DISTRACTION OSTEOGENESIS

Mechanical induction of new bone that occurs

between vascular bony surfaces that are gradually pulled apart by gradual distraction. New bone formed bridges the gap & remodels to normal bone macrostructure. Tension stress effect on growth & genesis of tissues.

 Developed by Ilizarov in 1956

Highly modular fixators allow formation of new

bone in almost any plane as D.O follows the vector of applied force. Age: as long as Pt had # healing potential. INDICATION: bone grafting, LLD, nonunion, deformity, bone defects 2* to trauma, infection, tumor.

Advantages over bone grafting

Reduces donor site morbidity

Autograft is limited
No fear of transmission of antigens, bacteria,

viruses, dead foreign bodies. In infected wounds. Risk of # in B.G over extended period of time B.G will never incorporate in to living B.

Components of D.O

1. 2. 3.

Application of ext.fix stability, applies forces Corticotomy Postop period Latency period Distraction P. Consolidation P.

DEFINITION
CORTICOTOMY: low energy osteotomy, performed

using an osteotome to cut only the cortical surface thus preserving the medullary canal, nutrient vessel, endosteum, periosteum LATENCY PERIOD: Initial healing response is allowed to bridge the cut surfaces before distraction is initiated.

 Rate: no of millimeter that the bone surfaces are

pulled apart each day. Rhythm: no of distractions per day Healing index: no of centimeters of N.B divided by no of months from the surgery to date of full wt bearing.

 Transformation osteogenesis: conversion of non

osseous tissues such as fibrocartilage in nonunion in to normal bone. Done through comb compression & distraction forces, augmented by corticotomy. Bone transportation: regeneration of intercalary B.D through corticotomy & distraction & tranf. Osteogenesis.

Critical factors for B. formation

Stability of fixation [circular F]

Atraumatic corticotomy.
Rate Rhythm of distraction.

HISTOLOGY
LATENCY P: similar to # healing DISTRACTION P: mesenchymal cells begin to

organize in to bridge of collagen & immature vascular sinusoids, bridge formed always parallel to direction of distraction. I Week Distraction: central zone of relatively avascular fibrous tissue bridges the 7 mm of C.gap. FIZ: fibrous interzone [no osteoid/ O.B]

II WEEK - Distraction
Clusters of osteoblasts appear on each side of FIZ

adj to vascular sinuses. Collagen bundles fuse with osteoid like M. 1* bone spicules enlarge gradually by circumferential apposition. Later osteoid began to mineralize the 1*B.S PMF[primary mineralisation front] PMF extend from both corticotomy site, towards the central FIZ.

III Week
Mineralization process continues.

As the gap increases, bridge is formed by

elongation of bone spicules. Large thin sinusoids surround each micro column of new bone MCF [micro column formation]. At the end of D., FIZ ossifies & MCF unifies completely bridging the gap.

Microcolumn new bone formation

Physiology
Fibrous interzone assumes the role of growth

plate. [pseudo G.P] Intramembranous ossification in its purest form. [if stability] Local & regional blood supply is most important determining factor.

Pathophysiology
Excessive rate

Sporadic rhythm
Frame stability Poor local & regional stability Traumatic corticotomy Inadequate consolidation phase. Initial diastasis.

 Rate & Rhythm: biosynthetic pathways at cellular

levels , protein synthesis & mitosis. Macromotion: [shear force] disrupt the delicate bone & vascular channels Peripheral vascular disease Traumatic corticotomy- disturb the local blood flow Initial diastasis- inhibit the formation of 1* fibrovascular bridge.

Indications for increase in R & R

Young Pt [up to 12-14 yrs]

X ray premature consolidation.

X ray uncompleted bone cut at the site of

corticotomy. In any event, increase in distraction speed & rhythm cannot exceed 2 mm/ day.

Indication for reduction

Severe pain at the site of distraction, esp after creating 3-4 cm gap. Clinical signs of peripheral vascular & neurological deficiency. X ray slow development of regeneration Reduction in D cannt be less than .25- .50 mm/ day .

 Ilizarov recommended that the number of actual

distractions (rhythm of distraction) should be at least four, achieving a total of 1 mm of total distraction (rate of distraction) in four divided doses. constant distraction over a 24-hour period produces a significant increase in the regenerate quality

ASSESSMENT
Corticotomy: check for completeness in C-arm.

Distracting <2 mm, angulation < 10-15*, rotating < 20-30*. Adequate reduction of corticotomy gap. Length & alignment of D.G checked weekly or biweekly by X ray. N.B mineralization appears by 3rd wk of D. fuzzy, radiodense columns extending from both cut surfaces

 N.B formation should span entire cross sectional

area of host bone cut surfaces. N.B appears bulging, FIZ is narrowing distraction should be accelerated. N.B shows as hour glass appearance, FIZ widens D. rate reduced.

 USG: not regularly used. Cyst formation stop

distraction, gap is gradually closed. QCT: [Quantitative C.T] measuring the mineralization of osteogenic area. Compared with similar region on normal contralateral limb described as % of normal. Normally FIZ- 25-35%, PMF- 40-55%, MCF- 6070%.

 Triphasic bone scan: both sides of distraction gap

should be hot in all three phases. If it is cold, stop distraction.

consolidation
Plain x rays monthly basis, condition of the

cortex & medullary canal are noted in the osteogenic area orthogonal views Bone density may appear reduced. QCT- demonstrates stability.

ACCORDION TECH
Monofocal compression- distraction tech for

nonunion treatment. Alternate compression & distraction maneuver is used 2-3 times to stimulate bone neogenesis. Local scar tissues are initially crushed to be transformed in to tissues capable of neogenesis.