# Unraveling the molecular landscape of congenital pseudoarthrosis of the tibia: insights from a comprehensive analysis of 159 probands

## TL;DR

This study identifies rare genetic mutations and molecular pathways linked to congenital pseudarthrosis of the tibia, a rare bone disorder, by analyzing 159 patients.

## Contribution

The study reveals novel genetic variants and osteocyte-related pathways associated with congenital pseudarthrosis of the tibia.

## Key findings

- Loss-of-function variants were enriched in CPT patients compared to healthy controls.
- Rare protein-damaging variants in genes like NF1, GLI3, and PTH1R were identified in CPT cases.
- Osteocyte-related pathways, such as ossification, were affected in 70.4% of CPT cases.

## Abstract

Congenital pseudarthrosis of the tibia (CPT, HP:0009736), commonly known as bowing of the tibia, is a rare congenital tibia malformation characterized by spontaneous tibial fractures and difficulty in reunion after tibial fractures during early childhood, with a prevalence between 1/250,000 and 1/140,000. While 80%–84% of CPT cases present with neurofibromatosis type 1, caused by the variations in the NF1 gene, the underlying cause of CPT remains unclear. Considering its congenital nature and the low prevalence, we hypothesized that the rare genomic protein-damaging variations may contribute to CPT.

In this study, we conducted whole exome sequencing on 159 patients with CPT and found loss-of-function (LoF) excesses in the 159 patient cases compared to 208 healthy controls from the 1000 Genomes Project. The LoF variant types primarily included stop-gained and frameshift variants, both present in 97% of the 159 patients with CPT, as well as splice-changing variants, which were found in 78% of these patients. Rare LoF variations in osteocyte-related pathways, such as ossification, were identified in 112 of the 159 CPT cases (70.4%). The top seven genes carrying rare protein-damaging variants that might be related to CPT are NF1, GLI3, MRC2, PTH1R, RYR1, NPR2 and ITGA11.

These findings shed light on novel genetic mutations and osteocyte transcriptome-related molecular pathways involved in CPT, providing a new framework for understanding the genetic regulation of CPT pathology and suggesting potential directions to further elucidate its pathogenesis.

The online version contains supplementary material available at 10.1186/s13023-025-03759-4.