APR 1 fli t-m

RESTORATION OF % SS -OF BONE

INC%% D ING AN ANA%% S I S OF T SES .

OF FRACT% RE TREATED B% BONE GRAFT AT % . S .

ARM % GENERA% HOSPITA% NO . 3 , CO%ON IA,N . J .

*

FRED H. A%BEE, M .D ., Sc .D .

ASSISTED B%

E%MER P. % EIGE%,M .D .

NE% %ORK

I n the task o f restoring loss o f bone substance andfunct ion in the w ide var iety o f t raumat i sms resul t ingf rom the war

,the pla st i c su rgeon i s con f ronted w i th

a correspondingly var ied array o f mechan ica l prob lems .

The recogn i t ion o f the underly ing b iolog i c and phys iolog i c s ign ificance o f t i s sue growth and metabol i sm i sa fundamenta l requ i rement in the success ful t reatmento f these cases . The surgica l repa ir o f bone , and morepart i cu lar ly the use o f the bone gra f t in cases o fpseudarth ros i s w ith or wi thout bone lo ss

,i s based

not only on the u l t imate establ i shment o f adequatefixat ion o f the bone f ragments , but al so on the atta inment o f a prope r env i ronment for the nour i shment o fthe gra f t . Th i s enta i l s the exact coaptat ion o f partso f the gra f t to respect ive parts o f the host bone ; i nother words

,the adequate and extens ive contact o f

a l l fou r correspond ing bone layers , namely , periosteum ,

cortex,endosteum and marrow .

M ECHAN I CA% STRESS AND BONE GRO% TH

Throughout his plast i c work , both i n civ i l ian pract i ceand army exper ience , the author has been great lyimpres sed wi th the st r ik ing influence exerted bymechan ica l s t res s on the growth and metabol ism o fbone . I n cases o f los s o f substance o f long durat ion ,

i n the rad ius,humerus or any long bone , the bone

cortex has o f ten become reduced to one - fi fth it s normalth ickness

,i n fact

,a lmos t to eggshel l cons i stency , la rge ly

owing t o remova l o f the s t imulus o f mechani ca l s t ress .

Such a cond i t i on i s , o f course , in di rect sequence to thegenera l phys i olog ic l aw o f bone growth ; i t i s , in fact .

R ead be fo re t h e Congress o f th e I ta l ian O r t hoped ic Assoc iat ion .Bo l ogn a

,Oc t . 1 8 1 9 1 9 .

2

umagn ifica t ion o f law.I f bone , whose nou r

i shm ent and blood supply have no t been great lyimpa i red

,shou ld su ff e r so mate r ia l ly as a re su l t o f l os s

o f the st imulus o f mechan ica l st res s , how much greate rmust be the e ff ect o f the same inh ib i to ry i nfluence s

.on

any f ree bone gra f t whose blood supp ly and nou r i shment a re not yet e stabl i shed .

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F ig . l.—R eq u i s i t e appo s i t ion o f bon e l ay er s o f gra ft w i t h res ec t i ve

pa rt s o f ho st bon e . The gra ft i s o f su ffic i en t l engt h to ext end we l l eyondt h e e bu rn ated area o f t h e ho st fragmen t s , com i ng i n to gen e rou s co n t ac tw i t h t h e h ea l t hy vasc u l a r marrow subst an c e . Th e cro s s as ect ion at [3 showst he ebu rna t ed p lug o f bon e whe re , as a ru l e i n pseuda rt h ros is, i t c l osest h e mar row cav i ty i n t h e f ract u red en d s . He re t h e gu t t e r h as bee ndee pe ned su ffic ie n t ly to rece ive th e fu l l amoun t o f mar row o f t h e gra f t ,wh ich i s d emon st ra ted ( l ower d raw i ng and c ro ss- sec t i on a t D ) i n ex tensi ve co n tac t w i t h t h e ma rrow o f the host fra men ts. The a rrows ont h e ma rrow i n t h e hos t f ragmen t s in d icat e t h e irec t ion o f b lood su pp lyto t he gra ft from i ts pr i nc i pa l norma l sou rce , name ly , th e m a rrow subs ta nc e of th e host By th e i n se r t i on of th e i n lay , w i t h i t s fu l l amoun to f marrow , a con t i nuou s mar row b ridge i s fo rmed , ex te nd in g from t h ehea l t hy ma rrow o f bo t h host fra en t s th rough t he gu t te r i n t h eeburnated e nd s . Th is ma rrow br i ge p lay s a most impo r ta n t role a scond uc to r o f b l ood vesse l s a nd osteogen i c c e l l s f rom on e hos t fragm en tto the o t he r . The c ross - sec t io ns a t D and E show a l so th e cab i ne t -make rfi t o f t h e i n l ay gra f t w i th th e ho s t fragm en t s, wh i ch no t on ly a ffo rd smechan i ca l fixat io n o f par ts , bu t a l so favo rs th e st imu lus to bon e grow thf rom fr ic t iona l i r r i ta ti o n , em phasized by Roux .

A more su i tabl e ' env i ronmen t fo r success ful bonegrowth i s establ i shed by the cab ine t - maker fi t o fthe properly inserted i nlay gra f t than by any othe rknown techn ic . At the same t ime the b iologi c lawstha t obtai n in the t ransp l an ta t ion o f a l l va r i e t i e s o ft i s sues a re fulfi l l ed , s ince correspond ing t i ssue - l aye rs

3

a re b rought i n appos i t ion,thereby furn i shi ng idea l

cond i t i ons fo r the rap i d and complete estab l i shment o fthe bl ood Supply . % nder such cond i t ions

, % olff’s

law o f bone growth i s g iven favorable opportun ity toexe r t i ts i nfluence on bone prol i ferat i on and on theadequate adj ustment o f the

’

bone arch i tecture . Moreove r, by the inlay techn i c , the ful l i nfluence o f Roux

’s

F ig. 2 (Case —% ound i n wh ich an o ffic er , h i t a t Ou rcq R ive r

by f ragm en ts o f a h igh exp lo s ive sh e l l , lo st abou t 3% i nch es o f t heuppe r th i rd o f th e h umeru s

,inc l ud i ng t he en tfi e head . I n th i s case ,

d est ruc t ion o f prac t ical ly a l l t h e muscu latu re o f t h e sho u lder renderedt he pat ie n t i ncapab le o f sho u lde r mo t ion .

l aw o f f r i ct iona l i rr i tat ion i s ideal ly prov ided for , s inceextens i ve p l ane su r faces o f the gra f t a re brought intothe c loses t p roxim i ty w i th equal ly extens ive plane sur

face s o f the host f ragments .

4

TECHN IC

In work on bone t i s sues , which ea s i ly dry onexposure to the a i r

,ope rat i ve speed is neces sa ry ;

moreover,i n t he repa i r o f bone tha t f rom l a ck o f th e

st imu lus a ff orded by mechan i ca l st res s has‘

becom e

almos t eggshel l - l i ke i n cons i stency , grea t deli cacy.

o f

techni c and operat i ve speed a re fundamenta l requ i rements i n the difli cult work o f i n se rt i ng the nece s saryin l ay . I t would be imposs ib le to execute such accu ratei n lay techn i c by the fo rmer labo r ious methods % i thmal le t and ch i sel

.or osteotome . I n work o f th i s

nature,i n wh i ch the operat ing fie ld is f requen t ly l im

F ig . 3 ( Case l) .—D iagrammat i c d raw ing ( an te r io r v iew ) t o show

t he t rus swo rk o f t i b i a l gra ft s i n os i t ion and fi xed w i t h kanga roo t endo n .

Gra ft C i s i n l a i d i n to t he sh a t o f t h e h ume ra l f ragmen t a t E, an dmo rt i sed i n to t h e ac rom ion proc ess at D . Gra f t A i s mor t i sed i n to t h egl eno id bod o f t h e scapu la a t B , and at tach ed by mean s o f kangaroot en don to (gra ft C a t the po in t w h ere the l a t t er gra f t m ee t s t h e en do f t h e h ume ra l fragme n t .

i ted , where f rag i l i ty o f bone may be a constant menaceto success , and in wh ich an accurate cabine t - maker fi to f part s i s i nd i spensable

,an el ect r i ca l ly dr iven rota ry

tw in - saw seems absol utely essent i al . I n cont radi ct ionto a recent a sse rt ion , i t i s emphat i ca l ly s tated that themotor - saw , when properly used , does not heat norglaze the bone . During var ious operat i ons i n th e pa stfew months , the author has made repeated at tempt s todete rmine whether heat w as genera ted by the motorsaw when used properly , and i f so ,

to what degree . I nevery instance i t has been found that the mos t de l i cately

5

adj usted thermometers have fa i led to regi ste r ani ncrease in temperature , even to the f ract i on o f adegree , when placed d i rect ly on the motor - saw or onthe bone immed iate ly fol low ing the w i thdrawal o f thei nst rument .

F ig . 4 ( Case l) .—The p last ic ope ra t io n i n th i s case was per fo rmed

fou r an d o n e - ha l f mon th s a ft er t he pat i en t was wounded and twomon t h s af te r t he woun d had h ea led . The roen tgenogram demon st rat e sr es to rat ion o f l o s s o f bo n e by two t ib ia l g ra ft s , e igh t weeks a ft er operat io n . Craft 1 wa s i n l a id in to the shaft o f t h e hume rus and mort i sed i n tot h e ac rom ion proc ess . Craf t 2 was mort i sed i n to t h e gl en o id body o ft h e scapu l a an d con tac ted w i t h Gra f t l at t he po i n t where t ha t gra ftm et t h e humeru s . Du r ing the u n io n o f th e gra ft s t h e arm was h e l dby a p l as te r -o f -Pa r i s shou lde r sp ica i n an e l evat ed an te r io r po s tu re andi n suc h re l at io n to th e scapu l a that t h e power fu l t ho rac ic musc l e scont rollin th i s bon e m igh t late r move i t an d i n a l a rge measu re re sto rei t s lo ss of func t io n by cau s i ng th e scapu l o t ho rac ic mot ion to be compen satory fo r l o s s o f shou ld er mot ion .

M ethods of InternalF i.rati0n.

—For the i nl ay gra f t ,accu ra te ly cut and fi tted by motor - saw techn ic , thefixat ion a ff orded by kangaroo sutures i s adequate andpre fe rab le to that o f a l l meta l agents ( such - as p lates ,

6

na i l s . screws or w i re ) . K anga roo tendon , f rom thestandpo in t o f mechanica l st rength , absorbab i l i ty andto le rance by the t i ssues

,su rpa sses allknown fixat i on

agents . I t rema ins in S i t u suffi c ien t ly l ong fo r thepurpose o f fixat ion

,and begins to be absorbed w ith i n

forty days . Mo reove r,i t i s suffi ci en t ly e la st i c to a l low

the plane su r faces o f an in lay gra f t to rub i n a m i c roscopi c amount on the cont iguous plane su r faces o f thegutte r o f the host f ragment s , thus favoring the f r ict ionali r r i ta t i on law o f Roux .

The pract ice o f i nse rt i ng meta l p la tes (as recom

mended by some su rgeons ) is absol ute ly cont raind icat ed in th i s work . The use o f meta l pla tes as theinterna l fixat ion agent not only robs the gra f t o fmechan i ca l st res s , but an i nfluence i s thereby addedthat cont r ibutes s trongly toward the st i r ring up o f ol din fect ions

,i f such rema in in the t i s sues . % he rea s

,

in t i ssues reta in ing only a s l ight amount o f an or igi nali n fect ion ,

-a bone—gra f t operat ion speed i ly done w ithmin imum trauma may bri ng sat i s facto ry re su l t s

,the

int roduct ion o f a foreign body ( such as a meta l pl ate,

na i l s or screws ) adds a second dev ita l iz ing el ement,

which , i n the batt l e o f t i s sues , may turn the scal esun favorably , with the resul t that i n fect ion aga in b reaksout .

ANA%% S I S OF CASES

A ca re fu l ana lys i s o f the fi rs t 100ca ses o f f ractu ret reated by bone gra ft at % . S . Army Gene ral Hosp i ta lNo . 3 during the per iod from July 1 5 , 1 9 1 8 ,

t o May 1 ,1 9 1 9 , has y ie lded , i t i s bel ieved ,

va luable data in regardto poss ib i l i t i es o f t reatment .

O f the 100 cases , seventy - n ine involved bonesin wh i ch inj u ry resul ted f rom h igh explos ive shel l

,

mach ine gun bul let , or shrapnel seventeen were s implefractu re s o f the long bones ; the rema in ing fou r case swere compress ion f racture s o f the spi na l vertebrae .

Allthe s imple f ractures and the Sp ine cases have beensuccess fu l ly treated , i n that they have heal ed ,

i n eachinstance , without i n fect ion , and have shown bonegrowth by roentgenograph i c examinat i on w ith in areasonable per iod a fte r t ransplantat ion o f the gra ft .In every case o f fractu re o f the long bones

,funct ion

has been restored , whi le in the.

sp ine cases there ha sbeen an inh ibi t ion o f symptoms .

7

Of the seven ty - n ine cases o f f racture by proj ect i l es ,t reated by bone gra f t

,s i xty - five , or 82 pe r cent . , were

for los s o f substance vary i ng in amount f rom one—hal fi nch t o s ix i nches

,and averaging about two inches ;

ten ca ses were for nonunion w ithout los s o f bone ; therema in ing fou r case s were for malun ion . These case sa re cl a ss ified anatom ica l ly i n Table I .

TAB%E l.—SEVENT% -NINE CA SE S OF FRACT% RE TREATED

B% BONE GRAFT , GRO%PED ACCORD ING TO

THE BONES INJ% RED

S i t e of I n%u ry

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Humeru s and u l naMe taca rpa lMa nd i b le

To ta l c ase”. h ead and upper ext rem i t i e sT i b iaFemu rPate l la

Tot a l case s , lowe r e x t rem i t i e s

To ta l n umber o f cases con s idered

SPEC IA% M ETHODS

l

Som e o f the various methods o f plas t ic repa i remployed i n th i s ser i e s o f f ractures , more than fourfi f ths o f wh i ch involved los s o f bone , are br ieflydescr ibed in the fo l l ow ing groups o f ca ses :

R es toration of %oss of Bone at Shoulder.—Ow i ng

to the exposu re o f the upper port ion o f the body int rench war fare

,shoulder inj ur ies , and part icularly

those i nvo lv ing the upper part o f the humerus , havebeen f requent in the recent war . Through the ratherextens ive pract ice o f certa in surgeons a t the f ront ,more espec ial ly o f the French , o f remov ing large port ions o f bone a t o r near the shoulder - j o int in suchinj ur ies as these , there has resu lted a notabl e groupo f cases in wh i ch shou lder funct ion i s very nearlynegl ig ible

,i f not ent i rely destroyed , on account o f the

los s o f bony framework over whi ch the shou lder musc les m ight p lay . O f a l l surgica l cond i t ions , none present s a p i cture o f greater help les sness than a dangl inga rm from which the upper port ion o f the humerus i s

miss ing .

8

The h igh f requency o f shou lde r and forea rm i n%ur iesi s st r i k ingly borne out i n Table 1 . I n th i s se r i es o fseventy - n ine cases o f f ractu re by

.

wa r pro%ect i l e s .i nj ury to bones o f the upper ext rem i t i e s , as comparedwith those o f the low e r , has occu rred i n a ra t io o fnearly 4 to 1 . O f t he tota l numbe r o f cases o f i n j u ryin the upper ext rem ity

,the humerus ha s been i nvo l ved

in fourteen i nstance s,or more than 25 pe r cent . Ca ses

o f loss o f substance i n the humerus wi th loss o f shoulde r funct ion have been cla s s ified i n two groups . wi threspect to t reatment :

F ig . 5 ( Case l) .—Ty pe o f b rac e app l ied a ft e r remova l o f t h e p l ast e r

Sp ica . Th i s b rac e i s so ad%u st ed as to a l l ow t h e a rm to de sc e nd to alower pos i t io n t han t hat ma in ta i n ed du r i n g t h e u n io n o f t h e gra ft s toscapu l a and h um eru s . Th i s n ew po s i t ion b r in gs a s l igh t amoun t o fl a t e ra l s t re ss on t h e gra ft s , t h u s st imu l at i ng t he i r hype rt rophy an ddeve lopmen t . I t i s obv iou s t hat t h i s n ew po st u re cau se s th e lowe ran g l e o f t h e scapu l a to se pa rate i t se l f f rom th e t ho rac i c cage .

Group 1 . Restorat ion o f Shou lder Mot i on andFunct ion : Th is cl as s cons i st s o f cases in which thehumerus has been des troyed , but the musculature hasbeen suffic iently prese rved to enabl e the surgeon tohope for a return o f shoulde r - j o i nt mot ion and funct i on , prov ided the bone be replaced . The author hasrestored mot ion and funct i on in such cases by t ransplant ing i nto the humera l f ragment the head and uppe r

II

F ig . 6 ( Case —D iagrammat ic d raw i ngs l' to 1 0' i l l u st rat e t h e aut ho r ' s t e chn io r upper f ragmen t i n t h i s case ) i s con ica l i n sh ape an d too sma l l i n d i ame te r top rox imal

,o r lower , fragm en t i n t h ese d raw i ngs . A wedge - S haped p iec e o f co rtex . H , i

o f t h e w edge cav i ty may , o r may n o t , be made b y mean s o f a t h i n ost eo tome , aso st eopo ro t ic

,as i s u sua l i n t h ese cases , t h e bon e may be ben t o n bo t h s ide s o f t h e c

e n l a rged by d r iv in g a'

w edge - en ded g ra ft o f l a rger d iamet e r i n to i t . a s dem on s trat

i s fi rm ly immob i l ized i n t h e d i st a l o r u pper f ragmen t by mean s o f kan garoo f end tp rox imal f ragmen t by mean s o f a st ron g c l amp at t h e same t ime that t h e gra ft i s b to b%ec t o f t h i s p roced u re be i ng two fo l d ; fi rst

,t o re sto re as far as po ss ib l e t he Ie

t h e gra ft a s a s t imu l u s to bon e g rowt h . These d raw ings were made w i t h th e d i stao f t h e a rm du r i ng o pe rat io n .

9 .

end o f the fibula to rep l ace the upper port i on o f thehume rus that has been destroyed . He has resortedto th i s operat ion many t imes in h i s c i v i l pract i ce

,as

wel l as i n m i l i tary work,and has i nvar iab ly found that

the pat i en t can funct i onate sat i s facto r i ly w ithout theupper end o f the fibu la . I n these cases, whenever posS i bl e , t he pr incipa l musc les o f the shoulder , such as thepectora l i s maj or , the supra sp inatus and the subscapu

l a r i s , are fi rmly affixed subper iostea l ly to the t ransp lanted head and neck o f the fibu la .

Group 2 . Shou lderFunct ion Res tored by Com pensa tory Scapu lothorac ic Mot ion (Figs . 2

,3,4 and

Th i s group inc ludes ca ses in wh ich,in add i t ion to loss

o f bone , the muscu latu re o f the shoulder has beendest royed o r seve re ly in j u red to such a degree tha t onecannot h0pe to secu re a retu rn o f shoulder - j o intmot ion . I n these cases , the loss o f bone i s restored byankylos i ng the humerus to the scapu la by a t russ - worko f t ib ia l gra f ts , usual ly two in number . Dur ing theuni on o f the gra f ts , the arm i s immobi l i zed i n an elevated ante r io r po s tu re , and i s he ld in such re lat ion toth e scapu la

%that th e power ful scapulothorac ic muscles

wh i ch control th i s bone may later move i t . Thus,by

caus i ng the scapu lothorac ic mot ion to compensate fo rlos s o f shoul de r mot ion o f the arm , the los t mot ion o fthe a rm and the shou l der i s res tored to a surpr i s ingdegree .

I n restor i ng los s o f bone near j o ints,th i s techn i c has

been employed : By means o f an osteotome or ch i sel,a

wedge - shaped mort i s e i s made i n the j o int f ragm entand i s extended under the capsu le

,and somet imes

complete ly th rough to the j o int ca rt i lage,w i thout dam

aging the j o int . One end o f the gra f t i s d r iven intoth i s wedge - shaped mort i se . The other end o f the gra f ti s then in la id into the long bone f ragment by the usua lin lay techn i c and i s fixed wi th kanga roo tendon

(Fig .

Res toration of %ong Bones .

—Restorat ion o f thesha f t o f the humerus

,femur, t ibi a or any long , l a rge

bone has been accompl i shed by means o f a gra f t i n la idby the author’s usua l in lay techn ic , as i l lust rated inFigure 6, i n the large r f ragment a t A,

B,C and E .

On bones o f th e forea rm , or on any bone o f sma l ld iameter

,or i n cases in wh ich a bone o f l a rge d iamete r

ha s become con ical - ended , as f requent ly occu rs , th

10

mode o f repa i r wh i ch has been re so rted to i s des igna fed . for pu rpose o f desc r ipt ion , a s the fishpole

”

techn ic (F i g . 6 H,Iand J ) , s ince a S im i l a r me thod i s

employed by the art i san i n mend ing a fishpole .

The influence o f s t res s on the liypertrOphy andmetabol i sm o f bone has been more s t r i k ingly i l l us t ratedi n bone gra f t restorat ion o f the sha ft s o f long bonesthan i n any s imi la r c la s s o f wo rk . Howeve r sma l l thed iamete r o f the gra f t

,provi ded i t be p ro tected from

f ractu re by externa l suppo rt and at the same t ime bea l lowed to % i th s tand st re ss , i t w i l l eventual ly restorethe lost bone i n a lmos t every ana tomic pa rt i cu la r ,namely , i n d i amete r , s trength and exte rna l contou r , a swel l as i n respect to the i nt erna l a rch i t ectu re .

Im i i tobilisat ion i n Extrem i ty % ork—By making

F ig . 7 ( Case —Ext rem e l ax i ty o f le ft a rm due to l o s s o f sub stan c ei n sha ft o f h um eru s as resu l t o f woun d by m ac h in e -gun bu l l e t at Cant igny . The p l a st ic o pe rat io n fo r re s to rat io n o f bo n e an d fu nc t io n i nt h i s c ase was pe r fo rm ed sev en mon t h s a ft e r i n%u ry an d two mon th s a f t e rwound had h ea l ed .

the most o f a l l known mechan ical j o i nt s and by theinse rt ion o f kanga roo tendon in such ways as to a ff ordthe bes t i nte rna l fixat ion , i n conj unct ion wi th the mos tpe r fect exte rna l fixat ion by p laste r - o f - Par i s dres s ings

,

the ext rem i ty be i ng placed in var i ous pos i t i on s o f neut ra l muscle - pu l l ,

”immob i l i zat i on o f the invol ved frag

ments has been found poss ib le . Too grea t emphas i scannot be la i d on the importance o f putt i ng absorbablel igatures in the sk i n , so tha t ca re fu l ly appl i ed pla ste ro f - Pari s dres s ings need not be d i s turbed fo r a pe r iodo f a t leas t e ight weeks a f te r implan ta t ion o f the gra f t

.

Pla i n catgut No . 0or No . 1 wi th su tu re - hol es pudd led

1 1

wi th t i nctu re o f i od in,serves admirably for th i s pur

pose . Chrom ic catgut,No . 0or No . 1

,i s a l so su i tab le .

The bur i ed sutures in the so f t part s shou ld a lways besma l l i n d iameter and as l im i ted in number as poss ib le .

The on ly adequate postoperat ive dress ing in theseca se s i s the plaster - of - Par i s spl int

,appl ied wi th the

u tmost care and mol ded to the bony contours o f theext remi ty . I t Should always include at least one j o intabove and one j o int below the bone involved

,wi th due

F ig . 8 ( Ca s e —%o ss o f abou t I%: i nche s o f sh a ft o f h ume rus .

at tent ion g iven to pos i t ion,wh ich i s o f the greates t

importance.By way o f i l lus t rat ion , in cases o f inj ury

o f the upper port i on o f the ulna , the a rm should a lwaysbe put up s tra ight

,neve r w i th the e lbow flexed . I n

cases o f inj ury at or near the lesse r trochanter o f thefemur

,the ext rem i ty should always be immob i l ized in

a p las te r sp i ca w i th the th igh abducted and flexed .

Synthetic Graft ing of Tissues in Cons truction ofNew F ingers —In two cases o f loss o f four fingers

1 2

with the ad j o i n ing metaca rpa l bones as a resu l t o f h ighexplos ive shel l and Sh rapne l w oui i ds ,

.

the hand s werecomp l ete ly helple s s

, so fa r as gra sp i ng.

and ho ld ingwere conce rned

.I n t hese ca ses , funct i on has been

restored to a grea t exten t by the syn the t i c const ruct i ono f new d igi t s . One o f these ca se s i s i l l u st ra ted i n

F igu res 1 2,1 3 and 14. By prov id ing an appo sm g sur

face for the thumb,the use fu l ne ss o f the membe r has

i n each in stance been resto red .

F ig . 9 ( Case —M et hod o f immob i l izat ion o f frac tu re s o f h ume ru s .In t h i s c ase t h e d res s i ng was a l l owed t o r ema i n o n fo r e igh t w eek s .

I n plast i c work o f th i s natu re,whi ch i nvol ve s the

t ransplantat i on o f more than one k ind o f t i s sue,a two

step or mul t ip le - step procedure i s the only methodwhereby a success fu l sequence may be expected . I t i se ssent ia l , for example , in handl i ng so f t part s and bone

(as i n the const ruct i on o f new fingers,i n p la st i c repa i r

o f the j aw , etc . ) that sk in and subcu taneous t i s sue s befi rmly uni ted w i th the hos t - t i s sue and tha t c i rculat i ontherew i th be we l l e s tabl i shed be fo re implantat ion o f

1 3

bone . Ea se o f techn i c and the poss ib i l i ty o f obta in ingampl e so f t t i s sues and bone have al so led the author torecommend st rongly th i s type o f operat ive procedure .

Repatr of the Mandible— Probab ly no branch o fsurg i ca l repa i r pre sent s greate r d ifficu lty o f mechan ica lfi t t i ng and adj ust i ng than in inj ury to the lower j aw ,

i nvolv ing extens ive loss o f bone . Owing to the irregu

F ig. 1 0 ( Case —T ib ia l bon e g ra ft fi rm l y un i ted i n po s i t ion , ten

week s a f te r p l ast i c o pe rat ion .

lari ty o f contour o f the j aw fragments , hardness o fthe bone and lack o f

‘

anv i l s tab i l i ty , such work demandsan accu racy and prec i s ion o f techn ic that can be securedonly by the use o f de l icately adj usted motor tool s , suchas the author

’s t iny c i rcula r saws , burrs , dr i l l s , endm i l l s and the l ike .

O f pr imary importance i s the cosmet i c resu l t . Inmany cases th i s depends ent i rely on the construct iono f a su i t ab le gra f t f ramework over wh ich to restore

14

the contours o f t he face . Such a f ramewo rk mus tsecu re the adequate fixat ion o f the j aw frag ment s , aswel l as restor ing ,

i n many i n s tances , l oss o f bone sub

st ance . I n his pla st i c w ork on the j aw , the su rgeonwi l l do wel l to cooperate

,so fa r as poss ibl e , with the

prosthet i c dent i st i n the appl i cat ion o f the most effi c i en tintradentalspl ints . % se o f such spl ints i s , howeve r , inmany i nstances

,imposs ibl e , ow ing to the exten

s ive los s o f teeth and o f bone . I n the la tte r ca ses ,the sole mean s o f fixat ion must be prov ided by thegra ft

,wh ich shou ld be mol ded and fi rmly in l a id in to

each f ragment,adequate i n any emergency ( such as

remova l o f the denta l spl int on account o f p re ssurenecros is

,etc . ) to supply the requ i s i te fixat ion .

I n other work,such as the res torat ion o f t he Sha f t s

o f long bones,neck o f femur , etc . , the t ib ia ha s been

found a sat i s factory source f rom wh ich to obta i n thegra f t . I n work on the j aw i nvolv ing extens ive bonelos s , however , the t ibia l d imens i ons a re not a lwayssuffi c ient to supply a gra f t o f the necessa ry curve ands ize . I n such an event , the s ide o f the i l ium , adj acentto the anteri or super ior Spine

,i s the only bone , with

the poss ib le except i on o f the oute r table o f the skul l ,wh ich is o f adequate d imens ion to al low the prope rmodel i ng o f the gra f t

,wh ich i s done by mean s o f

motor - dr iven tool s i n a manner re sembl ing the scrol lwork o f the cab ine t - make r .R elief of Com pres s ion Fractures of the Vertebrae .

—The use o f the bone gra f t a s a means fo r rel i e f o fcompress ion f ractures o f the vertebra l bod ies hasaff orded h igh ly sat i s factory resu lt s . On account o fmeager bone growth and inadequate bone repa i r a roundcrushed vertebra l bod ies

,and because o f constan t inter

ference w i th bony un ion by the re sp i ra tory and volun

ta ry motion,nature , unass i sted ,

does not br ing aboutthe proper repair in these cases ,

’

even though effici entexterna l means o f immobi l i zat ion be employed formonths , and somet imes even for years . To supply thedefic iency resu lt i ng f rom lack o f bone repa i r , the bonegra ft o ff ers a sure means o f rel i e f

,and i t s ind ica t ions i n

such cases a re a s defin i te a s in any patho logi c or t raumat ic cond i t ions encounte red . I t i s i nserted i nto thesp inous processes by prec i se ly the same techn i c as hasbeen dev i sed by the author fo r the t reatment o f Pot t’sd i sea se o f the sp ine (Fig .

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1 6

The sca r,on account o f i ts l ow - grade t i ssue and i ts

defic ient b lood supply , furn i she s a most un favo rabl eenv i ronment for the recept ion and nouri shmen t o f thegra f t . To obv ia te the pos s ib i l i ty o f subsequent in fect ion i n cases wh i ch

,f rom the i r past h i s to ry , seem

un favorabl e,and in orde r to furn i sh hea lt hy t i s sues

i n wh ich to implant the bone gra ft late r , i t has beenthe author’s p ract i ce to exc i se the sca r a t a prel im ina ryoperat ion

,lay ing bare the bone end s , and replac ing

the sca r by pla st i c flaps o f hea l thy sk i n , subcutaneoust i ssue

,muscle

,fat

,et c . I f

,a s has usua l ly been the ca se ,

F ig . 1 3 ( Case —%e ft h an d o f an Amer ican so l d i e r who l o s t comple tely t h e fou r finge r s an d ad%o in i ng metaca rpal su r face fo l l ow i ng ah igh exp l o s ive sh e l l woun d a t Chat eau -Th i e rry . O n e may n o t e t h eabsen ce o f any appo s i ng su r face wh en t h e t h umb i s fle xed , as a resu l to f wh ich no t h ing can be g rasped o r h e l d .

sat i s factory heal ing o f the wound takes p lace,the

bone gra ft operat ion fol low s a f te r a period o f f romten days to two weeks . By mean s o f such a two - s tepoperat i ve procedure , heal thy t i s sue i s prov ided fo r thesubsequent implantat ion o f bone , and a succe ss fu lsequence i s more reasonably certa in .

Source of Graft Material.—Ow i ng to its access ib i l i tyand favorable contour , the t ib i a , perhaps o f al l thebones o f the body , as a source o f gra f t mater i a l a ff ords

17

the greate s t ea se o f techn i c . Moreover,bone from the

t ib i a i s nearly a lways pre ferabl e for gra f t ing purposes,

not on ly on account o f the d imens ions and the planesur face o f th i s bone , wh ich perm i t o f a w ide choi ce inthe se lect ion o f mater ia l , but a l so because o f i t s characteri st ic s t rength and osteogeni c act iv i ty . I n thet reatment by bone gra f t o f the foregoing ser ies o f 100ca ses o f f ractu re , the t ib i a w ith few except ions furnished the gra f t mater ia l . The except ions were incases o f s l i d ing gra f ts to res tore loss o f substance inthe humerus , femur or t ib ia , and in one instance o fsynthet i c t ranspl antat ion o f t i s sues t o form a newfinge r , i n wh i ch case bone was transplanted f rom thec lav ic l e .

Avoidance of Op erative Traum a—There are t raumat i c influences wh i ch have an important bear ing onthe succes s o f a bone gra f t operat ion . I t i s necessaryto avo i d certa in fau l ts in techn i c

,such as excessi ve

TAB%E 2 .— S% MMAR% OF T IME RE%% IRED IN BONE CRAFT

OPERAT IONS , ACCORD ING TO S ITE OF INJ% R%

f—T ime o f Operat ion—fl

Ave rage Sho r t es t1 hou r 45 m i nu tes47 m i nu te s 25 m i nu te s3 3 m i nu tes 1 9 m i nu te s5 5 m i nu tes 2 1 m i nu tes23 m inu tes 1 4 m i nu tes

l ength o f operat ing t ime , w i th the resul tant dry ing o fthe gra ft or hos t t i ssues f rom contact w i th the a i r ,rough use o f the retractors , poo r mechani ca l fi t o fgra f t

,absence o f coaptat ion o f s im i la r bone layers , or

d i rect t rauma f rom wedging or crush ing by the ch i se land mal let .Table 2 perm i ts a compar i son o f the average operat

ing t ime w i th the shortes t i n certa in cases , and has beeni nse rt ed because i t i s be l ieved that i n no othe r c lasso f surgery does length o f operat ing t ime so mater ia l lyi nfluence resul ts . In th i s work

,in wh ich we are dea l

i ng with r igi d t i s sues , every eff ort mus t be made tomai nta in to the ful les t poss ible extent the v iab i l i ty o fthe transp lanted bone , a cond i t ion la rgely dependenton the ea rly un ion o f gra ft t i s sue with hos t t issue andon the adequate es tabl i shment o f nour i shment . Dry ingo f the t i s sues f rom contact w ith the a i r shou ld be con

1 8

F ig . 1 3 ( Case —To resto re l o s t func t ion o f hand , t h e sy n t h et i ct ran sp l an tat io n o f so ft t i ssue s and bone was un de rt ake n i n a two - s te poperat i v e proc ed u re . Sk i n an d so f t pa rt s w ere fi rs t t u rn ed u p from t h ec he st wa l l t o fo rm a bone l e s s fi nge r . Th rough a ped ic l e le f t a t tac h edto t h e c h est wal l , supp ly o f b l ood was fu rn i sh ed un t i l c i rc u l at ion w i t ht h e han d was t ho rough ly estab l i sh ed . Th e han d an d a rm w e re ' im m o

b ilized i n pl ast er fo r fou r week s . I n t h e second op erat i v e st ep,t h e

bon e l e s s finger was fi rst c u t l oo se from th e ch e st wa l l . A t i b i a l g ra f t,

in s ert ed t h rough t h e so f t part s , was t h en mo r t i sed fi rm l y i n to t h e o smagnum . A s l i ve r gra f t , i n d icated by t h e a r row ,

was affi xed a l o n gs id efo r i nc rea sed o st eogen es i s . The roen tgenogram was t ak en fou r week sa ft e r t h e impl an tat ion o f t h e gra f t s , wh i ch now hav e b ecom e fi rm l yun i t ed to t h e bon e s o f t h e h an d .

1 9

stantlyguarded aga ins t , not on ly by the use o f sal ineso l ut i on , but by complet i ng the ope rat ion i n the shortestposs ib le t ime cons i sten t w i th good work and wi th m inimum t rauma .

F inalResults in Forty- E ight Cas es .— Too short a

t ime has el apsed to pass j udgment,at the present ‘date

,

on the en t i re ser ies o f 100 ca ses o f f ractu re. How

eve r, in forty - e igh t case s that were treated be foreMarch 1 , 1 9 1 9 , and have, there fore , afforded opportunity fo r obse rvat ion over a per iod o f at least tenmonths , we fee l j ust ified in report ing defin i te concluS i ons .

O f these forty - e ight cases,the resul ts in s ix are

quest ionable ; the gra f ts are s t i l l i n S i tu and the roent

gen ray revea l s bone growth,but the wounds were pr i

mari ly in fected and there yet rema in one or mores inuses . Three o f these ques t ionable cases

,however

,

show favorab le ind icat ions o f ul t imate good resul ts ;the other th ree cases w i l l p robably be fa i lu res .

Fou r o f the forty—e igh t cases are defin i te fa i lures . O f

these , one case , a s l id ing in lay f rom a t ib ia to a femurto stab i l i ze a resected knee

,was compl icated by pneu

mon ia five weeks a fte r the operat ion ; s inuses broke outon both s ides o f the knee

,w i th a resu l t ing in fect ion o f

the ent i re sca r t i s sue o f the knee and a fa i l u re o f parto f the gra f t to % take .

”O f two rad ius case s that were

fa i lu res , one Showed a pos i t ive % assermann a fter,

but not be fore,the operat ion ; and the pat ient h imsel f

removed the fixat ion dress ing on th ree d i ff erent occas ions . The other rad ius case showed a bad in fect iono f dense sca r t i s sue . The fourth , and last case o ffa i lu re

, w as a humerus case w i th loss o f th ree incheso f subs tance

,and w ith much scar t i ssue . The wound

broke down,and exam inat ion by roentgen ray revealed

that the lower end o f the gra ft was not attached to thed i sta l end o f the humerus .

Subtract ing th i s group o f t en cases , o f wh ich fourare defin i te fa i lu res and s ix quest ionable cases , we haveth i rty—e ight cases rema in ing, al l o f wh ich have shownper fect resu l t s i n respect to postoperat i ve pr imaryhea l ing o f the wound , prol i ferat i on o f new bone asdemonstrated by the roentgen ray , and restorat ion o ffunct ion

.Th i s y iel ds a rate o f 79 per cent . per fect

resu l ts,with a poss ib i l i ty o f an u lt imate 85 per cent . ,

shou ld th ree o f the quest ionable cases prove success ful .

20

A complet e report o f a l l the pla st i c ope rat ion s pe rformed at % . S . Army Genera l Hos ; ) i talNo . 3 % i l l hepubl i shed as soon as suffic ient t ime has e l apsed to pe rmit o f t rustworthy deduct ions .

S% M MAR%

The fol low i ng conc lu s ion s a re based not only on as tudy o f cases and resu lt s a t % . S . Army Genera l Hos

p i ta l No . 3 ,at Colon ia , N . J. ,

but a l so on the author’

sprev ious expe r ience w i t h ove r cases t rea ted bybone gra f t in ci v i l ian pract ice , a s we l l a s i n extens i ve

F ig . 1 4 ( Case —New finge r s i x week s af t e r l as t o pe rat io n . Thepat i e nt i s n ow ab l e to grasp an d ho ld ob%ec t s w i t h h i s t h umb an dgra ft ed finger .

animal exper imentat ion . I t is be l i eved tha t the ca re fulobservance o f these po ints i s es sent i a l to succe ss i n th i scl ass o f work .

1 . Early Observation of % ound .—A ca re fu l s tudy

o f the wound should be made be fore i t has healed , i fposs ible . The type o f in fect ing organi sm (S treptococcus hem olyticus , gas bac i l lus , the nature o f thec lean - up Operat ion and the manne r o f hea l ing o f thewound should be noted .

2. Tim e to Operate —In a few cases i t i s pe rm i s s ibl eto operate a f te r the % ound has been complete ly heal edfor a per iod o f two months , wh i l e i n others , on accoun t

21

o f poss ib le latent i n fect ion , i t may be adv i sab le to delaythe fina l pla s t i c work for at least s i x mon th s . I nsome o f the un favorabl e l at ter cases

,a two - step opera

t i ve method may be fol lowed,cons i st ing o f a prel im

inary exc i s ion o f sca r t i s sue wi th replacement by a

1 5 ( Case —Case o f co mpress ion fract u re o f t h i rd . fou rt han d fi ft h l umbar ve r t eb rae cau sed by fall i n dugout . Pane l o f ve r teb rae ( from c l ay mod e l o f case ) , show i ng re l i e f o f cond i t ion by a t ib i a lg ra f t i n l a id i n to sp i nou s processes from fi r s t l umbar to fi r s t sac ra lv ert eb ra e .

heal thy sk in flap,muscle

,fa t , etc . , fol lowed a f te r a

per iod o f f rom ten days to two weeks by the final boneplast i c operat i on .

3 . Im m ed iate Preoperative Obs ervat ions — For thepurpose o f determ in ing the exi stence o f latent infec

22

t i on,spl i nt s should be removed . and deep ma ssage and

rough man ipu lat i on shou ld be pract i ced fo r a peri od'

o f

f rom one to two w eeks prio r to t he operat ion . Du r i ngth i s t ime the tempera tu re should be obse rved . and t hepa rts should be ca re ful ly exam ined for loca l tende rness or any ev i dence o f a rec rudescence o f in fect ion .

The field o f operat i on shou ld have a forty—e igh t hou rpreparat i on

,iod i n techn i c be i ng pre fe rred .

4. Plan of Operation and Cho ice of 1 ncis ion.

—Bymeans o f roentgenograph ic and phys ica l exam inat ions ,the proposed plan o f opera t ion , espec ia l ly in re spect tolocat ion o f gra ft

,shou ld be dete rmined be fo re i nci s i on

is made . I f poss ible . the sk i n i nc i s ion shoul d not l ied i rect ly over the proposed bed o f the gra f t , and theopera t ion shou ld be so planned that the gra f t may becovered w i thout undue tens ion o f sk i n and , i f poss ibl e ,so placed that i t comes i n contact w it h heal thy t i s suei ns tead o f sca r t i s sue . I n severa l ca ses i n wh i ch th i shas been accompl i shed ,

t he gra f t has hea led i n by pr imary un ion

,whereas the s ca r , even a t a cons ide rabl e

d istance f rom the gra ft,has broken down comp l e te ly .

In case s o f extens ive l oss o f bone , the sca r t i ssue maybe pushed to one s ide , i n orde r tha t the gra f t may l iein heal thy t i s sue . Dra inage wicks o f any kind shoul dnever be inserted a t the t ime of Ope rat i on .

5 . Duration of Operation—It i s be l i eved that theshortes t poss ibl e operat ing t ime cons i s ten t w i th goodwork and w i th a m in imum amoun t o f t rauma i s requ is i te to succe ss fu l resul t s i n these cases .6. %se of Motor- Driven Ins trum ents — These a re

es sent ia l : (a) on account o f the necess i ty fo r rap idwork in orde r that d ry ing and t raumat i za t ion o f thegra ft t i ssues and host t i ssues m ay be avo ided ; ( b ) i norder tha t a cab ine t - maker fi t may provi de fo r mechanica l fixat ion o f pa rts and for the operat ion o f Roux’slaw o f f ri ct iona l s t imulus to bone growth w i th a v i ewto an early and adequate es tab l i shment o f nour i shmen tto the gra ft ; and ( c ) on accoun t o f the nece ss i ty forthe fu lfi lment o f the l aw o f anoc ias soc iat i on

.The

motor outfi t w ith i ts va rious tool s to produce au tomat i cfi t s seems indi spensable . The motor - Saw

,when used by

the prope r techn ic , does not hea t no r gla ze the bone .

7. Adequate %ength of Graft—The gra f t shoul da lways , when poss ib le , be o f the in l ay type , and suffi

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Feb . 28,1 920

, Vol. 74, pp. 5 89 -5 97

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