Long-term Follow-up Results of the Free Vascularized Fibular Graft in Congenital Pseudarthrosis of the Tibia

Duke Whan Chung; Chung Soo Han; Jung Chul Hwang

doi:10.4055/jkoa.2009.44.1.46

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Chung, Han, and Hwang: Long-term Follow-up Results of the Free Vascularized Fibular Graft in Congenital Pseudarthrosis of the Tibia

Original Article

Journal of the Korean Orthopaedic Association

Journal of the Korean Orthopaedic Association 2009; 44(1): 46-53.

Published online: 23 February 2009

DOI: https://doi.org/10.4055/jkoa.2009.44.1.46

Long-term Follow-up Results of the Free Vascularized Fibular Graft in Congenital Pseudarthrosis of the Tibia

Duke Whan Chung, M.D., Chung Soo Han, M.D., Jung Chul Hwang, M.D.

Department of Orthopedic Surgery, School of Medicine, Kyung Hee University, Seoul, Korea.

Address reprint requests to Duke Whan Chung, M.D. Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, 1, Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea. Tel: +82.2-958-8368, Fax: +82.2-964-3865, dukech@khmc.or.kr

Abstract

Purpose

To report the long-term follow-up results of a free vascularized fibular graft (FVFG) for the treatment of patients with congenital pseudarthrosis of the tibia (CPT).

Materials and Methods

Fourteen patients with CPT, who underwent FVFG and were followed-up for more than 4 years, were enrolled in this study. The average age at FVFG was 4.5 years (range, 1~10.6 years) with an average follow-up of 11.6 years (range, 4~26.6 years). In 11 cases, 24 additional procedures were performed due to the secondary problems, such as delayed union, nonunion, leg length discrepancy, and deformity of the tibia. The clinical and radiological data were reviewed to evaluate the outcomes of the FVFG.

Results

Bone union and hypertrophy of the fibular graft was observed in all cases. The average time of union in 7 cases, in whom bone union was achieved without the aid of any supplementary procedures, was 6.7 months (range, 3.5~11 months). At the last follow-up, the mean limb length discrepancy was 2.5 cm (range, 0~8 cm), and the average anterior apex and valgus angulation of the tibial shaft were 18.4° (range, 0~85°) and 9.9° (range, -5~34°), respectively. The mean ankle alignment was valgus 7.2° (range, -3~30°), and the mean range of motion of the ankle joint was dorsiflexion 17° and plantar flexion 30°.

Conclusion

FVFG is an effective procedure in congenital pseudarthrosis of the tibia which has the advantages of allowing a more aggressive resection of the abnormal bone and scar tissue and as well as resolving the bone defect after resecting the lesion. This procedure is expected to produce a better clinical result if rigid internal and external fixation are performed.

Keywords: Tibia, Congenital pseudarthrosis, Free vascularized fibular graft

Figures and Tables

Fig. 1

Case 4. (A) Bony union was failed after bone graft at other hospital. (B) Postoperative radiograph. (C) Seven months after FVFG, solid bony union was obtained. (D) One year nine months after FVFG, distal tibiofibular synostosis was performed due to valgus deformity of the ankle at recipient site. (E) Radiographs of the postoperative 8 year 9 months.

Fig. 2

Case 6. (A) Preoperative radiograph. (B) Postoperative radiograph. (C) Nine months after vascularized fibular graft. (D) Radiographs of the postoperative 8 year 9 months.

Fig. 3

Case 3. (A) Initial radiograph. (B) At other hospital, bone graft was performed and bony union was failed. (C) Postoperative radiograph. (D) Five months after FVFG, delayed union at proximal part was observed. (E) Two years four months after FVFG, distal tibiofibular synostosis was performed due to valgus deformity of the ankle at donor site. (F) Five years after FVFG, distal tibiofibular synostosis was performed at recipient site. (G) Radiograph prior to corrective osteotomy showing incomplete bony union and deformity of the tibia. Anterior apex and valgus angulation of the tibial shaft were 50 and 20 degree, respectively. (H) Eight years after FVFG, corrective osteotomy and bone graft, intramedullary rod fixation were performed. (I) Scanogram prior to bone lengthening using ilizarov external fixator showed the leg length discrepancy (LLD) about 4.5 cm. (J) Seventeen years after FVFG, bone lengthening was performed. (K) Twenty Five years nine months after FVFG, although LLD was resolved, however the valgus ankle deformity was shown.

Table 1

Patient Demographics

^*, café-au-lait spot. M, male; F, female; yo, years old; Rt, right; Lt, left; Preop, preoperative; LLD, leg length discrepancy; Ant, anterior; Lat, lateral; BG, bone grafting; IEF, ilizarov external fixator; y, years; m, months.

Table 2

Problem Lists and Performing Procedure

BG, bone grafting; IES, implanted electrical stimulation; IEF, ilizarov external fixator; IMRF, itramedullary rod fixation; CO, corrective osteotomy; L, langenskiöld operation.

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