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El-Gammal TA, Ali AES, Kotb MM, Saleh WR, Ragheb YF, Refai OA, Morsy MM, El-Gammal YT. Treatment of Concomitant Congenital Pseudarthrosis of the Fibula With Propeller Periosteal Flap. Ann Plast Surg 2023; 90:575-579. [PMID: 37311312 DOI: 10.1097/sap.0000000000003552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Congenital pseudarthrosis of the fibula is not an uncommon condition to accompany congenital pseudarthrosis of the tibia. Persistence of the fibular pseudarthrosis has been linked to inferior outcomes including tibial union and alignment, refractures, and ankle alignment. In this report, we present the results of a pedicled periosteal propeller flap technique for the treatment of fibular pseudarthrosis. METHODS Ten children with an average age at surgery of 5.3 years who had congenital pseudarthrosis of both tibia and fibula were studied. The tibia was treated with free vascularized fibular grafting, and the ipsilateral fibula was treated with a technique after resection of the pseudarthrosis. A periosteal flap from the proximal healthy part of the fibula is harvested off the bone, rotated 180° based on a branch from the peroneal vessels to cover the fibular defect and fashioned in the form of a tube filled with bone fragments. RESULTS The periosteal flap size ranged from 5 to 7 cm. Follow-up averaged 37.2 months. The tibia was united in all cases; in 2 of them, refractures occurred and healed with conservative management. The fibula was united in 8 cases. At final follow-up, 5 cases showed residual tibial deformity, and 5 showed residual ankle deformity. Average leg-length discrepancy was 1.4 cm (0-3 cm). CONCLUSION The pedicled periosteal propeller flap presents a useful new technique for managing concomitant congenital fibular pseudarthrosis.
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Affiliation(s)
- Tarek Abdalla El-Gammal
- From the Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University Hospitals and School of Medicine
| | - Amr El-Sayed Ali
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Mohamed Mostafa Kotb
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Waleed Riad Saleh
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Yasser Farouk Ragheb
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Omar Ahmed Refai
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Mohamed Mohamed Morsy
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Yousif Tarek El-Gammal
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
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Chou TFA, Liu TY, Wang MN, Yang CY. Treatment of Refractory Congenital Pseudoarthrosis of Tibia with Contralateral Vascularized Fibular Bone Graft and Anatomic Distal Tibial Locking Plate: A Case Series and Literature Review. CHILDREN 2023; 10:children10030503. [PMID: 36980061 PMCID: PMC10046898 DOI: 10.3390/children10030503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Abstract
Background: Congenital pseudoarthrosis of the tibia (CPT) remains a challenge for physicians. Several treatment options have been proposed, but the standard of care remains inconclusive. In this study, we present three patients for whom the failure of prior treatments was managed with a contralateral vascularized fibular bone graft (VFG) and an anatomic distal tibial locking plate. Methods: Between 2017 and 2021, three patients were referred for failed treatment of CPT. All patients had undergone multiple prior surgeries, including tumor excision and fixation with ring external fixators, plates, and screws. We performed radical tumor resection and reconstruction of bone defects with a VFG. The construct was fixed with an anatomic locking plate, and the patients were followed up for a mean of 45.7 months. Results: All three patients were able to obtain graft union at 19.3 weeks. At the final follow-up, all grafts achieved bony hypertrophy without evidence of bone resorption or local tumor recurrence. There was a mean leg length difference of 8.5 cm preoperatively, compared with 6.3 cm postoperatively. The average lower leg angulation was 7.4 degrees and the average ankle range of motion was 58.3 degrees. The mean VAS score was 0 and the mean AOFAS score was 88.3. No significant complications were noted. Conclusions: Implantation of a VFG and an anatomic distal tibia locking plate can be considered an option for treatment-refractory CPT. Patients can expect to achieve bone consolidation, ambulate as tolerated, and have a low complication rate.
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Affiliation(s)
- Te-Feng Arthur Chou
- Department of Orthopaedics, Kuang Tien General Hospital, Taichung 433401, Taiwan
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei 112201, Taiwan
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY 10461, USA
| | - Ting-Yu Liu
- Department of Orthopaedics, Kuang Tien General Hospital, Taichung 433401, Taiwan
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei 112201, Taiwan
- Department of Nursing, Hungkuang University, Taichung 433304, Taiwan
| | - Matthew N. Wang
- Department of Orthopaedics, Kuang Tien General Hospital, Taichung 433401, Taiwan
- Department of Nursing, Hungkuang University, Taichung 433304, Taiwan
| | - Chen-Yuan Yang
- Department of Orthopaedics, Kuang Tien General Hospital, Taichung 433401, Taiwan
- Department of Nursing, Hungkuang University, Taichung 433304, Taiwan
- Correspondence: ; Tel.: +886-4-2662-5111
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Zayda AI, Mesregah MK, Zalalo SH, Sakr SAH. Functional and radiological outcomes after treatment of congenital pseudarthrosis of the tibia using the Ilizarov technique: a retrospective single-center study. J Orthop Traumatol 2022; 23:48. [PMID: 36149607 PMCID: PMC9508293 DOI: 10.1186/s10195-022-00667-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Congenital pseudarthrosis of the tibia (CPT) is a challenging problem in orthopedic practice, with high rates of non-union, refracture, and residual deformities. After union, long-term follow-up is required to manage late post-union complications. This study aimed to assess the outcomes of the Ilizarov technique in the management of CPT. MATERIALS AND METHODS This retrospective study included patients with CPT treated with the Ilizarov method between 2005 and 2018. Intramedullary rods were used in 9 cases and iliac bone graft was used in 12 cases. An orthosis was applied till the end of follow-up in all cases. The American Orthopaedic Foot and Ankle Society (AOFAS) scale was used for the evaluation of the functional outcomes. RESULTS This study included 16 patients, 11 males and 5 females, with an average age of 5.4 ± 2.8 years. Seven cases had multiple previous surgeries. Six patients had neurofibromatosis. The mean follow-up period was 5.8 ± 3.4 years. The average AOFAS score improved significantly from 47.5 ± 7.6 preoperatively to 78.9 ± 8.9 at the latest follow-up. Union was achieved in 15 cases, and persistent non-union occurred in one case. The clinical results were excellent in one patient, good in seven cases, fair in 6, and poor in 2 cases. The radiological results were excellent in one patient, good in seven cases, fair in seven, and poor in one case. CONCLUSIONS The Ilizarov technique combined with intramedullary rod and primary or secondary bone graft provides a high union rate of CPT and can achieve simultaneous effective management of problems related to pseudarthrosis, including non-union, deformity, limb shortening, and adjacent joint contracture and subluxation. Level of evidence Level IV.
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Affiliation(s)
- Ahmed Ibrahim Zayda
- Department of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Shebin-El-Kom, Egypt
| | - Mohamed Kamal Mesregah
- Department of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Shebin-El-Kom, Egypt.
| | - Soliman Hassan Zalalo
- Department of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Shebin-El-Kom, Egypt
| | - Samy Abdel-Hady Sakr
- Department of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Shebin-El-Kom, Egypt
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Siebert MJ, Makarewich CA. Anterolateral Tibial Bowing and Congenital Pseudoarthrosis of the Tibia: Current Concept Review and Future Directions. Curr Rev Musculoskelet Med 2022; 15:438-446. [PMID: 35841513 PMCID: PMC9789274 DOI: 10.1007/s12178-022-09779-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Congenital pseudarthrosis of the tibia (CPT) is a rare condition closely associated with neurofibromatosis type I. Affected children are born with anterolateral bowing of the tibia which progresses to pathologic fracture, pseudarthrosis, and high risk of refracture even after initial union has been attained. There is currently no consensus on the classification of this disease or consensus on its treatment. The purpose of this review is to (1) review the clinical presentation, etiology, epidemiology, classification, and natural history of congenital pseudarthrosis of the tibia and (2) review the existing trends in treatment of congenital pseudarthrosis of the tibia and its associated complications. RECENT FINDINGS Current treatment protocols focus primarily on combining intramedullary fixation with external or internal fixation to achieve union rates between 74 and 100%. Intramedullary devices should be retained as long as possible to prevent refracture. Cross-union techniques, though technically difficult, have a reported union rate of 100% and no refractures at mid- to long-term follow-up. Vascularized fibular grafting and induced membrane technique can be successful, but at the cost of numerous surgical procedures. Growth modulation is a promising new approach to preventing fracture altogether, though further study with larger patient series is necessary. The primary consideration in treatment of CPT is expected union rate and refracture risk. Combined intramedullary and external or internal fixation, especially with cross-union techniques, show most promise. Perhaps most exciting is further research on preventing fracture through guided growth, which may reduce the morbidity of multiple surgical procedures which have been the mainstay of treatment for CPT thus far.
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Affiliation(s)
- Matthew J. Siebert
- grid.223827.e0000 0001 2193 0096Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 USA
| | - Christopher A. Makarewich
- grid.223827.e0000 0001 2193 0096Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 USA ,grid.415178.e0000 0004 0442 6404Primary Children’s Hospital, Salt Lake City, UT USA ,grid.509583.2Shriners Children’s, Salt Lake City, Utah USA
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Li Z, Yu H, Huang Y, Liu Y, Zhu G, Tan Q, Mei H, Yang G. Analysis of risk factors affecting union and refracture after combined surgery for congenital pseudarthrosis of the tibia: a retrospective study of 255 cases. Orphanet J Rare Dis 2022; 17:245. [PMID: 35739599 PMCID: PMC9229079 DOI: 10.1186/s13023-022-02375-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Congenital pseudarthrosis of the tibia (CPT) is a rare disease occurring in children. The aim of this study is to identify the factors affecting bone union and re-fracture after surgery for CPT and to provide reliable evidence for clinics. Methods We collected the detailed information of 255 cases with Crawford IV CPT treated by combined surgery in our hospital from 2013 to 2020. Basic characteristics were recorded. Univariate variance and logistic regression analysis were used to compare the correlations between factors and outcomes. Results 92.5% of patients achieved primary union, 7.5% of patients had non-union and 13.3% of patients had re-fracture. Logistic regression analysis showed that age at index surgery (Coef. = 0.171, 95%CI 0.015–0.327, P = 0.032), and CPT location (Coef. = − 1.337, 95%CI − 2.218–0.456, P = 0.003) had statistical differences, while no factors had significant correlation with re-fracture. Furthermore, ROC curve showed that the optimal age threshold for first surgery was 2.37 years old. Conclusions For patients with Crawford IV CPT treated by combined surgery, the younger the age at index surgery and the closer the CPT location to the distal end, the easier to achieve bone union.
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Affiliation(s)
- Zhuoyang Li
- Department of Orthopedics, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hui Yu
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong, China
| | - Yiyong Huang
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Yaoxi Liu
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Guanghui Zhu
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Qian Tan
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Haibo Mei
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China.
| | - Ge Yang
- Department of Orthopedics, Hunan Children's Hospital, Hunan, China.
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Surgical treatment options for congenital pseudarthrosis of tibia in children: cross-union versus other options: a systematic review. J Pediatr Orthop B 2022; 31:139-149. [PMID: 35102104 DOI: 10.1097/bpb.0000000000000924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The systematic review aimed to provide a comprehensive update on various surgical treatment options for congenital pseudarthrosis of tibia (CPT) in children and the outcome achieved in terms of union, union time and complications of non-union and refracture. A literature search was performed in PubMed (including Medline) database for broad keywords: 'Congenital pseudarthrosis of tibia and children'. Studies selected included full-text articles on surgical treatments of CPT following: intra-medullary rod (IMR)/Ilizarov/combined IMR with Ilizarov/vascularized fibular graft (VFG) and cross-union. Out of 719 studies, 57(1227 CPT patients/1235 tibias) were included for review. Cross-union group had 100% union rate with no non-unions, least refracture rate (22.5%) and minimal time to primary union (4.5 months). For IMR, Ilizarov, combined IMR with Ilizarov and VFG, the respective results were as follows: primary union rates - 67.7, 84.2, 83.7 and 65.3%; final union - 76.5, 81.5, 92.4 and 87.1%; primary union time - 12.6, 9.3, 5.3 and 9.5 months; non-union rates - 17.0, 13.6, 6.0 and 7.9%; refracture rates - 48.1, 47.7, 33.7 and 34.6%. The success probability was lowest for IMR (35.2%), 44% for Ilizarov, 55.5% for combined IMR with Ilizarov, 42.7% for VFG and highest 77.5% for cross-union group. Outcomes of the more recent cross-union technique fare better than other surgical methods. However, studies on cross-union are few and longer follow-up is lacking. Combined IMR with Ilizarov and VFG have better results compared to IMR or Ilizarov alone.
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Abstract
Constriction band syndrome (CBS) may be rarely associated with pseudarthrosis of tibia. Published literature includes only case reports. We evaluated the outcome of children with frank pseudarthrosis of the tibia with CBS and compared our results with other reported cases. We aimed to formulate a clinical classification of tibial involvement in CBS on the basis of the treatment guidelines. Seven patients with the presence of one or more constriction bands and radiological signs of tibial pseudarthrosis were included in the study. Eight reported cases of CBS with tibial involvement with management and follow-up details were reviewed. Only two tibial pseudarthrosis united spontaneously after the release of the constriction band. Two patients underwent simultaneous correction of tibial deformity and nailing with band release, one of which needed bone grafting for the pseudarthrosis union. Three patients subsequently needed an excision of tibial pseudarthrosis with nailing to achieve tibial union, two of them had autologous bone grafting along with nailing. Additional procedures were required for the correction of foot deformity and limb length discrepancy. Our findings were similar to the reported cases. The pseudarthrosis of the tibia with CBS does not always heal following band release. Additional surgeries may be required for persistent pseudarthrosis, limb length discrepancy and residual foot deformities. A functional and radiological classification is proposed for the treatment of tibial pseudarthrosis with CBS.
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Affiliation(s)
- Premal Naik
- Rainbow Superspeciality Hospital and Children's Orthopaedic Centre, Honorary Paediatric Orthopaedic Surgeon, Department of Orthopaedics, NHL Municipal Medical College, Ahmedabad, Gujarat
| | - Hitesh Shah
- Department of Orthopaedics, Paediatric Orthopaedics services, Kasturba Medical College, Manipal Academy of Higher Education, Manipal
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Zhou Y, Tan Q, Liu K, Liu Y, Zhu G, Mei H, Yang G. Epidemiological and clinical characteristics of congenital pseudarthrosis of the tibia in China. Front Pediatr 2022; 10:943917. [PMID: 36090554 PMCID: PMC9452726 DOI: 10.3389/fped.2022.943917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Congenital pseudarthrosis of the tibia (CPT) is a refractory and rare disease. Because of its extremely low incidence, little is known about its clinical features. In this retrospective study, we aim to analyze the clinical characteristics of patients with CPT. MATERIALS AND METHODS This is a retrospective study of children with CPT identified by the radiological review. Investigations of CPT included general conditions, the characteristics of CPT, treatment methods, and surgical complications. RESULTS We collected 514 CPT cases from March 1999 to March 2020 in our hospital, such as 317 (61.67%) boys, 197 (38.33%) girls; 330 (62.86%) in Crawford IV; 510 (97.14%) in mid and distal 1/3 tibia; 481 (93.58%) in less than 3 years at onset age; 297 (57.78%) in less than 3 years at the first outpatient visit. The most common post-operative complication was ankle valgus (101, 39.60%), followed by limb length discrepancy (91, 35.69%), refracture (38, 14.90%), osteomyelitis (15, 5.88%), and removal of internal fixation (10, 3.93%). CONCLUSIONS CPT with a higher incidence of Crawford IV frequently occurs in boys and the middle or distal part of the tibia; most patients have the onset age and first outpatient visit before 3 years; the major surgical complications are ankle valgus and limb length discrepancy.
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Affiliation(s)
- Yijun Zhou
- The First Affiliated Hospital of Ji'nan University (Guangzhou Overseas of Chinese Hospital), Guangzhou, China.,The First People's Hospital of Changde, Guangde Clinical Institute of Xiangya Medical College of South Central University, Changde, China
| | - Qian Tan
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Kun Liu
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Yaoxi Liu
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Guanghui Zhu
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Haibo Mei
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
| | - Ge Yang
- Department of Orthopedic Surgery, The Hunan Children's Hospital, Changsha, China
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Lippross S, Tsaknakis K, Lorenz HM, Hell AK. [Congenital pseudarthrosis of the tibia : A rare often underestimated disorder]. Unfallchirurg 2021; 124:755-767. [PMID: 34398278 DOI: 10.1007/s00113-021-01061-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 11/29/2022]
Abstract
Congenital pseudarthrosis of the tibia (CPT) is a rare disease that has challenged trauma and orthopedic surgeons for a long time. Clinically CPT mostly presents with progressive varus and antecurvation malformation of the tibia in infancy and childhood. In many cases CPT is associated with neurofibromatosis or fibrous dysplasia. Without knowledge of the clinical picture a discontinuity of the tibia and/or fibula visible on an X‑ray can be misinterpreted as a simple fracture. Histopathological investigations have revealed that a pathological alteration of the periosteum in the region of the pseudarthrosis, a hamartoma, may be essentially responsible for this disorder. Consequently, to treat the CPT a resection of the hamartoma must also be carried out. Multimodal treatment approaches combining pharmacological and surgical treatment, such as the cross-union technique of Paley, seem to have improved the prognosis of CPT.
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Affiliation(s)
- Sebastian Lippross
- Klinik für Orthopädie und Unfallchirurgie, UKSH Campus Kiel, Kiel, Deutschland
| | - Konstantinos Tsaknakis
- Kinderorthopädie, Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Heiko M Lorenz
- Kinderorthopädie, Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Anna K Hell
- Kinderorthopädie, Operatives Kinderzentrum, Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
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Reconstructive Approaches in Surgical Management of Congenital Pseudarthrosis of the Tibia. J Clin Med 2020; 9:jcm9124132. [PMID: 33371504 PMCID: PMC7767548 DOI: 10.3390/jcm9124132] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/14/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022] Open
Abstract
Treatment of congenital pseudarthrosis of the tibia remains a major challenge in pediatric orthopedics. Ideal timing and preference of surgical procedures are discussed controversially. A variety of reconstructive treatment strategies have been described in literature, but so far none has proven its superiority. The aim of treatment is to obtain long-term bone union, to prevent refracture, and to correct angular deformities and leg length discrepancies. This study retrospectively evaluates the outcome of different reconstructive strategies. Sixty-nine patients were identified who presented to our outpatient department between 1997 and 2019. Twenty-six of these patients underwent reconstructive surgical treatment and were included in this study. The study cohort was divided into three groups. Excision of the pseudarthrosis was performed in all patients in Group A and B, and in two patients of Group C. Group A (six/26 patients) received subsequent bone transport through external fixation maintaining original length. In Group B (15/26 patients), patients underwent either previous, simultaneous, or subsequent extrafocal lengthening through external fixation to reconstitute length. In Group C (five/26 patients), internal fixation with intramedullary nails was applied. Radiological and clinical evaluation was performed to assess bone union and complication rates. Results varied considerably between the study groups. Overall, the primary bone fusion rate was 69.2%. There were four refractures, all occurring in Group B. The long-term bone union rate without refracture was 53.8%. The overall complication rate was 53.8% and 23.1% showed persistent pseudarthrosis. Two secondary amputations were performed due to failed bone fusion. In conclusion, excision of the pseudarthrosis and extrafocal lengthening achieves a satisfying bone union rate and limb reconstruction, while bone transport does not offer significant advantages but shows higher complication rates. Intramedullary stabilization should be applied to maintain bone union, but shows lower bone union rates when used as a stand-alone treatment regimen. Regardless of the primary bone fusion rates, the probability of long-term bone union remains unpredictable.
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Popkov D, Popkov A, Dučić S, Lazović M, Lascombes P. Combined technique with hydroxyapatite coated intramedullary nails in treatment of anterolateral bowing of congenital pseudarthrosis of tibia. J Orthop 2020; 19:189-193. [PMID: 32025131 DOI: 10.1016/j.jor.2019.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/03/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose The goal of this study is to evaluate the treatment outcomes of anterolateral bowing and residual deformities of distal tibia in patients with CPT using circular external fixation and hydroxyapatite coated flexible intramedullary nailing without excision of affected part of tibia. Patients and methods Six patients (4 boys and 2 girls, mean age 12.4 ± 4.1 years) were included in the study. Mean follow-up is 2.1 years. In 4 patients with early onset of disease initial surgical treatment (at age of 5-8 years) was dysplastic zone or pseudarthrosis resection with proximal metaphyseal osteotomy for bone transport. Children with unbroken bowed tibia (2 cases of type II according to Crawford classification) had no previous surgery. Neurofibromatosis type I was diagnosed in 4 cases. Surgical technique for residual deformity correction consisted of percutaneous osteotomy, application of circular external frame and composite hydroxyapatite-coated intramedullary nailing. Results Mean external fixation time was 95.3 ± 17.5 days. All patients never get fractured after frame removal. At the present time, they are considered to be healed, in 2.1 years, in average, without fractures or deformity recurrence. Mean lower limb length discrepancy varied from 2 to 10 mm at the latest follow-up control. After realignment procedure, patients didn't require additional surgery but one. Intramedullary nails were removed in two years after deformity correction for individual reason. Conclusion Correction of anterolateral bowing or residual deformity in children with CPT is indicated. Association of external fixation with intramedullary nailing/rodding left in situ after frame removal ensure stability and accuracy of deformity correction. Biological methods of stimulation of bone formation in dysplastic zone are obligatory to ensure bone union. Intramedullary nailing with composite hydroxyapatite-coated surface provides mechanical and biological advantages in patients with CPT.
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Affiliation(s)
- Dmitry Popkov
- Clinic of Neuroorthopaedics and Systemic Diseases of the Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulyanova Street, 640014, Kurgan, Russian Federation
| | - Arnold Popkov
- Clinic of Neuroorthopaedics and Systemic Diseases of the Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulyanova Street, 640014, Kurgan, Russian Federation
| | - Siniša Dučić
- Orthopaedic Department, Children's University Hospital, Tiršova 10, Belgrade, Serbia
| | - Mikan Lazović
- Orthopaedic Department, Children's University Hospital, Tiršova 10, Belgrade, Serbia
| | - Pierre Lascombes
- Division of Paediatric Orthopaedics, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, CH - 1211, Geneva, 14, Switzerland
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Abstract
RATIONALE Bone malformation occurs in 10% to 25% neurofibromatosis type 1 (NF-1) patients, and the manifestations are scoliosis, congenital arch and pseudo-joint formation, bone cyst, and pathologic fracture. However, a large segmental defect without obvious signs of bone destruction has rarely been reported. PATIENT CONCERNS A 4.5-year-old male presented with a 4-year history of shortening of the right upper limb and radial head dislocation. The X-ray indicated a lack of the distal part of the right ulna and radial head dislocation. DIAGNOSIS The X-ray showed obvious bone resorption at the right ulna distal, proximal stubble, and distal part of the epiphyseal residue, which was 4.3 mm shorter after 14 months. The patient was finally diagnosed with NF-1 according to the pathologic examination. INTERVENTIONS The treatment included tumor resection, ulnar osteotomy, and fixation by an Ilizarov frame. OUTCOMES The Ilizarov frame was removed after 2.7 months of surgery. The radial head was successfully repositioned, and the elbow joint function was significantly improved. No recurrence of the deformity was noted until now. LESSONS Osteolysis (defect without bone destruction) is an extremely rare symptom in patients with NF1. Therefore, it is essential to make the right diagnosis by comprehensive and careful physical examination.
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Affiliation(s)
- Yiguo Shen
- Department of Orthopedics, Zhejiang University School of Medicine Children's Hospital
| | - Fangfang Chen
- Department of Orthopedics, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
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Zhu G, Zheng Y, Liu Y, Yan A, Hu Z, Yang Y, Xiang S, Li L, Chen W, Peng Y, Zhong N, Mei H. Identification and characterization of NF1 and non-NF1 congenital pseudarthrosis of the tibia based on germline NF1 variants: genetic and clinical analysis of 75 patients. Orphanet J Rare Dis 2019; 14:221. [PMID: 31533797 PMCID: PMC6751843 DOI: 10.1186/s13023-019-1196-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/04/2019] [Indexed: 12/13/2022] Open
Abstract
Background Congenital pseudarthrosis of the tibia (CPT) is a rare disease. Some patients present neurofibromatosis type 1 (NF1), while some others do not manifest NF1 (non-NF1). The etiology of CPT, particularly non-NF1 CPT, is not well understood. Here we screened germline variants of 75 CPT cases, including 55 NF1 and 20 non-NF1. Clinical data were classified and analyzed based on NF1 gene variations to investigate the genotype-phenotype relations of the two types of patients. Results Using whole-exome sequencing and Multiplex Ligation-Dependent Probe Amplification, 44 out of 55 NF1 CPT patients (80.0%) were identified as carrying pathogenic variants of the NF1 gene. Twenty-five variants were novel; 53.5% of variants were de novo, and a higher proportion of their carriers presented bone fractures compared to inherited variant carriers. No NF1 pathogenic variants were found in all 20 non-NF1 patients. Clinical features comparing NF1 CPT to non-NF1 CPT did not show significant differences in bowing or fracture onset, lateralization, tissue pathogenical results, abnormality of the proximal tibial epiphysis, and follow-up tibial union after surgery. A considerably higher proportion of non-NF1 patients have cystic lesion (Crawford type III) and used braces after surgery. Conclusions We analyzed a large cohort of non-NF1 and NF1 CPT patients and provided a new perspective for genotype-phenotype features related to germline NF1 variants. Non-NF1 CPT in general had similar clinical features of the tibia as NF1 CPT. Germline NF1 pathogenic variants could differentiate NF1 from non-NF1 CPT but could not explain the CPT heterogeneity of NF1 patients. Our results suggested that non-NF1 CPT was probably not caused by germline NF1 pathogenic variants. In addition to NF1, other genetic variants could also contribute to CPT pathogenesis. Our findings would facilitate the interpretation of NF1 pathogenic variants in CPT genetic counseling. Supplementary information The online version of this article (10.1186/s13023-019-1196-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guanghui Zhu
- Department of Pediatric Orthopaedics, Hunan Children's Hospital, The Pediatric Academy of the University of South China, 86# Ziyuan Road, Changsha, Hunan Province, 410007, People's Republic of China
| | - Yu Zheng
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, Hunan Province, People's Republic of China.,Center for Medical Genetics, School of Life Sciences, Central South University, 110 Xiangya Road, Changsha, Hunan Province, People's Republic of China
| | - Yaoxi Liu
- Department of Pediatric Orthopaedics, Hunan Children's Hospital, The Pediatric Academy of the University of South China, 86# Ziyuan Road, Changsha, Hunan Province, 410007, People's Republic of China
| | - An Yan
- Department of Pediatric Orthopaedics, Hunan Children's Hospital, The Pediatric Academy of the University of South China, 86# Ziyuan Road, Changsha, Hunan Province, 410007, People's Republic of China
| | - Zhengmao Hu
- Center for Medical Genetics, School of Life Sciences, Central South University, 110 Xiangya Road, Changsha, Hunan Province, People's Republic of China
| | - Yongjia Yang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, Hunan Province, People's Republic of China
| | - Shiting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, Hunan Province, People's Republic of China
| | - Liping Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, Hunan Province, People's Republic of China
| | - Weijian Chen
- Pathology Department, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, Hunan Province, People's Republic of China
| | - Yu Peng
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, Hunan Province, People's Republic of China
| | - Nanbert Zhong
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, Hunan Province, People's Republic of China. .,New York State Institute for Basic Research in Developmental Disabilities, Staten Island, NY, USA.
| | - Haibo Mei
- Department of Pediatric Orthopaedics, Hunan Children's Hospital, The Pediatric Academy of the University of South China, 86# Ziyuan Road, Changsha, Hunan Province, 410007, People's Republic of China.
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Singer D, Johnston CE. Congenital Pseudarthrosis of the Tibia: Results, at Skeletal Maturity, of the Charnley-Williams Procedure. JB JS Open Access 2019; 4:e0004. [PMID: 31334459 PMCID: PMC6613849 DOI: 10.2106/jbjs.oa.19.00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background This study assessed the outcomes, at skeletal maturity, for 34 patients in whom congenital pseudarthrosis of the tibia (CPT) had been treated with intramedullary (IM) rod fixation. Methods The results in skeletally mature patients in whom type-4 CPT had been treated with an IM rod at an average of 11.9 years earlier were reviewed. The rod procedures varied according to whether both the tibia and the fibula were resected and both bones (type A) or just the tibia (type B) were fixed with an IM rod or whether only the tibia was resected and the fibula received no surgery (type C). Outcome grading ranged from unequivocal union with brace-free function (grade 1) to a functional limb with residual angulation or cortical defects (grade 2) to a severely impaired extremity with insufficient union or refracture (grade 3). Results Thirty-four patients were evaluated at a mean age of 16.9 years, a mean of 11.9 years after their initial surgical procedure. Seventeen patients had a grade-1 result; 11 patients, grade 2; and 6, grade 3. Thus, 82% (28) of the 34 patients had a functional extremity at maturity. All patients with a final grade-3 outcome eventually requested amputation. The final outcomes were not affected by the age at the initial fracture or surgery, the presence of neurofibromatosis-1, or cross-ankle fixation. A total of 58 IM rod procedures were performed in the 34 patients. Twenty-four (73%) of the 33 type-A procedures produced grade-1 or 2 outcomes, as did 14 (88%) of the 16 type-B procedures. Of the 9 type-C procedures, none produced a grade-1 result and 4 produced a grade-2 outcome. The results of types A and B combined were superior to those of type-C procedures (p = 0.03). Refracture occurred in 13 of 33 patients with initial stability/union after rod fixation, with 3 of those fractures remaining ununited at the latest follow-up. A dystrophic fibula had no effect on the eventual achievement of a grade-1 or 2 outcome. Conclusions This review, in which all patients had reached skeletal maturity, documents functional (grade-1 or 2) outcomes in 82% of cases of IM rod fixation for CPT. This finding was almost identical to the result in our earlier report and confirms the long-term value of permanent IM rod fixation in maintaining union and function in patients with CPT. Procedures not addressing the fibula produced inferior results. Although 13 patients had a refracture following initial union, only 3 of these fractures failed to heal with additional treatment. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Dustin Singer
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas Texas
| | - Charles E Johnston
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas Texas.,Texas Scottish Rite Hospital for Children, Dallas, Texas
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Abstract
BACKGROUND Successful radiographic union in the treatment of congenital pseudarthrosis of the tibia (CPT) may be complicated by persistent pain, recurrent fracture, and poor function necessitating further intervention, including amputation. The long-term functional, radiographic, and clinical outcomes of patients who have undergone amputation as treatment for CPT are unknown. METHODS A retrospective study of patients with a diagnosis of CPT secondary to neurofibromatosis and eventual treatment with amputation were included. Clinical and radiographic data, including initial Crawford classification, type of amputation, subsequent operative procedures, and evidence of radiographic healing were collected. RESULTS A total of 17 patients with a mean age of 4.5 years (range, 0.7 to 9.2 y) at the time of amputation met inclusion criteria. Clinical follow-up averaged 11.1 years (range, 2.1 to 18.4 y), with radiographic follow-up averaging 9.1 years (range, 2.1 to 16.4 y). The mean number of surgeries before amputation was 2.2 procedures. Four patients underwent amputation as the primary procedure (3 Boyd, 1 below knee amputation (BKA)). At the time of amputation, a Boyd amputation was performed in 13 patients with stabilization of the pseudoarthrosis achieved with retrograde Rush rodding of the tibia and local autograft. A transtibial amputation (BKA) was performed in 4.After the Boyd procedure, 4 of the 13 patients (31%) demonstrated persistent nonunion of the pseudoarthrosis and required secondary procedures to gain union. At the most recent follow-up, 12 of 13 patients demonstrated successful radiographic healing of the pseudoarthrosis. Two patients, one for persistent pain and the other for refracture, were later converted to a BKA during the late teen years. All patients functioned well with the use of prosthetic devices. CONCLUSIONS Union of the pseudoarthrosis occurred in >90% of cases following amputation. However, secondary procedures were required in 13 of the 17 patients (76%). Early amputation in the treatment of CPT provides a stable extremity and potential for a high level of function with the use of an adequate prosthesis. LEVEL OF EVIDENCE Level IV-case series.
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What Factors Influence Union and Refracture of Congenital Pseudarthrosis of the Tibia? A Multicenter Long-term Study. J Pediatr Orthop 2018; 38:e332-e337. [PMID: 29664876 DOI: 10.1097/bpo.0000000000001172] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To identify factors influencing union of congenital pseudarthrosis of the tibia (CPT), refractures, and integrity of the tibia at maturity. METHODS Data of 119 children operated for Crawford-type IV CPT and followed-up till skeletal maturity were analyzed. Logistic regression and recursive partitioning analyses were used to test associations between several variables and the outcome. RESULTS Primary union occurred in 86% of children. At maturity, 69% remained soundly united. The odds ratio for failure of primary union was 3.89 (95% confidence interval, 1.05-14.40; P=0.042) when bone morphogenetic protein was used, and children who had a combination of the Ilizarov technique and intramedullary nailing were at risk for unsound union at maturity (odds ratio, 6.19; 95% confidence interval, 1.24-30.83; P=0.026). No other association reached statistical significance. On recursive partitioning, use of the Ilizarov technique, transfixing the ankle and subtalar joints, use of cortical graft and not operating on the fibula were associated with a better outcome; use of bone morphogenetic protein and combining intramedullary nailing with the Ilizarov technique were associated with poor results. CONCLUSIONS A larger sample is needed to confirm which factors truly influence the outcome of CPT. This may be feasible if data are collected prospectively through a multicenter registry.
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Jahmani R, Alorjani M. Anterolateral Bowing of Congenital Pseudoarthrosis of Tibia Treated by Percutaneous Osteotomy and Gradual Correction Using Taylor Spatial Frame, then Late Insertion of a Fussier-Duval Nail: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:426-430. [PMID: 29636441 PMCID: PMC5912006 DOI: 10.12659/ajcr.908482] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Male, 12 Final Diagnosis: Congenital pseudoarthrosis of tibia Symptoms: Limp • deformity Medication: — Clinical Procedure: Percutaneous osteotomy and gradual correction Specialty: Orthopedics and Traumatology
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Affiliation(s)
- Rami Jahmani
- Department of Special Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohammed Alorjani
- Department of Pathology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Abstract
BACKGROUND In congenital pseudarthrosis of the tibia, use of intramedullary (IM) fixation and autogenous bone graft has long been the standard of care. This study was undertaken to determine whether the addition of rhBMP-2 to this treatment method further enhances healing potential. METHODS Twenty-one patients with congenital pseudarthrosis of the tibia were evaluated. Fifteen of these patients had neurofibromatosis type 1 (NF1). All had IM fixation and autogenous bone graft, followed by a BMP-soaked collagen sponge wrapped around both the fracture site and bone graft. A minimum 2 years' follow-up was required. RESULTS Follow-up averaged 7.2 years (range, 2.1 to 12.8 y). Sixteen of 21 tibias achieved bone union following the index surgery, at an average 6.6 months postoperatively. The 5 persistent nonunions occurred in NF1 patients. Further surgery was undertaken in these 5 NF1 patients, including the use of BMP. One of the 5 healed, 1 had persistent nonunion, and 3 eventually had amputation. Of the 16 patients who healed initially following the index surgery, 5 refractured (3 had NF1). Of these 5 patients, the IM fixation at the index surgery did not cross the ankle joint, and refracture occurred at the rod tip in 4. Three of these 5 patients healed following further surgery, 1 had persistent nonunion, and 1 had amputation. All of those with eventual amputation had NF1. No deleterious effects related to the use of BMP-2 were recognized in any patient. CONCLUSIONS The addition of rhBMP-2 appears to be helpful in shortening the time required to achieve fracture union in those who healed, but its use does not insure that healing will occur. LEVEL OF EVIDENCE Level IV-therapeutic, case series.
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Abstract
Currently, the timing of surgery for congenital pseudarthrosis of the tibia (CPT) remains controversial. The aim of this study was to investigate the results of treatment of pseudarthrosis of the tibia in children younger than 3 years of age. A retrospective study was carried out to explore the relationship between postoperative complications and the age of surgery in children with CPT. The analysis was carried out on 42 patients with Crawford type IV CPT treated with a combined surgical technique between 2008 and 2012. Patients were divided into two groups according to their age: group A (<3 years) and group B (>3 years). The incidence rates of refracture, ankle valgus, tibial valgus, and limb-length discrepancy of the two groups were evaluated. Primary bone union was achieved in 28 out of 29 (97%) patients in group A and 12 out of 13 (92%) patients in group B (P>0.05). In group A, six (21%) patients developed a refracture; 14 (48%) patients had ankle valgus with a mean degree of 11° (range: 5°-25°); 11 (38%) patients had tibial valgus with a mean tibial valgus deformity of 8.6° (range: 5°-20°); and 12 (41%) patients had limb-length discrepancy with a mean limb length of 2.9 cm (range: 0.5-4 cm). In group B, five (38%) patients developed refracture; seven (54%) patients had ankle valgus with a mean degree of 14° (range: 5°-30°); seven (54%) patients had tibial valgus with a mean tibial valgus deformity of 10.7° (range: 5°-20°); and 10 (77%) patients had limb-length discrepancy with a mean limb length of 2.8 cm (range: 1.5-3 cm). Groups A and B were significantly different in limb-length discrepancy (P=0.033). This study suggests that there is no need to defer surgery for pseudarthrosis of the tibia until the child is older than 3 years of age.
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May JD, Paavana T, McGregor-Riley J, Royston S. Closed Tibial shaft fractures treated with the Ilizarov method: A ten year case series. Injury 2017; 48:1613-1615. [PMID: 28545726 DOI: 10.1016/j.injury.2017.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/03/2017] [Accepted: 05/15/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review the outcomes of patients treated with the Ilizarov method for an isolated, closed, simple diaphyseal, Tibial fracture at our institution over the last decade. METHODS The Ilizarov frame database was used to identify 76 skeletally mature patients who sustained an isolated, closed, extra-articular, simple, diaphyseal Tibial fracture; the injury also known as a "nail-able Tibial fracture." RESULTS The average age of the patient was 38 (17-70). All 76 patients progressed to union. The average time until union was 148 (55-398) days. The coronal and sagittal alignment was 3° (0-17°) and 4° (0-14°) respectively. No patient suffered from compartment syndrome. No patient developed septic arthritis. No patient had documented anterior knee pain or secondary knee specialist input post frame removal. On average, there were 9(4-29) follow up appointments and 10(5-26) radiographs post frame application. There is a 59% chance of a patient having a difficulty post frame application. The malunion rate was 5%. Persisting pinsite infection post frame removal occurred in 5 patients (6.5%). Drilling of the pinsite sequestrum resolved the infection in four of these patients, giving a deep infection rate of 1.3%. CONCLUSIONS The Ilizarov method has a role to play in the treatment of simple closed Tibial shaft fractures in patients who need to kneel. Patient education is a priority however; the patient must be made aware of the difficulty rate associated with the Ilizarov method when compared to the complication profile of alternative treatments.
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Affiliation(s)
- Jonathan David May
- Sheffield Teaching Hospitals, Herries Road, Sheffield, South Yorkshire S5 7AU, United Kingdom.
| | - Thumri Paavana
- Sheffield Teaching Hospitals, Herries Road, Sheffield, South Yorkshire S5 7AU, United Kingdom.
| | - Jonathan McGregor-Riley
- Sheffield Teaching Hospitals, Herries Road, Sheffield, South Yorkshire S5 7AU, United Kingdom.
| | - Simon Royston
- Sheffield Teaching Hospitals, Herries Road, Sheffield, South Yorkshire S5 7AU, United Kingdom.
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Ananthan A, Athalye Jape G, Du Plessis J, Annear P, Page R, Rao S. Amniotic Band Syndrome With Pseudoarthrosis of Tibia and Fibula: A Case Report. J Foot Ankle Surg 2017. [PMID: 28623060 DOI: 10.1053/j.jfas.2017.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Constriction of the lower limb by a congenital amniotic band has been proposed to explain the development of pseudoarthrosis of the tibia and fibula. We report a case of amniotic band syndrome in a preterm female infant with pseudoarthrosis of the tibia and fibula. She was born at 29 weeks of gestation with congenital amniotic bands and was noted to have a severely edematous left foot distal to the constricting band with rudimentary digits. The skin was pink and well perfused with palpable pulses. Radiography demonstrated pseudoarthrosis of the tibia and fibula. The limb deformities were managed with splints, positioning, and physiotherapy. She underwent Z-plasty with soft tissue release on the left lower leg on day 7 of life. At 36 weeks of postmenstrual age, a repeat radiograph showed markedly improved growth of the tibia and fibula with mature new bone formation, which avoided the need for further surgical intervention. During the follow-up period, she underwent left Syme's amputation at 18 months. At 29 months of age, the child was able to walk and run without support. The findings from our case confirm the potential for bone growth in patients with amniotic band syndrome, once the constricting band has been released. Simple release of the constriction band with Z-plasty resulted in growth of mature bone, replacing the pseudoarthrosis and, hence, the patient did not require surgical amputation. Thus, one should be cautious when deciding on surgical amputation, even in the presence of pseudoarthrosis, especially in preterm infants. Early limb-preserving surgery with release of the constricting band with an intention to salvage the limb appears appropriate.
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Affiliation(s)
- Anitha Ananthan
- Senior Resident, Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.
| | - Gayatri Athalye Jape
- Assistant Professor, Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Jean Du Plessis
- Assistant Professor, Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Peter Annear
- Orthopaedic Surgeon, Department of Orthopaedics, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Rohan Page
- Plastic Surgeon, Department of Plastic Surgery, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Shripada Rao
- Associate Professor, Centre for Neonatal Research and Education, University of Western Australia, Crawley, Western Australia, Australia
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Liu YX, Mei HB, Zhu GH, He RG, Liu K, Tang J, Wu JY, Ye WH, Hu X, Tan Q, Yan A, Huang SX, Tan XQ, Lei T. Relationship between postoperative complications and fibular integrity in congenital pseudarthrosis of the tibia in children. World J Pediatr 2017; 13:261-266. [PMID: 28070823 DOI: 10.1007/s12519-016-0074-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/08/2015] [Indexed: 10/20/2022]
Abstract
BACKGROUND This study aimed to investigate the relationship between postoperative complications and fibular integrity in congenital pseudarthrosis of the tibia (CPT) in children. METHODS A retrospective study was performed in 59 patients with Crawford type IV CPT who were treated with combined surgical technique from 2007 to 2011. The patients were divided into two groups, the CPT with fibular pseudarthrosis (group A) and CPT with intact fibula groups (group B), on the basis of fibula status after the union of CPT. The incidence rates of refracture, ankle valgus, tibial valgus, and limb length discrepancy in the two groups were investigated. RESULTS In group A, 14 (36.8%) cases had refracture, 30 (78.9%) had ankle valgus; 27 (71%) exhibited tibial valgus with an average tibial valgus of 7° (6°-20°), and 24 (63.2%) had limb length discrepancy with an average limb length of 1.26 cm (0.6-4.4 cm). In group B, 2 (9.5%) cases had refracture, 11 (52.4%) had ankle valgus, 8 (42.9%) had tibial valgus with an average tibial valgus deformity of 2.9° (6°-13°), and 13 (61.9%) had limb length discrepancy with an average limb length of 1.48 cm (0.5-5 cm). Significant difference in refracture and ankle valgus was found between groups A and B (P<0.05). CONCLUSIONS After the union of CPT, patients with fibular pseudarthrosis showed higher incidence of refracture and ankle valgus than those with intact fibula. Attention should be paid to the presence of fibular pseudarthrosis when managing CPT.
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Affiliation(s)
- Yao-Xi Liu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Hai-Bo Mei
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China.
| | - Guang-Hui Zhu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Rong-Guo He
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Kun Liu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Jin Tang
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Jiang-Yan Wu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Wei-Hua Ye
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Xin Hu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Qian Tan
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - An Yan
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Sheng-Xiang Huang
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Xiao-Qian Tan
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
| | - Ting Lei
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Pediatric Academy of University of South China, Changsha City, Changsha, China
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O’Donnell C, Foster J, Mooney R, Beebe C, Donaldson N, Heare T. Congenital Pseudarthrosis of the Tibia. JBJS Rev 2017; 5:e3. [DOI: 10.2106/jbjs.rvw.16.00068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Seo SG, Lee DY, Kim YS, Yoo WJ, Cho TJ, Choi IH. Foot and Ankle Function at Maturity After Ilizarov Treatment for Atrophic-Type Congenital Pseudarthrosis of the Tibia: A Comprehensive Outcome Comparison with Normal Controls. J Bone Joint Surg Am 2016; 98:490-8. [PMID: 26984917 DOI: 10.2106/jbjs.15.00964] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate clinical outcomes and the biomechanical function of the foot and ankle at skeletal maturity of patients treated for atrophic-type congenital pseudarthrosis of the tibia (CPT) compared with healthy young adult controls. METHODS Twenty-four patients (mean age of 19.1 years) who had undergone Ilizarov treatment for unilateral atrophic-type CPT were compared with twenty-four controls (mean age of 19.6 years). All participants were evaluated using validated outcome questionnaires, radiographs, physical examination, instrumented motion analysis including a multisegmental foot model, and pedobarographic measurement. RESULTS Within the CPT group, the mean score of the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale was 89.9 (range, 76 to 100), and the mean score of the Oxford Ankle Foot Questionnaire (OAFQ) was 42.8 (range, 15 to 60). Motion analysis and pedobarographic measurement showed differences in biomechanical function of the foot and ankle on the side affected by CPT: a slower walking speed due to the short stride length; decreased dorsiflexion in hallux motion; increased hindfoot pronation in the presence of forefoot supination; diminished ankle push-off power; delayed time to heel-rise; and decreased forefoot pressure relative to hindfoot pressure. However, sagittal motion of the hindfoot and forefoot on the affected side was relatively well preserved. Subgroup analysis demonstrated no significant differences in terms of clinical outcome scores and most biomechanical parameters between the tibiofibular synostosis group and the intact-fibula group. CONCLUSIONS Children with atrophic-type CPT can obtain satisfactory foot and ankle function at maturity after successful Ilizarov treatment. Early stabilization of the ankle mortise by fibular stabilization and preservation of ankle mobility during and after treatment is thought to be crucial to maintaining function of the ankle in patients with CPT. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sang Gyo Seo
- Department of Orthopedic Surgery, Asan Medical Center, Seoul, South Korea
| | - Dong Yeon Lee
- Division of Pediatric Orthopedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Yeon Soo Kim
- Division of Pediatric Orthopedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Won Joon Yoo
- Division of Pediatric Orthopedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Tae-Joon Cho
- Division of Pediatric Orthopedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - In Ho Choi
- Division of Pediatric Orthopedics, Seoul National University Children's Hospital, Seoul, South Korea
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Borzunov DY, Chevardin AY, Mitrofanov AI. Management of congenital pseudarthrosis of the tibia with the Ilizarov method in a paediatric population: influence of aetiological factors. INTERNATIONAL ORTHOPAEDICS 2015; 40:331-9. [PMID: 26546064 DOI: 10.1007/s00264-015-3029-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/21/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Our study compared the rates of union achieved with the Ilizarov method in congenital pseudarthrosis of the tibia (CPT) associated with neurofibromatosis type 1 (NF1) or CPT of idiopathic origin in paediatric patients. METHODS We studied the outcomes of 28 children that were treated for CPT between 2005 and 2013. Group 1 included children (n = 14, mean age = 9.7 years) with CPT associated with NF1 while group 2 were CPT cases that had radiographic confirmation of dysplastic lesions in the tibia but lacked clinical NF1 manifestations (n = 14, mean age = 8.6 years). There was no statistical difference between the groups regarding their age or number of previous operations per patient. Individual technical solutions were planned for each patient but coaptation of bone fragments and autologous local tissue grafting to achieve a greater bone thickness and contact area at the pseudarthrosis level were mainly used. Refracture-free rate after the first operation, number of re-operations per patient, and union rates in the groups were compared. RESULTS Bone union and weight bearing were obtained in all the cases after the first operation. Refracture-free rate was 42.86 % in group 1 and 35.71% in group 2 (no statistical difference, p > 0.05). Mean number of re-operations per patient was 1.07 and 0.78 respectively (p > 0.05). Subsequent treatment for refractures with the Ilizarov techniques gained 92.86% of union in both groups at the follow-ups by completion of the study (range, 2-9 years). CONCLUSIONS The Ilizarov method yields comparable results in the management of CPT associated with NF1 or tibial dysplasia of idiopathic origin in paediatric cases. Further research should focus on the ways to support the Ilizarov method in order to reduce the number of repetitive surgeries or eliminate them.
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Affiliation(s)
- Dmitry Y Borzunov
- Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, Kurgan, 640014, Russian Federation
| | - Alexander Y Chevardin
- Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, Kurgan, 640014, Russian Federation.
| | - Alexander I Mitrofanov
- Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, Kurgan, 640014, Russian Federation
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Bhowmick K, Varghese VD. Retrograde Intramedullary Nailing for Recurrent Fracture in Congenital Pseudarthrosis of the Tibia. J Foot Ankle Surg 2015; 55:1287-1291. [PMID: 26342666 DOI: 10.1053/j.jfas.2015.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Indexed: 02/03/2023]
Abstract
We present the case of a 23-year-old male with congenital pseudarthrosis of the tibia, who had undergone treatment with Ilizarov ring fixation and had experienced 4 episodes of repeat fracture. He had associated type 1 neurofibromatosis, and his radiographs confirmed a type 6 Boyd's congenital pseudarthrosis of the left tibia, with concomitant arthritic ankle and subtalar joints. He was treated successfully with retrograde intramedullary nailing of the tibia and autologous bone grafting. At his final follow-up visit at 3 years postoperatively, he displayed complete union with no repeat fractures.
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Affiliation(s)
- Kaushik Bhowmick
- Assistant Professor, Department of Orthopaedics, Christian Medical College, Vellore, India.
| | - Viju Daniel Varghese
- Assistant Professor, Department of Orthopaedics, Christian Medical College, Vellore, India
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27
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Zhu GH, Mei HB, He RG, Liu K, Tang J, Wu JY. Effect of distraction osteogenesis in patient with tibial shortening after initial union of Congenital Pseudarthrosis of the Tibia (CPT): a preliminary study. BMC Musculoskelet Disord 2015; 16:216. [PMID: 26293924 PMCID: PMC4546181 DOI: 10.1186/s12891-015-0680-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 08/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of our retrospective study was to evaluate the preliminary result of distraction osteogenesis in patient with tibial shortening after initial union of Congenital Pseudarthrosis of the Tibia (CPT). METHODS All the CPT cases with tibial shortening after initial union managed by proximal tibial lengthening using Ilizarov technique were identified. All the patient charts and radiograms were reviewed. RESULTS Between March 2007 and January 2012, 11 CPT cases were included with an average follow-up of 41 months (range, 34-51 months). The mean age at surgery was 8.5 years (range, 3.9-14.5y). The average length of discrepancy was 5.6 cm (range, 2.0-8.2 cm). Eight (8) cases had radiological findings of proximal tibial dysplasia, while the other 3 cases had not. The average distraction length gained was 5.3 cm (range, 3.5-8.0 cm) with a mean elongation rate of 21.4% (range, 15-30%). The Healing Index (HI) was 63.1 d/cm (range, 47-77 d/cm). In the 8 patients with proximal tibial dysplasia, 5 cases had lateral callus, 3 had central callus, and poor bone regeneration was observed in all of them with an average HI of 67 d/cm. In the other 3 patients without proximal tibial dysplasia, concave shaped callus was identified with an average HI of 52.7 d/cm. None of the patients had re-fracture, nonunion, axis deviation or angulation of the distraction area. Ankle joint stiffness was found in 2 of the patients. No evidence of knee contracture was detected. There were 5 cases with pin-tract infection which was managed by pin-tract nurse and oral administration of antibiotics. CONCLUSIONS We concluded that proximal tibial lengthening after initial union of CPT was effective for management of tibial shortening, however it was characterized by poor bone regeneration with different types of callus from normal, greater healing index and prolonged fixator wearing. We recommended that tibial lengthening could be considered when the limb length discrepancy (LLD) was more than 4 cm in younger children after primary union of CPT.
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Affiliation(s)
- Guang-hui Zhu
- Dept of Orthopedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 Ziyuan road, Changsha, Hunan, P.R. China.
| | - Hai-bo Mei
- Dept of Orthopedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 Ziyuan road, Changsha, Hunan, P.R. China.
| | - Rong-guo He
- Dept of Orthopedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 Ziyuan road, Changsha, Hunan, P.R. China.
| | - Kun Liu
- Dept of Orthopedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 Ziyuan road, Changsha, Hunan, P.R. China.
| | - Jin Tang
- Dept of Orthopedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 Ziyuan road, Changsha, Hunan, P.R. China.
| | - Jiang-yan Wu
- Dept of Orthopedics, Hunan Children's Hospital, The Pediatric Academy of University of South China, 86 Ziyuan road, Changsha, Hunan, P.R. China.
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28
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Sabharwal S, Louie KW, Reid JS. What's new in limb-lengthening and deformity correction. J Bone Joint Surg Am 2014; 96:1399-406. [PMID: 25143503 DOI: 10.2106/jbjs.n.00369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sanjeev Sabharwal
- Department of Orthopedics, Rutgers-New Jersey Medical School, 90 Bergen Street, Doctor's Office Center, Suite 7300, Newark, NJ 07103. E-mail address for S. Sabharwal:
| | - Kevin W Louie
- Department of Orthopedics, Rutgers-New Jersey Medical School, 90 Bergen Street, Doctor's Office Center, Suite 7300, Newark, NJ 07103. E-mail address for S. Sabharwal:
| | - J Spence Reid
- Department of Orthopedics, Rutgers-New Jersey Medical School, 90 Bergen Street, Doctor's Office Center, Suite 7300, Newark, NJ 07103. E-mail address for S. Sabharwal:
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