Application of distraction osteogenesis in managing bone cysts

Background

Despite the great amount of research concerning bone cysts, there is still no commonly accepted method of treatment. The aim of this study was to evaluate the effectiveness managing bone cyst with hybrid external fixator by distraction osteogenesis.

Materials and methods

Between 1982 and 2009, 25 patients with unicameral (20 patients) and aneurismal (five patients) bone cysts were treated using this method. Eighteen patients had a history of pathological fracture at the same location. Cysts were located in the humerus, femur, tibia, and radius. Median follow-up was 48 (range 31–91) months. Results were evaluated on plain radiographs according to the classification system of Capanna et al. Functional assessment was done using the modified system recommended by Enneking et al.

Results

In our study group of 25 bone cysts, 15 were classified as completely healed and nine as healed with residual radiolucency. Recurrence was observed in one patient. Absence of response to treatment was not observed. All patients had excellent functional outcomes, except one with recurrence who was rated poor.

Conclusions

As bone cysts are found in long bones in 90–95 % of patients, and taking into account our achieved positive results in almost all patients, we recommend this method of distraction osteogenesis as a treatment option. It is an effective, economical method of treatment, which eliminates deformity and restores bone length, especially in patients with pathologic fractures.     

Bone transport using the Ilizarov method: a review of complications in 100 consecutive cases

We present the results of treatment of 100 patients (72 men, 28 women) by the Ilizarov method of bone transport using circular (55) and monolateral external fixators (45). A total of 26 femurs (18 monolateral, 8 circular) and 74 tibias (49 circular, 25 monolateral) was examined. There were no significant differences between the circular fixator and the monolateral fixator with regard to treatment time, complications in the treated bone segments or compliance with the presence of the fixator. The main complications (pseudoarthrosis at bone contact points after transport, insufficient ossification of lengthened bone, knee stiffness) were resolved with further treatment for all patients with the exception of one case which continued with repeated infections. The circular fixator allows for deformity corrections during bone transport but the monolateral fixator is tolerated better by patients, especially in those with femoral defects.     

Management of thromboangiitis obliterans using distraction osteogenesis: A retrospective study

Background:

Thromboangiitis obliterans (TAO), also known as Buerger disease, is characterized by thrombosis in medium-sized arteries and veins along with a marked inflammatory response. TAO can be managed by using the principle of distraction osteogenesis to induce neoangiogenesis. We report thirty patients of TAO in the age-group of 20–50 years were treated with the Ilizarov method.

Materials and Methods:

Patients with severe rest pain (n=30), absent distal pulsation (n=30) and ulcer (n=6) and/or gangrene of the toes (n=4), who had failed the conservative pharmacological modalities of treatment were included. A lateral tibial corticotomy was performed and distraction applied by use of olive wire. A two-ring frame was used for all cases.

Results:

Of the 30 cases, 25 patients became pain free while 1 had partial relief of pain. The four patients worsened on treatment and developed frank infection were amputed. The average distraction was 1.8±0.3 mm (range: 1.5–2.2 cm). The mean consolidation period was 98±11 days, after which the fixator was removed. The total duration of treatment was 122±23 days. There were two cases of osteomyelitis in our series; both healed after debridement and both patients had good result, with relief of pain. The ulcers started healing by 4–6 weeks.

Conclusion:

The principle of the distraction osteogenesis including neoangiogenesis can be used for treatment of TAO and has an acceptable complication rate.     

Preliminary experience with motorized distraction for tibial lengthening

Limb lengthening by callus distraction is commonly performed with the use of external fixation. Lengthening is routinely performed by the patient through small increments throughout the course of a day. Ilizarov has shown that both the rate and frequency of distraction are important factors in the quality of osteogenesis. We report the effect of motorized high frequency distraction for tibial lengthening in comparison with manual low-frequency distraction at the same rate. Manual distraction (0.25 mm four times a day) in a group containing 43 tibiae was compared with motorized distraction (1/1,440 mm 1,400 times a day) in a group containing 27 tibiae. There was no significant difference in time to union or in the incidence of complications.     

The correction of the relapsed club foot by closed distraction

Correction of a relapsed clubfoot deformity by distraction with an external fixator is a recognized alternative to open surgery. Most published series report a good outcome but none are prospective observational studies using the scoring system of the International Clubfoot Study Group (ICFSG). We present a series of 9 relapsed club feet treated with closed gradual distraction using this scoring method.     

Complications of distraction osteogenesis in brachymetatarsia: Comparison between the first and fourth brachymetatarsia

BackgroundRecently, distraction osteogenesis has been widely used to treat brachymetatarsia. However, few papers have compared complications associated with this treatment. The purpose of the present study was to compare the complications between the first and fourth brachymetatarsia treated by distraction osteogenesis.MethodsWe performed distraction osteogenesis to 83 metatarsals in 41 patients between 1999 and 2012. A total of 30 metatarsals received treatment for the first metatarsal (Group A) while 53 metatarsals received treatment with the fourth metatarsal (Group B).ResultsThe complication rate in Group A (40%) was higher than that in Group B (18.9%). Those who had high percentage of lengthening gain were more likely to have complications. A cut-off value for lengthening gain developing complication was 41.3%.ConclusionComplication incidence after distraction osteogenesis was increased when lengthening gain was more than 41.3% for brachymetatarsia. In the 1st metatarsal lengthening, the most common complication was stiffness. In contrast, complications of the 4th metatarsal lengthening were pin-track infection and angular deformity.     

Biochemical changes in articular cartilage after joint immobilization by casting or external fixation

Knees of mature dogs were immobilized for 6 weeks by long-leg casts allowing 8 degrees-15 degrees of motion, a model studied by others, or with external fixators, a new, more severe model that kept the joints rigid. Some animals were allowed to recover for 1 week after the immobilization period. Articular cartilage was examined histologically and biochemically. After 6 weeks of immobilization, water increased 7% in both casted and fixator-immobilized joints compared with normal knee cartilage, while hexuronic acid was 23 and 28% lower, respectively. The limited motion permitted by the casts resulted in a smaller depression of proteoglycan synthesis and less proteoglycan loss during immobilization than occurred in the rigid external fixator group. The protective effect of limited motion was shown clearly during the recovery period: as measured by hexuronic acid content, cartilage from the casted joints had almost recovered within 1 week, whereas the external fixator group experienced little or no recovery during the week after treatment. In contrast to previous studies by others with casted joints, both newly synthesized [35S]sulfate-labeled and accumulated unlabeled proteoglycans from both casted and fixator-immobilized cartilages were able to form complexes with exogenous hyaluronic acid to the same extent as those from control cartilage. Thus, in immobilized cartilage, failure of the newly synthesized proteoglycan to bind to hyaluronate is not a mechanism of accelerated proteoglycan loss. The accelerated proteoglycan turnover appears to be caused by a combination of decreased synthesis and increased proteolysis of the secreted proteoglycans.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of alpha-tocopherol on bone formation during distraction osteogenesis: a rabbit model

Purpose  

The purpose of this study was to evaluate the effects of alpha-tocopherol on distraction osteogenesis.     

Nailing treatment in bone transport complications

A series of cases of reamed intramedullary nailings carried out after complications in regenerated bone and docking site had occurred in bone transport is presented here. Nine patients (femur = 5; tibia = 4) had treatment with resection after open fractures or infection and underwent bone transport. The mean length of regenerated bone was 9.5 cm (range 6–18 cm). After bone transport, the fixator remained in place for a mean period of 12.8 months (range 8–24 months). In six cases (femur 4; tibia 2), the thickness of the cortical wall of the regenerate column was insufficient, and in two of these, there was, in addition, nonunion of the docking site. In the two tibial cases, nailing was carried out shortly after the fixator had been removed and after refracture of the regenerated bone had occurred due to insufficient cortical thickness. In one femur, nailing was carried out for nonunion of the docking site. Follow-up involved clinical and X-ray checks. The mean follow-up was 3.9 years (range 2–6 years). In all cases, union and with complete corticalization of the regenerate column was observed at an average 6 months after nailing (range 4–11 months). Infection occurred in one tibia 4 months after nailing. The infection was treated with antibiotics, and the nail was subsequently removed. We conclude that nailing is a potential solution for regenerated bone and docking site problems but, if used after prolonged periods of external fixation, may necessitate antibiotic therapy for at least 10 days after the fixator has been removed.     

Deformity correction for vitamin D-resistant hypophosphatemic rickets of adults

We performed correction for bowing deformity of the lower extremities due to vitamin D-resistant hypophosphatemic rickets of three adults, six segments. The operative method was gradual correction and lengthening using distraction osteogenesis by Ilizarov external fixator or Heidelberg external fixator. The orders of the corrections were simultaneous correction of the bilateral femur for one patient, simultaneous correction of the ipsilateral leg for one patient, and diagonal correction of the bilateral leg for one patient. The mean correction angle was 30.5°. The mean external fixation period was 146 days. Each orders of the corrections had its merits and demerits. All patients obtained a physiological alignment and good bone formation by taking Vitamin D and oral phosphate supplements even an adult patient. All the patients had articular pain, such as hip, knee, and ankle, however, these pains healed up. All the patients were satisfied with the outcomes at the time of the final follow-up interview in terms of their cosmetic improvement. Distraction osteogenesis for bowing deformity of the lower extremities due to vitamin D-resistant hypophosphatemic rickets was very effective method and could be applied to adult patients. However, the order of the corrections should be considered carefully depending on each patient.     

同种异体兔耳软骨ECM复制兔耳软骨的实验研究──软骨组织工程的实验研究预试验报告

我们这项研究旨在寻求一种能够避免组织移植和人工材料的缺点，又能获得自体组织移植相同的效果的移植材料。选用１０只纯种新西兰大耳白兔，异体兔耳软骨细胞外基质（ＥＣＭ）。兔耳软骨缺损分别以下列四组方式修复：①兔耳软骨ＥＣＭ＋兔耳软骨骨膜，②兔耳软骨ＥＣＭ，③兔耳软骨膜，④空白。术后６、１２、２４、４８周分别切取修复区域标本，做ＨＥ、奥新蓝两种染色。结果显示，ＥＣＭ植入体内后６周有轻度的炎症反应，术后１２周炎症异物反应消失，ＥＣＭ周边无包裹现象，术后１２周骨膜细胞长入ＥＣＭ，但细胞排列不规则。术后２４周、４８周ＥＣＭ仍然存在，无吸收现象，软骨膜与ＥＣＭ覆着处细胞长入ＥＣＭ，排列较１２周时规则，呈奥新蓝反应强阳性。结论：①ＮＥＣＭ可以作为组织充填物而长期存在并有较好的组织亲和性和相容性，因此有希望成为新一代的组织替代物。②ＮＥＣＭ可以诱导软骨膜细胞向其中生长而重建软骨，因此软骨ＮＥＣＭ有可能是复合生长因子。③软骨膜可以作为软骨ＮＥＣＭ复制软骨组织的细胞来源。④根据本实验观察一年的结果证明应用兔耳软骨ＥＣＭ，可以复制出新的软骨。     

骨外固定器应用的术后管理工作初步总结

我科自 1990年引进骨外固定技术处理骨折 ,取得非常满意效果 ,并逐步总结出一套术后管理工作程序 ,供大家探讨完善。1　临床资料　　早期应用ＳＧＤ式[1] 、夏氏组合式[2 ] 、沟槽式[3 ]等外固定器共处理四肢骨折 2 6例 ,年龄 2 6～ 5 8岁 ,平均 36 7岁 ;其中胫腓骨骨折 19例     

Bone consolidation is enhanced by rhBMP-2 in a rabbit model of distraction osteogenesis.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a differentiation factor which has been shown to induce bone formation and heal bony defects in a variety of animal models. A possible application of rhBMP-2 is to accelerate bone regeneration during distraction osteogenesis. which clinically is a long procedure, often involving significant complications. In this study we tested the ability of rhBMP-2 to accelerate the consolidation phase of distraction osteogenesis in a rabbit model of leg lengthening. Tibiae were lengthened 2 cm over a period of ten days. rhBMP-2 was administered at the end of the lengthening phase. Two modes of rhBMP-2 application were tested: surgical implantation of rhBMP-2/ACS (absorbable collagen sponge) into the regenerate (50 microl of 1.5 mg/ml rhBMP-2, total dose = 75 microg rhBMP-2), and percutaneous injection of rhBMP-2/buffer (0.1 ml of 0.75 mg/ml rhBMP-2. total dose = 75 microg rhBMP-2) into three sites within the regenerate. Also, there were three groups of control animals: (1) no surgical intervention, (2) surgical implantation of buffer/ACS and (3) percutaneous injection of buffer. Rabbits were sacrificed at 5, 14 and 28 days after the interventions. Radiographic evaluation indicated a significant increase in bony union of the distraction regenerate in the rhBMP-2 treated groups compared with the untreated groups at 5 and 14 days. At 28 days, formation of a cortex and reestablishment of the medullary canal was evident only in the rhBMP-2 treated groups. The bone mineral content (BMC) of the regenerate was significantly higher in the rhBMP-2 treated groups at 5 and 14 days. However, at 28 days, BMC of the regenerate was similar in all groups. The average volumetric density of the regenerate was significantly higher in the rhBMP-2 injection group at day 14. In Summary, both injection of rhBMP-2/buffer and implantation of rhBMP-2/ACS enhanced the consolidation stage of distraction osteogenesis in this rabbit model.     

跨腕关节支撑钢板与外固定架治疗桡骨远端粉碎性骨折的临床研究

目的比较跨腕关节支撑钢板与外固定架治疗桡骨远端粉碎性骨折的临床疗效。方法对自2007年7月~2010年6月收治的57例闭合性桡骨远端粉碎骨折(AO C2、C3型)采用跨腕关节钢板和外固定架进行治疗。结果术后12个月随访,两组桡骨茎突长度无统计学差异(P>0.05),关节面台阶有统计学差异(P<0.05)。术后6、12个月随访时,两组间旋前、旋后、掌屈、背伸活动范围比较,无统计学差异(P>0.05)。根据Jakim评分标准,两组优良率差异无统计学意义(P>0.05)。外固定架组并发症发生率显著高于钢板组(P<0.05)。结论①跨腕关节钢板和外固定架治疗桡骨远端粉碎骨折,骨折复位情况和临床治疗效果相当;②跨腕关节钢板固定手术创伤较大,但稳定性好,并发症较少;③跨腕关节钢板和外固定架结合克氏针固定后,可减少术后碎骨块再移位的可能性;④跨腕关节钢板固定治疗桡骨远端粉碎性骨折,骨折复位好,能保持骨折部的撑开以维持桡骨长度,防止短缩,可以取得较好的疗效。     

Combined effects of recombinant human BMP-2 and Nell-1 on bone regeneration in rapid distraction osteogenesis of rabbit tibia

Distraction osteogenesis (DO) has been accepted as an effective technique for bone lengthening. However, the long treatment period and possible fibrous union or nonunion hampers its further clinical application. Bone regeneration in DO involves multiple stages of repair and coordinated action of multiple cell types. Consequently, it may be possible to enhance bone regeneration through treatment strategies that target more than one repair process or cell types. The goal of this study was to determine the combined effects of recombinant human bone morephogenetic protein 2 (rhBMP-2) and NEL-like molecule-1 (NELL-1) on bone formation in DO. Unilateral tibiae in 48 rabbits were lengthened for 7 days at a rate of 2 mm/day after 3-day lag. At the end of distraction, the animals were randomly divided into four groups (n = 12) and received phosphate-buffered saline, 50 μg rhNell-1 or 50 μg rhBMP-2, or both 25 μg rhBMP-2 and 25 μg rhNell-1 at the lengthened segment, respectively. After 4-week consolidation bony healing was assessed using histology, radiography, dual energy X-ray absorptiometry, micro-CT, and three-point bend testing. Treatment with rhNell-1 and/or rhBMP-2 resulted in better bone formation and higher BMD and BMC than the saline group, whilst excellent bone formation and the highest BMD and BMC was observed in the combined treatment group. Both rhNell-1 and rhBMP-2 groups presented more mature characteristics in the micro-architecture than the saline group, whereas the combined treatment group presented the highest BV/TV, Tb.Th and Tb.N as well as the lowest Tb.Sp. The peak load of the lengthened tibia increased by 71% in the combined treatment group, 54% in the rhBMP-2 group, and 25% in the rhNell-1 group compared to the control group, respectively. This work suggests that BMP-2 and Nell-1 enhance each other's ability and dual delivery of two agents can significantly improve bony healing in tibial DO.     

Osteofibrous dysplasia treated with distraction osteogenesis: a report of two cases

We treated two patients with osteofibrous dysplasia of the tibia using en bloc marginal excision of the lesion and bone transport, a distraction osteogenesis procedure. In one patient, we had performed curettage procedures twice, each time followed by local recurrence and deformity. In contrast, with marginal excision and bone transport using an Ilizarov apparatus, the disease healed. In the other patient, we performed marginal excision and bone transport as the first procedure, which resulted in a healed lesion. In patients with osteofibrous dysplasia requiring treatment by an open method, curettage frequently is followed by local recurrence and deformity. We now prefer marginal excision of the lesion to avoid long-term failures, as in our first case. Distraction osteogenesis has proven useful for restoring structure and function in the affected limb.     

骨缝牵引成骨修复腭裂的临床初步研究

目的 临床探索骨缝牵引成骨修复腭裂的新技术。方法 选择2～4岁的腭裂患儿。一期手术在全麻下安置腭裂牵引器，牵引腭骨向中线和向后移动；牵引期持续约4～5个月。裂隙合拢后进行二期手术，修复裂隙。用误差为0．2％的游标卡尺，测量牵引前和牵引后上颌牙弓宽度、裂隙宽度和硬腭长度。结果 临床应用8例。2例因牵引器在安置后l周内脱落而终止牵引。6例经不同时间的牵引后，裂隙缩小，裂隙两侧的组织显著延长。其中牵引时间最长为126d，最短为37d；裂隙宽度平均缩小6．5mm；硬腭长度平均延长4．8mm。结论 临床证实了骨缝牵引具有诱导腭部组织再生、关闭或缩小裂隙和延长硬腭的可能性。     

??Asymmetric scalloping of the regenerate??: a radiological sign of pseudoaneurysm in distraction osteogenesis

Pseudoaneurysm formation is an uncommon but well-recognised and important complication in limb reconstruction surgery. Postoperative diagnosis is usually clinical or an incidental finding. We present an 11-year-old girl, who underwent two-stage limb lengthening with a circular fixator, for a previously treated pseudoarthrosis of the tibia. During the lengthening plan, a concave defect was noted on one side of the regenerate, which was found to be due to extrinsic compression by a pseudoaneurysm. Normal regenerate formation was seen after selective embolisation of the pseudoaneurysm. This concave appearance on one side of the regenerate has previously been described secondary to a difference in stability on the two sides of the osteotomy, when a monolateral fixator is used, but not due to extrinsic compression by a pseudoaneurysm. The authors propose that this radiographic appearance of “asymmetrical scalloping” on one side of the regenerate may represent a radiological sign of a pseudoaneurysm formation and should provoke investigation for the same.     

组织牵伸与有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形

目的探讨组织牵伸结合有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形的临床问题。方法 2004年6月至2009年2月共治疗17例成人足外伤后严重的马蹄内翻足畸形。Dimeglio分型：Ⅲ型,严重畸形13足;Ⅳ型,畸形非常严重4足。牵伸矫形器由胫骨外固定器和特殊形状的足部外固定器构成,在畸形状态能适应牵伸器顺利安装情况下,仅选择距下关节融合。如果畸形超出牵伸支架的可调空间,选择有限截骨三关节融合术,部分矫正足的内翻、内收畸形,至能顺利安装牵伸支架,残留的畸形通过牵伸逐渐矫正。结果治疗结束时所有病例的马蹄内翻足畸形均得到完全矫正。14例随访半年至3年,平均11个月;5足轻度复发,马蹄畸形均未大于20°,仍能跖行;踝关节活动度部分有一定改善。根据国际马蹄足畸形研究学组（ICFSG）的评分系统：优3足,良9足,可2足,差0足。结论组织牵伸结合有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形,便于外固定器的安装,更好地预防畸形复发、减少牵伸的时间,发挥Ilizarov技术的优势。