Clin Orthop Surg.  2011 Mar;3(1):1-8. 10.4055/cios.2011.3.1.1.

Ilizarov Treatment of Congenital Pseudarthrosis of the Tibia: A Multi-Targeted Approach Using the Ilizarov Technique

• Choi IH
• Cho TJ
• Moon HJ

• KMID: 999454
• DOI: http://doi.org/10.4055/cios.2011.3.1.1

Abstract

Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging problems in pediatric orthopaedics. The treatment goals are osteosynthesis, stabilization of the ankle mortise by fibular stabilization, and lower limb-length equalization. Each of these goals is difficult to accomplish but regardless of the surgical options, the basic biological considerations are the same: pseudarthrosis resection, biological bone bridging of the defect by stable fixation, and the correction of any angular deformity. The Ilizarov method is certainly valuable for the treatment of CPT because it can address not only pseudarthrosis but also all complex deformities associated with this condition. Leg-length discrepancy can be managed by proximal tibial lengthening using distraction osteogenesis combined with or without contralateral epiphysiodesis. However, treatment of CPT is fraught with complications due to the complex nature of the disease, and failure is common. Residual challenges, such as refracture, growth disturbance, and poor foot and ankle function with stiffness, are frequent and perplexing. Refracture is the most common and serious complication after primary healing and might result in the re-establishment of pseudarthrosis. Therefore, an effective, safe and practical treatment method that minimizes the residual challenges after healing and accomplishes the multiple goals of treatment is needed. This review describes a multi-targeted approach for tackling these challenges, which utilizes the Ilizarov technique in atrophic-type CPT.

Keyword

Congenital pseudarthrosis of the tibia; Ilizarov osteosynthesis; Fibular pseudarthrosis

MeSH Terms

Humans
*Ilizarov Technique/adverse effects
Pseudarthrosis/*congenital/*surgery
Tibia/*surgery

Figure

• 

  Fig. 1 Classification of fibular status. Type A has normal fibular integrity in the presence of established atrophic-type congenital pseudarthrosis of the tibia (CPT), whereas type B has atrophic-type CPT with concomitant fibular pseudarthrosis. Type A1 has a fibula with a normal appearance or mild dysplasia, and type A2 has moderate fibula dysplasia but without fracture or pseudarthrosis. Type B1 has mild dysplasia (> 50% of the width of the contralateral normal side) with little or no proximal migration of the distal fibular physis relative to the tibia; type B2 shows moderate dysplasia with atrophic ends and mild proximal migration of the distal fibular physis relative to the tibia; whereas type B3 has a severely dysplastic fibula with atrophic ends, which is often associated with a narrow or obliterated medullary canal, and marked proximal migration of distal fibular physis.

• 

  Fig. 2 The author's fibular status-based algorithmic approach for osteosynthesis, ankle stabilization and leg-length equalization. We advocate internal bone transport of the tibia when there is no established fibular pseudarthrosis (type A) and the resection gap of the tibia is substantial. Circumferential-onlay bone grafting may be indicated if the resection gap is small. Fibular osteotomy and shortening may be indicated to accommodate its length at the time of acute compression of the tibia. When the quality of the fibula is sufficient (type B1), end-to-end osteosynthesis of the fibula at the time of tibial osteosynthesis is preferred to restore normal ankle mortise. However, when the pseudarthrotic fibula is too dysplastic, all efforts should be made to stabilize the ankle using either a '4-in-1 osteosynthesis' for type B2 or by distal tibiofibular fusion for type B3. When more than 2-3 cm of residual shortening is anticipated, either the bifocal compression-distraction technique (acute resection, realignment, and compression with proximal lengthening) or internal bone transport is recommended. LLD: limb length discrepancy, BG: bone graft, TL: tibial lengthening, TF: tibiofibular.

• 

  Fig. 3 '4-in-1 osteosynthesis' for atrophic-type congenital pseudarthrosis of the tibia (CPT), with type B2 fibular pseudarthrosis. (A) Preoperative radiograph taken at age 6 years and 4 months. (B) Immediate postoperative radiograph showing a combined Ilizarov bifocal, distal compression and proximal distraction method and intramedullary nailing using the smooth Steinmann pin. Approximately 6 cm length gain could be obtained. (C) Radiograph taken at age 9 years showing a well-aligned tibia.

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