Does The Lengthening Frequency Affect The Outcome of Distraction Osteogenesis? Comparing Two Times a Day with Four Times a Day Lengthening Protocol

Pasin Tangadulrat; Nath  Adulkasem; Jidapa Wongcharoenwatana; Thanase Ariyawatkul; Chatupon Chotigavanichaya; Perajit Eamsobhana

doi:10.33192/smj.v76i6.266954

Authors

Pasin Tangadulrat Department of Orthopedics, Faculty of Medicine Prince of Songkla University, Songkhla, Thailand
Nath Adulkasem Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Jidapa Wongcharoenwatana Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Thanase Ariyawatkul Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Chatupon Chotigavanichaya Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Perajit Eamsobhana Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

DOI:

https://doi.org/10.33192/smj.v76i6.266954

Keywords:

Distraction Osteogenesis, Limb lengthening, Healing index, Lengthening frequency

Abstract

Objective: Distraction osteogenesis (DO) is a well-known technique. The traditional method utilized the lengthening frequency of four times a day (QID). Many mechanical factors may affect the DO outcome. However, the effect of distraction frequency has not been proven clinically. Therefore, we aim to investigate whether the BID and QID lengthening frequency affect the healing index and complications of the DO.

Materials and Methods: We retrospectively reviewed patients who had undergone DO from 2010 – 2021. The patient was divided into BID and QID groups. Demographics, lengthening outcomes, and complications between the two groups were compared. We used the inverse probability of treatment weighting (IPTW) to determine the effect of treatment.

Results: The median healing index (HI) of the patients whose lengthening was done QID is 41.36 (IQR 32.72 - 67.68) days/cm, and BID is 49.12 (IQR 35.28 - 62.54) days/cm, which did not differ significantly. The Odds ratio of achieving HI < 45 days/cm for patients receiving QID lengthening compare to BID is 1.12 (95% CI 0.31-3.99, p = 0.862 ). The IPTW did not show a difference in average treatment effects between QID and BID lengthening. The rates of minor and major complications were not significantly different between the two groups (26.1% in QID group and 32.1% in BID group).

Conclusion: The frequency of QID and BID lengthening results in comparable HI and complications for patients who undergo DO. However, prospective research is needed to evaluate the effect of frequency differences in a clinical setting.

References

ILIZAROV GA. Clinical Application of the Tension–Stress Effect for Limb Lengthening. Clin Orthop Relat Res. 1990;250:8-26.

Birch JG. A Brief History of Limb Lengthening. J Pediatr Orthop. 2017;37:S1-S8.

Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;239:263-85.

ILIZAROV GA. The Tension-Stress Effect on the Genesis and Growth of Tissues: Part I. The Influence of Stability of Fixation and Soft-Tissue Preservation. Clin Orthop Relat Res. 1989;238:249-81.

Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990;250:81-104.

Watson JT. Distraction osteogenesis. J Am Acad Orthop Surg. 2006;14:S168-74.

Yasui N, Kojimoto H, Sasaki K, Kitada A, Shimizu H, Shimomura Y. Factors affecting callus distraction in limb lengthening. Clin Orthop Relat Res. 1993;293:55-60.

FISCHGRUND J, PALEY D, SUTER C. Variables Affecting Time to Bone Healing During Limb Lengthening. Clin Orthop Relat Res. 1994;301:31-7.

Noonan KJ, Leyes M, Forriol F, Cañadell J. Distraction osteogenesis of the lower extremity with use of monolateral external fixation. A study of two hundred and sixty-one femora and tibiae. J Bone Joint Surg Am. 1998;80:793-806.

Maffulli N, Lombari C, Matarazzo L, Nele U, Pagnotta G, Fixsen JA. A review of 240 patients undergoing distraction osteogenesis for congenital post-traumatic or postinfective lower limb length discrepancy. J Am Coll Surg. 1996;182:394-402.

De Bastiani G, Aldegheri R, Renzi-Brivio L, Trivella G. Limb lengthening by callus distraction (callotasis). J Pediatr Orthop. 1987;7:129-34.

Lascombes P, Popkov D, Huber H, Haumont T, Journeau P. Classification of complications after progressive long bone lengthening: proposal for a new classification. Orthop Traumatol Surg Res. 2012;98:629-37.

Li R, Saleh M, Yang L, Coulton L. Radiographic classification of osteogenesis during bone distraction. J Orthop Res. 2006;24:339-47.

Tirawanish P, Eamsobhana P. Prediction of Callus Subsidence in Distraction Osteogenesis Using Callus Formation Scoring System: Preliminary Study. Orthop Surg. 2018;10:121-7.

Mizuta H, Nakamura E, Kudo S, Maeda T, Takagi K. Greater frequency of distraction accelerates bone formation in open-wedge proximal tibial osteotomy with hemicallotasis. Acta Orthop Scand. 2004;75:588-93.

Schiller JR, Moore DC, Ehrlich MG. Increased lengthening rate decreases expression of fibroblast growth factor 2, platelet-derived growth factor, vascular endothelial growth factor, and CD31 in a rat model of distraction osteogenesis. J Pediatr Orthop. 2007;27:961-8.

Liu Y, Cai F, Liu K, Liu J, Zhang X, Yusufu A. Cyclic Distraction-Compression Dynamization Technique Enhances the Bone Formation During Distraction Osteogenesis. Front Bioeng Biotechnol. 2021;9:810723.

Shen J, Ye X. Effect of "accordion" technique on bone consolidation during distraction osteogenesis. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2018;32:558-67.

Fu R, Feng Y, Bertrand D, Du T, Liu Y, Willie BM, et al. Enhancing the Efficiency of Distraction Osteogenesis through Rate-Varying Distraction: A Computational Study. Int J Mol Sci. 2021;22(21):11734.

Horn J, Steen H, Huhnstock S, Hvid I, Gunderson RB. Limb lengthening and deformity correction of congenital and acquired deformities in children using the Taylor Spatial Frame. Acta Orthop. 2017;88:334-40.

Donnan LT, Saleh M, Rigby AS. Acute correction of lower limb deformity and simultaneous lengthening with a monolateral fixator. J Bone Joint Surg Br. 2003;85:254-60.

Koczewski P, Shadi M. Factors influencing bone regenerate healing in distraction osteogenesis. Ortop Traumatol Rehabil. 2013;15:591-9.

Scheider P, Ganger R, Farr S. Age-related Outcomes and Complications of Osteodistraction in the Pediatric Upper Extremity: A Large Retrospective Single-center Study of 61 Cases. J Pediatr Orthop. 2022;42:e181-e7.

Aaron AD, Eilert RE. Results of the Wagner and Ilizarov methods of limb-lengthening. J Bone Joint Surg Am. 1996;78:20-9.

Juan JA, Prat J, Vera P, Hoyos JV, Sánchez-Lacuesta J, Peris JL, et al. Biomechanical consequences of callus development in Hoffmann, Wagner, Orthofix and Ilizarov external fixators. J Biomech. 1992;25:995-1006.

Pietrzak S, Grzelecki D, Parol T, Czubak J. Comparison of Intramedullary Magnetic Nail, Monolateral External Distractor, and Spatial External Fixator in Femur Lengthening in Adolescents with Congenital Diseases. J Clin Med. 2021;10(24):5957.

Galal S, Shin J, Principe P, Mehta R, Khabyeh-Hasbani N, Hamilton A, et al. Humerus Lengthening: A Comparison of the Internal Lengthening Nail to External Fixation. Hss J. 2021;17:207-12.

Szymczuk VL, Hammouda AI, Gesheff MG, Standard SC, Herzenberg JE. Lengthening With Monolateral External Fixation Versus Magnetically Motorized Intramedullary Nail in Congenital Femoral Deficiency. J Pediatr Orthop. 2019;39:458-65.

Jasiewicz B, Kacki W, Tesiorowski M, Potaczek T. Results of femoral lengthening over an intramedullary nail and external fixator. Chir Narzadow Ruchu Ortop Pol. 2008;73:177-83.

Balci H, Bayram S, Pehlivanoglu T, Anarat FB, Eralp L, Şen C, et al. Effect of lengthening speed on the quality of callus and complications in patients with congenital pseudarthrosis of tibia. Int Orthop. 2021;45:1517-22.

Van Nguyen L, Van Le D. Functional outcomes and complications of tibial lengthening using unilateral external fixation and then plating. A prospective case series. Ann Med Surg (Lond). 2022;74:103262.

Popkov A, Pietrzak S, Antonov A, Parol T, Lazović M, Podeszwa D, et al. Limb Lengthening for Congenital Deficiencies Using External Fixation Combined With Flexible Intramedullary Nailing: A Multicenter Study. J Pediatr Orthop. 2021;41:e439-e47.

Hafez M, Nicolaou N, Offiah A, Giles SN, Madan SS, Fernandes JA. Femoral Lengthening in Children-A Comparison Between Magnetic Intramedullary Lengthening Nails and External Fixators. J Pediatr Orthop. 2022;42:e290-e4.

Sheridan GA, Fragomen AT, Rozbruch SR. Integrated Limb Lengthening Is Superior to Classical Limb Lengthening: A Systematic Review and Meta-analysis of the Literature. J Am Acad Orthop Surg Glob Res Rev. 2020;4(6):e20.00054.