LETTER
Clavicle Lengthening by Distraction Osteogenesis for Congenital Clavicular Hypoplasia: Is it a Real Indication? To the Editor: We read the article “Clavicle lengthening by distraction osteogenesis for congenital clavicular hypoplasia: case series and description of technique” by Sewell et al1 with great interest. We would like to thank the authors for this study. Bone-lengthening surgery using distraction osteogenesis is now a classic technique for orthopedic applications. Application of the lengthening technique according to the classic rules will increase success of the results. As per the classic distraction osteogenesis technique described by Ilizarov,2–4 after low-energy osteotomy there should be 5 to 7 days of latent stage, followed by distraction stage. Distraction stage
TO THE
EDITOR
consists of 4 phases a day, with 1 mm/ day lengthening. In this study, 4 clavicles lengthened 1 mm/day and 3 clavicles lengthened 0.75 mm/day. However, there is no information about which patients and for what reason 0.75 mm/ day lengthening is selected. Consolidation stage should be 2 times longer than distraction stage. For a patient with clavicular lengthening of 41 mm, time for removal of the external fixator should be as follows: latent stage (5 to 7 d)+distraction stage (41 d for 41 mm mean)+consolidation stage (41 mm to 82 d mean), for a total of 130 to 150 days. However, in this study the external fixator removal time was 263th day for this patient. In other patients too the external fixator removal times are longer than it must be. Long period for external fixator removal increases the risk for pin-site infection. Authors should question about the indications for external fixator usage for congenital hypoplasia of the clavicle due to such a long period of time for acquisition of union. We feel that the third and fifth patient did not
get the required benefit with the usage of this technique. For these patients, the authors should have used nonvascularized grafts with internal fixation. Bulent Karslioglu, MD Yusuf E. Eyi, MD Yusuf Erdem, MD Hakkari Military Hospital Hakkari, Turkey
REFERENCES 1. Sewell MD, Higgs DS, Lambert SM. Clavicle lengthening by distraction osteogenesis for congenital clavicular hypoplasia: case series and description of technique. J Pediatr Orthop. 2013;33:314–320. 2. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and softtissue preservation. Clin Orthop Relat Res. 1989;238:249–281. 3. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;239: 263–285. 4. Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res. 1990;250:8–26.
The authors declare no conflicts of interest.
e36 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 35, Number 4, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Clavicle Lengthening by Distraction Osteogenesis for Congenital Clavicular Hypoplasia: Is it a Real Indication? To the Editor: We read the article “Clavicle lengthening by distraction osteogenesis for congenital clavicular hypoplasia: case series and description of technique” by Sewell et al1 with great interest. We would like to thank the authors for this study. Bone-lengthening surgery using distraction osteogenesis is now a classic technique for orthopedic applications. Application of the lengthening technique according to the classic rules will increase success of the results. As per the classic distraction osteogenesis technique described by Ilizarov,2–4 after low-energy osteotomy there should be 5 to 7 days of latent stage, followed by distraction stage. Distraction stage
TO THE
EDITOR
consists of 4 phases a day, with 1 mm/ day lengthening. In this study, 4 clavicles lengthened 1 mm/day and 3 clavicles lengthened 0.75 mm/day. However, there is no information about which patients and for what reason 0.75 mm/ day lengthening is selected. Consolidation stage should be 2 times longer than distraction stage. For a patient with clavicular lengthening of 41 mm, time for removal of the external fixator should be as follows: latent stage (5 to 7 d)+distraction stage (41 d for 41 mm mean)+consolidation stage (41 mm to 82 d mean), for a total of 130 to 150 days. However, in this study the external fixator removal time was 263th day for this patient. In other patients too the external fixator removal times are longer than it must be. Long period for external fixator removal increases the risk for pin-site infection. Authors should question about the indications for external fixator usage for congenital hypoplasia of the clavicle due to such a long period of time for acquisition of union. We feel that the third and fifth patient did not
get the required benefit with the usage of this technique. For these patients, the authors should have used nonvascularized grafts with internal fixation. Bulent Karslioglu, MD Yusuf E. Eyi, MD Yusuf Erdem, MD Hakkari Military Hospital Hakkari, Turkey
REFERENCES 1. Sewell MD, Higgs DS, Lambert SM. Clavicle lengthening by distraction osteogenesis for congenital clavicular hypoplasia: case series and description of technique. J Pediatr Orthop. 2013;33:314–320. 2. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and softtissue preservation. Clin Orthop Relat Res. 1989;238:249–281. 3. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;239: 263–285. 4. Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res. 1990;250:8–26.
The authors declare no conflicts of interest.
e36 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 35, Number 4, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
