Evaluation of bone healing in femurs lengthened via the gradual distraction method

BACKGROUND: Treatment of leg length inequality via lengthening of the shorter extremity is an infrequent orthopedic procedure due to the requirement of special distraction devices and possible serious complications. Essential qualitative changes in operative technique development are associated with the name of G. A. Ilizarov, who paved the way for the autoregenerate gradual distraction method in the 1950s. MATERIAL AND METHODS: In the years 1990 through 2006 a total of 57 patients underwent femur lengthening via gradual distraction using various types of external fixators at the Department of Pediatric Surgery, Orthopedics, and Traumatology, Faculty Hospital in Brno. The quality of bone healing was monitored and a number of parameters followed and statistically evaluated using regularly scheduled X-ray examinations. RESULTS: In 11 cases we had to remove the external fixator following the distraction phase, perform an osteosynthesis via a splint and fill the distraction gap via spongioplasty. The bone healing was satisfactory in the remaining 46 patients and the lengthened bone required no other fixation method. The analysis showed statistically significant deceleration in bone healing following distraction in female patients over 12 years of age, and in boys over 14 years of age. Lack of periosteal callus five weeks after surgery always signified serious problems in further healing. Severe complications were recorded in 11 cases during the distraction phase, and in 9 cases after the removal of the distraction apparatus. CONCLUSIONS: The aim of this report was to present the results of our study of distraction gap bone healing using the gradual lengthening approach.     

A Model for Ulnar Dysmelia

The treatment of pregnant rats with the carbonic anhydrase inhibitor, acetazolamide, produced gross limb malformations primarily affecting the forepaw, but also producing variable ulnar dysmelia. Analysis of the cytoarchitecture of the ulnar dysmelic limbs showed the presence of cartilaginous and fibrocartilaginous connections between the ulnar and radial chondroepiphyses, with variable deformation of the radial chondroepiphysis by the tethering effect (although the growth plate, per se, did not appear affected at the stage of development studied). The extremely variable experimental appearances duplicated most of the variations seen in the human disease analogue, and suggest this drug-induced embryopathy may be useful as a model for the study of postaxial forelimb deformities in the postnatal phase in order to adequately assess the structural changes of disparate growth between radius and ulna due to the presence of the cellular continuity between the two distal chondroepiphyses.     

Biomechanical influences of pin placement and elbow angle on hinge alignment and joint distraction of bridged elbow-pin-fixator construct

Joint distraction and mobilization with a hinged external fixator preserves elbow stability and mobility. However, the alignment of both elbow and fixator hinges was the initial prerequisite of the arthrodiatasis technique. The main goal of this study was to numerically evaluate the kinematic influence of the device, surgery, and joint factors on hinge alignment. The kinetic effects of the pins placement and elbow angle on concentric distraction and mobilization were also discussed. A unilaterally hinged elbow-fixator system with a 14 links and 10 degrees-of-freedom was instrumented into a humeroulnar model. The Denavit–Hartenberg method with the homogeneous transformation matrixes was applied to perform kinematic analysis of the linkage system. The predicted results revealed that the concurrence of hinge alignment (i.e., kinematic) and concentric distraction (i.e., kinetic) necessitates two telescopic tubes orthogonal to the elbow hinge. The degrees-of-freedom arrangement of the fixator articulators plays a significant role in hinge alignment. After joint distraction, two hinges might be misaligned due to the difference in the structural rigidity of the pins, fixator, and stiffened elbow. Furthermore, those two prerequisite are interactive and sensitive to elbow angle, fixator design, and pin placement of the bridged elbow-pin-fixator construct. In addition, the ideally concentric distraction might occur only at an elbow angle of 120° owing to the ulnar anatomy. Meticulous planning is necessary for such highly technically demanding surgery.     

Biomechanical properties of tendons during lower-leg lengthening in dogs using the Ilizarov method.

Ten dogs were provided with a circular fixator. Segment resection of the fibula and tibial osteotomy in the right lower leg was performed. 5 days after surgery, a lengthening of the right lower leg by 2.5 cm was performed on 6 dogs using a distraction rate of 0.5 mm, twice per day. 3 dogs with leg lengthening and 2 dogs of the control group without leg lengthening were sacrificed at the end of the distraction phase of 25 days and the remaining dogs after another 25 days. Postmortally the tendons of the tibialis anterior, extensor digitorum longus, peroneus longus and the achilles tendon were taken from the operated right side and the left non-operated control side and were examined biomechanically in cyclic tests. The control group without lengthening showed no changes in the biomechanical properties in the tendons of either side nor in those of the unlengthened left side of the operated dogs. In contrast the biomechanical tests revealed a marked decrease of the elastic modulus, an increase of distraction length and an increase of modulus reduction on the lengthened side compared to the non-operated left side.     

Biomolecular phases in transverse palatal distraction: A review

Transverse palatal distraction is a biological process of regenerating new bone and enveloping soft tissues in the maxillary palate region. This technique is similar to Osteo-distraction (OD) procedure for bone lengthening in which gradual and controlled traction forces are applied on the osteotomy gaps to produce new bone in between the surgically separated bone segments. This review describes the different phases after osteotomy and the biological process involved during the new bone and soft tissue formation. The mechanical environment formed in the distraction area is due to the traction forces by the distractor appliance. This environment stimulates differentiation of pluripotent cells, neovascularization, osteogenesis and remodeling of newly formed bone. The role of different pro-inflammatory cytokines, interleukins, bone morphogenic proteins, transforming growth factors, fibroblast growth factors-2) and extracellular matrix proteins (osteonectin, osteopontin) during the distraction phases has been described in detail. Also, an important note on the nutritional aspect during Osteo-distraction will benefit the clinicians to guide their patients after osteotomy throughout the distraction process.     

Safety and efficacy of botox injection in alleviating post-operative pain and improving quality of life in lower extremity limb lengthening and deformity correction

Background

Distraction osteogenesis is the standard treatment for the management of lower limb length discrepancy of more than 3 cm and bone loss secondary to congenital anomalies, trauma or infection. This technique consists of an osteotomy of the bone to be lengthened, application of an external fixator, followed by gradual and controlled distraction of the bone ends. Although limb lengthening using the Ilizarov distraction osteogenesis principle yields excellent results in most cases, the technique has numerous problems and is not well tolerated by many children. The objective of the current study is to determine if Botulinum Toxin A (BTX-A), which is known to possess both analgesic and paralytic actions, can be used to alleviate post-operative pain and improve the functional outcome of children undergoing distraction osteogenesis.

Methods/Design

The study design consists of a multi centre, randomized, double-blinded, placebo-controlled trial. Patients between ages 5–21 years requiring limb lengthening or deformity correction using distraction will be recruited from 6 different sites (Shriners Hospital for Children in Montreal, Honolulu, Philadelphia and Portland as well as DuPont Hospital for Children in Wilmington, Delaware and Hospital for Sick Children in Toronto, Ont). Approximately 150 subjects will be recruited over 2 years and will be randomized to either receive 10 units per Kg of BTX-A or normal saline (control group) intraoperatively following the surgery. Functional outcome effects will be assessed using pain scores, medication dosages, range of motion, flexibility, strength, mobility function and quality of life of the patient. IRB approval was obtained from all sites and adverse reactions will be monitored vigorously and reported to IRB, FDA and Health Canada.

Discussion

BTX-A injection has been widely used world wide with no major side effects reported. However, to the best of our knowledge, this is the first time BTX-A is being used under the context of limb lengthening and deformity correction.

Trial Registration

NCT00412035     

Reduced gap strains induce changes in bone regeneration during distraction.

A bilateral New Zealand white rabbit model of distraction osteogenesis (DO) was used to investigate the relationship between strain environment and bone regeneration during limb lengthening. In seven (n = 7) rabbits, a stiffener was applied to the fixator on one side to reduce strains within the gap tissue after lengthening was completed. Animals were euthanized six days later and their distraction zones were harvested and analyzed for changes in new bone volume and architecture. Nonlinear finite element analyses (FEA) were performed to predict changes in the gap strain environment. FEA results predicted a nearly uniform sevenfold decrease in average strain measures within the distraction zone. No change in total average new bone volume and significant decreases in both bone volume fraction (BV/TV) and trabecular thickness (Tb.Th) were observed in tibiae in which gap strains were reduced experimentally, compared to contralateral controls. These results suggest that fixator stiffening influenced the architecture but not the amount of newly formed bone. This animal model of distraction might be used to study the mechanisms by which strain fields affect events in bone repair and regeneration, such as cell proliferation, precursor tissue differentiation, and altered growth factor and nutrient delivery to tissues.     

Ulnar polydactyly

A retrospective review of 148 patients with ulnar polydactyly was conducted to analyze the types, patterns of involvement, associated anomalies, treatments, and outcomes of this malformation. The hands only were involved in 123 patients, both hands and feet in 20 patients, and five patients had mixed radial and ulnar polydactyly. Ulnar polydactyly was more prevalent among males. Among African Americans, the condition was often bilateral. When unilateral, ulnar polydactyly occurred more often on the left side. The racial distribution was 103 African Americans (70 percent), 37 Caucasians (25 percent), four Native Americans, three Latin Americans, and one Asian. Five types were encountered: type I cutaneous nubbin, type II pedunculated digit, type III articulating digit with fifth metacarpal, type IV fully developed digit with sixth metacarpal, and type V polysyndactyly. The distribution of types in order of frequency was type II, III, V, I, and IV. Types I and II ulnar polydactyly combined were more prevalent (82 percent) than types III, IV, and V (18 percent). Types I and II were more common among African Americans. Types III, IV, and V ulnar polydactyly occurred more frequently among Caucasians, but these were slightly less prevalent than types I and II in this racial group. Five patients were syndromic; four were Caucasians, and one Asian. Most cases of ulnar polydactyly of the hand were treated by ligation (71 percent) in the nursery, whereas polydactyly of the foot was more often referred to a specialist to be treated by surgical ablation (92 percent). Treatment complications occurred more frequently in the hands than in the feet. The complication rate after ligation of ulnar polydactyly of the hand was 23.5 percent. The two main complications were tender or unacceptable nubbins and infections.     

Limb reconstruction by free-tissue transfer combined with the Ilizarov method.

In four complex cases of extremity reconstruction, we have been able to overcome the problems of combined bone and soft-tissue loss and length discrepancy by a combination of free-tissue transfer and the Ilizarov method of slow distraction. It is our observation that gradual distraction of a free tissue is a safe and viable procedure; the free tissue tolerates the pins of the circular external fixator well, and there is an equal degree of distraction and regeneration of the transferred free tissue and the native recipient tissue without evidence of wound dehiscence. Corticotomy through free tissue and in close proximity to vascularized bone is safe, with the subsequent bone regeneration not unlike that of normal bone. Manipulation by slow distraction does not appear to compromise the vasculature of the recipient bed for later microsurgical procedures or endanger the axial flow pattern of the transferred free tissue.     

Rat mandibular distraction osteogenesis: part III. Gradual distraction versus acute lengthening

Distraction osteogenesis is a well-established method of endogenous tissue engineering. This technique has significantly augmented our armamentarium of reconstructive craniofacial procedures. Although the histologic and ultrastructural changes associated with distraction osteogenesis have been extensively described, the molecular mechanisms governing successful membranous distraction remain unknown. Using an established rat model, the molecular differences between successful (i.e., osseous union with gradual distraction) and ineffective (i.e., fibrous union with acute lengthening) membranous bone lengthening was analyzed. Herein, the first insight into the molecular mechanisms of successful membranous bone distraction is provided. In addition, these data provide the foundation for future targeted therapeutic manipulations designed to improve osseous regeneration. Vertical mandibular osteotomies were created in 52 adult male Sprague-Dawley rats, and the animals were fitted with customized distraction devices. Twenty-six animals underwent immediate acute lengthening (3 mm; a length previously shown to result in fibrous union) and 26 animals were gradually distracted (after a 3-day latency period, animals were distracted 0.25 mm twice daily for 6 days; total = 3 mm). Four mandibular regenerates were harvested from each group for RNA analysis on 5, 7, 9, 23, and 37 days postoperatively (n = 40). Two mandibular regenerates were also harvested from each group and prepared for immunohistochemistry on postoperative days 5, 7, and 37 (n = 12). In addition to the 52 experimental animals, 4 control rats underwent sham operations (skin incision only) and mandibular RNA was immediately collected. Control and experimental specimens were analyzed for collagen I, osteocalcin, tissue inhibitor of metalloproteinase-1, and vascular endothelial growth factor mRNA and protein expression. In this study, marked elevation of critical extracellular matrix molecules (osteocalcin and collagen I) during the consolidation phase of gradual distraction compared with acute lengthening is demonstrated. In addition, the expression of an inhibitor of extracellular matrix turnover, tissue inhibitor of metalloproteinase-1, remained strikingly elevated in gradually distracted animals. Finally, this study demonstrated that neither gradual distraction nor acute lengthening appreciably alters vascular endothelial growth factor expression. These results suggest that gradual distraction osteogenesis promotes successful osseous bone repair by regulating the expression of bone-specific extracellular matrix molecules. In contrast, decreased production or increased turnover of bone scaffolding proteins (i.e., collagen) or regulators of mineralization (i.e., osteocalcin) may lead to fibrous union during acute lengthening.     

Lengthening the human mandible by gradual distraction.

Lengthening of the mandible by gradual distraction was performed on four young patients (average age 78 months). The amount of mandibular bone lengthening ranged from 18 to 24 mm; one patient with Nager's syndrome underwent bilateral mandibular expansion. Following the period of expansion, the patients were maintained in external fixation for an average of 9 weeks to allow ossification. The patients were followed for a minimum of 11 months to a maximum of 20 months with clinical and dental examinations as well as photographic and radiographic documentation. The technique holds promise for early reconstruction of craniofacial skeletal defects without the need for bone grafts, blood transfusion, or intermaxillary fixation.     

Characterization of midface maxillary membranous bone formation during distraction osteogenesis

The purpose of the study was to follow the early events in bone formation and neovascularization during maxillary distraction and after the consolidation period and to define the characterization of the new bone in the distracted area. Maxillary osteotomy was performed in seven sheep. In five animals, an external distraction device was used for maxillary lengthening of 20 mm at a rate of 1 mm/day for 20 days. Another two animals served as controls without distraction. Sequential biopsies were performed. The methods used for analysis were histologic, immunohistochemical, and ultrastructural by transmission electron microscopy. During the 5 days of latency, a fibrin clot was formed that after 5 days of distraction was replaced by granulation tissue, proliferating mesenchyme-like cells, and capillaries. After 10 days of distraction, the regenerated tissue could be divided into three main zones and two transitional areas: a central zone occupied by many polygonal mesenchyme-like cells and spindle-shaped cells that proliferated intensively; two paracentral zones on both sides of the central zone in which many cells showed morphologic signs of apoptosis leading to a decreased number of fibroblast-like cells embedded in wavy collagen fibers; a transitional area from the central to the paracentral zone in which concentric cellular colonies were believed to represent a novel form of vasculogenesis; distal-proximal zones, located on both sides of the paracentral zones and in continuation with the old bone, showed delicate new woven bone trabeculae that grew continuously in the direction of lengthening and gradually became mineralized; and a transitional area from the paracentral to the distal-proximal zones in which there was recruitment of preosteoblasts from the distracted tissue to the trabecular tips. These further differentiated into osteoblasts that contributed to the trabecular growth. The histologic feature pattern was similar after 15 and 20 days of continuous distraction. At the end of lengthening, after 20 days, delicate longitudinally oriented trabeculae continued to grow by recruiting preosteogenic cells from the central distracted tissue, became mineralized, and were rimmed by osteoblasts. After 6 weeks of retention, the trabeculae thickened and consisted of a mixture of lamellar and woven bone. In conclusion, the distraction force creates a pool of undifferentiated mesenchyme-like cells with osteogenic potential and triggers capillary formation, a clear zonation can be observed during active lengthening, and new bone trabeculae begin to form between 5 and 10 days after distraction, soon become aligned with osteoblasts, and continue to grow as long as distraction force is applied. This characterization may help in any exogenous involvement with growth factors to improve bone quality.     

Vascular dominance in the forearm

The dominance of the radial or ulnar artery at the forearm level and their contributions to the circulation of the hand remain a matter of contention. Therefore, the authors proposed to investigate the predominance of one of these arteries first by anatomic studies on 40 fresh cadaver upper extremities, and then by dynamic studies. The dynamic studies included color Doppler sonography in 22 individuals (44 hands) and five-channel plethysmography in 40 individuals (40 right hands). It was found that the ulnar artery is dominant at the elbow, but after originating its collateral branches, the radial artery becomes the dominant artery in the distal forearm and, consequently, constitutes the major source of vascularization to the hand. The ulnar artery is rarely dominant at the forearm level and is physiologically less important. Therefore, there is no hemodynamic reason to prefer the radial artery to the ulnar artery for any invasive maneuvers.     

Increased plant density of winter wheat can enhance nitrogen–uptake from deep soil

Background and Aims

Increased plant density improves grain yield and nitrogen (N)–use efficiency in winter wheat (Triticum aestivum L.) by increasing the root length density (RLD) in the soil and aboveground N–uptake (AGN) at maturity. However, how the root distribution and N–uptake at different soil depths is affected by plant density is largely unknown.

Methods

A 2–year field study using the winter wheat cultivar Tainong 18 was conducted by injecting ¹⁵?N–labeled urea into soil at depths of 0.2, 0.6, and 1.0 m under four plant densities of 135 m^?2, 270 m^?2,405 m^?2, and 540 m^?2.

Results

We observed significant RLD and ¹⁵?N–uptake increases at each soil depth as the plant density increased from 135 to 405 m^?2. ¹⁵?N–uptake increased with plant density as the soil depth increased, although the corresponding RLD value fell with depth. The ¹⁵?N–uptake at each soil depth was positively related to the RLD at the same depth. The total AGN was positively related to RLD in deep soil, especially at 0.8–1.2 m.

Conclusions

Increasing the plant density from 135 m^?2 to the optimum increases AGN primarily by increasing the RLD in deep soil and therefore increasing the plant density of winter wheat can be used to efficiently recover N leached to deep soil. Moreover, the total root numbers per unit area and RLD still increased at supraoptimal density while shoot number and N uptake stagnated.     

Functional-adaptive anatomy of the forelimb in the Didelphidae, and the paleobiology of the Paleocene marsupials Mayulestes ferox and Pucadelphys andinus

An attempt to determine the locomotor activities of Mayulestes ferox (Borhyaenoidea) and Pucadelphys andinus (Didelphoidea) from the early Paleocene site of Tiupampa (Bolivia) is presented. The functional anatomy of the forelimbs of these South American marsupials is compared to that of some living didelphids: Caluromys philander, Micoureus demerarae, Marmosa murina, Didelphis marsupialis, Monodelphis brevicaudata and Metachirus nudicaudatus. Deductions from bone morphology to myology and locomotor behavior in the fossils are inferred from the comparisons with living forms. Some features of the postcranial skeleton, indicative of arboreal adaptations, are found in the extinct marsupials: anteriorly projected acromion, hemispherical head of the humerus, extended humeral lateral epicondylar ridge, medially protruding humeral entepicondyle, proximal ulnar posterior convexity, and deep flexor fossa on the medial side of the ulna. But other features are related to a more terrestrial pattern: the well-developed tubercles of the humeral head, the elongated olecranon process of the ulna, and the oval shape of the radial head. Mayulestes had clear arboreal abilities, but, as a predaceous mammal, probably hunted on the ground. Pucadelphys was less specialized, close to the living Monodelphis, a terrestrial insectivorous form with some skeletal features related to arboreal locomotion that are probably plesiomorphic for marsupials.     

Simulation of extension,radial and ulnar deviation of the wrist with a rigid body spring model

A novel computational model of the wrist that predicts carpal bone motion was developed in order to investigate the complex kinematics of the human wrist.This rigid body spring model (RBSM) of the wrist was built using surface models of the eight carpal bones, the bases of the five metacarpal bones, and the distal parts of the ulna and radius, all obtained from computed tomography (CT) scans of a cadaver upper limb. Elastic contact conditions between the rigid bodies modeled the influence of the cartilage layers, and ligamentous structures were constructed using nonlinear, tension-only spring elements. Motion of the wrist was simulated by applying forces to the tendons of the five main wrist muscles modeled.Three wrist motions were simulated: extension, ulnar deviation and radial deviation. The model was tested and tuned by comparing the simulated displacement and orientation of the carpal bones with previously obtained CT-scans of the same cadaver arm in deviated (45°ulnar and 15°radial), and extended (57°) wrist positions. Simulation results for the scaphoid, lunate, capitate, hamate and triquetrum are presented here and provide credible prediction of carpal bone movement. These are the first reported results of such a model. They indicate promise that this model will assist in future wrist kinematics investigations. However, further optimization and validation are required to define and guarantee the validity of results.     

Strain-related bone remodeling in distraction osteogenesis of the mandible

Distraction osteogenesis has become a mainstay in craniofacial surgery. However, there are several unresolved problems concerning the biology of bone regeneration. We investigated the biomechanical effects of mandibular lengthening in 32 rabbits on a cellular and histologic level. The mandible was subjected to a corticotomy, held in a neutral position for 4 days, and then lengthened at various strain rates and frequencies for 10 days. Radiographic, histologic, and electron microscopic examinations showed a strain-related bone regeneration. Application of physiologic strain rates (2000 microstrains or 0.2 percent) led to a bridging of the artificial fracture exhibiting woven ossification, whereas at 20,000 microstrains trabecular bone formation was demonstrated. In contrast, hyperphysiologic strain magnitudes (200,000 microstrains and 300,000 microstrains) showed a fibrous tissue formation. Multiple strain applications (10 cycles/day versus 1 cycle/day) increased the width of the distraction gap without changing the stage of bone regeneration. The gradual distraction of bone in physiologic magnitudes at higher frequencies seems to be desirable for a bony differentiation and may help to improve clinical applications.     

Kinematic simulation of fracture reduction and bone deformity correction under unilateral external fixation

Combined kinematic analysis and graphic models of two unilateral external fixators are presented to simulate and visualize the correction of bone fracture deformities through systematic adjustments of the fixator joints. The models were developed as rigid linkage systems, and the analysis utilized the 4x4 transformation matrices and the kinematic chain theory to obtain the necessary rotations and translations at each joint of the fixator to correct bone deformities at the fracture site. Three-dimensional malalignments with fracture gaps were simulated to correct the deformities. Due to the redundant pair variables in the fixator joints and other problems in obtaining unique solutions, an optimization technique was used to solve the governing linkage loop equations. For each adjustment solution, the bone correction paths were infinite but a unique and optimal reduction path was obtained by applying corrections to all joints simultaneously and in small increments. When the deformity exceeded a certain range, no admissible solution could be obtained, partially due to the limitation of the unilateral fixator configuration and partially due to the restricted joint rotation and translation in the fixator design. The present models and analysis technique can be used to investigate a fixator's adjustability to correct a 3-D bone deformity at a fracture or lengthening site facilitating patient care planning and medical personnel training.     

Remodeling of the temporomandibular joint following mandibular distraction osteogenesis in the transverse dimension

Transverse mandibular distraction osteogenesis involves moving the osteotomized segments of the mandible in either a varus or valgus direction. This maneuver allows for widening of the bigonial distance or for a lateral shift of an asymmetric mandibular midline. During this process, a significant amount of torque is placed on the mandibular condyles, because they act as the pivot point for the mandibular translation. Although standard linear distraction osteogenesis induces transient, reversible changes in the temporomandibular joint, it is not known what effect the varus and valgus stresses of transverse distraction have on the temporomandibular joint. We therefore designed a study to document the temporomandibular joint changes following various degrees of transverse distraction.Bilateral transverse mandibular distraction was performed on 10 adult, female mongrel dogs using an external, multiplanar mandibular distraction device. The distraction protocol was as follows: (1) complete osteotomy at the angle of the mandible, (2) 5-day latency period, (3) distraction rate of 1 mm/day, (4) rhythm of one turn per day, (5) linear activation 16 to 30 mm bilaterally, and (6) 8-week consolidation period. A variety of varus and valgus distraction vectors were applied to the mandible only after 10 mm of initial linear distraction had been achieved. Posteroanterior and lateral cephalograms were performed throughout the entire process. Pre-distraction and post-consolidation computed tomographic scans were also performed. Changes in mandibular conformation, axis of rotation, temporomandibular joint structure, and glenoid fossa changes were directly assessed by evaluating the postmortem craniofacial skeleton. The findings were compared with those of normal, age-matched mongrel dog skulls.Significant remodeling changes were observed in the temporomandibular joints of all animals involved in the study. The mandibular condyles demonstrated varying degrees of flattening and erosion at all contact points with the craniofacial skeleton. In some cases, the condyle became part of the distraction regenerate process and was hypertrophied in all dimensions. The condyles were frequently displaced out of the glenoid fossa, particularly on the side in the direction of varus distraction. When the latter occurred, a new fossa was created on the undersurface of the zygomatic arch. Varying degrees of mandibular rotation in the sagittal plane were also observed, which led to abnormal torquing of the condyles in the coronal plane, depending on whether the axis of rotation occurred primarily around the condyle or around the distraction regenerate zone.In conclusion, transverse mandibular distraction is an effective means of producing a varus or valgus shift in the gonion relative to the midsagittal plane. However, unlike linear or angular mandibular distraction, transverse distraction has a multitude of nontransient effects on the temporomandibular joint. Therefore it must be emphasized that in clinical practice, transverse distraction should be used cautiously. One must also be aware that such a maneuver in distraction can have negative effects on the temporomandibular joint.     

Three-dimensional load measurements in an external fixator

On the basis of a six-degree-of-freedom adjustable fracture reduction hexapod external fixator, a system which can be used for measuring axial and shear forces as well as torsion and bending moments in the fixator in vivo was developed. In a pilot study on 9 patients (7 fresh fractures and 2 osteotomies of the tibia), the load in the fixator during the healing process was measured after 2, 4, 8 and 12 weeks and at fixator removal. The measured values enabled both the type of fracture to be determined as well as the monitoring of the healing process. In well-reduced type A3 fractures small axial (direction of the bone axis) forces were found in the fixator. A2, B2 and C3 fractures showed distinct axial forces, which decreased during the healing process, according to an increasing load transfer over the bone. Bending moments in the fixator showed good correspondence with the clinical healing process, except in the case of a C3 fracture. A combination of bending moment and axial force proved to be particularly suitable to assess fracture healing. In transverse fractures, the well-known resorption phenomenon of bone in the fracture gap at approximately 4 weeks was detected by the system. Compared with other external fixator load measurements in vivo, the hexapod offers the advantage of being able to measure all forces and moments in the fixator separately and with a relatively simple mechanical arrangement. In our opinion, it will be possible to control fracture healing using this system, thereby minimizing radiation exposure from radiographs. Furthermore, the measurement system is a step towards the development of external fixator systems that enable automatic adjustments of the callus mechanical situation ("automatic dynamization") and inform the patients about the optimal weight bearing of their extremity ("intelligent fixator").