Clinical Orthopaedics and Related Research

, Volume 466, Issue 12, pp 2955–2961 | Cite as

DEXA as a Predictor of Fixator Removal in Distraction Osteogenesis

Symposium: Advances in Limb Lengthening and Reconstruction

Abstract

Premature removal of the fixator after a lengthening procedure can result in gradual bending or acute fracture of the regenerate. We reviewed the records of 26 patients who underwent 28 limb lengthenings between 1997 and 2005 to assess the post lengthening regenerate fracture rate and bone healing index when using dual energy xray absorptiometry (DEXA) to aid in deciding on when to remove the fixator. Sixteen male and 10 female patients with an average age at lengthening of 12.3 years underwent an average lengthening of 5.2 cm (range, 3–9.1 cm). Nineteen femurs and nine tibiae were lengthened. Serial monthly DEXA scans were analyzed for bone mineral density. Bone healing indices and post fixator removal complications were assessed. The fixators were removed once the bone mineral density had plateaued to a less than 10% increase and plain radiographs showed no obvious defects precluding fixator removal. There were no regenerate fractures and only one fracture in the proximal segment of the lengthened bone after apparatus removal and the healing index for the series averaged 47 d/cm (range, 20–73 d/cm). Using serial DEXA scans during the consolidation phase of lengthening has a low rate (3.6%) of fractures while maintaining an acceptable bone healing index without excessively increasing fixation time.

Level of Evidence: Level IV, therapeutic retrospective study. See the Guidelines for Authors for a complete description of levels of evidence.

References

  1. 1.
    Aarnes GT, Steen H, Ludvigsen P, Waanders NA, Huiskes R, Goldstein SA. In vivo assessment of regenerate axial stiffness in distraction osteogenesis. J Orthop Res. 2005;23:494–498.PubMedCrossRefGoogle Scholar
  2. 2.
    Abe M, Shirai H, Okamoto M, Onomura T. Lengthening of the forearm by callus distraction. J Hand Surg [Br]. 1996;21:151–163.Google Scholar
  3. 3.
    Aldegheri R. Distraction osteogenesis for lengthening of the tibia in patients who have limb-length discrepancy or short stature. J Bone Joint Surg Am. 1999;81:624–634.PubMedGoogle Scholar
  4. 4.
    Antoci V, Ono CM, Antoci V, Jr, Raney EM. Bone lengthening in children: how to predict the complications rate and complexity? J Pediatr Orthop. 2006;26:634–640.PubMedGoogle Scholar
  5. 5.
    Birch JG, Samchukov ML. Use of the Ilizarov method to correct lower limb deformities in children and adolescents. J Am Acad Orthop Surg. 2004;12:144–154.PubMedGoogle Scholar
  6. 6.
    Cattermole HC, Cook JE, Fordham JN, Muckle DS, Cunningham JL. Bone mineral changes during tibial fracture healing. Clin Orthop Relat Res. 1997;339:190–196.PubMedCrossRefGoogle Scholar
  7. 7.
    Codivilla A. On the means of lengthening, in the lower limbs, the muscles and tissues which are shortened through deformity. 1905. J Bone Joint Surg Am. 1905;s2–2:353–369.Google Scholar
  8. 8.
    Danziger MB, Kumar A, DeWeese J. Fractures after femoral lengthening using the Ilizarov method. J Pediatr Orthop. 1995;15:220–223.PubMedGoogle Scholar
  9. 9.
    Dinah AF. Predicting duration of Ilizarov frame treatment for tibial lengthening. Bone. 2004;34:845–848.PubMedCrossRefGoogle Scholar
  10. 10.
    Eldridge JC, Bell DF. Problems with substantial limb lengthening. Orthop Clin North Am. 1991;22:625–631.PubMedGoogle Scholar
  11. 11.
    Eski M, Ilgan S, Cil Y, Sengezer M, Ozcan A, Yapici K. Assessment of distraction regenerate using quantitative bone scintigraphy. Ann Plast Surg. 2007;58:328–334.PubMedCrossRefGoogle Scholar
  12. 12.
    Eyres KS, Bell MJ, Kanis JA. Methods of assessing new bone formation during limb lengthening. Ultrasonography, dual energy X-ray absorptiometry and radiography compared. J Bone Joint Surg Br. 1993;75:358–364.PubMedGoogle Scholar
  13. 13.
    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
  14. 14.
    Fischgrund J, Paley D, Suter C. Variables affecting time to bone healing during limb lengthening. Clin Orthop Relat Res. 1994;301:31–37.PubMedGoogle Scholar
  15. 15.
    Garcia-Cimbrelo E, Olsen B, Ruiz-Yague M, Fernandez-Baillo N, Munuera-Martinez L. Ilizarov technique. Results and difficulties. Clin Orthop Relat Res. 1992;283:116–123.PubMedGoogle Scholar
  16. 16.
    Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res. 1990;250:8–26.PubMedGoogle Scholar
  17. 17.
    Kawano M, Taki J, Tsuchiya H, Tomita K, Tonami N. Predicting the outcome of distraction osteogenesis by 3-phase bone scintigraphy. J Nucl Med. 2003;44:369–374.PubMedGoogle Scholar
  18. 18.
    Maffulli N, Cheng JC, Sher A, Lam TP. Dual-energy X-ray absorptiometry predicts bone formation in lower limb callotasis lengthening. Ann R Coll Surg Engl. 1997;79:250–256.PubMedGoogle Scholar
  19. 19.
    Njeh CF, Fuerst T, Hans D, Blake GM, Genant HK. Radiation exposure in bone mineral density assessment. Appl Radiat Isot. 1999;50:215–236.PubMedCrossRefGoogle Scholar
  20. 20.
    Noonan KJ, Leyes M, Forriol F, Canadell 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.PubMedGoogle Scholar
  21. 21.
    Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990;250:81–104.PubMedGoogle Scholar
  22. 22.
    Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening. J Bone Joint Surg Am. 1997;79:1464–1480.PubMedGoogle Scholar
  23. 23.
    Reichel H, Lebek S, Alter C, Hein W. Biomechanical and densitometric bone properties after callus distraction in sheep. Clin Orthop Relat Res. 1998;357:237–246.PubMedCrossRefGoogle Scholar
  24. 24.
    Reiter A, Sabo D, Pfeil J, Cotta H. Quantitative assessment of callus distraction using dual energy X-ray absorptiometry. Int Orthop. 1997;21:35–40.PubMedCrossRefGoogle Scholar
  25. 25.
    Saraph V, Roposch A, Zwick E-B, Linhart WE. Tibial lengthening over nails in children using modified Ender nails: preliminary results of a new treatment. J Pediatr Orthop B. 2004;13:383–388.PubMedGoogle Scholar
  26. 26.
    Shrimpton PC, Wall BF, Hart D. Diagnostic medical exposures in the U.K. Appl Radiat Isot. 1999;50:261–269.PubMedCrossRefGoogle Scholar
  27. 27.
    Simpson AH, Cole AS, Kenwright J. Leg lengthening over an intramedullary nail. J Bone Joint Surg Br. 1999;81:1041–1045.PubMedCrossRefGoogle Scholar
  28. 28.
    Skaggs DL, Leet AI, Money MD, Shaw BA, Hale JM, Tolo VT. Secondary fractures associated with external fixation in pediatric femur fractures. J Pediatr Orthop. 1999;19:582–586.PubMedCrossRefGoogle Scholar
  29. 29.
    Stanitski DF, Shahcheraghi H, Nicker DA, Armstrong PF. Results of tibial lengthening with the Ilizarov technique. J Pediatr Orthop. 1996;16:168–172.PubMedGoogle Scholar
  30. 30.
    Starr KA, Fillman R, Raney EM. Reliability of radiographic assessment of distraction osteogenesis site. J Pediatr Orthop. 2004;24:26–29.PubMedGoogle Scholar
  31. 31.
    Tjernstrom B, Thoumas KA, Pech P. Bone remodeling after leg lengthening: evaluation with plain radiographs, and computed tomography and magnetic resonance imaging scans. J Pediatr Orthop. 1992;12:751–755.PubMedGoogle Scholar
  32. 32.
    Velazquez RJ, Bell DF, Armstrong PF, Babyn P, Tibshirani R. Complications of use of the Ilizarov technique in the correction of limb deformities in children. J Bone Joint Surg Am. 1993;75:1148–1156.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons 2008

Authors and Affiliations

  1. 1.Division of OrthopaedicsShriners Hospital for Children, McGill UniversityMontrealCanada
  2. 2.Division of Orthopaedic SurgeryMcGill UniversityMontrealCanada

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