Underwent Distraction Osteogenesis Research Articles

Distraction Osteogenesis and Endoscopic Suturectomy in the Treatment of Rachitic Craniosynostosis: A Case Series and Updated Literature Review With Discussion of Cephalometrics

Background: Individuals with genetic or nutritional rickets frequently suffer from craniosynostosis. While cranial vault remodeling is most often performed, other approaches, such as distraction osteogenesis and endoscopic suturectomy, are infrequently reported. Here, we discuss the status of the current literature and describe 2 patients with rachitic craniosynostosis, one of whom had previously undergone endoscopic suturectomy, who both successfully underwent distraction osteogenesis. Case description: Two male patients with rickets-associated craniosynostosis, 1 genetic and 1 nutritional, underwent posterior-vault distraction osteogenesis (PVDO). The patient with genetic rickets previously underwent endoscopic-assisted cranial suturectomy of the sagittal suture with barrel-staving at an outside hospital and subsequently re-fused all cranial sutures 19 months postoperatively necessitating reintervention. Complete distraction was confirmed by X-ray and both patients recovered without complication and without re-synostosis at 18 month follow-up. The patient with nutritional rickets required subsequent fronto-facial advancement because of poor midface growth. Conclusion: PVDO effectively treats rachitic craniosynostosis associated with both genetic and nutritional etiologies. Long-term follow up is warranted to monitor for skull-base involvement and associated midface retrusion in these patients.

A retrospective study of occlusal reconstruction in patients with old jaw fractures and dentition defects

PurposeThis study evaluated the methods and clinical effects of multidisciplinary collaborative treatment for occlusal reconstruction in patients with old jaw fractures and dentition defects. MethodsPatients with old jaw fractures and dentition defects who underwent occlusal reconstruction at the Third Affiliated Hospital of Air Force Military Medical University from January 2018 to December 2022 were enrolled. Clinical treatment was classified into 3 phases. In phase I, techniques such as orthognathic surgery, microsurgery, and distraction osteogenesis were employed to reconstruct the correct 3-dimensional (3D) jaw position relationship. In phase II, bone augmentation and soft tissue management techniques were utilized to address insufficient alveolar bone mass and poor gingival soft tissue conditions. In phase III, implant-supported overdentures or fixed dentures were used for occlusal reconstruction. A summary of treatment methods, clinical efficacy evaluation, comparative analysis of imageological examinations, and satisfaction questionnaire survey were utilized to evaluate the therapeutic efficacy in patients with traumatic old jaw fractures and dentition defects. All data are summarized using the arithmetic mean ± standard deviation and compared using independent sample t-tests. ResultsIn 15 patients with old jaw fractures and dentition defects (an average age of 32 years, ranging from 18 to 53 years), there were 7 cases of malocclusion of single maxillary fracture, 6 of malocclusion of single mandible fracture, and 2 of malocclusion of both maxillary and mandible fractures. There were 5 patients with single maxillary dentition defects, 2 with single mandibular dentition defects, and 8 with both maxillary and mandibular dentition defects. To reconstruct the correct 3D jaw positional relationship, 5 patients underwent Le Fort I osteotomy of the maxilla, 3 underwent bilateral sagittal split ramus osteotomy of the mandible, 4 underwent open reduction and internal fixation for old jaw fractures, 3 underwent temporomandibular joint surgery, and 4 underwent distraction osteogenesis. All patients underwent jawbone augmentation, of whom 4 patients underwent a free composite vascularized bone flap (26.66%) and the remaining patients underwent local alveolar bone augmentation. Free gingival graft and connective tissue graft were the main methods for soft tissue augmentation (73.33%).The 15 patients received 81 implants, of whom 11 patients received implant-supported fixed dentures and 4 received implant-supported removable dentures. The survival rate of all implants was 93.82%. The final imageological examination of 15 patients confirmed that the malocclusion was corrected, and the clinical treatment ultimately achieved occlusal function reconstruction. The patient satisfaction questionnaire survey showed that they were satisfied with the efficacy, phonetics, aesthetics, and comfort after treatment. ConclusionOcclusal reconstruction of old jaw fractures and dentition defects requires a phased sequential comprehensive treatment, consisting of 3D spatial jaw correction, alveolar bone augmentation and soft tissue augmentation, and implant-supported occlusal reconstruction, achieving satisfactory clinical therapeutic efficacy.

The Effect of Ketorolac on Bone Healing Rate Following Osteotomy in Pediatric Patients with Deformity or Limb-length Discrepancy

Abstract Background: The mechanism of action of nonsteroidal anti-inflammatory drugs (NSAIDs) and the results of testing in some animal fracture models have created concerns with bone healing when these drugs are used for perioperative orthopedic analgesia. Given that distraction osteogenesis patients require new bone to be formed, they would potentially be sensitive to the effects of NSAIDs such as Ketorolac. We sought to determine the relationship between the perioperative use of Ketorolac and the duration of healing in pediatric patients undergoing distraction osteogenesis for either limb lengthening or deformity correction surgery. Materials and Methods: A single-center retrospective chart review of 94 pediatric patients aged 17 years or younger who had undergone surgery for limb lengthening, deformity correction, or a combination of limb lengthening and deformity correction was carried out. We collected and analyzed patient demographics, details of surgery and pathology, perioperative pain management, duration of healing, and incidence of complications in this cohort of patients. Results: Patients were divided into three groups: a deformity correction group (n = 46), a limb lengthening group (n = 30), and a combined deformity correction and limb lengthening group (n = 18). The mean magnitude of deformity was 21°. Patients in the lengthening group had a mean lengthening of 4.1 cm. Patients in the combined group had a mean magnitude of deformity of 14.7° and a mean lengthening of 3.8 cm. Patients in all three groups received an average of 4 doses of ketorolac in the perioperative period. We found no correlation between the total amount of ketorolac used and the duration of healing among patients who had deformity correction, limb lengthening, or a combination of deformity correction and limb lengthening surgery (P = 0.82, 0.20, and 0.18, respectively). The correlation results also showed no sex variations in either group. Conclusions: Ketorolac can safely be used as an analgesic in pediatric patients undergoing distraction osteogenesis for limb lengthening, deformity correction, or a combination of both procedures.

Is physeal distraction osteogenesis a good choice to treat CPT patients with tibial shortening?

The purpose of this study was to evaluate the healing index and complications of distraction osteogenesis through the physis in children with Congenital pseudarthrosis of the tibia (CPT) using Ilizarov external fixation device. Nine children with CPT who underwent distraction osteogenesis through the physis surgery with an Ilizarov external fixation device between June 2018 and August 2020 were included in the study. The average follow-up time was 36.1 months. X-ray examination was performed 1 month after physis lengthening, and the callus quality was evaluated using the Li classification. Any complications and the quality of the callus after tibial lengthening were followed up. The average age at the time of operation was 9.4 years, and the average follow-up time was 36.1 months. The average lengthening length of children with CPT was 6.6 cm. The incidence of good callus morphology was 100%, and the healing index was 51.1 d/cm. The average fixation time of the external fixation device was 316 days. Needle tract infection occurred in one case, ankle stiffness occurred in one case, ankle plantar flexion 20° deformity occurred in one case, angular deformity of the tibial lengthening segment occurred in one case (7°) and limited movement of knee joint occurred in one case (0-20°-70°). The osteogenic quality of the patients of distraction osteogenesis through the physis with tibial shortening and small diameter of the proximal tibia is good, which provides a choice of operation for the children with CPT.

Posterior Cranial Retraction Combined With Bilateral Parietal Distraction for Children With Nonsyndromic Craniosynostosis.

The nonsyndromic craniosynostosis is the most common of craniosynostoses in childhood. There are many treatments. We aim to treat 12 cases of nonsyndromic craniosynostosis via posterior cranial vault distraction osteogenesis combined with bilateral parietal distraction. Data of a total of 12 patients (7 boys and 5 girls) with nonsyndromic sagittal synostosis who underwent distraction osteogenesis between January 2015 and August 2020 were retrospectively analyzed. Bilateral parietal bone flaps and posterior occipital flaps were designed and cut. Then, distraction device was placed, which was distracted at 5 days after surgery (twice per day, 0.4-0.6 mm/d, and lasting for 10-15 days). After 6 months of fixation, the secondary surgery was performed to remove the device. The scaphocephaly was corrected, and the appearance was satisfactory. Postoperative follow-up time was 6 to 14 months, with an average of 10 months, and the mean CI was 63.2 and 78.25 before and after surgery, respectively; the mean anterior-posterior skull diameter was shortened (12.63 ± 3.47) mm, the transverse diameter of both temporal regions was lengthened (15.4 ± 4.18) mm, and the scaphocephalic deformity was significantly improved. There was no detachment or rupture of the extender postoperatively. No severe complications, such as radiation necrosis or intracranial infection, were observed. Posterior cranial retraction combined with bilateral parietal distraction in children with nonsyndromic craniosynostosis, in which the proposed technique did not exhibit severe complications, and it is worthy of further promotion and application in clinical practice.

How Low Should We Go? Safety and Craniometric Impact of the Low Occipital Osteotomy in Posterior Vault Remodeling.

A larger volume cranial vault expansion is likely facilitated by a low posterior cranial osteotomy beneath the torcula; however, this may impart an increased risk of venous bleeding. The authors compared the safety of infratorcular versus supratorcular osteotomy in patients undergoing posterior vault reconstruction or posterior vault distraction osteogenesis and analyzed volumetric changes. Patients undergoing initial posterior vault reconstruction or distraction osteogenesis between 2009 and 2021 at the authors' institution were grouped by occipital osteotomy location and analyzed retrospectively. Craniometric analysis was performed if patients had high-resolution computed tomography scans available within 180 days preoperatively and postoperatively. A total of 187 patients were included: 106 (57 percent) who underwent posterior vault distraction osteogenesis and 81 (43 percent) who underwent posterior vault reconstruction. Infratorcular osteotomy was more common in reconstruction [ n = 65 (80 percent)] than in distraction osteogenesis [ n = 61 (58 percent); p < 0.002]. Blood transfused was similar between low and high osteotomy cohorts in the distraction osteogenesis ( p = 0.285) and reconstruction ( p = 0.342) groups. However, median transfused blood volume per kilogram of patient weight was greater in the low versus high osteotomy distraction osteogenesis ( p = 0.010) and reconstruction ( p = 0.041) cohorts. Intraoperative venous sinus injury was rare. In the distraction osteogenesis cohort, there was increased median intracranial volumetric gain in the low (263 ml) compared with the high osteotomy cohort (127 ml; p = 0.043); however, when controlled for distraction distance, only a trend was observed ( p = 0.221). Patients undergoing distraction osteogenesis showed a larger median intracranial volume increase (168 ml) compared with those undergoing reconstruction (73 ml; p < 0.001). Infratorcular osteotomy can be performed safely in most patients undergoing cranial vault remodeling and does not appear to be associated with greater hemodynamic instability or sinus injury. Therapeutic, III.

Efficacy and safety of botulinum toxin type A in distraction osteogenesis of the lower extremities: a meta-analysis of randomized controlled trials

BackgroundTo explore the efficacy and safety of botulinum toxin in patients who received distraction osteogenesis of the lower extremities.MethodsWe searched the PubMed, Medline, Cochrane Library, and Web of Science databases for randomized controlled trials that administered botulinum toxin to individuals who underwent distraction osteogenesis of the lower limbs. The final search was conducted on July 6, 2021. Quality assessments were conducted using the Cochrane risk of bias tool and the Jadad scale. We performed random-effects meta-analysis to calculate the standardized mean differences (SMDs) and confidence intervals (CIs) of the pooled effect sizes, and subgroup analysis and meta-regression were performed for potential moderators.ResultsOur analysis of four randomized controlled trials, which enrolled a total of 257 participants, revealed that the difference in pain during the distraction phase was not statistically significant between groups (SMD, − 0.165; 95% CI, − 0.379 to 0.050, p = 0.133, I2 = 0.0%). The meta-regression analyses did not find any influence on the effect size, considering age (β = − 0.0092; p = 0.61) and the amount of lengthening (β = 0.0023; p = 0.99). Subgroup analysis did not reveal difference between different doses of botulinum toxin and single or multi-site study design. An analysis of two randomized controlled trials enrolling a total of 177 individuals demonstrated a limited effect of botulinum toxin in reducing postoperative pain (SMD, − 0.239; 95% CI, − 0.641 to 0.162, p = 0.24, I2 = 37.6%), total adverse events (SMD, − 0.207; 95% CI, − 0.505 to 0.090, p = 0.17, I2 = 0.0%), and infection of pin site (SMD, − 0.131; 95% CI, − 0.428 to 0.165, p = 0.39, I2 = 0.0%). No botulinum toxin–related adverse events were reported.ConclusionsThe current evidence does not support the administration of botulinum toxin in patients who receive distraction osteogenesis of the lower limbs. However, we were unable to draw decisive conclusions because of the limitations of our meta-analysis. Future well-designed, large-scale randomized controlled trials are necessary to confirm our conclusions.

Analysis of Actual Versus Predicated Intracranial Volume Changes for Distraction Osteogenesis Using Virtual Surgical Planning in Patients With Craniosynostosis.

The primary outcome metric in patients with craniosynostosis are changes in intracranial volumes (ICVs). In patients who undergo distraction osteogenesis (DO) to treat craniosynostosis, changes are also dependent on the length of distraction. Virtual surgical planning (VSP) has been used to predict anticipated changes in ICV during cranial vault reconstruction. The purpose of this study is to analyze the actual versus predicted ICV changes using VSP in patients who undergo DO for craniosynostosis management. All patients with craniosynostosis treated with DO at a single institution, Rady Children's Hospital, between December 2013 and May 2019 were identified. Inclusion criteria are as follows: VSP planning with predicted postoperative ICV values and preoperative and postdistraction CT scans to quantify ICV. Postoperative ICV and VSP-estimated ICV were adjusted for age-related ICV growth. The primary outcome measure calculated was age-adjusted percent volume change per millimeter distraction (PVCPD), and results were analyzed using paired Wilcoxon signed rank tests. Twenty-seven patients underwent DO for cranial vault remodeling. Nineteen patients were nonsyndromic, and 8 patients were syndromic. The median postoperative PVCPD was 0.30%/mm, and the median VSP-estimated PVCPD was 0.36% per millimeter (P < 0.001). A subanalysis of nonsyndromic patients showed a median postoperative PVCPD of 0.29%/mm in nonsyndromic patients that differed significantly from the VSP estimate of 0.34%/mm (P = 0.003). There was also a significant difference in syndromic patients' observed PVCPD of 0.41%/mm versus VSP estimate of 0.79%/mm (P = 0.012). Virtual surgical planning overestimates the change in ICV attributable to DO in both syndromic and nonsyndromic patients.

Morphologic and Aerodynamic Changes of Upper Airway in Pediatric Hemifacial Microsomia Patients Undergoing Distraction Osteogenesis.

Current studies on hemifacial microsomia (HFM) patients undergoing unilateral distraction osteogenesis (DO) mainly confined to description of facial morphology. This study was to investigate the effect of unilateral DO on upper airway in pediatric HFM patients using computational fluid dynamics. The investigators implemented the present retrospective study composed of 20 patients (age 9.5 ± 2.5 years, 11 males, 9 females) with moderate HFM performed unilateral DO on the ramus of mandible. Computational fluid dynamics models of the upper airway were obtained based on the computed tomography data sets which were taken before and 6 months after distraction. Morphologic and aerodynamic parameters were respectively computed and compared at peak inspiration. Paired t-tests were used to compare the differences between the before and after parameters with the significance set at P < 0.05. The authors observed that after DO, oropharynx and nasopharynx were the major expanded regions, average pressure increased in all cross-sections, average velocity decreased significantly except in the superior border of the epiglottis plane, and the airflow resistance significantly reduced in the whole upper airway (P < 0.05). The results indicate that unilateral DO may expand the constricted oropharynx and nasopharynx, obtain a relatively symmetrical airway shape and decrease the airflow resistance which consequently reduce the workload necessary for breathing and facilitate inspiration.

S4A-12 SESSION 4A: GENERALITIES IN CRANIOSYNOSTOSIS – PART I THE EFFICACY OF OUR NOVEL SUTURECTOMY TECHNIQUE WITH ABSORBABLE PLATES IN EARLY SURGERY FOR CRANIOSYNOSTOSIS

Introduction: Surgical procedures for craniosynostosis patients with severe intracranial hypertension include suturectomy, cranial distraction and conventional cranial reconstruction. Suturectomy has been performed in children younger than 3 months of age with insufficient bone strength. Conventional suturectomy is generally ineffective, because bone formation occurs rapidly in the grooves, resulting in recurrent elevation of intracranial pressure and severe deformity. Therefore, the surgical effects should be extended by preventing bone formation during the early postoperative period to correct the severe deformity and subsequently achieve sufficient bone formation and strength. This study examined the efficacy of our newly developed suturectomy technique using an absorbable plate. We present our novel method and the postoperative follow-up. Methods: Our new method was indicated for craniosynostosis cases younger than 3 months of age who had severe intracranial hypertension, scaphocephaly, or plagiocephaly between 2011 and 2018. All patients underwent suturectomy. Suture lines that indicate premature fusion were incised at a width of approximately 7–10 mm to insert the absorbable plates. The bone stumps on both sides of the grooves were covered with absorbable sheet-type plates. Evaluation was conducted primarily with three-dimensional computed tomography and clinical photographs, and the preoperative and postoperative cephalic index were analyzed. Results: Twenty-three patients who underwent surgery were evaluated. The cranial shape was brachycephaly in five, scaphocephaly in four, oxycephaly in five, clover-leaf deformity in three, and plagiocephaly in four. There were eleven syndromic (1 Crouzon, 4 Apert, 3 Pfeiffer and 3 Saethre-Chotzen syndromes) and twelve non-syndromic patients. The patients’ mean age at the time of surgery was 43.5 days (12 to 76), and the mean follow-up period was 44.2 months (7 months to 7 years). The postoperative cephalic index improved in all patients. Secondary surgery was not required in five of eleven syndromic and in all non-syndromic patients. There were no major complications. Conclusion: Placement of an absorbable plate during strip craniectomy can prevent bone formation during the early postoperative period and promote bone formation after plate absorption. Even in patients who underwent distraction osteogenesis, the planning of the procedure was relatively easy because improvement in cranial shape had been achieved. In particular, some syndromic craniosynostosis patients were able to avoid additional surgery. Also, good outcomes were obtained without adjunctive therapy, such as helmet therapy. The present approach is less invasive and expected to be highly effective.

Daily subcutaneous Teriparatide injection increased bone mineral density of newly formed bone after tibia distraction osteogenesis, a randomized study

Long bone defects are often treated by bone segment transport with the Ilizarov method requiring months spent with fixator mounted until bony consolidation of the newly formed bone. Shortening of consolidation would allow earlier fixator removal and earlier return to work. In pre-clinical studies parathyroid hormone, increased bone mineral density and mechanical properties of regenerate bone formed during distraction osteogenesis. Clinical studies showed that Teriparatide accelerated fracture healing in patients with osteoporotic fracture of the pelvis, hip, wrist and shoulder. We hypothesized that rhPTH(1-34) (Teriparatide) administered to patients who had undergone distraction osteogenesis, would increase mineralization of the regenerate formed during the consolidation phase.Sixteen patients with tibial defects after infection, underwent bone segment transport and at the time of docking the transport segment, were randomized to 8 weeks treatment with daily subcutaneous 0.20-μg Teriparatide injection followed by 8 weeks with no treatment, or to 8 weeks with no treatment followed by 8 weeks with daily subcutaneous 0.20 μg Teriparatide injection. Bone mineral density (BMD) of the regenerate was measured at the time of docking, 8 weeks after docking and 16 weeks after docking with DEXA. Functional evaluation was performed after one year. The design was a cross-over study.Overall BMD increased 0.14 g/cm2 in 8 weeks without treatment and 0.33 g/cm2 under Teriparatide treatment. After adjustment for a potential phase difference, 8 weeks of Teriparatide treatment led to an additional 0.19 g/cm2 BMD increase (95%-CI:[0.11,0.28], p < 0.001). The ratio of the BMD increase between the two treatments was 0.33/0.14 = 2.43 (CI: [1.21,3.65]).Teriparatide treatment during the consolidation phase of distraction osteogenesis doubled the mineralization rate of the regenerate when compared to no treatment.

Reconstruction of massive tibial defects after resection of adamantinoma with double-level distraction osteogenesis

Adamantinoma is an extremely rare disease that typically involves large portions of the tibial cortex requiring extensive resections, for which a myriad of complex reconstructions have been performed with varying success. Techniques of bone regeneration utilizing internal or external methods are used to manage bone defects in trauma, infection and congenital deformities, but less commonly used for oncological osseous defects. We present four cases of patients diagnosed between 2015 – 2018 with tibial adamantinoma in a background of osteofibrous dysplasia who underwent distraction osteogenesis reconstruction via a double level cable bone transport. In all cases wide resection of the adamantinoma was performed to achieve negative surgical margins and the defect reconstructed by double level bone transport using Ilizarov cables guiding distraction osteogenesis. Bone transport occurred at a combined mean rate of 2 mm per day: 1mm proximally and 1mm distally. Full weight-bearing and ambulation were encouraged immediately. The mean age at time of surgery was 18 years (14 – 25) and the mean size of tibial defect was 23 cm (17.5 – 26). The mean time in external fixation was 8.5 months (6 – 12 months), yielding a mean External-Fixation Index (EFI) of 0.44 month/cm (0.3 – 0.69). The average MSTS score at mean follow time of 20 months (13-27 months) is 28 (26 – 30). At last follow up all patients are infection free and without evidence of disease. Despite typical complications of prolonged external fixation, all four patients have excellent results with an average MSTS score of 28. The mean EFI of 0.44 month/cm is well below the standard EFI of 1 month/cm, suggesting this subset of patients may require less external fixation time than previously considered. The case series supports the hypothesis that double level D.

Pseudarthrose de la fibula après distraction ostéogénique du tibia

IntroductionThere is concern regarding potential non-union of the fibula following distraction osteogenesis and if non-union of the fibula leads to poor outcome. HypothesisAssess the incidence of fibula non-union in patients undergoing distraction osteogenesis of the tibia and to report the effects on patient outcome. We also describe the management of this complication. Materials and methodsA consecutive series of patients undergoing distraction osteogenesis at a tertiary centre under a single surgeon. The amount of distraction, site of osteotomy, union of the fibula and tibia were recorded. ResultsFifty-eight distraction procedures. Mean age was 37.2, 36 males and 22 females. Mean follow-up 23.4 months. Forty-nine (84.5%) achieved fibula union at frame removal, and 9 (15.5%) went on to non-union. Of the fibulas that united, the mean lengthening was 9.25mm. In fibula non-union there was significantly greater lengthening (23.66mm)(P=0.004). Fifty-four (93.1%) of the tibias united following osteotomy and distraction, whilst 4 (6.9%) went onto non-union requiring operative treatment. Of the 4 tibias that did not unite, 3 (75%) also had fibula non-union (P=0.01). Three (33.3%) of the 9 fibulas that did not unite developed symptoms. Two of these required surgery in the form of fibula plating. Both of these patient's symptoms resolved following surgery. DiscussionFibula non-union is a relatively common complication following osteotomy in distraction osteogenesis. The length of fibula distraction and tibia non-union are significant risk factors. We recommend surgical intervention for those patients who have symptomatic fibula non-unions. Level of evidenceIV, Case series.

Medial submuscular plating of the femur after limb lengthening and correction with frame in patients with limb length discrepancy and/or angular deformity

Objective To evaluate the medial submuscular plating of the femur after limb lengthening and correction with frame in patients with limb length discrepancy and/or angular deformity. Methods A retrospective study was conducted involving 12 patients who had been referred to Department of Orthopaedic Trauma, Beijing Jishuitan Hospital from December 2009 to November 2016 for limb length discrepancy and/or angular deformity. They were 3 males and 9 females, with an average age of 23 years (from 14 to 32 years). Altogether 4 left and 8 right sides were involved. Of them, 11 got their length discrepancy and/or angular deformity secondary to injury to distal femoral epiphyseal plate caused by trauma in their childhood and one had length discrepancy and angular deformity following unsuccessful conservative treatment of superior condylar fracture of the femur. The femoral shortening ranged from 3 to 11 cm (average, 6.7 cm), and the varus or valgus deformity of the knee ranged from 8° to 18° (average, 12°). First, a monolateral fixator was installed on the lateral femur. The limb was lengthened from 7 to 14 days after diaphysis osteotomy. Femoral supracondylar osteotomy was conducted again in patients with knee angular deformity after the lengthening reached the expected length and the deformity was corrected with the aid of external fixator. After medial submuscular plating via the femoral lateral approach using minimally invasive techniques, the external frames were removed. The time for plate removal, limb lengthening and correction of the varus or valgus deformity were documented. Results The mean follow-up was 31 months (from 23 to 43 months) for the 9 patients who had their plates still in situ, and 6.5 months (from 2 to 14 months) for the 3 patients who had subsequently their plates removed. None had blood transfusion. All underwent distraction osteogenesis of the femur to their preoperatively expected length, ranging from 3 to 9 cm (mean, 6.2 cm). Both varus and valgus deformities were corrected. None developed a deep infection. The range of motion of the knee joint was similar to that before operation in all but one patient who had a range of motion 40° less than the pre-operative one. The time for external fixation averaged 91 days (from 46 to 113 days), with an external index of 22 d/cm. All patients were satisfied with their outcomes. Conclusion Medial femoral submuscular plating after limb lengthening and angular deformity correction with the external fixator on the lateral side is a useful technique for patients with femoral limb length discrepancy and/or angular deformity, significantly shortening the time for external fixation. Key words: Femur; External fixators; Bone plates; Surgical procedures, minimally; Abnormalities

Fibular non-union in distraction osteogenesis of the tibia

IntroductionThere is concern regarding potential non-union of the fibula following distraction osteogenesis and if non-union of the fibula leads to poor outcome. HypothesisAssess the incidence of fibula non-union in patients undergoing distraction osteogenesis of the tibia and to report the effects on patient outcome. We also describe the management of this complication. Materials and methodsA consecutive series of patients undergoing distraction osteogenesis at a tertiary centre under a single surgeon. The amount of distraction, site of osteotomy, union of the fibula and tibia were recorded. ResultsFifty-eight distraction procedures. Mean age was 37.2, 36 males and 22 females. Mean follow-up 23.4 months. 49 (84.5%) achieved fibula union at frame removal, and 9 (15.5%) went on to non-union. Of the fibulas that united, the mean lengthening was 9.25mm. In fibula non-union there was significantly greater lengthening (23.66mm) (p=0.004). Fifty-four (93.1%) of the tibias united following osteotomy and distraction, whilst 4 (6.9%) went onto non-union requiring operative treatment. Of the 4 tibias that did not unite, 3 (75%) also had fibula non-union (p=0.01). Three (33.3%) of the 9 fibulas that did not unite developed symptoms. Two of these required surgery in the form of fibula plating. Both of these patient's symptoms resolved following surgery. DiscussionFibula non-union is a relatively common complication following osteotomy in distraction osteogenesis. The length of fibula distraction and tibia non-union are significant risk factors. We recommend surgical intervention for those patients who have symptomatic fibula non-unions. Level of evidenceIV, case series.

Rehabilitation post-distraction osteogenesis for brachymetacarpia: a case report.

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The sequential treatment of temporomandibular joint ankylosis with secondary deformities by distraction osteogenesis and arthroplasty or TMJ reconstruction

The purpose of this study was to evaluate the sequential treatment of patients with temporomandibular joint (TMJ) ankylosis and secondary deformities by distraction osteogenesis and subsequent arthroplasty or TMJ reconstruction. This study included 40 patients treated at a stomatological hospital in China; they ranged in age from 9 to 53years (mean age 24.5years). Ten of these patients were diagnosed with unilateral TMJ ankylosis and 30 with bilateral TMJ ankylosis. Twenty-seven patients also presented obstructive sleep apnoea–hypopnoea syndrome (OSAHS). All patients underwent distraction osteogenesis as the initial surgery, followed by arthroplasty or TMJ reconstruction. Some patients underwent orthognathic surgery to improve occlusion and face shape along with or after arthroplasty or TMJ reconstruction. The therapeutic effects were evaluated in terms of the improvements in maximum inter-incisal opening (MIO), appearance, and respiratory function. After the completion of treatment, all patients showed improvements in MIO and appearance, and the symptom of snoring disappeared. The airway space was significantly increased. Patient follow-up ranged from 6 to 85months (mean 28.3months), and four patients experienced relapse. This study suggests that treating TMJ ankylosis with secondary deformities by distraction osteogenesis as the initial surgery and arthroplasty or TMJ reconstruction as the second-stage treatment may achieve favourable outcomes, especially for patients with OSAHS; however, some patients may require orthognathic surgery.

Alar Pinning in Rigid External Distraction for Midfacial Hypoplasia.

Distraction osteogenesis with a rigid external distractor is a widely accepted treatment for midfacial hypoplasia. In this study, the authors introduce the utilization of alar pinning with the external halo distractor for maxillary advancement, in place of an oral splint. A retrospective chart review was conducted of 7 patients who successfully underwent distraction osteogenesis using the alar pinning technique. Midfacial hypoplasia was secondary to Crouzon syndrome (n = 4), Apert syndrome (n = 1), Pfeiffer syndrome (n = 1), or bacterial meningitis (n = 1). Three patients were managed with monobloc osteotomies, 2 with Le Fort III osteotomies, 1 with Le Fort III osteotomy and frontoorbital advancement, and 1 with Le Fort I osteotomy alone. Patient charts were analyzed for postoperative course and complications relating to the alar pins. Two patients had minor complications specifically related to the alar pins. One patient had concern for a mild skin infection at a pin site that resolved with oral antibiotics. The other patient had loosening of an alar pin, which did not require operative management. Retrospective chart review indicated that all patients were pleased with their results from the distraction, and no patients opted for further advancement. Utilization of alar pin sites for external distraction is a feasible and reasonable option for treatment of midfacial hypoplasia involving a Le Fort osteotomy or monobloc procedure. Fixation sites within the alar crease minimize the visibility of pin site scars and eliminate the need for a custom-made oral splint, which prevents usage of the upper dentition and frequently requires consulting a dentist or orthodontist for fabrication. Alar pinning with an external halo distraction system for management of midfacial hypoplasia has minimal complications and is an alternative to using a custom-made oral splint.

Low-intensity pulsed ultrasound does not influence bone healing by distraction osteogenesis: a multicentre double-blind randomised control trial.

The aim of this double-blind prospective randomised controlled trial was to assess whether low intensity pulsed ultrasound (LIPUS) accelerated or enhanced the rate of bone healing in adult patients undergoing distraction osteogenesis. A total of 62 adult patients undergoing limb lengthening or bone transport by distraction osteogenesis were randomised to treatment with either an active (n = 32) or a placebo (n=30) ultrasound device. A standardised corticotomy was performed in the proximal tibial metaphysis and a circular Ilizarov frame was used in all patients. The rate of distraction was also standardised. The primary outcome measure was the time to removal of the frame after adjusting for the length of distraction in days/cm for both the per protocol (PP) and the intention-to-treat (ITT) groups. The assessor was blinded to the form of treatment. A secondary outcome was to identify covariates affecting the time to removal of the frame. There was no difference in the time to removal of the frame between the PP (difference in favour of the control group was 10.1 days/cm, 95% confidence interval (CI) -3.2 to 23.4, p=0.054) or ITT (difference 5.0 days/cm, 95% CI -8.2 to 18.21, p = 0.226) groups. The smoking status was the only covariate which increased the time to removal of the frame (hazard ratio 0.47, 95% CI 0.22 to 0.97, p = 0.042). LIPUS does not influence the rate of bone healing in patients who undergo distraction osteogenesis. Smoking may influence bone healing. Cite this article: Bone Joint J 2017;99-B:494-502.

The Unnecessity of Positron Emission Tomography Computed Tomography in the Etiologic Evaluation of Neurodevelopmental Delay in Craniosynostosis Patients.

BackgroundIn evaluation of craniosynostosis patients in terms of neurodevelopmental delay, positron emission tomography computed tomography (PET-CT) scan can be used to assess brain abnormalities through glucose metabolism. We aimed to determine the unnecessity of PET-CT in this study.MethodsThirty-eight patients diagnosed with craniosynostosis who underwent distraction osteogenesis from October, 2010 to November, 2013 were reviewed. Magnetic resonance imaging (MRI) and PET-CT scan were carried out for evaluation of the brain structure and function, whereas X-ray and CT scan were taken for evaluation of the skull.ResultsNine patients reported abnormal MRI findings which were not significant, and five patients showed local problem on brain on PET-CT scan. No correlation was found among them.ConclusionPET-CT evaluation of possible abnormal brain findings do not affect surgical planning or require additional therapy. Preoperative PET-CT scan is not the essential study to get any etiologic information of the disease consequences or to establish the treatment plan.