Congenital Tibial Pseudoarthrosis Treated with Internal and External Fixation Using the 4 in 1 Technique

A 5 year old female presents with idiopathic congenital pseudarthrosis of the tibia and fibula (CPT). Four years ago, she had ORIF with bone graft, an internal rod, and a circular external fixator. The tibial nonunion failed to heal and she underwent revision surgery 3 years ago with bone graft, Rush rod application across the foot, external fixation, and bone grafting using the 4 in 1 technique, supplemented with postoperative zoledronate. Solid healing was achieved. One year later, the Rush rod was removed to free the ankle joint, and it was replaced with a Fassier-Duval growing rod. At 12 months follow-up, she had 20° of dorsiflexion and 45° of plantar flexion with solid healing of the tibia and fibula and cross union.