The  Accordion  Maneuver  And  The  Effects    OF  Compression  Loading  ON  Delayed  Regenerate  Bone  FormaAon  In  Cases  

OF  Limb  Lengthening    

Makhdom  AM,Cartaleanu  SA,  Villumure  I,    Hamdy  RC  

Disclosure

I,  [Asim  Makhdom]  declare  that  in  the  past  3  years:    I  have/  have  not  received  support  from  the  following  companies:  

 [N/A]    I  have/  have  not  done  consulFng  work  for  the  following  companies:  

 [N/A]      I  have/  have  not  done  speaking  engagements  for  the  following  companies:  

 [N/A]    I  or  my  family  hold/  do  not  hold  individual  shares  in  the  following:  

 [N/A]      

Background  

•  In  1950s  Prof.  Ilizarov  has  established  the  distracFon  osteogenesis  concept  and  the  law  of  tension  stress    

   “Gradual  tracFon  of  living    Fssues  creates  stresses  that  can  sFmulate  and  maintain  the  regeneraFon  and  acFve  growth  of  certain  Fssue  structures”  

Problem  !  

Ø  Delayed  or  absent  callus  formaFon  in  the  distracFon  gap  !    

Ø  Treatment:  ü  Bone  graV    ü  Bone  marrow  injecFon  ü  BMP-­‐7  local  injecFon  ü  bisphosphonates    

Can  we  sFmulate  bone  regeneraFon  using  the    accordion  maneuver  ?    

•  DistracFon  in  am                                DistracFon  in  early    aVernoon                                          DistracFon  in  late  aVernoon                                            DistracFon  at  night    

 •  DistracFon  in  am                                  Compression  in  pm    

ObjecFves    

Ø Primary  :  •  To  report  our  experience  with  the  accordion  maneuver  with  absent  or  delayed  callus  during  limb  lengthening  procedures    

Ø Secondary:    •  To  review  the  literature  with  regard  the  role  of  accordion  maneuver  in  DO.    

Methods    

Ø Study  design:  RetrospecFve  review:    •  Medical  records  (All  paFents  who  have  had  the  accordion  maneuver  over  the  last  5  years).  

•  radiographic  informaFon.      

Accordion:  0.25  mm  distracFon  in  AM,  followed  by  0.25  mm  compression  early  PM,  then  0.25  mm  of  distracFon  late  PM  (0.25  mm  of  lengthening/day).    

IndicaFons    

•  Absent  bone  formaFon  aVer  3-­‐4  weeks  of  distracFon.    

Results  Data     Case  1   Case  2   Case  3   Case  4  Age and gender   18y.o., female   10y.o., male   20y.o., male   18y.o., male  

Diagnosis   Blount disease   Fibular hemimelia   Tibial hemimelia   HME  

Surgical procedure  

Tibial lengthening with circular Ilizarov  

Tibial lengthening with circular Ilizarov  

Tibial lengthening with circular Ilizarov  

Tibial lengthening with circular Ilizarov  

Total lengthening duration  

14 weeks   12 weeks   11 weeks   13 weeks  

Healing index   52.8 days/cm   54.1 days/cm   122.5 days/cm   72.12 days/cm  

Outcome and complications   ü Healed    

 ü Healed    

X Not healed

ü Healed  

•  18  Y  M    •  MHE  •  Tibial  Lengthening    •  4  weeks  later  aVer  distracFon    

Four  weeks  aLer  the  rouAne    distracAon    

Five  weeks  aLer  the              accordion  

At  the  final  follow  up    Six  weeks  aLer  the  rouAne    distracAon    

What  does  the  literature  say  ?      

Authors    

Number of patients  

 Technique for accordion

maneuver  Ilizarov  1989   Used  in  some  paFents     (no details)  

 Iacobellis et al. 2010   3 > all healed   (no details)  

Hatzokos et al. 2011   8 > 6 healed   (no details).  

Kawoosa et al. 2003   1 > healed   (no details)  

El-Mowafi et al. 2005   Was  used  in  some  paFents  ?     (no details)  

El –Sayed et al. 2010   29 > 19 healed   (no details)  

Tsuchiya et al. 1997    

Was  used  in  some  paFents  ?      

(no details)  

Vidyadhara and Rao 2007   Was  used  in  some  paFents  ?      

(no details).  

Remaining  quesFons  ?        

•  When  to  use  the  accordion  maneuver  ?  

•  For  how  long  ?  •  Which  regimen  should  be  

used  ?    

LimitaFons    

•  Small  sample  size.  •  No  control  group.  •  Is  it  the  slow  distracFon  

rate  or  effect  of    compression  ?    

Conclusion    

•  Our  accordion  regimen  a  safe,  non-­‐invasive  approach  that  can  

boost  the  osteogenic  potenFal  of  a  dormant  regenerate.  

•  The  literature  review  of  clinical  studies  showed  anecdotal  

reports  with  variable  outcomes.  

•   MulF-­‐insFtuFonal  clinical  and  experimental  studies  can  

address  many  remaining    quesFons.  

MechanotransducFon  

•  Wolfs  law  {Physiological  state}  •  Dynamic  compression  >staFc  compression  

{Huang  and  Ogawa  2010}.  •  In  DO:  Ø Weight  bearing    Ø DynamizaFon  of  fixator.    Ø Slow  the  distracFon  rate.    Ø Accordion  Maneuver  !      

-­‐Mandibular  DO  rabbit  model    -­‐AVer  12  days  of  distracFon,  treated  group  was  received  3  weeks  of  accordion  followed  by  5  weeks  of  consolidaFon.  While  the  control  group  had  8  weeks  of  consolidaFon.    -­‐Significantly  higher  bone  volume  was  found  in  treated  group  when  compared  with  control.