Combination of the Ilizarov Method and Intramedullary Fixation for the Treatment of Congenital Pseudarthrosis of the Tibia in Children: A Retrospective Observational Study

Surgical treatment of congenital pseudarthrosis of the tibia in children: CPAM-LRC consensus and guidelines

PURPOSE

Congenital pseudarthrosis of the tibia (CPT) is a rare condition typically manifesting within the first decade of life. The primary objectives of surgical intervention for CPT include achieving long-term bony union of the tibia, preventing or minimizing limb length discrepancies (LLD), avoiding mechanical axis deviations of the tibia and adjacent joints, and preventing refracture. This study aims to conduct a systematic review of current treatment methods for CPT to determine the most effective non-surgical and surgical management strategies for pediatric patients with this condition.

METHODS

A review of the literature was performed according to the PRISMA guidelines. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases was performed over the years 1989 to 2024. Randomized controlled trials, cohort studies and case-control studies on the surgical treatments of CPT in children were included. Random-effects models were used to estimate the pooled primary union rate, primary union time and refracture rate. Then a consensus statement of surgical treatment of CPT in children was achieved based on Delphi methodology which included 2 rounds of electronic questionnaires and 1 round of virtual consensus meeting.

RESULTS

Seventy-four studies were included, 23 of which on intramedullary rods (IMR) involving 364 patients, 15 on Ilizarov methods with 230 patients, and 23 studies combining IMR with Ilizarov involving 458 patients. The pooled primary union rate for IMR, Ilizarov method, and Ilizarov combined with IMR was 69% (95% CI: 0.55-0.82), 89% (95% CI: 0.77-0.98) and 85% (95% CI: 0.74-0.94), respectively. The pooled primary union time for IMR, Ilizarov method, and Ilizarov combined with IMR was 8.95 months (95% CI: 6.53-11.37), 7.14 months (95% CI: 5.53-8.74), and 5.62 months (95% CI: 4.89-6.35), respectively. The pooled refracture rate among primary unions for IMR, Ilizarov method, and Ilizarov combined with IMR was 85% (95% CI: 0.60-1.00), 81% (95% CI: 0.56-0.98), and 60% (95% CI: 0.26-0.90), respectively. After 2 rounds of electronic questionnaires and 1 round of virtual consensus meeting, a consensus statement and guidelines of surgical treatment of CPT in children was provided.

CONCLUSION

The CPAM-LRC consensus panel provided recommendations to improve management of pediatric patients with CPT in clinical practice. Combined techniques for pediatric patients after fracture or the formation of pseudarthrosis commonly include excision of the pseudarthrosis site, external fixation, intramedullary fixation, and autogenous bone grafting. Vascularized fibular graft and cross-union can be considered a viable alternative to corticocancellous autograft. Use of recombinant bone morphogenic protein (rhBMP) is not currently conclusive.

Physiotherapy Intervention Focusing on Proprioceptive Retraining for Tibial Pseudoarthrosis Patients Operated With Ilizarov External Fixator: A Case Report

Pseudoarthrosis of the tibia is an uncommon condition that occurs due to non-union of bone and typically requires surgery. It may cause fractures that develop spontaneously or after minor trauma. Physiotherapy is an excellent treatment for this uncommon condition. The tibia of the affected limb becomes malformed and bends backwards. This case report outlines the interdisciplinary programme adopted to successfully manage a 23-year-old female patient with right-sided tibial pseudoarthrosis. Following the implantation of Ilizarov's external fixator to correct the deformity, the patient was referred to the physiotherapy department for post-operative management. After the implementation of a tailor-made physiotherapy protocol focusing on proprioceptive retraining, significant improvements were seen in her joint proprioception, muscular strength and range of motion.