True innovation—improvement way beyond the incremental—is rare in orthopaedics, whether it’s pre- and postoperative management, surgical technique, or prosthetic design. Innovation is even rarer, understandably, in addressing conditions that themselves are rare. Rarer still are innovations in treating pediatric conditions because of the many different congenital etiologies that don’t present in sufficient numbers to meaningfully study interventions.
Congenital pseudarthrosis of the tibia is one such rare pediatric condition, and it is one of the most challenging problems facing pediatric orthopaedic surgeons. In its pre-fracture state, this condition is called congenital tibial dysplasia or anterolateral bowing of the tibia. The goal of treatment at this stage is preventing fracture in the dysplastic, bowed area, because post-fracture union is difficult to achieve and maintain—and because chronic nonunion puts patients at risk for long-term pain, deformity, and disability.
In the December 2, 2020 issue of The Journal, Laine et al. present results of a simple outpatient surgical solution to this problem in 10 pediatric patients who were followed for an average of 5 years. Using a limited-exposure, plate-and-screw approach to control physeal growth, these authors produced correction in tibial alignment in all 10 patients. Most importantly, no patient developed a tibial fracture or pseudarthrosis after the guided-growth procedure, which also improved radiographic appearance of dysplastic bone and preserved leg length. Although 6 of the 10 patients required a plate exchange, the authors’ institution now offers this procedure as first-line treatment to all patients presenting with pre-fracture congenital tibial dysplasia.
Congenital bowing of the tibia is a condition that will probably never be subject to a controlled clinical trial due to the (fortunately) low number of patients affected. However, carefully conducted small cohort studies such as this can reveal true innovation that advances care for small but very vulnerable populations.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
