克劳福德 IV 型先天性胫骨假关节：带血管腓骨移植治疗及骨骼成熟时的结果。

Crawford Type IV Congenital Pseudarthrosis of the Tibia: Treatment With Vascularized Fibular Grafting and Outcome at Skeletal Maturity.

机构信息

Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University Hospitals and School of Medicine, Assiut, Egypt.

出版信息

J Pediatr Orthop. 2021 Mar 1;41(3):164-170. doi: 10.1097/BPO.0000000000001751.

DOI:10.1097/BPO.0000000000001751

PMID:33448723

Abstract

BACKGROUND

Vascularized fibular grafting (VFG) is currently accepted as one of the best treatments for congenital tibial pseudoarthrosis (CPT). However, with longer follow-up, functional results deteriorate, and some problems become evident.

METHODS

Thirty-nine patients with CPT were treated with VFG. Their age at surgery averaged 5.2 years. Twenty-one cases aged 3 years or less at the time of surgery. All cases were Crawford type IV affected by neurofibromatosis-1. Fourteen patients had 1 to 7 previous surgeries with an average of 4.2 procedures. The length of the fibula used averaged 9.9 cm, and the fibula was fixed by intramedullary wires in 26 cases, and transfixion screws in 11 cases.

RESULTS

Follow-up averaged 8.1 years. Seventeen cases (43.6%) reached skeletal maturity before the final follow-up. Primary bone union was achieved in 37 cases (96%) after an average of 3.2 months. Stress fracture occurred in 21 cases (51.3%) and was recurrent in 11 cases. Twenty-one cases (53.8%) developed tibial shaft deformities with an average valgus angle of 13.8 degrees and procurvatum angle of 18.8 degrees. The overall final limb length discrepancy (LLD) averaged 2.2 cm. Ipsilateral ankle valgus deformity occurred in 21 cases (53.8%) and averaged 10 degrees. A total of 17 cases required an average of 2 secondary procedures. The tibial deformity did not appear to remodel with age, but the LLD and the angle of ipsilateral ankle valgus deformity continued to significantly increase until skeletal maturity.

CONCLUSION

This study reports the largest single center experience of CPT cases treated with VFG. Free VFG is an excellent treatment option for CPT. Best results are achieved when the procedure is performed at or before the age of 3 years, in the absence of previous surgeries, and with the use of intramedullary fixation. The resulting LLD and the degree of ipsilateral ankle valgus increase with age until skeletal maturity, however, tibial deformity does not remodel and should be corrected at any age if it is excessive. Donor side mild ankle valgus may occur despite sound tibiofibular synostosis.

LEVEL OF EVIDENCE

Level IV.

摘要

背景

带血管腓骨移植（VFG）目前被认为是治疗先天性胫骨假关节（CPT）的最佳方法之一。然而，随着随访时间的延长，功能结果恶化，一些问题变得明显。

方法

39 例 CPT 患者接受 VFG 治疗。手术时的平均年龄为 5.2 岁。21 例患者在手术时年龄在 3 岁以下。所有病例均为受神经纤维瘤病-1 影响的 Crawford Ⅳ型。14 例患者有 1 至 7 次既往手术，平均手术次数为 4.2 次。使用的腓骨长度平均为 9.9cm，26 例采用髓内钢丝固定，11 例采用贯穿钉固定。

结果

平均随访 8.1 年。17 例（43.6%）在最终随访前达到骨骼成熟。37 例（96%）在平均 3.2 个月后实现了主要骨愈合。21 例（51.3%）发生应力性骨折，11 例（27.5%）为复发性骨折。21 例（53.8%）发生胫骨骨干畸形，平均外翻角为 13.8°，内翻角为 18.8°。总的最终肢体长度差异（LLD）平均为 2.2cm。21 例（53.8%）出现同侧踝关节外翻畸形，平均为 10°。共 17 例需要平均 2 次二次手术。胫骨畸形似乎不会随年龄而重塑，但 LLD 和同侧踝关节外翻畸形的角度会继续显著增加，直到骨骼成熟。

结论

本研究报告了单中心治疗 CPT 病例中最大的 VFG 经验。游离 VFG 是 CPT 的一种极好的治疗选择。最好的结果是在 3 岁或以下、无既往手术史且采用髓内固定的情况下进行手术。然而，随着年龄的增长，最终的 LLD 和同侧踝关节外翻的程度会继续增加，直到骨骼成熟，但是，胫骨畸形不会重塑，如果畸形过大，应在任何年龄进行矫正。尽管胫腓骨吻合良好，但供侧可能会出现轻度踝关节外翻。