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PubMedDate not supplied

Selective soft tissue release preserves growth plate architecture during limb lengthening.

Although distraction osteogenesis has proven successful in children, concerns remain regarding potential growth inhibition of the lengthened limb. Twenty-one 8-week-old New Zealand White rabbits underwent a unilateral 40% tibial lengthening with the contralateral tibia as control. The animals were divided into Achilles tendon release and non-release groups. Radiographs and histomorphometric analysis of the proximal tibial growth plate was performed 5 and 10 weeks after distraction. The corrected length of tibias without tenotomy was significantly shorter than the contralateral controls, whereas those with tenotomy were statistically equivalent to the contralateral control tibias. Histologically, the operated limbs without tenotomy showed a significant decrease in thickness and loss of cellular architecture of the proximal tibial growth plate compared with the tenotomy groups, which were of near-normal appearance. A concomitant tendo Achilles lengthening performed with 40% tibial lengthening preserves proximal tibial growth plate architecture in this model.

Achilles Tendon↗
PubMed1999

Mandibular lengthening with an implanted motor-driven device: preliminary study in sheep.

Distraction osteogenesis with external or intraoral devices is an established method for lengthening human mandibles. In this preliminary study in three sheep a newly designed, fully implantable electromechanical device for mandibular lengthening was used. After osteotomy, the device was screw fixed to the mandible, and the power and control unit was inserted subcutaneously in the neck region. After a healing period of five days, the device was activated magnetically, allowing calibrated distraction steps of 0.04 mm/h, resulting in a total of 1.0 mm/day. Over a period of 14 days, a maximum mandibular lengthening of 13.6 mm could be achieved without transmucosal activation. Depending on stability of the screw fixation, membranous and/or cartilaginous bone formation was observed in the callus by radiological and histological evaluation. Further experimental research is ongoing to prove the clinical usefulness of this device.

Animals↗
PubMed2000

[Effect of bFGF on regeneration of distracted mandibles after radiation].

The potential of distraction osteogenesis in mandibular reconstruction has been limited by its questionable efficacy in previously irradiated bone. The possible osteogenetic effect of recombinant human basic fibroblast growth factor (bFGF) on lengthening of irradiated mandibles was investigated in beagle dogs. We studied nine adult dogs which underwent a full course of external beam radiation therapy (60 Gy/30 fractions). Six months after completion of radiotherapy, the molars were extracted bilaterally followed by bone lengthening of the mandible using an intraoral device. On postoperative day 3 and 7 we injected 10 micrograms bFGF into the osteotomy site of each right hemimandible. The left sides were used as controls. The time course in ossification of the distracted area was evaluated at 2, 4, and 6 weeks after completion of bone lengthening. The radiographs of the newly formed bone tissue were measured by digital image analysis. Corresponding to the radiographic findings, the histological examination of the removed jaws showed an earlier and more intensive bone formation in the treated side after 2, 4, and 6 weeks compared to the control side. We conclude that bFGF promotes the ossification of distracted mandibles after radiation therapy in dogs.

Adult↗
PubMed2002

Alveolar distraction: analysis of 10 cases.

OBJECTIVE: The purpose of this study was to evaluate intraoperative and postoperative complications of alveolar distraction and outcome. STUDY DESIGN: Ten patients with alveolar ridge deficiencies were treated with alveolar distraction osteogenesis by means of intraosseous distractors (Lead system, Stryker Leibenger, Kalamazoo, Mich). The deficiencies were caused by atrophy after periodontal disease or atrophy after tooth extraction (n = 6), benign tumor resection (n = 2), trauma (n = l), or oligodontia in a case of ectodermal dysplasia (n = l). The location of the defects was the anterior mandible (7), posterior mandible (1), and anterior maxilla (2). The mean follow-up was 1.8 years, with a range of 10 months to 3 years. RESULTS: The mean alveolar distraction achieved in 10 cases was 8.7 mm (5-15 mm). The intraoperative and postoperative problems encountered were lingual (n = 3) and palatal (n = 2) displacement of the distracted segment, fracture of the distracted segment in a very thin alveolar bone (n = 1), and intraoperative bleeding (n = 1). CONCLUSION: Overall complication rate was 70%. However, most of the complications were minor and eliminated easily. Implant success rate was 85%.

Adult↗
PubMed2005

Case report: Reconstruction of an intercalary defect with bone transport after resection of Ewing's sarcoma.

We report a 13-year-old girl with Ewing's sarcoma of the tibia who was treated with multiagent chemotherapy, followed by local control tumor surgery consisting of wide resection of the tumor and bone transport with distraction osteogenesis for reconstruction. The bone defect created by resection was 13 cm long and was replaced by bone transport using a monolateral external fixator. Evaluation of the resected specimen revealed wide tumor-free margins with 100% chemonecrosis. A planned Harmon-type autogenous bone grafting between the middle and proximal segments of the tibia (docking site) was done primarily after docking occurred, and a solid union was obtained by 23 months after resection. The bone healing index (treatment index) was 54 days/1 cm distraction, which is indicative of slow healing. Clinical evaluation of the affected extremity using the Musculoskeletal Tumor Society rating system revealed 80% normal functional capability. Indications for bone transport in reconstruction of bone defects created by wide resection of bone sarcomas are discussed. In retrospect, we have concerns regarding the suitability of this technique in the setting of diaphyseal sarcoma reconstruction in patients with Ewing's sarcoma who require aggressive and intense multiagent chemotherapy.

Adolescent↗
PubMed2002

Vibratory coherence as an alternative to radiography in assessing bone healing after osteodistraction.

Distraction osteogenesis is used in orthopedics to lengthen bones by cutting or breaking the bone and gradually separating the two pieces as new bone fills the intervening space. There is a need for early assessment of the degree of bone healing that allows for normal functioning without unwanted side effects. This study compared different techniques used to evaluate the degree of bone healing during mandibular osteodistraction in 21 rabbits. For each rabbit, the mandible was cut in a surgical procedure and then 72 h later distraction began at a rate of 3 mm per day. Bone formation at the distraction site was assessed by in vivo photodensitometry on head radiographs, an in vivo (nondestructive) vibratory coherence test across the distraction site, a postmortem, ex vivo (destructive) three-point bending mechanical test, and by postmortem, ex vivo (destructive) histological examination. Statistical analyses included analysis of variance and correlation coefficient tests. The findings revealed that the results of bone photodensity and the mechanical three-point test are highly and positively correlated with the results of the vibration test. The use of the vibration test may provide a substitute for or augment the routine use of radiography for in vivo evaluation and monitoring of bone healing.

Acceleration↗
PubMed2004

[Surgical correction of exophthalmos in craniofacial synostosis].

OBJECTIVE: To analyze the efficacy and complications of the surgical correction of exophthalmos in craniofacial synostosis. METHODS: Three different procedures were used in exophthalmos patients with different ages. In patients aged 1 - 3 years old, the fronto-orbital advancing osteotomy to deepen the upper part of orbital cavity was employed. In patients aged 4 - 15 years old, Le Fort III osteotomy and distraction osteogenesis were selected. In patients aged 16 years old or more, Le Fort III osteotomy or monobloc craniofacial osteotomy with immediately advancement of the midface segments were selected. RESULTS: Good results were achieved for all 18 patients. The proptosis reduced 7.8 mm postoperatively. The depth of the skull base increased 8.2 mm and inferior orbit margin was advanced 7.8 mm as compared with the preoperative measurements. The angle between the maxilla and skull base (SNA) increased 9 degree. All of these measurements indicated that the proptosis and craniofacial contouring were approached to the normal situation after surgical intervention. CONCLUSION: Both immediate advancement and gradual distraction after frontal, orbital, and maxillar osteotomy to enlarge the orbital cavities are the best approaches for the treatment of exophthalmos in craniofacial synostosis.

Adolescent↗
PubMed2005

Posttraumatic thumb reconstruction.

LEARNING OBJECTIVES: After reading this article, the reader should be able to: 1. Discuss the critical anatomic features of the thumb as they affect on reconstructive decision making. 2. Define the goals of reconstruction. 3. Discuss an algorithm for thumb reconstruction according to the level of amputation. 4. Understand the role of prosthetics in thumb reconstruction. BACKGROUND: The function of the thumb is critical to overall hand function. Uniquely endowed with anatomic features that allow circumduction and opposition, the thumb enables activities of pinch, grasp, and fine manipulation that are essential in daily life. Destruction of the thumb secondary to trauma represents a much more significant loss than would result from loss of any other digit. Therefore, significant effort has been focused on thumb reconstruction. Numerous techniques have been described, ranging from simple osteoplastic techniques to complex microsurgical procedures. With an appreciation of the unique anatomic properties of the thumb, the hand surgeon is better able to understand the goals of thumb reconstruction and to develop an algorithm for thumb reconstruction. With such an understanding, an individualized reconstructive plan can be developed for each patient. METHODS: A great many options are available for posttraumatic thumb reconstruction. Optimal results are obtained by pursuing an organized and logical approach to reconstruction based upon the level of tissue loss. Reconstruction methods depend on the location of the amputation and range from homodigital and heterodigital flaps to partial-toe transfer or a great-toe wrap-around flap to first-web-space deepening using Z-plasties, a dorsal rotation flap, or a distant flap, to distraction osteogenesis, lengthening of the thumb ray, spare parts from another injured digit in the acute setting for pollicization or heterotopic replantation, and microvascular toe transfer. RESULTS: Amputations in the distal third of the thumb are generally well-tolerated. The primary reconstructive issues are the restoration of a padded and sensate soft-tissue cover, as well as aesthetic considerations. First-web-space deepening will generally provide excellent results for amputations at the distal half of the middle third. In the proximal half of the middle third, lengthening of the thumb ray is generally required. Distraction lengthening of the first metacarpal is a useful and reliable technique that provides up to 3 cm of length without requiring complex microsurgical methods. Spare parts from another injured digit may be used in the acute setting for pollicization or heterotopic replantation. Microvascular toe transfer is an excellent option for elective reconstruction. However, other options also are available and may be more appropriate in some cases. Less ideal options include the various types of osteoplastic reconstruction. CONCLUSIONS: The reconstruction of posttraumatic thumb defects is a challenging and rewarding surgical endeavor. The value of a functioning thumb is immense, and its reconstruction is worthy of considerable effort. Despite the elegant reconstructive options available, the best results are obtained with replantation or revascularization whenever possible. Finally, the treatment plan always must be derived from a careful assessment of each patient's posttraumatic function and specific reconstructive needs.

Algorithms↗
PubMed2000

Non-invasive densitometric and histomorphometric study of the regenerated bone in the distraction gap in rabbits.

The long period of external fixation after the completion of distraction, which is necessary to obtain enough strength for resisting without fixation is a significant disadvantage of distraction osteogenesis. The purpose of this study is to understand the mechanical property of the regenerated bone and try to find an appropriate timing for safely removing the fixation device. An external fixation device was applied to the right tibia in rabbits and transverse osteotomy was performed just below the tibio-fibula junction. The tibiae were lengthened 7.2 mm at 0.72 mm a day for 10 days after surgery. A bone mineral density (BMD) and stress strain index (SSI) analyzed by peripheral quantitative computed tomography showed a significant increase on day 40, but returned to the control level at day 64 after the completion of distraction. Therefore, the newly formed bone between the host cortical bone seemed to be enough to resist the mechanical stress on day 40 during the consolidation period in this study. The present results suggested the possibility of removing the fixation device during the period when the BMD and SSI showed a significantly high level during the consolidation period.

Absorptiometry, Photon↗
PubMed2003

Enhancement of the fibula free flap by alveolar distraction for dental implant restoration: report of a case.

We describe the utilization of distraction osteogenesis in the free fibular microvascular bone graft to the mandible for increasing bone height for future osseointegrated dental implants. Successful reconstruction of a resected mandible requires restoration of both function and esthetic form. Although current reconstructive techniques restore anterior-posterior and lateral projection, often the graft's vertical height is not sufficient for the placement of osseointegrated dental implants and subsequent oral prosthesis. The patient was a sixteen-year-old male who was found to have a large desmoplastic fibroma of the left mandible, which was resected. The defect was successfully restored with a free fibular microvascular bone graft and reconstruction plate. Nevertheless, the patient had persistent problems with mastication and it was decided to perform a segmental osteotomy of the neomandible. Two internal vertical distraction devices were then placed in the mandible. The appliances were then activated five days postoperative, twice a day, for a total of 14 days. At that time 1.5 cm of distraction had occurred and the patient was placed in a consolidation phase for four months. The patient then had sufficient bone height and was restored with 8 osseointegrated dental implants.

Adolescent↗
PubMed2006

Rehabilitation after intramedullary skeletal kinetic distractor implantation: a report of two cases and a suggested therapy program.

Adult limb lengthening occurs via distraction osteogenesis and traditionally involves use of an external fixator. Complications after placement of hardware often disrupt rehabilitative efforts and hinder patients' progress. A completely internal limb-lengthening device has been developed and increasingly used, and it may more commonly be seen by a physiatrist in consultation for postoperative rehabilitation. We present two cases of patients who underwent implantation of the intramedullary skeletal kinetic distractor and required acute inpatient rehabilitation. One patient had previously suffered a malunion deformity with a resultant limb shortening, and the second patient was born with a congenital leg-length inequality. Both patients had successful femoral intramedullary skeletal kinetic distractor implantation and were transferred for acute inpatient rehabilitation. Distraction occurred daily, based on the patient's level of physical activity in therapy, and was measured using a hand-held monitor. Both patients were successfully discharged home, without complications throughout the hospital stay. Knowledge of the theory and mechanism of action of the device is important to guide both the amount and type of therapy prescribed and to follow patient progress. We present general guidelines during the acute rehabilitation of a patient after intramedullary skeletal kinetic distractor surgery.

Adult↗
PubMed2003

Development of a mechanical testing system for a mandibular distraction wound.

The purpose of this study was to develop a mechanical testing system to estimate stiffness of an experimental porcine mandibular distraction osteogenesis (DO) wound. The system was designed to function without changing the morphology of the healing mandible. A customized jig was designed to allow cantilever-bending tests of the Yucatan mini-pig hemi-mandible. Experimental and control hemi-mandibles were placed in the jig and the proximal segment was secured. A material testing unit applied progressively increasing downward force on the pre-molar occlusal surface. The maximum force applied was 0.030 kN. The stiffness value for each hemi-mandible was represented by the slope of the plot of force (kN) vs displacement (mm). Radiographs were taken before and after mechanical testing to demonstrate any gross morphologic changes or identifiable fractures across the distraction wound. A total of 24 mini-pigs underwent DO of the right mandible with 0-day latency and distraction rates of 1, 2, and 4 mm per day resulting in a 12 mm gap. At the completion of 0, 8, 16, and 24 days of neutral fixation, two animals for each of three different distraction rates were sacrificed for mechanical testing. Stiffness of control hemi-mandibles ranged between 0.018 and 0.317 kN/mm (median 0.063; mean 0.099 +/- 0.080). Stiffness of experimental hemi-mandibles ranged between 0 and 0.025 kN/mm (median 0.004; mean 0.005). The subset that was tested at the end of neutral fixation had stiffness between 0.005 and 0.025 (median 0.011; mean 0.012 +/- 0.011). No morphologic changes were evident on the X-rays after testing. The results indicate that the cantilever-bending model is useful for testing stiffness of an experimental mandibular DO wound without destroying its morphology.

Animals↗
PubMedDate not supplied

[Limb lengthening with a fully implantable mechanical distraction intramedullary nail].

AIM: The morbidity of fixator-assisted distraction osteogenesis should be reduced by intramedullary lengthening devices. The ISKD (intramedullary skeletal kinetic distractor) is a new, fully implantable mechanical lengthening nail. In a prospective cohort trial the possibilities and limitations of the device used on femur and tibia are examined. METHODS: 22 patients with a mean age of 25 (range: 16-46) years were treated with an ISKD for femoral (n = 16) and tibial (n = 6) lengthening. The average leg length discrepancy was 48 (range: 25-80) mm. The follow-up was 21 (range: 7-37) months. Clinical and radiological results and complications were evaluated. RESULTS: The results of femoral and tibial applications of the ISKD are different. At the tibia, in three patients a pseudarthrosis occurred and slow callus formation was observed twice. An equinus contracture became evident in 2 patients. At the femur, in one case the lengthening was not accomplished with the device. Five patients were manipulated under anaesthesia at least once to achieve the aim of distraction. Three of these patients received retrograde implantation of the ISKD. An infection or interlocking screw failure was not observed either at the femur or the tibia. CONCLUSION: The ISKD reduces fixator-associated problems but incorporates its own difficulties which are mainly based on the guidance of the device. Careful patient advice in monitoring the lengthening process is mandatory. At the femur 8 cm of lengthening can be achieved but the nail tends to "block". Proper reaming and osteotomy techniques are important. A lengthening of more than 1 mm/day is recommended to prevent early consolidation. At the tibia weak callus formation and soft tissue contractures occur, therefore not more than 4 cm lengthening should be planned, the distraction speed has to be reduced noticeable below 1 mm/day and the initial immobilisation should be for more than a week.

Adolescent↗
PubMed2002

Mandibular distraction in the absence of an ascending ramus and condyle.

The introduction of distraction osteogenesis (DO) as a method of mandibular elongation has provided the craniofacial surgeon with a valuable tool in the approach to patients with mandibular deficiencies. A growing number of case reports and clinical series have proven the efficacy of mandibular DO as an augmentative technique in patients with hemifacial microsomia (HFM). Although DO has become a part of the treatment algorithm for many patients with HFM, surgeons have been reluctant to apply the technique in patients with complete agenesis of the ascending mandibular ramus and condyle (grade III HFM). In the following cases, mandibular DO was successfully performed in two patients with grade III HFM. Preoperative images and intraoperative findings confirmed that both patients lacked the entire ascending mandibular ramus and condyle on the affected side. After unilateral multiplanar DO, both patients showed new bone formation within the distraction gap and development of a pseudoarthrosis between the proximal segment of the mandible and the skull base. Facial symmetry improved dramatically, and speech and mandibular excursion were maintained. The patients have been followed for 1 to 2 years after distraction with durable functional and esthetic outcomes. Mandibular DO offers many advantages compared with rib grafting, including avoidance of donor site morbidity, application in patients who are not candidates for graft harvest, and use after rib graft failure. The following cases support the use of mandibular DO as a mechanism of endogenous tissue engineering in patients with complete agenesis of the ascending mandibular ramus and condyle.

Child↗
PubMed2006

A novel mouse model for the study of the inhibitory effects of chronic ethanol exposure on direct bone formation.

Excessive alcohol consumption has been reported to interfere with human bone homeostasis and repair in multiple ways. Previous studies have demonstrated that chronic ethanol exposure in the rat via an intragastric dietary delivery system inhibits direct bone formation during distraction osteogenesis (DO, limb lengthening). The opportunity to extend the rat ethanol studies to mice is now possible due to the development of mouse models of DO. This study employed a novel combination of liquid ethanol diet delivery and a murine DO model to test the hypothesis that chronic ethanol exposure would result in deficits in direct bone formation during DO in contrast to the pair-fed controls. Twenty-eight 12-month-old C57BL/6 male mice were acclimated to the Lieber-DeCarli liquid control diet #710027 (Dyets Inc.) over a 1-week period. The mice were separated into two diet groups (n=14/group): pair-fed control and ethanol (diet #710260). After being on diet for 82 days, all mice underwent placement of an external fixator and osteotomy on the left tibia. Following a 6-day latency period, distraction began at a rate of 0.075 mm twice a day (b.i.d.) for 14 days. The weight changes were equivalent for both groups. The hypothesis that chronic ethanol exposure would inhibit direct bone formation and produce skeletal toxicity was supported by radiographic (P=.011) and histologic (P=.002) analyses of the % new bone formation in the DO gaps, by peripheral quantitative computed tomography analysis of the total volumetric bone mineral density of the contralateral proximal tibias (P<.001) and contralateral femoral necks (P=.012), by three-point bending on the contralateral tibias (P<.001 energy to break), by pin site bone formation measures (P<.001), and by ethanol-associated increased adipocyte area (adjacent to the gap) percentages (P<.002). We conclude that this model can be used to study the mechanisms underlying inhibition of bone formation by chronic ethanol exposure and to test preclinical interventions.

Absorptiometry, Photon↗
PubMed2003

Normal palatal sutures in newborns and fetuses: a critical fact for successful palatal distraction.

Distraction osteogenesis (DO) has recently been applied to the palate. Successful posterior lengthening and medial advancement of the palates was continuously reported. Based on these studies, it is obvious that DO will play a major role in the management of problems related to palatal defects in the near future. Although the results are appealing, they may not be applicable for humans due to anatomic differences. All experimental studies used normal palatal sutures of young dogs for size expansion. Therefore, it is necessary to know normal palatal sutures in infants before one can clinically apply this new technique. With consent, palates of fetuses and neonates who died of various causes were examined. Eight fresh cadavers were available for the dissection, with two being skeletonized using the boiling process. There were three fetal deaths in utero (33-41 weeks of gestational age) and five postnatal deaths (aged between 5 hours and 6 months). All specimens were grossly normal in shape and size except for one with a unilateral complete cleft of lip and palate. A midline palatal suture was found in every noncleft specimen, while premaxillary and transverse palatomaxillary sutures were present in every specimen. Laterally, there was no true suture except for the most posterior portion, which was contiguous with the greater palatine foramen. The palatal sutures of third-trimester fetuses and neonates are not different from adult ones. There is no lateral suture that will allow distraction in the medial direction. It is only the posterior hard palate (palatine bones) that can potentially be moved medially and posteriorly by sutural expansion with DO.

Animals↗
PubMed2004

Limb lengthening and correction of deformity in the lower limbs of children with osteogenesis imperfecta.

We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods. The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions. We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI.

Adolescent↗
PubMed2002

Blindness as a complication of Le Fort I osteotomy for maxillary distraction.

High Le Fort I osteotomy and maxillary distraction has become an accepted method for the treatment of maxillary retrusion in children and teenagers with cleft lip and palate or craniofacial anomalies. This procedure effectively corrects the dentofacial deformity in these patients. No major surgical morbidity has been reported. During the past 4 years, 94 cleft patients with maxillary hypoplasia received Le Fort I osteotomy and distraction osteogenesis at the authors' center. Two of them developed blindness after this operation. The first case was a girl with bilateral cleft lip and palate with median facial dysplasia. She received high Le Fort I osteotomy at age 12 years 4 months to correct maxillary retrusion. Right eye swelling and ecchymosis was found after surgery. The patient complained of vision loss in that eye 2 days later. Computed tomography showed subarachnoid hemorrhage and skull base hematoma. There were no atypical fractures in the orbit, pterygoid plates, sphenoid bone, and skull base. Angiogram revealed left ophthalmic and basilar artery aneurysm. The second case was a 12-year-old boy with left cleft lip and palate. He received Le Fort I osteotomy to correct maxillary retrusion. During surgery, abnormal pupil dilatation was found after the osteotomy and down-fracture of maxilla. Emergent computed tomography found no hemorrhage or atypical fractures. Examination revealed complete left optic neuropathy and partial right abducens nerve palsy with mydriasis. Magnetic resonance imaging, magnetic resonance angiography, and repeated computed tomography revealed no sign of orbital injury, vascular problem, or abnormal fractures. The cause of blindness was unknown. In both cases, a steroid was used. Maxillary distraction was continued. Recovery of meaningful visual sense did not occur after 3 and 2 years' follow-up, respectively. A review of the literature revealed five other patients who suffered from visual loss after Le Fort I osteotomy. Inadvertent skull base fractures were identified in two cases, but a cause for the blindness was not known in the others. Induced hypotension and indirect trauma may be responsible for the optic nerve injury. In none of the cases was meaningful visual sense recovered, although high-dose steroids were given. In conclusion, a total of seven cases developed blindness after Le Fort I osteotomy. Once blindness develops, the prognosis is poor. High Le Fort I osteotomy should be performed with extreme care, and perhaps the informed consent should include visual loss as a complication of the procedure.

Abducens Nerve Diseases↗