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Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia

Topic updated on 03/28/16 8:51pm
Introduction
  • Three types of tibial bowing exist in children
    • anterolateral bowing (this topic)
    • posteromedial bowing (physiologic) 
    • anteromedial bowing (fibular hemimelia) 
  • Anterolateral bowing is a continuum of disease that can be divided into
    • anterolateral bowing of tibia 
    • congenital pseudarthrosis of tibia  
  • Associated conditions
    • neurofibromatosis type I 
      • is found in 50-55% of patients with anterolateral bowing
      • only 6-10% of patients with neurofibromatosis will have anterolateral tibial bowing
Classification
  • Numerous classification systems have been proposed (Boyd, Andersen, Crawford) however none guide management or are predictive of outcome
Presentation
  • Symptoms
    • majority present with bowing in the first year of life
  • Physical exam
    • deformity 
    • careful skin examination for cafe-au-lait spots and other signs of neurofibromatosis
Treatment
  • Nonoperative
    • bracing in total contact orthosis
      • indications
        • bowing without pseudarthrosis or fracture
          • spontaneous remodeling is not expected
        • goal is to prevent further bowing and fractures
        • osteotomy for bowing alone is contraindicated
      • technique
        • maintained until skeletal maturity
  • Operative
    • surgical fixation
      • indications
        • bowing with pseudarthrosis or fracture 
    • amputation 
      • indications
        • typically indicated after multiple failed surgical attempts, severe limb length discrepancy
        • Method- Syme or Boyd amputation
Techniques
  • Surgical fixation
    • goals
      • resection of pseudarthrosis to grossly normal bone, correction of deformity, bone grafting and stabilization of the remaining segments
    • techniques
      • intramedullary nailing with bone grafting  
      • free fibular graft 
        • contralateral fibula is used, ipsilateral is involved in pseudarthrosis
      • Ilizarov or circular frame fixation with lengthening or bone transport
Complications
  • Recurrent fracture
    • seen in 50% or more of patients even after initial union 

 

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(OBQ04.255) Anterolateral tibial bowing is associated with which of the following lower extremity conditions in children? Topic Review Topic

1. Calcaneovalgus foot deformity
2. Congenital pseudoarthrosis of the tibia
3. Fibular hemimelia
4. Congenital talipes equinovarus
5. Congenital vertical talus

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