Vertebra-Pediculoplasty: A New Approach to Treatment of Split-Type and Delayed-Union Osteoporotic Vertebral Fracture with a Risk of Cement Dislodgement.

BACKGROUND: The clinical outcomes of balloon kyphoplasty (BKP) for split-type osteoporotic vertebral fractures (OVF) are poor. These may be owing to the vertebral body bifurcating anteriorly and posteriorly when a load is applied and the filled cement being unstable. We report the usefulness of BKP combined with pediculoplasty using cannulated screws (vertebra-pediculoplasty) for OVF with a risk of cement dislodgement. METHODS: Between April 2020 and February 2021, this surgery was performed on 10 patients with split-type and delayed-union OVF. The diagnosis was made using imaging findings on preoperative computed tomography or intraoperative images during balloon inflation. Early postoperative ambulatory rehabilitation was performed, and clinical outcomes were evaluated. RESULTS: Early pain relief was obtained in all patients. The stability of the fractured vertebrae was demonstrated using both supine and seated radiographs from the early postoperative period, and good clinical results were obtained. The cement in this surgery was stabilized using a cannulated screw in the vertebral body, anteroposteriorly, and craniocaudally. The cement mass integrated with the cannulated screw was stabilized with the vertebral lamina and pedicle as a stopper. CONCLUSIONS: Vertebra-pediculoplasty could be an effective method for managing OVF with a high risk of cement dislodgement, which has been difficult to treat using conventional BKP.

Treatment of lower limb deformities and limb-length discrepancies with the external fixator in Ollier's disease.

BACKGROUND: In this study, we addressed two questions on the treatment for Ollier's disease: (1) how much callus formation occurs when an osteotomy is performed intralesionally and (2) how is the stability of the wires and half-pins that are inserted intralesionally. METHODS: Four children with Ollier's disease underwent treatment of 12 lower limb segments using distraction osteogenesis until completion of their growth. All osteotomies were performed at the centers of the deformities, resulting in a total of seven osteotomies performed intralesionally. RESULTS: Full correction of the deformity and full restoration of length were achieved in all cases, but a residual limb-length discrepancy of <10 mm remained. The mean external fixation index in the intralesional distraction osteogenesis group was 39.7 days/cm versus 30.8 days/cm in the extralesional distraction osteogenesis group. Conversion from abnormal cartilage to normal regenerate bone was seen in only one segment. Although approximately two-thirds of the wires and half-pins were inserted intralesionally, in all but one case (in which an iatrogenic fracture occurred) the wires and half-pins were well stabilized throughout the external fixation period. CONCLUSIONS: Although deformity and limb-length discrepancies due to Ollier's disease were successfully resolved by distraction osteogenesis, enchondroma may arise in distracted calluses when osteotomized intralesionally. However, the stability of the external fixator was sufficient to lengthen limbs and correct deformities even when wires and half-pins were inserted intralesionally.

Correction and lengthening for deformities of the forearm in multiple cartilaginous exostoses.

BACKGROUND: Multiple cartilaginous exostoses cause various deformities of the epiphysis. In exostoses of the ulna, the ulna is shortened and the radius acquires varus deformity, which may lead to dislocation of the radial head. In this study, we present the results of exostoses resection, with correction and lengthening with external fixators for functional and cosmetic improvement, and prevention of radial head dislocation. METHODS: We retrospectively reviewed seven forearms of seven patients who had deformities of the forearm associated with multiple cartilaginous exostoses. One patient had dislocation of the radial head. Operative technique was excision of osteochondromas from the distal ulna, correction of the radius, and ulnar lengthening with external fixation up to 5 mm plus variance. We evaluated radiographs and the range of pronation and supination. Furthermore, we conducted a follow-up of ulnar length after the operation. RESULTS: Dislocation of the radial head of one patient was naturally reduced without any operative intervention. At the most recent follow-up, six of the seven patients showed full improvement in pronation-supination. Ulnar shortening recurred with skeletal growth of four skeletally immature patients; however, it did not recur in one skeletally mature patient. Overlength of 5 mm was negated by the recurrence of ulnar shortening about 1.5 years after the operation. CONCLUSIONS: We treated seven forearms of seven patients by excision of osteochondromas, correction of radii, and gradual lengthening of ulnas with external fixators. The results of the procedure were satisfactory, especially for function of the elbow and wrist. However, we must consider the possible recurrence of ulnar shortening within about 1.5 years during skeletal growth periods in immature patients.

Correction of juxtaarticular deformities in children using the Ilizarov apparatus.

BACKGROUND: Deformity correction using external fixation was performed for various disorders in children. We reviewed 18 children who underwent juxtaarticular deformity correction using the Ilizarov apparatus with either a transverse or focal dome osteotomy. The amount of deformity correction, external fixation time, external fixation index, length gained, and incidence of complications were examined. METHODS: A series of 27 operations were performed in lower limb segments on 10 femurs and 17 tibias in 10 boys and 8 girls. The mean age at operation was 12 years (5-18 years). Deformity corrections were performed using a transverse osteotomy in 16 segments and a focal dome osteotomy in 11. RESULTS: The average deformity corrected was 19 degrees (6 degrees-31 degrees). Acute correction was done in 14 segments and gradual correction in 13 segments. The mean lengthening was 4.2 cm in 12 segments (2-8 cm). The mean external fixation time was 161 days (78-352 days). In acute corrections, the external fixation time with a focal dome osteotomy (101 days) tended to be shorter than with a transverse osteotomy (142 days). CONCLUSIONS: Accurate limb alignment was obtained for all cases. A focal dome osteotomy by maximizing the area of bony contact was more effective than a transverse osteotomy for acute deformity correction.

Reconstruction with distraction osteogenesis for juxta-articular nonunions with bone loss.

BACKGROUND: Nonunions of a juxta-articular lesion with bone loss, which represent a challenging therapeutic problem, were treated using external fixation and distraction osteogenesis. METHODS: Seven juxta-articular nonunions (five septic and two aseptic) were treated. The location of the nonunion was the distal femur in four patients, the proximal tibia in one patient, and the distal tibia in two patients. All of them were located within 5 cm from the affected joints. Preoperative limb shortening was present in six cases, averaging 2.9 cm (range, 1-7 cm). The reconstructive procedure consisted of refreshment of the nonunion site, deformity correction, stabilization by external fixation, and lengthening to eliminate leg length discrepancy or to fill the defect. Shortening-distraction was applied to six patients and bone transport to one patient for reconstruction. Intramedullary nailing to reduce the duration of external fixation was simultaneously performed in two cases. All the patients had at least 1 year of follow-up evaluation. RESULTS: Osseous union without angular deformity or leg length discrepancy greater than 1 cm was achieved in all patients. The mean amount of lengthening was 5.8 cm (range, 2.2-10.0 cm). The mean external fixation period was 219 days (range, 98-317 days), and the mean external fixation index was 34.4 days/cm (range, 24.5-47.6 days/cm). All patients reported excellent pain reduction. There were no recurrences of infection in five patients with prior history of osteomyelitis. The functional results were categorized as excellent in two, good in three, and fair in two. CONCLUSION: Despite the length of postoperative external fixation, distraction osteogenesis can be a valuable alternative for the treatment of juxta-articular nonunions.

Effects of timing of low-intensity pulsed ultrasound on distraction osteogenesis.

We investigated the effects of low-intensity pulsed ultrasound (LIPUS; 30 mW/cm2 spatial and temporal average) on the timing of LIPUS treatment in distraction osteogenesis. Lengthening of the right tibia was performed in 75 male Japanese white rabbits using unilateral fixators (waiting period, 7 days; distraction rate, 1.5 mm/day; distraction period, 7 days). Rabbits were divided into four groups according to the timing of the LIPUS treatment. Control group had no stimulation. Waiting group was treated with a daily 20-min session of LIPUS during a 7-day latency period. Lengthening group was treated during the lengthening period. Maturation group was treated for the first 7 days after completion of distraction. We evaluated the distraction site by radiography and histology every week for 4 weeks. Bone mineral density (BMD) and mechanical strength were tested and microfocus X-ray computed tomography was performed on specimens 2 weeks after completion of distraction. The lengthening group had greater BMD and mechanical strength than the other groups, bone regeneration was enhanced more in the maturation group than in the control or waiting groups. Histologically, endochondral bone formation in the lengthening and the maturation groups occurred earlier than in the control or waiting groups. These results suggest the LIPUS effect is mediated via endochondral pathways. We concluded that LIPUS stimulates bone formation in distraction osteogenesis and is most effective during the lengthening phase.

Bone transport with frozen devitalized bone: an experimental study using rabbits and a clinical application.

We evaluated the feasibility of bone transport with frozen devitalized bone in the tibia of 20 adult female rabbits. A 1.5-cm segmental defect was created, followed by proximal tibial transverse osteotomy to remove a 2.5-cm segment to be transported after devitalization with liquid nitrogen. The proximal and distal tibia and the devitalized autogenous bone each were fixed with two half-pins. After 2 weeks, transport of the devitalized segment was initiated at 1 mm/day. In a control group, callus formed at proximal and distal osteotomy sites, and distracted callus gradually maturated. The docking site fused and the medullary canal reappeared by 8 weeks after completing distraction. In the frozen-bone group, bone formation proceeded from the proximal tibial end, and the distraction callus slowly matured. The transported segment remained nonviable until revascularization proceeded from its periphery, evident 8 weeks after completion of distraction. Docking sites fused well without infection at pin sites. There was no sign of infection around the pin sites of the devitalized bone. We finally describe similar successful treatment of a 13-year-old girl with tibial deformity resulting from osteofibrous dysplasia who was treated successfully with this procedure. Therefore, bone transport using frozen devitalized bone can regenerate living bone. This experimental model represents the development of a new reconstruction technique of bone transport with devitalized bone.

Gradual closed correction of equinus contracture using the Ilizarov apparatus.

We treated 16 patients with equinus contracture using the Ilizarov method without open soft tissue release. No hinge was used in seven patients; instead, their ankle joint was used as the hinge (natural hinge; unconstrained construct). In the remaining nine patients, medial and lateral hinges connecting the tibial and foot rings were placed at the center of the talar dome (rotating hinge; constrained construction). We assessed the results in terms of the extent of dorsiflexion, its improvement, and complications. There was little difference between the results in the natural hinge group and the rotating hinge group. The natural hinge system is therefore the method of choice for treating equinus contracture because it is less invasive and simpler. However, particular care is needed during correction to avoid complications such as anterior subluxation of the talus and joint space narrowing. When complications do occur, intervention should be immediate.

Ankle arthrodesis combined with tibial lengthening using the Ilizarov apparatus.

We report our experience using the Ilizarov method to perform combined ankle arthrodesis and tibial lengthening in six patients (mean age 47 years; range 25-66 years). The average distraction length was 4.1 cm (range 1.1-6.8 cm), and the mean period of follow-up was 36 months (range 26-44 months). Three patients had active infection of the ankle. Four patients had undergone previous surgery, two of which were primary ankle arthrodeses. We performed compression-distraction in three patients and bone transport in three. In the compression-distraction group, the mean length gained was 1.9 cm, the mean external fixation index (EFI) was 144 days/cm, and the mean external fixation time was 246 days. In the bone transport group, the mean length gained was 6.2 cm, the mean EFI was 35.4 days/cm, and the mean external fixation time was 233 days. All cases achieved a good clinical result with a solid ankle arthrodesis and no infection, deformity, or need for additional support. The Ilizarov method may be practically applied for ankle arthrodesis, especially in complicated cases. The EFI and external fixation time tended to increase for patients with a length gain of 3 cm or less.

The natural limb is best: joint preservation and reconstruction by distraction osteogenesis for high-grade juxta-articular osteosarcomas.

This paper introduces an innovative technique of highly conservative limb-saving surgery for juxta-articular osteosarcoma. This technique consists of marginal tumour excision, joint preservation and reconstruction by distraction osteogenesis. Ten patients, with a mean age of 19.5 years and high-grade osteosarcoma, underwent this procedure. The distal femur and proximal tibia were affected in five patients each. After effective pre-operative chemotherapy, the tumour was excised with preservation of the epiphysis, the articular surface and the maximun amount of healthy soft tissue. This was followed by application of an external fixator. Bone transport was performed for seven patients and shortening-distraction for three. The limb function was rated excellent in seven patients, good in one and fair in two. At the final follow-up, three patients were dead after a mean of 25.3 months while seven patients remained free of disease with a mean follow-up of 55.4 months. Joint preservation and biological reconstruction through distraction osteogenesis can produce excellent and long-lasting functional results.