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PubMed2005

The healing potential of the periosteum molecular aspects.

The presence of pluripotential mesenchymal cells in the under surface of the periosteum in combination with growth factors regularly produced or released after injury, provide this unique tissue with an important role in the healing of bone and cartilage. The periosteum contributes in the secondary callus formation with cells and growth factors and should always be preserved and protected when surgery is performed for the management of a fracture. The current evidence about the cellular interactions, the stimulants and the signalling pathways related to osteogenesis and chondrogenesis is described. An essential knowledge of the basics related to the contribution of the periosteum in the healing of fractures, osteotomies, during the process of distraction osteogenesis and in some degree in the repair of cartilagenous defects, provides the surgeons with a better insight to understand the upcoming "biological" interventions in the management of skeletal injuries.

Cell Differentiation↗
PubMed1992

Recent advances in limb lengthening. Part I: Clinical advances.

The discipline of limb lengthening has undergone numerous advances in recent years. An increased understanding of the biology of distraction osteogenesis, as well as technical advances, has made lengthening more feasible. However, significant problems remain unsolved, and complications--although less severe and long standing--still remain. Little is known about the effect of distraction on soft tissues. Lengthening in skeletally mature patients remains difficult. The myriad of conditions that require lengthening often confounds comparison of techniques. Uniform indications for limb lengthening may never exist, but increasing experience helps guide patient selection.

Bone Lengthening↗
PubMed1991

Bridging bone gaps with the Ilizarov technique. Biologic principles.

For the treatment of bone gaps of less than 4 cm, cancellous autografting remains the treatment of choice. But for gaps exceeding 4 cm, the distraction osteogenesis is a viable option. The following conditions should be satisfied: (1) patient selection; (2) stable fixation; (3) osteotomy by corticotomy; (4) 7- to 14-day latency period before initiating distraction; and (5) a controlled rate and rhythm of distraction of 1 mm per day (0.25 mm, four times a day). This type of treatment leaves the pathologic focus alone, and bone healing occurs on the healthy bone. The quality of bone regenerate may be improved by a motorized unit and by better soft-tissue coverage using early grafts and flaps. Interface healing is probably improved by cancellous grafting and internal fixation after the transport period, thus decreasing the fixator time.

Bone Lengthening↗
PubMed2001

[Mandibular elongation and remodeling by gradual distraction. An experience of 277 cases].

Distraction osteogenesis at the craniofacial skeleton offers superior results than using standard osteotomies and other surgical techniques when treating mandibular hypoplasia. After ten years, we have performed 221 patients with hemifacial microsomia and 56 patients with micrognathia using external mandibular distraction. For every single patient the distraction vector is different according to the degree of bone hypoplasia. The bone elongation ranged from 12 to 49 mm, and the results were excellent: facial symmetry was reestablished, the menton became horizontal and the long term result controls shows stability clinically and occlusally.

Adolescent↗
PubMed1996

Multiple segmental gradual distraction of facial skeleton: an experimental study.

The method of distraction osteogenesis was used to move several facial segments in different directions with formation of new bone. On 3 young adult sheep a Le Fort II osteotomy, combined with circumferential orbital osteotomies, was performed. The periosteum over the osteotomies was preserved. Titanium bone screws were placed as bone markers. The segments were fixed with pins and plates to a combined distraction apparatus in order to advance the segments in different directions. By a gradual distraction, the midface was advanced forward by 30 mm. The left orbit was moved laterally 20 mm and the right orbit was moved forward 20 mm. In both orbits there was a concomitant globe movement. New bone formation in the distracted area was obvious radiographically, clinically, and histologically. In conclusion, multiple segmental distraction is possible in the adult sheep face and may offer three-dimensional (3D), controlled correction of complex face deformities.

Animals↗
PubMed1996

The effects of the Ilizarov distraction technique on bone and muscle in a canine model: a preliminary report.

This study examined the functional and morphological changes experienced by bone and muscle during Ilizarov distraction osteogenesis. Although extensive research has been conducted in the area of regenerate bone formation, the effect of limb lengthening on the biomechanical properties of bone and muscle has not been thoroughly addressed. In this study, an Ilizarov external fixator was applied to one tibia of nine skeletally mature dogs, and distracted 3 cm over thirty days. The contralateral tibia served as control. Histology and weekly radiographs assessed muscle morphology and bone growth. The contractile capabilities of the gastrocnemius muscles from the experimental and control limbs were measured prior to sacrifice, and the bending stiffness of the tibias of five dogs was determined. All dogs experienced loss of knee extension secondary to muscle contracture and/or stiffness about the joint. These dogs did not bear weight on the experimental limb. In one dog, spontaneous resolution of the muscle contracture allowed partial weight bearing during the last three weeks of consolidation. Despite 3 cm distraction, tibial lengthening ranged from 1.7 to 3 cm. Biomechanical testing revealed a significant reduction in the bending stiffness of the lengthened bones when compared with control values (p < 0.003). The weight of the lengthened muscles was 35% less than control values, a finding consistent with the histology which showed mild muscle fiber degeneration in all dogs. The contractile capabilities of the lengthened muscles were reduced to 29-80% of control values (p < 0.005). In contrast, the lengthened muscle from the weight bearing dog retained 85% of the weight and 104% of the maximum contractile force of the control muscle.

Animals↗
PubMed1989

[Treatment of post-osteomyelitic circular defects in shin bones by the method of compression-distraction osteosynthesis with the use of allogenic bone matrix].

The authors propose to stimulate distraction osteogenesis by means of implanting bone matrix both into the resection area after removing the suppurative necrotic focus and into the region of the osteotomized fragment. The suggested method of treatment of post-osteomyelitic defects of the tibia reduces the duration of the period of treatment 2-3-fold as compared with the commonly accepted terms in compression and distraction osteosynthesis without bone matrix.

Bone Matrix↗
PubMedDate not supplied

[Computerized tomography aspects of tibial distraction regeneration].

Computer tomography (CT) potentialities in examinations of patients over the course of distraction osteosynthesis and in assessment of the bone regenerate structure of different sites in various periods of its formation and 'maturation' were studied in 25 patients (22 men and 3 women aged 14 to 54, mean age 31.7) in periods from 24 days to 5 years. CT permitted a visual and densitometric assessment of the developing bone regenerate surrounded by metal constructions. The distraction osteogenesis involves the development of bone regenerate copying the anatomical shape and structure of the regenerated tubular bone at the site of its osteotomy. CT helps follow up all the periods of bone regenerate formation and maturation and permits the detection of deviations in this process, if any. This method permits analysis of the bone regenerate ossification time course, that is important for the assessment of the distraction rate and of the time of removing the external fixation apparatus.

Adolescent↗
PubMed2006

Improved outcomes in cleft patients with severe maxillary deficiency after Le Fort I internal distraction.

BACKGROUND: Correction of severe maxillary deficiency in cleft lip-cleft palate patients often results in undercorrection, relapse, and need for secondary corrective procedures. Le Fort I internal distraction osteogenesis offers an alternative to one-step orthognathic advancement, with advantages of gradual lengthening through scar and earlier treatment in growing patients. METHODS: Patients with cleft lip-cleft palate deformities and maxillary deficiency were divided into three groups treated by Le Fort I advancement: group 1, mild to moderate deficiency (< 10 mm) with conventional orthognathic procedure; group 2, severe deficiency (> or = 10 mm) with conventional orthognathic procedure; and group 3, distraction procedure for severe deficiency (> or = 10 mm) (n = 51). Preoperative, postoperative, and follow-up (> 1 year) lateral cephalogram measurements were compared including angular (SNA and SNB) and linear (Deltax = horizontal and Deltay = vertical) changes. The Pittsburgh Speech Score was used to assess for velopharyngeal insufficiency (score > 3). RESULTS: Results demonstrated that group 1 patients had a mean SNA change from preoperatively (78.7) to postoperatively (83.8), and a horizontal change of 5.0 mm, with no relapse. Group 2 patients had a mean SNA change from preoperatively (76.3) to postoperatively (82.0) and a horizontal change of 7.2 mm, with 63 percent relapse. Group 3 patients had a mean SNA change from preoperatively (74.1) to postoperatively (84.9) and a horizontal change of 16.5 mm, with 15 percent relapse. Thus, for severe maxillary deficiency, the distraction group had 48 percent less relapse than the conventional Le Fort I group. Postoperative speech evaluation showed velopharyngeal insufficiency in the following: group 1, four of 20 patients (20 percent); group 2, nine of 11 patients (82 percent); and group 3, nine of 20 patients (45 percent). CONCLUSION: These data suggest that Le Fort I internal distraction for severe cleft maxillary deficiency leads to better dental occlusion, less relapse, and better speech results.

Cleft Lip↗
PubMed1992

Corticotomy.

A correctly performed corticotomy is essential to the success of distraction osteogenesis and prepares for deformity correction, limb lengthening, elimination of bone and soft-tissue defects, reshaping of bones, and treatment of cavitary osteomyelitis. The modern corticotomy has evolved from the initial open osteotomies, which eventually proved to be traumatic to bone's osteogenic elements, and closed bone osteoclasis, which proved time consuming and difficult to control. Ultimately, this led to the combination of an open partial subperiosteal cortical osteotomy, followed by manual osteoclasis of the remainder of the bone cortex. The various types of corticotomy, each with its own special purpose, include transverse or oblique, longitudinal, "splinter," and partial. The techniques and indications for each are outlined. Consideration is given to the latency period--the time from corticotomy to onset of distraction. Morphologic studies have shown that optimally this period should be from seven to ten days. The complications of corticotomy include damage to the osteogenic elements through rough surgical technique, displacement of the fragments after corticotomy, and incomplete corticotomy.

Bone Lengthening↗
PubMed1999

Leg lengthening over an intramedullary nail.

Distraction osteogenesis is widely used for leg lengthening, but often requires a long period of external fixation which carries risks of pin-track sepsis, malalignment, stiffness of the joint and late fracture of the regenerate. We present the results of 20 cases in which, in an attempt to reduce the rate of complications, a combination of external fixation and intramedullary nailing was used. The mean gain in length was 4.7 cm (2 to 8.6). The mean time of external fixation was 20 days per centimetre gain in length. All distracted segments healed spontaneously without refracture or malalignment. There were three cases of deep infection, two of which occurred in patients who had had previous open fractures of the bone which was being lengthened. All resolved with appropriate treatment. This method allows early rehabilitation, with a rapid return of knee movement. There is a lower rate of complications than occurs when external fixation is used on its own. The time of external fixation is shorter than in other methods of leg lengthening. The high risk of infection calls for caution.

Adolescent↗
PubMed2002

Skeletal toxicity associated with chronic ethanol exposure in a rat model using total enteral nutrition.

Chronic alcohol abuse decreases bone mass, inhibits osteoblast differentiation and function, increases fracture incidence, and delays fracture healing. Four studies were designed to use intragastric ethanol delivery as part of a total enteral nutrition (TEN) system to determine the negative systemic effects of chronic ethanol on 1) the rat skeleton and 2) local rapid bone formation during limb lengthening (distraction osteogenesis, DO). In study 1, three-point bending tests demonstrated that after 75 days of ethanol exposure, the tibiae had significantly lower load to failure versus control diet (p = 0.0006) or ad libitum chow-fed rats (p = 0.0029). Study 2 examined alcohol's effects on the density and cross-sectional area of the proximal tibial metaphysis using peripheral quantitative computed tomography and found that after 25 days of ethanol exposure the trabecular volumetric bone mineral density (p = 0.011) and cortical cross-sectional area (p = 0.011) were lower compared with controls. In study 3, a comparison of distracted tibial radiographs and histological sections demonstrated ethanol-related decreases in both gap mineralization (p = 0.03) and bone column formation (p = 0.01). Histological comparisons in study 4 reproduced the ethanol-related deficits in new bone formation during DO (p = 0.001). These results indicate that the TEN system is a viable model to study ethanol's effects on the skeleton and that chronic ethanol delivery via TEN decreases trabecular bone density, cortical area, and mature bone strength. Also, the DO studies demonstrate, for the first time, that chronic ethanol inhibits rapid bone formation during limb lengthening.

Alcoholism↗
PubMed2005

A novel surgical procedure for bridging of massive bone defects.

BACKGROUND: Bony defects arising from tumor resection or debridement after infection, non-union or trauma present a challenging problem to orthopedic surgeons, as well as patients due to compliance issues. Current treatment options are time intensive, require more than one operation and are associated with high rate of complications. For this reason, we developed a new surgical procedure to bridge a massive long bone defect. METHODS: To bridge the gap, an in situ periosteal sleeve is elevated circumferentially off of healthy diaphyseal bone adjacent to the bone defect. Then, the adjacent bone is osteotomized and the transport segment is moved along an intramedullary nail, out of the periosteal sleeve and into the original diaphyseal defect, where it is docked. Vascularity is maintained through retention of the soft tissue attachments to the in situ periosteal sleeve. In addition, periosteal osteogenesis can be augmented through utilization of cancellous bone graft or in situ cortical bone adherent to the periosteal sleeve. RESULTS: The proposed procedure is novel in that it exploits the osteogenic potential of the periosteum by replacing the defect arising from resection of tissue out of a pathological area with a defect in a healthy area of tissue, through transport of the adjacent bone segment. Furthermore, the proposed procedure has several advantages over the current standard of care including ease of implementation, rapid patient mobilization, and no need for specialized implants (intramedullary nails are standard inventory for surgical oncology and trauma departments) or costly orthobiologics. CONCLUSIONS: The proposed procedure offers a viable and potentially preferable alternative to the current standard treatment modalities, particularly in areas of the world where few surgeons are trained for procedures such as distraction osteogenesis (e.g. the Ilizarov procedure) as well as areas of the world where surgeons have little access to expensive, complex devices and orthobiologics.

Journal Article↗
PubMed2005

[Management of fibular hemimelia with the Ilizarov circular external fixator].

OBJECTIVES: We evaluated the results of treatment with the Ilizarov circular external fixator for limb length inequality and deformities in patients with type IA, IB, and type II fibular hemimelia. METHODS: Tibial corticotomy and distraction osteogenesis with the Ilizarov technique were performed in five male patients (mean age 11.4 years; range 4 to 20 years). According to the classification of Achterman and Kalamchi, fibular hemimelia was type IA, IB, and II in three patients, one patient, and one patient, respectively. Involvement was on the right in three patients, and on the left in two patients. Two patients had equinus and one patient had valgus deformities. No instability existed in the ankle and knee joints. The mean leg discrepancy was 8.7 cm (range 3 to 16.5 cm), and the mean lengthening index was 1.6 cm/month (range 1.4 to 2 cm). The mean follow-up was 33 months (range 15 to 68 months). RESULTS: On final examinations, full range of motion of the knee was obtained. A plantigrade foot was achieved in three feet, while two sustained an equinus deformity of 17 and 15 degrees, respectively. Pin tract infections were observed in four patients, all of which were treated with oral antibiotics and dressing. During distraction, three patients had pain. Two patients had a limited range of motion of the ankle joint, without instability or subluxation of the ankle and knee joints. These joint problems were successfully dealt with by physical exercises. CONCLUSION: The Ilizarov technique is a convenient method in the correction of angular and rotational deformities while enabling distraction in type I and type II fibular hemimelia.

Abnormalities, Multiple↗
PubMed1995

Introduction of an intraoral bone-lengthening device.

It has been demonstrated that distraction osteogenesis is an effective clinical tool with applications for the entire human skeleton. Therapeutic exploitation in the correction of the asymmetrical and hypoplastic mandible has been reported previously. However, the main criticism of this technique has been the residual cutaneous scars resulting from the surgical incision and the path of the expansion device. In order to obviate the need for skin incisions, we have developed and demonstrated the feasibility of a miniaturized mandibular bone lengthener that is suitable for intraoral placement. Ten growing mongrel dogs were studied. Under general anesthesia, a buccal mucosal incision was made along the oblique line, and the body and ramus of the mandible were exposed in a supraperiosteal plane. Two 2.0-mm half-pins were placed percutaneously in the area of the angle of the mandible, and two other pins were placed 3.5 cm anteriorly. The clamps of the lengthening device were then attached to the half-pins in an intraoral position. An osteotomy was made by connecting percutaneously made drill holes between the clamps in a line positioned posterior to the third molar. The mucosa was closed loosely over the device. Distraction was commenced on the eighth postoperative day. The results were assessed with pre- and post-lengthening photographs, cephalograms, and CT scans with three-dimensional reconstruction. All animals demonstrated a contralateral cross-bite. The newly developed bone also was examined histologically. The intraoral method of mandibular lengthening offers the same advantages of extraoral lengthening but without the need for a cutaneous incision and resulting scar.

Animals↗
PubMed1997

Surgical treatment of obstructive sleep apnea in neurologically compromised patients.

Children with cerebral palsy are at risk of developing obstructive sleep apnea, which is initially managed by medical therapy but often requires tracheostomy for stabilization of the airway. We report preoperative and postoperative polysomnographic findings in a prospective series of 18 patients with cerebral palsy and obstructive sleep apnea who were refractory to medical management and underwent aggressive surgical treatment of upper airway obstruction. Fifteen of the 18 children (83 percent) in whom tracheostomy was recommended were spared the procedure. Eighteen children with cerebral palsy failed medical management of obstructive sleep apnea and were advised to have tracheostomy. There were 9 boys and 9 girls, ranging in age from 9 months to 17 years and 6 months at the time of operation. Tonsillectomy and adenoidectomy was performed in 9 patients, turbinectomy and/or septoplasty in 9, tongue-hyoid advancement in 13, uvulopalatoplasty in 13, conventional mandibular advancement in 2, distraction osteogenesis of the mandible in 2, and tongue reduction in 7. A concomitant Wilkes-Brody procedure for drooling was performed in 6 patients. Preoperative and postoperative polysomnographic data were compared by means of a paired t test. The mean preoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 3.61, 7.02, and 73.7, respectively. Mean postoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 0.67, 1.44, and 88.2, respectively. Lowest oxygen saturation and respiratory disturbance index were both improved significantly, with p values of 0.0367 and 0.0021, respectively. Fifteen patients are tracheostomy-free (83 percent) at a mean follow-up time of 30 months (range 14 to 49 months.) Two (11 percent) of the children ultimately required tracheostomy, and one (6 percent) died from respiratory failure following the parents' decision not to proceed with further treatment. Our results confirm the efficacy of an aggressive surgical approach to the treatment of obstructive sleep apnea in neurologically compromised children. Many children and their families may potentially avoid the long-term commitment and cumulative hazards of tracheostomy. Additional strategies that have been adopted include identification and aggressive management of seizures, esophageal reflux, and excessive oral secretions and the application of mandibular distraction and skeletal expansion whenever feasible. Close postoperative monitoring is necessary with reoperation for recurrent symptoms of obstructive sleep apnea if documented by sleep study and associated with evidence of recurrent or residual morphologic abnormalities.

Adenoidectomy↗
PubMed2006

Interventions for replacing missing teeth: bone augmentation techniques for dental implant treatment.

BACKGROUND: Dental implants require sufficient bone to be adequately stabilised. For some patients implant treatment would not be an option without bone augmentation. A variety of materials and surgical techniques are available for bone augmentation. OBJECTIVES: General objectives: To test the null hypothesis of no difference in the success, function, morbidity and patient satisfaction between different bone augmentation techniques for dental implant treatment. SPECIFIC OBJECTIVES: (A) to test whether and when augmentation procedures are necessary; (B) to test which is the most effective augmentation technique for specific clinical indications. Trials were divided into three broad categories according to different indications for the bone augmentation techniques: (1) major vertical or horizontal bone augmentation or both; (2) implants placed in extraction sockets; (3) fenestrated implants. SEARCH STRATEGY: The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Several dental journals were handsearched. The bibliographies of review articles were checked, and personal references were searched. More than 55 implant manufacturing companies were also contacted. Last electronic search was conducted on 1 October 2005. SELECTION CRITERIA: Randomised controlled trials (RCTs) of different techniques and materials for augmenting bone for implant treatment reporting the outcome of implant therapy at least to abutment connection. DATA COLLECTION AND ANALYSIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using weighted mean differences for continuous outcomes and odd ratios for dichotomous outcomes with 95% confidence intervals. The statistical unit of the analysis was the patient. MAIN RESULTS: Thirteen RCTs out of 29 potentially eligible trials reporting the outcome of 330 patients were suitable for inclusion. Since different techniques were evaluated in different trials, no meta-analysis could be performed. Six trials evaluated different techniques for vertical or horizontal bone augmentation or both. Four trials evaluated different techniques of bone grafting for implants placed in extraction sockets and three trials evaluated different techniques to treat bone dehiscence or fenestrations around implants. AUTHORS' CONCLUSIONS: Major bone grafting procedures of extremely resorbed mandibles may not be justified. Bone substitutes (Bio-Oss or Cerasorb) may replace autogenous bone for sinus lift procedures of extremely atrophic sinuses. Both guided bone regeneration (GBR) procedures and distraction osteogenesis can augment bone vertically, but it is unclear which is the most efficient technique. It is unclear whether augmentation procedures at immediate single implants placed in fresh extraction sockets are needed, and which is the most effective augmentation procedure, however, sites treated with barrier + Bio-Oss showed a higher position of the gingival margin, when compared to sites treated with barriers alone. Non-resorbable barriers at fenestrated implants regenerated more bone than no barriers, however it remains unclear whether such bone is of benefit to the patient. It is unclear which is the most effective technique for augmenting bone around fenestrated implants. No bone promoting molecule has been shown to be effective or necessary in conjunction with dental implant treatment. The use of particulated autogenous bone from intraoral locations, also taken with dedicated aspirators, might be associated with an increased risk of infective complications. These findings are based on few trials including few patients, having sometimes short follow up, and being often judged to be at high risk of bias.

Animals↗
PubMed1996

Effect of capacitive coupled electrical stimulation on regenerate bone.

An in vivo study was carried out to determine if capacitive coupled electrical stimulation increased the rate of recovery of strength of regenerate bone produced as a result of lengthening by the Ilizarov technique. Thirty-four adult male beagles underwent a right tibial mid-diaphyseal corticotomy, followed by a 5-day delay, and then 21 days of lengthening (1 mm/day). At the start of the post-distraction period (day 27), stimulation (3-6.3 V peak to peak, 5-10 mA root-mean-square at 60 kHz) was applied for 28 days to one group. The nonstimulated group (n = 17) underwent a 28-day period with no stimulation. From each group, four tibiae were prepared for histology; both ends of the remaining bones were embedded in polymethylmethacrylate and tested in torsion (internal rotation at 4.7 degrees/sec) until failure. Statistically significant changes included a 37% lower maximum torque capacity and a 40% decrease in strain energy to failure in the stimulated group compared with the nonstimulated group. The findings are supported by measured trends to a lower modulus of rigidity (37% decrease) and a smaller percentage of active osteoid perimeter (20% decrease) for the stimulated group. The experimental data suggest that when this dose of capacitive coupled electrical stimulation is applied to the regenerating bone created during distraction osteogenesis, it delays the recovery of bone strength compared with an untreated control.

Animals↗