected group of patients had avascular necrosis with less than 20% head involvement and cysts less than 1 cm in diameter. Follow-up ranging from 2 to 5 years (mean, 38 months) showed improvement in hip function without evidence of prosthesis loosening. There were no femoral neck fractures or revisions. A vascularized fibular bone graft does not prevent good early results with hip resurfacing but may add technical complexity owing to its position within the femoral head and neck.     

Free vascularized fibular graft for tibial pseudarthrosis in neurofibromatosis

Four patients with neurofibromatosis and a dysplastic type of congenital pseudarthrosis of the tibia were treated by resection of the lesion and reconstruction of the extremity with a free vascularized fibular graft. Solid union of the graft was achieved within 3 months in 3 children. However, valgus malalignment of the tibia progressed in all 3. One child was treated with resection of a lateral fibrotic band and another with distal tibial epiphysial distraction and realignment. In the fourth patient, who was skeletally mature, a nonunion developed proximally.     

带血管蒂的逆行腓骨移植治疗先天性胫骨假关节25例报告

目的 提高先天性胫骨假关节治疗水平。方法 对先天性胫骨假关节25例患者采用带血管蒂的同侧腓骨逆行移植治疗。结果 其中23例均在术后3－6个月愈合,效果良好。结论 此方法所移植的腓骨具有丰富的血供,长度理想,能保证病变的胫骨切除长度,骨愈合快,操作简单,不损伤健侧,成功率高,易于被患儿家长所接受。     

Free vascularized fibular graft for tibial pseudarthrosis in neurofibromatosis

Four patients with neurofibromatosis and a dysplastic type of congenital pseudarthrosis of the tibia were treated by resection of the lesion and reconstruction of the extremity with a free vascularized fibular graft. Solid union of the graft was achieved within 3 months in 3 children. However, valgus malalignment of the tibia progressed in all 3. One child was treated with resection of a lateral fibrotic band and another with distal tibial epiphysial distraction and realignment. In the fourth patient, who was skeletally mature, a nonunion developed proximally.     

Lengthening in free vascularized fibular graft

A free vascularized fibular bone transfer was successfully performed in a 1-year-old child to reconstruct the loss of the right humeral shaft following neonatal osteomyelitis. Subsequent growth of the child resulted in gross arm length discrepancy, with associated functional deficits. Callostatic distraction-lengthening of the vascularized fibular graft was carried out to compensate for this limb length discrepancy by using an Ilizarov external fixator. Lengthening of 6 cm over a 3-month period, representing a 75% increase in the original length of the transplanted fibula, was achieved. Active bone regeneration, good corticalization and endosteal medullary cavity formation was observed in the lengthened fibula. The combined modalities of vascularized bone transfer and Ilizarov callostatic distraction-lengthening offer a solution for reconstruction for large segmental bone loss associated with growth arrest of the epiphyseal plates in children.     

Vascularized free fibular bone graft in the management of congenital tibial pseudarthrosis

Congenital pseudarthrosis of the tibia (CPT) remains one of the most challenging problems confronting the orthopaedic surgeon. The operative results are frequently less than successful; many cases require several surgical procedures, and a significant number of them ending in amputation. The purpose of this study was to access the surgical results, complications, secondary procedures, and long‐term results of free vascularized fibular graft (FVFG) in the treatment of congenital pseudarthrosis of the tibia. Between 1992 and 2007, nine patients with CPT were treated consecutively at our clinic with free fibula transfer. There were six females and three males. The mean age at the time of operation was 6.5 years (range, 1–12 years). Stability, after reconstruction with FVFG, was maintained with internal fixation in five patients, unilateral frame external fixation in three patients, and intramedullary pin in one patient. Average postoperative follow‐up time was 9 years (range, 2–15 years). In seven patients, both ends of the graft healed primarily within 3.7 months (range, 1.5–6 months). In one patient, the distal end of the graft did not unit. This patient required three subsequent operations to achieve union. Stress fracture occurred in the middle of the grafted fibula in one patient, who underwent four additional operations before union, was achieved. Despite the relatively high‐complication rate, FVFG remains a valid method for the treatment of CPT. However, even achieving union of pseudarthrosis is not enough for the resolution of the disease. This is only half of the problem; the other half is to maintain union. Long‐term follow‐up beyond skeletal maturity, if possible, is necessary to evaluate surgical results. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Free vascularized osteocutaneous fibular graft to the tibia

We reviewed the clinical results of reconstruction performed for extensive tibial bone and soft tissue defect with a free vascularized osteocutaneous fibular graft in 46 patients (43 male and 3 female). The mean duration of follow-up was 30 months (range 13-76 months). The mean age at the time of reconstruction was 41 years (range 15-66 years). In the 46 consecutive procedures of free vascularized osteocutaneous fibular grafts, bony union was achieved in 43 grafted fibulae at an average of 3.75 months after operation. There were two delayed unions and one non-union. Forty-four cutaneous flaps survived, and two cutaneous flaps failed due to deep infection and venous insufficiency. One necrotized cutaneous flap was replaced with a latissimus dorsi free flap and the other with a soleus muscle rotational flap without replacing the grafted fibulae; unions were obtained without significance complications. All grafted fibulae hypertrophied during the follow-up periods. The most common complication was fracture of the grafted fibulae in 15 patients, and it occurred at an average of 9.7 months after the reconstruction. The fractured fibulae were treated with long leg above-the-knee cast immobilization or internal fixation with conventional cancellous bone graft. Free vascularized osteocutaneous fibular graft is a good treatment modality for the reconstruction of extensive bone and soft tissue defect in the leg. Fracture of the grafted fibula, one of the most common complications after this operation, can easily be treated with cast immobilization or internal fixation with conventional cancellous bone graft.     

Combining free vascularized fibula graft and the Ilizarov external fixator: recent approaches to congenital pseudarthrosis of the tibia

The present study compares a recent approach for congenital pseudarthrosis of the tibia, combining a free vascularized fibula graft and an Ilizarov external fixator. Between 1984 and 1993, seven vascularized fibula grafts were performed. In the first six cases, casts or unilateral external fixators were applied, and five of these cases were complicated by fractures of the graft, necessitating secondary procedures or long-term immobilization. The mean follow-up was 12.1 years. Five patients can now walk unassisted, and one uses a brace only outdoors. On average, a brace was required for 18 months. In the recent Ilizarov external fixator case, the fixator was removed after 4 months and a brace was unnecessary at 10 months. There was no leg-length discrepancy, severe ankle deformity, or fracture of the grafted fibula 7 years postoperatively. Combining a free vascularized fibula graft with an Ilizarov external fixator is recommended for this condition.     

Congenital pseudarthrosis of the tibia in adults treated by a free vascularized iliac crest graft

Congenital pseudarthrosis of the tibia is a rare condition. It usually presents during early childhood, at which time the surgeon is faced with numerous challenges including difficulties in achieving union and preventing refractures and recurrences. Patients frequently end up with a severe deformity or an amputation. When an adult patient presents with previously untreated congenital pseudarthrosis of the tibia, the surgeon is faced with the additional problems of a longstanding soft tissue contracture and disuse atrophy of the limb. Two patients with congenital pseudarthrosis of the tibia were treated by free vascularized iliac crest graft. Soft tissue deformity was corrected using an external fixation device. The patients were not freely ambulatory before surgery. Union across the pseudarthrosis was achieved in both patients with a double-staged operation, within a short period of time. A functional stable painless limb with good knee and ankle motion has allowed both patients to resume bipedal gait and achieve a successful rehabilitation. © 1994 Wiley-Liss, Inc.