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1. The history of autogenous bone grafting
S-A2
1. The history of autogenous bone grafting
P.-J. Meeder, M.D.1 and Ch. Eggers, M.D.2 1 Head of the Dept. of Trauma and Reconstructive 2 Head of the Dept. of Trauma Reconstructive
Surgery, University
Clinic Heidelberg,
D-69120 Heidelberg
and Hand Surgery, St. George’s Hospital, D-20099 Hamburg
Spontaneous filling of bone cavities and spontaneous bridging of large defects of the long tubular bones in humans is not to be expected, irrespective of whether these defects are due to trauma, severe bone loss, extensive posttraumatic pseudarthrosis, insufficient growth in lengthening operations or excision of benign or malignant turnours. In all such cases, transplantation nf autogenous bone is today the elective procedure and is usually carried out in combination with stable internal fixation. Successful bridging of the defect is dependent on amount of several factors, namely, an adequate osteoinductive material, biomechanical stability of the graft bed, adequate vascularization of the osseous bed -and functional loading of the graft at the right time as a stimulus for restoration of form and function of the injured bone or bones. In 1863, Wolff defined nsteoplasty as an operation in which “Bone or bone stimulating tissue is implanted in the body in order to effect the permanent existence of bone at that site.” Basing his opinion on animal experiments, he expressed the hope that it would be possible to treat both congenital and acquired defects using autogenous bone grafting in the future, In 18X9, Seydel closed a 20 cm defect in the skull by repeated grafting of autogenous per&teal bone flaps from the tibia. In 1893, .Schmitt reported an operation by Bergrnann in which the latter succeeded in bridging a 12 cm tibia1 defect, resulting from resection of a sarcoma, by insertion of an autogenous fibular graft. Since Payr’s first publication in 1908 “On osteoplastic substitution in cases of resection of the jaw (maxillomandibular defects) using parts of the rib by
means of pedicled chest flaps or free grafts”, autografting of the rib has become a well-known and frequent operation in maxillofacial surgery to bridge defects of the mandible (Lexer, 1924; Longacre and de Stefano, 1957; Schmelzle and Schwenzer, 1977). In 1910, Dobrotworski closed a cranial defect for the first time using a rib which had been split longitudinally. He wrote “The rib offers extraordinary advantages and convenience as a covering for cranial fractures”. Having described his first four successful closures of cranial defects, Dobrotworski closed his publication in 1911 with the remark: “The rib could be used as a bone substitute in many cases of defect of the limbs”. This was the beginning of autogenous bone grafting as an internationally recognized, regular procedure in surgery and orthnpaedic& In 1919, -Albee was able to report on 1600 successful cases of bone grafting. The possible applications of autogenous honk graft were systematically researched by. Lexer (1867-iY39) and Phemister (1882-1951). They demonstrated the universal clinical application of the compact tibia1 graft complete with periosteum which has been named after them. Lexer recognized the important role played by stability in acceptance and healing of his cortico-cancellous bone grafts which he introduced according to the principles of carpentry and inlaid or nailed. He coined the phrases highly, partially and non-osteogenic with reference to the host site. In 1980, Eitel -et al. classified these three types of host bed in terms of the existing damage as fc~llows: - highly osteogenic refers to a site with or without compensated deficiency
Mm-h: Hisfory
ofautogenous
bow grafting
- partially osteogenic refers to a compromised vascularity and associated
S-A3 site with instability
- non-osteogenic refers to a site at which active infection and associated instability.
there is
In 1932 and 1936, Matti described autografting of pure cancellous bone in the treatment of pseudbut this procedure did not become arthrosis, established despite very positive results. The use of autogenous cancellous bone, in particular at partially osteogenic sites, only became possible with the advent of modern methods of internal and external fixation. This permits stable fixation and total immobilization of pseudarthroses and skeletal defects. Nowadays, autogenous cancellous bone is the substance of choice for bridging and filling defects, particularly in cases of infected fractures and pseudarthroses (Burri, 1974). In the last two decades, bone grafting procedures have taken on a new dimension d.ue to the additional possibilities offered by microsurgery. Microsurgery made it possible to test and to apply free combined tissue grafts. In lY7S, Taylor transplanted a free musculoskeletal flap from the contralateral fibula using primary anastomosis and attached it to the anterior tibia1 artery and vein. Further osteocutaneous, myocutaneous and vascularized flaps are: groin flaps with iliac crest, intercostal flaps and Latissimus dorsi flaps with rib (Anderl et al., 19X2). The incorporation of the graft, i.e. attachment and deposition, was described as “causal osteogenesis” by Schweiberer (1970). Well into the fifties, there was heated debate on the subject of osteogenesis: osteoblast and induction theories seemed completely incompatible. The osteoblast theory was propagated by Ollier (1X67) whereas Barth postulated the theory of induction. The osteoblast theory stated that the transplanted bone cells actively contributed to the regeneration of bone. The induction theory assumed that the graft did not survive but stimulated the pluripotent mesenchymal cells of the host tissue to differentiate into osteogenic cells which caused “creeping substitution” of the graft (Barth, 1X93,1894, 1x95). On the basis of hi&~logical investigations carried out on biopsy specimens and grafting in experimental studies, Axhausen confirmed in 1909 that in fresh, autngenous bone graft covered by periosteum there was necrosis of the bone ends as established by Barth, but that the periosteum survived to a large extent and actively influenced osteogenesis, as Ollier had assumed. Axhausen (1952, 1954, lY62) succeeded in finding a synoptic explanation of these phenomena and resolved the dualism of the osteoblast and induction theories by developing the theory of biphasic regeneration. The first phase of osteogenesis is autochthonous, the second phase inductive (Spiessl, 1976). These two
phases merge provided that conditions for successful grafting exist, i.e. graft and host bed are adequately vascularized, there is mechanical stability and there is close contact between the graft and the host tissue. Autogenous graft has all the characteristics of living bone: cells, collagen fibrils, proteoglycans and apatite crystals. The cells on the surface of the graft are initially nourished by diffusion and later by revascularization. After only a few days, at the latest after 3-4 days (Schweiberer, 197(I), the osteoblastic cells proliferate and form woven bone. This effects a transitional attachment of the graft to the host bed during the initial osteoblastic phase by osteoid formation (Schweiberer et al., 19X2). The vitality and effectiveness of the transplanted cells on the surface of the graft were demonstrated by radioisotope tests (Ray et al., 1963). The central arras of the graft do not react since they are dead. The bone matrix is resorbed by osteoclasts. The complex of mucopolysaccharides of the extracellular matrix leads to the differentiation into osteoblasts of the invading mesenchymal cells with proliferating vessels. The osteoinductive potential of the matrix and its break-down products has been determined by tests in the Millipore diffusion chamber (Ecke, 1967) and in subtraction tests (Schweiberer, 1970). Revascularization and osteoinductivity also depend on the quality and quantity of graft. Clark and Clark (1939) and Stringa (lYS7) showed that the proliferation rate of the capillaries in a cancellous bone block is between 0.22 and 0.43 mm/diem depending on the experimental design. This means that it is 10x as fast as for compact cortical graft (Maatz et al., 1953) and the bone regeneration rate is 3x greater in cancellous grafts (Frost, 1963). The greater osteogenic potential of cancellous bone can be explained by its loose, spongy which is better suited to structure vascularization. However, Wolter et al. (1975) observed greater osteninductive potential in compressed cancellous bone in an experiment investigating drill hole defects. This could not be confirmed .by Eggers (1984) who found that compaction of cancellous bone by powerful compression did not lead to a significant improvement in bone regeneration and that the statements made by W&r et al. (1975) must be interpreted as a product of their particular experimental design. Today, the macroscopical surface area, volume and mass of the graft can be regarded as the parameters contributing significantly to osteogenic capacity (Rudzki et al., 1976).
S-A4
References
Lexer, E. (lY24) Die freien Transplantationen Dfsch. Chir., 26b, Enke, Stuttgart.
Albee F.H. (1YlY) Orthopedic and Kecvnstructiun Industrial and Civilian, Saunders, Philadelphia.
Surgery,
Anderl H., Hussl H., Papp C. et al. (1982) Aktuelle rekonstruktive Verfahren zur Defektdeckung an den ExtremitRten, Clrirurg, 53, 235-240. Axhausen G. (190) Zur Frage der Zrrltmlhl. Chir., 36, Suppl. 133-134.
freien
Ostevplastik,
Axhausen C. (1YOY) Die histologischen und klinischen Gesetze der freien Osteoplastik auf Grund van Tierversuchen, Arch. Min. Clrir., 88, 23-145. Axhausen G. (190) Uber den Vorgang partieller Sequestrierung tranhplantierten Knochengewebes, nebst neuen histologischen Untersuchung& iiber Knochentransplantation am Menschen, Arch. Klill. Chir., 89, 281-302. Axhausen W. (1952) Die Kliochenregeneration - ein zweiphasisches Geschehen, Zmfydbt. Chir., 77, 435-442. Axhausen W. (1954) Der biologische Wert heteroplastischer Knochentransplantate, Lnngtwlw~k’s Arch. Chir., 279, 48-52.
Teil II, New
Lungacre, J.J. and de Stefanh, G.A. (1957) I&construction of extensive defects of the skull with split-rib grafts, Plast. Reconstr. Surg., 19,186-200. Longacre, J.J. and Stefan6, G.A. de (1957) Further observations of the behavior of autogenous split-rib-grafts in the reconstruction of extensive defects of the craitium and face, Plast. Rrconstr. Surg., 20, 281-296. Maatz, K., Lentz, W. and Graf, R. (1953) Experimentelle Grundlagen der Transplantation konservierter Knochen, Larrgr~~Imk’s Archio Klirr. Chir., 273, 850-855. Matti, H. (1932) Ueber die Behandlung von Pseudarthrosen mit Spongiosatransplantation, Arch. Orthoy. Unfall-Chir., 31,21 X-231. Matti, H. (1936) Technik und Kesultate meiner Pseudarthrosenoperation, Zentyalhl. Chir., 63,1442-1453. Oilier, L. (1867) Trait6 expbrimental rtg&tration des 05 et de la production osseux, Masson, Paris.
et clinique de la artificielle du tissue
Axhausen W. (lY(72) Die Bedeutung der Individualund Artspezifitnt der Gewebe fiir die freie Knocheniiberpflanzung, Ht@ Unfallhtdkd., 72, l-l 17.
Payr, E. (1908) Ueber osteoplastischen Kieferresektion (Kieferdefekten) durch mittels gestielter Brustwandlappen oder plantation, Zrntralbl. Cl?ir., 35, 1065-1070.
Barth, A. (18Y3) Ueber histologische Befunde nach Knochenimplantationen, Verb. Dtsch. GES. Chir., 22. Kongr., 234-242.
Kay, K.D. and Sabet, T.Y. (1963) Bone Grafts: Cellular survival versus induction, 1. B(JYfc It Surg., 45-A, 337-344.
Barth, A. (18Y4) Ueber Osteoplastik Beziehung, Arch. K/i?r. Clrir., 48, 466-477.
in
histologischer
Barth, A. (18Y4) Ueber Ostevplastik in histologischer Beziehung, Vtyrtr.Dtsclr. Gcs. Chir., 23. Kong., 201-212. Barth, A. (18Y4) Zur Knochenstiicke, Rcvlirwy
Frnge Klirr.
der
Vitalitat replantierter Wodrtwschr., 31, 340-341.
Barth, A. (1895) Histologische Untersuchungen iiber Knoclieliimplantationen, Rritr. PaUr. And. u. AlIs. Pnthol., 17, 65-l 42. Burri, C. (1974) Posttraumatische Bern, Stuttgart, Wien.
Osteitis,
Huber
Verlag,
Burri, C. (1974) Die Behandlung der sekundar-chronischen Osteomyelitis, Rii‘cllr~rcin. Ort/lo@eri, 13, 122-l 45. Clark, E.K. and Clark, E.L. (lY3Y) Microscopic observations on the growth of blood capillaries in the living mammal, Am. 1. Amt., 64, 251. Dobrotworski, W.J. (1Yll) Die Kippen als Material Knochenautoplastik, Ztvztralbl. Chir., 38, 10X1-1083.
zur
Ecke, H. (lY67) Neue Wege der quantitativen Bestimmung der oss#ren Kegeneration an Knochentransplantaten, Langenbeck’s Arch. Chir., X9,448-450. Eggers, C. (1984) Wertigkeit von Knochentransplantaten in der Traumatologie. Autologe Spongiosa und Kortikalismikrospgne. Bedeutung der Transplantatverdichtung und der Lagerstabilitat, Postdoctoral thesis, Hamburg 1984. Eitel, F., Schweiberer L., Saur K. et al. (lY80) Theoretische Grundlagen der Knochentransplantation: Osteogenese und Kevascularization als Leistung des Wirtslagers, l-12. In: Hierholzer, G. and Zilch, H. (1980) Transplantatlager und lmplantatlager bei verschiedenen Operationsveifahren, Springer, Berlin, Heidelberg, New Yurk. Frost, H.M. (1963) Bone remodelling Springfield, Illinois.
dynamics,
Thomas,
Ersatz nach Iiippenstiicke freier Trans-
Rudzki, M., Burri, C. and Hutzschenreuter, P. (lY74) Der Ein- und Umbau von autologer Spongiosa und Kompakta im ersatzschwachen Knocheilager, La&e&ck’s Arch. Chir. Strppl., Chir. Forum, 263-266. Schmelzle, K. and Schwenzer, N. (1977) Untersuchungen zur Knochellregeneration nach Kippenentnahme, 348-353. In: S&mid, E.; Widmaier, W. and Reichert, H. (1974) Wiederherstellung von Form und Funktion organischer Einheiten der verschiedenen Ktirperregionen; 13. Jahrestagg. Dtsch. Ges. Plast. Wiederherstelfungschir., Thieme, Stuttgart. Schmitt, A. (1893) Ueber Osteoplastik in klinischer und experimenteller Beziehung, Arch. Kliw . Chir., 45, 401-488. Schweiberer, L. (1970) Experimentelle Untersuchungen von Knochentransplantaten mit unver%nderter und mit denaturierter Knochengrundsubstanz, Hefte Urrfallheilkd., 103,1-70. Schweiberer, L., Eitel, F. and Betz, A. Spongiosatransplantation, Chirurg, 53, lY5-200.
(1982)
Seydel, H. (188Y) Eine neue Methode, grosse Knochendefekte des Schadels zu decken, ZbI. C!lir., 16,2OY-211. Spiessl, B. transplantation,
(1976) Grundsatzliches zur KnochenForts&r. Kiefir Gcsichtsc/~ir., 20, 14-17.
Stringa, G. (lY57) Studies of the vascularization grafts, 1. Boric It Surg., 39-B, 395.
of bone
Taylor, G.I., Miller, G.D.H. and Hamm, F.J. (1975) The Free Vascularized Bone Graft - A Clinical Extension of Microvascular Techniques, Plast. Reconstr. Surg., 55,533-544. Wolff, J. (1863) Die Osteoplastik in ihren Beziehungen Chirurgie und Physiologic, Arch. Min. Chir., 4,183-296.
zur
Walter, D., Hutzschenreuter I-‘.,Burri C. et al. (1975) Einbau autologer Spongiosa am Kompaktknochen in Abhlngigkeit von der Vitalit& der transplantierten Zellen, Langenbeck’s Arch. Chiv., Chir. Forum, 383-387.
1. The history of autogenous bone grafting
P.-J. Meeder, M.D.1 and Ch. Eggers, M.D.2 1 Head of the Dept. of Trauma and Reconstructive 2 Head of the Dept. of Trauma Reconstructive
Surgery, University
Clinic Heidelberg,
D-69120 Heidelberg
and Hand Surgery, St. George’s Hospital, D-20099 Hamburg
Spontaneous filling of bone cavities and spontaneous bridging of large defects of the long tubular bones in humans is not to be expected, irrespective of whether these defects are due to trauma, severe bone loss, extensive posttraumatic pseudarthrosis, insufficient growth in lengthening operations or excision of benign or malignant turnours. In all such cases, transplantation nf autogenous bone is today the elective procedure and is usually carried out in combination with stable internal fixation. Successful bridging of the defect is dependent on amount of several factors, namely, an adequate osteoinductive material, biomechanical stability of the graft bed, adequate vascularization of the osseous bed -and functional loading of the graft at the right time as a stimulus for restoration of form and function of the injured bone or bones. In 1863, Wolff defined nsteoplasty as an operation in which “Bone or bone stimulating tissue is implanted in the body in order to effect the permanent existence of bone at that site.” Basing his opinion on animal experiments, he expressed the hope that it would be possible to treat both congenital and acquired defects using autogenous bone grafting in the future, In 18X9, Seydel closed a 20 cm defect in the skull by repeated grafting of autogenous per&teal bone flaps from the tibia. In 1893, .Schmitt reported an operation by Bergrnann in which the latter succeeded in bridging a 12 cm tibia1 defect, resulting from resection of a sarcoma, by insertion of an autogenous fibular graft. Since Payr’s first publication in 1908 “On osteoplastic substitution in cases of resection of the jaw (maxillomandibular defects) using parts of the rib by
means of pedicled chest flaps or free grafts”, autografting of the rib has become a well-known and frequent operation in maxillofacial surgery to bridge defects of the mandible (Lexer, 1924; Longacre and de Stefano, 1957; Schmelzle and Schwenzer, 1977). In 1910, Dobrotworski closed a cranial defect for the first time using a rib which had been split longitudinally. He wrote “The rib offers extraordinary advantages and convenience as a covering for cranial fractures”. Having described his first four successful closures of cranial defects, Dobrotworski closed his publication in 1911 with the remark: “The rib could be used as a bone substitute in many cases of defect of the limbs”. This was the beginning of autogenous bone grafting as an internationally recognized, regular procedure in surgery and orthnpaedic& In 1919, -Albee was able to report on 1600 successful cases of bone grafting. The possible applications of autogenous honk graft were systematically researched by. Lexer (1867-iY39) and Phemister (1882-1951). They demonstrated the universal clinical application of the compact tibia1 graft complete with periosteum which has been named after them. Lexer recognized the important role played by stability in acceptance and healing of his cortico-cancellous bone grafts which he introduced according to the principles of carpentry and inlaid or nailed. He coined the phrases highly, partially and non-osteogenic with reference to the host site. In 1980, Eitel -et al. classified these three types of host bed in terms of the existing damage as fc~llows: - highly osteogenic refers to a site with or without compensated deficiency
Mm-h: Hisfory
ofautogenous
bow grafting
- partially osteogenic refers to a compromised vascularity and associated
S-A3 site with instability
- non-osteogenic refers to a site at which active infection and associated instability.
there is
In 1932 and 1936, Matti described autografting of pure cancellous bone in the treatment of pseudbut this procedure did not become arthrosis, established despite very positive results. The use of autogenous cancellous bone, in particular at partially osteogenic sites, only became possible with the advent of modern methods of internal and external fixation. This permits stable fixation and total immobilization of pseudarthroses and skeletal defects. Nowadays, autogenous cancellous bone is the substance of choice for bridging and filling defects, particularly in cases of infected fractures and pseudarthroses (Burri, 1974). In the last two decades, bone grafting procedures have taken on a new dimension d.ue to the additional possibilities offered by microsurgery. Microsurgery made it possible to test and to apply free combined tissue grafts. In lY7S, Taylor transplanted a free musculoskeletal flap from the contralateral fibula using primary anastomosis and attached it to the anterior tibia1 artery and vein. Further osteocutaneous, myocutaneous and vascularized flaps are: groin flaps with iliac crest, intercostal flaps and Latissimus dorsi flaps with rib (Anderl et al., 19X2). The incorporation of the graft, i.e. attachment and deposition, was described as “causal osteogenesis” by Schweiberer (1970). Well into the fifties, there was heated debate on the subject of osteogenesis: osteoblast and induction theories seemed completely incompatible. The osteoblast theory was propagated by Ollier (1X67) whereas Barth postulated the theory of induction. The osteoblast theory stated that the transplanted bone cells actively contributed to the regeneration of bone. The induction theory assumed that the graft did not survive but stimulated the pluripotent mesenchymal cells of the host tissue to differentiate into osteogenic cells which caused “creeping substitution” of the graft (Barth, 1X93,1894, 1x95). On the basis of hi&~logical investigations carried out on biopsy specimens and grafting in experimental studies, Axhausen confirmed in 1909 that in fresh, autngenous bone graft covered by periosteum there was necrosis of the bone ends as established by Barth, but that the periosteum survived to a large extent and actively influenced osteogenesis, as Ollier had assumed. Axhausen (1952, 1954, lY62) succeeded in finding a synoptic explanation of these phenomena and resolved the dualism of the osteoblast and induction theories by developing the theory of biphasic regeneration. The first phase of osteogenesis is autochthonous, the second phase inductive (Spiessl, 1976). These two
phases merge provided that conditions for successful grafting exist, i.e. graft and host bed are adequately vascularized, there is mechanical stability and there is close contact between the graft and the host tissue. Autogenous graft has all the characteristics of living bone: cells, collagen fibrils, proteoglycans and apatite crystals. The cells on the surface of the graft are initially nourished by diffusion and later by revascularization. After only a few days, at the latest after 3-4 days (Schweiberer, 197(I), the osteoblastic cells proliferate and form woven bone. This effects a transitional attachment of the graft to the host bed during the initial osteoblastic phase by osteoid formation (Schweiberer et al., 19X2). The vitality and effectiveness of the transplanted cells on the surface of the graft were demonstrated by radioisotope tests (Ray et al., 1963). The central arras of the graft do not react since they are dead. The bone matrix is resorbed by osteoclasts. The complex of mucopolysaccharides of the extracellular matrix leads to the differentiation into osteoblasts of the invading mesenchymal cells with proliferating vessels. The osteoinductive potential of the matrix and its break-down products has been determined by tests in the Millipore diffusion chamber (Ecke, 1967) and in subtraction tests (Schweiberer, 1970). Revascularization and osteoinductivity also depend on the quality and quantity of graft. Clark and Clark (1939) and Stringa (lYS7) showed that the proliferation rate of the capillaries in a cancellous bone block is between 0.22 and 0.43 mm/diem depending on the experimental design. This means that it is 10x as fast as for compact cortical graft (Maatz et al., 1953) and the bone regeneration rate is 3x greater in cancellous grafts (Frost, 1963). The greater osteogenic potential of cancellous bone can be explained by its loose, spongy which is better suited to structure vascularization. However, Wolter et al. (1975) observed greater osteninductive potential in compressed cancellous bone in an experiment investigating drill hole defects. This could not be confirmed .by Eggers (1984) who found that compaction of cancellous bone by powerful compression did not lead to a significant improvement in bone regeneration and that the statements made by W&r et al. (1975) must be interpreted as a product of their particular experimental design. Today, the macroscopical surface area, volume and mass of the graft can be regarded as the parameters contributing significantly to osteogenic capacity (Rudzki et al., 1976).
S-A4
References
Lexer, E. (lY24) Die freien Transplantationen Dfsch. Chir., 26b, Enke, Stuttgart.
Albee F.H. (1YlY) Orthopedic and Kecvnstructiun Industrial and Civilian, Saunders, Philadelphia.
Surgery,
Anderl H., Hussl H., Papp C. et al. (1982) Aktuelle rekonstruktive Verfahren zur Defektdeckung an den ExtremitRten, Clrirurg, 53, 235-240. Axhausen G. (190) Zur Frage der Zrrltmlhl. Chir., 36, Suppl. 133-134.
freien
Ostevplastik,
Axhausen C. (1YOY) Die histologischen und klinischen Gesetze der freien Osteoplastik auf Grund van Tierversuchen, Arch. Min. Clrir., 88, 23-145. Axhausen G. (190) Uber den Vorgang partieller Sequestrierung tranhplantierten Knochengewebes, nebst neuen histologischen Untersuchung& iiber Knochentransplantation am Menschen, Arch. Klill. Chir., 89, 281-302. Axhausen W. (1952) Die Kliochenregeneration - ein zweiphasisches Geschehen, Zmfydbt. Chir., 77, 435-442. Axhausen W. (1954) Der biologische Wert heteroplastischer Knochentransplantate, Lnngtwlw~k’s Arch. Chir., 279, 48-52.
Teil II, New
Lungacre, J.J. and de Stefanh, G.A. (1957) I&construction of extensive defects of the skull with split-rib grafts, Plast. Reconstr. Surg., 19,186-200. Longacre, J.J. and Stefan6, G.A. de (1957) Further observations of the behavior of autogenous split-rib-grafts in the reconstruction of extensive defects of the craitium and face, Plast. Rrconstr. Surg., 20, 281-296. Maatz, K., Lentz, W. and Graf, R. (1953) Experimentelle Grundlagen der Transplantation konservierter Knochen, Larrgr~~Imk’s Archio Klirr. Chir., 273, 850-855. Matti, H. (1932) Ueber die Behandlung von Pseudarthrosen mit Spongiosatransplantation, Arch. Orthoy. Unfall-Chir., 31,21 X-231. Matti, H. (1936) Technik und Kesultate meiner Pseudarthrosenoperation, Zentyalhl. Chir., 63,1442-1453. Oilier, L. (1867) Trait6 expbrimental rtg&tration des 05 et de la production osseux, Masson, Paris.
et clinique de la artificielle du tissue
Axhausen W. (lY(72) Die Bedeutung der Individualund Artspezifitnt der Gewebe fiir die freie Knocheniiberpflanzung, Ht@ Unfallhtdkd., 72, l-l 17.
Payr, E. (1908) Ueber osteoplastischen Kieferresektion (Kieferdefekten) durch mittels gestielter Brustwandlappen oder plantation, Zrntralbl. Cl?ir., 35, 1065-1070.
Barth, A. (18Y3) Ueber histologische Befunde nach Knochenimplantationen, Verb. Dtsch. GES. Chir., 22. Kongr., 234-242.
Kay, K.D. and Sabet, T.Y. (1963) Bone Grafts: Cellular survival versus induction, 1. B(JYfc It Surg., 45-A, 337-344.
Barth, A. (18Y4) Ueber Osteoplastik Beziehung, Arch. K/i?r. Clrir., 48, 466-477.
in
histologischer
Barth, A. (18Y4) Ueber Ostevplastik in histologischer Beziehung, Vtyrtr.Dtsclr. Gcs. Chir., 23. Kong., 201-212. Barth, A. (18Y4) Zur Knochenstiicke, Rcvlirwy
Frnge Klirr.
der
Vitalitat replantierter Wodrtwschr., 31, 340-341.
Barth, A. (1895) Histologische Untersuchungen iiber Knoclieliimplantationen, Rritr. PaUr. And. u. AlIs. Pnthol., 17, 65-l 42. Burri, C. (1974) Posttraumatische Bern, Stuttgart, Wien.
Osteitis,
Huber
Verlag,
Burri, C. (1974) Die Behandlung der sekundar-chronischen Osteomyelitis, Rii‘cllr~rcin. Ort/lo@eri, 13, 122-l 45. Clark, E.K. and Clark, E.L. (lY3Y) Microscopic observations on the growth of blood capillaries in the living mammal, Am. 1. Amt., 64, 251. Dobrotworski, W.J. (1Yll) Die Kippen als Material Knochenautoplastik, Ztvztralbl. Chir., 38, 10X1-1083.
zur
Ecke, H. (lY67) Neue Wege der quantitativen Bestimmung der oss#ren Kegeneration an Knochentransplantaten, Langenbeck’s Arch. Chir., X9,448-450. Eggers, C. (1984) Wertigkeit von Knochentransplantaten in der Traumatologie. Autologe Spongiosa und Kortikalismikrospgne. Bedeutung der Transplantatverdichtung und der Lagerstabilitat, Postdoctoral thesis, Hamburg 1984. Eitel, F., Schweiberer L., Saur K. et al. (lY80) Theoretische Grundlagen der Knochentransplantation: Osteogenese und Kevascularization als Leistung des Wirtslagers, l-12. In: Hierholzer, G. and Zilch, H. (1980) Transplantatlager und lmplantatlager bei verschiedenen Operationsveifahren, Springer, Berlin, Heidelberg, New Yurk. Frost, H.M. (1963) Bone remodelling Springfield, Illinois.
dynamics,
Thomas,
Ersatz nach Iiippenstiicke freier Trans-
Rudzki, M., Burri, C. and Hutzschenreuter, P. (lY74) Der Ein- und Umbau von autologer Spongiosa und Kompakta im ersatzschwachen Knocheilager, La&e&ck’s Arch. Chir. Strppl., Chir. Forum, 263-266. Schmelzle, K. and Schwenzer, N. (1977) Untersuchungen zur Knochellregeneration nach Kippenentnahme, 348-353. In: S&mid, E.; Widmaier, W. and Reichert, H. (1974) Wiederherstellung von Form und Funktion organischer Einheiten der verschiedenen Ktirperregionen; 13. Jahrestagg. Dtsch. Ges. Plast. Wiederherstelfungschir., Thieme, Stuttgart. Schmitt, A. (1893) Ueber Osteoplastik in klinischer und experimenteller Beziehung, Arch. Kliw . Chir., 45, 401-488. Schweiberer, L. (1970) Experimentelle Untersuchungen von Knochentransplantaten mit unver%nderter und mit denaturierter Knochengrundsubstanz, Hefte Urrfallheilkd., 103,1-70. Schweiberer, L., Eitel, F. and Betz, A. Spongiosatransplantation, Chirurg, 53, lY5-200.
(1982)
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