Determinación de los parámetros idóneos de la distracción osteogénica de la mandíbula. Estudio experimental / Determination of mandibular distraction osteogenesis most suitable parameters. An experimental study

Resumen Antecedentes: Respecto a la distracción osteogénica (generación ósea inducida), con mayor o menor éxito han sido descritos diversos protocolos para el manejo del período de latencia, velocidad de distracción y período de consolidación. Objetivo: Entender mejor el proceso de la distracción mandibular y establecer los factores determinantes y sus tiempos óptimos. Material y métodos: Se estudiaron 27 perros sometidos a distracción osteogénica unidireccional, bilateral de la mandíbula. Los procesos de distracción se aplicaron con seis variantes, dos por cada factor (período de latencia, período de distracción y velocidad de distracción). Se estudiaron los cambios mediante biopsias del hueso y radiografías de la zona a los 0, 7, 14, 21, 45 y 55 días del proceso. Resultados: Los parámetros de distracción osteogénica más eficientes fueron período de latencia de cinco días, período de consolidación de seis semanas, 1 mm diario de velocidad de distracción para distancias menores a 20 mm y 3 mm diarios para distancias mayores. Conclusiones: El estudio histológico secuencial permitió observar la aparición de los elementos celulares (osteocitos, osteoclastos, matriz osteoide, trabeculado, etcétera) y su participación en el tejido de granulación, el hueso neoformado y el hueso maduro compacto.

Abstract Background: Distraction osteogenesis is a process of induced bone generation. Various protocols have been described for the management of the latency period, distraction speed and consolidation period, with greater or lesser success. Objective: To better understand the process of mandibular distraction and establish the determining factors and their optimal times. Material and methods: Twenty-seven dogs were studied, which had 54 distractors placed and that underwent unidirectional, bilateral mandibular distraction osteogenesis. The distraction processes were applied using six variants, two for each factor: latency period, distraction period and distraction speed. The changes were examined by means of bone biopsies and X-rays of the area at 0, 7, 14, 21, 45 and 55 days of the process. Results: The most efficient osteogenic distraction parameters were a latency period of five days, a consolidation period of six weeks, distraction speed of 1 mm/day for distances of less than 20 mm, and 3 mm/day for longer distances. Conclusions: The sequential histological study allowed to observe the appearance of cellular elements (osteocytes, osteoclasts, osteoid matrix, trabeculate, etc.) and their participation in granulation tissue, newly-formed bone and compact mature bone.

Application and accuracy assessment of a novel 3D-printed osteotomy guide in anterior maxillary segmental distraction osteogenesis / 上海交通大学学报（医学版）

Objective·To evaluate the effects of anterior maxillary segmental distraction osteogenesis(AMSDO)in treating sagittal maxillary hypoplasia in cleft lip and palate(CLP)patients and to report a 3D-printed surgical guide to facilitate the osteotomy.Methods·Twelve patients with CLP who underwent AMSDO were included in this study.Virtual osteotomy was performed in a 3-dimensional model and the osteotomy line were fabricated into a tooth-borne surgical guide by using 3D-printing technique.Lateral cephalograms taken before surgery(T0),at the end of consolidation(T1)and six months after consolidation(T2)were used to evaluate the effects of AMSDO.The accuracy of the osteotomy guide was measured by superimposing the postoperative CT data to virtual planning.Results·All the patients went through surgery without serious complications.SNA and overjet changed significantly both from T0 to T1 and from T0 to T2.ANB,facial convexity,and palatal length changed without significance from T0 to T1 and from T0 to T2.SNB remained stable.All the variables remained relatively stable from T1 to T2.The anteroposterior linear root-mean-square deviation(RMSD)between planning and actual results was 0.90 mm,while the angular RMSD in the sagittal plane was 5.07°.Conclusion·AMSDO is an effective treatment for maxillary hypoplasia secondary to CLP.The accuracy of this 3D-printed osteotomy guide is clinically acceptable,and this can simplify the surgery with fewer complications.

A study on the animal model preparation and early histological changes of trans-sutural distraction osteo-genesis / 实用口腔医学杂志

Objective:To establish an animal model of trans-sutural distraction osteogenesis in SD rats.Methods:A self-designed V-shaped distraction device(distractor)was fabricated with the traction force(N)of 0,1.3,2.2,3.0,4.3 and 5.0 corresponding to the distraction length(mm)of 5,4,3,2,1 and 0 respectively,meeting the trans-sutural distraction osteogenesis requirements in skull of 5-week-old SD rats.The distractor was plased into the sagittal suture of 12 SD rats.Continuous sampling was conducted 1,3,5 and 7 days respectively(n=3)after operation.The tissue changes in the trans-sutural distraction area were observed by HE and Masson's trichrome staining.Inflammation levels were determined using Arg-1 immunofluorescence staining.The early angiogenesis was clarified through co-staining with CD31 and EMCN.Results:A stable trans-sutural distraction osteogenesis model was estab-lished,5 mm distraction osteogenesis width was observed completely within 7 days of distraction.Significant new bone formation was observed at 7 days after operation.Arg-1 expression increased and was concentrated at the bone margins,overlapping with the areas of new bone formation.EMCN expression gradually decreased,and by day 7 CD31 was predominant,indicating the basic maturation of blood vessels.Conclusion:This study successfully constructed a stable and effective trans-sutural distraction osteogenesis animal model,and provides an experimental basis for the investigation of its early continuous histological changes.

Biomechanical characteristics of a novel interspinous distraction fusion device BacFuse for the repair of lumbar degenerative disease / 中国组织工程研究

BACKGROUND:Interspinous distraction fusion device BacFuse was used for the management of lumbar degenerative disease and obtained good clinical efficacy in recent years.However,the related biomechanical study was lacking. OBJECTIVE:To explore the related biomechanical characteristics of BacFuse,a novel interspinous distraction fusion device,which was used in lumbar degenerative disease. METHODS:After constructing the goat spinal models(L1-L6),they were grouped into four groups based on different simulated surgeries:the control group,the BacFuse group(L3/4),the screw-rod fixation group(L3/4)and the Topping-off group(L3/4 screw-rod fixation + L2/3 BacFuse fixation).The goat lumbar spine surgical model was assembled into a biomechanical testing system.A biomechanical machine was used for mechanical loading,simulating lumbar spine movement of flexion,extension,lateral flexion and rotation with a 4 Nm moment.A visual tracking system was used for positioning and capturing.Finally,mechanical and optical calibration was completed to calculate the range of motion of the L2/3,L3/4 and L4/5 segments. RESULTS AND CONCLUSION:(1)Compared with the control group,the range of motion of the L3/4 segment in the BacFuse group decreased 27.27%,70%,38.1%and 23.08%in the flexion,extension,lateral bending and rotation directions,respectively(P<0.05).The range of motion of L3/4 segment in the screw-rod fixation group decreased 72.73%,80%,71.43%and 73.08%in the flexion,extension,lateral bending and rotation directions,respectively(P<0.05).(2)Compared with the control group,the range of motion of the adjacent segment L2/3 increased by 33.33%,25%and 23.81%in the extension,lateral bending and rotation directions,respectively in the BacFuse group(P<0.05),with no significant change in flexion.In the screw-rod fixation group,there was a 50%,44.44%,50%and 58.96%increase in the adjacent segment L2/3 in the flexion,extension,lateral calibration and rotation directions,respectively(P<0.05).(3)Compared with the control group,the BacFuse group showed an increase in range of motion in proximal segment L4/5 in the extension and rotation directions by 27.3%and 17.39%(P<0.05)respectively,with no significant change in flexion or lateral bending.In the screw-rob fixation group,the proximal segment L4/5 demonstrated 38.89%,22.73%and 26.09%(P<0.05)increases in range of motion in the flexion,extension and rotation directions,respectively,with no significant change in lateral bending.(4)In the Topping-off group,the range of motion of L2/3 was reduced by 37.04%,73.08%,56.67%and 38.46%in flexion,extension,lateral flexion and rotation,respectively,compared to the screw-rob fixation group(P<0.05).Compared with the screw-rob fixation group,the Topping-off group showed a 20%reduction in the range of motion of the L4/5 in the flexion direction(P<0.05),with no significant differences seen in extension,lateral bending and rotation.(5)It is concluded that the interspinous distraction fusion device BacFuse significantly reduces the range of motion of the implanted segment and provides some stability.It still retains more mobility and reduces the impact on the adjacent segment compared to screw-rob fixation,while the Topping-off tip,which can be used for intervertebral fusion fixation,significantly reduces the range of motion of the adjacent segment and reduces the risk of adjacent segment degeneration.

Effect of tibial nerve injury on treatment of tibial single-plane osteotomy and bone transport / 中国组织工程研究

BACKGROUND:Peripheral nerves play an important role in bone metabolism.In clinical practice,the specific impact of nerve injury on bone transport technology needs further study. OBJECTIVE:To investigate the effect of tibial nerve injury on the treatment of tibial slip by single-plane osteotomy. METHODS:Thirty-two patients with tibial bone defects admitted to Tangshan Second Hospital from May 2011 to June 2022 were selected.According to the presence or absence of tibial nerve injury,patients were divided into the tibial nerve injury group(n=16)and the non-tibial nerve injury group(n=16).Both groups were treated with single-plane osteotomy and bone slip.After treatment,the patients were followed up to collect the mineralization zone healing index,external fixation index,docking point healing and needle infection.After the removal of external fixation,the bone healing and functional evaluation were evaluated by a classification of the Association for the Study and Application of the Method of Ilizarov(ASAMI). RESULTS AND CONCLUSION:(1)All 32 patients were followed up for(25.28±4.79)months.There were no significant differences in bone healing time,external fixation time,healing index and external fixation index between the two groups(P＞0.05).Needle infection occurred in two cases of the tibial nerve injury group and one case of the non-tibial nerve injury group,all of which were PALEY I,and there was no significant difference between the two groups(P＞0.05).The non-union rate of the occlusal end of the tibial nerve injury group was 31%,and that of the non-tibial nerve injury group was 13%;there was no statistical difference between the two groups(P＞0.05).The excellent and good rate of ASAMI bone healing score in the two groups was 100%;the excellent and good rate of limb score was 81%in the tibial nerve injury group and 94%in the non-tibial nerve injury group;there was no statistical difference between the two groups(P＞0.05).(2)Our research shows that tibial nerve injury has no significant effect on the mineralization speed,external fixation time,union of the occlusal end,infection of the needle tract,and the quality of bone formation in the mineralized area of the single-plane osteotomy.

Mechanism by which alendronate promotes rapid mandibular distraction osteogenesis in rabbits / 中国组织工程研究

BACKGROUND:Some studies have found that local application of alendronate can promote osteogenesis,but less is reported on the process of distraction osteogenesis. OBJECTIVE:To observe the promoting effect of alendronate on rapid mandibular distraction in a rabbit model and explore its possible mechanism. METHODS:Thirty-six male New Zealand white rabbits were randomly divided into groups A,B and C(n=12 per group)after operation and rapid distraction(3-day delay period followed by 3-day distraction at 1.5 mm/12 hours).At the 1st,3rd and 7th days of the consolidation period,animal were injected with 200 μg/kg alendronate in group A and 100 μg/kg alendronate in group B,while those in group C were treated as controls.CT scanning and dual energy X-ray bone mineral density measurement were performed at 4 and 8 weeks of the consolidation period.After the radionuclide scanning was completed at the 4th week,several animals were sacrificed and the samples were collected for western blot assay and tartrate resistant acid phosphatase staining.A three-point bending test was performed after the animals were sacrificed at the 8th week. RESULTS AND CONCLUSION:CT results showed that bone formation in the distraction space of group B was significantly better than that in groups A and C.At the 4th week,the bone mineral density in group B was(0.092±0.010)g/cm2,which was 1.26 times higher than that in group A(P＜0.001)and 1.28 times higher than that in group C(P＜0.001).At the 8th week,the bone mineral density in group B was(0.175±0.029)g/cm2,which was 1.38 times higher than that in group A(P＜0.001)and 1.45 times higher than that in group C(P＜0.001).Tartrate resistant acid phosphatase staining showed that the number of osteoclast-like cells in group C were 2.83 times more than that in group A(P＜0.001)and 2.21 times more than that in group B(P＜0.001).The radionuclide intensity was higher in group C than in groups A and B.Western blot assay results showed that the expression of Runx2 was significantly stronger in group B than in groups A and C.The maximum biomechanical load in group B was(158.48±23.21)N,which was 1.26 times higher than that in group A(P=0.007)and 1.31 times higher than that in group C(P=0.003).To conclude,the low concentration of alendronate may promote rapid distraction osteogenesis of the rabbit mandible by inhibiting osteoclast signals.

Bone Regenerate Evaluation MethodsMétodos de avaliação do regenerado ósseo / Métodos de avaliação do regenerado ósseoBone Regenerate Evaluation Methods

Abstract Since its introduction by Ilizarov, the distraction osteogenesis technique has been used to treat trauma-related conditions, infections, bone tumors, and congenital diseases, either as methods of bone transport or elongation. One of the major dilemmas for the orthopedic surgeon who performs osteogenic distraction is establishing a reproducible method of assessing the progression of the osteogenesis, enabling the early detection of regenerate failures,inorder toeffectively interfereduring treatment, andtodeterminetheappropriate time to remove the external fixator. Several quantitative monitoring methods to evaluate the structural recovery and biomechanical properties of the bone regenerate at different stages,aswell as the bone healing process, are under study. These methods can reveal data on bone metabolism, stiffness, bone mineral content, and bone mineral density. The present review comprehensively summarizes the most recent techniques to assess bone healing during osteogenic distraction, including conventional radiography and pixel values in digital radiology, ultrasonography, bone densitometry and scintigraphy, quantitative computed tomography, biomechanical evaluation, biochemical markers, and mathematical models. We believe it is crucial to know the different methods currently available, and we understand that using several monitoring methods simultaneously can be an ideal solution, pointing to a future direction in the follow-up of osteogenic distraction.

Resumo Desde que foi descrita por Ilizarov, a técnica de osteogênese por distração tem sido utilizada para o tratamento de diversas condições relacionadas ao trauma, infecções, tumores ósseos edoenças congênitas, naforma detransporteou alongamento ósseo. Um dos dilemas mais comuns do cirurgião ortopédico que realiza distração osteogênica é o estabelecimentodeum método reprodutível deverificaçãoda progressão da osteogênese, que permita a detecção precoce de falhas no regenerado, para que se possa interferir de formaeficazduranteotratamento,bemcomodeterminarotempoapropriadoderemoção dofixadorexterno.Recentemente,váriosmétodosdemonitoramentoquantitativo,comos quais se poderia avaliar a recuperação da estrutura e as propriedades biomecânicas do regenerado ósseoemdiferentes estágios, alémdoprocessodecicatrização óssea, têm sido amplamente investigados. Por esses métodos, pode-se saber o conteúdo mineral ósseo, a densidade mineral óssea, a rigidez e o metabolismo ósseo. Nesta revisão, resumimos de forma abrangente as técnicas mais recentes para avaliar a cicatrização óssea durante a distração osteogênica, entre elas, métodos como aradiografia convencional e os valores de pixels em radiologia digital, a ultrassonografia, a densitometria e a cintilografia ósseas, a tomografia computadorizada quantitativa, a avaliação biomecânica, os marcadores bioquímicos e os modelos matemáticos. Consideramos fundamental o conhecimento dos diversos métodos à disposição atualmente e entendemos que a utilização de vários métodos de monitoramento simultaneamente possa ser uma solução ideal, que aponte para uma direção futura no seguimento da distração osteogênica.

Preliminary application of a novel distraction reductor in the surgical treatment of unstable distal radius fractures with metaphyseal volar comminution / 中华创伤骨科杂志

Objective:To evaluate a novel distraction reductor in the surgical treatment of unstable distal radius fractures with metaphyseal volar comminution.Methods:From January 2019 to December 2020, 27 patients with unstable distal radius fracture complicated with metaphyseal volar comminution were treated at Department of Orthopaedics, Zhoupu Hospital Affiliated to Shanghai University of Medicine & Health Sciences. They were 6 males and 21 females, with an age of (69.4±9.4) years. All fractures were unilateral and closed, involving the right side in 17 cases and the left side in 10 cases. All patients were treated by internal fixation with an anatomical locking plate through the volar approach and the novel distraction reductor was used to reduce the fracture ends. Regular imaging examinations were performed to evaluate the reduction, maintenance and union of fractures after surgery. One year after operation, the curative efficacy was assessed by evaluation of the range of wrist motion, Disabilities of the Arm, Shoulder and Hand (DASH) score, Gartland-Werley score and Bartra radiology score.Results:All the operations went on successfully with a duration of (92.3±8.9) min. All the incisions healed primarily. The follow-up time was (15.9±2.9) months. The radial height, palmar tilt, ulnar inclination and articular surface step-off immediately after operation [(11.23±1.51) mm, 12.10°±3.44°, 20.54°±3.44°, and (0.95±0.42) mm] were not significantly lost compared with those one year after operation [(11.22±1.55) mm, 12.07°±3.44°, 20.51°±3.33°, and (0.93±0.40) mm] (all P>0.05). One year after operation, the range of wrist motion was good with dorsiflexion of 59.7°±5.5°, palm flexion of 63.0°±9.1°, pronation of 66.5°±5.5°, supination of 61.2°±5.6°, radial deviation of 22.7°±4.8°, and ulnar deviation of 30.3°±6.1°; DASH score was 13.5±5.5; Bartra radiology score was 88.6±6.5, giving an excellent and good rate of 88.9% (24/27);Gartland-Werley score was 2.7±2.1, giving an excellent and good rate of 92.6% (25/27). Follow-ups observed no poor fracture healing, internal fixation failure, tendon or nerve injury or traumatic arthritis. Conclusion:In the surgical treatment of unstable distal radius fractures with metaphyseal volar comminution, the novel distraction reductor can lead to ideal reduction of displaced fractures and effectively correct the shortening caused by volar cortex comminution to achieve satisfactory functional effects in clinic.

Risk factors for first weaning failure following mandibular distraction osteogenesis in pediatric patients with Pierre Robin sequence: a nested case-control study / 中华麻醉学杂志

Objective:To identify the risk factors for the first weaning failure following mandibular distraction osteogenesis in pediatric patients with Pierre Robin sequence (PRS).Methods:Clinical data of pediatric patients with PRS who underwent mandibular distraction osteogenesis from January 2018 to February 2023 were collected, including sex, age, premature birth, birth weight, surgical weight, cleft palate, syndrome type PRS, laryngeal/tracheobronchial malacia, simple congenital heart disease, complex congenital heart disease, preoperative mechanical ventilation, preoperative pulmonary infection, blood albumin concentration, difficulty in tracheal intubation under a visual laryngoscope, surgical duration, postoperative ventilator-associated pneumonia, duration of mechanical ventilation at first weaning, and traction length at first weaning. Children in whom the first postoperative machine withdrawal failed were included in observation group and matched to control cases(control group) in a 1∶4 ratio. The risk factors of which P values were less than 0.05 would enter the logistic regression analysis to stratify the risk factors for postoperative weaning failure. Results:There were significant differences in birth weight, cleft palate, duration of mechanical ventilation and traction length at first weaning, rate of combined cleft palate, preoperative pulmonary infection rate, rate of preoperative mechanical ventilation, and rate of postoperative ventilator-associated pneumonia between the two groups ( P<0.05). Binary logistic stepwise regression analysis showed that the preoperative mechanical ventilation ( OR=18.154, 95% CI 3.971-82.990, P<0.001) and postoperative ventilator-associated pneumonia ( OR=36.942, 95% CI 1.307-1043.985, P=0.034) were independent risk factors for first weaning failure after mandibular distraction osteogenesis, while birth weight gain ( OR=0.225, 95% CI 0.076-0.668, P=0.007) was a protective factor for first weaning failure ( P<0.05). Conclusions:Preoperative mechanical ventilation and postoperative ventilator-associated pneumonia are independent risk factors and birth weight gain is a protective factor for first weaning failure following mandibular distraction osteogenesis in pediatric patients with PRS.

Model test study on treatment of Pruzansky type ⅡB and Ⅲ hemifacial microsomia with artificial condyle-mandibular distractor complex / 中国修复重建外科杂志

OBJECTIVE@#To preliminarily verify the effectiveness of self-designed artificial condyle-mandibular distraction (AC-MD) complex in the treatment of Pruzansky type ⅡB and Ⅲ hemifacial microsomia (HFM) through model test.@*METHODS@#Five children with Pruzansky type ⅡB and Ⅲ HFM who were treated with mandibular distraction osteogenesis (MDO) between December 2016 and December 2021 were selected as the subjects. There were 3 boys and 2 girls wih an average age of 8.4 years (range, 6-10 years). Virtual surgery and model test of AC-MD complex were performed according to preoperative skull CT of children. The model was obtained by three-dimensional (3D) printing according to the children's CT data at a ratio of 1∶1. The occlusal guide plate was designed and 3D printed according to the children's toothpaste model. The results of the model test and the virtual surgery were matched in three dimensions to calculate the error of the residual condyle on the affected side, and the model test was matched with the actual skull CT after MDO to measure and compare the inclination rotation of the mandible, the distance between the condylar of the healthy side and the residual condyle of the affected side, and the lengthening length of the mandible.@*RESULTS@#The error of residual condyle was (1.07±0.78) mm. The inclination rotation of the mandible, the distance between the condylar of the healthy side and the residual condyle of the affected side, and the lengthening length of the mandible after 3D printing model test were significantly larger than those after MDO ( P<0.05).@*CONCLUSION@#In the model test, the implantation of AC-MD complex can immediately rotate the mandible to the horizontal position and improve facial symmetry, and the residual condyle segment can be guided close to the articular fossa or the preset pseudoarticular position of the skull base after operation.

The airway management and treatment of newborns with micrognathia and laryngomalacia / 临床耳鼻咽喉头颈外科杂志

Objective:To explore the perioperative airway management and treatment of newborns with micrognathia and laryngomalacia. Methods:From January to December 2022, a total of 6 newborns with micrognathia and laryngomalacia were included. Preoperative laryngoscopy revealed concomitant laryngomalacia. These micrognathia were diagnosed as Pierre Robin sequences. All patients had grade Ⅱ or higher symptoms of laryngeal obstruction and required oxygen therapy or non-invasive ventilatory support. All patients underwent simultaneous laryngomalacia surgery and mandibular distraction osteogenesis. The shortened aryepiglottic folds were ablated using a low-temperature plasma radiofrequency during the operation. Tracheal intubation was maintained for 3-5 days postoperatively. Polysomnography（PSG） and airway CT examination were performed before and 3 months after the surgery. Results:Among the 6 patients, 4 required oxygen therapy preoperatively and 2 required non-invasiveventilatory support. The mean age of patients was 40 days at surgery. The inferior alveolar nerve bundle was not damaged during the operation, and there were no signs of mandibular branch injury such as facial asymmetry after the surgery. Laryngomalacia presented as mixed type: type Ⅱ+ type Ⅲ. The maximum mandibular distraction distance was 20 mm, the minimum was 12 mm, and the mean was 16 mm. The posterior airway space increased from a preoperative average of 3.5 mm to a postoperative average of 9.5 mm. The AHI decreased from a mean of 5.65 to 0.85, and the lowest oxygen saturation increased from a mean of 78% to 95%. All patients were successfully extubated after the surgery, and symptoms of laryngeal obstruction such as hypoxia and feeding difficulties disappeared. Conclusion:Newborns with micrognathia and laryngomalacia have multi-planar airway obstruction. Simultaneous laryngomalacia surgery and mandibular distraction osteogenesis are safe and feasible, and can effectively alleviate symptoms of laryngeal obstruction such as hypoxia and feeding difficulties, while significantly improving the appearance of micrognathia.

Compresión-distracción en el tratamiento de pseudoartrosis de tibia distal utilizando el aparato de Ilizarov: reporte de casos / Compression-distraction in the treatment of distal tibial no union using the Ilizarov apparatus: case report / Compressão-distração no tratamento da pseudoartrose distal da tibia com Ilizarov: relato de caso

El método de Ilizarov, con sus diferentes variantes y mediante la utilización de su aparato, desarrollado en la década del 50, continúa vigente, sobre todo en el tratamiento de las complicaciones de fracturas, principalmente aquellas vinculadas a la infección y a las dificultades de la consolidación. Reportamos 2 pacientes adultos con diagnóstico de pseudoartrosis hipertrófica, rígida, con deformidad, sin infección activa y sin dismetría, tratados mediante el método de distracción y compresión realizado con el aparato de Ilizarov. En ambos casos se logró la alineación y consolidación del miembro con escasas complicaciones.

The Ilizarov method, with its different variants and using its apparatus, developed in the 1950s, is still valid, especially in the treatment of fracture complications, mainly those linked to infection and consolidation difficulties. We report 2 adult patients with a diagnosis of hypertrophic, rigid nonunion, with deformity, without active infection and without dysmetria, treated by the distraction and compression method performed with the Ilizarov device. In both cases, the alignment and consolidation of the limb was achieved with few complications.

O método de Ilizarov, com suas diferentes variantes e pelo uso de seu aparato, desenvolvido na década de 1950, ainda é válido, principalmente no tratamento de complicações de fraturas, principalmente aquelas ligadas à infecção e dificuldades de consolidação. Relatamos 2 pacientes adultos com diagnóstico de pseudoartrose hipertrófica, rígida, com deformidade, sem infecção ativa e sem dismetria, tratados pelo método de distração e compressão realizado com o dispositivo de Ilizarov. Em ambos os casos, o alinhamento e a consolidação do membro foram alcançados com poucas complicações.

Evaluation of Different Pre-treatment Behaviour Modification Techniques in 4–7-year Olds: A Randomised Controlled Trial

Purpose: The aim of this study is to evaluate and compare the effectiveness of five pre?treatment behaviour modification techniques in 4–7?year olds in reducing dental anxiety by evaluating pulse rate, partial pressure of oxygen, systolic blood pressure, diastolic blood pressure, salivary flow rate, salivary pH, and through modified facial anxiety scale. Material and Methods: Using simple random sampling technique (drawing of lots), 125 children were equally distributed into 5 groups of 25 each: Group 1: tell?show?do (control); Group 2: tell?show?play?doh; Group 3: Playmobil Dentist; Group 4: mobile dentist games; Group 5: role play as dentist. Samples in each group were treated in a single appointment after using the behaviour modification techniques. Class I or Class II cavities were prepared on carious primary molar and restored using glass ionomer cement. Patient’s anxiety level was assessed by recording blood pressure, pulse rate, oxygen saturation, salivary pH, salivary flow rate, and facial anxiety scale at different time intervals, that is before the treatment, during the treatment, and after the treatment. Results: All the intervention Groups (Groups 2–5) showed reduced anxiety scores in both physiological and facial anxiety compared to the control group, that is tell, show do. The modified distraction techniques aid in better modification. Conclusion: Tell?show?play?doh, Playmobil dentist games, mobile dentist games and role play as dentist are effective distraction techniques as compared to conventional tell?show?do techniques which can be incorporated in day?to?day clinical practice to reduce dental anxiety in paediatric patients

Treatment of Brachymetatarsia by Distraction Osteogenesis Using Monolateral External Fixator / Tratamento da braquimetatarsia por distração osteogênica com fixador externo monolateral

Abstract Objective To describe the profile of the patients and the results obtained with the use of an external fixator for metatarsal lengthening in brachymetatarsia. Methods A retrospective analysis of the medical records of patients with brachymetatarsia treated between January 2018 and April 2020 was performed. During this period, eight feet of six patients were operated on. Frequencies were estimated according to demographic and surgical aspects. Results All patients (100%; n= 6) were female, with a mean age of 28 years old, ranging from 15 to 48 years old, and were motivated to seek the orthopedic service due to aesthetic deformity. The deformity was bilateral in two patients and unilateral in four patients. The average lengthening time was 22 days ( ± 7.15, 95% confidence interval [CI]: 19.04-26.81). The lengthening speed was 0.5 mm/day, and the average total length of the lengthening was 11.46 mm ( ± 3.57; 95%CI: 9.52-13.40). Half of the patients (50%; n= 3) had local infection of the pins and were treated with antibiotics, and the others did not report any postsurgical complications. All patients denied pain or calluses after the surgical procedure and reported satisfaction with the results. Conclusion All patients were female and sought surgery for brachymetatarsia for aesthetic reasons. Osteogenic distraction at a rate of 0.5 mm/day resulted in successful lengthening of the metatarsal, with a low frequency of complications, good clinical outcomes, and high patient satisfaction.

Resumo Objetivo Descrever o perfil dos pacientes e os resultados obtidos com o uso de fixador externo para alongamento de metatarso em braquimetatarsia. Métodos Foi realizada uma análise retrospectiva dos prontuários de pacientes com braquimetatarsia tratados entre janeiro de 2018 e abril de 2020. Durante este período, foram operados oito pés de seis pacientes. Foram coletadas e estimadas as frequências em relação a aspectos demográficos e cirúrgicos. Resultados Todas as pacientes (100%; n= 6) eram do sexo feminino, com média de idade de 28 anos, variando de 15 a 48 anos, e motivadas a buscar o serviço de ortopedia em função da deformidade estética. O acometimento era bilateral em duas pacientes e unilateral em quatro pacientes. O tempo médio de alongamento foi de 22 dias ( ± 7,15; intervalo de confiança [IC] 95%: 19,04-26,81). A velocidade de alongamento foi de 0,5 mm/dia e o comprimento médio total do alongamento foi de 11,46 mm ( ± 3,57; IC95%: 9,52-13,40). Metade das pacientes (50%; n= 3) teve infecção local dos pinos e foi tratada com antibióticos; as demais não relataram nenhuma complicação pós-cirúrgica. As pacientes negaram dor ou calosidade após o procedimento cirúrgico e relataram satisfação com os resultados. Conclusão Todas as pacientes eram do sexo feminino e buscaram a cirurgia para braquimetatarsia por motivos estéticos. A distração osteogênica a uma taxa de 0,5 mm/dia resultou em alongamento bem-sucedido do metatarso, com uma baixa frequência de complicações, bons resultados clínicos e alta satisfação das pacientes.

Hygienic economic evaluation of inter-spinal distraction fusion and fixation for lumbar disc herniation / 国际外科学杂志

Objective:To analyze the clinical efficacy of inter-spinal distraction fusion and fixation and Posterior lumbar interbody fusion in the treatment of lumbar disc herniation with stenosis, and to evaluate the health economics of the two surgical methods.Methods:Retrospectivly analyzed the clinical data of 400 patients with lumbar disc herniation with stenosis, who were enrolled in Beijing Friendship Hospital, Capital Medical University from Jan. 2015 to Jan. 2019, including 190 male cases and 210 female cases, aged from 50 to 87 years old, with the average age of 67.97. All patients were divided into two groups according to different surgical methods. Among them, 200 patients used interspinous process fusion and distraction fixation (ISDFF group), the other 200 cases used posterior lumbar decompression and pedicle internal fixation (PLIF group). All patients completed the follow-up time of more than 1 year after operation. The basic information of patients′ age, gender, total number of days in hospital, intraoperative bleeding, operation time, surgical incision length and other basic information were observed. The Oswestry dysfunction index (ODI), the Japanese Orthopaedic Association Score (JOA) and the visual analog scale (VAS) were used to evaluate the relief of symptoms before and after the two groups of patients. Total medical expenses, anesthesia expenses, surgical expenses and other expenses were analysed. The software of SPSS 20.0 were conducted to analyze data.Results:The patients in the ISDFF group were (70.84±8.93) years old, and the PLIF group was (65.10±10.23) years old ( t=5.98, P=0.008). The operation time in the ISDFF group was (59.21±16.22) min, and the operation time in the PLIF group was (81.31±17.24) min( t=13.20, P<0.001). The bleeding volume of the ISDFF group was (33.24±11.31) mL, and the bleeding volume of the PLIF group was (67.30±17.61) mL ( t=23.02, P<0.001). The length of the surgical incision in the ISDFF group was (8.27±2.53) cm, and the length of the surgical incision in the PLIF group was (11.15±1.91) cm ( t=11.848, P<0.001). The total hospitalization time in the ISDFF group was (15.15±0.54) days, and the total hospitalization time in the PLIF group was (19.86±0.97) days( t=4.26, P<0.001). There was no significant difference in preoperative ODI, JOA and VAS between the two groups ( P>0.05). Symptoms of postoperative patients were significantly improved compared with preoperative. There were statistical differences in ODI, JOA and VAS between the two groups before and after operation ( P<0.05). However, ODI, JOA and VAS were no statistical difference between the two groups after operation. Complications occurred in 5 cases of the two groups of patients, including two cases of superficial infection in the PLIF group, two cases of dural tear in the PLIF group, one case of spinous process fracture in the ISDFF group. The total hospitalization fee for ISDFF was (57 450±8 670) (yuan), and the total hospitalization fee for PLIF was (75 770±1 640) (yuan), with statistical differences ( t=9.92, P<0.001). The cost of ISDFF operation was 1864±38.19 (yuan), and the cost of PLIF operation was 2352±41.39 (yuan) ( t=8.65, P<0.001). ISDFF antibacterial drug usage fee was 635.5±64.69 (yuan), PLIF antibacterial drug usage fee was 1449±307.1 (yuan) ( t=2.59, P<0.001). The one-time medical material cost during the ISDFF operation was (38 990±300) (yuan), and the one-time medical material cost during the PLIF operation was (52 110±150) (yuan) ( t=5.88, P<0.001). The excellent and good rate of ISDFF group was 92%, and that of PLIF group was 86%. In this study, the total cost of hospitalization was used as an indicator to measure the cost, and further cost-effectiveness evaluation was made. For every good patient, the cost of the ISDFF group was 62 450 yuan, and the cost of the PLIF group was 88, 100 yuan. Conclusions:ISDFF is beneficial to reduce the cost of medical insurance in China, which is in line with the direction of national reform to reduce medical expenditure. It is a surgical method worthy of wide promotion and has a good application prospect.

Analysis of the effect of inter-spinal distraction fusion and fixation combined with limited decompression on the treatment of lumbar spinal stenosis in elderly patients / 国际外科学杂志

Objective:To analyze the effect of inter-spinal distraction fusion and fixation (ISDFF) combined with limited decompression on the treatment of lumbar spinal stenosis in elderly patients.Methods:A total of 32 elderly patients with lumbar spinal stenosis, aged from 80 to 87 years old (mean age: 82.0±2.0 years) including 10 males and 22 females, in the Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University from January 2016 to January 2020 were enrolled in this retrospective study. Clinical evaluation and imaging measurement were performed before operation, after operation, 6 months and 24 months after operation. SPSS software was used for statistical analysis. Measured data of normal distribution were expressed as means±standard deviation. One way analysis of variance was used for comparison between groups. Paired t-test was used to compare between preoperative and postoperative as well as between preoperative and 24 months′ follow-up. Results:All of the 32 patients had one or more common accompanying diseases, such as hypertension, diabetes, coronary heart disease, and so on. All patients were successfully completed the operation with a total of 32 segments. VAS score was decreased from (6.22±0.91) before operation to (1.94±0.76) at 24 months( t=16.52, P<0.001). ODI score was also demonstrated the similar trend, from (54.17±10.65) preoperatively to (19.91±4.20) at 24 months follow-up( t=15.89, P<0.001). JOA score was significantly increased from (11.69±3.36) before surgery to (23.44±1.66) at the last follow-up ( t=-19.90, P<0.001). In the change of imaging, the intervertebral angle was decreased from preoperation (9.12±4.65) to (6.77±2.70) at 24 months( t=3.53, P=0.001). The posterior disk height was increased from (0.68±0.19) cm to (0.76±0.19) cm at the last follow-up( t=-2.45, P=0.020). Conclusions:As a new type of minimally invasive internal fixator, the ISDFF combined with limited decompression can relieve the pain of elderly patients with lumbar spinal stenosis and improve the quality of life. It is suitable for the treatment of elderly patients with lumbar spinal stenosis.

Minimally invasive adjustable plate and anterior ring distraction reduction for fresh Denis type ⅡB sacral fracture with sacral nerve injury / 中华创伤骨科杂志

Objective:To explore the surgical techniques and clinical effects of minimally invasive adjustable plate (MIAP) together with distraction reduction by minimally invasive anterior pelvic ring internal fixator (INFIX) in the treatment of fresh Denis type ⅡB sacral fracture with sacral nerve injury.Methods:From June 2017 to June 2020, 12 fresh Denis type ⅡB sacral fractures were treated by anterior-posterior distraction reduction and fixation with MIAP and INFIX. There were 8 males and 4 females, with an average age of 30 years (from 16 to 44 years). Preoperatively, imaging found Denis ⅡB fracture of the sacrum and magnetic resonance neurography of the lumbosacral plexus showed injury to the sacral nerve root at the sacral foramen. All patients had symptoms of S 1 nerve root injury on the affected side after injury, with 9 cases of grade M0 and 3 cases of grade M1. The time from injury to operation averaged 11 days (from 5 to 19 days). INFIX combined with MIAP was used to distract and fixate the compressed sacral fracture. The quality of fracture reduction and recovery of sacral nerve function were evaluated postoperatively. Results:According to the criteria proposed by Lindahl et al., the quality of fracture reduction was excellent in 8 cases, good in 2 and fair in 2. The 12 cases were followed up for an average of 20 months (from 12 to 36 months). All sacral fractures got united after an average of 6 weeks (from 5 to 8 months). At one-year follow-up, according to the criteria proposed by the Nerve Injuries Committee of the British Medical Research Council, the postoperative muscle strength recovery was evaluated as complete recovery in 10 cases and as partial recovery in 2 cases.Conclusion:In the treatment of fresh Denis type ⅡB sacral fracture, MIAP combined with INFIX can obtain satisfactory clinical effects because the compressed sacrum can be effectively distracted, the sacral foramen be expanded and the sacral nerve be decompressed indirectly.

Effect of local gene therapy on expression of Wnt3a and β-catenin in callus of distraction gap during mandibular distraction osteogenesis in rabbits / 中华医学美学美容杂志

Objective:To investigate the effect of electroporation-mediated local gene therapy on the expression of Wnt3a and β-catenin in callus of distraction gap during mandibular distraction osteogenesis of rabbits.Methods:The experiments were conducted in the laboratory of the Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University from September 2019 to December 2019. Forty eight New-Zealand rabbits were randomly divided into control group (group A), gene therapy group (group B) and normal saline group (group C), with 16 rabbits in each group. After bilateral mandible osteotomy and distractors were implanted, the distractors were activated at a speed of 0.8 mm/d on 4th day, postoperatively, and lasted for 7 days, followed by consolidation period. Group A distracted only, group B was subject to local injection of recombinant plasmid pIRES-hBMP2-hVEGF165 in the distraction gap and electroporation stimulation at the beginning of activation distractors; and group C local injection of the same dose of normal saline in the distraction gap and electroporation stimulation at the beginning of activation distractors. Four animals in each group were sacrificed on the day at the end of distraction, 7th, 14th, 28th days of consolidation period, respectively. The callus in the distraction gap was taken for immunohistochemical staining and RT-PCR to detect the expression of Wnt3a and β-catenin, and image analysis was performed. SPSS 22.0 statistical software was used for data analysis.Results:Immunohistochemical staining showed that Wnt3a and β-catenin were mainly located in the cytoplasm and nuclei of fibroblasts, chondrocytes and osteoblasts in callus tissue. Immunohistochemistry and RT-PCR showed that the expression of Wnt3a and β-catenin reached a peak at the end of distraction. With the disappearance of distraction tension, the expression of Wnt3a and β-catenin gradually decreased. After gene therapy intervention, the expression of Wnt3a and β-catenin was significantly increased, and the expression of Wnt3a and β-catenin in group B was the highest at each time point, with statistically significant difference compared with groups A and C ( F=96.3, P<0.01). Conclusions:Gene therapy promotes the expression of Wnt3a and β-catenin in the callus of distraction gap, regulating the balance of the bone reconstruction system and thus promoting the formation of new bone in the distraction gap.

One-stage biplanar osteotomy correction of angulation and shortening deformity of the lower extremity after epiphyseal injury of the distal femur with a monorail external fixator / 中华实用儿科临床杂志

Objective:To investigate the clinical effectiveness of one-stage biplanar osteotomy correction of angulation and shortening deformity of the lower extremity after epiphyseal injury of the distal femur with a monorail external fixator.Methods:The data of 5 patients (2 males and 3 females) with angulation and shortening deformity in the lower extremity after epiphyseal injury of the distal femur were retrospectively analyzed.The patients underwent monorail external fixator assisted one-stage osteotomy correction of the distal femur and distraction osteogenesis of the middle and upper femur in Zhengzhou Orthopeadics Hospital from May 2017 to December 2019.The mean age was 13.6 years old (range: 10 to 17 years old). The affected limbs were shortened by 5.1 cm on average (range: 3.9 to 6.5 cm). The average angulation deformity of the distal femur was 24.9° (range: 17.0°to 30.5°). The mechanical lateral distal femoral angle (mLDFA), the mechanical posterior distal femoral angle (mPDFA), the mechanical axis deviation (MAD), the range of motion (ROM) of the knee, and the length of the lower limbs before surgery and at the final follow-up were measured and analyzed.Results:All patients were followed up for 22 months on average (range: 15 to 32 months). For all the 5 patients, the mechanical axis was well realigned, mLDFA, mPDFA, and MAD returned to normal range, and the length of the affected limb achieved the goal as planned before the surgery.Besides, the affected limbs were lengthened by 5.6 cm on average (range: 3.9 to 8.0 cm), and the median healing index was 35.6 d/cm (range: 29.0 to 45.0 d/cm). The bone callus in the distraction area and the osteotomy end were well healed at the final follow-up, as indicated by the X-ray results.At the end of the distraction period, the flexion ROM of the knee in all patients reached basically 90°.By the final follow-up, all patients had a normal knee ROM.No vascular or nerve injury, dislocation of hips or knee joints, re-fracture after disassembly, deep infection and other complications were observed in all patients.Conclusions:One-stage biplanar osteotomy correction of angulation and shortening deformity of the lower extremity after epiphyseal injury of the distal femur with a monorail external fixator is safe and feasible.The method requires no multiple operations and improves the tolerance of patients during the treatment period.

Distraction of Children Undergoing Vaccination / Distração de Crianças Durante Vacinação / Distracción de Niños durante la Vacunación

Abstract Vaccination is a procedure considered painful for children; therefore, the healthcare team should provide conditions for adequate pain assessment and control. This study sought to evaluate whether behavioral distraction procedures contribute to reduce pain perception and anxiety indicators in children during vaccination. One hundred and four children between three and 12 years attending a Health Center in the Federal District participated in the study. Children were divided into four groups: baseline, groups with balloons, cards and tablets. Data were obtained by means of sociodemographic questionnaires, the Monica and Friends Pain Scale and the Observational Scale of Distress Behavior. The collected data were measured using the SPSS Statistics program. Results show that the intervention groups had lower averages, concerning pain levels, incidence of competing behaviors and duration of vaccine procedures, compared to baseline.

Resumo A vacina é um procedimento considerado doloroso para crianças, portanto, a equipe de saúde deve fornecer condições para avaliação e controle adequados da dor. O objetivo deste estudo foi avaliar se procedimentos de distração comportamental contribuem para a redução da percepção de dor e de indicadores de ansiedade de crianças durante a vacinação. Participaram 104 crianças entre três e 12 anos em um Centro de Saúde do Distrito Federal. As crianças foram divididas em quatro grupos: linha de base, grupos com balões, cartões e tablet. Os dados foram obtidos através de: questionários sociodemográficos, Escala de Dor da Turma da Mônica e Observational Scale of Distress Behavior. Os dados coletados foram medidos por meio do programa SPSS Statistics. Os resultados revelaram que os grupos de intervenção apresentaram médias menores, em termos de níveis de dor, incidência de comportamentos concorrentes e duração dos procedimentos de vacina, em relação à linha de base.

Resumen La vacunación es un procedimiento considerado doloroso para los niños, por lo que el equipo de salud debe brindar las condiciones adecuadas para evaluación y control del dolor. El objetivo de este estudio fue evaluar si los procedimientos de distracción conductual contribuyen a disminuir la percepción del dolor y los indicadores de ansiedad en los niños durante la vacunación. En este estudio participaron 104 niños de entre 3 y 12 años de un Centro de Salud del Distrito Federal (Brasil). Los niños se dividieron en cuatro grupos: grupo de línea de base, grupo con globos, tarjeta y tableta. Los datos se obtuvieron a través de cuestionarios sociodemográficos, la Escala de Dolor de Mónica y sus Amigos y la Observational Scale of Distress Behavior. Los datos recopilados se midieron utilizando el programa SPSS Statistics. Los resultados revelaron que los grupos de intervención tenían medias más bajas, en cuanto a los niveles de dolor, incidencia de conductas concurrentes y duración de los procedimientos de vacunación, en comparación con el de línea de base.