Prophylactic bypass grafting and long-term bracing in the management of anterolateral bowing of the tibia and neurofibromatosis-1

J Bone Joint Surg Am. 2008 Oct;90(10):2126-34. doi: 10.2106/JBJS.G.00272.


Background: Congenital anterolateral bowing of the tibia is a pre-pseudarthrosis stage of congenital pseudarthrosis of the tibia and is associated with a substantial risk of fracture and pseudarthrosis. We evaluated the results of prophylactic bypass grafting performed in combination with bracing to prevent fracture and pseudarthrosis.

Methods: This retrospective series included ten patients with pre-pseudarthrosis of the tibia treated, between 1991 and 2002, with prophylactic bypass grafting with an allograft fibula placed posteromedially in a stress-bearing fashion. The average patient age was 2.3 years at the time of diagnosis, 3.6 years at the time of surgery, and ten years at the time of final follow-up. The mean duration of follow-up was seventy-eight months. Brace protection was recommended at the time of diagnosis and was continued after the operation until maturity. Despite the bracing, a low-energy fracture developed and partially healed prior to the bypass grafting in one patient. The remaining nine patients had no fractures prior to the bypass grafting. At the time of final follow-up, the patients were examined clinically and radiographically for the presence of a fracture or pseudarthrosis and for residual deformity, including malalignment, ankle and knee joint abnormalities, and leg length discrepancy.

Results: No patient had either a fracture or a pseudarthrosis of the tibia at the time of follow-up. All grafts united to the tibia at both ends. Complications included an allograft fracture in three patients, which healed in all; allograft resorption in one patient; and pseudarthrosis of the ipsilateral host fibula in one patient. At the time of final follow-up, a mean of 9 mm (range, 0 to 37 mm) of leg length discrepancy was found. A corrective osteotomy was done for four patients (three because of ankle valgus and one because of diaphyseal deformity).

Conclusions: In this small series of ten patients with congenital anterolateral bowing of the tibia treated with bypass strut grafting and long-term bracing, there were no cases of pseudarthrosis of the tibia. Distal tibial deformity may persist throughout the growth period and require operative correction in patients treated with this procedure.

Level of evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

MeSH terms

  • Bone Transplantation / methods*
  • Braces*
  • Child
  • Child, Preschool
  • Cohort Studies
  • Female
  • Fibula / transplantation
  • Humans
  • Infant
  • Male
  • Neurofibromatosis 1 / complications*
  • Pseudarthrosis / etiology
  • Pseudarthrosis / prevention & control*
  • Pseudarthrosis / surgery
  • Retrospective Studies
  • Tibia / abnormalities*
  • Tibial Fractures / etiology
  • Tibial Fractures / prevention & control*
  • Tibial Fractures / surgery
  • Treatment Outcome