Rhythm Of Distraction Research Articles

Use of a Motorized Intramedullary Bone Transport Nail for Trauma: Tips, Tricks, Corticotomy Techniques, and Rate and Rhythm.

The introduction of internal magnetic nails (IMNs) for bone lengthening and bone transport has given us exciting new tools with which to treat segmental bone loss. Distraction osteogenesis has a long record of success in recreating even large segments of bone, but the availability of IMNs now offers the possibility of performing distraction osteogenesis without the drawbacks of external fixation. However, there are aspects of treatment with IMNs that are critical to understand to achieve success and minimize complications. These include assessment of feasibility in relation to available bone stock and segment configuration, the condition of the soft tissue envelope, and the presence of contamination or infection. They also include execution aspects such as bone end preparation, nail placement, need for and positioning of adjuvant fixation, corticotomy techniques, rate and rhythm of distraction, staged screw exchange, docking site preparation, and nail extraction. We discuss these issues in detail and introduce some novel techniques not previously described including the comminuted wedge osteotomy, testing of the nail with initial compression, and retention plug application for nail extraction to assist in optimizing success in certain clinical situations.

A Review on Variability in Treatment Protocols With Posterior Cranial Vault Distraction.

Prior studies have confirmed the ability of posterior cranial vault distraction osteogenesis (PVDO) to expand the intracranial volume in patients with craniosynostosis. To date, there is scant literature on the optimal distraction protocol for PVDO. The authors sought to review the literature and define a common protocol for posterior cranial vault distraction. The authors performed a systematic review for published PVDO protocols. The data collected from these studies included age at the time of PVDO, number of distraction devices placed, time for latency, rate and rhythm of distraction, distraction length, time for consolidation, and surgical outcomes. A total of 286 patients were identified within 24 studies from 2011 to 2019. The mean age of patients identified was 25.34 months. After application of distractors, latency period ranged between 1 and 7 days, with most patients undergoing 5 to 7 days of latency. Once distraction was begun, the majority of patients (77.4%) underwent 1 mm of distraction daily. Total lengths of distraction ranged between 13 and 35 mm, with the largest cohort of patients undergoing 26 to 30 mm of total distraction. A total of 60 complications were reported for a total of 212 patients, yielding an overall complication rate of 28.3%. Although there is variability in reported PVDO protocols, the majority are similar to distraction osteogenesis protocols described for long bone sites. Increased patient age correlates with selection of a greater latency period and total distraction length, while frequency of complications is also increased.

External fixators: looking beyond the hardware maze.

External fixation has a wide variety of orthopedic applications. Although external fixator frames may have a complex appearance, these constructs are formed from several basic components and can be broadly categorized into unilateral, circular, or hybrid designs. The introduction of computer-aided circular external fixation devices (hexapod frames) has simplified the treatment of multiaxial and especially rotational deformities. Serial radiography plays a central role in the evaluation of callus formation (at the level of treated fracture or nonunion as well as the regenerate and docking site with distraction osteogenesis), tailoring the rate and rhythm of distraction during distraction osteogenesis, evaluation of frame complications, and determination of the timing of frame removal. The goals of this article are to review: the components, types, and relevant terminology of external fixator constructs with special emphasis on the Taylor spatial frame, the principles and techniques of distraction osteogenesis, and complications of external fixation.

Устранение обширного мягкотканного дефекта бедра посредством дермотензии по технологии Г.А. Илизарова

The authors present a clinical case of a successful surgical treatment of a soft-tissue defect in a female patient with pelvic bone fractures and a severe extensive defect of the femoral soft tissues by using traction appliances fixed to the Ilizarov fixator. The method of transosseous osteosynthesis was used for treatment. Secondary sutures were applied after soft tissue necrectomy and the ligature ends were fixed to the mentioned traction appliances. Optimal rate and rhythm of distraction was produced in the process of dermotension. The traction of the wound ends towards each other started on the second day after surgery with the rate of 0.5 mm 6–8 times a day and continued 15 days. A 30-cm long juxtaposition of the wound edges was achieved. It enabled to use interrupted sutures. The integumentary tissue defect of the area over 1500 cm2 was eliminated. The remaining wound areas that measured 5.0 cm × 10.0 cm and 8.0 cm × 12.0 cm in size were eliminated using the Tyrs dermoplasty. The patient’s skin biomechanical condition was evaluated by acoustic velocimetry in order to prevent skin overstretching. Microcirculation of tissues in the wound and that of the stretched skin was controlled by ultrasound high-frequency Dopplerography. The healing of the wound soft-tissue defect using graduated dermotension is associated with redistribution of stresses in the integumentary tissue and with formation of its new mechano-biological status. Indirect signs of skin overstretching near the wound edges were not revealed. Three types of blood flow in the wound tissue were recorded with ultrasound Dopplerography: microcirculatory, arterial, and venous with a clear respiratory wave. The calculated index of differences near the wound edge and in the wound soft tissues varied from 5.0 to 23.0 relative units that is typical for an active granulation process. Good anatomic and functional results were achieved clinically. Static and locomotor functions of the lower limb recovered completely. The patient was satisfied with the cosmetic and functional results. The technique of dermotension using the Ilizarov fixator was used at the Center’s clinic in 19 patients with open fractures of long bones that were accompanied with soft tissue defects of various sizes.

Utilisation rationnelle de la distraction osseuse en chirurgie craniofaciale

Distraction osteogenesis, initially developed by Ilizarov for limb, is the tissular extension caused by the progressive space of the osseous pieces following an osteotomy. Distraction is osteogenesic and histogenic. Twenty-five years ago, at the instigation of McCarthy, this technique was used to handle the craniofacial malformations in the various floors of the face: mandibular, mediofacial and cranial. The most wide-spread protocols respect a latency period from 0 to 7days, a rhythm of distraction from 1 to 2mm a day in 2 at 4times and a period of consolidation from 4 to 8weeks. Distraction is the result of the inventiveness of the pioneers then the work to always adapt to the multiple complex clinical situations. The surgeon has to choose between internal or external materials allowing a mono- or multi-vectorial extension, in osseous and/or dental anchoring. The mandibular distraction is very effective for the treatment of the secondary obstructive syndromes in the unilateral or bilateral severe hypomandibular malformations. She also allows desobstruction of the superior airways within the framework of the mediofacial hypoplasies as well as the secondary treatment of the growth defects in cleft lips and palates. Finally, the distraction osteogenesis enhanced reliability of the fronto-facial advancement in early and secondary treatment of craniofaciosynostosis. This is a real support of the facial growth, which has to be included in a plan of global treatment.

Assessment of Mandibular Distraction Regenerate Using Ultrasonography and Cone Beam Computed Tomography: A Clinical Study.

Distraction osteogenesis (DO) is becoming a popular method of reconstruction for maxillofacial bony deformities or defects secondary to trauma or surgical tumor ablation. However, the technique is very sensitive in terms of the rate and rhythm of distraction. Because of this, there is a need for monitoring of the distraction regenerate during the distraction as well as the consolidation period. The present study was conducted to assess the regenerate using two imaging modalities, namely, ultrasonography (USG) and cone beam computed tomography (CBCT) to determine their relative efficacies and to weigh their clinical usefulness in assessment of DO regenerate. The study was conducted on 12 patients (18 sites) who underwent mandibular distraction for correction of facial deformities. The results showed that overall USG correlated better with the condition of regenerate (r = 0.606) as compared with CBCT (r = 0.476). However, USG was less effective as compared with CBCT in assessing the regenerate once corticomedullary differentiation occurred in the bone.

Motorized, Telescopic, Intramedullary Lengthening Nails for Limb Length and Deformity Correction

A new generation of remote controlled internal limb lengthening nails is now available. This article will review the history, techniques, and early outcomes of motorized limb lengthening nails. Recommendations are made for patient selection, preoperative planning, intraoperative techniques, postoperative care, and avoidance of complications. These devices allow an accurate and well controlled rate and rhythm of distraction for limb lengthening. Early clinical reports indicate improved outcomes and less patient pain compared with external fixator lengthenings. Proper preoperative planning is an essential part of the methodology. Acute intraoperative correction is often required with fixator-assisted nailing techniques, as later adjustment during or after lengthening is not possible without additional surgery. Antegrade and retrograde femoral and antegrade tibial techniques are discussed, including patient indications, preoperative planning, surgical steps, pearls, pitfalls, and complications.

Application of a Novel Intraorally Customized Transport Distraction Device in the Reconstruction of Segmental Mandibular Defect

The purpose of this study was to evaluate the clinical result of segmental mandible reconstruction by using a novel intraorally customized trifocal curvilinear distractor. A customized curvilinear distractor with self-locking system and bidirection transport assembly was designed on the basis of the mandibular contour of a patient diagnosed with ameloblastoma. Two transport disks, each containing the first molar, were designed for trifocal distraction osteogenesis after partial mandibulectomy intraorally. The latency period is 7 days and distraction rhythm is 1 mm/d. After 6 months of consolidation, the second operation was performed to remove the device. A new bone bridged the mandibular defects through transport distraction successfully. Partial bony nonunion between the transport disks was noted when removing the distractor; rigid internal fixation using a titanium plate and bone graft was carried out to ensure the continuity. Bilateral sagittal split ramus osteotomy was performed to advance the mandible when anterior-posterior jaw bone discrepancy occurred before final denture restoration. Customized trifocal curvilinear transport distraction osteogenesis can successfully reconstruct segmental mandible defect intraorally, but special consideration should be paid on the dock site bone healing and overcorrection of curvilinear reconstruction in the future.

HISTOMORPHOMETRIC ANALYSIS OF THE KNEE ARTICULAR CARTILAGE AND SYNOVIUM FOR METADIAPHYSEAL LEG LENGTHENING (EXPERIMENTAL-AND-MORPHOLOGICAL STUDY)

The knee articular cartilage and synovial membrane have been studied for metadiaphyseal leg lengthening using the methods of light miscroscopy, computer morpho- and stereometry. The manner of bone integrity breaking, the rate and rhythm of distraction conformed to the lengthening technique most often used in the clinic. The results of the histomorphometric analysis have demonstrated that when osteotomy at the level of metadiaphysis and manual distraction by 1 mm a day for 4 times is performed, synovitis of mild and moderate degree develops through subsynovial layer hypervascularization, as well as reactive-destructive changes in nerve fibers with the tendency to regeneration. The structural-functional changes of reactive and/or destructive-reparative character have been revealed in the articular cartilage, and the manifestation degree of these changes correlates with synovial membrane changes. The intensity of the destructive-reparative processes in the articular cartilage and synovial membrane depends on fixation stability.

Clinical application of transport distraction osteogenesis arthroplasty in the treatment of temporomandibular joint bony ankylosis

To explore the clinical application of transport distraction osteogenesis arthroplasty (TDOAP) in the treatment of temporomandibular joint (TMJ) bony ankylosis. From December 1999 to December 2011, a total of 73 patients (89 sides of TMJ) underwent TDOAP were included. There were 39 males and 34 females with a mean age of 19.6 years (range: 3 - 60). Among them, 27 patients were recurrence cases and 30 cases were accompanied with micrognathia and obstructive sleep apnea-hypopnea syndrome (OSAHS). The mean preoperative degree of mouth opening was 6.6 mm (range: 1 - 20). After a release of ankylosis, a transport disc was performed and fixed to ramus with a distractor. Distraction began at Days 4 - 8 postoperation. The distraction rhythm and rate were 0.25 mm four times daily. Distraction stopped when planning distance was achieved. And a distractor was maintained in place for 3-6 months after completion of distraction and then removed. Active postoperative training of mouth opening was implemented. The mean distance of distraction was 15.3 mm (range: 12 - 23). The range of mouth opening of 65 patients increased to normal and bone formation in gaps were perfect. The mean follow-up period was 44.8 months (range: 18 - 102). Eight cases were recurrent. And 1/37 over 15 years old and 7/36 under 15 years old had recurrence. TDOAP is an effective treatment for TMJ ankylosis. A pediatric patient, especially recurrent, should be operated after adolescence to decrease recurrence. Micrognathia and OSAHS should be also considered during the treatment of ankylosis.

Distraction osteogenesis for bone repair in the 21st century: Lessons learned

Bone regeneration obtained by distraction osteogenesis is influenced by a series of factors. These include factors that are related to the mechanical stability of the system of distraction (internal or external devices), and to factors directly depending on the biology of the bone tissue, such as the method of bone interruption (osteotomy), the delay and rhythm of distraction, the anatomical site of the osteotomy, and the histological characteristics of the bone requiring reconstruction. The stability of the system of bone fixation depends on the rigidity of the frame, the connexion of the apparatus to the bone (wires, pins) and the intrinsic stability of the segment (length and level of maturation of bone regenerate). The radiological characteristics of bone regeneration (hypo- or hypertrophy) lead to the adaptation of the rhythm of distraction. Following more than 28 years of experience of application of the Ilizarov method for bone reconstruction, the authors describe the technique of frame assembly and the methods of evaluation and treatment of the complications of new bone formation.

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.

Poster 147: Unilateral Augmentation of the Zygomaticomaxillary Complex With Rigid External Distraction Osteogenesis for Treating Hemifacial Hypoplasia: Report of 2 Cases

We report on performing unilateral augmentation of the zygoma with modified application of distraction osteogenesis with using a rigid external device in two patients who had radiation therapy during their childhood bone growth period. Two patients (one male and one female) with severely atrophied zygomatic complex were treated with a rigid external distraction device (Red II system, KLS Martin, Germany). The patients had severe depression of the right zygomatic complex resulting from growth disturbances that were due to the radiation therapy they received in childhood. One patient had undergone two jaw surgeries for correction of facial asymmetry before undergoing distraction osteogenesis. The distraction device was eccentrically positioned to distract the zygomatic segment to the anterolateroinferior direction. The distraction rhythm and rate were 0.5 mm of activation twice a day in one patient and once in the other patient. The distraction was continued until obtaining a little overcorrection and symmetrical prominence of the zygoma. The follow-up period was more than 1 year for both patients. n/a No surgical complications occurred during the follow up period. The distracted zygomatic bone segment showed stability when the external device was removed. However, rigid fixation with titanium miniplates was performed for the purpose of preventing relapse. To our knowledge, this is the first clinical report on performing distraction osteogenesis of the zygomaticomaxillary complex using a rigid external device in the three-dimensional direction. One patient showed clinically satisfactory results and the other patient suffered moderate relapse. These results suggest that more clinical experience with this technique is needed.

Linear Increase in Axial Stiffness of Regenerate Callus during Limb Lengthening

Distraction osteogenesis is a powerful tool for addressing segmental defects and limb-length discrepancies. Guidelines for the rate and rhythm of distraction have been described. The possibilities of early consolidation or nonunion threaten clinical success. A quantifiable method for monitoring the distraction gap would be useful. Previous methods to measure regenerate callus stiffness have not gained widespread clinical acceptance, largely because of cumbersome instrumentation. A rabbit tibial lengthening model was used to show the clinical utility of a digital torque wrench in monitoring axial stiffness of the regenerate bone callus during distraction osteogenesis. We confirmed the linear increase in peak torsional stiffness with time, which has been reported by others. This relationship may prove to be a useful clinical adjunct in guiding the rate and rhythm of distraction during limb lengthening.

Tratamento da falha óssea parcial pelo transporte ósseo parietal

OBJETIVO: Descrever a técnica de transporte ósseo parietal para tratamento de falha óssea parcial, e descrever o resultado clínico e radiográfico de uma série de pacientes tratados por esta técnica. CASUÍSTICA E MÉTODO: tratamos nove pacientes portadores de lesão óssea parcial, sendo seis localizada na tíbia e três no fêmur. Todos apresentavam lesão infectada, acompanhada de pseudo-artrose. O procedimento iniciou-se com estabilização do segmento ósseo com fixador externo, seguido de corticotomia parietal, em osso sadio adjacente à falha, para criar o fragmento que foi transportado. Este fragmento foi transfixado por fios olivados, que conectados às hastes sulcadas permitiam o transporte ósseo. Em dois pacientes os fragmentos utilizados eram de osso adjacente (fíbula), transportados para a tíbia em direção da tíbia. A latência, velocidade e ritmo de distração foram os preconizados por Ilizarov. RESULTADOS: a infecção e a pseudo-artrose foram curadas em todos os casos, com preenchimento da falha óssea. As complicações encontradas foram infecção nos orifícios dos fios na pele e regenerado hipotrófico. CONCLUSÃO: o tratamento da falha óssea parcial pelo transporte ósseo parietal determinou solução do processo infeccioso, com consolidação da pseudo-artrose e preenchimento da falha óssea.

Cellular and molecular characterization of a murine non-union model

Purpose. We have developed a method to study the molecular and cellular events underlying delayed skeletal repair in a model that utilizes distraction osteogenesis. Methods. The clinical states of delayed union and non-union were reproduced in this murine model by altering distraction parameters such as the inclusion and exclusion of a latency phase and variations in the rate and rhythm of distraction. Radiographic, cellular, and molecular analyses were performed on the distraction tissues. Results. Eliminating the latency period delayed bony union, but did not appreciably alter the extent of platelet endothelial cell adhesion marker (PECAM) immunostaining. Following elimination of a latency phase and a threefold increase in the rate of distraction, there was a further delay in bone regeneration and a higher rate of non-union (60%). Instead of bone, the distraction gap was comprised of adipose or fibrous tissue. Once again, despite the rigorous distraction protocol, we detected equivalent PECAM staining within the distraction gap. In a minority of cases, cartilage and osseous tissues occupied the distraction gap likely by a prolonged process of endochondral ossification. Conclusions. Here, we have altered the mechanical environment in such a way to reproducibly create delays in skeletal regeneration. These delays in skeletal tissue regeneration appear to develop even in the presence of endothelial cells, which suggests that mechanisms other than a disruption to the vascular network can account for some cases of non-union.

Distraction osteogenesis: use in mandibular and maxillary reconstruction

Distraction osteogenesis is a technique that generates viable new bone through the gradual stretching of existing bone. The technique has long been used for the lengthening of long bones by early orthopedic surgeons, but only within the past few decades has distraction osteogenesis been applied to the mandible and facial skeleton. Advances in technique, engineering, and biochemistry have expanded the role and have facilitated the use of this conventional treatment. The authors discuss the current research regarding the controversy over the ideal latency and consolidation periods as well as the optimal rate and rhythm of distraction. Notable advancements in mechanical design have led to more efficient bone growth and faster recovery. Recent cutting-edge devices capable of the simultaneous delivery of various growth agents are merging clinical treatment and current research. This article highlights the need for future studies that will further elucidate the biochemistry of bone physiology and better define the role of hormones, growth proteins, and gene therapy in clinical distraction osteogenesis.

Craniofacial Distraction Osteogenesis: A Review of 3278 Cases

The nascent field of craniofacial distraction osteogenesis has not yet been subjected to a rigorous evaluation of techniques and outcomes. Consequently, many of the standard approaches to distraction have been borrowed from the experience with long bones in orthopedic surgery. The ideal "latency period" of neutral fixation, rate and rhythm of distraction, and consolidation period have not yet been determined for the human facial skeleton. In addition, because the individual craniofacial surgeon's experience with distraction has generally been small, outcomes and meaningful complication rates have not yet been published. In this study, a four-page questionnaire was sent to 2476 craniofacial and oral/maxillofacial surgeons throughout the world, asking about their experiences with distraction osteogenesis. Information about the types of cases, indications for surgery, surgical techniques, postoperative management, outcomes, and complications were tabulated. Of 274 respondents (response rate, 11.4 percent), 148 indicated that they used distraction in their surgical practice. One hundred forty-five completed surveys were entered into a database that provided information about 3278 craniofacial distraction cases. Statistical analyses were performed comparing the rates of premature consolidation, fibrous nonunion, and nerve injury, on the basis of the use of a latency period and different rates and rhythms of distraction. In addition, the rates of all complications were determined and compared on the basis of the number of distraction cases performed per surgeon. The results of the study clearly show a wide variation in the surgical practice of craniofacial distraction osteogenesis. Although the cumulative complication rate was found to be 35.6 percent, there is a pronounced learning curve, with far fewer complications occurring among more experienced surgeons (p < 0.001). The presence of inferior alveolar nerve injury as a result of mandibular distraction was much lower for respondents whose distraction regimens consisted of no more than 1 mm of distraction per day (19.5 percent versus 2.4 percent; p < 0.001). No evidence was found to support the use of a latency period or to divide the daily distraction regimen into more than one session per day. Conclusions could not be drawn from this study regarding the length of the consolidation period. Overall, the surgeon-reported outcomes are comparable with those published for other craniofacial procedures, despite the higher incidence of complications. Although conclusions made on the basis of a subjective questionnaire need to be interpreted cautiously, this study has strength in the large numbers of cases reviewed. Because of the anonymity of responses, it has been assumed that surgeons who responded to the survey reported accurate numbers of complications and successful outcomes. Finally, additional clinical and animal studies that will be of benefit in advancing the field of craniofacial distraction osteogenesis are outlined.

Effect of rhythm and level of distraction on muscle structure: an animal study.

To determine the optimal rhythm of distraction and level of osteotomy for maximal muscle preservation during limb lengthening, histologic and ultrastructural analysis of the peroneus tertius muscle was performed in 46 goats. Thirty-nine animals with 20% or 30% tibial lengthening at the rate of 0.75 mm per day at each osteotomy level were divided in two groups. The first group included 15 animals undergoing tibial middiaphyseal lengthening with automated distractor producing one (n = 5), four (n = 5), or 720 (n = 5) increments per day. The second group included 24 animals in which lengthening was performed at the proximal (n = 4), middle (n = 6), distal (n = 6), or double (n = 8) level of the tibia with distraction rhythm of three times per day. The remaining seven animals served as controls. Histomorphologic features of the lengthened muscles were characterized by a polymorphous appearance with foci of necrosis, atrophy, and sclerosis scattered among apparently normal muscle fibers. The intensity and dispersion of degenerative changes were in direct proportion to the amount of lengthening but in reverse proportion to the frequency of distraction. Tibial lengthening at the diaphysis caused intense fibroblast proliferation and remarkable muscle sclerosis, whereas metaphyseal distraction was associated with a predominance of muscle tissue regeneration over atrophy and sclerosis. Bifocal lengthening and a more fractionated rhythm of distraction were associated with enhanced preservation of existing muscle fibers and greater regenerative activity of the muscle.

Behavior of Blood Vessels During Lower-Leg Lengthening Using the Ilizarov Method

Using a ring fixator, lengthening of the right lower leg by 2.5 cm at a distraction rate of 2 x 0.5 mm per day was performed in 24 beagle dogs. After a postoperative latency period of 5 days and a distraction phase of 25 days, half the dogs were killed (30-day group). The remaining half were killed after a second interval of 25 days (55-day group). After the experiment, the anterior tibialis artery and vein with their supporting vessels, as well as the lesser saphenous vein of both the lengthened right side and the control side were excised and examined histologically, histomorphometrically, and electron microcopically. No morphologic changes of the vascular walls and no increase of collagenous or elastic fibers could be found. The histomorphometric evaluations showed a significant increase in the number of vasa vasorum in the dogs of both the 30- and 55-day groups. No significant difference in thickness of the vascular wall, tunica media, and adventitia could be observed between the lengthened and the control side in both dog groups. It seems that blood vessels can adapt to continuous tension during callus distraction without suffering structural damage and are the least limiting factor concerning distraction speed, distraction rhythm, and distraction length during callus distraction.