Ultrasound evaluation of the tibial graft structure during fixation with the Ilizarov device in patients with achondroplasia

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Abstract

BACKGROUND: Bone regeneration during fixation needs to be evaluated due to clinical measures taken to prevent possible complications, such as evaluation of the correct segment axis, verification of the equality of the extended and contralateral segments (with repeated lengthening), maintenance of fixation rigidity, functional control of the load on the operated limb, and the patient’s motor activity. All of these factors have a direct impact on the structure and maturation of the distraction graft and readiness for device removal. It is relevant to study the proximal graft in bilocal treatment based on the greatest elongation (5.5 [5.0; 6.0] cm) compared to the distal graft. Proximal graft maturation affects the timing of device removal.

AIM: The aim was to evaluate the structure of the tibial distraction graft in achondroplasia patients of different ages during the fixation period.

MATERIALS AND METHODS: AVISUS Hitachi (Japan) was used for ultrasound scanning with a 7.5 MHz linear sensor. The graft was evaluated using standard programs. The study included achondroplasia patients aged 6–9 years (group I, n = 15) and 10–15 years (group II, n = 15). The study was conducted at 5, 30, 60, and 90 days (with repeated limb lengthening) from the start of the fixation period. In group I of monolocal tibial lengthening, the elongation was 6.5 [6; 7] cm. For bilocal leg lengthening in groups I and II, the proximal graft elongation was 5.5 [5.0; 6.0] cm, and the distal graft elongation was 2.5 [2.0; 3.0] cm.

RESULT: In groups I and II, a favorable course of osteogenesis was observed, with typical stages of graft formation. Group II showed slower development of typical structures, resulting in longer fixation times. Therefore, the fixation time was 55 ± 5 days (p ≤ 0.05) in group I and 63 ± 3 days (p ≤ 0.05) in group II (in case of favorable progression). The exception was 1 patient (out of 10 patients with repeated leg lengthening), who developed a hypoechoic cyst-like lesion in the graft midzone during distraction. The time to cortical plate formation increased to 85 ± 5 days (p ≤ 0.05).

CONCLUSIONS: Ultrasound evaluation of tibial distraction regeneration during fixation showed that the activity of reparative osteogenesis during this period corresponds to the activity of reparative osteogenesis during distraction. Although it is not possible to fully visualize elongation achieved during fixation due to the formation of echo-dense fragments at the ends of the parent bone, ultrasound scanning allows evaluation of changes in graft filling, vascularization, and graft readiness for removal of the external fixation device.

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About the authors

Tatyana I. Menschikova

Ilizarov National Medical Research Centre for Traumatology and Orthopedics

Author for correspondence.
Email: tat-mench@mail.ru
ORCID iD: 0000-0002-5244-7539
SPIN-code: 2820-9120

PhD, Dr. Sci. (Biology)

Russian Federation, Kurgan

Anna M. Aranovich

Ilizarov National Medical Research Centre for Traumatology and Orthopedics

Email: aranovich_anna@mail.ru
ORCID iD: 0000-0002-7806-7083
SPIN-code: 7277-6339

MD, PhD, Dr. Sci. (Medicine), Professor

Russian Federation, Kurgan

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2. Fig. 3. Sonograms of the proximal tibial regenerate after 30 days of fixation in colour Doppler mapping and 3D reconstruction mode. The vessels in the zone of active osteogenesis are visualised (asterisks show the cluster of bone trabeculae with an acoustic density of 168 units)

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3. Fig. 4. Sonogram of the tibial regenerate of patient with achondroplasia K., 16 years old. Repeated tibia lengthening was performed - 5.5 cm. Structural state of the regenerate after 60 days of fixation. The length of the echopositive area of the regenerate - 33 mm, ultrasound penetration depth - 34 mm; acoustic density of the structure in the zone of active osteogenesis - 198.6 specific units (asterisks), hypoechogenic zone of the regenerate - 19 specific units (1), connective tissue layer (2) - 125.6 specific units

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4. Fig. 1. Sonograms of the proximal tibial regenerate at various fixation periods in patient B., 7 years old (group I). Achondroplasia, short stature; stage I of treatment; tibial elongation of 8.5 cm. a, Fixation period, 2 days (echogenic fragments in different zones of the regenerate are marked with asterisks). b, Fixation period, 31 days (asterisks indicate echogenic fragments with actively ongoing osteogenesis, showing an acoustic density (AD) of 200 ± 22.0 arbitrary units. The connective tissue areas between these fragments had an AD of 122 ± 21.0 arbitrary units; regenerate length, 17 mm; ultrasound penetration depth, 10 mm). c, Fixation period, 60 days (asterisks mark the formed cortical plate contour with an AD of 191 ± 12 arbitrary units)

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5. Fig. 2. Sonograms of the proximal regenerate of the tibia in patient I., aged 14 years (group II, stage I treatment). Achondroplasia, short stature. a, Fixation period, 5 days; elongation, 7 cm; echopositive regenerate length, 38.6 mm; ultrasound penetration depth, 30.7 mm; acoustic density of the structure in the active osteogenesis zone, 186 ± 11.0 arbitrary units (echo-dense fragments marked with asterisks). b, Fixation period, 30 days; echopositive regenerate length, 30.6 mm; ultrasound penetration depth, 18.9 mm; acoustic density of the structure in the active osteogenesis zone, 189 ± 11 arbitrary units. c, Fixation period, 65 days; echopositive regenerate length, 24.2 mm; ultrasound penetration depth, 11.8 mm; acoustic density of the structure in the active osteogenesis zone, 198 ± 6 arbitrary units

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