Medical uses
Distraction osteogenesis (DO) is used in orthopedic surgery, and oral and maxillofacial surgery to repair skeletal deformities and in reconstructive surgery. [1] [2] [3] It was originally used to treat problems like unequal leg length, but since the 1980s is most commonly used to treat issues like hemifacial microsomia, micrognathism (chin so small it causes health problems), craniofrontonasal dysplasias, craniosynostosis, as well as airway obstruction in babies caused by glossoptosis (tongue recessed too far back in the mouth) or micrognathism. [1]
In 2016, a systematic review of papers describing bone and soft tissue outcomes of DO procedures on the lower jawbone was published; the authors had planned to do a meta-analysis but found the studies were too poor in quality and too heterogeneous to pool. [4] From what they were able to generalize, the authors found there was significant relapse in the vertical plane for bone, and a higher risk of relapse when there was an initial high gonial angle or Jarabak ratio (sella–gonion/nasion–menton). [4] For soft tissue, little evidence was available regarding the vertical dimension, while a 90% correspondence between skeletal and soft tissue was found for sagittal positioning; the dental-to-soft tissue agreement was around 20%. [4]
A 2018 Cochrane review of DO on the upper jawbone to treat cleft lip and cleft palate compared with orthognathic surgery found only one study, involving 47 participants and performed between 2002 and 2008 at the University of Hong Kong. [5] This was not sufficient evidence from which to generalize, but the authors noted that while both procedures produced notable hard and soft tissue improvements, the DO group had greater advancement of the maxillary and less horizontal relapse five years after surgery. [5] There was no difference in speech or nasal emissions outcomes nor in adverse effects; the DO group had lower satisfaction at three months after surgery but higher at two years. [5]
Procedure
In the first phase, called the "osteotomy/surgical phase", the bone is cut, either partially, only through the hard exterior, or completely, and a device is fitted which will be used in the next phases. In the second phase, the latency period, which lasts generally seven days, the appliance is not activated and early stages of bone healing are allowed. In the third phase, the "distraction phase", the device, which is mounted to the bone on each side of the cut, is used to gradually separate the two pieces, allowing new bone to form in the gap. When the desired or possible length is reached, which usually takes three to seven days, a consolidation phase follows in which the device keeps the bone stable to allow the bone to fully heal. After the consolidation phase, the device is removed in a second surgical procedure. [1]
The device is usually manually operated by twisting a rod that separates the bone using a rack and pinion or similar system ; the rate of separation is carefully determined because going too quickly can cause nonunion, in which unstable fibrous connective tissue is formed instead of bone, and going too slowly can allow premature union to occur. Generally the rate is about a millimeter per day, achieved in two steps per day. The frequency of steps and how much the device is moved at each step, is called the "rhythm". The devices sometimes contain a spring that provides tension to continually separate the bones, instead of being manually operated at set intervals. [1]
In addition to these manually operated systems, there are also motorized systems like the Fitbone from Wittenstein. The Fitbone is a fully implantable, motorized, lengthening and correction nail. [6] Advantages of this device are accurate deformity correction, low scar tissue formation, and reduced risk of infection. [7] [8] Furthermore, the patients describe the procedure as more comfortable than limb lengthening with mechanical systems. [9]
History
The procedure was first proposed by Bernhard von Langenbeck in 1869, but the first publication of efforts to implement it clinically was by Alessandro Codivilla in 1905. [1] The paper presented the results of efforts to treat 26 people who were born with malformed legs; Codivilla cut the femur, put a pin in the heel bone, and applied traction to each person. [1] [10] His paper showed high levels of complications, including infection, tissue death, and bones that failed to join, and his methods were not adopted. [1]
The Russian orthopedic surgeon Gavriil Ilizarov studied DO methods in over 15,000 people starting in the 1950s; he developed external fixation devices and methods to separate severed leg bones gradually, and using them he determined optimal rates of separation. His work led to widespread use of DO. [1] [2]
The first use in the jaw was pioneered by Wolfgang Rosenthal in 1930 but it was not further explored until the 1980s; the first paper of the modern era describing clinical use was published in 1992. [1] [11]
Society and culture
In India, cosmetic limb-lengthening surgery is a high demand but also unregulated industry. [12] [13] Height is highly attractive in India and cosmetic limb-lengthening has been used by some young Indians to improve marriage and career prospects. [14] Others have used it in preparation for a new job in another country such as the United States. [13] American and British men (with average heights of 5 feet 9.5 inches and 5 feet 9.75 inches ,respectively) are around 5 inches taller than Indian men. [12] One surgeon in India stated: "This is one of the most difficult cosmetic surgeries to perform, and people are doing it after just one or two months' fellowship, following a doctor who is probably experimenting himself. There are no colleges, no proper training, nothing." [14]
People as young as 13 or 14 have undergone the procedure in India. Some patients have received infections and had to undergo additional surgeries months later to regain the ability to walk, while others found that they gained less height than expected. [13] Other patients have said the surgeons had misled them about the potential complications and dangers of the surgery. [12] [15] The cost of the procedure is US$25,000 in India compared to $75,000, which it would cost in the United States. [13]
In 2006, limb lengthening was banned by China's Ministry of Health after a series of operations resulting in serious side-effects. [16]
The plot of the 1997 American dystopian science fiction film Gattaca involves one character assuming the identity of another and leg lengthening is depicted as part of the elaborate ploy to achieve this subterfuge, along with the use of various bodily fluids to avoid detection by DNA sequencing. [17]
Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.
An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.
External fixation is a surgical treatment wherein Kirschner pins and wires are inserted and affixed into bone and then exit the body to be attached to an external apparatus composed of rings and threaded rods — the Ilizarov apparatus, the Taylor Spatial Frame, and the Octopod External Fixator — which immobilises the damaged limb to facilitate healing. As an alternative to internal fixation, wherein bone-stabilising mechanical components are surgically emplaced in the body of the patient, external fixation is used to stabilize bone tissues and soft tissues at a distance from the site of the injury.
Orthognathic surgery, also known as corrective jaw surgery or simply jaw surgery, is surgery designed to correct conditions of the jaw and lower face related to structure, growth, airway issues including sleep apnea, TMJ disorders, malocclusion problems primarily arising from skeletal disharmonies, and other orthodontic dental bite problems that cannot be treated easily with braces, as well as the broad range of facial imbalances, disharmonies, asymmetries, and malproportions where correction may be considered to improve facial aesthetics and self-esteem.
In medicine, the Ilizarov apparatus is a type of external fixation apparatus used in orthopedic surgery to lengthen or to reshape the damaged bones of an arm or a leg; used as a limb-sparing technique for treating complex fractures and open bone fractures; and used to treat an infected non-union of bones, which cannot be surgically resolved. The Ilizarov apparatus corrects angular deformity in a leg, corrects differences in the lengths of the legs of the patient, and resolves osteopathic non-unions; further developments of the Ilizarov apparatus progressed to the development of the Taylor Spatial Frame.
Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some small or acute fractures can be cured without bone grafting, but the risk is greater for large fractures like compound fractures.
Nonunion is permanent failure of healing following a broken bone unless intervention is performed. A fracture with nonunion generally forms a structural resemblance to a fibrous joint, and is therefore often called a "false joint" or pseudoarthrosis. The diagnosis is generally made when there is no healing between two sets of medical imaging, such as X-ray or CT scan. This is generally after 6–8 months.
Ollier disease is a rare sporadic nonhereditary skeletal disorder in which typically benign cartilaginous tumors (enchondromas) develop near the growth plate cartilage. This is caused by cartilage rests that grow and reside within the metaphysis or diaphysis and eventually mineralize over time to form multiple enchondromas. Key signs of the disorder include asymmetry and shortening of the limb as well as an increased thickness of the bone margin. These symptoms are typically first visible during early childhood with the mean age of diagnosis being 13 years of age. Many patients with Ollier disease are prone to develop other malignancies including bone sarcomas that necessitate treatment and the removal of malignant bone neoplasm. Cases in patients with Ollier disease has shown a link to IDH1, IDH2, and PTH1R gene mutations. Currently, there are no forms of treatment for the underlying condition of Ollier disease but complications such as fractures, deformities, malignancies that arise from it can be treated through surgical procedures. The prevalence of this condition is estimated at around 1 in 100,000. It is unclear whether the men or women are more affected by this disorder due to conflicting case studies.
An open fracture, also called a compound fracture, is a type of bone fracture that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. Open fractures are emergencies and are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue. An open fracture can be life threatening or limb-threatening due to the risk of a deep infection and/or bleeding. Other complications including a risk of malunion of the bone or nonunion of the bone. The severity of open fractures can vary. For diagnosing and classifying open fractures, Gustilo-Anderson open fracture classification is the most commonly used method. It can also be used to guide treatment, and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection. Cephalosporins are generally the first line of antibiotics. Therapeutic irrigation, wound debridement, early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections. The bone that is most commonly injured is the tibia and working-age young men are the group of people who are at highest risk of an open fracture. Older people with osteoporosis and soft-tissue problems are also at risk.
The Taylor Spatial Frame (TSF) is an external fixator used by paediatric and orthopaedic surgeons to treat complex fractures and bone deformities. The medical device shares a number of components and features of the Ilizarov apparatus. The Taylor Spatial Frame is a hexapod device based on a Stewart platform, and was invented by orthopaedic surgeon Charles Taylor. The device consists of two or more aluminum or carbon fibre rings connected by six struts. Each strut can be independently lengthened or shortened to achieve the desired result, e.g. compression at the fracture site, lengthening, etc. Connected to a bone by tensioned wires or half pins, the attached bone can be manipulated in three dimensions and 9 degrees of freedom. Angular, translational, rotational, and length deformities can all be corrected simultaneously with the TSF.
Alessandro Codivilla was an Italian surgeon from Bologna and head of the surgical department of the hospital of Castiglion Fiorentino, known for his work in orthopaedics and first describing the pancreaticoduodenectomy.
Epiphysiodesis is a pediatric orthopedic surgery procedure that aims at altering or stopping the bone growth naturally occurring through the growth plate also known as the physeal plate. There are two types of epiphysiodesis: temporary hemiepiphysiodesis and permanent epiphysiodesis. Temporary hemiepiphysiodesis is also known as guided growth surgery or growth modulation surgery. Temporary hemiepiphysiodesis is reversible i.e. the metal implants used to achieve epiphysiodesis can be removed after the desired correction is achieved and the growth plate can thus resume its normal growth and function. In contrast, permanent epiphysiodesis is irreversible and the growth plate function cannot be restored after surgery. Both temporary hemiepiphysiodesis and permanent epiphysiodesis are used to treat a diverse array of pediatric orthopedic disorders but the exact indications for each procedure are different.
An intramedullary rod, also known as an intramedullary nail or inter-locking nail or Küntscher nail, is a metal rod forced into the medullary cavity of a bone. IM nails have long been used to treat fractures of long bones of the body. Gerhard Küntscher is credited with the first use of this device in 1939, during World War II, for soldiers with fractures of the femur. Prior to that, treatment of such fractures was limited to traction or plaster, both of which required long periods of inactivity. IM nails resulted in earlier return to activity for the soldiers, sometimes even within a span of a few weeks, since they share the load with the bone, rather than entirely supporting the bone.
Dror Paley is a Canadian-trained orthopedic surgeon, who specializes in limb lengthening and deformity correction procedures.
The Octopod Circular External Fixator is a medical device developed to treat bone fractures and deformities. The device consists of 4 main vertical struts between 2 rings and 4 assistant diagonal struts. This 3rd Generation Circular External Fixator contains 8 combined mobile struts from which it derives its octopod name. With the octopod method, the device can reach a wider correction range, thereby solving a major problem of the 2nd Generation Circular External Fixators, that of having to frequently change struts. The previous difficulties in taking manual measurements when using both 1st and the 2nd Generation External Fixators are resolved by using the 3rd Generation Circular External Fixator.
Anthropometric cosmetology is the medical practice to correct or modify deformities in the upper and lower extremities of the body. This is done in order to attain an aesthetically pleasing appearance or to eliminate physical and psychological discomforts.
The following outline is provided as an overview of and topical guide to trauma and orthopaedics:
Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.
William Harrison Bell was an American Oral and Maxillofacial Surgeon and a Professor of Surgery who is known for his contributions to the field of Orthognathic Surgery. Dr. Bell's groundbreaking research provided a biologic basis for the Le Fort I osteotomy and other orthognathic surgical procedures used to reposition the facial skeleton. Active throughout his life, his later work provided a biologic rationale for distraction osteogenesis of the facial skeleton, a technique used to gradually lengthen bone at a rate of 1mm a day. A prolific author, his publications provided a thorough description of the diagnosis and management of dentofacial deformity, surgical technique, and detailed figures that illustrated the operations in sufficient detail that would provide generations of surgeons the necessary information from which to apply a surgical-orthodontic approach to facial deformity. He is credited in the United States with pioneering the transition of the field of Oral Surgery to become Oral and Maxillofacial Surgery.
Andrew A.C. Heggie is an oral and maxillofacial surgeon at the Royal Children's Hospital in Melbourne, Australia. His primary interest has been the management of developmental skeletal facial deformity, including patients with cleft lip and palate, craniofacial microsomia and infants with micrognathism. His contribution to the treatment of infant upper airway obstruction for Pierre Robin sequence, using internal devices for jaw lengthening using distraction osteogenesis, has replaced the need for tracheostomy in this condition. In 2019, Heggie was awarded Member of the Order of Australia for significant service to medicine and dentistry in the field of oral and maxillofacial surgery.
