Osteosynthesis With Barrel-Bone Grafting Technique for Failed Recalcitrant Cases of Congenital Pseudarthrosis of Tibia: Outcomes and Complications in a Series of 17 Patients.

BACKGROUND: Congenital pseudarthrosis of the tibia (CPT) is a complex pediatric orthopaedic condition with difficulty in achieving union and associated deformities. The purpose of this study was to evaluate the results of osteosynthesis with the barrel-bone grafting technique for failed recalcitrant cases in terms of union rate, refracture, and complications.

METHODS: This was a retrospective analysis of previously operated, failed cases of CPT reoperated between January 2019 and September 2023 using the "barrel-bone grafting" method. These cases were operated by 2 senior pediatric orthopaedic surgeons. Details of previous treatment were obtained from the history and operative notes. The surgical steps were similar to the "4-in-1 barrel-bone grafting method," though with certain differences. Cross-union was attempted in all patients. However, in cases where the fibula was nonreconstructable, absent, or sclerotic and thin, a 3-in-1 union or pure tibial 2-in-1 union was attempted. Transcalcaneal fixation was performed in cases of very distal tibial pseudarthrosis. An above-knee plaster was given for 3 months, followed by a clamshell orthosis.

RESULTS: Seventeen patients (mean age: 4 y) were analyzed at a mean follow-up of 27 months (12 to 60 mo). All patients achieved union, of which 2 patients achieved cross-union, 3 achieved 3-in-1, and 12 had only tibial union. Thirteen patients had tibial fixations, while 4 patients required transcalcaneal fixations. The time to union was 4 months, and the mean postoperative LLD was 2.3 cm (1 to 6 cm). There was 1 superficial skin necrosis and 1 delayed wound healing. No patient developed refractures till final follow-up. Three patients had ankle valgus, which was kept under observation.

CONCLUSION: The barrel-bone grafting method is an effective technique for achieving robust, fracture-free union in recalcitrant cases of CPT. In the absence of a reconstructable fibula, a 3-in-1 or pure tibial union also gives adequate stability and prevents refracture.

LEVEL OF EVIDENCE: Level IV.