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PubMed2002

[Morphogenic processes in dosed distraction].

Dosed distraction of bone regenerate is paralleled by distraction of soft tissues (skin, muscles, nerves, etc.), which is particularly obvious during liquidation of medium-sized and extensive mandibular defects. Such distraction of soft tissues leads to their regeneration and growth. However regeneration of soft tissues is paralleled by dystrophic processes, which are never observed in bone regenerate. Dosed distraction can be used in repair of combined bone and soft tissue defects and deformations of the face of different etiology.

Bone Morphogenetic Proteins↗
PubMed1999

Accelerating bone formation and earlier healing after using demineralized bone matrix for limb lengthening in rabbits.

We studied the effects of grafting with demineralized bone matrix during lengthening of the tibia in young Japanese White rabbits. The demineralized bone matrix was made from frozen cortical bone harvested from other rabbits. A 5-mm gap was created in the tibial diaphysis by a subperiosteal osteotomy; a maximum of 20 mm (2-3 mm/day) of tibial lengthening was reached in a week with use of an external fixator. The control group of 20 rabbits did not receive an implant; the group of 21 experimental rabbits received an implant of demineralized bone matrix in the surgical gap. The control group failed to demonstrate radiographic callus 5 weeks after surgery, and nonunion was persistent after 1 year. In the group with demineralized bone matrix, new radiodensity was demonstrated within the lengthening gap at 3 weeks, with a gradual increase in bone density to 85% that of the intact tibia after 12 weeks. Bone union was seen within 1 year for all experimental animals for whom the external fixator was removed 8 weeks after the procedure. These bones showed normal bone structure histologically. The lengthening was carried out at a rapid distraction rate of 2-3 mm/day; therefore, this method allows for satisfactory bone formation at a faster rate than normal.

Absorptiometry, Photon↗
PubMed1998

Midfacial advancement by bone distraction for treatment of craniofacial deformities.

Craniofaciostenosis is often associated with midfacial hypoplasia and has been treated traditionally using Le Fort advancement osteotomies and bone grafts. The surgical procedure requires a prolonged operating time, several osteotomies with a significant blood loss, and wide surgical exposure. According to the principles of bone lengthening, we performed midfacial advancement by bone distraction in 4 patients with midfacial hypoplasia to reduce the operative time and complication rate. In 2 patients with Crouzon's syndrome we performed a Le Fort III osteotomy and placed the distraction device behind the malar eminence and screwed it on the temporal bone bilaterally. In the other 2 children, with Apert's syndrome, we performed frontal advancement and remodeling before placing the device during the same surgery behind the malar bone without any midfacial osteotomy. It appears to us that patients with more severe deformities will need surgical procedures to offer more satisfactory results. In these patients, distraction is an initial therapy to reduce the severity of the deformity, making it possible to effect a better treatment afterward.

Acrocephalosyndactylia↗
PubMed2000

Internal craniofacial distraction with biodegradable devices: early stabilization and protected bone regeneration.

Internal craniofacial distraction has several advantages over distraction with external devices. The scars may be less conspicuous; the devices are buried and therefore easier for patients to tolerate; and the devices are more rigidly secured to bone, preventing uncontrolled rotation of the advancing segments. There are several types of internal devices. The Modular Internal Distraction System developed by one of the authors (S.R.C.) and Stryker-Leibinger, Inc. has had widespread use for midface distraction, but requires a substantial surgical procedure for device removal. This is justified in selected children with syndromic craniosynostosis, who frequently need secondary orbitocranial reconstruction at the conclusion of distraction with any type of device. It would be preferable to develop a device that would retain the positive characteristics of the Modular Internal Distraction system, while allowing easy removability. Moreover, the entire distraction procedure would benefit from a technique that would assist in bone regeneration within the distraction gap. Such a biodegradable, stabilizing device may enable early explanation, accelerating the recovery period, while providing fixation of the distraction gap and protected bone regeneration. Accordingly, we have developed a new, biodegradable distraction device with Macropore, Inc. that may be used with the Modular Internal Distraction system to permit easy removability of the device without the need for a large operation for exposure. Second, we have developed a biodegradable stabilizer that permits earlier removal of the distraction device while providing simultaneous fixation and protected bone regeneration. Last, we have demonstrated the feasibility of midcourse correction of the distraction procedure, should this be necessary for whatever reason.

Absorbable Implants↗
PubMed2004

Fronto-orbital advancement with simultaneous LeFort III-distraction.

BACKGROUND: Patients with pronounced forms of craniosynostosis often suffer from hypoplasia of the facial skeleton. Different techniques have been described to correct these malformations consisting mainly of a standardised fronto-orbital advancement to correct the neurocranium followed by a conventional LeFort III-osteotomy for the correction of the viscerocranium several months later. METHOD AND PATIENTS: In order to optimise treatment, these techniques were confined into a one step procedure. This comprised a standard fronto-orbital advancement and a simultaneous LeFort III-osteotomy, followed by distraction of the facial skeleton 7 days later using a rigid external distractor (RED). RESULTS: Six patients have been treated with excellent functional and cosmetic results and a high rate of patients' satisfaction. Postoperatively, one patient suffered from rhinorrhoea necessitating revision of the base of the skull 7 days later. In a second patient, the RED distractor could not be fixed due to insufficient ossification of the skull 6 months after subtotal craniectomy. In another patient, partial necrosis of the calvarial skin occurred. No other significant adverse events occurred. DISCUSSION: Upto today the LeFort III advancement plus fronto-orbital advancement were always performed intraoperatively in one single step. When applying the distraction technique, the viscerocranium can be transposed much further than by conventional techniques. Beside this, using the external RED distractor, the distraction vector can be modified and adjusted according to clinical progress postoperatively. In addition, the time gap between the operation and start of distraction allows the soft tissues to reattach, probably reducing the risk of ascending infections. CONCLUSION: The combination of fronto-orbital advancement and LeFort III advancement by distraction can optimise the clinical outcome and lower the risk of ascending infections.

Bone Plates↗
PubMed1999

Application of ultrasound in callus distraction of the hypoplastic mandible: an additional method for the follow-up.

Mandibular callus distraction was performed on 14 patients. In addition to established radiological methods, sonography was performed to monitor the clinical progress. Ultrasound shows a precise picture of all interesting items in distraction treatment. Although the value of radiographs is not obsolete completely, sonography was found to be a meaningful supplement in the clinical monitoring of callus distraction. Furthermore the method is capable of early recognition of complications and it can reduce X-ray exposure.

Adolescent↗
PubMed2002

Effects of traction, distension, and joint position on distraction of the hip joint: an experimental study in cadavers.

PURPOSE: To quantify the effects of traction alone and in combination with distension of air in different joint positions in order to find out the conditions for adequate distraction of the hip joint with minimal traction force. TYPE OF STUDY: Experimental cadaver study. METHODS: Eight cadaver hip joints were studied. The cadavers were placed supine on a fracture table and traction was applied in different joint positions for flexion and abduction with and without distension using air. For the measurement, the joint space between the acetabulum and femoral head was separated by 4 different lines characterizing the lateral margin of the acetabulum, the superior portions of the lunate cartilage, and the acetabular fossa. RESULTS: At all measurement lines, distraction of the hip was significantly better when traction and distension were combined. At traction forces from 250 to 300 N, traction plus distension resulted in a 1.59- to 2.25-fold increase of joint distraction compared to traction alone. The maximum effect of distension was achieved between 200 and 250 N. Up to traction forces of 250 N, the joint vacuum force counted for more than half of the total resistance. The effects of flexion and abduction on distraction of the hip were smaller. A trend for better distraction was found for 20 degrees of flexion and a significantly better distraction by avoiding abduction. CONCLUSIONS: High traction forces by breakage of the joint seal can be avoided by distension using air. The passive resistance of the soft tissues increases at higher traction forces. Slight flexion without abduction showed further increase of joint distraction. Reducing the amount of traction may possibly reduce the risk of soft tissue perineal and neurologic injuries.

Adult↗
PubMedDate not supplied

Long-term results of lower limb lengthening by physeal distraction.

Of the many methods of limb elongation, lengthening by physeal distraction is among the newest. The goal of this study was to estimate the long-term results of femoral and tibial lengthening by epiphyseal distraction. The authors examined 40 patients who underwent 24 femoral and 16 tibial lengthenings. The average follow-up period was 9.6 years. An average of 4.6 cm of femoral lengthening and 4.7 cm of tibial lengthening was achieved. The femoral healing index was 38.1 days/cm and the tibial healing index was 35.7 days/cm. After lengthening the epiphyseal cartilage started to function in all patients, and premature growth cartilage fusion was not observed during follow-up. Complications occurred in eight patients during femoral lengthening and in four during tibial lengthening. The authors suggest that physeal distraction is a good method for moderate and simple limb lengthening. Particular care should be applied to knee joint function, especially during femoral lengthening.

Adolescent↗
PubMed1998

The morphological basis of increased stiffness of rabbit tibialis anterior muscles during surgical limb-lengthening.

When the tibialis anterior muscle of the rabbit is progressively stretched during surgical limb distraction, the muscle fibres lengthen by addition of new serial sarcomeres, provided that stretch is carried out at an appropriate rate. However, in spite of the apparent adaptation to the new functional length, range of joint movement is greatly decreased. In this study we have first, made measurements of the passive tension developed by distracted muscles over the range of joint movement and secondly made quantitative measurements of endomysial and perimysial connective tissue content. It was found that at all ankle joint angles greater than 90 degrees, the passive tension developed by the distracted muscles was greater than both contralateral and sham-operated controls. Image analysis showed that the ratio of collagen to contractile material was increased in distracted muscles compared with muscles from sham-operated controls, due to increased deposition of collagen type III. Scanning electron microscopy showed the presence of a dense perimysial weave surrounding the distracted muscle fibres. These quantitative and qualitative changes in the connective tissue component could account for the increased stiffness demonstrated by the physiological measurements. It would seem that in distracted muscle the connective tissue element adapts less readily than the contractile component, with prolonged stretch leading to damage to the perimysial and endomysial network, with subsequent fibrosis and loss of muscle compliance. Such changes could help explain the loss of range of movement noted in the distracted limbs of patients undergoing surgical limb-lengthening and in other conditions that result in muscle contractures.

Adaptation, Physiological↗
PubMed2002

The transgingival approach for placement of distraction implants.

PURPOSE: Since 1997, distraction implants have been clinically used for alveolar ridge distraction and, later, for prosthetic treatment. While 63 patients have been treated by the authors by alveolar ridge distraction with distraction implants with an open approach, the aim of this study was to demonstrate a minimally invasive technique of distractor placement via a transgingival approach. PATIENTS AND METHODS: Twelve patients were treated with a modified surgical incision using distraction implants. A tissue punch was used to remove transgingival mucosa, and a segmental osteotomy was performed using a vestibular incision. The distracted segment was pedicled at the lingual and crestal mucoperiosteum. Distraction was carried out for 0.5 mm per day, divided into 2 to 4 turns per day. A distraction of 5 to 7 mm was performed. At the end of distraction, the distraction insert was changed into a definitive stable implant insert. Prosthetic treatment was performed 4 months after the distraction period with fixed superstructures. The follow-up was performed with the aid of dental radiographs, evaluation of peri-implant probing depths, and Periotest values (Siemans, Bensheim, Germany). RESULTS: The outcome of this technique showed minimal scarring of the gingiva with good aesthetic results, the clinical and radiologic findings were satisfying, and the Periotest values were negative at every examination. The rate of complications was low. CONCLUSION: Minimal scarring and good aesthetic and functional outcome resulted in patients with alveolar ridge distraction performed with a transgingival approach.

Alveolar Bone Loss↗
PubMed2001

Changes in the temporomandibular joint after mandibular lengthening with different rates of distraction.

This study assessed the changes in the condyle after mandibular lengthening with 2 different rates of distraction (1 mm/day and 2 mm/day). Unilateral mandibular distraction was performed in 8 young adult goats. The animals were sacrificed 8 weeks after the completion of distraction, and the temporomandibular joint (TMJ) specimens were harvested and processed for histologic examination and histomorphometric analysis. Adaptive changes in the condyle were observed in the goats distracted at a rate of 1 mm/day, whereas degenerative alterations were found in those distracted at a rate of 2 mm/day. This study suggests that the TMJ is able to withstand the impact of distraction at a rate of 1 mm/day, but more rapid distraction may induce degeneration in the condylar cartilage.

Animals↗
PubMed2004

Mandibular distraction: surgical refinements and long-term results.

Mandibular distraction is the treatment of choice for the surgical correction of mandibular hypoplasia. It is a less invasive and time-intensive technique and has a significantly decreased morbidity rate. The author's experience of lengthening mandibles for the past 12 years has shown that when the mandibular hypoplasia is more severe, better results will be obtained in the long term with earlier treatment. Orthodontics plays a very important role in correcting post-distraction occlusal changes and promoting balanced growth. The simultaneous expansion of the overlying soft tissues is the major advantage of this technique when it is compared with conventional osteotomies.

Adult↗
PubMed2004

The influence of cyclic compression and distraction on the healing of experimental tibial fractures.

Interfragmentary displacement has a main effect on callus formation in fracture healing. To test whether compressive or distractive displacements have a more pronounced effect on new bone formation, a sheep osteotomy model was created whereby the gap tissue was subjected to constant bending displacement. A diaphyseal osteotomy with a gap of 2 mm was created in 18 sheep tibiae and stabilized with a special unilateral actuator-driven external fixator. Two experimental groups with six sheep each received either 10 or 1000 cycles evenly distributed over 24 h. The third group of six sheep served as a control group without actively induced displacement. The amount and direction of cyclic displacement was kept constant throughout the observation period, resulting in 50% compressive and 50% distractive displacement within the osteotomy gap. At sacrifice, six weeks after surgery, bending stiffness was measured and new bone formation was assessed radiologically and microradiographically. In all cycled groups, the amount of periosteal callus formation was up to 25 times greater on the compression compared to the distraction side (p < 0.001). The application of the higher number of daily cycles resulted in an up to 10-fold greater amount of periosteal new bone formation on the compression side (p < 0.012), while the difference on the distraction side was not significant. Ten cycles applied a day were sufficient to create an abundant periosteal callus on the compression side. In the 1000 cycle group, bending stiffness revealed slightly lower values but the difference was not significant. Solid periosteal bridging of the gap was observed in two sheep in the control group, whereas bridging in the cycled groups was observed exclusively at the medullary side. In conclusion, cyclic compressive displacements were found to be superior over distractive displacements. A higher number of enforced and maintained compressive displacements enhanced periosteal callus formation but did not allow bony bridging of the gap.

Animals↗
PubMed2000

Three-dimensional planning of alveolar ridge distraction by means of distraction implants.

OBJECTIVE: In recent years, three-dimensional (3D) CT-based planning methods have increasingly been implemented in oral and maxillofacial surgery. Alveolar ridge distraction is accomplished by unidirectional distraction devices which in turn must be positioned optimally in all three dimensions. It is the aim of this study to demonstrate 3D planning of alveolar ridge distraction by means of distraction implants. PATIENTS AND METHODS: In 1997, nine patients were treated with distraction implants for a deficient alveolar ridge. A CT-scan-based 3D milled model of the facial skull was prepared for each patient to enable preoperative diagnosis and operative planning. RESULTS: Exact preoperative diagnosis of the alveolar ridge defect and atrophy was enabled by the 3D polyurethane model. Correct positioning of the distraction implants and predictability of the course of distraction was facilitated by preoperative planning according to the 3D model. CONCLUSION: Three-dimensional planning according to a milled model is an indispensable aid to positioning of distraction implants and therefore to directed augmentation of the alveolar ridge. Correct distractor positioning is vital for optimal subsequent prosthetic treatment.

Adult↗
PubMed2004

Improved comfort in lower limb lengthening with the intramedullary skeletal kinetic distractor. Principles and preliminary clinical experiences.

INTRODUCTION: Limb lengthening by external fixators is associated with many problems such as pain at the pin tracts, muscle transfixation, pin tract infections, reduced joint motion, and prolonged fixation time. The intramedullary skeletal kinetic distractor (ISKD) is a new internal, mechanically activated implant, which distracts by mild rotations of 3 degrees. MATERIAL AND METHODS: In a prospective clinical study, four patients with an mean age of 29 years (18-36 years) underwent intramedullary lengthening via ISKD. The average lengthening of three femora and one tibia was 31 mm (26-40 mm). RESULTS: All patients performed the rotations for the distraction themselves without any significant problems. One patient took mild analgesics during the first days of distraction, whereas three patients did not require any analgesics. The average patient discharge occurred 10 days (8-11 days) postoperatively with no complications during the hospital stay. The planned length of distraction was achieved in all patients with normal alignment and normal joint orientation. Full weight bearing was performed on average after 10 weeks (7-14 weeks). Consolidation was noted 80 days (51-111 days) postoperatively with an average consolidation index of 2.9 days/mm. No complications were observed during the follow-up period of 14 months. The Enneking score was 26.8 points, and according to the classification of Paley all patients had an excellent result. CONCLUSIONS: From these preliminary results we conclude that the comfort of limb lengthening with the ISKD is increased by the elimination of fixator-associated complications and by the simple distraction mechanism, which is well tolerated by the patients. Further advantages of the ISKD are early full weight bearing and excellent limb function.

Adolescent↗
PubMed1998

[An experimental study of a new bidirectional distraction appliance].

The goals of mandibular distraction are to restore a normal length but also a normal shape to the hypoplastic mandible. These two goals are related to the elongation vector which is itself related to the location of the cortictomy and of the device. Other factors influence this elongation vector. So it is impossible to precisely predict the elongation vector. With the monodirectional distraction device no modification can be made during the distraction time. With a bidirectional distraction device offering the possibility to modulate the angulation between the two elongation rods it is possible to adjust the elongation vector during distraction. Precise distraction gap modeling is possible. This is particularly important to correct anterior open-bite. This device was tested on animals (pigs).

Animals↗