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PubMed2005

[Experimental histological study of the articular cartilage of the external femoral condyle in tibial elongation in dogs].

The tibia was elongated in 18 adult mongrel dogs with the rate of 1 mm per day produced with 60 increments (1st series, autodistraction) or 8 increments (2nd series, manual distraction). On completion of 28 days of distraction, followed by 30 days of fixation and 30 days without the fixator, the articular cartilage of the external femoral condyle was studied in the experimental and 3 intact animals using the methods of light and scanning electron microscopy, computer morphometry and stereometry. It was established that the structural changes in the cartilage during the experiment included destruction of the superficial area. The degree of destruction severity was directly related to the duration of the stage when the fixator was on. In a month after the fixator removal the return to the motor stereotype resulted in restoration of the cartilage surface in the 1st series, whereas in the second one the changes persisted. The studies performed revealed general features of the morpho-functional state of the articular cartilage in tibial lengthening in both experimental series, and showed that the autodistraction mode was less traumatic for the articular cartilage.

Animals↗
PubMed2005

[Central bone transport system optimizes reconstruction of bone defects. Results of 40 treatments].

BACKGROUND: This article describes the results, experiences, and advantages of a bone transport system with one single rope or a fully implantable distraction nail for the treatment of bone defects that totally avoids soft tissue cross traction. METHODS: 40 patients with bone defects were treated by central bone transport systems. 30 post-traumatic defects (12 aseptic, 18 post-septic) and 10 defects after resection of bone tumors (2 benign, 8 malignant). Thirty defects were located at the tibia and ten at the femur; the mean defect size was 10.1 cm; 36 central rope systems and 4 motorized distraction nails were used. The follow-up examination took place after an average of 2.4 years. RESULTS: All defects were totally bridged. The mean distraction time was 131 (57-208) days and the mean time of external fixation 283 (126-326) days. The time of partial load bearing was 466 (302-594) days and the healing index was 47 (33.1-60.4) d/cm. In 34 patients autologous bone grafting at the docking site was performed, and in 30 patients the external fixator was replaced by internal stabilization. The mean leg length discrepancy compared to the contralateral side was 4+/-3 mm, and the leg axis deviation from the center of the knee joint was 1.5+/-7.0 degrees . There were 1.8 complications per patient on average (15 pin tract infections with replacement, 2 premature consolidations). CONCLUSIONS: In contrast to conventional methods reduced pin tract infections offer better conditions for internal fixation. Control of length and axis can be optimized, immobilization of the patients is reduced, and the comfort of treatment is significantly improved.

Adolescent↗
PubMed2006

Treatment of osteochondral lesions of the talus with cryopreserved talar allograft and ankle distraction with external fixation.

This article presents the results of a retrospective review of six osteochondral lesions on six patients (five men and one woman) treated with transplantation of cryopreserved talar allograft and ankle joint distraction. All patients complained of ankle pain existing for a long time secondary to a traumatic episode confirmed through MRI. Lesions ranged in measurement from 0.8 cm x 0.8 cm to 3.2 cm x 1.8 cm with an average size of 2.1 cm x 1.5 cm. Each patient underwent talar dome transplantation using fresh frozen talar allograft followed by ankle distraction. Distraction was obtained using a three-ring multiplanar external fixation device. All surgeries were performed between 2002 and 2004. All external fixators were removed at 8 weeks and patients remained partial-weight bearing in a removable cast boot for an additional 8 weeks. Serial postoperative radiographs showed complete consolidation of the allograft within 16 weeks. The average follow up time was 24 months, and all patients related a subjective decrease in symptoms and increase in activity levels. Patients were also evaluated utilizing the Maryland Foot Score both pre- and postoperatively. Preoperatively, four patients were graded as fair and two were graded as poor. Postoperatively, two patients related excellent results, three patients related good results, and one patient related fair results. Several patients experienced minor complications such as pin site irritation (five patients), painful talar wire (one patient), and periostitis (one patient). No patients experienced any major complications and none have required additional surgery. We feel that these initial results warrant further investigation of this treatment.

Adult↗
PubMed2002

Bone mineralization gradient at the callotasis site.

Thirteen patients (18 lengthenings; mean age at operation, 11.0 years) underwent dual-energy X-ray absorptiometry (DEXA) scanning weekly during the distraction phase, at 2-week intervals until removal of the fixator, and at the time of each outpatient visit after removal of the apparatus for a median of 353 days. The three transverse regions remained significantly different in the 7 achondroplastic patients throughout the study, but the difference among these regions became nonsignificant by fixator removal in the 11 limb length discrepancy (LLD) patients. The most proximal region was significantly more mineralized throughout the study in the achondroplastic patients. The central region became the region of highest mineralization in the LLD patients by week 16 after removal of the fixator. The three longitudinal regions showed significantly different mineralization at all time points except at fixator removal. The central and medial regions always showed the highest mineralization. The mechanical characteristics of the fixator and the biomechanical features of the lengthening site may account for the mineralization gradient reported in this study and should probably be taken into account when planning removal of the fixator and subsequent weight-bearing.

Absorptiometry, Photon↗
PubMed2002

Single-stage craniofacial distraction using resorbable devices.

We report on the use of a new type of internal bone distraction devices designed for craniofacial applications. These resorbable devices allow a single operative procedure for device placement, eliminating the need for a second open operative procedure for hardware removal. We report on three models of resorbable devices. The midface orbital frontal device was used for midface and monoblock advancement. The mandibular adolescent device was used in older children and adolescents. In neonates and young children, the mandibular infant device was used. Twenty-one patients (9 female, 12 male) aged 6 days to 15 years (mean = 53 months) underwent bony expansion of the craniofacial skeleton over a 2-year period. A total of 39 devices were implanted: 32 in the mandible, 3 in the maxilla alone, and 4 in the maxilla and frontal bones. Expansion distances ranged from 15 to 30 mm. Expansion took place at 1 to 2 mm/d. Latency periods ranged from 48 to 72 hours. There were no device structural failures and no major complications.

Absorbable Implants↗
PubMed2001

Changes in canine skeletal muscles during experimental tibial lengthening.

In 24 beagles, lengthening of the right tibia was performed by callus distraction after osteotomy and application of a ring fixator. Distraction was started at the fifth postoperative day, with a distraction rate of 0.5 mm twice per day, and ended after 25 days. A control group of six additional dogs underwent tibial osteotomy and external fixation without distraction. Twelve animals with and three animals without leg lengthening were euthanized immediately after the distraction period of 25 days (Group A); the remaining 15 dogs were euthanized after an additional consolidation phase of another 25 days (Group B). From the distracted right leg and from the left control leg the tibialis anterior muscle, extensor digitorum longus muscle, peroneus longus muscle, and gastrocnemius muscle were removed and studied by means of routine histologic, histochemical, and immunohistochemical analyses, and electron microscopic examination. The muscles of the control group showed no differences between the right and left sides. However, in the other 24 dogs of Groups A and B, the authors saw marked alterations affecting only the lengthened muscles but not the muscles of the control limbs. These changes were highly significant and included muscle fiber degeneration and regeneration, target fibers, central cores, minicores, marked endomysial and perimysial fibrosis, and atrophy of Type 1 and Type 2 fibers. In the consolidation period (Group B) fiber type grouping indicated that reinnervation had occurred. In addition, an increase in satellite cells and myoblasts and proliferation of nuclei were observed. The findings of the current study indicate that leg lengthening results not only in muscle fiber degeneration followed by regeneration and reinnervation but also in formation of new muscle tissue.

Animals↗
PubMed2005

Cementless total hip arthroplasty and limb-length equalization in patients with unilateral Crowe type-IV hip dislocation.

BACKGROUND: Total hip arthroplasty in patients with unilateral congenital high dislocation of the hip (Crowe type IV) presents many challenges, including the problem of a marked limb-length discrepancy. The purpose of this retrospective study was to analyze the results of total hip replacement with limb-length equalization in these patients. METHODS: From 1988 to 1996, fifty-six patients (forty-seven women and nine men) with unilateral Crowe type-IV dislocation of the hip were treated with a cementless total hip arthroplasty at a mean age of 35.4 years. The preoperative limb-length discrepancy averaged 4.9 cm. Prior to the total hip arthroplasty, forty-eight patients with a limb-length discrepancy of >4.0 cm underwent iliofemoral distraction with use of an external fixator for eight to seventeen days. The acetabular cup was placed in the anatomical position in every patient. Shortening femoral osteotomies were not required. RESULTS: The iliac fixator pins loosened in six patients. No patient had a pin-site infection, hip joint infection, or nerve palsy. At the time of follow-up, at an average of 147.2 months, the Harris hip score averaged 90.2 points. Overall, the mean lengthening after the total hip arthroplasty was 4.6 cm. There were no revisions of the femoral stem. Nine cups were revised, four because of polyethylene wear and five because of loosening. CONCLUSIONS: We were able to safely place the acetabular cup at the anatomical position without femoral shortening by bringing the femoral head to the normal level preoperatively; thus, we could restore nearly normal limb length. We believe that our twelve-year results are similar to those of total hip arthroplasty in patients without dysplasia.

Adult↗
PubMed2005

[An open wedge tibial head osteotomy using continuous callus distraction. An alternative method for the treatment of of varus arthrosis].

High tibial osteotomy is an accepted method for treatment of medial osteoarthritis. An alternative technique is an open-wedge osteotomy and consecutive callotasis (CO) using an external fixator. The purpose of this study was to evaluate the clinical and radiological results and the efficiency of this technique for precise correction. This prospective study included 41 patients (44 knees) evaluated by the HSS score, radiological stage of osteoarthritis, bone healing, and complications after a follow-up period of 49 (36-61) months. The HSS score increased from median 67 preoperatively to 82 points at the time of follow-up (p<0.001). Of 44 knees, excellent/good results were found in 70.5% and fair/poor in 29.5%. The median preoperative femorotibial anatomical angle was 3.6 degrees varus and 9.4 degrees valgus at the latest follow-up examination. The total time in external fixation was median 80 (61-125) days. We observed one early collapse of the new bone wedge, one complete corticotomy, and pin tract infections in ten cases. Furthermore, two hematomas required revision surgery. Hemicallotasis with external fixators allows constant manipulation of alignment during the healing process to optimize alignment. The disadvantage of the external fixation is the risk of pin track infection. Therefore, CO may constitute an important contribution to our algorithm in the treatment of varus gonarthrosis.

Adult↗
PubMedDate not supplied

[Surgical correction of malunited fractures of the forearm in children].

AIM: In our goal-oriented society the demands for a forearm with full function are increasing. Functional deficits are not acceptable even if they persist only for a limited period of time. Therefore a rising number of surgical corrections of malunited forearm fractures in the pediatric patient has been performed during the last years. However literature about indication, technique and outcome in these patients is rare. For that reason we report our experience about surgical correction of malunited fractures of the forearm in 14 children. METHODS: Fourteen patients with an average age of 13 years at the time of surgical correction of a malunited fracture of the forearm were included. Seven had a deformity of the shaft, five at the distal forearm without and two with growth disturbance. Malunions without growth disturbance were corrected with an osteotomy and plate fixation. Those with growth disturbance were first treated with callus distraction. Previous to and 24 (3 to 100) months after surgical correction the patients were examined clinically and radiologically. Range of motion was noted. Additionally to the range of motion, grip strength and pain (VAS) were documented. Patients with correction of the distal forearm were asked to fill out the DASH questionnaire. RESULTS: In all groups a significant increase of the range of motion was noted in pro-/supination of 61 per cent to 85-0-80 degrees. In patients with distal correction additionally the range of motion in extension/flexion of the wrist improved 30 per cent to 70-0-65 degrees and in ulnar/radialduction 22 per cent to 30-0-35 degrees. At follow-up the grip strength following distal corrections was 98 per cent of the opposite side. The patients had no pain (VAS < 3 points). The median subjective functional result was excellent with a median DASH score of 3.5 points. CONCLUSIONS: Our results show that potent techniques for surgical correction of malunited forearm fractures in the growing skeleton are available. These techniques allow excellent functional outcome.

Adolescent↗
PubMed1998

Changes of callus diameter during axial loading and after fixator removal in leg lengthening.

We retrospectively reviewed nine tibial lengthenings in seven achondroplastic patients. The callotasis method was used, and a unilateral type lengthener, either the Dynamic Axial Fixator (Orthofix, Italy; eight legs) or the High Functional Fixator (Matsumoto Co., Japan; one leg), was applied. The distracted length averaged 14.6 (range 10-18) cm. The minimum diameter of the callus was measured using a ruler on anteroposterior and lateral radiographs. The callus diameter ratio (%) was calculated as the callus diameter divided by the original diaphysis diameter. For periods during axial loading and after removal of the fixator in each patient, a single regression line was drawn on the callus diameter ratio data using the least squares method, and the diameter change rate (%/day) was evaluated by inclination of this line. The diameter change rates during axial loading were negative in six legs, but those after fixator removal were positive in all legs, and the latter were significantly greater than the former. The diameter change rates after fixator removal on the anteroposterior radiographs were negatively correlated with the callus diameter ratio at the time of fixator removal (r = 0.84, P = 0.0008). Simple axial loading may not be a sufficient mechanial environment for restoration of the physiological shape, and it is important to be aware that we cannot expect the callus diameter to increase by this means alone.

Achondroplasia↗
PubMed2002

Calvarial bone distraction with a contractile bioresorbable polymer.

The aim of the present study was to evaluate the possibility of mobilizing calvarial bone with a fully implantable and bioresorbable device. The animal model used was the New Zealand white rabbit (n = 12). An island bone flap attached to the dura mater was created in the parietal region and amalgam markers were placed in this bone flap and in the ipsilateral frontal bone. In one group of six rabbits (group 1), a specially processed contractile 70L/30D,L polylactic acid plate, 15 x 6 x 0.6 mm, was attached to the island flap by one extremity, and to the fixed ipsilateral frontal bone by the other. In group 2 (control), no plate was added. Bone marker movement was followed with serial radiography. In group 1, there was a progressive reduction in mean marker distance over the first 48 hours, and stability thereafter. In group 2 (control), mean marker distance remained stable until the second postoperative week, after which time there was a slight increase until the end of the experimental period. At 4 weeks, the mean marker separation differed significantly between group 1 (mean, -3.62 mm; SD, 0.79 mm) and group 2 (mean, 0.34 mm; SD, 0.14 mm; p <0.001). In conclusion, a totally implantable and bioresorbable device was successfully used to mobilize calvarial bone. Polymer contractility will likely constitute the basis of a new generation of bioresorbable distractors for use in craniofacial surgery.

Absorbable Implants↗
PubMed2007

Intraoral osteotomies using piezosurgery for distraction in an infant with Pierre-Robin sequence.

Airway management in infants with Pierre Robin sequence (PRS) is often challenging. Advancement of the tongue base using mandibular distraction in neonates can avoid tracheotomy and is increasingly propagated. The osteotomies can be performed via intra- and extraoral approaches. Nowadays, for precise bone cutting, piezosurgical devices have been introduced in maxillofacial surgery, which we used for osteotomies via the intraoral approach in the 7-week-old patient presented in this study. Instead of a preoperative CT scan, a 3D data set was generated preoperatively in the operating theatre using a 3D C-arm system. After bilateral transcutaneous pin placement and osteotomies, a second 3D data set was acquired. Primary and secondary reconstructions clearly visualized the patient's bone despite the low level of ossification in newborns and the presence of a large amount of metal implants. In view of the low level of radiation exposure going along with the 3D C-arm imaging, a follow-up examination after removal of the distractors was performed. With this report of a 7-week-old female infant with the diagnosis of PRS, we want to extend the surgical and diagnostic armamentarium for the treatment of infants with PRS.

Electrosurgery↗
PubMed2001

Peripheral nerve lengthening by controlled isolated distraction: a new animal model.

We have developed a simple and effective animal model to study the distraction neurogenesis utilizing the sciatic nerve-lengthening technique in rats. The model allows macroscopic, physiological, and histological evaluation of the distraction site. Fourteen adult Harlan Sprague Dawley rats (300-350 g) were used in this study. A 10 mm segment of the right sciatic nerve of each animal in the nerve-lengthening group was resected. Gradual nerve lengthening was performed by advancing the proximal nerve stump at a rate of 1 mm/day. The proximal stump neuroma was then resected and a direct nerve anastomosis was performed. On the left side a standard autogenous nerve-grafting procedure was performed with a 10 mm segment of sciatic nerve used as an in situ nerve graft. Three months after the second surgery, the sciatic nerves were exposed and investigated by gross observation and EMG followed by histological processing and tissue analysis. Neomicrovascularization was observed surrounding the sciatic nerve anastomosis in all five specimens of the nerve-lengthening group as compared to the more white-colored scar tissue that was observed in the nerve-grafting group. The EMG results were similar for both groups. Histological studies of the lengthened nerves showed axon morphology equivalent to the grafted nerves. This study demonstrated a clear evidence of the successful nerve regeneration within a segmental nerve gap by nerve lengthening.

Animals↗
PubMedDate not supplied

[Reduction of spondylolisthesis by temporary adjacent segment distraction].

AIM OF THE STUDY: Multiple instrument systems are currently available for the reduction of spondylolisthesis, where posteriorly oriented tensile forces are directly acting on the slipped vertebra. The aim of this clinical study was to evaluate the clinical efficacy of a new indirect reduction manoeuvre applied to the lumbar spine. METHOD: A total number of 32 patients (14 female, 18 male) suffering of spondylolisthesis were reduced by transpedicular instrumentation during June 2001 until October 2003. The cranial adjacent vertebra was temporarily instrumented and the reduction of the slipped vertebra was facilitated by the application of traction on the instrumentation leading to tension of the longitudinal ligaments. Posterior transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion (ALIF) was then carried out according to the degree of degenerative shortening of the anterior long. spinal ligament. On the last follow up (average 32 month postoperatively; min.: 22 month) both the reduction of the spondylolisthesis and the ossification of the interbody fusion was evaluated radiologically. Physical function and patients satisfaction was measured by means of the SF 36 questionnaire. RESULTS: The dislocation was reduced in all cases (81% on average). At the time of the last follow up bony fusion was depicted on the radiographs in all 32 patients. A distinct improvement in all categories of the SF 36 (in 5 out of 8 categories statistic significant) could be demonstrated. CONCLUSION: Temporary intraoperative instrumentation of the cranial adjacent segment proofs to be a simple an effective method for the sufficient reduction of spondylolisthesis.

Adult↗
PubMed2004

Bone lengthening for congenital differences of the hands and digits in children.

PURPOSE: We investigated the growth of bones after lengthening to evaluate the effectiveness and usefulness of bone lengthening in congenital hand deficiencies. METHODS: Bone lengthening was performed to treat congenital hand deficiencies including hypoplastic thumb, hypoplasia of the small finger, cleft hand, metacarpal synostosis, brachymetacarpia, symbrachydactyly, and amniotic band syndrome. A total of 15 patients (1-13 years old) underwent lengthening of 23 bones. The average of distraction was 10 mm. The mean follow-up period was 59 months. The length of the bones at follow-up evaluation was measured and then compared with the length of the bones immediately after lengthening. The bone growth after lengthening, the percentage of growth after lengthening, and the growth rate were compared among diagnostic groups. RESULTS: In the cases involving older patients the bone length changed little and the growth plates of these patients closed naturally soon after lengthening. In contrast, in the cases in which the patients were younger than 7 years old the lengthened bones grew continuously. The amount of bone growth was different for each disease in the younger patients. In patients with amniotic band syndrome the lengthened bones grew at the same rate as the bones in the hand. Other diagnoses such as symbrachydactyly had a different growth pattern in the hand. CONCLUSIONS: We conclude that bone lengthening is a reliable method for the correction of congenital differences of the hand. The indications for this procedure must be determined while considering the relationship between the specific disease and subsequent bone growth.

Adolescent↗
PubMed2000

Minimally invasive orthognathic surgery: endoscopic vertical ramus osteotomy.

The endoscopic procedure for placement and activation of a distraction device for mandibular advancement has been previously reported. The purpose of this study was to demonstrate the feasibility of endoscopic exposure, dissection and osteotomy for mandibular set-back. Two cadaver and three anesthetized minipigs were used in this study. Access to the mandibular ramus was achieved through a 2.0 cm submandibular incision. The dissection was carried sharply to the mandible and completed in the subperiosteal plane. Visualization was achieved using a 2.7 mm diameter endoscope (Karl Storz, Germany). Landmarks were identified and a custom-made retractor was inserted into the sigmoid notch. A vertical ramus osteotomy was created (bilaterally) from the sigmoid notch to the mandibular angle. The mandible was set back (average 6 mm) and fixed using 2.0 mm diameter, bicortical screws. Live animals were sacrificed three weeks postoperatively. The mandibles were examined clinically and radiographically to verify proper osteotomy position and clinical union. In all animals, exposure, accurate identification of landmarks, osteotomy placement and screw fixation were achieved. In the live animals (n=3), union between the proximal and distal segments was documented by clinical and radiographic examination. This study demonstrates the feasibility of the EVRO procedure for mandibular set-back in a minipig model.

Animals↗
PubMed2005

Osteogenesis and angiogenesis in regenerating bone during transverse distraction: quantitative evaluation using a canine model.

For some patients with a bone defect, curved deformity, or small diameter bone, transverse distraction might be better indicated than bone transport or lengthening. However, detailed quantitative evaluation of osteogenesis or angiogenesis during transverse distraction by creating a well-controlled animal model has not been done. We established a transverse distraction model of the canine tibia. A rectangular cortex was separated for a distraction fragment. Seven days after the operation, 0.5-mm distraction was applied twice daily for 14 days. After a 28-day consolidation period, the animals were sacrificed. Quantitative evaluations of the rates of mineralization and the increases of bone mineral density indicated faster mineralization and earlier corticalization of the regenerating bone in the initial stage of the consolidation period. The average blood vessel volume ratio in the distraction area was more than three times greater than in the intact contralateral tibiae. We hypothesized that adequate preservation of the marrow arteries and stability of the distraction site throughout an experimental period could induce this faster osteogenesis. Our results indicated that the transverse distraction technique was feasible. The transverse distraction technique could be indicated for patients with small-diameter bones or with massive bone defects.

Animals↗
PubMed2001

Immediate postexpansion changes following the use of the transpalatal distractor.

PURPOSE: This study analyzed the immediate postexpansion positional changes of the maxillary halves resulting from the use of the transpalatal distractor (Surgi-Tec NV, Bruges, Belgium). PATIENTS AND METHODS: Corticotomies were performed in the same way as surgically assisted rapid palatal expansion, all from a buccal sulcus approach. Titanium abutment plates with box extension were placed horizontally in the vertical wall of the palatal vault overlying the second premolar root through a mucoperiosteal incision and fixed with titanium screws 5 mm in length. An appropriate telescopic distraction module was fitted in the slots of the boxes. Expansion started 1 week after surgery, at a rate of 0.33 mm/d. Digital measurements on digital photographs of the models were obtained from 20 postadolescent patients before and immediately after transpalatal distraction. The distractor was placed at the level of the second premolar. Pterygomaxillary separation was not performed. Changes in the intercanine, interpremolar and intermolar width, in the dental arch perimeter, and in the premolar and molar angulations in the frontal plane were analyzed and correlated. RESULTS: Width expansions of 35.7%, 31.7%, and 22.7% were noted in the canine, premolar, and molar regions, respectively. There was a mean increase of the arch perimeter of 10.5%, which correlated well (P <.001) with the expansion at the canine and premolar level. The mean angulation changes in the frontal plane of the premolar and molar segments were minimal, -8.3 degrees +/- 9.6 degrees and 0.9 degrees +/- 9.9 degrees, respectively. The change in angulation at the molar level correlated (P <.005) with the amount of expansion in that region. Premolar angulation did not correlate with the expansion, and segment angulation did not correlate with age. CONCLUSIONS: The expansion at the canine level was 1.5 times greater than at the molar level (corrected value relative to the original intermolar width). The change in arch perimeter can be predicted from the expansion at the canine and premolar level. Expansion in the frontal plane occurs with little tipping of the segments.

Adolescent↗