Combined ilizarov fixation and intramedullary nailing for treatment of congenital pseudarthrosis of the tibia

Background: Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging conditions in pediatric orthopedics. Multiple objectives must be achieved to correct this condition successfully, including obtaining union, prevention of refracture, management of limb-length discrepancy (LLD), and correction of deformities of the ankle and leg. This combined treatment conjoins the improved union rate and improved limb-length equalization of Ilizarov fixation and the controlled alignment and refracture prevention associated within tramedullary nailing. Objective: To evaluated the outcome of combined Ilizarov fixation with intramedullary pinning in term of union of pseudathrosis and residual deformities. Material and Method: Thirteen children who were treated by this technique were evaluated in this study. Clinical presentation and radiographs were evaluated and union time, secondary operations and time of follow-up were recorded. At final followup, condition of tibial and fibula pseudarthrosis, LLD, refracture and deformities of the tibia and ankle were documented. Results: Union was achieved in 11 children. For the other 2 children, a secondary procedure using iliac bone graft was required to achieveunion. Fibular pseudarthrosis persisted in 9 patients. A total of 30 secondary operations were performed for various indications. At final follow-up, mean anterior bowing was 8.5 degrees (range: 0-20°), mean medial bowing was9.5 degrees (range: 0-25°), and ankle valgus was present in 5 patients. The mean LLD was 1.7 cm (range: 0-3). Two patients had limping gait. No donor site morbidity was observed in any patient. Refracture occurred in three cases after nail removal. In these three cases, secondary operations using the same technique were performed with favorable outcome. Conclusion: The results of this study demonstrate that Ilizarov fixation combined with intramedullary nailing is a safe, effective and practical treatment for management of CPT. This combination technique achieves multiple objectives including rigid-stable fixation, management of LLD, correction of residual deformity and prevention of refracture. Moreover, this technique can be used in cases with previous operations that resulted in nonunion.