Outcome Of Distraction Osteogenesis Research Articles

Post-Traumatic Segmental Tibial Defects Management: A Systematic Review of the Literature

Introduction: Segmental tibial defects pose significant challenges in orthopedic surgery due to their complexity and high complication rates. This systematic review aimed to evaluate both the effectiveness and outcomes of distraction osteogenesis (D.O.) and the Masquelet technique in treating post-traumatic segmental tibial defects. Materials and Methods: A literature search was performed on PubMed, Scopus, and Cochrane. Relevant retrospective and prospective observational studies with a minimum of 12 months follow-up were included. The primary outcome was bone union rate; the secondary outcomes were the type and rate of complications and the clinical and radiological outcomes. Results: Twenty-seven studies met the inclusion criteria, 18 studies reported data on D.O. and 9 on the Masquelet technique. D.O. demonstrated an overall union rate of 79.4% across 422 patients, and the Masquelet technique demonstrated an overall bone union rate of 85% across 113 patients. For D.O., on average, there was one complication per patient, and with the Masquelet technique, there were 0.5 complications per patient. Conclusions: D.O. and the Masquelet technique are the main treatment options for post-traumatic segmental tibial defects. Although union rates are similar, the Masquelet technique showed fewer complications. Treatment choice should consider patient-specific factors and more comparative studies are needed.

The Outcomes of Distraction Osteogenesis over an Intramedullary Nail for the Treatment of Bone Defects in Infectious Nonunions.

The concurrent utilization of an external fixator and intramedullary nail (IMN) for segment transportation may potentially decrease the duration of external fixator implementation and reduce associated complications. This study aimed to report the outcomes of bone transport utilizing a combination of IMN and Ilizarov frame in a cohort of individuals who had tibia or femur critical-sized bone deficiency resulting from nonunion. The present research used a single-arm clinical trial design to enroll a series of patients presenting with critical-sized bone defects resulting from infectious nonunion of the tibia or femur. The study was conducted during the period of 2017-2020 in a referral Orthopedic Surgery Center located in Tehran, Iran. The management of patients with infectious nonunion was carried out through two main stages, including infection eradication and bone transportation. The process of bone healing and segment transportation was evaluated by radiographic assessment throughout the follow-up period. A total of 39 patients with bone defects in the tibia (19 cases) or femur (20 cases) with a mean age of 31.44 (±11.95, range=18-60) were included in this study. Twenty-nine (74.3%) patients had open fractures. The bone defect exhibited an average size of 6.31 ± 1.95 cm. The mean of the consolidation index (CI) was 0.97 (range=0.51-1.32) mo/cm, and the mean of the external fixator index was 0.67 (range=0.41-1.10). Although the CI was longer in patients with open fracture compared to those with closed fracture, the difference was not statistically significant (P=0.353). After the end of the two-year follow-up, complete union was observed in 35 patients (89.7%). Intercalary segmental bone transportation using the Ilizarov technique over an IMN, as well as preserving the advantages of the conventional callotasis method, reduces the complications of long-term use of the Ilizarov frame and increases patient adherence to treatment.

Clinical Outcomes of Distraction Osteogenesis in Fourth Brachymetatarsia

Clinical Outcomes of Distraction Osteogenesis in Fourth Brachymetatarsia

A systematic review on the outcome of distraction osteogenesis in TMJ ankylosis

IntroductionTMJ ankylosis (TMJa) management by arthroplasty alone fails to address the deformity and the compromised airway. Distraction osteogenesis (DO) can offer a pragmatic solution to TMJa. The aim of the study was to generate evidence towards the role of DO in TMJa, evaluate its efficiency and develop an algorithm for use of DO in TMJa. Material and methodsThe research question was formulated using the PICOS statement for reporting guidelines in systematic reviews, where the efficiency of DO was evaluated in terms of mouth opening, correction of facial deformity and asymmetry, airway correction, and its long term effects. Results1130 articles reported DO as a treatment modality for TMJ ankylosis, of which 32 prospective studies, 16 retrospective and 2 RCTs were included in the study. DO was used for mandibular distraction in 45 studies and for simultaneous maxillamandibular distraction in only five studies. An algorithm for use of DO in TMJa was developed. ConclusionAlthough DO has proven its application in TMJ ankylosis cases, its best use is for correction of obstructive sleep apnoea. Relapse causing loss of posterior ramal height is a concern after transport DO. Prearthroplastic DO appears to best correct mandibular deformity. A maxillomandibular deformity requires simultaneous maxillomandibular distraction. However, a metanalysis is still awaited for effectiveness of DO in TMJ ankylosis.

What is the impact of distraction osteogenesis on the upper airway of hemifacial microsomia patient with obstructive sleep apnea: a case report

BackgroundCurrent research about hemifacial microsomia (HFM) patients after distraction osteogenesis (DO) most emphasize the morphologic changes. This case report shows the outcome of DO on the upper airway of a HFM patient with obstructive sleep apnea (OSA) based on the use of computational fluid dynamics (CFD).Case presentationAn 11-year-old boy was diagnosed as HFM with OSA, and underwent unilateral DO. Polysomnography and CT scans were performed before and 6 months after treatment. After DO, lowest blood oxygen saturation increased from 81% to 95% and apnea and hypopnea index decreased from 6.4 events/hour to 1.2 events/hour. The oropharynx and nasopharynx were obviously expanded. We observed apparently increased average pressure, decreased average velocity and pressure drop in all cross-sections, and largely decreased airflow resistance and maximum velocity entirely in the airway.ConclusionsThe results suggest that DO might be effective for the treatment of OSA by expanding the upper airway and reducing the resistance of inspiration.

Management of metacarpophalangeal bone defects after hand trauma by distraction osteogenesis with mini external fixation

Objective To evaluate the outcomes of distraction osteogenesis with mini external fixation in management of metacarpophalangeal bone defects after hand trauma. Methods From June 2010 to December 2015, 16 patients with metacarpophalangeal bone defects after hand trauma received distraction osteogenesis at our department. They were 11 men and 5 women, from 20 to 45 years of age (average, 32.5 years). There were altogether 20 bone defects: 8 cases had single metacarpal bone defect, 2 unilateral second and third metacarpal bone defects and 6 phalangeal shortening after repair of digital stump (involving thumb in 4 cases, index finger in one and index and middle fingers in one). The metacarpophalangeal bone defects averaged 1.8 cm (from 1.0 to 3.1 cm). Under the fluoroscopic guide, 4 or 6 mini half-pins in one line were directly drilled into the dorsal aspect of the involved metacarpophalangeal bone before the Orthofix fixator was mounted. The proximal (18 digits) or distal (2 digits) osteotomy between the second and third pinholes was performed via the dorsal approach. The external fixator and pins were removed without anesthesia after callus maturation. Results Average follow-up period was 12.2 months (range, from 9 to 26 months). All the metacarpal bone defects were reconstructed and all the phalangeal shortenings were lengthened; the bony callus was completely calcified at the lengthened part. The mean lengthening was 1.9 cm (from 1.0 to 3.1 cm); the percentage of lengthening ranged from 26% to 51% (average, 34%). The bone lengthening index (time cost by average 1 cm) was 70.9 d/cm (from 60.0 to 87.1 d/cm). According to the Tentative Assessment Criteria for Upper Extremity Function by Hand Surgery Society, Chinese Medical Association, the total activity of motion (TAM) was excellent in 13 cases, good in 4, fair in 2, and poor in one, yielding an excellent to good rate of 85.0%. Conclusion Distraction lengthening using mini external fixation is a valid option with a minor rate of complications which allows for early functional exercise to help restore the appearance and function of the affected fingers. Key words: Hand; Injury; External fixators; Bone lengthening; Bone defect

Distraction Osteogenesis for Surgical Treatment of Craniosynostosis: A Systematic Review.

Distraction osteogenesis has been proposed as an alternative to cranial remodeling surgery for craniosynostosis, but technique descriptions and outcome analyses are limited to small case series. This review summarizes operative characteristics and outcomes of distraction osteogenesis and presents data comparing distraction osteogenesis to cranial remodeling surgery. A systematic review of the literature was undertaken. Descriptive analysis, operative technical data, outcomes, or postoperative complications of distraction osteogenesis for craniosynostosis were included. A total of 1325 citations were reviewed, yielding 53 articles and 880 children who underwent distraction osteogenesis for craniosynostosis. Distraction plates were used in 754 patients (86 percent), whereas springs were used for the remaining 126 patients (14 percent). Standard and spring distraction osteogenesis was reported to successfully treat the primary condition 98 percent of the time. Suboptimal results were reported in 11 patients (1.3 percent), and minor complications were reported in 19.5 percent of cases (n = 172).Major complications were rare, occurring in 3.5 percent of cases (n = 31), and included two reported deaths. Absolute operative times and blood loss were marginally greater for cranial remodeling surgery cases, but the differences were not statistically significant. Distraction osteogenesis is an effective cranial vault remodeling technique for treating craniosynostosis. No statistical differences were found with respect to operative time, blood loss, need for transfusion, or intensive care unit resources compared with cranial remodeling surgery. Outcome studies with longer follow-up periods specifically investigating cost, relapse, and reoperation rates are necessary to effectively compare this treatment modality as an alternative to cranial remodeling surgery. Therapeutic, IV.

Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia

Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6cm) bone defects of tibia treated with distraction osteogenesis. The study included 35 patients (30 males and 5 females) who had minimum of 6cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27cm. Mean follow-up period was 25.4 months. Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness. Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients.

Distraction osteogenesis for brachymetatarsia: Clinical results and implications on the metatarsophalangeal joint

Background: Distraction osteogenesis (DO) using external fixation has revolutionized the management of brachymetatarsia, yet not without complications (30-100% incidence), the most common involving the metatarsophalangeal (MTP) joint. Questions/Purposes: What are the clinical outcomes of DO for brachymetatarsia? What are the challenges and outcomes particularly related to the MTP joint? Does the method of stabilizing MTP joint during DO affect the outcome? Materials and Methods: This is a retrospective study of 44 metatarsals (MTs) in 27 patients who underwent DO. Regarding MTP joint stabilization; 43% were fixed with K-wire across the joint, 32% with pinning of phalanges short of joint and attaching the K-wire to the external fixator, 7% by pinning of phalanges and distraction arthroplasty of the MTP joint, 2% no stabilization, and 16% by other methods. Clinical outcomes were analyzed by a nonvalidated 9-item questionnaire at the latest follow-up in addition to a review of postoperative radiographs. Complications, particularly pertaining to MTP joint were recorded. Statistical Analysis: The paired t-test was used to assess the difference in MT length. Fisher's exact test used to evaluate rates of complications by MTP fixation method. McNemar's test was used to measure the difference in outcome questionnaire responses. Cochran-Armitage trend test was used to assess differences in toe-limitation before and after surgery. Results: Postoperatively, MT length showed a significant increase of 12.98 ± 3.74 mm (28.55 ± 9.25%). Problems included MTP stiffness in 64%, MTP subluxation in 27%, and MTP dislocation in 7%, with no significant differences in outcome by MTP joint stabilization. Satisfaction with surgery was reported by 95% of patients. Conclusion: DO is an effective treatment for brachymetatarsia, with high patient satisfaction. The most commonly reported problem was MTP joint stiffness with no functional deficit. There was no significant difference in the rate of MTP joint-specific complications by stabilization method. Larger patient numbers are required for validation of an optimal MTP joint stabilization method. Level of Evidence: IV, Case Series.

Histomorphometric comparison between continuous and discontinuous distraction osteogenesis

Experimental research on optimising the distraction protocol has been performed extensively in the past. However, relatively little research has been done on the rhythm of distraction. Findings in the orthopaedic literature showed that the outcome of distraction osteogenesis (DO) is positively influenced by increasing the rhythm of distraction. The aim of this study is to quantitatively compare continuous with discontinuous rhythms of distraction in rabbits. Tissue blocks of regenerated bone were harvested from thirty-eight young adult female New-Zealand White rabbits. After a latency period of three days, rabbits were subjected for eleven days to either single daily activation of the distractor at a rate of 0.9 mm/d, or triple daily activation at a rate of 0.9 mm/d, or continuous activation at a rate of 0.9 mm/d. After three weeks of consolidation, bone regenerates were analysed using histomorphometry. The continuous DO group showed significantly (p<.01) more regenerate bone volume in the central part of the regenerate than the discontinuous DO groups. Higher osteoblastic activity was seen, as well as more blood vessels (p<.05). Bone volume and the number of blood vessels correlated significantly in the central part of the regenerate (p<.05). Also, the early mineral apposition rate (MAR) was higher than the late MAR (p<.05). Continuous DO significantly accelerates bone formation when compared with discontinuous DO.

Distraction osteogenesis of the femur using conventional monolateral external fixator

The author has developed a new simple technique of distraction osteogenesis using conventional monolateral external fixator for femoral lengthening. The primary purpose of the present study was to evaluate the results of treatment with this new technique of femoral lengthening and also to evaluate the effect of preoperative and intraoperative variables on the outcome of distraction osteogenesis in general. Fifty-one femora in 50 patients were lengthened. Limb-length discrepancy was the primary indication in all patients. The mean age of the patients at the time of the surgery was 21.9 years (range 5-48 years). The average follow-up period was 24.6 months after removal of the fixator (range 6-120 months). All lengthenings were performed using conventional AO/ASIF external fixator. Twenty-two femora had associated axial or rotational deformities. Gradual distraction was performed to increase length and to correct angular deformity in coronal plane. Acute closed wedge angular correction in sagittal plane or derotation was performed in 12 femora in this study. The length of the 51 femora was increased by an average 4.4 cm (range 1-13 cm), or 12% (range 2.5-40.9%). The average healing index was 50.5 days/cm (range 22.5-110.6 days/cm). Average gradual angular correction in coronal plane in 14 femora was 20.4 degrees (range 10-45 degrees ). Average acute correction in sagittal plane in five femora was 17 degrees (range 10-20 degrees ). Average acute derotation in six femora was 24.2 degrees (range 10-60 degrees ). There were a total of 61 complications, including 26 problems, 18 obstacles, and 17 sequelae. The overall rate of complications was 1.2 per femur. Fifteen femora had delayed consolidation (healing index >54 days/cm). Three of 51 lengthening procedures did not lead to consolidation (nonunion). A significant negative parabolic relationship was noted between the healing index and the amount of length gained (R = -0.47 and P = 0.004). There was a significantly positive exponential relationship between age and healing index (R = 0.51 and P < 0.001). Acute deformity correction, level of osteotomy (submetaphysis versus diaphysis) had no significant effect on healing index. The greater amount of length gained was associated with complications. The newly presented technique of distraction osteogenesis is a useful and cost-effective method for femoral lengthening. Increased lengthenings produced a better healing index but might associate with complications. Younger age was associated with better bone healing but age had no effect on complication rate. Level of osteotomy, acute deformity correction had no effect on healing index and rate of complications.

Effects of diclofenac and tenoxicam on distraction osteogenesis

In the management of bone defects, pseudoarthrosis, deformities, chronic osteomyelitis and in extremity lengthening procedures, the technique of distraction osteogenesis (DO) has been frequently used. In this experimental animal study, the effects of two non-steroidal anti-inflammatory drugs, i.e., diclofenac and tenoxicam, on the outcomes of distraction osteogenesis are investigated. In this study, 30 mature New Zealand-type male rabbits (2.5-4.5 kg) were used. The rabbits were randomized into three groups, each consisting of ten animals. Under optimal operating conditions, a pre-reconstructed circular external fixator was applied on the right tibias of rabbits, and osteotomy was performed with a Gigli saw just below the tibial tuberosity. After seven postoperative days, distraction was initiated at a rhythm of 2 x 0.5 mm/day. During the 10 days of distraction, adjunctive therapy was not instituted for group I (control group). For 10 days, group II received i.m. diclofenac sodium (0.5 mg/kg per day) and group III was treated with tenoxicam (8 mg/kg per day i.m.). At the end of 3 weeks postoperatively, five rabbits from each group were killed for histologic examinations. The remaining rabbits were killed at the end of eight postoperative weeks for biomechanical and histological analysis. Besides, radiological examinations were performed at the end of 3, 6 and 8 weeks postoperatively for the radiologic evaluation of calluses. For statistical evaluations between groups, Kruskal-Wallis variance analysis, and for intergroup assessments, Mann-Whitney test were performed. For radiological evaluations, the scoring system developed by Lane and Sandhu, and for histopathological assessments, the grading system of Huddlestone et al. were used. Biomechanical tests were realized using torsional loading. During the first 3 weeks, the groups did not differ much in the radiological parameters. However, in the diclofenac group and in especially the tenoxicam group, the histological scores were lower than in the control group. Radiological images obtained at the end of 6 weeks demonstrated inadequate consolidation in the diclofenac and tenoxicam groups when compared with the control group. At the end of 8 weeks postoperatively, in consideration of biomechanical, radiological and histological tests, significantly worse regenerates were obtained in the diclofenac and tenoxicam groups. During the distraction osteogenesis period, diclofenac and tenoxicam affected the quality of regenerate unfavorably. This effect is sustained during all periods of bone healing. However, this finding should be supported by experimental and human studies.

Clinical Outcomes of Distraction Osteogenesis in First Brachymetatarsia

Purpose : To evaluate the clinical results of lengthening in first brachymetatarsia using a distraction osteogensis with an external fixator. Materials and Methods : Fifteen cases in nine patients, who had received firstmetatarsal distraction osteogenesis from January 1996 to December 2002, were enrolled in this study. At the final follow-up, the application time of the external fixator was measured and the percentage of lengthening, healing index, complication rate, and the patients satisfaction was analyzed. The patients satisfaction was evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) scores, which were scored according to the level of stiffness, pain, function, and alignment. Results : The score according to the AOFAS-Hallux Metatarsophalangeal joint and Inter-Phalangeal joint scale was excellent in 13 patients and good in 2. All patients were satisfied with the procedure. The average percentage of lengthening was 48.7%. The average healing index was 72.8 days/cm. The major complication was a cavus foot, which was noticed in four feet. All the first toes showed some decrease in motion at the metatarsophalangeal joint. The other complications were hallux valgus, angulation of the metatarsals, and a pin tract infection each in two feet. Conclusion : Distraction osteogenesis is an effective method for first brachymetatarsia. However, excessive lengthening can cause potential complications.

Management of neonatal and pediatric airway obstruction: treatment with distraction osteogenesis

The use of distraction osteogenesis (DO) for the successful treatment of obstructive sleep apnea in the pediatric population has been reported by multiple authors over the last several years. The focus of this clinic will be to review the diagnosis and treatment modalities for neonates and children with airway obstruction. The clinician for this course has treated children and neonates with DO over the last 7 years and will present the techniques, pitfalls, and outcomes of his experience. The use and long-term outcomes of DO and other airway-changing surgery will be discussed.

Muscle Regeneration and Fiber-Type Transformation during Distraction Osteogenesis

The successful outcome of distraction osteogenesis depends in part on the adequate adaptation of the surrounding soft tissue. We characterized the adaptation of the tibialis anterior during distraction osteogenesis at different rates (0.7 and 1.4 mm/day) and amounts (15 and 30%) of lengthening. We documented the increased expression of neonatal and slow myosin heavy chain in the tibialis anterior of skeletally immature rabbits. There was neither expression of neonatal myosin heavy chain in the experimental soleus or in the slow muscle fibers of the tibialis anterior nor increased expression of slow myosin heavy chain in the soleus or gastrocnemius. The increased amount of neonatal myosin heavy chain was concentrated in the distal half of the muscle, whereas the increase in the number of fibers that were labeled with antibodies to slow myosin occurred to the same extent throughout the tibialis anterior. Electrophysiological methods showed that the tibialis anterior was functionally intact during and after distraction osteogenesis. We concluded that in the tibialis anterior of young, skeletally immature animals, distraction osteogenesis seems to induce a recapitulation of the developmental process without leading to functional changes. In addition, during distraction osteogenesis, a fiber-type transformation occurs similar to that observed in models of muscle overloading.