Epiphyseal Distraction Research Articles

Epiphyseal distraction prior to resection in paediatric bone sarcomas : four decades of experience.

Paediatric bone sarcomas are a dual challenge for orthopaedic surgeons in terms of tumour resection and reconstruction, as it is important to minimize functional and growth problems without compromising survival rates. Cañadell's technique consists of a Type I epiphysiolysis performed using continuous distraction by an external fixator prior to resection. It was designed to achieve a safe margin due to the ability of the physeal cartilage to be a barrier to tumour spread in some situations, avoiding the need for articular reconstruction, and preserving the growth capacity most of the times. Despite initial doubts raised in the scientific community, this technique is now widely used in many countries for the treatment of metaphyseal paediatric bone sarcomas. This annotation highlights the importance of Cañadell's work and reviews the experience of applying it to bone sarcoma patients over the last 40 years.Cite this article: Bone Joint J2023;105-B(1):11-16.

The basic principle and clinical outcomes of epiphysis preservation limb salvage in the treatment of limb osteosarcoma in children and adolescents

Epiphyseal preservation limb salvage is a method for the treatment of limb osteosarcoma in children and adolescents. The purpose is to avoid the unequal length of bilateral limbs and improve the affected limb function without increasing the occurrence of life-threatening complications. Strictly following the indications is the key to ensure the success of the operation.Before operation, epiphyseal distraction or imaging method is used to determine the position of osteotomy in operation, which has reached the safe boundary of tumor resection. Many ways were used to repair the tumor bone defect. A lot of studies confirmed that all kinds of surgical methods have achieved satisfied clinical outcomes, but there are different surgical complications. Only when the epiphyseal plate and epiphysis are kept at the same time can the length of the limb be ensured to be equal; the result of intra-epiphyseal osteotomy is that the block of bone growth leads to the unequal length of the limb. The biological reconstruction of bone defect can restore the length of limbs by bone lengthening after bone growth stops. Key words: Osteosarcoma; Extremities; Surgical procedures, operative; Treatment outcomes

Distraction-suppression effect on osteosarcoma

Osteosarcoma is the most common primary malignant bone tumor. It occurs mainly in children and adolescents. In patients with open growth plate, epiphyseal distraction is used to separate the uninvolved epiphysis from adjacent tumor. This helps preserve the growth potential and restore joint and limb function to a great extent. Interestingly, epiphyseal distraction also appears to inhibit the proliferation of osteosarcoma tumor cells and to increase sensitivity to chemotherapy.Tumor interstitial pressure (TIP) is often elevated in the microenvironment of most solid tumors, including osteosarcoma. Elevated TIP can promote the proliferation, invasion, and migration ability of osteosarcoma cells and also decrease the uptake and distribution of chemotherapeutic agents. Studies have confirmed that the sustained volumetric strain produced in distracted tissue decreases TIP; it stretches extracellular matrix, decreases interstitial density, and increases vessel diameter. We hypothesize that lowering of TIP during the period of epiphyseal distraction inhibits the proliferation and invasion of osteosarcoma cell and, at the same time, increases blood perfusion in the tumor and thus enhances uptake and distribution of chemotherapy agents. If the hypothesis is proved to be true, distraction of tumor segment could be a novel supplementary treatment for osteosarcoma by manipulation of TIP.

Preliminary clinical research on epiphyseal distraction in osteosarcoma in children.

BackgroundThe feasibility of distal femur epiphysis preservation through epiphyseal distraction by external fixator in childhood osteosarcoma was explored.MethodsBetween July 2007 and May 2011, 10 children who were suffering from distal femur osteosarcoma received epiphyseal distraction by external fixator, combined with tumor resection and repair with massive allograft bone to preserve the epiphysis of the distal femur and knee function. There were six male and four female patients, 9- to 14-years old (average 10.5 years old). The tumors were staged clinically according to the Enneking staging method: six cases were classified as stage in IIA and four cases as stage in IIB. All patients were diagnosed by biopsy, then received chemotherapy before and after surgery. All patients received tumor bone resection and the defects of the bone were repaired with massive allograft bone that was fixed by intramedullary nails; the distracted epiphysis and allograft bone were fixed with cancellous screws.ResultsAll cases received follow-up from 15 to 56 months (average 38.5 months). There were no local recurrences. One case died of lung metastasis and one case had poor incision healing for rejection of allograft bone. According to the functional evaluation criteria of the International Society of Limb Salvage (ISOLS) after operation, five cases were rated excellent, four cases good and one case fair. The ratio of excellent or good was 90.0%. There was no statistically significant difference in length between the operated and the normal lower limbs during the last review.ConclusionsEpiphyseal distraction by external fixator can result in satisfactory limb length and joint function for children with a malignant bone tumor.

An Experimental Study of the Effect of Periosteal Stripping on Limb Length in Rabbits

Introduction: Various methods have been tried in the past for lengthening the shorter limb, e.g., introduction of foreign material or drilling of the metaphysis, obliteration of nutrient foramen, use of short-wave diathermy, lumber sympathectomy, creation of an artificial arteriovenous fistula, and epiphyseal distraction. This study was undertaken to find a simple technique for limb lengthening by a minor surgical procedure, particularly where limb discrepancy is short. Materials and Methods: The experiments were carried out on the right hind leg of 40 rabbits of three months of age in batches of five, each of which was a control. All were anesthetized using Nembutal intra-peritoneally at 40–60 mg/kg of body weight and were then allocated to one of the five experimental groups: A] Control rabbits – anesthesia given but no operation done; B] Vertical periosteal division; C] Vertical periosteal division with periosteal stripping; D] Circular periosteal division; E] Circular periosteal division with periosteal stripping. Before proceeding to operate on the rabbits, the measurements of right and left tibiae of each rabbit were recorded by a vernier caliper from the highest point of tibial tuberosity to the tip of the medial malleolus. After a total duration of 8 weeks from the date of operation, the animals were sacrificed and the tibial lengths were compared from the upper margin of the medial condyle (as this was now the most prominent point) to the tip of the medial malleolus again for comparison. Results: The maximum increase was obtained in the group with circular division along with periosteal stripping, while in the group with vertical division, the minimum increase was obtained. Conclusion: Circumferential periosteal division with stripping is an ideal procedure for minor length discrepancies or for those with limb inequality undergoing other procedures. It is simple and safe and would not require more than a short period in the hospital.

Osteoneogenesis in callus and epiphyseal distraction

X-rays were reviewed after callus distractions (50 cases) and distraction epiphysiolysis (10 cases) in 45 patients. With the aid of a computerized digitization system for analogue films, the relative x-ray density of the distraction area was determined in the medial, lateral, ventral and dorsal surface areas, and in the median line of the callus tissue. Bone formation became evident within 21.7 +/- 3.7 days post-distraction in the thigh and 25.4 +/- 4.9 days in the shank. The lowest density values were found at the end of the distraction phase followed by a continual increase in x-ray density in the fixation phase. There was a significant decrease in callus x-ray density in the shank from lateral to medial and from dorsal to ventral, and in the thigh from medial to lateral and from dorsal to ventral. When the corticotomized callus distraction is compared to the distraction epiphysiolysis without corticotomy it becomes apparent that the differences between lateral-medial x-ray densities and dorsal-ventral x-ray densities were significantly greater in the group with callus distraction. The deminished bone formation in the ventromedial area of the shank and the ventrolateral area of the thigh seems to be due to soft tissue damage and disturbances in local bone blood supply after the operative approach for corticotomy.

Preoperative Soft-Tissue Distraction for Radial Longitudinal Deficiency: An Analysis of Indications and Outcomes

Preoperative soft-tissue distraction for congenital radial deficiency is well described, but indications are unclear and long-term outcomes are lacking. This study evaluated one surgeon's 16-year experience with preoperative soft-tissue distraction using uniplanar devices. Eight extremities in seven consecutive patients (average age, 2.5 years) with type 4 radial deficiency and severe wrist deformity were distracted before centralization (seven extremities) or radialization (one extremity). In the short term, average hand-forearm angle improved by 89 degrees and average hand-forearm position improved by 31 mm. In the long-term, wrist deformity recurred commensurate with the degree of initial deformity. Fortuitously, one infant experienced unintended epiphyseal distraction that lengthened the ulna by 15 mm before radialization. One patient required recentralization; two developed minor pin-track infections. Multiple distractor readjustments were necessary early in the series. Preoperative soft-tissue distraction for radial deficiency is indicated in late-presenting or neglected patients or cases with severe, irreducible wrist angulation and displacement. Dramatic correction is possible using uniplanar distractors. Although minor complications are common, they diminish with experience. Using this technique, the surgeon avoids skeletal shortening and undue strain on the nerves and vessels at the time of centralization or radialization.

Infantile Blount's disease treated by hemiplateau elevation and epiphyseal distraction using a specific external fixator: preliminary report

The treatment of infantile Blount's disease remains controversial. The progressive development of epiphysiodesis of the medial tibial physis induced a complex deformity of the lower limb such as severe genu varum, joint incongruity, torsion instability and leg length discrepancy with major functional consequences. Nine knees on eight children (average age was 7 years and 2 months) were treated by a one-time procedure using a specific external fixator that combined elevation of the medial tibial plateau, axial correction in the valgus, complete sterilization of the upper tibial growth cartilage, leg lengthening anticipation and de-rotation if necessary. Magnetic resonance imaging was useful to describe the deformity and to prepare for surgery. Corrections were progressively obtained through the physis plan by means of short incisions and the use of a specific external fixator. The primary results at an average of 24 months were good with a low rate of complications but final evaluation will be conducted at the end of the children's growth period.

Chondrocyte injection in distraction epiphysiolysis (rabbit model)

The purpose of this study was to determine if cultured chondrocytes could prevent premature closure of the physis after physeal distraction in a rabbit model. Epiphyseal distraction at the proximal tibial epiphysis was performed in 24 immature rabbits. Chondrocytes were harvested from the iliac apophysis. The animals were divided into three groups: A, epiphyseal distraction alone; B, injection of phosphate buffered saline (PBS) after epiphyseal distraction; and C, injection of cultured chondrocytes after epiphyseal distraction. After epiphyseal separation was noted radiographically, each animal was evaluated at routine intervals. At 2 to 4 weeks, significant tibial lengthening as compared to the contralateral tibia was noted in all three groups. At 10 weeks, lengthening was apparent only in group C; in groups A and B, the operated tibia was shorter than the unoperated one. Histologic examination at 4 weeks revealed partial bony bridge formation with cell clustering in the fibrocartilaginous matrix in groups A and B. In group C, the matrix showed a typical hyaline aspect with cells organized in columns at the injection site. The zone of hypertrophic chondrocytes was enlarged. It appears that the injected cells differentiated into hypertrophic chondrocytes and delayed premature physeal closure. At 10 weeks after distraction of the physis, the width of the physis was restored to 75% of normal, but disordered chondrocyte growth with cell clustering was present in the cell-injected group.

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.

Pioneers in the lengthening of the extremities

Successful lengthening of the extremities was first published at the beginning of the twentieth century. Those reports in which methods such as the distraction of fragments, callus or epiphysis were mentioned for the first time are reviewed. Lengthening of the extremities by epiphyseal distraction was first mentioned by Bernhard v. Langenbeck in 1869 in an animal experiment. The publications of Codivilla, who introduced lengthening by fragment distraction, Kirschner, Bier and others are cited and analyzed critically. Thus, the historical development of the lengthening of the extremities is reported from 1869 to the middle of the twentieth century.

Congenital Pseudarthrosis of the Tibia Associated with Neurofibromatosis-1: Treatment with Ilizarov's Device

We reexamined 21 patients with congenital pseudarthrosis of the leg (congenital pseudoarthrosis of the tibia; CPT) associated with neurofibromatosis-1 (NF-1), > or =2 years after the termination of treatment, for a statistical study of the results obtained by using Ilizarov's external fixator. Of the 21 tibias operated on, 17 consolidated after the first treatment, whereas four did not. Of the 17 consolidated tibias, four refractured and were retreated by using a variety of methods. Only one healed. At follow-up, which occurred > or =2 years after the removal of the fixator, the results were nine consolidations without deformities or with shortening <2 cm, five consolidations with axial deviation, and seven nonconsolidations. The statistically significant results were that (a) patients who were aged 5 years or older at operation had better results, and (b) the assembly II (resection of CPT stumps and their short-term compression possibly associated with corticotomy or epiphyseal distraction to correct limb discrepancy) gave better final results compared with the other device assemblies. We conclude that treatment with Ilizarov's fixator allows (a) a good percentage of healing over time (66.7%), especially in cases of normotrophic and cystic CPT; (b) further operations with or without the fixator to correct secondary or residual axial deviation; and (c) correction of limb discrepancy. This treatment avoids risking injury to the healthy contralateral leg. Additionally, for treatments that do not achieve satisfactory results, other treatment methods are not excluded. The CPT still remains a difficult problem for the orthopedic surgeon to solve.

Epiphyseal Distraction and Centrally Located Bone Bar: An Experimental Study in the Rabbit

Epiphyseal Distraction and Centrally Located Bone Bar: An Experimental Study in the Rabbit

Osteoneogenesis and its influencing factors during treatment with the Ilizarov method.

The radiographs of 57 patients who had undergone 58 callus distractions and 13 epiphyseal distractions were evaluated. During the course of treatment, the density of the distraction areas on radiographs was measured in total and along the medial, lateral, ventral, and dorsal margins using a digital radiograph processing system. The densities of the whole distraction length were correlated to the following parameters: age of patient, start of distraction after corticotomy, mean distraction speed, mean amount of weight load during the period of distraction and consolidation, location of corticotomy (distal femoral metaphysis versus the proximal tibial one), and diclofenac medication. Except for the location of corticotomy and the diclofenac medication, the density was influenced by all these parameters. Age of the patient and weight load were the most important parameters. Patients with leg shortening caused by poliomyelitis and a patient with a shortened leg after amniotic strangulation showed a slower rise of the density trend curve on radiographs than the other patients. When comparing the different regional density curves, a significant gradual density decrease could be observed from the medial to the lateral side in the femur, from lateral to medial in the tibia, and from the dorsal to the ventral side in both bones. The respective differences between lateral and medial density, and between dorsal and ventral density, were significantly higher in cases of callus distraction than in cases in which epiphyseal distraction had been used. The amount of bone regeneration varied regionally primarily because of the inhomogeneous soft tissue covering of the bone and the impairment of its local blood supply by the surgical exposure for the corticotomy. The clinical relevancy of the various parameters for osteoneogenesis is discussed in this article.

Correction of an angular deformity of the thumb in a juvenile by epiphyseal distraction

Angular digital deformity secondary to an epiphyseal fracture of the thumb proximal phalanx was treated by gradually distracting the growth plate with a mini phalangeal distractor. Epiphyseal Distraction has been described in the knee, 1 ankle I and wrist 2 for correction of angular deformity. The advent of miniature equipment makes it possible in the digits.

Infantile Type of Blountʼs Disease

The proper treatment of the infantile type of Blount's disease is still a controversial issue. We postulate the hypothesis of the etiopathogenesis of the infantile type of Blount's disease as a disease related to a dysplastic linkage between epiphysis and metaphysis. Therefore, considering the radiographic observations of a 26-month-old girl admitted in our department in 1986 with the infantile type of Blount's disease (type II Langenskiold--tibial femoral angle 24 degrees), the consequential optimal management of this condition is the need to apply a treatment consisting of the epiphyseal distraction capable of interrupting this dysplastic linkage, avoiding recurrences and damage to the growth cartilage. This child was treated with early, slow, and monocompartmental distraction by Ilizarov apparatus for 11 weeks. When the Ilizarov apparatus was removed, full recovery was achieved, the leg was clinically straight, and the mechanical axis was restored. The long-term follow-up (7 years) confirms this operation as a definitive treatment. It was less traumatic for the child, without recurrences or disorders of growth cartilage, supporting the dysplastic origin of infantile type of Blount's disease and the efficacy of this type of treatment.

Epiphyseal distraction for bony bridges: a biomechanical and morphologic study.

Partial physeal bridges were produced by resecting part of the lower femoral physis in 8-week-old rabbits. After 4 weeks, an external fixator, strain-gauged to measure distraction forces, was applied across the physis. Distraction was performed for 15 days: 1.0 mm/day medially and 0.5 mm/day laterally. Weekly radiographs were obtained. Animals were killed at 0, 3, and 6 weeks after distraction. Characteristic force patterns were evident if the bridge fractured. Medial fixator forces just before bridge fracture were very high (mean 89 N, SD 28 N), although forces in the lateral fixator were low (mean 25 N, SD 15 N). All animals killed 3 and 6 weeks after distraction ceased showed complete physeal closure. Results suggest that distraction epiphysiolysis may have high potential for producing premature physeal fusion.

Treatment of a Monteggia fracture case complicated by ignored tetanos, with a limb lengthening apparatus

It is complicated to treat delayed pediatric. Monteggia type fracture-dislocations. A seven year-old male patient of open Monteggia fracture-dislocation was initially treated by closed reduction in an urban hospital. With the development of tetanus infection the reduction became ineffective. A different course of treatment was then carried out. At the first session we have performed gradual distraction by an external fixator which is used for epiphyseal distraction in our clinic. As a conseauence redial head brought to the level of capitellum and fractured segments of ulna were appositioned. At the secont session, radial head was reduced and osteosynthesis of ulna was performed.

Growth Retardation After Experimental Limb Lengthening by Epiphyseal Distraction

Summary: Growth retardation occurring as a result of limb lengthening by epiphyseal distraction in two animal species was quantified by using femur or tibia as the experimental bone. The growth plate subjected to distraction appeared radiolucent after the lengthening procedure but was less distinct and had reduced height as compared with the control. In seven of 22 animals, the growth plate of the lengthened bone appeared to close earlier than in the control. After lengthening, bilateral longitudinal growth was evaluated semiquantitatively from radiographs until growth had ceased or residual growth was negligible. Growth retardation was consistently experienced in all animals, with an average reduction in growth potential of each study ranging from 40 to 70%. The results show that epiphyseal distraction is a valid method of limb lengthening, but it appears to have a consistently harmful effect on the growth plate and should be used clinically only in patients close to maturity.

Growth Retardation After Experimental Limb Lengthening by Epiphyseal Distraction

Growth retardation occurring as a result of limb lengthening by epiphyseal distraction in two animal species was quantified by using femur or tibia as the experimental bone. The growth plate subjected to distraction appeared radiolucent after the lengthening procedure but was less distinct and had reduced height as compared with the control. In seven of 22 animals, the growth plate of the lengthened bone appeared to close earlier than in the control. After lengthening, bilateral longitudinal growth was evaluated semiquantitatively from radiographs until growth had ceased or residual growth was negligible. Growth retardation was consistently experienced in all animals, with an average reduction in growth potential of each study ranging from 40 to 70%. The results show that epiphyseal distraction is a valid method of limb lengthening, but it appears to have a consistently harmful effect on the growth plate and should be used clinically only in patients close to maturity.