A Comparative Study of the Efficacy of Combined and 4-in-1 Surgery in the Treatment of Crawford Type IV Congenital Tibial Pseudarthrosis.

Abstract

To compare the differences in efficacy between combined surgery and 4-in-1 surgery in treating children with Crawford IV congenital pseudarthrosis of the tibia (CPT). We retrospectively analyzed the clinical data of 130 children with CPT who underwent either combined surgery (defined as tibial intramedullary nailing, Ilizarov external fixation, and localized bone grafting; group A, n=54) or 4-in-1 bone fusion (group B, n=76) between March 2013 and December 2018. Preoperative and postoperative radiographic parameters were compared, including cross-sectional area ratio at the healing site, ankle valgus angle (VTA), distal fibular shortening (DFS), medial proximal tibia angle (MPTA), tibial diaphyseal angle, limb length discrepancy, Malhotra classification, and refracture rate. Statistical analyses included independent-sample t tests, Mann-Whitney U tests, χ2 tests, or Fisher exact tests. No significant differences were observed between the 2 groups in baseline characteristics, preoperative radiographic parameters, or the initial healing rate (88.9% vs. 90.8%, P=0.73). However, group B demonstrated a significantly larger cross-sectional area ratio at the healing site and a markedly lower refracture rate (11.8% vs. 37.0%, P<0.001). Group B also showed a more pronounced deterioration in the Malhotra classification at final follow-up (P<0.001). The 4-in-1 and combined techniques were equally effective in achieving initial union for Crawford type IV CPT. The principal difference was a significantly lower refracture rate in the 4-in-1 group, although this benefit was associated with a higher risk of ankle valgus and fibular shortening. The choice of procedure should be individualized, balancing the goal of long-term stability against the risk of ankle deformity. Level III-therapeutic study.