Appropriate osteotomy site and number in limb lengthening

The effects of the placement of osteotomy site on osteogenesis during monofocal and bifocal lengthening were investigated in 47 immature rabbits allocated to 4 groups according to osteotomy site: (1) monofocal in the proximal diaphysis; (2) monofocal in the distal diaphysis; (3) bifocal in the proximal and distal diaphysis; and (4) bifocal in the proximal diaphysis. The right tibia was distracted at an overall rate of 1.0 mm per day for 15 days. These groups were compared by assessment of soft radiograph findings and torsional strength 2 and 6 weeks after the end of distraction. Microangiography was done in 5 rabbits in the bifocal proximal and distal group. The proximal distracted site showed favorable bone regeneration compared with the distal site, and torsional strength was significantly greater in the proximal than in the distal osteotomy group. Less bone formation and lower torsional strength were observed in the bifocal proximal diaphysis group, with short intermediate segment, than that in the other bifocal group, with long intermediate segment. The nutrient artery in the latter group was preserved in the intermediate segment and reanastomosed to the metaphyseal arteries. These results suggest that the proximal diaphysis is more suitable for the osteotomy site than is the distal diaphysis. In a 2-level osteotomy, the inflow site of the nutrient artery should be included within the intermediate segment.