Skeletal Radiology

, Volume 37, Issue 9, pp 843–847

Quantitative assessment of mineralization in distraction osteogenesis

  • Sunit Hazra
  • Hae-Ryong Song
  • Sandeep Biswal
  • Suk-Ha Lee
  • Seok Hyun Lee
  • Ki-Mo Jang
  • Hitesh N. Modi
Scientific Article



The most important decision in distraction osteogenesis is the timing of fixator removal. Various methods have been tried, such as radiographic appearance of callus and bone mineral density (BMD) assessment, but none has acquired gold standard status. The purpose of this study was to develop another objective method of assessment of callus stiffness to help clinicians in taking the most important decision of when to remove the fixator.

Materials and methods

We made a retrospective study of 70 patients to compare the BMD ratio and pixel value ratio. These ratios were calculated at the time of fixator removal, and Pearson’s coefficient of correlation was used to show the comparability. Inter- and intra-observer variability of the new method was also tested.


Good correlation was found between BMD ratio and pixel value ratio, with a Pearson’s coefficient of correlation of 0.79. The interobserver variability was also low, with high intra-observer reproducibility, suggesting that this test was simple to perform.


Pixel value ratio is a good method for assessing callus stiffness, and it can be used to judge the timing of fixator removal.


Distraction osteogenesis BMD Callus stiffness Pixel Lengthening Ilizarov 


  1. 1.
    Maffulli N, Hughes T, Fixsen JA. Ultrasonographic monitoring of limb lengthening. J Bone Joint Surg Br 1992; 74: 130–132.PubMedGoogle Scholar
  2. 2.
    Minty I, Maffulli N, Hughes TH, Shaw DG, Fixsen JA. Radiographic features of limb lengthening in children. Acta Radiol 1994; 35: 555–559.PubMedCrossRefGoogle Scholar
  3. 3.
    Maffulli N, Cheng JCY, Sher A, Ng BKW, Ng E. Bone mineralization at the callotasis site after completion of lengthening bone 1999; 25: 333–338.Google Scholar
  4. 4.
    Salmas MG, Nikiforidis G, Sakellaropoulos G, Kosti P, Lambiris E. Estimation of artifacts induced by the Ilizarov device in quantitative computed tomographic analysis of tibiae. Injury 1998; 29: 711–716.PubMedCrossRefGoogle Scholar
  5. 5.
    Minematsu K, Tsuchiya H, Taki J, Tomita K. Blood flow measurement during distraction osteogenesis. Clin Orthop 1998; 347: 229–235.PubMedGoogle Scholar
  6. 6.
    Eyres KS, Bell MJ, Kanis JA. New bone formation during leg lengthening. Evaluated by dual energy X-ray absorptiometry. J Bone Joint Surg Br 1993; 75: 96–106.PubMedGoogle Scholar
  7. 7.
    Eyres KS, Bell MJ, Kanis JA. Methods of assessing new bone formation during leg lengthening. Ultrasonography, by dual energy x-ray absorptiometry and radiography compared. J Bone Joint Surg Br 1993; 75: 358–364.PubMedGoogle Scholar
  8. 8.
    Guichet JM, Braillon P, Bodenreider O, Lascombes P. Periosteum and bone marrow in bone lengthening: A DEXA quantitative evaluation in rabbits. Acta Orthop Scand 1998; 69: 527–531.PubMedCrossRefGoogle Scholar
  9. 9.
    Tselentakis G, Owen PJ, Richardson JB, et al. Fracture stiffness in callotasis determined by dual-energy X-ray absorptiometry scanning. J Pediatr Orthop B 2001; 10: 248–254.PubMedCrossRefGoogle Scholar
  10. 10.
    De Backer AI, Mortelé KJ, De Keulenaer BL. Picture archiving and communication system—part one: filmless radiology and distance radiology (review). JBR-BTR 2004; 87: 234–421.PubMedGoogle Scholar
  11. 11.
    Kabachinski J. DICOM: key concepts—part I. Biomed Instrum Technol 2005; 39: 214–216.PubMedGoogle Scholar
  12. 12.
    Passadore DJ, Isoardi RA, Ariza PP, Padin C. Use of a low-cost, PC based image review workstation at a radiology department. J Digit Imaging 2001; 14 [2 Suppl 1]: 222–223.PubMedGoogle Scholar
  13. 13.
    Dugas M, Trumm C, Stabler A, et al. Case-oriented computer-based training in radiology: concept, implementation and evaluation. BMC Med Educ 2001; 1: 5–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Swaton N. Learn from experience: insights of 200+ PACS customers. Radiol Manage 2002; 24: 22–27.PubMedGoogle Scholar
  15. 15.
    Shim JS, Chung KH, Ahn JM. Value of measuring bone density serial changes on a picture archiving and communication system (PACS) monitor in distraction osteogenesis. Orthopedics 2002; 25: 1269–1272.Google Scholar
  16. 16.
    Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop 1990; 250: 8–25.PubMedGoogle Scholar
  17. 17.
    Fischgrund J, Paley D, Suter C. Variables affecting time to bone healing during limb lengthening. Clin Orthop 1994; 301: 31–37.PubMedGoogle Scholar
  18. 18.
    Starr KA, Fillman R, Raney EM. Reliability of radiographic assessment of distraction osteogenesis site. J Pediatr Orthop 2004; 24: 26–29.PubMedGoogle Scholar
  19. 19.
    Young JW, Kovelman H, Resnik CS, Paley D. Radiologic assessment of bones after Ilizarov procedures. Radiology 1990; 177:89−93.PubMedGoogle Scholar

Copyright information

© ISS 2008

Authors and Affiliations

  • Sunit Hazra
    • 1
  • Hae-Ryong Song
    • 2
  • Sandeep Biswal
    • 1
  • Suk-Ha Lee
    • 3
  • Seok Hyun Lee
    • 4
  • Ki-Mo Jang
    • 1
  • Hitesh N. Modi
    • 1
  1. 1.Department of Orthopedic SurgeryKorea University, Guro HospitalSeoulKorea
  2. 2.Department of Orthopedic SurgeryRare Diseases Institute, Korea University, Guro HospitalSeoulKorea
  3. 3.Department of OrthopedicsKonkuk University HospitalSeoulKorea
  4. 4.Department of Orthopedic SurgeryDongguk University International HospitalIlsanKorea

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