Treatment of established and anticipated nonunion of the tibia in childhood

Nonunion in long bone fractures is rare in the skeletally immature patient. The authors report the outcome of a series of patients treated for tibial bone loss and nonunion at average follow-up of 66 months. Nine children aged 18 months to 17 years were treated. Three patients had established nonunion ranging from 7 months to 6 years, three had bone loss (1-6 cm), and three had fractures in which nonunion was anticipated (one Gustilo IIIb and two Tscherne III). Treatment involved wound excision for open fractures, debridement of devascularized bone, and stabilization with monolateral fixators (two patients) and circular fixators (seven patients). Five patients had unifocal treatment and four had multifocal treatment (three bone transports). Treatment time ranged from 3 to 12 months and was not related to the complexity of treatment. Functional outcome was measured using the Short Musculoskeletal Functional Assessment, a validated outcome assessment tool. At the latest follow-up (average 66 months), the mean knee flexion was 134 degrees and mean ankle range was 12 degrees dorsiflexion, 31 degrees plantar flexion. Physeal arrest was present in three children (limb length discrepancy 2-4 cm), but with no deformity. Functional outcome revealed a "Dysfunction Index" of 0% to 19% (average 7%) and a "Bother Index" of 0% to 16% (average 6%). Good function can be obtained following treatment of these severe injuries.