Journal of Pediatric Orthopaedics - 2026-03-03 - Journal Article
A Comparative Study of the Efficacy of Combined and 4-in-1 Surgery in the Treatment of Crawford Type IV Congenital Tibial Pseudarthrosis.
Cai H, Zhu G, Mei H
Topics
Key Takeaway
4-in-1 surgery reduced refracture rate to 11.8% versus 37.0% for combined tibial nailing/Ilizarov/bone graft in Crawford Type IV CPT, but at the cost of significantly worse Malhotra ankle valgus classification at final follow-up.
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Summary
This retrospective study compared combined surgery (intramedullary nailing + Ilizarov fixation + bone graft) versus 4-in-1 bone fusion for Crawford Type IV CPT in 130 children treated between 2013 and 2018. Initial union rates were equivalent (88.9% vs. 90.8%, P=0.73), but the 4-in-1 group achieved a significantly larger cross-sectional area ratio at the healing site and a refracture rate of 11.8% versus 37.0% (P<0.001). The 4-in-1 group demonstrated significantly worse Malhotra ankle valgus classification at final follow-up (P<0.001), indicating a durability-versus-deformity tradeoff between the two techniques.
Key Limitation
Mean follow-up duration is not reported, making it impossible to determine whether the Malhotra ankle valgus deterioration in the 4-in-1 group is progressive or plateau-stable, which is critical for counseling families on long-term functional outcomes.
Original Abstract
OBJECTIVE
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).
METHODS
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.
RESULTS
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).
CONCLUSIONS
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 OF EVIDENCE
Level III-therapeutic study.