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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
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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]
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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”
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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
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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
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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.
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Methods
Ø Study design: RetrospecFve review: • Medical records (All paFents who have had the accordion maneuver over the last 5 years).
• radiographic informaFon.
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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).
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IndicaFons
• Absent bone formaFon aVer 3-‐4 weeks of distracFon.
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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
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• 18 Y M • MHE • Tibial Lengthening • 4 weeks later aVer distracFon
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Four weeks aLer the rouAne distracAon
Five weeks aLer the accordion
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At the final follow up Six weeks aLer the rouAne distracAon
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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).
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Remaining quesFons ?
• When to use the accordion maneuver ?
• For how long ? • Which regimen should be
used ?
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LimitaFons
• Small sample size. • No control group. • Is it the slow distracFon
rate or effect of compression ?
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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.
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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 !
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-‐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.