Abstract
Introduction: Nonunion of long bone fractures is rare in the skeletally immature. Many of these injuries threaten the survival of the limb and attempts to salvage the limb can only be justified if the ultimate limb function out performs that of a prosthesis. To our knowledge there has been no report of functional outcome following the treatment of such injuries. We report the outcome of a series of patients treated for tibial bone loss and nonunion at average follow-up of 52 months.
Patients and method: Nine children aged 18 months to 17 years were treated. Three patients had established nonunion ranging from 7 months to 6 years, three had bone loss (1–6cm) and three had fractures in which nonunion were anticipated (1 Gustilo IIIb and 2 Tcherne III’s). Five injuries involved the physeal growth plate (2 with partial physeal loss – Peterson VI).
Treatment involved wound excision for open fractures, debridement of devascularised bone and stabilisation with monolateral fixators (2 patients) and circular fixators (7 patients). Five patients had unifocal treatment, four had multifocal treatment (3 bone transports). Duration of non-union or bone loss ranged from 3 to 72 months, average 17 and median 12. Treatment time ranged from 3 to 12 months, and was not related to the complexity of treatment. The longest treatment times occurred when segments of devascularised bone had been left unexcised, a situation we termed “bone loss insitu”.
An independent observer assessed the patients. Functional outcome was measured using the Short Musculoskeletal Assessment Form, a validated outcome assessment tool (Swiontkowski et al. JBJS [A], 1999).
Results: At the latest follow-up (average 52 months), the mean range of knee motion was 3–125° and mean ankle range was 13° dorsiflexion, 35° plantarflexion. Physeal arrest was present in three children (limb length discrepancy 2–4 cm) but with no deformity. Functional outcome revealed a “Dysfunction Index” of 0–19% (ave. 7%) and a “Bother Index” of 0–16% (ave. 6%).
Conclusion: Limb salvage of severe tibial fractures in which nonunion were established or anticipated were worthwhile. Good function can be obtained. The duration of treatment was not related to the complexity of treatment but was increased by leaving sterile but avascular bone unexcised.
The abstracts were prepared by Mr N. M. P. Clarke. Correspondence should be addressed to him at the British Orthopaedic Association, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC2A 3PN.
