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Bernstein M, Little MTM, Marecek G. Current Management of Acute and Posttraumatic Critical Bone Defects. J Orthop Trauma 2024; 38:S1-S8. [PMID: 38502596 DOI: 10.1097/bot.0000000000002762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 03/21/2024]
Abstract
SUMMARY Limb reconstruction in patients with critical-sized bone defects remains a challenge due to the availability of various technically demanding treatment options and a lack of standardized decision algorithms. Although no consensus exists, it is apparent from the literature that the combination of patient, surgeon, and institutional collaborations is effective in providing the most efficient care pathway for these patients. Success relies on choosing a particular surgical approach that manages infection, soft tissue defects, stability, and alignment. Recent systematic reviews demonstrate high success rates with the following management options: Ilizarov bone transport, Masquelet (induced membrane) technique, cancellous bone grafting, and vascularized bone grafts.
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Affiliation(s)
- Mitchell Bernstein
- Department of Surgery, McGill University Health Center, Montreal QC, Canada
- Department of Pediatric Surgery, McGill University Health Center, Montreal QC, Canada; and
| | - Milton T M Little
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Beverly Hills, CA
| | - Geoffrey Marecek
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Beverly Hills, CA
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Blázquez-Carmona P, Mora-Macías J, Martínez-Vázquez FJ, Morgaz J, Domínguez J, Reina-Romo E. Mechanics Predicts Effective Critical-Size Bone Regeneration Using 3D-Printed Bioceramic Scaffolds. Tissue Eng Regen Med 2023; 20:893-904. [PMID: 37606809 PMCID: PMC10519928 DOI: 10.1007/s13770-023-00577-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/25/2023] [Accepted: 07/11/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND 3D-printed bioceramic scaffolds have gained popularity due to their controlled microarchitecture and their proven biocompatibility. However, their high brittleness makes their surgical implementation complex for weight-bearing bone treatments. Thus, they would require difficult-to-instrument rigid internal fixations that limit a rigorous evaluation of the regeneration progress through the analysis of mechanic-structural parameters. METHODS We investigated the compatibility of flexible fixations with fragile ceramic implants, and if mechanical monitoring techniques are applicable to bone tissue engineering applications. Tissue engineering experiments were performed on 8 ovine metatarsi. A 15 mm bone segment was directly replaced with a hydroxyapatite scaffold and stabilized by an instrumented Ilizarov-type external fixator. Several in vivo monitoring techniques were employed to assess the mechanical and structural progress of the tissue. RESULTS The applied surgical protocol succeeded in combining external fixators and subject-specific bioceramic scaffolds without causing fatal fractures of the implant due to stress concentrator. The bearing capacity of the treated limb was initially altered, quantifying a 28-56% reduction of the ground reaction force, which gradually normalized during the consolidation phase. A faster recovery was reported in the bearing capacity, stiffening and bone mineral density of the callus. It acquired a predominant mechanical role over the fixator in the distribution of internal forces after one post-surgical month. CONCLUSION The bioceramic scaffold significantly accelerated in vivo the bone formation compared to other traditional alternatives in the literature (e.g., distraction osteogenesis). In addition, the implemented assessment techniques allowed an accurate quantitative evaluation of the bone regeneration through mechanical and imaging parameters.
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Affiliation(s)
- Pablo Blázquez-Carmona
- Escuela Técnica Superior de Ingeniería, Universidad de Sevilla, Avenida Camino de los Descubrimientos s/n, 41092, Seville, Spain.
- Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla, Seville, Spain.
| | - Juan Mora-Macías
- Escuela Técnica Superior de Ingeniería, Universidad de Huelva, Huelva, Spain
- Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla, Seville, Spain
| | - Francisco J Martínez-Vázquez
- Escuela Técnica Superior de Ingeniería, Universidad de Sevilla, Avenida Camino de los Descubrimientos s/n, 41092, Seville, Spain
| | - Juan Morgaz
- Departamento Medicina y Cirugía Animal, Universidad de Córdoba, Campus Universitario de Rabanales, Córdoba, Spain
| | - Jaime Domínguez
- Escuela Técnica Superior de Ingeniería, Universidad de Sevilla, Avenida Camino de los Descubrimientos s/n, 41092, Seville, Spain
- Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla, Seville, Spain
| | - Esther Reina-Romo
- Escuela Técnica Superior de Ingeniería, Universidad de Sevilla, Avenida Camino de los Descubrimientos s/n, 41092, Seville, Spain
- Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla, Seville, Spain
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Calvo-Gallego JL, Mora-Macías J, Reina-Romo E, Domínguez J, Martínez-Reina J. Evolution of relaxation properties of callus tissue during bone transport. Proc Inst Mech Eng H 2022; 236:1457-1461. [DOI: 10.1177/09544119221113692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Callus tissue exhibits a viscoelastic behavior that has a strong influence on the distribution of stresses and their evolution with time and, thus, it can affect tissue differentiation during distraction procedures. For this reason, a deep knowledge of that viscoelastic behavior can be very useful to improve current protocols of bone distraction and bone transport. Monitoring stress relaxation of the callus during distraction osteogenesis allows characterizing its viscoelastic behavior. Different procedures have been used in the literature to fit the response of a given viscoelastic model to the force relaxation curve. However, these procedures do not ensure the uniqueness of that fit, which is of the utmost importance for statistical purposes. This work uses a fitting procedure already validated for other tissues that ensures that uniqueness. Very importantly too, the procedure presented here allows obtaining more information from the stress relaxation tests, distinguishing relaxation in different time scales, which provides a deeper insight into the viscoelastic behavior and its evolution over time. As it was observed in the results, relaxation is faster at the first days after osteotomy and becomes slower and more gradual with time. This fact can be directly linked to the temporal evolution of the callus composition (water, organic phase, and mineral content) and also to the progression of tissue differentiation, with a prevalence of hard tissues as time passes.
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Affiliation(s)
| | - Juan Mora-Macías
- Department of Mining, Mechanical, Energy and Construction Engineering, University of Huelva, Huelva, Spain
| | - Esther Reina-Romo
- Department of Mechanical Engineering, University of Seville, Seville, Spain
| | - Jaime Domínguez
- Department of Mechanical Engineering, University of Seville, Seville, Spain
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Bachmeier AT, Euler E, Bader R, Böcker W, Thaller PH. Novel approach to estimate distraction forces in distraction osteogenesis and application in the human lower leg. J Mech Behav Biomed Mater 2022; 128:105133. [PMID: 35217291 DOI: 10.1016/j.jmbbm.2022.105133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/18/2022] [Accepted: 02/11/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE In distraction osteogenesis (DO) of long bones, new bone tissue is distracted to lengthen limbs or reconstruct bone defects. However, mechanical boundary conditions in human application such as arising forces are mainly based on limited empirical data. Our aim was the numerical determination of the callus distraction force (CDF) and the total distraction force (TDF) during DO in the tibia of adults to advance the understanding of callus tissue behavior and optimize DO procedures. METHOD We implemented a mathematical model based on an animal experiment to enable the calculation of forces arising while distracting callus tissue, excluding the influence of surrounding soft tissue (muscles, skin etc.). The CDF progression for the distraction period was calculated using the implemented model and varying distraction parameters (initial gap, area, step size, time interval, length). Further, we estimated the CDF based on reported forces in humans and compared the results to our model predictions. In addition, we calculated the TDF based on our CDF predictions in combination with reported resisting forces due to soft tissue presence in human cadavers. Finally, we compared the progressions to in vivo TDF measurements for validation. RESULTS Due to relaxation, a peak and resting CDF is observable for each distraction step. Our biomechanical results show a non-linear degressive increase of the resting and peak CDF at the beginning and a steady non-linear increase thereafter. The calculated resting and peak CDF in the tibial metaphysis ranged from 0.00075 to 0.0089 N and 0.22-2.6 N at the beginning as well as 20-25 N and 70-75 N at the end of distraction. The comparison to in vivo data showed the plausibility of our predictions and resulted in a 10-33% and 10-23% share of resting CDF in the total resting force for bone transport and elongation, respectively. Further, the percentage of peak CDF in total peak force was found to be 29-58% and 27-55% for bone transport and elongation, respectively. Moreover, our TDF predictions were valid based on the comparison to in vivo forces and resulted in a degressive increase from 6 to 125 N for the peak TDF and from 5 to 76 N for the resting TDF. CONCLUSION Our approach enables the estimation of forces arising due to the distraction of callus tissue in humans and results in plausible force progressions as well as absolute force values for the callus distraction force during DO. In combination with measurements of resisting forces due to the presence of soft tissue, the total distraction force in DO may also be evaluated. We thus propose the application of this method to approximate the behavior of mechanical callus properties during DO in humans as an alternative to in vivo measurements.
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Affiliation(s)
- A T Bachmeier
- 3D-Surgery, Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany; Biomechanics and Implant Technology Research Laboratory, University Medicine Rostock, Rostock, Germany.
| | - E Euler
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - R Bader
- Biomechanics and Implant Technology Research Laboratory, University Medicine Rostock, Rostock, Germany
| | - W Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - P H Thaller
- 3D-Surgery, Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
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Blázquez-Carmona P, Sanz-Herrera JA, Mora-Macías J, Morgaz J, Domínguez J, Reina-Romo E. Time-Dependent Collagen Fibered Structure in the Early Distraction Callus: Imaging Characterization and Mathematical Modeling. Ann Biomed Eng 2022; 50:1798-1809. [PMID: 35732853 PMCID: PMC9794544 DOI: 10.1007/s10439-022-02992-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/09/2022] [Indexed: 12/31/2022]
Abstract
Collagen is a ubiquitous protein present in regenerating bone tissues that experiences multiple biological phenomena during distraction osteogenesis until the deposition of phosphate crystals. This work combines fluorescence techniques and mathematical modeling to shed light on the mechano-structural processes behind the maturation and accommodation-to-mineralization of the callus tissue. Ovine metatarsal bone calluses were analyzed through confocal images at different stages of the early distraction osteogenesis process, quantifying the fiber orientation distribution and mean intensity as fiber density measure. Likewise, a mathematical model based on the experimental data was defined to micromechanically characterize the apparent stiffening of the tissue within the distracted callus. A reorganization of the fibers around the distraction axis and increased fiber density were found as the bone fragments were gradually separated. Given the degree of significance between the mathematical model and previous in vivo data, reorganization, densification, and bundle maturation phenomena seem to explain the apparent mechanical maturation observed in the tissue theoretically.
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Affiliation(s)
- Pablo Blázquez-Carmona
- Escuela Técnica Superior de Ingeniería, Universidad de Sevilla, Avenida Camino de los Descubrimientos s/n, 41092 Seville, Spain
| | - José A. Sanz-Herrera
- Escuela Técnica Superior de Ingeniería, Universidad de Sevilla, Avenida Camino de los Descubrimientos s/n, 41092 Seville, Spain
| | - Juan Mora-Macías
- Escuela Técnica Superior de Ingeniería, Universidad de Huelva, 21007 Huelva, Spain
| | - Juan Morgaz
- Hospital Clínico Veterinario, Universidad de Córdoba, Ctra. Nacional IV-A, Km 396, 14014 Córdoba, Spain
| | - Jaime Domínguez
- Escuela Técnica Superior de Ingeniería, Universidad de Sevilla, Avenida Camino de los Descubrimientos s/n, 41092 Seville, Spain
| | - Esther Reina-Romo
- Escuela Técnica Superior de Ingeniería, Universidad de Sevilla, Avenida Camino de los Descubrimientos s/n, 41092 Seville, Spain
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Demir B, Ozkul B, Lapcin O, Beng K, Arikan Y, Yalcinkaya M. A Modification of Internal Bone Transport Method for Reconstruction of Nonunion of Forearm. Indian J Orthop 2019; 53:196-203. [PMID: 30906002 PMCID: PMC6394197 DOI: 10.4103/ortho.ijortho_52_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Defects of bone and soft tissue occur frequently after high-energy trauma, infections, and tumor resection. Treatment options are limited and outcomes are controversial in nonunion. Classical reconstruction methods are challenging. We describe a method of internal bone transport for treatment of complicated nonunion of the forearm. This method permits axial and internal bone transport without harming the distorted and complex neurovascular anatomy or soft-tissue envelope. MATERIALS AND METHODS Five patients (mean age, 27 years) with defect nonunion (3 ulna, 2 radius) were treated. Mean preoperative defect size was 36 mm, mean shortening was 14 (0-30) mm, and the extent of surgical resection was 24 (20-40) mm. Total bone loss due to defect, resection, or shortening was 74 mm. According to Paley classification, two of the patients had B1, and three had B3 defect nonunion. This study treats defect nonunion of the forearm using an internal bone-transport method. Our method involved cannulated screws, a cerclage wire, and a circular fixator being used in combination. When transportation was completed, internal fixation of the docking site with a plate and screws was done, with bone grafting after fixator removal. Bone healing and functional outcomes were assessed with radiographs and disabilities of the arm, shoulder, and hand (DASH) scores, respectively. RESULTS Mean followup was 67.6 months. Solid osseous union and functional improvement were achieved in all cases. Mean bone loss was 66 mm, mean fixator time was 131.8 days, the lengthening index was 1.3 days/mm, and the fixator index was 2.1 days/mm. DASH score was 82.2 before treatment and 15.36 after treatment. CONCLUSIONS Using our method, internal bone transport and progressive axial docking of defects can be done with minimal effects on surrounding neurovascular arrangements and soft tissues. Size of fixators can be decreased and formation of painful scar tissue can be avoided.
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Affiliation(s)
- Bilal Demir
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Baris Ozkul
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey,Address for correspondence: Dr. Baris Ozkul, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital. Rumeli Hisari Street. No: 62, 34470, Baltalimani, Sariyer, Istanbul, Turkey.” E-mail:
| | - Osman Lapcin
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Kubilay Beng
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Yavuz Arikan
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Merter Yalcinkaya
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
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Meyers N, Schülke J, Ignatius A, Claes L. Evolution of callus tissue behavior during stable distraction osteogenesis. J Mech Behav Biomed Mater 2018; 85:12-19. [PMID: 29803766 DOI: 10.1016/j.jmbbm.2018.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/11/2018] [Accepted: 05/09/2018] [Indexed: 10/16/2022]
Abstract
Multiple studies have sought to characterize the mechanical behavior of callus tissue in vivo during distraction osteogenesis. The aims of such studies are to understand the mechanobiology of distraction and elucidate the complex viscoelasticity and evolution of the tissue. The former objective has direct clinical relevance to surgical technique and process control while the latter is necessary for the calibration and validation of the predictive healing models. Such models seek to reduce the researcher's dependence on animal studies and prospectively allow improved surgical planning. To date, no study has been capable of controlling the mechanical conditions sufficiently enough to decouple the distraction process from the secondary mechanical stimulation associated with the finite stiffness of the fixation constructs employed. It is the goal of this work to understand the mechanobiology of pure distraction as well as characterize viscoelastic tissue behavior under precisely defined mechanical conditions. This is achieved using a novel lateral distraction model. The structural integrity of the bone is maintained, allowing the collection of force relaxation data due to a stepwise distraction process without the superimposed influence of secondary mechanical stimulation. The average instantaneous modulus increases from approximately 2 kPa to approximately 1100 kPa while the equilibrium modulus increases from approximately 0 kPa to 200 kPa over the distraction period.
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Affiliation(s)
- Nicholaus Meyers
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany.
| | - Julian Schülke
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Anita Ignatius
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Lutz Claes
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
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Mechanical characterization via nanoindentation of the woven bone developed during bone transport. J Mech Behav Biomed Mater 2017. [DOI: 10.1016/j.jmbbm.2017.05.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Model of the distraction callus tissue behavior during bone transport based in experiments in vivo. J Mech Behav Biomed Mater 2016; 61:419-430. [DOI: 10.1016/j.jmbbm.2016.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 04/01/2016] [Accepted: 04/08/2016] [Indexed: 11/18/2022]
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A novel intramedullary callus distraction system for the treatment of femoral bone defects. Strategies Trauma Limb Reconstr 2016; 11:113-21. [PMID: 27221258 PMCID: PMC4960057 DOI: 10.1007/s11751-016-0255-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 05/03/2016] [Indexed: 01/08/2023] Open
Abstract
An intramedullary device has some advantages over external fixation in callus distraction for bone defect reconstruction. There are difficulties controlling motorized intramedullary devices and monitoring the distraction rate which may lead to poor results. The aim of this study was to design a fully implantable and non-motorized simple distraction nail for the treatment of bone defects. The fully implantable device comprises a tube-in-tube system and a wire pulling mechanism for callus distraction. For the treatment of femoral bone defects, a traction wire, attached to the device at one end, is fixed to the tibial tubercle at its other end. Flexion of the knee joint over a predetermined angle generates a traction force on the wire triggering bone segment transport. This callus distraction system was implanted into the femur of four human cadavers (total 8 femora), and bone segment transport was conducted over 60-mm defects with radiographic monitoring. All bone segments were transported reliably to the docking site. From these preliminary results, we conclude that this callus distraction system offers an alternative to the current intramedullary systems for the treatment of bone defects.
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How does the rate of dentoalveolar distraction affect the bone regenerate produced? Am J Orthod Dentofacial Orthop 2011; 140:e211-21. [DOI: 10.1016/j.ajodo.2011.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 06/01/2011] [Accepted: 06/01/2011] [Indexed: 11/23/2022]
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Picado CHF, Garcia FL. Correção de falhas ósseas diafisárias: trasnporte ósseo fixado com placa. ACTA ORTOPEDICA BRASILEIRA 2007. [DOI: 10.1590/s1413-78522007000100010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
O objetivo deste estudo é descrever um novo sistema de transporte ósseo que dispensa o uso de fios transfixantes. O sistema, constituído por uma placa, um carro móvel e por um dispositivo tracionador, foi instalado na tíbia direita de 17 ovelhas para preencher um defeito ósseo de 1 cm. O transporte ósseo foi iniciado 7 dias após a cirurgia numa taxa de 0,8 mm/dia, dividido em 0,2 mm a cada 6 horas. Radiografias em ântero-posterior e perfil foram realizadas imediatamente após a cirurgia e semanalmente até o término do transporte. Em todos os 12 animais que completaram o estudo, o defeito ósseo foi preenchido com formação do regenerado e consolidação do foco alvo. O estudo demonstra que o sistema aqui apresentado realiza o transporte ósseo de maneira efetiva, eliminando o uso de fios ou pinos transfixantes.
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Rahal S, Volpi R, Vulcano L. Uso do transporte ósseo no tratamento de perda óssea segmentar extensa da tíbia: estudo experimental em cães. ARQ BRAS MED VET ZOO 2005. [DOI: 10.1590/s0102-09352005000100005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Avaliou-se a técnica de transporte ósseo realizada com fixador externo de Ilizarov no tratamento de defeito ósseo segmentar extenso promovido na tíbia de sete cães. Após aplicação de montagem constituída de um semi-anel proximal, um anel médio e outro distal, ligados entre si por meio de hastes rosqueadas, foi excisado um segmento da diáfise média distal da tíbia e fíbula direitas de 30% do comprimento ósseo. A reconstrução do defeito foi realizada por transporte de um segmento ósseo obtido por osteotomia subperiosteal da parte proximal da tíbia, entre o semi-anel proximal e o anel médio. O período de latência foi de seis dias e o ritmo do transporte foi de 0,5mm a cada 12 horas. Na área de acoplamento foi aplicada compressão. O fixador permaneceu em fase neutra por 14 semanas e, após a remoção do aparelho, os animais foram observados por mais quatro semanas. O resultado funcional foi considerado excelente em um animal, bom em um, satisfatório em três e deficiente nos outros dois. O transporte ósseo permitiu a reparação de falhas ósseas segmentares extensas, porém pode apresentar dificuldades no direcionamento do segmento ósseo transportado e de sua consolidação na área de acoplagem.
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Meffert RH, Tis JE, Inoue N, McCarthy EF, Brug E, Chao EY. Primary resective shortening followed by distraction osteogenesis for limb reconstruction: a comparison with simple lengthening. J Orthop Res 2000; 18:629-36. [PMID: 11052500 DOI: 10.1002/jor.1100180416] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Resective distraction osteogenesis is a new approach to treat segmental diaphyseal bone defects by primary limb shortening and secondary distraction osteogenesis from the same site. A rabbit model was introduced to compare the bone-regeneration characteristics of this technique with those of simple lengthening procedures. Twenty-four skeletally mature New Zealand White rabbits were divided into two equal groups. In the test group, limbs were lengthened after a 10-mm segmental diaphyseal bone resection and limb shortening. In the control group, a simple subperiosteal osteotomy for limb lengthening was performed without resection. New bone formation was evaluated mechanically, radiologically, histomorphometrically, and densitometrically. Bone bridging occurred in all animals. Normalized mechanical values for the newly reconstructed tibiae demonstrated similar torsional stiffness (71+/-3.3 compared with 71+/-8.2%; p = 0.95) and strength (64+/-5.3 compared with 68+/-7.3%; p = 0.66) in the two groups. The average normalized callus diameter was significantly greater in the test group than in the control group (p < 0.01). The remodeling index calculated from densitometry, however, showed a significantly less progressed stage of remodeling in the test group (p < 0.05). Histomorphometric analysis of the callus center supported this finding, showing significantly lower values for trabecular thickness (p < 0.05) and total bone volume (p < 0.01) in the test group. The results demonstrated the possibility of new bone formation after resection and monofocal shortening. This suggests a new therapeutic option to treat diaphyseal segmental bone defects.
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Affiliation(s)
- R H Meffert
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland 21205-2196, USA
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Meffert RH, Inoue N, Tis JE, Brug E, Chao EY. Distraction osteogenesis after acute limb-shortening for segmental tibial defects. Comparison of a monofocal and a bifocal technique in rabbits. J Bone Joint Surg Am 2000; 82:799-808. [PMID: 10859099 DOI: 10.2106/00004623-200006000-00006] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Segmental bone defects can be treated with immediate limb-shortening followed by monofocal or bifocal distraction osteogenesis. In the present study, the efficacy of monofocal distraction osteogenesis was compared with that of bifocal distraction osteogenesis in a rabbit model. METHODS Twenty-four skeletally mature New Zealand White rabbits were divided into two equal groups: one group had monofocal distraction osteosynthesis, and the other had bifocal distraction osteosynthesis. In both groups, a one-centimeter-long segment of bone was resected from the midpart of the tibial shaft. In the monofocal reconstruction group, the limb was immediately shortened to close the segmental defect and the defect was allowed to heal for ten days. Lengthening was then begun at this site, with use of a specially designed external fixator, at a rate of 0.5 millimeter per twelve hours. In the bifocal reconstruction group, the segmental defect was closed immediately and the fragments were fixed with microplates. A subperiosteal osteotomy was performed proximal to the tibiofibular junction, and lengthening was performed at the site of the osteotomy. The animals in both groups were killed twenty days after the lengthening was completed. New-bone formation then was evaluated with use of radiographs, densitometry, biomechanical testing, and histological and histomorphometric analysis. RESULTS Osseous consolidation occurred in all but one of the animals. Biomechanical testing demonstrated that the tibiae that had been treated with use of the simple monofocal reconstruction technique tended to have greater torsional stiffness (p = 0.14) and strength (p = 0.09). Follow-up radiographs revealed that both groups had a significant decrease in radiolucent area (p < 0.05), which occurred at essentially the same rate after lengthening. No significant differences were found between the groups with respect to new-bone mineral density, new-bone area, or the amount of callus. Thus, after resection of a diaphyseal bone segment comprising 10 percent of the original length of the tibia and acute shortening, limb reconstruction was completed successfully through distraction osteogenesis with use of either a monofocal or a bifocal technique in rabbits. CONCLUSIONS In the present study, both monofocal and bifocal techniques of shortening and distraction osteogenesis were effective for the reconstruction of segmental bone defects. Under some conditions, the monofocal method may provide a simpler means of treating such defects. CLINICAL RELEVANCE Damage to the soft-tissue envelope as well as venous and lymphatic stasis impose limits on the amount of limb-shortening that can be achieved with use of the monofocal method and also influence the indications for this procedure in the clinical setting.
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Affiliation(s)
- R H Meffert
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland 21205-2196, USA
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Richards M, Kozloff KM, Goulet JA, Goldstein SA. Increased distraction rates influence precursor tissue composition without affecting bone regeneration. J Bone Miner Res 2000; 15:982-9. [PMID: 10804030 DOI: 10.1359/jbmr.2000.15.5.982] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The effect of increased distraction rate on bony tissue differentiation was studied using a paired bilateral model of rat femur lengthening. After a 6-day latency period, one randomly selected femur for each rat was distracted at 0.5 mm/day (normal rate) for 12 days, and the contralateral femur was distracted at 1.5 mm/day (increased rate) for 4 days. Femoral lengthening for each side was 6.0 mm, leaving the increased rate leg with an extra 8 days of consolidation compared with the normal rate limb. Group I rats (n = 9) were killed at day 18 postsurgery and analyzed for cartilage tissue composition and distribution. Group II rats (n = 7) were killed on day 36 postsurgery and analyzed by three-dimensional microcomputed tomography (MCT) for changes in new bone volume. Digital color analysis of slides stained with type II collagen antibody showed increases in cartilaginous tissue formation on the increased rate side (1.51 mm2 vs. 0.83 mm2; p = 0.10). No differences in new bone volume were detected between increased rate limbs and their contralateral controls (46.13 mm3 vs. 42.69 mm3; p = 0.63). These findings suggest that intermediate distraction rates may influence precursor tissue composition without affecting the final amount of new bone formed. Because damage to the tissue was not detected at either time point, these changes in chondrogenesis may reflect sensitivity of the pluripotential gap tissue to tension accumulation during lengthening. Future work with this in vivo model is focused on improving our understanding of the mechanisms behind this strain sensitivity.
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Affiliation(s)
- M Richards
- Orthopaedic Research Laboratories, University of Michigan, Ann Arbor 48109-0486, USA
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17
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Farhadieh RD, Gianoutsos MP, Dickinson R, Walsh WR. Effect of distraction rate on biomechanical, mineralization, and histologic properties of an ovine mandible model. Plast Reconstr Surg 2000; 105:889-95. [PMID: 10724247 DOI: 10.1097/00006534-200003000-00010] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Craniofacial microsomia is a common congenital malformation. Ilizarov's method of distraction osteogenesis applied to the mandible has yielded promising results both experimentally and clinically. Because the technique is used predominantly in a pediatric population, length of treatment and compliance may be problematic. To date, the limits of distraction rate in the craniofacial skeleton have not been defined. This study was designed to investigate the effects of distraction rate, in a large animal model, on the mineralization, biomechanical, and histologic properties of lengthened mandibles. Clinically faster distraction rates would decrease the overall treatment time. Twenty-four animals were divided into four groups, with varying rates of distraction (1, 2, 3, and 4 mm/day). A uniaxial distractor at the angle of the mandible was used. The mandibles were lengthened to 24 mm and fixed for a period of 5 weeks, when the animals were killed. The specimens were analyzed with respect to mineralization using dual energy x-ray absorptiometry, biomechanical strength, through a modified three-point bending test, and histologic properties with hematoxylin and eosin stains. Biomechanical, mineralization, and histologic analyses of the samples indicated that group 1 (1 mm/day) samples were significantly superior (p<0.05) to those of group 4 (4 mm/day). Although bone formation was achieved in all groups, group 1 (1 mm/day) demonstrated the strongest biomechanical and histologic properties. Bone mineral density obtained using dual energy x-ray absorptiometry may be clinically useful as a reliable, noninvasive, and relatively cheap predictor for removal time of the fixator.
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Affiliation(s)
- R D Farhadieh
- Division of Surgery, Prince of Wales Hospital, University of New South Wales, Sydney, Australia
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Richards M, Waanders NA, Weiss JA, Bhatia V, Senunas LE, Schaffler MB, Goldstein SA, Goulet JA. Reduced gap strains induce changes in bone regeneration during distraction. J Biomech Eng 1999; 121:348-55. [PMID: 10396702 DOI: 10.1115/1.2798331] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A bilateral New Zealand white rabbit model of distraction osteogenesis (DO) was used to investigate the relationship between strain environment and bone regeneration during limb lengthening. In seven (n = 7) rabbits, a stiffener was applied to the fixator on one side to reduce strains within the gap tissue after lengthening was completed. Animals were euthanized six days later and their distraction zones were harvested and analyzed for changes in new bone volume and architecture. Nonlinear finite element analyses (FEA) were performed to predict changes in the gap strain environment. FEA results predicted a nearly uniform sevenfold decrease in average strain measures within the distraction zone. No change in total average new bone volume and significant decreases in both bone volume fraction (BV/TV) and trabecular thickness (Tb.Th) were observed in tibiae in which gap strains were reduced experimentally, compared to contralateral controls. These results suggest that fixator stiffening influenced the architecture but not the amount of newly formed bone. This animal model of distraction might be used to study the mechanisms by which strain fields affect events in bone repair and regeneration, such as cell proliferation, precursor tissue differentiation, and altered growth factor and nutrient delivery to tissues.
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Affiliation(s)
- M Richards
- Orthopaedic Research Laboratories, University of Michigan, Ann Arbor 48109-0328, USA
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Gardner TN, Evans M, Simpson H, Kenwright J. Force-displacement behaviour of biological tissue during distraction osteogenesis. Med Eng Phys 1998; 20:708-15. [PMID: 10098617 DOI: 10.1016/s1350-4533(98)00043-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Limb lengthening and bone transport treatments are used frequently, and complications during treatment are common. Knowledge of the origin of tensile forces which resist distraction and the force-displacement response of biological tissues during extension would assist in reducing complication rates. Two tibial diaphyseal lengthenings carried out using an Ilizarov fixator were monitored by a displacement transducer to determine extension of the lengthening tissue (the regenerate bone), and by force transducers to determine tensile forces in the tissues that resist extension. The position of the force vector within a cross-section of the limb at the regenerate (provided by CT) was used to determine the origin of these forces. The muscle groups and adjacent fascia resisting extension were the gastrocnemius in one subject and the anterior and peroneal compartments in the other. In response to distraction, these tissues had relatively high stiffness (> 200 N/mm), less "immediate" displacement (< 35% of long term non-recoverable displacement) and inconsistent force relaxation properties (0-90%). In contrast, when the force vector was located in the vicinity of the regenerate, tissue exhibited lower stiffness (< 50 N/mm) and more immediate displacement (> 65% of long term nonrecoverable displacement), but also exhibited inconsistent force relaxation (0-67%).
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Affiliation(s)
- T N Gardner
- Oxford Orthopaedic Engineering Centre, Nuffield Orthopaedic Centre, Headington, UK.
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