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Tan SHS, Pei Y, Chan CX, Pang KC, Lim AKS, Hui JH, Ning B. A good index surgery for congenital pseudarthrosis of the tibia minimizes complications following surgery. Bone Jt Open 2024; 5:999-1003. [PMID: 39504994 PMCID: PMC11540463 DOI: 10.1302/2633-1462.511.bjo-2024-0045.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2024] Open
Abstract
Aims Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of CPT include intramedullary rodding, external fixation, combined intramedullary rodding and external fixation, vascularized fibular graft, and most recently cross-union. The current study aims to compare the outcomes and complication rates of cross-union versus other surgical approaches as an index surgery for the management of CPT. Our hypothesis was that a good index surgery for CPT achieves union and minimizes complications such as refractures and limb length discrepancy. Methods A multicentre study was conducted involving two institutions in Singapore and China. All patients with CPT who were surgically managed between January 2009 and December 2021 were included. The patients were divided based on their index surgery. Group 1 included patients who underwent excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for their index surgery. Group 2 included patients who underwent all other surgical procedures for their index surgery, including excision of hamartoma, intramedullary rodding, and/or external fixation, without cross-union of the tibia and fibula. Comparisons of the rates of union, refracture, limb length discrepancy, reoperations, and other complications were performed between the two groups. Results A total of 36 patients were included in the study. Group 1 comprised 13 patients, while Group 2 comprised 23 patients. The mean age at index surgery was four years (1 to 13). The mean duration of follow-up was 4.85 years (1.75 to 14). All patients in Group 1 achieved bony union at a mean of three months (1.5 to 4), but ten of 23 patients in Group 2 had nonunion of the pseudarthrosis (p = 0.006). None of the patients in Group 1 had a refracture, while seven of 13 patients who achieved bony union in Group 2 suffered a refracture (p = 0.005). None of the patients in Group 1 had a limb length discrepancy of more than 2 cm, while ten of 23 patients in Group 2 have a limb length discrepancy of more than 2 cm (p = 0.006). In Group 1, four of 13 patients had a complication, while 16 of 23 patients in Group 2 had a complication (p = 0.004). Excluding removal of implants, four of 13 patients in Group 1 had to undergo additional surgery, while 18 of 23 patients in Group 2 had to undergo additional surgery following the index surgery (p = 0.011). Conclusion A good index surgery of excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for CPT achieves union and minimizes complications such as refractures, limb length discrepancy, and need for additional surgeries.
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Affiliation(s)
- Si H. S. Tan
- Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Yingzhi Pei
- Pediatric Orthopedics, Children's Hospital of Fudan University, Shanghai, China
| | - Chloe X. Chan
- Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Khang C. Pang
- Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Andrew K. S. Lim
- Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - James H. Hui
- Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Bo Ning
- Pediatric Orthopedics, Children's Hospital of Fudan University, Shanghai, China
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Perrin S, Protic S, Bretegnier V, Laurendeau I, de Lageneste OD, Panara N, Ruckebusch O, Luka M, Masson C, Maillard T, Coulpier F, Pannier S, Wicart P, Hadj-Rabia S, Radomska KJ, Zarhrate M, Ménager M, Vidaud D, Topilko P, Parfait B, Colnot C. MEK-SHP2 inhibition prevents tibial pseudarthrosis caused by NF1 loss in Schwann cells and skeletal stem/progenitor cells. Sci Transl Med 2024; 16:eadj1597. [PMID: 38924432 DOI: 10.1126/scitranslmed.adj1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 01/15/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024]
Abstract
Congenital pseudarthrosis of the tibia (CPT) is a severe pathology marked by spontaneous bone fractures that fail to heal, leading to fibrous nonunion. Half of patients with CPT are affected by the multisystemic genetic disorder neurofibromatosis type 1 (NF1) caused by mutations in the NF1 tumor suppressor gene, a negative regulator of RAS-mitogen-activated protein kinase (MAPK) signaling pathway. Here, we analyzed patients with CPT and Prss56-Nf1 knockout mice to elucidate the pathogenic mechanisms of CPT-related fibrous nonunion and explored a pharmacological approach to treat CPT. We identified NF1-deficient Schwann cells and skeletal stem/progenitor cells (SSPCs) in pathological periosteum as affected cell types driving fibrosis. Whereas NF1-deficient SSPCs adopted a fibrotic fate, NF1-deficient Schwann cells produced critical paracrine factors including transforming growth factor-β and induced fibrotic differentiation of wild-type SSPCs. To counteract the elevated RAS-MAPK signaling in both NF1-deficient Schwann cells and SSPCs, we used MAPK kinase (MEK) and Src homology 2 containing protein tyrosine phosphatase 2 (SHP2) inhibitors. Combined MEK-SHP2 inhibition in vivo prevented fibrous nonunion in the Prss56-Nf1 knockout mouse model, providing a promising therapeutic strategy for the treatment of fibrous nonunion in CPT.
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Affiliation(s)
- Simon Perrin
- Université Paris Est Creteil, INSERM, IMRB, 94000 Creteil, France
| | - Sanela Protic
- Université Paris Est Creteil, INSERM, IMRB, 94000 Creteil, France
| | | | - Ingrid Laurendeau
- INSERM UMR S1016, Institut Cochin, Université Paris Cité, 75014 Paris, France
| | | | - Nicolas Panara
- INSERM UMR S1016, Institut Cochin, Université Paris Cité, 75014 Paris, France
| | - Odile Ruckebusch
- Université Paris Est Creteil, INSERM, IMRB, Plateforme de Cytométrie en flux, 94000 Creteil, France
| | - Marine Luka
- Paris Cité University, Imagine Institute, Laboratory of Inflammatory Responses and Transcriptomic Networks in Diseases, Atip-Avenir Team, INSERM UMR 1163, 75015 Paris, France
- Labtech Single-Cell@Imagine, Imagine Institute, INSERM UMR 1163, 75015 Paris, France
| | - Cécile Masson
- Bioinformatics Core Facility, Institut Imagine-Structure Fédérative de Recherche Necker, INSERM U1163, 75015 Paris, France
- INSERM US24/CNRS UAR3633, Paris Cité University, 75015 Paris, France
| | - Théodora Maillard
- Service de Médecine Génomique des Maladies de Système et d'Organe, Hôpital Cochin, DMU BioPhyGen, Assistance Publique-Hôpitaux de Paris, AP-HP, Centre-Université Paris Cité, F-75014 Paris, France
| | - Fanny Coulpier
- Université Paris Est Creteil, INSERM, IMRB, 94000 Creteil, France
| | - Stéphanie Pannier
- Department of Pediatric Orthopedic Surgery and Traumatology, Necker-Enfants Malades Hospital, AP-HP, Paris Cité University, 75015 Paris, France
| | - Philippe Wicart
- Department of Pediatric Orthopedic Surgery and Traumatology, Necker-Enfants Malades Hospital, AP-HP, Paris Cité University, 75015 Paris, France
| | - Smail Hadj-Rabia
- Department of Dermatology, Reference Center for Rare Skin Diseases (MAGEC), Imagine Institute, Necker-Enfants Malades Hospital, AP-HP, Paris Cité University, 75015 Paris, France
| | | | - Mohammed Zarhrate
- INSERM US24/CNRS UAR3633, Paris Cité University, 75015 Paris, France
- Genomics Core Facility, Institut Imagine-Structure Fédérative de Recherche Necker, INSERM U1163, 75015 Paris, France
| | - Mickael Ménager
- Paris Cité University, Imagine Institute, Laboratory of Inflammatory Responses and Transcriptomic Networks in Diseases, Atip-Avenir Team, INSERM UMR 1163, 75015 Paris, France
- Labtech Single-Cell@Imagine, Imagine Institute, INSERM UMR 1163, 75015 Paris, France
| | - Dominique Vidaud
- INSERM UMR S1016, Institut Cochin, Université Paris Cité, 75014 Paris, France
- Service de Médecine Génomique des Maladies de Système et d'Organe, Hôpital Cochin, DMU BioPhyGen, Assistance Publique-Hôpitaux de Paris, AP-HP, Centre-Université Paris Cité, F-75014 Paris, France
| | - Piotr Topilko
- Université Paris Est Creteil, INSERM, IMRB, 94000 Creteil, France
| | - Béatrice Parfait
- INSERM UMR S1016, Institut Cochin, Université Paris Cité, 75014 Paris, France
- Service de Médecine Génomique des Maladies de Système et d'Organe, Hôpital Cochin, DMU BioPhyGen, Assistance Publique-Hôpitaux de Paris, AP-HP, Centre-Université Paris Cité, F-75014 Paris, France
| | - Céline Colnot
- Université Paris Est Creteil, INSERM, IMRB, 94000 Creteil, France
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Dong C, Li C, Brückner U, Hellmich H, Krieg AH. Preventing of nonunion in congenital pseudarthrosis of the tibia cases of Crawford Type I and II through the use of allograft bypass and a brace: Midterm findings. J Child Orthop 2024; 18:187-199. [PMID: 38567047 PMCID: PMC10984155 DOI: 10.1177/18632521241228168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/22/2023] [Indexed: 04/04/2024] Open
Abstract
Background Congenital pseudarthrosis of the tibia is a limb deformity, which can be distressing for the affected patients and the pediatric orthopedic surgeons involved. We hypothesized that the modified McFarland procedure would avoid fractures and even have a corrective effect on the affected tibia in congenital pseudarthrosis of the tibia patients. Toward this end, we evaluated the midterm results of treating congenital pseudarthrosis of the tibia patients of Crawford Type I and II with allograft bypass combined with long-term bracing. Methods This study retrospectively evaluated 7 patients with congenital pseudarthrosis of the tibia who were treated with allograft bypass combined with long-term bracing between 2009 and 2018. The median follow-up was 7.0 years (range 3.8-10.0 years). The medical records and radiographs were reviewed for demographic data, clinical characteristics, outcomes, and complications. Results At the time of the last follow-up, all allografts revealed complete consolidation in the patients' tibiae at both ends. All patients presented no functional restriction of the lower limbs and no amputation or non-union has occurred. Most of the obvious deformities of the tibia diaphysis or ankle joint were corrected. Two complications occurred that required successful revision surgery. Conclusion In this series of seven congenital pseudarthrosis of the tibia patients, the allograft bypass technique showed satisfactory midterm results and validated our hypothesis. For congenital pseudarthrosis of the tibia patients of Crawford Type I and II, this procedure combined with long-term bracing, which involves the affected leg only, can delay or possibly prevent fractures, decrease tibial malalignment, and preserve leg length. Level of evidence level IV.
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Affiliation(s)
- Chao Dong
- Pediatric Orthopedic Department, University Children’s Hospital Basel (UKBB), Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Joint Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, P.R. China
| | - Chengxiang Li
- Pediatric Orthopedic Department, University Children’s Hospital Basel (UKBB), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Ute Brückner
- Pediatric Orthopedic Department, University Children’s Hospital Basel (UKBB), Basel, Switzerland
- Department of Pediatric Surgery, St. Elisabethen Hospital, Lörrach, Germany
| | - Hermann Hellmich
- Pediatric Orthopedic Department, University Children’s Hospital Basel (UKBB), Basel, Switzerland
- Department of Pediatric Surgery, St. Elisabethen Hospital, Lörrach, Germany
| | - Andreas H Krieg
- Pediatric Orthopedic Department, University Children’s Hospital Basel (UKBB), Basel, Switzerland
- University of Basel, Basel, Switzerland
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Mastantuoni G, Aulisa AG, Giordano M, Savignoni P, Toniolo RM, Falciglia F. Anterolateral congenital tibial bowing: case report. Front Pediatr 2023; 11:966358. [PMID: 37181425 PMCID: PMC10166803 DOI: 10.3389/fped.2023.966358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 04/04/2023] [Indexed: 05/16/2023] Open
Abstract
Background The treatment of congenital curvatures (bowing) of the tibia still represents a challenging problem for all pediatric orthopedic surgeons because of its unpredictable course, especially if pseudoarthrosis occurs after a pathologic fracture of the tibia. Case presentation We describe the case of a child affected by an isolated curvature of his left leg. The congenital malformation was discovered at birth and no other pathological clinical finding was present. The first x-ray showed the presence of a congenital curvature of the tibia of the antero-lateral type. He was born in another country (Romania) and when he first came to our clinical observation at the Orthopedic and Traumatology Department, Pediatric Hospital "Bambino Gesu'", Rome, the child was 14 months of age and had already started walking. Only a leg discrepancy of about 2 cm was present with consequent pelvis obliquity. At the beginning, we prescribed external lower limb orthoses and a simple shoe rise to prevent a tibial pathologic fracture and reduce pelvic obliquity. At periodical clinical follow-up visits and despite the external lower limb orthoses prescribed, a progressive worsening of the severe congenital tibial curvature was observed together with signs and symptoms, such as pain and limping, that suggested an objective "pre-fracture stage" of the tibial curvature; we decided to perform surgery. At the time of surgery, the child was three and a half years old. Surgery consisted of a double osteotomy, both of the fibula and of the tibia. Subtraction of the distal meta-diaphyseal portion of the fibula and tibial osteotomy in Correspondence: of the major anterolateral curvature. The tibial osteotomy was then stabilized by an internal Rush rod inserted proximally to the tibia under the cartilage growth plate and made it end inside the distal tibial epiphysis, crossing the distal tibial cartilage growth plate, preserving the ankle joint. Results The patient had an immediately excellent outcome. The tibial osteotomy site healed perfectly. At periodical orthopedic follow-up visits, the child was found to be always better. No clinical significative evidence of growth disturbances, due to the Rush rod that crossed the distal tibial cartilage growth plate, were noted. X-rays showed that the Rush rod progressively migrated with tibial growth together with the tibial bone growth, always getting further away from the distal tibial cartilage growth plate. Moreover, even the leg-length discrepancy and the pelvic obliquity improved. After an eight-year follow up, the patient, now a young boy of 11 and a half years, has an excellent outcome. Conclusions Our case report undoubtedly provides further important information for the treatment of these rare congenital disorders. In particular, it highlights the management of the "pre-fracture stage" in a severe congenital tibial antero-lateral curvature in a very young child and describes the surgical technique performed.
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Affiliation(s)
| | - Angelo Gabriele Aulisa
- UOC of Traumatology, Bambino Gesù Children’s Hospital (IRCCS), Rome, Italy
- Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, Via S. Angelo in Theodice, Localita’ Folcara, Cassino, Italy
| | - Marco Giordano
- UOC of Traumatology, Bambino Gesù Children’s Hospital (IRCCS), Rome, Italy
| | - Pietro Savignoni
- UOC of Traumatology, Bambino Gesù Children’s Hospital (IRCCS), Rome, Italy
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Muacevic A, Adler JR. Congenital Pseudoarthrosis of the Tibia: A Narrative Review. Cureus 2022; 14:e32501. [PMID: 36654595 PMCID: PMC9840411 DOI: 10.7759/cureus.32501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
Congenital pseudoarthrosis of the tibia, also known as CPT, is a rare bone disease mostly occurring in the pediatric age group of 10. The case generally represents anterolateral bowing of the tibia with refractures. This condition is quite rare and has very few cases per year. CPT is still a challenging concern in orthopedics. Bone reunion often requires repeated surgical measurements. With advancements, we have new treatment plans that include induced membrane techniques and bone marrow stromal cell grafts of various induced and morphogenetic protein, which still requires confirmation. Different treatment strategies based on surgical, mechanical, and biological concepts have been shown with varying success rates. Ilizarov technique and vascularised fibular grafts have vastly increased the effectiveness in treating CPT of the tibia. Constant and recurrent refracture, residual deformities, and difficulty obtaining bone union remain the challenges in managing CPT. Hence, phasing CPT as bowing the tibia in an anterolateral fashion is more appropriate because it's a heterogeneous entity with varying prognoses.
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