Treatment of Concomitant Congenital Pseudarthrosis of the Fibula With Propeller Periosteal Flap.

INTRODUCTION: Congenital pseudarthrosis of the fibula is not an uncommon condition to accompany congenital pseudarthrosis of the tibia. Persistence of the fibular pseudarthrosis has been linked to inferior outcomes including tibial union and alignment, refractures, and ankle alignment. In this report, we present the results of a pedicled periosteal propeller flap technique for the treatment of fibular pseudarthrosis. METHODS: Ten children with an average age at surgery of 5.3 years who had congenital pseudarthrosis of both tibia and fibula were studied. The tibia was treated with free vascularized fibular grafting, and the ipsilateral fibula was treated with a technique after resection of the pseudarthrosis. A periosteal flap from the proximal healthy part of the fibula is harvested off the bone, rotated 180° based on a branch from the peroneal vessels to cover the fibular defect and fashioned in the form of a tube filled with bone fragments. RESULTS: The periosteal flap size ranged from 5 to 7 cm. Follow-up averaged 37.2 months. The tibia was united in all cases; in 2 of them, refractures occurred and healed with conservative management. The fibula was united in 8 cases. At final follow-up, 5 cases showed residual tibial deformity, and 5 showed residual ankle deformity. Average leg-length discrepancy was 1.4 cm (0-3 cm). CONCLUSION: The pedicled periosteal propeller flap presents a useful new technique for managing concomitant congenital fibular pseudarthrosis.

Congenital Pseudarthrosis of the Tibia: Long-term Outcome of Treatment With Intramedullary Vascularized Fibular Graft Combined With Ilizarov Distraction.

BACKGROUND: Late presenting cases of congenital pseudarthrosis of the tibia, are further complicated with severe shortening. Limb length discrepancy (LLD) cannot be corrected by vascularized fibular grafting and the use of Ilizarov distraction is associated with a high rate of complications. The aim of this study was to report the long-term follow-up of a combined technique previously published under the name "telescoping vascularized fibular graft". MATERIALS AND METHODS: Eleven patients operated at an average age of 10.2±3.2 years were reviewed. All cases were Crawford type IV affected by neurofibromatosis 1. Nine patients had an average of 4.3 previous operations. Preoperative LLD averaged 7.9±2.5 cm. RESULTS: Follow-up averaged 10±5.4 years. Seven cases (63.6%) reached skeletal maturity before final follow-up. Primary union was achieved in all cases after an average of 7.2±1.3 months. Full weightbearing was possible after an average of 10.6±2.2 months. Recurrent stress fractures occurred in 9 cases (81.8%) and healed with casting in 6 cases and required internal fixation in 3 cases. Eight cases (72.8%) developed tibial shaft deformities, mainly procurvatum that required corrective osteotomy in 2 cases. Final LLD averaged 2.7±1.3 cm. Complete tibialization of the graft was achieved after an average of 17.0 ± 3.6 months. Valgus deformity of the ipsilateral ankle averaged 12.4 degrees±7.5. CONCLUSION: The presented technique avoids osteotomy of the diseased bone and allows simultaneous treatment of the pseudarthrosis and correction of shortening. Compared with conventional bone transport, it requires shorter time of frame application and therefore better patient tolerability because there is no waiting for consolidation of the regenerate. The dis-impaction of the doweled fibula occurs proximally, allowing the less active site located at the distal aspect of the pseudarthrosis to heal without displacement. A shortcoming of the presented technique is the more propensity for axial deviation and refractures that seldom require surgery. LEVEL OF EVIDENCE: Level-IV.

Long-term Evaluation of Teres Major to Infraspinatus Transfer for Treatment of Shoulder Sequelae in Obstetrical Brachial Plexus Palsy.

BACKGROUND: The long-term results of soft tissue rebalancing procedures of the shoulder in obstetric brachial plexus palsy have been scarcely reported. The effect of this procedure on the evolution of secondary bone changes has been a subject of controversy. METHODS: Twenty-six children are included in this study. All initially had postganglionic C5-6 or C5-7 (Narakas types I and II) obstetric brachial plexus palsy, which spontaneously recovered. Children included are those who had persistent external rotation weakness with or without internal rotation contracture, nondysplastic glenohumeral joint, and functioning teres major. All had anterior shoulder release and teres major to infraspinatus transfer to correct internal rotation deformity and/or increase active shoulder external rotation. Patients were 18 males and 8 females. The right upper limb was affected in 16 patients, and the left in 10. Surgery was performed at an average age of 3.01 years (range, 1-10 years). Follow-up averaged 8.2 years (range, 5-16 years). Eight cases (30%) were followed up for 10 years or greater. Age at final follow-up averaged 10.5 years (range, 6-17.8 years). RESULTS: The results showed to be significant: 67 degrees (63%), 71.3 degrees (412%), and -32 degrees (-35%), respectively. There was no single recurrence of internal rotation deformity. Global Mallet score averaged 20 ± 2.7. Global abduction and external rotation averaged 3.5 ± 0.8 and 4 ± 0.3, respectively. Shoulder abduction range included an average of 45 degrees glenohumeral and 65 degrees scapulothoracic motion. Postoperative internal rotation in adduction was limited to 55.96 ± 25.65 degrees and was significantly lower that the preoperative value. Radiological measurements showed no significant differences between the operated and normal sides. CONCLUSIONS: We conclude that the long-term results after soft tissue rebalancing, combined with open reduction when required, demonstrated significant improvement of abduction and external rotation and significant loss of internal rotation. The difference in glenoid version and humeral head subluxation continued to be insignificant compared with the normal side.