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Updated: Jun 18, 2026
Surgical Angiogenesis in Porcine Tibial Allotransplantation: A New Large Animal Bone Vascularized Composite Allotransplantation Model
Published on: August 13, 2017
Vascularised fibula grafts for early tibia reconstruction in infants with congenital pseudarthrosis
Dominique Erni1, Sora De Kerviler, Ralph Hertel
1Department of Plastic, Reconstructive and Hand Surgery, Inselspital, University of Bern, Bern, Switzerland. dominique.erni@insel.ch
Insights
This study shows that aggressive surgical treatment, including free vascularized fibula grafts, can successfully manage congenital pseudarthrosis of the tibia (CPT) in infants, preventing severe long-term complications.
Area of Science:
- Orthopedics
- Pediatric Surgery
- Regenerative Medicine
Background:
- Congenital pseudarthrosis of the tibia (CPT) results from abnormal bone development, leading to fractures and nonunion.
- Conventional treatments for CPT have high failure rates, including persistent pseudarthrosis, malunion, and growth disturbances.
- A more aggressive surgical approach is being explored as a promising alternative for CPT management.
Purpose of the Study:
- To evaluate the efficacy of a surgical protocol involving wide resection, free vascularized fibula grafts, and external fixation for treating congenital pseudarthrosis of the tibia in young children.
- To assess the outcomes and complication rates associated with this aggressive treatment strategy in pediatric patients with CPT.
Main Methods:
- Ten children diagnosed with CPT (age 12-31 months) underwent surgical treatment between 1995 and 2007.
- The protocol included resection of the affected tibia, reconstruction with contralateral free vascularized fibula grafts, and stable external fixation.
- Vascular anastomoses were performed at the distal tibia stump, with grafts measuring 7-9cm.
Main Results:
- Radiographic evaluation showed successful osseous consolidation in 19 out of 20 graft/tibia junctions within 6 weeks post-surgery.
- Complications included pin-tract infections (3 patients) and graft fractures (5 patients), all managed successfully.
- Long-term follow-up demonstrated tibialization of the graft, normal gait, and equal limb length in most patients, despite some initial growth disturbances in two.
Conclusions:
- Despite a notable complication rate and the challenges of infant free flap surgery, this aggressive surgical concept effectively prevents severe sequelae of congenital pseudarthrosis of the tibia.
- Free vascularized fibula grafting combined with stable fixation offers a viable solution for CPT, promoting limb length equalization and functional recovery.
- Early intervention with this advanced surgical technique holds significant promise for improving long-term outcomes in children with CPT.
Abstract:
Congenital pseudarthrosis of the tibia (CPT) is caused by an ill-defined, segmental disturbance of periosteal bone formation leading to spontaneous bowing, followed by fracture and subsequent pseudarthrosis in the first 2 years of life. The results of conventional treatment modalities (e.g., bracing, internal and external fixation and bone grafting) are associated with high failure rates in terms of persisting pseudarthrosis, malunion and impaired growth. As a more promising alternative, a more aggressive approach, including wide resection of the affected bone, reconstruction with free vascularised fibula grafts from the healthy contralateral leg and stable external fixation at a very early stage has been suggested. Between 1995 and 2007, 10 children (age 12-31 months, median 20 months) suffering from CPT were treated at our institutions according to this principle. Two patients were treated before a fracture had occurred. The length of the fibula graft was 7-9cm. End-to-end anastomoses were performed at the level of the distal tibia stump. The follow-up was 80 months (median, range 12 months to 12 years). Radiologic examination at 6 weeks postoperatively showed normal bone density and structure of the transplanted fibula in all cases and osseous consolidation at 19 of the 20 graft/tibia junctions. One nonunion was sucessfully treated with bone grafting and plate osteosynthesis. Pin-tract infection occurred in three patients. Five children sustained graft fractures that were successfully treated with internal or external fixation. Two patients developed diminished growth of the affected limb or foot; all others had equal limb length and shoe size. At long-term follow-up, tibialisation of the transplant had occurred, and normal gait and physical activities were possible in all children. We conclude that in spite of a relatively high complication rate and the reluctance to perform free flap surgery in infants at this young age, the present concept may successfully prevent the imminent severe sequelae associated with CPT.
