In order to reduce the incidence of congenital pseudarthrosis of the tibia (CPT) refracture, current tibial-fibular surgery is quite popular. The fibular growth pattern of CPT after tibial-fibular fusion is unclear. To explore the changes in fibular growth patterns in CPT patients with 3-in-1 osteosynthesis. A retrospective analysis of 33 children with CPT who were admitted to the hospital from April 2013 to June 2020 and who underwent combined surgery with 3-in-1 osteosynthesis was performed. Among them, 19 were males, and 14 were females; 16 cases were on the left, and 17 cases were on the right. Twenty-two children with neurofibromatosis type I (NF-1) were present. The average age at the time of surgery was 33.3 months (13 to 72 mo). In this study, self-control was used, and the study group underwent combined surgery with 3-in-1 osteosynthesis on the tibia and fibula on the affected side of the children with CPT. The control group included healthy fibula and tibia from children with CPT. The patients' ankle valgus, proximal tibial-fibular epiphyseal plate distance, and ankle pain were recorded. In this study, with an average follow-up of 94.5 months, 18 patients developed ankle valgus, and 22 patients have proximal displacement of the fibula. No children experienced ankle pain. 3-in-1 osteosynthesis with CPT may change the growth pattern of the fibula, leading to a relative proximal shift of the fibula in relation to the tibia, but this still requires validation through a prospective multicenter large-sample investigation.

McCune-Albright syndrome (MAS) is a rare disease. MAS manifests in the skeletal system as Fibrous dysplasia (FD). In MAS patients, bone lesions often result in fractures under weight-bearing forces during childhood, and pseudarthrosis formation is highly likely after fractures. There is currently no ideal treatment for fractures in children with MAS. This case study presents the innovative application of the cross-union technique in treating a 14-year-old female MAS patient with a distal tibial and fibular fracture nonunion. The patient had a history of conservative treatment with persistent symptoms, including an inability to bear weight and walk independently. A "cross-union" procedure was performed using a Fassier-Duval rod, locking plate, and K-wire fixation. At the final follow-up 12 months postoperatively, x-rays revealed a stable "cross-union" bone connection at the distal ends of the tibia and fibula, with no occurrence of refracture or other complications. The Radiographic Union Score for Tibial Fractures (RUST) was 12, and the Olerud Molander Ankle Score was 60. We successfully applied the "cross-union" technique to a MAS child with nonunion after a distal tibiofibular fracture. We look forward to further improvement and promotion of the "cross-union" technology in the future, bringing new hope for treating fractures in MAS/FD children.

Congenital pseudoarthrosis tibia (CPT) is a relatively rare disease, characterized by anterolateral bowing of the tibia, non-union, and limb length discrepancy. Various surgical treatments have been described in literature for its management with differing favorable outcomes. In this report, we present a case of 3-year-old child with CPT of Crawford type IV, with associated fibular dysplasia. Maternal fibula was harvested and used as a bone graft and was stabilized by intra-medullary fixation. Complete union was achieved at 1 year after the primary surgery. No re-fractures were seen in a follow-up period of 2 years. Using maternal fibula as an alternative to use as a bone graft in the management of congenital pseudoarthrosis tibia may prove beneficial. Moreover, it is cheaper and readily available and needs less surgical expertise when compared to its alternatives such as use of bone morphogenetic protein 7, allogenic cadaveric grafting, or use of vascularized fibular graft.

The periosteum is the main organ responsible for bone regeneration. Vascularized Periosteal Grafts (VPG) have demonstrated exceptional efficacy and speed in facilitating bone union among children with challenging bone healing conditions. Despite their promising results, the overall impact of these interventions has yet to be comprehensively evaluated through systematic review. This systematic review aimed to provide comprehensive insights into bone union outcomes and complications related to the use of VPG in children. MEDLINE/PubMed, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Library were searched from database inception to September 2023 and screened for relevant studies. Data were collected regarding patient demographics, disease, treatment, anatomical location, graft used, donor and receptor vessels, skin paddle monitoring, follow-up duration, time to union, consolidation, and complications. The correlation between age and bone union was assessed using Pearson and Spearman correlation coefficients, as appropriate. Study quality was assessed using the Methodological Index for Non-randomized Studies Criteria. A total of 15 studies involving 135 patients were included. All the studies were classified as Level 4 evidence. The mean MINORS score was 5.1 ± 1. The aim of the VPG was nonunion treatment in 90 patients (67%), nonunion prevention in 35 patients (26%), and bone union acceleration in 10 patients (7%). The origin of the bone union problem was traumatic in 59 cases (44%), congenital pseudoarthrosis of the tibia or fibula in 48 patients (35%), oncologic in 23 patients (17%), and infectious in 5 patients (4%). Nine different sources of periosteal flaps were used to enhance bone union. Bone union rate was 96% with a mean time of 4.2 months (range 1-18 months). Spearman test showed a non-statistically significant negative correlation between age and bone union time (r = -0.3, p = 0.759). VPGs are a safe and reliable treatment for promoting bone union, especially in the context of complex pediatric bone-healing challenges.

Congenital Pseudarthrosis of the Tibia (CPT) is a rare pediatric condition presenting substantial challenges for orthopedic surgeons. Aiming to achieve bone union, with subsequent complications such as refractures being common. The aim of the present study is to evaluate the results of our intentional cross-union protocol and to compare these outcomes with those obtained from our previously used techniques. Sixteen patients, with a mean age of 4.8 years (range: 1-13.3 years), who were treated with the intentional cross-union protocol were included in Group (A) Eleven patients, with a mean age of 3.5 years (range: 1.3-7.6 years), who primarily underwent intramedullary rodding with bone graft, were included in Group (B) The intentional cross-union protocol involved cross-union of the tibia and fibula, autogenous iliac bone grafting, and the insertion of bone morphogenetic protein 2 (BMP-2) aimed at achieving tibia-fibula cross-union. Retrospective evaluation of serial radiographs was conducted, and the outcomes regarding union and any subsequent complications were analyzed. A total of 27 patients with CPT were included in the study. All 16 patients (100%) in Group A successfully achieved primary union. Among the 11 patients in Group B, only 4 cases achieved primary union, with a primary healing rate of 36.4%. Seven cases with delayed healing required 2-4 revision surgeries for final healing. The time to union was significantly shorter in Group A (3.37 ± 0.64 months) compared to Group B (8.67 ± 3.0 months). The cross-sectional area of union was also significantly larger in Group A (6.71 ± 0.58 cm²) compared to Group B (1.18 ± 0.19 cm²). In Group A, there were no cases of refracture, whereas in Group B, 7 cases (77.8%) experienced refracture, indicating a statistically significant difference. Our study demonstrates that the Cross-union protocol is highly effective for achieving union and preventing refracture in CPT. With such significant improvement, it has notably altered the prognosis of this challenging condition. IV.