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PubMed2006

Distraction osteogenesis.

The treatment of bone loss resulting from acute trauma has traditionally been a complex surgical problem. Numerous procedures have been devised to reconstitute bone stock, obtain fracture union, and provide a stable functional limb. Traditional internal bone transport has been used successfully for bony reconstruction for both acute and reconstructive bone loss. Potential complications are primarily related to the complexity of the external device, prolonged time in the frame, and nonunion of the docking and regenerate segments. Recent advances in fixator and pin design have reduced the complexity of these devices as well as the incidence of pin- and frame-related complications. Gradual shortening, rapid distraction using autodistractors, transporting over intramedullary devices, and using orthobiologic and adjuvant techniques to assist in the consolidation of regenerate and docking sites are now being combined to decrease the morbidity and excessive frame time required to complete these reconstructions.

Equipment Design↗

PubMed2000

Distraction osteogenesis for obstructive apneas in patients with congenital craniofacial malformations.

Infants with congenital craniofacial malformations often have associated severe mandibular hypoplasia causing obstruction of the hypopharynx by retroposition of the base of the tongue into the posterior pharyngeal airway. Management depends on the severity of the airway obstruction. Most cases can be managed by prone positioning until the infant outgrows the problem at 3 to 6 months of age. In more critical cases, monitoring of oxygen saturation, temporary placement of a nasopharyngeal tube, and placement of an endotracheal tube will be useful procedures. Tracheotomy is an effective method for more severe cases, but longstanding tracheotomies result in high morbidity and occasional mortality. Mandibular distraction was performed in seven patients, ranging in age from 1 to 18 months, with critical obstructive apnea secondary to mandibular hypoplasia characterized by an apnea/hypopnea index greater than 20 apneas per hour and oxygen saturation below 80 percent. Two patients were tracheotomized previously. Mandibular lengthening, from 16 to 25 mm on the left side and from 10 to 22 mm on the right, was achieved in 21 to 25 days. Improvement of airway obstruction parameters was measured on polysomnograms and lateral cephalograms. Mandibular lengthening by gradual distraction is a successful method for young patients with severe mandibular hypoplasia causing critical obstructive apneas. Avoidance of tracheotomy or early decannulation in previously tracheotomized patients is a great advantage for patients with congenital craniofacial malformation.

Apnea↗

PubMed2006

Axial deformity correction in children via distraction osteogenesis.

We performed a retrospective analysis of the results of 62 tibial and 54 femoral lengthenings in 88 consecutive patients. The patients mean age was 13.5 years and mean follow-up was four years. There was a significant difference between metaphyseal (27+/-1.2 days/cm) and diaphyseal (39.4+/-1.7 days/cm), tibial (34+/-1.7 days/cm) and femoral (31+/-1.4 days/cm) lengthening (P<0.05), but no significant difference among the lengthening indexes when treating one-, two-, or three-dimensional deformities, congenital (34+/-2.4 days/cm) and acquired (32+/-1.0 days/cm) limb length discrepancy (LLD) (P>0.05). The lengthening index was 33+/-1.1 days/cm, distraction regenerate length 6+/-0.4 cm, and lengthening percentage 21+/-2.1. The scatter plots of new regenerate length against time and the scatter plots of neurological complication, residual deformities, broken pins, joint contractures, and hypertension rate against lengthening percentage showed a positive linear relationship (r=0.8). We found the correlations between quantitative and qualitative parameters that should help to predict the treatment outcomes. Lengthening index depends on the amount of length gained. Higher length of new bone regenerate leads to a decrease in lengthening index. Expected gain in bone length can aid in estimating the duration of treatment. The lengthening percentage correlates very well with the complication rate and can be used to predict the complication rate.

Adolescent↗

PubMed2001

Weight-bearing alters the expression of collagen types I and II, BMP 2/4 and osteocalcin in the early stages of distraction osteogenesis.

This study was performed to investigate the effect of loading on the biology of newly forming bone during limb lengthening. Unilateral 2.0 mm femoral lengthenings were performed in 20 male Sprague Dawley rats. Half (n = 10) of the animals were allowed to bear weight freely, while the other half were prevented from weight-bearing via an ipsilateral through-knee amputation. The animals in each group were sacrificed after one (n = 5) or four (n = 5) days of consolidation (post-operative days seven and 10, respectively). In situ hybridization for osteocalcin and collagen I, and antibody staining for collagen II and BMP 2/4 were used to evaluate the molecular influence of loading. There was more new bone in the distraction gap of the weight-bearing animals than there was in the non-weight-bearing animals. BMP 2/4 expression, and the messages for collagen I and osteocalcin, were more abundant in tissue from the weight-bearing animals; collagen II was higher in the non-weight-bearing animals. This suggests that early regenerate tissue is capable of responding to loading, and that weight-bearing appears to stimulate intramembranous ossification. These findings support the concept of early weight-bearing after limb lengthening.

Animals↗

PubMed2005

Extreme bone lengthening using distraction osteogenesis after trauma: a case report.

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 x 20 cm. An acute shortening using a 50 degrees angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.

Adult↗

PubMed2001

[Distraction osteogenesis with double internal devices combined with early frontal facial advancement for the correction of facial craniosynostosis. Report of clinical cases].

Frontofacial monobloc advancement is a surgical procedure which corrects at the same time both frontal and facial retrusions in faciocraniosynostosis. The high risk morbidity limited its use to major exorbitism or severe breathing impairment. We report the results of a preliminary experience in five children with a mean age of 3.8 years. All patients presented with a Crouzon or Pfeiffer syndrome. The procedure performed was a frontofacial monobloc osteotomy with peroperative mobilization. Two pairs of distractors (Martin-Medizin) were implanted. The upper pair of frontal distractors was located behind the supraorbital bar. The pair of temporo-zygomatic distractors (a modification of the MicroFrance prototypes) was implanted behind the zygomatic bone. In one patient a transfacial pin was connected to the anterior part the lower distractors, to avoid facial bipartition. Distraction was performed according to classical protocols with a 1 mm advancement per day, until sufficient advancement was obtained. The correction of exorbitism and facial retrusion was obtained in all cases. An open-bite was created by the advancement in two out of the five patients. Minor infection occurred in one patient. This combination of distractors with frontofacial advancement seemed to increase the efficacy and reduce the morbidity. This might lead to a one stage strategy for faciocraniosynostosis treatment, even if minor additive procedures will be necessary when children get older and that insufficient facial growth still reoccurs.

Child, Preschool↗

PubMed2005

Analysis of skeletal movements in mandibular distraction osteogenesis.

PURPOSE: The purpose of this study was to use geometric parameters of movement, calculated from 3-dimensional computed tomography (CT) data, to determine the curvilinear distractor dimensions required to correct mandibular deformities in a series of patients. MATERIALS AND METHODS: Preoperative CT scans from 15 patients with symmetric (n = 5) and asymmetric (n = 10) deformities were imported into a CT-based software program (Osteoplan; an open-source visualization application developed by Gering et al at the Surgical Planning Laboratory [SPL, Brigham and Womens Hospital, Boston, MA]). The software was used to reconstruct virtual 3-dimensional models from these scans. Two experienced surgeons, working with a computer scientist, then used Osteoplan to create an ideal treatment plan for each patient. In each case, the 3-dimensional curvilinear movement was quantified using 4 "parameters of movement" (POMs). These parameters were then used to prescribe a distraction device capable of executing the planned skeletal correction. Curvilinear distractor dimensions calculated by Osteoplan included the radius of curvature of the prescribed device, and the distractor elongation, pitch, and handedness. RESULTS: Treatment plans including POMs were developed for each patient. The radii of curvature for the prescribed distractors ranged from 2.3 to 14.1 cm, the distractor elongation dimensions ranged from 0.7 to 3.2 cm, and the pitch (horizontal plane) dimensions ranged from 0.005 to 0.8 cm. Handedness was either a left (n = 12) or right (n = 8) turning helix. CONCLUSION: The results of this study indicate that, using geometric parameters of movement calculated from 3-dimensional CT scans, curvilinear devices could be prescribed for correction of the range of skeletal deformities in this group of patients.

Computer Simulation↗

PubMed2006

LeFort III advancement with and without osteogenesis distraction.

The LeFort III osteotomy is the surgical treatment performed in patients with mid-facial retrusions in craniofacial dysostoses such as Crouzon, Apert, Pfeiffer syndromes, etc. The first authors to report the accomplishment of this osteotomy were Gillies and Harrison in 1951, this technique was then resumed and improved by Tessier in 1967, who made five different variants mainly regarding the typology of the osteotomy concerning the lateral wall of the orbit. Recently, distraction techniques have been applied to the upper mid-face which foresees a gradual advancement of the mid-face through the osteogenetic distraction procedure. The purpose of this retrospective clinical outcome study is to evaluate and compare the two different surgical techniques through the experience acquired during the treatment of 15 cases of craniofacial dysostoses from 1990-2005, and through international literature. The standard surgery technique was performed in 5 of these patients, whereas the osteogenetic distraction technique was performed in the remaining 10. All patients were studied preoperatively through the acquisition of photographic images, cephalometric analysis of the skull, and the study on plaster models of the occlusion of the dental arches. The instrumental exams required before surgery are the following: telecranium X-rays in two projections, orthopanoramic X-rays, CT. The results of this study indicate that the osteodistraction technique represents the choice treatment in severe retrusions of the mid-face while the traditional surgical technique remains indicated in adult patients that are in need of moderate advancements.

Adolescent↗

PubMed1997

Histopathologic and biochemical changes in the muscles affected by distraction osteogenesis of the mandible.

Lengthening of the canine mandible using an intraoral distraction device was performed in order to study the effects of distraction on the associated muscles of mastication. Biopsies of the masseter and digastric muscles were taken after lengthening at four different time intervals to assess the temporal changes in the masticatory muscles of 10 dogs. Biopsies of the muscles on the contralateral side also were taken from 6 of these dogs before lengthening to establish a control group. Each biopsy was analyzed histologically and spectophotomerically for RNA, DNA and protein content. The digastric muscle underwent transient atrophy with initiation of distraction but regenerated completely after 48 days of fixation. The masseter muscle was unchanged initially but showed evidence of atrophy only after 20 mm of distraction it continued to exhibit evidence of atrophy during fixation. Protein synthesis was decreased significantly during periods of atrophy in the masseter; no such change was noted in the digastric. Unlike the masseter, the digastric fibers lie in a plane parallel to the vector of distraction. These findings suggest that any muscle affected by skeletal distraction in the same plane or vector (e.g., digastric) adapts with compensatory regeneration and hypertrophy. Moreover, those muscles lying in a different plane (e.g., masseter) show persistent evidence of atrophy with decreased protein synthesis.

Animals↗

PubMed2002

Three-dimensional histomorphometric analysis of distraction osteogenesis using an implanted device for mandibular lengthening in sheep.

The aim of this study was to lengthen the sheep mandible with a fully buried device and to quantitatively analyze the tissue regenerate in the distraction gap by means of two-dimensional and three-dimensional histomorphometry. A custom-made device for continuous distraction was used in five adult sheep and fixed with three bicortical screws on either side of an osteotomy, anterior to the premolar region of the mandible. A cable-connected power and control unit was implanted in the neck region. After a 5-day latency period, distraction was activated every 2 hours and advanced at a rate of 1.01 mm per day. The distraction period was planned for 14 days, but because of stability problems and cable breakage, the actual distraction period ranged from 2 to 17 days, resulting in gap distances from 1.7 to 17.1 mm (mean, 0.95 mm/day). Osteogenesis was followed by radiographic imaging, and after a 6-week consolidation period, the harvested mandibles were serially sectioned for histologic and two-dimensional histomorphometric analysis, with three-dimensional reconstruction. Histologic examination of the specimens demonstrated predominantly membranous bone formation with remodeling bridging the distraction gap mainly in the periosteal region of the lingual side. In addition, cartilaginous areas and chondral bone formation were observed where the bridging appeared incomplete. Because of device fixation on the buccal side of the mandible, the preservation of the lingual periosteum seemed to play the major role for sufficient bone repair in the distraction gap. Cartilage within the distraction gap suggests fixation instability in this animal model.

Animals↗

PubMed1994

The histologic analysis of distraction osteogenesis of the mandible in rabbits.

The process of bone formation in mandibular lengthening by distraction was studied in 30 rabbits. The mandible was subjected to a corticotomy, held in a neutral position for 2 weeks, and then lengthened at 0.18 mm per 12 hours for 24 days using a unilateral external fixation device (Orthofix M-100). On completion of the distraction, x-ray analysis showed that the distracted gap was filled with callus organized into three zones, namely, two sclerotic zones with a central radiolucent zone. These zones became indistinguishable from the adjacent preexisting mandible at 10 weeks after distraction. Histologically, new bone, which was formed by both intramembranous and endochondral ossification, underwent remodeling and resulted in cortical bone by 8 to 10 weeks after completion of distraction.

Animals↗

PubMed1993

[The clonogenic properties of the bone marrow in dogs during distraction osteogenesis].

The status of canine hemopoietic and stromal progenitor cells in regeneration of bone tissue was studied in distraction osteosynthesis, by using the bone marrow culture technique in the diffusion chambers. Normal osteogenesis was demonstrated to be characterized by certain phase changes in the cloning of progenitor cells of myelopoiesis, whereas abnormal osteogenesis, the activity of hemopoietic cells remained virtually unchanged, but the cloning of CFU-F increased in intact bones.

Animals↗

PubMed1994

The use of ultrasound mean acoustic attenuation to quantify bone formation during distraction osteogenesis performed by the Ilizarov method. Preliminary results in five dogs.

RATIONALE AND OBJECTIVES: Management of distraction during Ilizarov limb lengthening remains primarily clinical and empirical. Estimates of tissue acoustic attenuation were evaluated for their ability to quantify bone formation within the distraction gap. METHODS: Five dogs had tibias lengthened by the method of Ilizarov. Mean acoustic attenuation measurements at multiple positions across the distraction gap were compared with corresponding x-ray computed tomography attenuation measurements. RESULTS: Computed tomography and ultrasound attenuation displayed similar quantitative behavior across the gap. Linear correlation between them ranged from R2 = .878 to R2 = .131. Fibrous interzone width estimates based on computed tomography and ultrasound attenuation measurements were correlated, based on our preliminary data with R2 = .519. These estimates are independent of the width of distraction. CONCLUSIONS: Ultrasound parallels computed tomography as a measure of bone formation within the distraction gap. Future studies are needed to improve acoustic attenuation data acquisition techniques and to evaluate their potential as a tool for optimizing early distraction rates in patients at risk for rate-related complications.

Acoustics↗

PubMed2000

[Regulation of distractional osteogenesis: biochemical aspects].

The samples of intact compact bone, bone tissue of new-born puppies (BP), distractional regenerate bone (DRB), new cancellous bone (NCB) filling in the transported fragment were fractionated by the degree of maturity while substituting canine tibial shaft defect using bifocal distraction-compression osteosynthesis. Comparative analysis of the composition of the mineral phase and the organic matrix of different derivatives of bone tissue revealed the identity of low-mineralized fractions of BP and NCB. It was suggested that the fractions were produced by DRB cells which were phenotypically different from osteogenic ones. There is evidence that the high proliferating potential of the least mature DRB fraction is maintained by relative hypoxia in the "growth zone" of the latter and by the changing concentrations of local factors depending on the rate of distraction.

Animals↗

PubMed1994

The role of distraction osteogenesis in the reconstruction of the mandible in unilateral craniofacial microsomia.

Laboratory and clinical studies have shown that mandibular distraction is an effective and powerful reconstructive surgical technique. It is safely performed without the need for blood transfusion or bone graft. Because of concomitant expansion of the functional matrix (the associated skin, subcutaneous fat, and muscles of mastication), there is a multidimensional expansion of the lower jaw with minimal, if any, evidence of relapse. Moreover, the surgical reconstruction can be commenced by 2 years of age, and the vector of distraction can be controlled by preoperative design. Finally, the increase in resulting mandibular bone stock will provide more reconstructive options in the future for traditional orthognathic surgical techniques. The technique has been criticized, either for the cutaneous incision for the approach to the mandible or for the scar resulting from the path of the distracting screws. However, with careful placement of the device, the resulting scar can be placed in the lines of minimal tension with a resulting satisfactory scar. It has been assumed that the osteotomy results in interruption of the inferior alveolar nerve. However, questioning of the older patients has failed to detect any change in sensation of the lower lip. The status of the inferior alveolar nerve in the hypoplastic mandible has also never been studied. Insertion of the screws required an area of bone stock that is edentulous, and this finding can make application of the device difficult in some patients. The length of treatment has been criticized--approximately 3 months. However, this is offset by the ease of treatment, the degree of safety, and the reduction in hospital time without the need for blood transfusion or bone graft. The results to date indicate that the technique can be applied to the correction of the milder mandibular deficiencies.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone Lengthening↗

PubMed1990

[Treatment of defects of the long bones using distraction osteogenesis (Ilizarov) and intramedullary nailing. Theoretic principles, animal experiments, clinical relevance].

For large shaft defects of tibia and femur, distraction-compression osteosynthesis (Ilizarov) provides an ideal autologous bone graft. Combination of this with an intramedullary interlocking nail instead of an external fixator could improve patient comfort, because transport with a small external device takes only one-third of the total fixation period. Using 21 adult female sheep we created standardized tibia shaft defects 20 mm (medium size) and 45 mm (large size) in length. The tibiae were stabilized with non-reamed intramedullary interlocking nails. Following corticotomy by chisel, segments were transported using subcutaneous traction wires with a screw as a fulcrum to maintain stationary skin exit points without soft tissue problems. The external traction devices were removed after 12 or 16 weeks. Animals were sacrificed after 12 or 24 weeks with medium-size defects, and after 16 or 32 weeks with large defects. We evaluated the results clinically, by standardized weekly X-rays and, after sacrifice, by quantitative computed tomography (QCT). No animals had to be excluded from the study. Despite primary destruction of the intramedullary circulation all distraction gaps were spanned with bone. X-Rays showed typical signs of good quality of distraction bone regeneration (narrow radiolucent zone in the middle of the regenerate, longitudinal structure), continuous calcification, and cortex formation. QCT cross sections showed completely circular bone regeneration with small and large defects. Bone regeneration was faster on the dorsal side, where more bone was formed than ventrally. Small defects can remain ventrally in the regenerate; these close secondarily.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1994

Distraction osteogenesis. A comparison of corticotomy techniques.

The left hindlimbs of 15 adult mongrel dogs were lengthened using the Ilizarov external fixator. Five dogs were assigned to each of three separate groups: (I) corticotomy; (II) osteotomy with multiple drill holes and an osteotome; (III) osteotomy with an oscillating saw. Distraction began on postoperative day seven and continued at a rate of 0.25 mm every six hours for 26 days. The regenerate segments were evaluated with weekly radiographs and Dual Energy Photon X-ray (DEPX) beginning at day seven. Barium perfusion studies and histologic preparations were also performed after the dogs were killed. Periosteal callus formation was apparent in all groups at two weeks, and endosteal callus appeared in Groups I and II at three to four weeks. Perfusion studies at the end of the distraction period demonstrated vessels bridging across the regenerate gap in Groups I and II. Vessels bridging the gap were diminished in the oscillating-saw Group III specimens. During the distraction period, the appearance and length of the regenerate bone was similar for each group radiographically and by DEPX scanning. No histologic differences were seen in Groups I and II. Three of the four tibias cut with the oscillating saw did not consolidate at ten weeks. A simple transverse osteotomy yields regenerate bone that is indistinguishable from the technically more difficult corticotomy. Use of the oscillating saw may lead to delayed consolidation.

Absorptiometry, Photon↗

PubMedDate not supplied

Maxillary post-traumatic outcome correction. Literature review and personal experience. Part III: loss of maxillary substance (free flaps-distraction osteogenesis).

Revascularised free flaps retain dual vascularisation, both periosteal and medullary, undoubtedly present optimal survival and minimal re-absorption in view of the prevalence of osteogenetic rather than osteoclastic phenomena. A revascularised free bone flap involves the transfer of a certain amount of bone tissue, whether or not associated with a muscular, skin and/or facial component, with the features of an axial flap, dissecting the vascular stalk of the donor site and re-anastomosing both the arterial and the venous components on to recipient vessels in the site of the primary defect. The vessels in question measure only about 2-4 mm, so that micro-surgery techniques must be applied. For bone defects less than 6 cm, with upkeep of the mandibular or maxillary cortical bone and preservation of the soft tissues, with residual bone of at least 8 mm in height and 4 mm in thickness, alveolar distraction may represent a valid alternative to bone grafts, at the same time as ensuring an increase of the alveolar bone and intraoral soft tissues involved in the distraction process.

Humans↗