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An evaluation of sliding bone grafts of the tibia
AN EVALUATION HERBERT
E.
OF SLIDING BONE GRAFTS THE TIBIA*
PEDERSEN,
M.D.
Dearborn,
AND
A.
JACKSON
DAY,
OF
M.D.
124ichigan
S
INCE AIbee poputarized the inlay graft for the treatment of ununited fractures, there have been conflicting reports on its usefulness. For some years the onIay graft of cortical hone, multiple iliac grafts of cancellous bone and, since the recent war, massive onlay grafts have been more popuIar, indicating a high rate of failure with the inlaid sIiding cortica1 graft. Henderson,? CampbeII* and Key* in the treatment of delayed and non-union of long bones reported better results with massive autogenous onlay grafts fixed with screws. Bishop et al2 stated that “inlay grafts shouId be used only in cases of delayed union where an actua1 healing process is aIready present.” Armstrong’ stated that for the tibia “the sIiding inIay graft is particularly unsatisfactory.” It is generaIIy agreed that successfut grafting depends on many factors such as the presence of good coverage with normal skin and subcutaneous tissue in the operative area, absence of infection, minima1 trauma during operation, use of a Iarge piece of autogenous (or homogenous) bone fixed across the fracture site, good apposition of the graft to raw bleeding bone of the host and continuous immobiIization until healing is we11 advanced. The authors believe that for the tibia, except in rare situations, the sIiding inIay bone graft fuIhIIs the criteria. In 1946 Day6 reported on the resuIts of treatment of IOO consecutive fresh fractures of the tibia and emphasized that the sliding inIay graft fixed by stee1 screws was the method of choice for the initial treatment of simpIe, transverse, unstabIe fractures requiring more than simple screw fixation. Burns and MichaeIis,3 by means of the sIiding inIay graft, have treated deIayed and non-union of the tibia successfully in twenty-five of twenty-six consecutive cases since 1940, and WalIace’O has recentIy reported similar success in the treatment of oId warfare fractures which previously had Iong-standing infection.
The present report is based on a study of twenty-five consecutive sIiding inIay grafts of the tibia performed since 1946. It is believed that the results suggest a greater usefulness than is generally recognized and that recent changes in technic make the operation more successful than when first introduced. Patients were seIected for operation who had good skin coverage and had no evidence of open wounds or infection for at least two months prior to operation. Of the twenty-five cases five were for recent unstable fractures, three for delayed union, sixteen for non-union and one for malunion. With four exceptions these were originaIIy compound fractures. Of nineteen patients operated upon for delayed or non-union, the origina treatment in each was as follows: traction eight, plates two, screws two, inadequate immobilization one, and manipulation and continuous plaster four; in two cases origina treatment was unknown. The operation performed in twenty-one cases was a cIassica1 sliding graft, in which the graft was fixed across the fracture site with SMO staimess steel screws with wide wood-type threads. Three times additiona1 iIiac hone was packed about the fracture or was used to fiII a gap, and once a massive sliding graft was used. It is believed that the following technical points are important factors in achieving success. The major graft is cut at Ieast 3 inches long and 3/a inch wide, and the minor graft 235 by 34 inch. The grafts are cut with the motor saw using a single blade held at such an angle that the graft is beveled. The double bIade saw is never used. When the major fragment is fitted across the fracture site, the bevel prevents it from fahing into the marrow space. The beve1 Iikewise makes it possibIe to fix the graft to the major fragments with two screws above and below the fracture line. When the operation was performed for delayed union and when ahgnment and apposi-
* From the Department of Surgery, Division of Orthopedics, U. S. Veterans Administration Hospital, Dearborn, Mich. Reviewed in the Veterans Administration and pubIished with the approval of the Chief Medical Director. The statements and conclusions published by the authors are the resuIt of their own study and do not necessariIy reffect the opinion or policy of the Veterans Administration.
March,
I 952
287
288
Pedersen,
Day-SIiding
tion were satisfactory, the fibrous calIus was not disturbed and the fragment ends were not completely mobilized. However, in the unstabIe fresh fractures and in the cases of non-union and deIayed union with poor alignment the fragment ends were dissected free, the marrow TABLE SLIDING
1
GRAFTS
Reason for Operation 13 non-union. .................... 3 deIayed union. ................. 3 recent fractures., ............. 1 malunion ......................
Healing Time (mo.) 9.
5.3 6. I 7.
space was freely opened and accurate reduction was achieved. It was occasionaIIy necessary to sacrifice some Iength in cutting the major fragment ends with the motor saw to get good apposition. Of the twenty-five cases twenty-two have progressed to compIete unrestricted weight bearing. There were three faiIures. One patient did not report for follow-up care but had a second operation at another hospital. The other two were followed up and reoperated upon when faiIure was obvious. The average heaIing time in months, up to unrestricted weight bearing, is listed in Table I. Regarding the two faiIures foIIowed up, the first had origina!ly a compound comminuted war fracture which became infected and sIowIy heaIed foIlowing pedicIe flaps and muItipIe sequestrectomies. The patient had been waIking for fifteen months when he refractured the Ieg through the oId fracture site in the Iower third of the tibia. There was marked scIerosis and no meduIIary cavity. FoIlowing progressive absorption of bone during plaster immobilization he was treated by means of a sliding graft with additiona ihac bone packed about the fracture. Eleven months later union seemed firm and he began fuI1 weight bearing. After one month of weight bearing he noticed pain and fiIms revealed a fracture through the graft area. He has since been reoperated upon and the fracture appears to be uniting. The second faiIure was that of non-union at the Iower third of the tibia of six years duration, with marked scIerosis at the fracture site and marked osteoporosis proximaIIy and distaIIy. The origina reduction was by traction with transfixion pins in the OS caIcis and upper tibia and pIaster immobilization. One year Iater the patient had a sIiding graft fixed with Parham bands for non-union. Eighteen months following that operation whiIe in a walking Y
Bone Grafts of Tibia caliper he slipped and refractured the leg. At this institution he had a massive sliding graft. ApproximateIy six months after the operation fracture of the graft was noted. Progressive absorption and scIerosis at the fracture site followed. However, it has been two years since the Iast operation; the patient is using a walking caIiper, is free of pain and the fracture line is MIing in. The other complications in this series incIuded two significant infections and one fracture of the graft. One of the infections occurred in a compound comminuted fracture operated upon four months after the origina injury because of over-riding of the fragments and the absence of any heauIing. Despite the infection and folIowing remova of the screws and sequestrectomy, there was soIid bony union and com.plete soft tissue heaIina in sixteen months. The second postoperative ‘Lfection occurred in a . non-union of two years’ duration. The Iower two screws were removed, the wound heaIed and soIid union folIowed in 8.4; months from the origina overation. One -graft ‘fractured immediateIy following surgery, presumabIy due to poor handling of the extremity. On continuous immobiIization union was delayed but complete in eIeven months. 2
COMMENTS
It is beIieved that these resuIts and others recentIy reported indicate that the sliding inlay graft fixed with meta screws is an exceIIent Drocedure for the treatment of recent unstabIe ‘fractures, deIaved union and a11 but the most compIicated n&-unions of the tibia. With such treatment it is unnecessary to disturb the sound Ieg whiIe it is stil1 possibIe to bridge and fix the fracture with autoaenous cortica1 bone. Since the meduIIary cavity is widely opened, there is the additiona advantage of having apposition of the canceIIous portion of the graft to that of the host. The superficia1 position of the medial surface of the tibia makes it easy to cut the graft; and since the graft is inIaid, there is no increased buIk to make wound cIosure diffrcuIt or to interfere with heaIing. (Figs. I to 3.) The two faiIures were discussed in detail because it is beIieved that thev were unusual fracture problems and faiIure might have been anticipated foIlowing any type of bone graft. It is suggested that the sIiding graft as now performed shouId be more successfu1 than when first introduced. The technic of cutting a beveIed graft makes a cabinetmaker’s fit un-
American Journal of Surgery
Pedersen,
Day-Sliding
Bone
Grafts
IA
of Tibia
IB
FIG. I. This case illustrates the use of the sliding graft in a fresh unstable fracture. This was a compound double fracture treated in skeletal traction for two months, at which time the skin was weI1 heated (A). B, there was solid bony union six months after surgery.
2A
28
2c
FIG. 2. In this type of case it is thought that early grafting should be advised. The patient was first seen after two months of skeIeta1 traction for a compound fracture (A), at which time deIayed or non-union couId be predicted. The Ieg was immobilized in plaster for an additiona five months, with no healing (B). When the skin maceration was treated, he had a sliding bone graft. FuII weight bearing was possibIe eight months later (c).
March, I 952
290
Pedersen,
Day-Sliding
Bone Grafts of Tibia
3‘4 3B FIG. 3. When first seen this was a non-union of two years’ duration with marked scIerosis at the fracture site (A). Despite postoperative infection full weight bearing was started in 8.5 months. Because of persistent drainage and the reaction about the Iower two screws noted here (B) the screws were removed and the infection controIIed.
necessary and prevents the graft from falIing into the marrow space.The beveIed graft can be cut onIy with the singIe bIade saw since the saw cuts are not paraIIe1. In fact the doubIe bIade saw supplied with motor saws originates from the AIbee operation and the AIbee bone saw and shouId probabIy be eIiminated from the motor saw accessories. It is possibIe now to fix the graft with stainIess steel screws of uniform composition which produce Iittle if any tissue reaction. Those screws also aid by producing compression between the graft and host bone. AIthough fractures of the graft due primariIy to osteoporosis do occur and have been stressed as a cause of faiIure,5 it is beIieved that the danger can be minimized by carefu1 handIing of the extremity. FinaIly, it is recognized that the avaiIabiIity of antibiotics contributes to better resuIts. A study of the healing time up to fuI1 weight bearing in those patients with deIayed union and recent unstable fractures reveaIs that union progressed at rates comparabIe to those noted by others in uncompIicated, unoperated fractures. It is beIieved that when open reduction becomes necessary it is better to use an osteogenic bone graft for fixation rather than a metal pIate or muItipIe pins. It is also thought that rather than wait for established non-union it is
wise to suggest earIy bone grafting in those fractures which are known to heal poorIy, after sufficient time has eIapsed to demonstrate poor caIIus formation. REFERENCES
ARMSTRONG, J. R. Bone grafting in treatment of fractures of the tibia and fibula. Lancet, 2: 188191, ‘943. 2. BISHOP, W. A., JR., STAUFFER, R. C. and SWENSON, A. L. Bone grafts: an end result study of the healing time. J. Bone @ Joint Surg., 29: 961-970, I.
1947. 3. BURNS, B. H. and MICHAELIS, L. S. SIiding graft for ununited fracture of the tibia. Lancet, I: 337-338. 1944. 4. CAMPBELL, W. C. Onlay bone graft for ununited fractures. Arch. Surg., 38: 313-327. 1939. 5. D’AuB~GN~, R. M. SurgicaI treatment of nonunion of Iong bones. J. Bone FY Joint Surg., VIA: 256266, 1949. 6. DAY, A. J. The biomechanica1 treatment of IOO fractured legs. J. Michigan M. Sm., 45: 16251629, 1946. 7. HENDERSON, &I. S. Bone grafts in ununited fractures. J. Bone e+ Joint Surg., 20: 635-647, 1938. 8. KEY, J. A. The choice of operation for deIayed and non-union of Iong bones. Ann. Surg., I 18: 665688, 1943. g. KIRK, N. T. Non-union and bone grafts. J. Bone r‘” Joint Surg., 20: 621-626, 1938. IO. WALLACE, P. Treatment of fractures with long standing osteomyelitis. Arch. Surp., 61: 379-386. 1950.
American Journal oj Surgery
E.
OF SLIDING BONE GRAFTS THE TIBIA*
PEDERSEN,
M.D.
Dearborn,
AND
A.
JACKSON
DAY,
OF
M.D.
124ichigan
S
INCE AIbee poputarized the inlay graft for the treatment of ununited fractures, there have been conflicting reports on its usefulness. For some years the onIay graft of cortical hone, multiple iliac grafts of cancellous bone and, since the recent war, massive onlay grafts have been more popuIar, indicating a high rate of failure with the inlaid sIiding cortica1 graft. Henderson,? CampbeII* and Key* in the treatment of delayed and non-union of long bones reported better results with massive autogenous onlay grafts fixed with screws. Bishop et al2 stated that “inlay grafts shouId be used only in cases of delayed union where an actua1 healing process is aIready present.” Armstrong’ stated that for the tibia “the sIiding inIay graft is particularly unsatisfactory.” It is generaIIy agreed that successfut grafting depends on many factors such as the presence of good coverage with normal skin and subcutaneous tissue in the operative area, absence of infection, minima1 trauma during operation, use of a Iarge piece of autogenous (or homogenous) bone fixed across the fracture site, good apposition of the graft to raw bleeding bone of the host and continuous immobiIization until healing is we11 advanced. The authors believe that for the tibia, except in rare situations, the sIiding inIay bone graft fuIhIIs the criteria. In 1946 Day6 reported on the resuIts of treatment of IOO consecutive fresh fractures of the tibia and emphasized that the sliding inIay graft fixed by stee1 screws was the method of choice for the initial treatment of simpIe, transverse, unstabIe fractures requiring more than simple screw fixation. Burns and MichaeIis,3 by means of the sIiding inIay graft, have treated deIayed and non-union of the tibia successfully in twenty-five of twenty-six consecutive cases since 1940, and WalIace’O has recentIy reported similar success in the treatment of oId warfare fractures which previously had Iong-standing infection.
The present report is based on a study of twenty-five consecutive sIiding inIay grafts of the tibia performed since 1946. It is believed that the results suggest a greater usefulness than is generally recognized and that recent changes in technic make the operation more successful than when first introduced. Patients were seIected for operation who had good skin coverage and had no evidence of open wounds or infection for at least two months prior to operation. Of the twenty-five cases five were for recent unstable fractures, three for delayed union, sixteen for non-union and one for malunion. With four exceptions these were originaIIy compound fractures. Of nineteen patients operated upon for delayed or non-union, the origina treatment in each was as follows: traction eight, plates two, screws two, inadequate immobilization one, and manipulation and continuous plaster four; in two cases origina treatment was unknown. The operation performed in twenty-one cases was a cIassica1 sliding graft, in which the graft was fixed across the fracture site with SMO staimess steel screws with wide wood-type threads. Three times additiona1 iIiac hone was packed about the fracture or was used to fiII a gap, and once a massive sliding graft was used. It is believed that the following technical points are important factors in achieving success. The major graft is cut at Ieast 3 inches long and 3/a inch wide, and the minor graft 235 by 34 inch. The grafts are cut with the motor saw using a single blade held at such an angle that the graft is beveled. The double bIade saw is never used. When the major fragment is fitted across the fracture site, the bevel prevents it from fahing into the marrow space. The beve1 Iikewise makes it possibIe to fix the graft to the major fragments with two screws above and below the fracture line. When the operation was performed for delayed union and when ahgnment and apposi-
* From the Department of Surgery, Division of Orthopedics, U. S. Veterans Administration Hospital, Dearborn, Mich. Reviewed in the Veterans Administration and pubIished with the approval of the Chief Medical Director. The statements and conclusions published by the authors are the resuIt of their own study and do not necessariIy reffect the opinion or policy of the Veterans Administration.
March,
I 952
287
288
Pedersen,
Day-SIiding
tion were satisfactory, the fibrous calIus was not disturbed and the fragment ends were not completely mobilized. However, in the unstabIe fresh fractures and in the cases of non-union and deIayed union with poor alignment the fragment ends were dissected free, the marrow TABLE SLIDING
1
GRAFTS
Reason for Operation 13 non-union. .................... 3 deIayed union. ................. 3 recent fractures., ............. 1 malunion ......................
Healing Time (mo.) 9.
5.3 6. I 7.
space was freely opened and accurate reduction was achieved. It was occasionaIIy necessary to sacrifice some Iength in cutting the major fragment ends with the motor saw to get good apposition. Of the twenty-five cases twenty-two have progressed to compIete unrestricted weight bearing. There were three faiIures. One patient did not report for follow-up care but had a second operation at another hospital. The other two were followed up and reoperated upon when faiIure was obvious. The average heaIing time in months, up to unrestricted weight bearing, is listed in Table I. Regarding the two faiIures foIIowed up, the first had origina!ly a compound comminuted war fracture which became infected and sIowIy heaIed foIlowing pedicIe flaps and muItipIe sequestrectomies. The patient had been waIking for fifteen months when he refractured the Ieg through the oId fracture site in the Iower third of the tibia. There was marked scIerosis and no meduIIary cavity. FoIlowing progressive absorption of bone during plaster immobilization he was treated by means of a sliding graft with additiona ihac bone packed about the fracture. Eleven months later union seemed firm and he began fuI1 weight bearing. After one month of weight bearing he noticed pain and fiIms revealed a fracture through the graft area. He has since been reoperated upon and the fracture appears to be uniting. The second faiIure was that of non-union at the Iower third of the tibia of six years duration, with marked scIerosis at the fracture site and marked osteoporosis proximaIIy and distaIIy. The origina reduction was by traction with transfixion pins in the OS caIcis and upper tibia and pIaster immobilization. One year Iater the patient had a sIiding graft fixed with Parham bands for non-union. Eighteen months following that operation whiIe in a walking Y
Bone Grafts of Tibia caliper he slipped and refractured the leg. At this institution he had a massive sliding graft. ApproximateIy six months after the operation fracture of the graft was noted. Progressive absorption and scIerosis at the fracture site followed. However, it has been two years since the Iast operation; the patient is using a walking caIiper, is free of pain and the fracture line is MIing in. The other complications in this series incIuded two significant infections and one fracture of the graft. One of the infections occurred in a compound comminuted fracture operated upon four months after the origina injury because of over-riding of the fragments and the absence of any heauIing. Despite the infection and folIowing remova of the screws and sequestrectomy, there was soIid bony union and com.plete soft tissue heaIina in sixteen months. The second postoperative ‘Lfection occurred in a . non-union of two years’ duration. The Iower two screws were removed, the wound heaIed and soIid union folIowed in 8.4; months from the origina overation. One -graft ‘fractured immediateIy following surgery, presumabIy due to poor handling of the extremity. On continuous immobiIization union was delayed but complete in eIeven months. 2
COMMENTS
It is beIieved that these resuIts and others recentIy reported indicate that the sliding inlay graft fixed with meta screws is an exceIIent Drocedure for the treatment of recent unstabIe ‘fractures, deIaved union and a11 but the most compIicated n&-unions of the tibia. With such treatment it is unnecessary to disturb the sound Ieg whiIe it is stil1 possibIe to bridge and fix the fracture with autoaenous cortica1 bone. Since the meduIIary cavity is widely opened, there is the additiona advantage of having apposition of the canceIIous portion of the graft to that of the host. The superficia1 position of the medial surface of the tibia makes it easy to cut the graft; and since the graft is inIaid, there is no increased buIk to make wound cIosure diffrcuIt or to interfere with heaIing. (Figs. I to 3.) The two faiIures were discussed in detail because it is beIieved that thev were unusual fracture problems and faiIure might have been anticipated foIlowing any type of bone graft. It is suggested that the sIiding graft as now performed shouId be more successfu1 than when first introduced. The technic of cutting a beveIed graft makes a cabinetmaker’s fit un-
American Journal of Surgery
Pedersen,
Day-Sliding
Bone
Grafts
IA
of Tibia
IB
FIG. I. This case illustrates the use of the sliding graft in a fresh unstable fracture. This was a compound double fracture treated in skeletal traction for two months, at which time the skin was weI1 heated (A). B, there was solid bony union six months after surgery.
2A
28
2c
FIG. 2. In this type of case it is thought that early grafting should be advised. The patient was first seen after two months of skeIeta1 traction for a compound fracture (A), at which time deIayed or non-union couId be predicted. The Ieg was immobilized in plaster for an additiona five months, with no healing (B). When the skin maceration was treated, he had a sliding bone graft. FuII weight bearing was possibIe eight months later (c).
March, I 952
290
Pedersen,
Day-Sliding
Bone Grafts of Tibia
3‘4 3B FIG. 3. When first seen this was a non-union of two years’ duration with marked scIerosis at the fracture site (A). Despite postoperative infection full weight bearing was started in 8.5 months. Because of persistent drainage and the reaction about the Iower two screws noted here (B) the screws were removed and the infection controIIed.
necessary and prevents the graft from falIing into the marrow space.The beveIed graft can be cut onIy with the singIe bIade saw since the saw cuts are not paraIIe1. In fact the doubIe bIade saw supplied with motor saws originates from the AIbee operation and the AIbee bone saw and shouId probabIy be eIiminated from the motor saw accessories. It is possibIe now to fix the graft with stainIess steel screws of uniform composition which produce Iittle if any tissue reaction. Those screws also aid by producing compression between the graft and host bone. AIthough fractures of the graft due primariIy to osteoporosis do occur and have been stressed as a cause of faiIure,5 it is beIieved that the danger can be minimized by carefu1 handIing of the extremity. FinaIly, it is recognized that the avaiIabiIity of antibiotics contributes to better resuIts. A study of the healing time up to fuI1 weight bearing in those patients with deIayed union and recent unstable fractures reveaIs that union progressed at rates comparabIe to those noted by others in uncompIicated, unoperated fractures. It is beIieved that when open reduction becomes necessary it is better to use an osteogenic bone graft for fixation rather than a metal pIate or muItipIe pins. It is also thought that rather than wait for established non-union it is
wise to suggest earIy bone grafting in those fractures which are known to heal poorIy, after sufficient time has eIapsed to demonstrate poor caIIus formation. REFERENCES
ARMSTRONG, J. R. Bone grafting in treatment of fractures of the tibia and fibula. Lancet, 2: 188191, ‘943. 2. BISHOP, W. A., JR., STAUFFER, R. C. and SWENSON, A. L. Bone grafts: an end result study of the healing time. J. Bone @ Joint Surg., 29: 961-970, I.
1947. 3. BURNS, B. H. and MICHAELIS, L. S. SIiding graft for ununited fracture of the tibia. Lancet, I: 337-338. 1944. 4. CAMPBELL, W. C. Onlay bone graft for ununited fractures. Arch. Surg., 38: 313-327. 1939. 5. D’AuB~GN~, R. M. SurgicaI treatment of nonunion of Iong bones. J. Bone FY Joint Surg., VIA: 256266, 1949. 6. DAY, A. J. The biomechanica1 treatment of IOO fractured legs. J. Michigan M. Sm., 45: 16251629, 1946. 7. HENDERSON, &I. S. Bone grafts in ununited fractures. J. Bone e+ Joint Surg., 20: 635-647, 1938. 8. KEY, J. A. The choice of operation for deIayed and non-union of Iong bones. Ann. Surg., I 18: 665688, 1943. g. KIRK, N. T. Non-union and bone grafts. J. Bone r‘” Joint Surg., 20: 621-626, 1938. IO. WALLACE, P. Treatment of fractures with long standing osteomyelitis. Arch. Surp., 61: 379-386. 1950.
American Journal oj Surgery