Anterolateral approach in bone grafting for ununited fractures of tibia

ANTEROLATERAL

APPROACH

IN BONE

GRAFTING FOR UNUNITED FRACTURES

OF TIBIA *

J. HUBER

M.D.

WAGNER,

PlTTSBURGH,

F

PENNSYLVANIA

OR a period of ten or tweIve

years starting

immediately

after

World War I it had been customary for me to utilize a sIiding inlay type of graft along the anterior flat surface of the tibia

when grafting change

for non-union

in the approach

above-named

in this bone,

Since

1932,

has been made and instead

type of graft,

however,

of utiIizing

we are now using an anterolatera1

a the

&ding

inIay type of graft. It is the technic of this procedure which wiII be covered in this presentation rather than a discussion of the pros and cons of bone grafting or a discussion of the indications, contraindications etc. of this procedure. Various types of technics have been described in carrying out tibia1 bone grafts incIuding the use of man? materiaIs as fixing agents for bone grafts, these having been and being catgut, kangaroo tendon, siIk, silver or stee1 wire, bone screws and in some instances

even bone pIates.

Since

Igzz nothing

but Sherman

type screws have been used in our clinic for the fixation

of bone grafts

and we feel that

screws

we were the first

fixation of bone grafts. There are severa advantages

to utilize

meta

in this technic

in the

and it is these which

we wish to discuss

somewhat in detail. These are: The incision is not made over the flat I. Site of Incision. avascuIar unpadded portion of skin which Iies immediately over the periosteum

covering

the flat anterior

surface

of the bone but rather

is made IateraI to the anterior ridge of the tibia over soft underIying fatty and muscuIar tissue thereby affording a more vascuIarized area

of skin as the operative

area.

With

this type

of incision

the

periosteum is very IittIe disturbed from the flat anterior portion of the tibia, it being mainIy stripped off from the IateraI side of the bone aIong with the muscIes which are retracted IateraIIy and posteriorly so as to afford exposure of the bone. * It is not the purpose of this paper to discuss the pros and cons of bone grafting but rather to present the technic of a procedure that has given the author and his associates excellent results in a large series of tibia1 bone grafts. 282

WAGNER-BONE 2.

Fixation.

fixation, in that

this

As we utilize Sherman approach

the heads

affords

a more

approach

the anterior

ideal

muscles

creating

steel screws in

IocaIe

for the screws,

subcutaneously

but rather

tibia1

covering the screws thereby or the incision from within.

283

type stainless

do not lie immediateIy

case in the anterior underneath

GRAFTING

are buried which

falI over

no pressure

as is the

deep Iaterally

points

completely on the skin

3. Morticing and Impacting of the Graft. In this approach a better bed is afforded for the graft and anchoring of the tip of the graft can more easily be carried out thereby necessitating Iess metallic interna fixation.

preventing

bowing and

TECHNIC;

Site

of

regardIess

Incision.

When

of the type

incision

of necessity

anterior

surface

utilizing

of fixation had

to

of the tibia.

the

anterior

sIiding

or the size and type

be made This,

immediately

of graft, over

the

graft the flat

you know, is the most avascuIar

portion of the lower leg and is the place where the skin immediateIy overlies the periosteum of the bone as in this area there is but a very minimum amount of intervening subcutaneous fat. This anatomical arrangement has several disadvantages in that healing may be retarded because of sIoughing of part of the suture line due to the poor blood supply

and as it is the most exposed

portion

of the

trauma

as we11 as to pressure

Iower

In the anterolateral

leg it is very

however,

to the anterior

do not present

susceptibIe

to external

from within.

approach,

1; to $!4 of an inch Iateral disadvantages

easiIy

and Ieast protected

themseIves.

is loose, has some subcutaneous

as the incision

is made

ridge of the tibia, On the contrary,

fat and is overIying

these

the skin

a soft muscuIar

bed which is much more vascuIar than the area previousIy described so that there is a tendency for better healing, a1mos.t compIeteIy eIiminating

dangers

of sIoughing

of part of the suture

line and does

completeIy eliminate the danger of having necrosis of part of the skin due to pressure from within. This incision can be of any desired Iength and in some of our cases has extended from the anterior tibia1 tubercIe down to the IeveI of the ankIe joint proper. Skin ffaps are then reflected

IateralIy

and after the skin edges have been carefully

blocked the fascia and the periosteum is incised following which the muscIes and periosteum are retracted IateraIIy and posteriorIy en masse thereby affording an excehent visuaIization of the entire Iateral aspect of the tibia as high up and as far down as is desired,

WAGNER-BONE

284

GRAFTING

FIG. I. Case I. B. B., December 29, 1943, shows the non-union as it existed at time of admission to the hospital.

A short flap of periosteum

is refIected

medialIy

just beyond the ridge

of the tibia just to the point where the saw Iine for the graft is to be made.

This

advantage, independent

complete

and decided

i.e. the operative area is in almost every of the site of the previousIy traumatized

incision

aIso has another

case entireIy and scarred

skin due either to a compound in previous

operative

cases of non-union

wound or to a surgica1 wound utiIized

treatment

are compound

as the compound

very

of the origina rather

than

fracture. simple

As most

fractures

wound is most often along the anterior

and

Bat of the

tibia, this incision made away from this area is in its entirety one going through fresh tissues that have not previousIy been traumatized or operated

upon and in some cases invoIved

in some infectious

process whether it was of the soft tissues aIone or of soft tissues and bone. Here one feeIs more sure that he is not stirring up some quiescent infection tized scarred

by going through

the previousIy

infected

or trauma-

area.

In some cases there still exists or persists a small draining sinus or a smaI1 uIcerated area along the medial or anteromedia1 aspect of the tibia and it wouId be dangerous to attempt a bone graft using an anterior type of sliding graft with this present. On the other hand, by using our approach we do not go near these areas and we fee1 that a graft can safeIy be carried out on the bone with the smaI1 uIcerated area being cared for SimuItaneousIy with or after the bone graft has been carried out.

WAGNER-BONE As all our grafts

Fixation.

used in bone grafting, In the anterior

of the various

our remarks sliding

285

are fixed with Sherman

we shall not go into a discussion aIone.

GRAFTING

being

tibia1 graft

type screws,

other

confined

fixing agents

to screw

fixing

the screws which are used

for lixation are inserted through the graft into the posterior portion of the tibia and as a result the heads come to lie immediately over the anterior Ilat tibia1 surface. This has severai disadvantages in that they are immediately under the suture Iine thereby causing pressure from within on the suture line which itself is already in a poor area so far as tendency for healing by primary intention is concerned portion

in that of the

it has been

lower

leg. Another

screw heads can readily which

they

susceptible

due to the lack

overlie

trauma

through

the

undesirabIe

be palpated

immediately to external

made

feature

from without

and being

thus

as well as external

of protective

most

subcutaneous

avascular is that

through

the

the skin

situated

are very

pressure,

this being

tissue

in this area.

In

contrast to this, by using the lateral approach the screws are inserted from the lateral toward the medial aspect of the tibia being at a right angle to the anterior ridge of the tibia. In this locale they lie deep in the leg and are protected

by the overlying

anterior

muscles

so that not only are the screw heads no longer palpable

without

but they are so well covered

pressure without

on the

skin

is completely

Morticing

over

the

tibia1 from

by soft parts that all danger

screw

heads

either

from

within

of or

eliminated.

and Impacting

of the Graft.

This

not a new one, has been used by us for the past

procedure, 20

years.

which

is

We utilize

this morticing and impacting of the graft ends in all type of sliding grafts regardIess of the bone which is being grafted. After the Iength and thickness of the graft has been determined and the saw cuts have been made, the distal and proximal ends of the grafts are then undercut so that

the end of the graft

itself

is bevelled

for a distance

of

about J,$ to 3; of an inch at approximately a 30 to 45’ angIe. This along with the fact that the average graft is anywhere from f/hto a/; of an inch in width, makes for a graft which is heavy enough to permit

good impaction,

this morticing

having

been carried

out at

either end of the tibia. The procedure can be carried out with or without reversal of the bone grafts as each piece of bone, the one from the upper fragment as well as the one from the lower fragment, has at one end this prepared bevelled-like end and the bone proper at these ends has the underlying undercut arrangement which will permit for the pounding in and impacting of the graft thereby giving

286

WAGNER-BONE

GRAFTING

B

A

FIG. 2. A, February 29, 19~. taken postoperatively shows the graft heId in pIace with a single screw but does not show a mark morticing of the graft at its lower end. This was not necessary here, however, as there was no pull from the muscles. B, May 6, 1944,shows the condition of the graft at the time that cxterna1 fixation was removed.

exceIIent fixation at the one end, preventing necessitating

much less metallic

interna

these grafts with one screw holding the site of non-union non-union,

and impacting

bowing

fixation.

of the graft and

We attempt

to fix

the graft which transverses

at

either above or beIow the site of

this most times is suflicient and no further screw fixation

is necessary. In some instances when the muscIe spasm is marked or where deformity has Iong persisted with anguIation of the bones, and it is feIt that too much strain wil1 be pIaced upon the graft because of this long-existing muscle pull, two, three or sometimes even four screws may be used. This, however, than the ruIe, and is well iIIustrated CASE

CASE

I.

B.

B.

age

is the exception

rather

in the case reports.

REPORTS

fifty-six,

was

admitted

to

the

hospital

February 27, 1944, with a history of having been invoIved in an automobiIe accident on April I, 1943, sustaining a compound fracture of his Ieft tibia and fibuIa for which he was treated in Youngstown, Ohio, unti1 now. Examination at this time showed a non-union of the mid tibia with no open wounds on the skin. X-rays were taken and showed non-union near the mid portion of the Ieft tibia with demineraIization and disuse atrophy of the bone. Bone graft was advised. He was operated upon the foIIowing day and under pentotha1 anesthesia a sIiding IateraI bone graft with single

WAGNER--BONE

GRAFTING

287

FIG. 3. March I, 1946, shows the end result Amost two years after the operation. It was noted that the graft had Mended in nicely with the main tibia1 fragments and that the site of the non-union is readiIy noticeable. It is difhcult to tell b\-hew the graft was pIaced unless one looks quite clos~l~.

screw fixation was carried out. Wound heaIed per primam. Patient was made ambulatory on the tenth postoperative day and he was discharged from the hospital on the 15th postoperative day March ‘3, ‘944. He returned as an outpatient for further observation and checkup and Figure I shows his progress from the x-ray standpoint. Complete heaIing with solid union deveIoped. Patient was permitted full weight bearing without external fixation at the end of fourteen weeks. He was last seen on March I, 1946, at which time he had no complaints, stated he had been doing his work completely and a final x-ray was taken which is included in Figure I. CASE II. A. G. age forty-four, was admitted to the hospita1 May 24, 1945, with a history of having been injured on April I I, 1944, while working in n steel milI in Youngstown, Ohio, sustaining a

WAGNER-BONE

A

GRAFTING

C

B

25, 1945, preoperatively shows a non-union of the tibia with marked demineralization of the bone. n, shows the &ding lateral graft with single screw fixation and in the anteroposterior view shows very clearly the morticing and impaction of the lower end of the graft. The upper smaller graft is heId in place without fixation, June 9, 1945. c, December I, 1945, taken six months postoperativeIy shows exceIIent healing with blending of the graft into the major tibia1 fragments and obIiteration of the site of non-union.

FIG.

4. Case II. A. G. A, May

compound

fracture

of his left tibia

and fibula

in the region

of the

middle and Iower thirds. A ctosed reduction was carried out and progress was satisfactory for a while but around New Year’s day of this year

a draining

sinus developed

at the site of the compound

fracture. This discharge cleared up in a few weeks but patient’s leg was stiI1 painful, he was unabIe to bear his full weight and was sent here for examination. Examination at this time showed the Ieft lower leg to be atrophied and showed no evidence non-union third

of any draining

demonstrabIe

cIinicaIIy

of the Ieg and x-rays

complete

heaIing

was aIso a marked with disuse

a non-union

was a definite

site in the Iower of the tibia

was no deformity

The

with

at the frac-

osseous union couId be demonstrated.

demineralization

atrophy.

There

at the fracture

showed

in the fibuIa. There

ture site but no definite

sinuses.

There

of the bones of the Ieg and foot

foot and ankle

were manipuIated

after

admission. Patient was encouraged to walk around on the limb to increase the bIood supply of the part and on June 8, 1945, fifteen days after admission, the condition of the leg was thought to be such that grafting couId safeIy be done. A latera sliding bone graft with singIe screw fixation was carried out. (Fig. 2.) Postoperative course was uneventfu1, wound heaIed per primam and the patient was made ambuIatory with the aid of crutches on the tenth postoperative day and he was discharged on the twentieth postoperative day June 28, 7945.

WAGNER--BONE

GRAFTING

2%

FIG. 5. Case III. J. P. A, August I, 1945. preoperative plate shows non-union, angulation and overriding of the fragments at the fracture site. B, immediate postoperative picture, shows nicely the morticing of the graft and shows three-screw fixation which was necessary to overcome the marked muscIe pulI on the graft. The upper graft, however, needed no fixation. c, December IO, ,945, shows healing at the end of two months. D, June 20, 1946, shows condition of the leg ten months after operation and after the screws have been removed. Note how the graft blends in with the major tibia1 fragment above as we11 as the minor tibia1 fragment below. There is some absorption of the tibia at the fracture site but this has since HIed in.

He returned as an outpatient for further observation. The graft heaIed niceIy and at the end of fourteen weeks al1 externa1 fixation was removed and the patient was permitted weight bearing. When Iast seen one year after the operation the Ieg was solidIy heaIed. Patient had been working at his reguIar duties since the sixth postoperative month and the Iast x-ray taken on December I,

WAGNER--BONE

290

1945, showed an exceIIent

osseous

GRAFTING

organization

between

the graft

and the main bone fragments. was admitted to the hospital CASE III. J. P. age thirty-six, July 3 I, 1943with a history of having sustained a compouQld fracture of his Ieft tibia and fibula in Weston, W. V. in August, 1944. He was treated by cIosed reduction at the time of his origina injury, the cast not being removed

until six weeks Iater.

At that

time as there

was no evidence of bony healing, an open reduction with pIate fixation was carried out. HeaIing did not take pIace SatisfactoriIy. Some severa

drainage months

deveIoped

at the site of the compound

Iater the pIate and screws were removed.

was not satisfactory, the draining compound wound and the patient with compIete media1 displacement fragments

of the tibia

wound

and

His progress

sinus persisting at the site of the deveIoping a marked anguIation of the proxima1 ends of the dista1

and fibuIa.

X-ray was taken on admission and showed the ununited fracture as we11 as the oId screw holes in the tibia and some irreguIarity at the ends of the tibia1 fragments but no definite evidence of infection was noted. There was aIso a marked demineralization of the bones with disuse atrophy. The draining area at the site of the compound wound was treated IocaIIy and in time heaIed. Patient’s foot and ankle were manipuIated on severa occasions. Check x-rays immediateIy postoperativeIy showed that the dista1 screw had puIIed out of the graft permitting

WAGNER-BONE

GRAFTING

A

FIG. 7.

291

B

June 29, 1944, shows healing of the graft months after grafting. B, June 13, ,946, over two years after the grafting was done, shows the end resuIts with complete blending of the graft into the major fragments and with the two transfixion screws bnreIy noticeable. A,

the graft to slip. The wound was alIowed to heaI and on August 1943 the Iower end of the wound was reopened,

the graft

2%

was sIid

into pIace and a new screw was inserted holding the graft in place and correcting all angulation. The wound again heaIed per primam, the

patient

was made

ambulatory

and

was discharged

hospita1 on September 16, 1945. He returned as an outpatient for further

observation

took

at the

pIace

weeks

sIowIy

but

was bearing

satisfactorily

weight

with

the

and

on April present

12,

1946,

patient

returned

at this time he was readmitted

at the site of the compound

end of eighteen

weight

but

to the hospital. X-rays

without

compIeteIy

and as a draining

wound.

the

and heahng

aid of crutches

externa1 support to the lower Ieg. At the end of six months he was bearing

from

sinus

but was

The sinus was

at this time

showed

absorption around the middle screw and some destruction of the major tibia1 fragments at the site of nonunion. This was cIeaned up IocaIIy and operation was carried out ApriI 24, 1946, at which time al1 three screws were removed with saucerization of the major tibia1 fragments at the site of non-union. A smaI1 sequestrum was aIso encountered and removed. The wound was permitted to granuIate from beIow and when healthy granmations were present the ulcerated area was grafted, this procedure being carried out on June 14, 1946.

Heahng

took

place

satisfactoriIy

and

compIeteIy.

Patient

WAGNER--BONE

GRAFTING

FIG. 8~.

FIG. 8~. FIG. 8. Case v. G. B. A, February 6, 1945, fourteen weeks after the original injury shows a non-union which developed at the fracture site. B, February g, 1945, shows immediate postoperative film with beveIIing and morticing of the graft cIearIy demonstrable and shows two-screw fixation, this being necessary because of the muscIe puI1 causing bowing in the preoperative Mm. The upper graft needed no fixation. c, June 13, 1946, sixteen months after the operation, shows compIete heaIing of the graft with bIending of the graft into the tibia1 fragments and with some scarring of the bone. Film, however, is not too clear.

wa.s discharged from the hospital July g, 1946, compIeteIy hea tied arr d instructed to report as an outpatient for further observati ion. The fina x-rays taken on June 2o,Ig46, showed excehent heah ing. Pa .tient has a good strong Ieg. The soft tissues are a11 cornpIe ;eIy he; aIed and strong. He is progressing SatisfactoriIy. CASE IV. F. P. age forty-nine, was admitted to the hospital j on JuIy

29,

1943,

with acompound

comminuted

fracture

of the right

WAGNER-BONE

GRAFTING

FIG. g. Drawing shows site of incision. It is noted that the incision is approximateIy 92’ inch Iateral to the ridge of the tibia and is made long enough to afford adequate exposure. FIG. IO. Shows the wound cdgcs being blocked with the use of MicheIe clips on steriIe towels. FIG. I I. Shows exposure of the fracture site with subperiosteal stripping of the periosteum and anterior tibia1 muscIes Iaterally and posteriorIy en masse. Clamps are on the periosteum. The fracture site with the non-union are clearIy visible.

294

WAGNER-BONE

GRAFTING

tibia and fibula, this having been sustained several hours prior to his admission when he was struck across his leg with a large piece of steel whiIe working in the mill. Examination on admission showed a ragged dirty compound wound near the junction of the middIe and lower third of the right leg with the bone fragment protruding thru the wound. Under pentotha1 anesthesia a debridement of the wound was carried out along with a cIosed reduction of the fracture. Check x-rays showed a satisfactory reduction of the fracture. The wound healed per primam. The bone, however, did not show any signs of healing and for this reason the patient’s hospital stay was prolonged, he being here unti1 September 2 I, I 943. At this time he was discharged on crutches with a waIking iron and cast to his Ieg and instructed to bear weight so as to stimuIate healing. He returned as an outpatient periodicaIIy but Iater x-rays again showed that no bony healing had taken place. The patient was readmitted to the hospita1 on October 28, 1943, our intentions at this time being to carry out a bone graft. He was operated on November 3, 1943, but at that time instead of grafting, the fractured ends of the tibia were freshened and an open reduction with plate fixation was carried out. This procedure was carried out as the appearance of the bones was such at the time of operation that it would Iead one to beIieve that heaIing, ahhough deIayed, wouId take pIace. Again the postoperative course in the hospita1 was uneventful but healing was SIOWso far as the bone was concerned, his hospita1 stay being prolonged until January 4, 1944. At this time he was discharged again with a soIid cast and a waIking iron and instructed to bear weight. He continued to return as an outpatient and was observed unti1 March 14, 1944, with non-union still being present. He was readmitted to the hospita1 for a bone graft. This was carried out the foIIowing morning under pentothal anesthesia and a sIiding graft with two-screw fixation performed. The wound again healed per primam and as in the previous two admissions bony union again was slow. His hospita1 stay was proIonged until June of 1944, at which time there was enough osseous heaIing to permit weight bearing. He returned as an outpatient and twenty-two weeks after his operation there was enough bony union to permit fuI1 weight bearing without the aid of crutches. He was Iast seen several weeks ago at which time the Ieg was compIeteIy heaIed, union was solid, patient had no compIaints and a satisfactory resuIt was obtained.

WAGNER-BONE

GRAFTING

FIG. 12. Shows the graft in place, being held there tightIy by means of a Berg clamp whiIe the hole for the Sherman screw is drilled. FIG. ‘3. Schematic sketch showing fracture with non-union indicating preoperative condition. FIG. 14. Schematic sketch showing reduction of fracture, cIeaning out of site on non-union, and cut graft with morticed edges. FIG. 13. Shows graft in position, being heId by a single Sherman screw. The lower end is tightly held m place by the morticing effect. Note that the small graft (b) is in pIace without any external fixation.

295

WAGNER-BONE

296 CASE v.

G. B. age twenty-five,

January

23, 1944, with a history

fracture

of his right

skull,

a severe

automobile

GRAFTING

brain

accident

Pa. hospital

tibia

of having

and fibula

concussion on December

at the time

to the hospital

sustained

along

and other

with these injuries

Examination

was admitted with

a compound

a fracture

soft tissue

of his

injuries

in an

25, 1943. He was in a Rochester,

until his transfer of admission

here.

to the

hospital

showed

the right lower leg to be in a solid plaster cast and after removal of the cast examination showed marked deformity of the leg with complete

healing

of the

compound

wound.

The

patient

was still

mentally confused at this time. X-ray examination showed complete overriding with both the tibia and hbula near the mid shaft with lateral displacement of the major distal tibia1 and fibular fragments along with comminution at the fracture site. He was operated upon under spinal and pentothal anesthesia on January 26, 1944 with difficulty. A complete reduction of the fracture was obtained, this being hxed with a Sherman plate. The fibula was also reduced through a separate

incision

and approximated

wounds took place by primary from the hospital

on March

end to end. Healing

intention

9, i944with

and patient lateral

of the

was discharged

plaster

splints applied

supportively. He returned

as an outpatient

for further observation

on May

14th

was readmitted to the hospital so that the bone plate which was causing some pain and which showed some absorption around one of the screws

could be removed.

day and the patient He continued

This

was discharged as an outpatient

was carried

out the following

from the hospital and

as healing

on May 23rd. did not

satis-

factorily take place and a non-union developed, bone graft was advised. He delayed this for two months before being readmitted to the hospita1 on February 5, 1944, this being hfteen months after the

initial

pentotha1

injury. anesthesia

He was operated a Iateral

sliding

on February bone graft

7th when

under

with two Sherman

screws for fixation was carried out. Postoperative course was uneventful, wound heaIed per primam and the patient was discharged from the hospital on March 17th, with his leg in a cast and with instructions to continue as an outpatient for further observation. He returned as such and sixteen weeks after the grafting was carried out a solid bony union had taken pIace which permitted the patient full weight bearing without external support. When last seen one month ago patient was compIetely heaIed, was back at work as an engineer and had no complaints whatsoever.

WAGNER-BONE

GRAFTING

SUMMARY

have

We

carrying lateral

just

presented

out an inlay approach.

The

anterior

approach

incIuded

the location

placed,

tion of morticing

been

graft

of this

discussed

of fixation

of the

bone

of the incision

technic

through

approach

in detail.

used

This

the

oId

discussion

for its being so and the utiliza-

of the graft to further

aid in fixation.

five cases in which this procedure

methods of fixation being empIoyed. show the progress of these cases.

in

an antero-

over

and the reasons

with its advantages,

and impacting

We have summarized various pictures

tibia1

advantages

have

the method

a discussion

sliding

The

was used,

accompanying

DISCUSSION JAMES SPENCER SPEED (Memphis) Dr. Wagner advantages rather

very much. of placing

has been pointed

IarIy the avoidance tibia.

grafts

than on the anterior

This

These

: I have enjoyed

this presentation

He has shown us from a practica1 or pIates

surface

the

of the tibia

media1 surface. out to have many obvious

of adherred

frequentry

on the IateraI

by

standpoint

scars on the anterior

require

extensive

can be done if you contemplate

either

pIastic

advantages,

particu-

media1 surface

work before

the dual graft

of the

a bone graft

on both

sides or a

single inlay or inIay graft on the media1 side. It has an added advantage against

the latera

frequentIy abIe,

without

but

in cases

introduction

surface

in that the compressive

of the tibia

any type of fixation. where

a flare-up

maintains

action of the muscles

the position

I prefer fixation

of infection

of the graft

if it seems advis-

may be anticipated

of screws adds to the risks, one can appIy these grafts

as an inIay or onIay,

whichever

one prefers,

aIong the IateraI

many cases where there is an open sinus on the media1 surface the graft

may be applied,

approach

just

infection.

This

without

lateral

procedure

infection

without

to the crest

treatment

thus avoiding

has been empIoyed

in the operative

I was very much interested on in the presence

preliminary of the tibia,

of non-union

the either

surface.

In

of the tibia,

of this area, by the area of

by us in a number

of cases

site.

in seeing some of the plates pIus infection,

that were put

and I think

many

of us

perhaps wouId criticize pIace. In Dr. Wagner’s

this procedure as such, but it has a very definite cases he utiIized the application of a pIate during

the period

to improve

of infection,

his position

and maintain

position

in

preparation or anticipation of a subsequent graft. This is a very vaIuabIe thing to do in many cases, because it eIiminates the necessity for extensive trauma at the time of the bone graft. I have had a number of cases in which

union has occurred

in spite of

WAGNER-BONE

298 infectioti,

GRAFTING

following the use of a pIate as a preliminary

position

for subsequent

of the graft,

I think,

graft.

The

Iateral

measure

approach,

the

is ideal for any type of case, evensimpIe

and we have used it almost

uniformIy

in our single grafts.

the use of the Iateral pIacing of the graft to medial placing outIined

by Dr. Wagner.

It shouId be utilized

RALPH G. CAROTHERS (Cincinnati)

to maintain

IateraI

pIacing

non-unions, I much prefer

for the purposes

more.

: I, too, have enjoyed this paper very-

much and I shouId like to bring up just two points: One is the IateraI approach, do not think subject

there

Lvhich is just good, plain, common

is anything

more to be said about

sense. I

it. The other

is the

of a pIate in a dirty case. We have been in the habit of using pIates or

screws for compound

fractures

they w-i11have to be taken immobilization

and lessening

One very dramatic

when they are fresh, even though

out later. There the amount

case occurred

tabes,

who had phIebitis

filthy.

It was through

is the advantage of scar.

two months

ago in a man who had

in the leg and an uIcer as big as a plate which was

that uIcer that he compounded

best surgery would be to make a transverse have been in trouble

incision

the leg. I thought

and strangeIy

he is stiI1 wearing his plate. The fracture

enough,

the

at his neck but I might

with the police if I had done that,

and gave him penicillin

we knob\

of maintaining

so I pIated the tibia

the whoIe thing healed,

healed and his condition

and

progressed

satisfactorily. HOMER STRYKER (Kalamazoo)

: I just want to add a point or two.

We have used this aImost routinely

but many times we use a graft from

the other

leg. We find it is not necessary

exposure.

You

anterior

do not have to remove

at al1 but just make a channel,

the periosteum

to make

nearIy

the periosteum chipping

and at the Iower end inserting

as much

of an

and scar from the

off a IittIe of the bone with it into the bone as the flare

goes out. Then perhaps a screw or two in the upper end is all that is required. Another

thing:

In these

united and it is necessary be attached

cases

to the soft tissue

In chiIdren primary

the fibuIa

has

side, with the periosteum

Ietting it go over against

fibular graft which aIready

with Ioss of bone substance

Ioss of bone substance,

in which

on the fibuIa, Iet the fibuIa still

on the Iateral

moved on the side toward the tibia, gives an additional

of non-union,

to do an osteotomy

the graft.

reThis

has its brood suppIy.

through

compound

we put a pin through

fractures

or

the upper end of the

tibia and one through the Iower end, or perhaps the OS calcis, unti1 the fibuIa is united enough to maintain the Iength. Later bridge that gap with a massive bone graft such as has been shown previousIy in the meeting. J. HUBER WAGNER (cIosing) : I just presented here and did not want to go into the grafts

the method and procedure

as I did. I think

this method

readiIy does away with the use of the fibuIa as a graft. Concerning going over to the other leg, that is another idea1 of this. There is aIways enough bone Ieft in any fracture that you can graft in the

WAGNER-BONE tibia,

whether

it be above

side. That

is the privilege

the entire

portion

GRAFTING

or beIow. You do not have to go into the other you have here. You can take as much as half of

of the tibia

and the good leg is not taking

and transpose

it. It lessens operative

shock

a chance.

I think the time for the use of fibuIa grafts stir up any discussion,

299

has passed.

I do not want to

but thank you very much for discussing

my paper.