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PubMed2004

To distract or not to distract: an algorithm for airway management in isolated Pierre Robin sequence.

Approaches advocated for treatment of airway obstruction among neonates with Pierre Robin sequence include positioning, tongue-lip adhesion, mandibular distraction, and tracheostomy, with no established guidelines regarding which modality is appropriate for a specific patient. This report proposes an algorithm for the management of neonatal upper airway obstruction among patients with isolated Pierre Robin sequence. Data for 21 patients with isolated Pierre Robin sequence who were treated by one surgeon during a 9-year period were reviewed. Eighteen patients presented during the first 1 week of life and three patients presented late, between 12 and 33 months of age. Follow-up periods ranged from 9 to 70 months (median, 33 months). Successful airway management was achieved with positioning alone for 10 patients, with tongue-lip adhesion for seven of nine patients, with tracheostomy for two patients, and with mandibular distraction for three patients. Changes in the maxillary-mandibular discrepancy were significant with natural mandibular growth during the first 1 year of life (p < 0.0001). Oromotor studies performed 3 months or more after tongue-lip adhesion reversal (n = 9) demonstrated no appreciable deficits in tongue function, relative to other children with cleft lips/palates. A multidisciplinary team should evaluate all patients with isolated Pierre Robin sequence, to fully assess the maxillary-mandibular relationship, anatomically define the site of airway obstruction, and identify feeding difficulties. Patients should be evaluated for episodes of desaturation occurring spontaneously, during feeding, or during sleeping. Patients with desaturation should be further evaluated with double endoscopy (nasoendoscopy and bronchoscopy). If the airway obstruction is localized to the tongue base alone and cannot be controlled with positioning, then tongue-lip adhesion is the initial treatment of choice, because such patients demonstrate significant mandibular growth during the first 1 year of life. Mandibular distraction among neonates is reserved for failures of tongue-lip adhesion in which isolated tongue-base airway obstruction is documented. Neither of the patients who experienced failure of tongue-lip adhesion in this series would have been a candidate for distraction with the algorithm presented. Avoiding routine neonatal distraction serves to avoid facial scarring, nerve and tooth bud injury, and potential disturbances of intrinsic mandibular growth. Patients with persistent respiratory difficulties beyond age 9 months require reevaluation for multiple sites of airway obstruction. Mandibular distraction may be one of several modalities required to avoid tracheostomy for such patients.

Algorithms↗
PubMed1998

Brachymetatarsia: congenitally short third and fourth metatarsals treated by distraction lengthening--a case report and literature summary.

Brachymetatarsia is an uncommon condition, and when present, it is usually asymptomatic. A case report demonstrating the use of distraction lengthening for symptomatic multiple congenital short metatarsals is presented. A 15-year-old female with congenital short third and fourth metatarsals was treated for painful transfer lesions under the second and fifth metatarsal heads and a secondary hallux valgus deformity. Surgical correction with a chevron osteotomy, soft tissue reconstruction of the second toe, and distraction lengthening of the third and fourth metatarsals was performed. Three years after treatment, the patient has an excellent clinical correction, with no evidence of recurrent transfer lesions. To our knowledge, this is the first report demonstrating the use of distraction lengthening without supplemental bone graft for multiple short metatarsals in a single extremity.

Abnormalities, Multiple↗
PubMed1999

Unilateral tibial hemimelia with leg length inequality and varus foot: external fixator treatment.

A 15-year-old girl with type II unilateral hemimelia presented with a 13.5-cm shortening of her right leg, absence of the distal half of the tibia, tibiofibular synostosis, and medial dislocation of a cavus and varus foot. She was treated by means of an external fixator. The shortening was significantly corrected, and realignment of the foot with the limb was achieved. An arthrodesis of the talus and lower end of the fibula was carried out operatively and stabilized with an external fixator. In the same surgical procedure, we performed an osteotomy of the tibiofibular synostosis, and progressive distraction was done with another external fixator. We emphasize the advantages of progressive distraction for the correction of congenital deformities of the limbs.

Adolescent↗
PubMed2006

Condylar mineralization following mandibular distraction in rats.

The impact of mandibular distraction on condyles is poorly understood. To examine how condylar mineralization is affected, we performed distraction in 128 one-month-old rapidly and 126 three-month-old slowly growing rats. The rate of distraction was 0.0 mm (sham), 0.2 mm (slow), 0.4 mm (moderate), or 0.6 mm (rapid). From 7 to 9 rats from each rate (n = 29-32) were killed at 4 time periods (D6, D10, D24, and D38) following osteotomy. Calcein and alizarin were injected 6 and 3 days, respectively, prior to death. Methacrylate-embedded sagittal condylar sections were examined under epifluorescence, and mineral apposition rates were measured. Results indicated that: (1) rapidly growing rats showed higher mineral apposition rates (p < 0.01-0.001) than did slowly growing rats; (2) mineral apposition rates were lower in distracted sides at all times in rapidly growing rats (p < 0.05-0.01), while this side-dependency was seen only at D24 in slowly growing rats (p < 0.05); and (3) distraction rates had little effect on mineral apposition rates. Thus, mandibular distraction decreases condylar mineral apposition rates, but only in rapidly growing rats, which is related to surgery and its functional consequences, not to the distraction rate.

Analysis of Variance↗
PubMed2002

[Osteo-distractive technique for bony repair of cleft palate in a dog model].

OBJECTIVE: To investigate the possibility of closing bony palatal cleft and lengthening hard palate. METHODS: Ten 6-month mongrel dogs were divided into three groups: the control(n = 2), sham control (n = 2) and the experimental group(n = 6). An 8 mm x 25 mm posterior hard palatal cleft was made surgically by bilateral and anterior osteotomies of the palate in six experimental dogs. After a 5-day latency period, a distraction device made of NiTi-shape memory alloy was placed in position for continuous extension of the hard palate. Each distractor was kept in place for 8 weeks after the cleft was closed. RESULTS: The posterior cleft was closed in 2-3 weeks period of the distraction, while the anterior cleft was narrowed to 1-2 mm in width. The hard palate was lengthened backward obviously. The new bone was observed in the area after the distraction. CONCLUSION: The above-mentioned technique may be an effective technique for bony repair of the cleft palate.

Animals↗
PubMed2005

[Morpho-functional characteristic of dog spinal ganglion neurons in post-distraction period].

The object of this work was to study the morpho-functional state of spinal ganglion neurons and to conduct the comparative quantitative analysis of the changes of neuronglial relations after hindlimb elongation in mongrel dogs by 14-16% of its initial length using different elongation rates. The longitudinal 5 microm thick serial sections of L(VI), L(VII) and S(I) ganglia stained with Nissl's thionine and cresyl violet and Einarssons's gallocyanin-chrome alume were studied. By days 45-48 of an experiment the reversible changes in the structure of some part of neurons were demonstrated, which included cytoplasmic and nuclear hyperchromatism, peripheral chromatolysis, nuclear and nucleolar dislocation, increase in the number of peri- and interneuronal gliocytes. The changes were most marked in the ganglia ipsilateral to the lengthening side with distraction rate of 3 mm per day; they were minimal contralaterally with the lengthening rate of 1 mm per day.

Animals↗
PubMed1997

[Distraction of the maxilla].

The distraction of the maxilla provides very useful possibilities in young children with unstable articulation and in infants in order to avoid excessively radical operations. The principles of the distraction are reviewed. The authors report 13 clinical cases and complications. The material needs to be perfected, as numerous incidents are still observed.

Child↗
PubMed2005

[Frequency and severity of callus defects. Dorsomedial vs ventrolateral approach for corticotomy in performing callus distraction of the tibia].

BACKGROUND: The purpose of this study was to compare a dorsomedial to the ventrolateral approach for corticotomy in performing callus distraction of the proximal metaphyseal tibia. PATIENTS AND METHODS: A total of 31 callus distractions were performed in 28 humans. The ventrolateral approach was used for 18 and the dorsomedial approach for 13 corticotomies. A scale of four severity grades was used to classify callus defect zones based on their extent as evidenced on serial X-rays. Biopsies were taken from higher-grade defects (grades 3-4). RESULTS: A total of 13 radiological evaluations revealed 12 defects using the ventrolateral approach. Seven defects (grades 1-2) healed spontaneously, whereas six defects (grades 3-4) required operative intervention as histological tissue examination showed no osteogenic potential. CONCLUSION: To prevent callus defects of the proximal tibia in the future and to ensure maximal osteogenic potential in the distraction zone, a minimally invasive dorsomedial approach appears to achieve favorable results.

Adolescent↗
PubMed2005

Trabecular organization in mandibular osteodistraction in growing and maturing rats.

PURPOSE: Our goal was to investigate the trabecular organization of the distraction regenerate during various consolidation phases and as a result of various distraction rates. MATERIALS AND METHODS: One hundred ninety-two growing and maturing rats (96 each) received unilateral mandibular osteotomies and distraction device placement. They were randomly allocated into 4 distraction rate groups (0, 0.2, 0.4, and 0.6 mm/day for 5 days) after a 3-day latency. Eight rats from each rate group were sacrificed at early (10 days), mid (24 days) and late (38 days) consolidation time points. Harvested hemimandibles were embedded in micro-bed resin, sectioned sagittally at 10 mum thickness and stained using the Von Kossa method. The histologic images were captured and processed using Adobe Photoshop (Version 7.0; Adobe Systems Inc, San Jose, CA). Custom-made software (MacAzimuth; written by Prof. J.M. Rensberger, University of Washington) was further used to analyze the orientation (anisotropy and angle distribution) and mass (density and thickness) of trabecular structures in the regenerates. RESULTS: Trabecular orientation significantly differed at the mid-consolidation time point with less anisotropy ( P < or = .000 to .023) and narrower angular distribution ( P < or = .007 to .021). Trabecular mass increased significantly from early to mid-consolidation ( P < or = .000 to .002). Growing rats showed greater trabecular organization than maturing rats did at the same time points ( P < or = .000 to .009). The trabecular organization parameters were associated significantly with bone mineral density and microdensity ( P < or = .000 to .044). CONCLUSION: The peak change in orientation occurred around the mid-consolidation with a greater increase in trabecular mass. Growing rats showed a greater capacity for trabecular organization at earlier time points. However, distraction rate did not have an effect on trabecular organization. These results suggest that trabecular organization can be used as an important indicator to evaluate bone maturation and quality in the distraction regenerate.

Age Factors↗
PubMed2005

A new Le Fort I internal distraction device in the treatment of severe maxillary hypoplasia.

PURPOSE: The purpose of this pilot study was to test a new Le Fort I internal distraction device. PATIENTS AND METHODS: A new internal Le Fort I distraction device designed by 1 of the authors was used in 3 patients with cleft lip and palate and severe maxillary hypoplasia who needed maxillary advancements in excess of 12 mm. Presurgical planning used CASSOS (SoftEnable Technology, Ltd, Hong Kong SAR, China) prediction tracing software and a stereolithographic model to calculate the distraction vector. The distractors were pre-bent and installed on the stereolithographic model and activated to advance the maxilla. Surgery was performed in a conventional manner, and distraction was started after a 7-day latency phase at the rate of 1 mm/day and continued until the presurgical plan was achieved. The distractor was removed after a 3-month consolidation phase. Cephalometric radiographs were taken at the completion of each phase. RESULTS: This new Le Fort I internal distraction device successfully distracted the maxillae as planned in all 3 patients. At the end of the distraction phase, the maxillary advancement was measured at 15.8 mm, 15.8 mm, and 13.5 mm, respectively. In each patient, a clockwise rotation of the maxilla was observed with a tendency to a posterior open bite. Postoperative radiographs also showed that the actual distraction vectors differed from the planned vectors. After the consolidation phase, radiographs showed a relapse of 2.6 mm, 0 mm, and 5.0 mm, respectively. There was no further relapse on 3-month follow-up radiographs. Each case showed radiographic evidence of excellent new bone formation at the osteotomy sites. CONCLUSION: The new Le Fort I internal distraction device produced the necessary advancement in all 3 patients. The study also showed that the actual distraction vector differed from the planned vector. This discrepancy was caused by a clockwise rotation of the maxilla during the distraction. Finally, the study showed a variable relapse rate not previously reported in maxillary distraction.

Adolescent↗
PubMed2003

Radiologic characterization of new bone generated from distraction after maxillary bone transport.

OBJECTIVE: The purpose of this study was to characterize the radiologic features of the new bone generated from distraction following maxillary bone transport. STUDY DESIGN: Maxillary dentoalveolar segments were transported by distraction to close posterior maxillectomy defects in 9 rhesus monkeys. The distracted dentoalveoli were harvested at 1, 2, 3, and 6 months after the completion of the distraction. The specimens were evaluated by plain radiography and microcomputerized tomography scanning, which included 2- and 3-dimensional quantitative analyses of bone regeneration volume and microstructural indices. RESULTS: Plain radiographs showed that radiolucency in the distraction regenerate reduced with time. Microcomputerized scanning found that bone formation and trabecular thickness increased in the new bone with longer consolidation. The high orientation and connectivity of the trabeculae were reduced at longer consolidation intervals. Within the whole distraction gap, bone volume was found to be site-specific. CONCLUSION: Morphologic analysis in the high resolution offered by microcomputerized tomography shows that active bone mineralization and remodeling occur in the new bone within 3 months after distraction in maxillary dentoalveolus.

Alveolar Process↗
PubMed2001

Positional changes and stability of bone segments during simultaneous bilateral mandibular lengthening and widening by distraction.

The purpose of this study was to analyse the skeletal changes and stability of the distracted segments during and after simultaneous widening and bilateral lengthening of the mandible in baboons with a miniaturized intraoral bone-borne osteodistractor. Distraction appliances were activated 5 days after vertical posterior body and midsymphyseal osteotomies at a rate of 0.9 mm/day for 10 days. The appliances were then stabilized for a period of 8 weeks, after which the animals were killed. The distraction gaps and gingival tissues were studied clinically and on standardized radiographs. The proportional movement of the distracted segments that we found supports the clinical use of the miniaturized intraoral bone-borne distraction appliance to widen and lengthen the mandible selectively. It also supports the concept of positioning the mandibular osteodistractors parallel to the common vector of distraction, which should parallel the corrected maxillary occlusal plane.

Animals↗
PubMedDate not supplied

[Controlled distraction as a therapeutic option in moderate degeneration of the intervertebral disc -- an in vivo study in the rabbit-spine model].

AIM: The aim of this study was to investigate the effects of temporary distraction on a degenerated intervertebral disc to characterize regenerative changes associated with disc distraction. METHOD: New Zealand white rabbits (n = 32) were used for this experimental animal study. The rabbits were randomly assigned to one of five groups. 6 animals were loaded for 28 days using a custom-made external loading device to stimulate disc degeneration (G2). In 6 animals the discs were first loaded for 28 days and after 28 days loading time the discs in six animals were treated as dynamic distraction with an external distraction device (G1). In six animals the discs were distracted for 28 days without previous loading (G5) and in six animals the discs were loaded for 28 days and afterwards the loading device was removed for 28 days for recovery without distraction (G3). Six animals were sham operated (G4) without application of axial load. After 28 to 56 days loading and distraction time, the animals were sacrificed and the lumbar spine was harvested for histological and radiographic analysis. Histology was performed according to a degeneration score and disc height was calculated radiographically. For the cell viability examination, the number of apoptotic cells was determined. RESULTS: After 28 days of loading (G2), the discs showed a significant decrease in disc space of the treated segment. Histologically, a disorganization of the architecture of the annulus occurred. The number of dead cells increased significantly in the annulus and cartilage endplate. These changes were reversible after 28 days of distraction (G1). The disc thickness increased significantly to physiological levels as compared to the specimens from the 28 days loading group without distraction. Histologically, the discs showed signs of tissue regeneration after 28 days of distraction (G1). The number of apoptotic cells decreased significantly in comparison to the loaded discs without distraction (G2). CONCLUSION: The results of this study suggest that disc regeneration can be induced by axial dynamic distraction in the moderately degenerated rabbit intervertebral disc. The decompressed rabbit intervertebral discs showed signs of tissue recovery at the cellular and histological levels after temporary disc distraction.

Animals↗
PubMed2005

Long-term skeletal and dental changes in patients with cleft lip and palate after maxillary distraction: a report of three cases treated with a rigid external distraction device.

We examined long-term skeletal and dental changes in three patients with cleft lip and palate who underwent maxillary distraction using a rigid external distraction device. Two were children, and one was an adult. Changes in the overjet (OJ), overbite (OB), and positions of the anterior nasal spine (ANS), upper incisors (U1), pogonion (Pog), and lower incisors (L1) were measured on preoperative to 36 months postoperative lateral-cephalograms. In the adult, the positions of all examination points were relatively stable from 6 to 36 months postoperatively, and the OJ and OB were maintained at over 2 mm at 36 months. In the children, the positions of ANS and U1 changed inferiorly, Pog and L1 changed anteroinferiorly, and OJ and OB tended to decrease from 6 to 36 months postoperatively. Long-term skeletal and dental stability following maxillary distraction was relatively well maintained in the adult patient. In the children, the maxillomandibular growth was observed after maxillary distraction, but the mandibular overgrowth might have been inhibited by the correction of class III dentoskeletal deformity resulting from the maxillary distraction.

Adult↗
PubMed2002

The treatment of infected tibial nonunion with aggressive debridement and internal bone transport.

Tibial nonunions are a challenging situation for both healing and reconstruction when infection is added. In this retrospective study, we discuss the cases in which we had managed to obtain union by aggressive debridement, circular external fixature, and internal bone transport. Fourteen cases had been treated between January 1995 and December 2000 in the Orthopedics and Traumatology Department of the Gulhane Military Medical Academy. The mean follow-up period was 33.2 (12-60 months) months. The mean length of defects was 4.4 (2.5-8 cm) cm. These defects were repaired by corticotomy and by internal bone transport only. Pseudoarthrosis and union of corticotomy sites occurred in a mean period of 6.8 (4.5-15) months. In two of our patients, reinfection occurred, and hyperbaric oxygen therapy was applied to them. We concluded that in tibial infected nonunions, satisfactory union and control of infection are possible by radical debridement, stable fixation by circular external fixature, osteotomy and callus distraction, antibiotic therapy, and hyperbaric oxygen therapy whenever needed.

Adult↗
PubMed1999

Midface surgery from Tessier to distraction.

The wall separating the face and the cranium was broken by Paul Tessier and Gérard Guiot in the 1960s, making it possible to perform a combined operation around the orbits and forehead, and opening up close cooperation between plastic surgeons and neurosurgeons, especially for treatment of the major malformations such as hypertelorism of major facial retrusions. The principles of mobilization of the orbits to correct teleorbitism or orbital dystopia are recalled with reference to the different variations and with clinical examples. Facial advancement to correct the retrusions created by faciocraniosynostosis is explained with the many possible variants, combined with a intracranial approach or not, with or without a bipartition. The indications are discussed as is the risk linked to combined advancement of face and forehead. The progressive bone elongation principle introduced by Ilizarov for the limbs has been applied to the face at the mandibular level by McCarthy, with great success. The distraction of bone structures is now also applied at the level of the midface and makes it possible to overcome the retraction of soft tissues and lower the risk of relapse of facial retrusion. Many technical problems have still to be solved, but the results are already very promising. Many other applications of the distraction principle will be developed for the midface level, with other technical improvements such as the use of absorbable mini-plates and screws.

Craniofacial Abnormalities↗
PubMedDate not supplied

Radius lengthening for the treatment of Bayne and Klug type II and type III radial longitudinal deficiency.

PURPOSE: We performed radius lengthening to treat radial deviation of the wrist in patients with Bayne and Klug type II and type III radial longitudinal deficiencies. The purpose of this investigation was to review our results of radius lengthening for radial longitudinal deficiency. METHODS: Beginning in 1991 radius lengthening was performed to treat 4 patients with radial longitudinal deficiency whose mean age at the initial lengthening was 16 months. The corrections for radial deviation of the wrists were performed simultaneously by soft-tissue distraction of the wrist. According to Bayne and Klug's classification 2 patients had type II and 2 patients had type III deficiencies. All but 1 patient had lengthening several times to correct the recurring discrepancy between the radius and the ulna. RESULTS: The corrections were achieved just after the lengthening but deformities recurred because of growth discrepancies between the radius and the ulna as the children grew. The radius was lengthened by a mean of 28 mm, with a mean length gain of 79%. The mean period in the fixator was 136 days. Two patients had both functionally and cosmetically acceptable correction after several lengthening procedures. In the other patient we abandoned this treatment method because of severe bone absorption at the distal end of the lengthened radius. One patient died of cardiac disease after one lengthening. CONCLUSIONS: Radius lengthening for Bayne and Klug type II and type III deficiencies may be accomplished successfully with the primary benefit of maintaining wrist and forearm motion. It is likely that at least 3 lengthenings may be required and this may need to be accompanied by a soft-tissue distraction at the ulnar carpal joint as well. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Child, Preschool↗