D ISTRACTION O STEOGENESIS Shelby Marks, Kijeon Choi, Taylor - - PowerPoint PPT Presentation

DISTRACTION OSTEOGENESIS

Shelby Marks, Kijeon Choi, Taylor Tebano, Stanley Gelin, and Sarah Bradner

LEARNING OBJECTIVES

 To understand the advancement of bone elongation

techniques that lead to modern day practice.

 Be able to describe what distraction osteogenesis is

and how it works.

 Identify and compare the different distraction

• steogenetic surgical processes to achieve skeletal

reconstruction.

 Understand the many causes/diseases for which

distraction osteogenesis is used.

 Recognize the complications and risks associated

with the process and identify post-operative care.

DISTRACTION OSTEOGENESIS

 Surgical reconstruction of skeletal

deformities and lengthening of the long bones of the body

 Procedure that moves 2 bone segments apart

using an external saw and allows new bone in gap

 Many FDA approved distraction devices

HISTORY

• Skeletal traction was described as long ago as

by Hippocrates (460-377 B.C.) when traction on long bones was performed by means of rubber straps

• Alessandro Codivilla (1861 -1912), Pioneer of

bone elongation techniques

• Italian Surgeon
• Published 1905 case report of femoral

extension using axial forces

• Introduced Limb lengthening techniques that

had a high complication rate

• Popularized by Russian orthopedic surgeon

Gavril Ilizarov

GAVRIL ILIZAROV

– Gavriil Abramovich Ilizarov was born in Caucasus (former USSR) in 1921 – No formal schooling till age 11 – Lone physician in Kurgan, Serbia – Developed Ilizarov method – An external fixator to regenerate bone under tension – modular ring – Died July 24 1992 in Kurgan, Russia due to heart failure

RUSSIAN ILIZAROV SCIENTIFIC CENTER FOR RESTORATIVE TRAUMATOLOGY AND ORTHOPAEDICS

• Founded in 1971 in Kurgan, Serbia
• Home to Ilizarov method
• The first department in Russia for

managing bone infection

• Place where limb lengthening techniques

were first devised and introduced into clinical practice.

HOW DOES IT WORK?

 Must be gradual

too quick: fibrous union instead of osseointegration too slow: early bone union Steps:

1)

Surgeon makes ostectomy (break) in abnormal bone and places distraction device. Allowed to start a few days of healing.

2)

Parent/ guardian turns a screw on distractor after surgery at home to stretch healing tissue (stretch~1mm/day)

3)

Stretch regenerated tissue forms into new bone

• ver next 2 months

4)

After bone is formed at necessary length, device is removed through a 2nd surgery

CELLULAR LEVEL:

 Aka callus distraction  Inflammation: formation of

blood clot and ingrowth of angiogenic elements

 Soft callus: replacement of

blood clot with granulation tissue and fibrocartilage

 Hard Callus: granulation and

fibrocartilage is is replaced with woven bone

 Remodeling: woven bone is

replaced with lamellar bone

TECHNIQUES

RIGID external device (RED) Frames surgery Intramedullary Nail

• Albizzia
• Guichet
• FITbone
• ISKD

LRS

• I. RIGID EXTERNAL DEVICE (RED)

 Found to give reliable results, control bone

movements

 easy removal  Cranial halo (semicircular piece) encircles front

• f patients forehead and secured with pins. Pins

touch but do not penetrate bone.

 Cranial halo is attached to vertical graphite

EXTERNAL DEVICE

Ex: Midface advancement

• metal “halo” device and dental splint remain after
• peration during healing (10weeks)
• 2nd surgery removes halo & splint
• caregiver turns twice a day
• 1/8th inch scar on lower eyelid but heals well

MIDFACE ADVANCEMENT

 Make cut in bones of face at specific points  Loosen midface from rest of skull  Advance into correct position

New advantages:

• bone grafts from rib and skull are no longer

needed with plates and screws

• larger advances in midface are achievable
• skin and muscles are now stretched too and

do not fight to push back

• duration of procedure is shorter

• II. FRAMES SURGERY “ILIZAROV

SURGERY”

 Oldest and most common

method

 Application of circular frame

• r external fixator

 Most common

1) Ilizarov frame 2) Taylor Spatial frame

FRAME MAKE-UP

 Frames are circular external

fixators that surround limb

 Consists of 4-6 rings made of

stainless steel or carbon fiber

 Thin wires and half pins are fixed

to rings and pass through skin to bone Half pins: attached on one side of frame Wires: other side through bone and attached and held under tension Rods and struts: between rings for stability and adjustment

INTRAMEDULLARY NAIL

ALBIZZIA- DR. GUICHET 1987

 Internal telescopic nail with

lengthening mechanism

 Lengthening achieved by

rotation

 Rotation makes “click” noise  Click allows higher

accuracy, patient knows how much they lengthened it

 15 clicks~1 mm  Fully implantable nail

allows for full weight bearing

 4 inch gain  Small scar

GUICHET- ADVANCED ALBIZZIA (2009)

 Improved method  Stronger steel makes it weight bearing  No longer “one size fits all”  Can accommodate different sized limbs

FITBONE (FULLY INTEGRATED TELESCOPIC BONE)

 Nail is distraction

device powered by internal engine

 Engine activated by

hand remote

 Activates distraction

by sending messages to receiver below skin

HOW DOES IT WORK?

 Similar function as car antenna  Fitbone elongation is propelled by gear  Inserted through “model entrance point”  Tiny scar

• III. ISKD (INTRAMEDULLARY SKELETAL

KINETIC DISTRACTOR)

 Activated by polar movements through

small rotation of bone segment being lengthened

 Amount of length is determined pre-op

and set at time of insertion

 Allows 3’’ gain

• IV. LRS (LIMB RECONSTRUCTION

SYSTEM)

 Includes different clamps

that slide on rigid rail and connected with distraction units

 Relies on callus

distraction

 Stability by allowing

different bone screw position in clamp along length of bone

 Rail length pick

depending on size of limb

 Osteotite bone screws

with hydroxyapetite coating

Distraction Osteogenesis for Congenital Deformities

Types of Congenital Deformities:



limb lengthening



facial deformities



amputation at the elbow



correction of airway obstruction in micrognathia



Fibular hemimelia



Hemihypertrophy



Olliers disease

LIMB LENGTHENING



Procedure:



a bone segment is surgically cute and a distraction device is used to slowly pull the two ends apart.



After the desired lengthening has been achieved, the bone consolidates until the lengthened gap has completely calcified.



Distraction phase and Consolidation Phase in distraction osteogenesis.



History: Discovered by Russian Orthopedic Gavril Ilizarov



Technique: external fixator



Today: minimally invasive techniques performed with internal distraction device

AMPUTATION AT THE ELBOW

• Patients with short congenital amputations below the elbow
• ften function as if they have had a disarticulation of the elbow
• Patients had lengthening of stumps by the Ilizarov technique to

improve fitting of prostheses

CONGENITAL FACIAL DEFORMITIES

 Hemifacial Microsomia: a rare congenital disease

characterized by facial asymmetry

 Cleft palate: separation of the roof of the mouth that

• ccurs in early development of fetus

 Severe mandibular hypoplasia (small lower jaw):

causes breathing problems includes conditions as:

 Brachygnathia: abnormal shortness or recession of

the lower jaw

 Micrognathia: an abnormally small, lower jaw and

chin.

 Why?

Hemifacial Microsomia



Distraction Process



Bimaxillary distraction osteogenesis allows correction of mandibular asymmetry with simultaneous correction of the position of the maxilla

Cleft Palate

CORRECTION OF AIRWAY

OBSTRUCTION

 Micrognathia

 Can use tracheostomy: May be life saving but is associated

with complications and developmental problems

 Alternative: internal mandibular distraction osteogenesis

FACIAL DEFORMITIES

 Treacher-Collins syndrome: a condition that affects the

development of bones and other tissues in the face

 Pierre-Robin Sequence: a group of disorders occurring

together that includes a small, lower jaw, breathing problems, and a tongue that tends to ball up at the back of the mouth

 Facial Injuries:

 cause damage to the maxilla or mandible  most common condition for which distraction osteogenesis is

performed

MAXILLOFACIAL DISTRACTION OSTEOGENESIS

 Two Main Uses:

• 1. Congenital

Craniofacial Defects

• 2. Facial injuries from

trauma/ impact

 Requires making

bones longer

MAXILLOFACIAL DO PROCESS

 Bonus Question:  Why is it the hardest

to grow bone in the face considering the current methods?

MAXILLOFACIAL DO

 Bone movements

must be carefully planned before a device is implanted

 There are no devices

that can change trajectory mid-course

MAXILLOFACIAL DO PROCEDURES

 Current Methods:  External and linear

(one dimension)

 Future device goals  Curvilinear devices

(capable of moving bone in 3 dimensions)

 Move bone

continuously, not in increments of 1mm

 Causes less pain,

wouldn’t require patient compliance, might promote faster bone growth

DEVELOPMENTAL DEFORMITIES

 Clavicle Lengthening  Reconstruction of forearm

deformity

 Foot deformities  Bow legs

CLAVICLE LENGTHENING

 Clavicular lengthening by distraction osteogenesis for

congenital clavicular hypoplasia enables gradual correction of deformity

 Has potential to improve shoulder pain, function, range

• f movement and cosmesis.

FOREARM DEFORMITY

 Deformity caused by osteochondromas corrected using an external

fixator for ulnar lengthening and radial deformity.

 Why? Cosmetic and functional problems

FOOT DEFORMITIES

 Distraction osteogenesis used for the treatment

• f brachymetatarsia:

 Condition in which there are one or more abnormally

short metatarsals, making the toe short as well

BOW LEGS

 Blount’s Disease: In some cases, abnormal growth of the bone

causes the bowing to get worse instead of better over time

 Caused by a growth disorder in the upper part of the tibial

bone

DISTRACTION

AFTER TUMOR RESECTION

After Bone Tumor

POST-TRAUMATIC INJURIES

 Growth Plate

Fractures

 Malunion  Shortening and

deformity

 Bone defects

INFECTION: OSTEOMYELITIS

 Lansana’s Story:

 13 year old boy from

Sierra Leone was bitten by a snake while chasing a soccer ball into a bush

 Infection set in his tibia,

which led to a massive bone loss of his tibia and his ankle joint

 Right leg was 6 inches

shorter then left, with a 45 degree internal rotation

COSMETIC USE

 Short Stature  Normal people that

are unhappy with their height

 Dwarfism  Achondroplasia

SHORT STATURE

 Generally

Discouraged

 Breaking perfectly

functioning limbs

 Confining themselves to

wheelchairs or crutches for over a year

 Voluntarily subjecting

themselves to pain and discomfort

 Exposed to unnecessary

risk of infection, damaged nerves and blood vessels, and fat embolism

 Expen$ive procedure   Before procedure, they

must pass the body image assessment (US)

COSMETIC - CHINESE

 National Geographic Video

DWARFISM

Achondroplasia:

 Arms:  Often times, the humerus

is much shorter than the radius and ulna

 Forearm:  More complex nerve

arrangement so few lengthenings are performed on that region

 Legs:  Femur and Tibia are

lengthened

 Fibula is cut and

separated alongside the tibia

BEFORE & AFTER SURGERY

POST-SURGERY

 Often prescribed painkillers and unable to work

while undergoing rehabilitation

 Following initial surgery:  Demanding Physical Therapy  Purpose:  Avoid stiffness and to stimulate the muscles, nerves,

and blood vessels to grow alongside the bone

WEIGHT BEARING

 Depends on design of fixator and

bony contact

 Volume of regenerate will affect

stability

 Initially want strong support for

early weight bearing

 Gradually remove wires and pins

so bone take on more load

MID FACE DISTRACTION: POST-SURGERY CARE

 Hygiene – do not submerge device, soft

toothbrush, no mouthwashes

 Diet – soft foods  Medications – antibiotics, tylenol  Activity – no sports, sitting and walking upright

good for healing/decrease swelling

THINGS TO LOOK

OUT FOR IN FACIAL

DISTRACTION

 Persistant fever or

headache

 Fall or blow to device  Increased swelling

after initial post-op swelling

• Loosening
• Redness or pus near pin sites

COMPLICATIONS

 Axial deformity  Pin tract infection  Fixator instability  Stress fractures in surrounding

bone

Axial Deformation

PIN TRACT INFECTION

 Disrupt blood supply  Local inflammation  Swelling

FIXATOR INSTABILITY

 Excessive motion

in between bone segments

 Premature

consolidation

NEW BONE PROPERTIES

 Approx. 50% mechanical stiffness during axial,

torsional, and bending loading after fixator removal up to 6 weeks

 Peak tensile forces increase with time after

completion

 Torsional loads to failure decrease with time -

Why?

FORCES DURING DISTRACTION

 Strain gauges  Distraction load (resistance to

distraction) increases with every turn

 Frictional forces – Where?

MONOBODY VERSUS CIRCULAR

Good for: Humerus and femur Until recently – preference in U.S. Less awkward/more comfort Less bulk (Clothing

• ptions)

Protect skin and provide elevation Prevent cantilever bending Additional rings – more support Hinges for across joints

CIRCULAR FIXATOR - STABILITY

 Smaller the diameter the better  However not too close to skin, avoid

compression

 Extra ring – no attachment to bone

but can be used to increase stability

VETERINARY CARE

 Canine limb