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PubMed2005

[Physeal distraction for limb length discrepancy and angular deformity].

PURPOSE OF THE STUDY: Physeal distraction or chondrodiastasis uses the growth plate as a zone of least resistance. Application of force thus provokes distraction and opening of the plate (Salter and Harris type I epiphyseal detachment). Progressive lengthening allows room for regenerate bone and enables limb lengthening and correction of angular deformations. MATERIAL AND METHODS: Twenty chondrodiastasis procedures were performed in fifteen patients. Mean age was 14.4 years (10.3-15.7). The underlying causes were trauma (n = 6), constitutional deformation (n = 8), infection (n = 2, distal lateral femoral epiphysiodesis), and malformation (n = 4). The localizations were: proximal tibia (n = 11), distal tibia (n = 4), distal femur (n = 4), distal radius (n = 1). The surgical procedure involved installation of an external fixator on either side of the physis after planification of the desired correction and taking into account the remaining growth potential of the physis. The distraction was performed by the patient at the rate of 1 mm per day. A one-sided external fixator was used for eleven patients (distal femoral correction and proximal tibial hemichondrodiastasis for angular deformation) and a circular fixator (to control 3D correction) in nine. Complications were noted according to the four grades of severity described by Caton. RESULTS: Mean follow-up was 26.1 months. Epiphyseal detachment was achieved in all patients, even in the presence of an epiphysiodesis bridge, in 7.7 days on average (2-15 days). Mean lengthening was 4.75 cm, mean angular correction was 22.2 degrees (mean preoperative angle 20.5 degrees ). For chondrodiastasis (symmetrical physeal distraction), the mean duration of correction was 4.6 months (1-9), mean time to healing was 8.3 months (4-13) and mean healing index was 55.6 days/cm (Verone). For hemichondrodiastasis (asymmetrical physeal distraction), mean duration of correction was 1.3 months (1-3), and mean time to healing was 2.7 months (2-5). The healing index was different and was 3 days per degree. Complications were studied using the Caton classification. There were 17 (85%) benign complications (not requiring revision under anesthesia) and 6 (30%) serious complications (requiring anesthesia and unplanned revision). There were 2 (10%) severe complications (knee flexion, ankle equinus). DISCUSSION: Chondrodiastasis has specific complications, mainly involving the distal femur (stiff knee, risk of septic arthritis). It provides rapid in situ correction resulting from epiphysiodesis bridges. The resection step proposed by Bollini is not necessary, but the growth plate is definitively sterilized. This implies that the procedure be used for preventive lengthening, depending on the predicted limb length discrepancy. This notion limits indications to older children. Besides the fact that several deformations can be corrected simultaneously, this technique does not require osteotomy and respects vascular supply to the regenerative tissue. It involves the physis responsible for the angular deformation or limb length discrepancy. It does not require internal fixation nor bone grafting and can be performed with weight bearing. Finally, the procedure can be adjusted as needed during the correction phase, with the patient in the standing position.

Adolescent↗
PubMed2002

Endoscopically assisted Le Fort I osteotomy to correct transverse and sagittal discrepancies of the maxilla.

PURPOSE: The purpose of this report was to show the feasibility of the combination of a minimally invasive endoscopic approach to the maxilla with transverse and sagittal distraction procedures. MATERIALS AND METHODS: Four human cadavers were used for training of a minimally invasive access to the maxilla to perform a endoscopically assisted Le Fort I osteotomy, before this technique was applied in 3 patients with transverse and sagittal growth deficits of the maxilla. Access to the maxilla was gained through a small mucosa incision in the vestibule to create a visualization port to the maxillary sinus through a bur hole. Landmarks were identified through the endoscope before a Le Fort I osteotomy was performed using chisels of different shapes and angulations. In 2 patients the maxilla was split sagittally to perform a transverse maxillary expansion; in 1 patient, a buried distractor was applied close to the piriform aperture to correct a sagittal growth deficit in a hypoplastic maxilla. RESULTS: Endoscopic exposure of the maxillary sinus walls from within the sinus, the accurate identification of landmarks, and the creation of a Le Fort I osteotomy were achieved in all cases. Distractor application close to the piriform aperture rendered good stability. CONCLUSION: The results of these cases indicate that the endoscopic approach to the maxillary sinus allows excellent exposure of the sinus walls to perform a endscopically assisted Le Fort I osteotomy. The combination of endoscopy and osteodistraction processes supports the tendency to perform minimally invasive, less-traumatizing surgical procedures, especially in individuals who are still growing.

Adolescent↗
PubMed2002

[Endoscopically-assisted LeFort I osteotomy in distraction procedures of the maxilla].

PURPOSE: The purpose of this study was to demonstrate the feasibility of combining a minimally invasive endoscopic approach to the maxilla with transverse and sagittal distraction procedures. MATERIALS AND METHODS: Four human cadavers were used for training of a minimally invasive access to the maxilla to perform an endoscopically assisted Le Fort I osteotomy, before this technique was applied in three patients with transverse and sagittal growth deficits of the maxilla. Access to the maxilla was gained through a small mucosa incision in the vestibule to create a visualization port to the maxillary sinus through a bur hole. Landmarks were identified through the endoscope before a Le Fort I osteotomy was performed using straight and angulated chisels of different form and angulation. In two patients, the maxilla was split sagittally to perform a transverse maxillary expansion. In one patient, a buried distractor was applied close to the piriform aperture to correct a sagittal growth deficit in a hypoplastic maxilla. RESULTS: The endoscopic exposure of the maxillary sinus walls from within the sinus, the accurate identification of landmarks, and the creation of a Le Fort I osteotomy was achieved in all cases. Distractor application close to the piriform aperture rendered good stability. CONCLUSION: The results of these case reports indicate that the endoscopic approach to the maxillary sinus allows excellent exposure of the sinus walls to perform an endoscopically assisted Le Fort I osteotomy. The combination of endoscopy and osteodistraction supports the trend toward minimally invasive, less traumatic surgical procedures, especially in individuals still growing.

Adolescent↗
PubMed2001

A comparison of two techniques for digital distraction lengthening in skeletally immature patients.

Since 1987, 16 skeletally immature patients aged 2 to 16 years (mean, 7.9 years) underwent 27 digital lengthening procedures of terminal bones, 20 metacarpals and 7 phalanges, using the distraction callotasis technique. Seven digits were lengthened with 2 fixator half-pins on either side of the osteotomy site (dual half-pin group). Twenty digits, which were too small to accommodate 4 half-pins, were lengthened over a longitudinal intramedullary guidewire with 1 fixator half-pin on either side of the osteotomy site (single half-pin/K-wire group). No bone grafts were needed. The mean preoperative bone length in the dual half-pin group was 30 mm (range, 23-40 mm) and that of the single half-pin/K-wire group was 18 mm (10-30 mm). The mean total length gained was 14 mm (9-23 mm) in the dual half-pin group and 12 mm (6-19 mm) in the single half-pin/K-wire group. The mean percent lengthened was 49% (22% to 96%) in the dual half-pin group and 70% (27% to 136%) in the single half-pin/K-wire group. Eighteen complications occurred: 15 in the 20 cases using the central guidewire (75%) and 3 in the 7 cases without the central guidewire (43%). Only 7 complications required repeat surgery. We conclude that the use of the single half-pin/K-wire technique allows successful and substantial lengthening for bones shorter than 23 mm, making correction surgery possible for younger children. This technique, however, has a greater risk for complications.

Adolescent↗
PubMed2000

Limb reconstruction with the callus distraction method after bone tumor resection.

The callus distraction method was applied to nine patients who were referred to us because of a bone tumor. Their mean age was 17 years and 3 months (range 7-37 years). Three were female, and 6 were male. All of the tumors were localised on the femur, and the histological diagnosis was two chondrosarcomas, one Ewing's sarcoma, three osteosarcomas, one giant cell bone tumor, and the remainder benign fibrous histiocytoma. The mean length of the defect after resection of the tumor was 11.5 (range 8-20) cm. Preoperative and postoperative chemotherapy were applied to patients with osteosarcoma and Ewing's sarcoma. The patients were followed up for 22 (range 15-30) months on average. The mean period of use of the external fixator was 12.5 (range 8-18) months. One patient suffered a tumour recurrence and died after 20 months. Complications included one deep infection, one skin invagination, and one premature consolidation and bone bridge in the defect area. All of the complications were successfully treated. Functional evaluation gave excellent results in four patients, good in three, and fair in two. This method can be used without any need for massive autogenous bone graft in repairing defects of any length and diameter produced after excision of the lesion and thus can be considered as an alternative to other techniques.

Adolescent↗
PubMed1999

Bone mineralization at the callotasis site after completion of lengthening.

We studied the course of bone mineralization of regenerate bone after callotasis lengthening. Twenty-three patients (eight boys) (mean age at operation 11.5 years, range 4-17 years; leg length discrepancy [LLD] at surgery ranging from 4 to 13 cm) underwent dual-energy X-ray absorptiometry (DEXA) scanning weekly during the distraction phase, at 2 week intervals until removal of the fixator, and at the time of their out-patient visits thereafter, for a mean of 794 +/- 420 days after removal of the apparatus. At removal of the fixator, the bone mineral content (BMC) of the regenerate was nearly 70% of the normal contralateral limb. With time, this value gradually increased, and tended to reach normal values, with no significant difference between femur and tibia. With time, the BMC of the regenerate tends to return to the value of the normal contralateral limb. Probably, once the limb length discrepancy has been equalized, the mechanical stimuli imparted through weight-bearing to the lengthened limb are of the same magnitude bilaterally. In this instance, then, the newly formed bone, responding to these physical stimuli, would normalize its mineral content, confirming that bone remodeling continues well after lengthening is terminated. Mineralization of the regenerate after completion of the lengthening process reaches values significantly greater than at removal of the fixator, with an increase of >50% of the prelengthening values, regardless of the underlying pathology. The final value of this increased BMC is not significantly different than in the normal contralateral unoperated limb. At least part of the increase in bone mineralization following callotasis lengthening is due to the normal process of growth and development.

Absorptiometry, Photon↗
PubMed2006

Range of curvilinear distraction devices required for treatment of mandibular deformities.

PURPOSE: The purpose of this study was to determine the range of fixed trajectory curvilinear distraction devices required to correct a variety of severe mandibular deformities. MATERIALS AND METHODS: Preoperative computed tomography (CT) scans from 18 patients with mandibular deformities were imported into a CT-based software program (Osteoplan). Three-dimensional virtual models of the individual skulls were made with landmarks to track movements. An ideal treatment plan was created for each patient. Upper and lower boundaries for the dimensions of curvilinear distractors were established based on manufacturing and geometric constraints. Then, anatomically acceptable distractor attachment points were identified on the models using proximal and distal grids. Treatment plans were simulated for a series of distractors with varying radii of curvature, elongations (arc-length of device), and placements along the grids. The outcomes using these distractors were compared with the ideal treatment plans. Discrepancies were quantified in millimeters by comparing landmarks in the simulated versus ideal movements. RESULTS: Approximately 400,000 simulated 3-dimensional movements, based on the distractor parameters and variations in placement were computationally evaluated for the 18 cases. It was determined that, by varying distractor placement, a family of 5 distractors, with 3, 5, 7, and 10 cm radii of curvature and a straight-line device, could be used to treat all 18 cases to within 1.8 mm of error. CONCLUSIONS: The results of this study indicate that a family of 5 curvilinear distractors may suffice to treat a broad range of mandibular deformities.

Computer Simulation↗
PubMed1999

Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults.

BACKGROUND: The successful correction of flatfoot in children through lengthening of the lateral column, osteotomy of the medial cuneiform, and advancement of the posterior tibial tendon led to the introduction of similar procedures to treat acquired pes planovalgus secondary to attrition or rupture of the posterior tibial tendon in adults. However, to our knowledge, no study has been published documenting whether these procedures are effective treatment for acquired flatfoot in adults. METHODS: The functional and radiographic results of complex reconstruction of a painful, flexible flatfoot associated with attrition or rupture of the posterior tibial tendon were evaluated in thirty-six patients (forty-one feet) with use of a detailed questionnaire, a comprehensive physical examination, and a review of the radiographs and the medical record. RESULTS: At a mean of thirty-four months (range, twenty-four to fifty months) postoperatively, thirty-six feet (88 percent) were less painful compared with the preoperative status or were pain-free and five of the six parameters that had been used to assess correction of the deformity radiographically had improved significantly (p<0.0001). Eight feet (20 percent) had a non-union at the calcaneocuboid joint, and thirteen feet (32 percent) had anesthesia or paresthesia of the sural nerve. Twenty-nine feet (71 percent) had had additional operations, including removal of hardware from twenty feet; bone-grafting to treat a nonunion at the site of the calcaneocuboid arthrodesis and revision of the internal fixation in four feet; a medial displacement calcaneal osteotomy because of recurrent valgus angulation of the hindfoot in two feet; and a Lapidus procedure because of a hypermobile tarsometatarsal joint with hallux valgus, a triple arthrodesis because of a nonunion at the site of the calcaneocuboid arthrodesis associated with loss of correction, and a dorsiflexion-abduction wedge osteotomy through the site of the calcaneocuboid arthrodesis (which had healed) for alignment of an overcorrected foot in one foot each. The outcomes of the procedures in thirty-five feet (85 percent) were rated by the patients as satisfactory, and thirty-three (92 percent) of the thirty-six patients (thirty-eight [93 percent] of the forty-one feet) stated that they would have the procedure again if the circumstances were similar. CONCLUSIONS: Despite the high prevalence of postoperative complications, most of our patients were satisfied with the result of the procedure after the short duration of follow-up. We believe that the relief of pain and the restoration of function achieved through effective correction of the severe pes planovalgus deformity account for the satisfactory outcomes in our patients.

Adult↗
PubMed2005

Pediatric obstructive sleep apnea syndrome.

OBJECTIVE: To review evidence-based knowledge of pediatric obstructive sleep apnea syndrome (OSAS). DATA SOURCES AND EXTRACTION: We reviewed published articles regarding pediatric OSAS; extracted the clinical symptoms, syndromes, polysomnographic findings and variables, and treatment options, and reviewed the authors' recommendations. DATA SYNTHESIS: Orthodontic and craniofacial abnormalities related to pediatric OSAS are commonly ignored, despite their impact on public health. One area of controversy involves the use of a respiratory disturbance index to define various abnormalities, but apneas and hypopneas are not the only abnormalities obtained on polysomnograms, which can be diagnostic for sleep-disordered breathing. Adenotonsillectomy is often considered the treatment of choice for pediatric OSAS. However, many clinicians may not discern which patient population is most appropriate for this type of intervention; the isolated finding of small tonsils is not sufficient to rule out the need for surgery. Nasal continuous positive airway pressure can be an effective treatment option, but it entails cooperation and training of the child and the family. A valid but often overlooked alternative, orthodontic treatment, may complement adenotonsillectomy. CONCLUSIONS: Many complaints and syndromes are associated with pediatric OSAS. This diagnosis should be considered in patients who report the presence of such symptoms and syndromes.

Adenoidectomy↗
PubMed1997

Scanning electron microscopy of the bone-bioactive implant interface.

Rods of three bioactive materials, apatite/wollastonite glass ceramic (AW-GC), bioactive glass (BG), and dense slip-cast hydroxyapatite (HA), were implanted in the femora of 23 Wistar rats for periods of 1-4 weeks. The samples were harvested following vascular perfusion fixation and the femora freeze-fractured for scanning electron microscopy to expose the bone/implant interface. The focus of our observations was when new bone was forming on the implant surfaces irrespective of the implantation period. Scanning microscopy of the hydroxyapatite rods demonstrated that in areas where bone bonding had occurred, the implant surface was composed of globular accretions which fused to form a cement-like matrix to which collagen fibers were attached. Dissolution of individual grains of the implant surface created a roughened surface topography. Such features were not found in the transcortical portions of these implants. Similar globular accretions were also found on the surface of bulk AW-GC, although bone apposition was not disrupted by the critical point-drying procedure, and thus the interface was more difficult to image. Nevertheless, the collagen of the bony compartment interdigitated with an interfacial layer which was morphologically similar to that found on HA. The most surface reactive material, BG, demonstrated an interfacial structure where the surface reactive calcium phosphate layer was clearly distinguished from the underlying bulk implant material. However, this layer was separated from the overlying collagen-containing bony compartment by a second, thinner, calcified layer which corresponded to the cement line matrix into which the collagen fibers were inserted. Our results show that the new bone interface formed with these three bioactive materials is morphologically comparable to that of cement lines found naturally in bone-remodeling sites, and that this interfacial layer is formed on the chemically active surface of the biomaterial. The degree to which the cement line matrix interdigitated with the implant was a product of the reactivity of the implant surface.

Animals↗
PubMed1999

[Complex reconstruction of the area of the maxilla and mid-face after radical tumor surgery].

The esthetic and functional restoration of facial defects is always a daunting challenge. The advent of free vascularized tissue transfers in combination with oral implants enables the surgeon to attain a high level of flexibility in the treatment of such defects. Due to its anatomical properties, the osteocutaneous scapula flap qualifies to a high degree for reconstruction purposes in the midfacial area. From July 1990 to February 1997, reconstruction of complex facial defects after oncologic surgery was performed in 17 patients using free vascularized tissue transfer. In four cases, a free scapula flap was used. Advantages and disadvantages of this technique are illustrated in these patients. Complete oral rehabilitation requires bony continuity of the jaws and stable dentition. To attain this goal, additional grafting procedures are required in most cases when insertion of oral implants is planned. As for the soft tissues, the problem of measuring the amount of tissue needed often leads to an overcorrection, requiring several debulking procedures.

Adult↗
PubMed2004

[Application of the "Taylor Spatial Frame" with unilateral implantation of a medial sledge prosthesis after posttraumatic dislocation of the femur. A complicated progression].

For years the Ilizarov fixator has been an established method for the treatment of orthopedic and trauma patients. The Taylor Spatial Frame is a software-navigated hexapod construction on the basis of the Ilizarov fixator. Unicompartmental arthroplasty of the knee is an option especially in medial osteoarthritis. The therapeutic procedure with a complicated development is illustrated by a case report on a patient with post-traumatic deformity of the femur and medial osteoarthritis of the knee.

Arthroplasty, Replacement, Knee↗
PubMed1999

[Focus debridement of chronic sequestered talus osteomyelitis by TCNC arthrodesis. A new technique with ring fixateur].

A technique utilizing the Ilizarov ring fixator to stabilize a tibio-calcaneo-naviculo-cuboideal arthrodesis following talus resection is introduced. The advantages of this method will be demonstrated with the help of a case history. The described method permits early weight bearing, while supplying stability and compression of the fusion, thereby avoiding further loss of bone stock, while reducing the risk of thromboembolic complications. The Ilizarov ring fixator construction allows for the combination of the fusion with the correction of a preexisting or ensueing leg length discrepancy.

Adolescent↗
PubMed2001

[LISS tractor. Combination of the "less invasive stabilization system" (LISS) with the AO distractor for distal femur and proximal tibial fractures].

Minimally invasive plate osteosynthesis (MIPO) in conjunction with the less invasive stabilization system (LISS) first requires reduction and retention of the fracture using such aids as external fixation, distractors, and percutaneous reduction clamps before the plate can be applied. Based on the open indirect "biological" technique of osteosynthesis, the LISS was combined with an AO distractor (LISS tractor) integrated into the LISS plate. This made reduction possible against the plate before final fixation of the LISS plate. The LISS tractor concept was validated in three patients and we present the technique here. No malalignments > 5 degrees occurred. Fluoroscopy lasted 3.0 min (range: 2.1-4.5) and the operation 125 min (range: 90-150). Modification of the well-known LISS technique by integrating the distractor into the LISS plate to simplify reduction and to provide temporary retention of the fracture has the potential to reduce the fluoroscopy time, the operation time, the rate of malalignments, and the learning curve for this MIPO technique.

Aged↗
PubMed2006

[Hip arthroscopy. Portal technique and arthroscopic anatomy].

In hip arthroscopy everything revolves around entry points. Only with a precise entry technique are safety and efficiency guaranteed. Most pathological changes of the hip for which an arthroscopic intervention can be used are located in the central compartment: two lateral (anterolateral and posterolateral) and one anterior portal are the three standard portals allowing an optimal approach to practically all pathological changes in this compartment. Significant diseases and lesions can occur in the peripheral compartment which would be overlooked by arthroscopy of the central compartment. Two portals are needed for arthroscopy of the periparal compartment: the anterolateral, as well as one distally, converging on the ventral neck of the thigh. Hip arthroscopy is undergoing continual development, however, there are still major requirements for clarification of the pathology and pathomechanisms of injuries and diseases of the this joint.

Arthroscopes↗
PubMed2005

The Taylor spatial frame for deformity correction in the lower limbs.

The Taylor spatial frame uses the slow correction principles of the Ilizarov system but adds a six-axis deformity analysis incorporated within a computer program. To evaluate its use in our community, we used it in lengthening and deformity correction of the lower limbs to treat 22 cases from 1999 to 2001. There were 14 females and eight males (average age 16.5 years). Our target was lengthening in eight cases, correction of deformities in eight and both in six. The results were excellent in 18 cases, good in two, and fair in two. Despite the cost, patient profile and a steep learning curve, our results were encouraging but less favorable than with the Ilizarov external fixator.

Adolescent↗
PubMed2003

Effect of extracorporeal shock waves on callus formation during bone lengthening.

The effects of extracorporeal shock waves (ESWs) on callus formation during bone lengthening were studied in 25 female Japanese white rabbits. Bone lengthening of 9.8 mm was obtained over 2 weeks using the Orthofix M-100 bone fixator. ESWs were applied 3 weeks after surgery. Pins were removed 7 weeks after surgery, and specimens were prepared after the animals were killed at 9 and 24 weeks. The shock wave setting used was 0.42 mJ/mm(2) with a pulse interval of 2 Hz; 3000 shots each were applied to the central and peripheral areas. The specimens were evaluated using radiography, bone mineral density (BMD) measured by dual energy absorptiometry (DXA), and a three-point bending test to evaluate mechanical strength. Histological examination was performed on the lengthened portion. Radiographs and histological observations revealed no apparent fractures in nonlengthening tibias at the shock wave energy densities used. Radiographic observations revealed no apparent differences between the control group and the ESW group. BMD measurements by DXA revealed significantly increased bone mass in the ESW group 9 weeks after surgery. At 24 weeks after surgery the mean BMD had decreased to 25% and 15% of the values at 9 weeks in the control and ESW groups, respectively. The three-point bending test revealed no significant differences between the groups. Histological observations revealed significant capillary formation and osteoblasts and chondrocytes in the bone marrow as well as bridging of newly formed trabeculae 2 weeks after the bone was lengthened. At 4 weeks after treatment, observations included parts of the lengthened portion with no cortex or immature bone. At 9 weeks after surgery, cortex formation and a normal medullary cavity were clearly observed in the control group, whereas observations in the treated group included areas of the lengthened portion with no cortex and formation of immature trabecular structures and increased cancellous bone in the center of the lengthened portion. At 24 weeks after surgery, more prominent cortex formation and fatty marrow were observed in the ESW group than in the control group.

Animals↗

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