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Living sutures
LIVING SUTURES AS A SUPPLEMENT
TO PLASTIC BONE SURGERY*
CHAS. MURRAY GRATZ,M.D. NEW
T
AND RICHARD YORK
HE successful transpIantation of Iibrous tissues has resulted from basicaIly sound research and wide
FIG. I. X-ray of peIvis October I, 193I. Note separation of symphysis pubis; downward displacement of right side of pelvis; fracture at junction of ramus of ischium and ramus of pubis; fracture at junction of ramus of ischium with tuberosity of ischium.
cIinica1 observation. The abihty of these tissues when used in the form of sutures
P. ROBISON,
M.D.
CITY
to grow soIidIy to bone, muscIe and fascia, coaptated, has been fairly ij properly definiteIy estabIished and makes unnecessary further reiteration of their advantages over absorbabIe and non-absorbabIe sutures in selected cases. It wouId, therefore, seem IogicaI to assume that physioIogicaIIy Iiving sutures should be a vaIuabIe suppIement in certain cases requiring pIastic bone surgery, where by forming a scaffoId over or through the component host and scion tissues, a more expeditious bony union might resuIt. In going over the Iiterature, Patterson’ reports the use of fascia Iata in 14 cases of fractures and dislocations; 5 cases are reported in fuI1 and good resuIts were obtained in the entire series. In one case infection occurred, but the suture survived the infection for over two weeks. In the 5 cases fuIIy reported fascia Iata from the thigh was used and in one case a fragment of bone was used as a modified graft with good resuIts. The use of a maximum amount of autogenous tissue with an equabIe decrease in foreign material is indicative of the present trend in surgery. In devising a technique, however, the exponents of this principle encounter obstacIes. The primary diffrcuIty is the frequent necessity of two extra incisions, one to secure the osseous graft and the other to obtain the fascia1 transpIant . By virtue of the extra incisions the severity of the operation is increased; the patient may take exception to too many and unIess care is exercised incisions, may become unduIy the technique compIicated.
* From the Departments of Orthopedic Surgery, New York Post-Graduate HospitaI-Columbia University. (Case report from Broad Street Hospital.) Presented before the Section on Orthopedic Surgery, N. Y. Academy of Medicine.
362
NEW SERIES VOL. XXVI, No. z
Gratz & Robison-Living
The ehmination of one incision is possibIe in many cases by a careful study of the anatomica structures involved, and in the
FIG. 2. X-ray October I, 1931. with marked overriding and fragments with large spicuIe of fracture wideIy separating
Supracondylar fracture lateral dispIacement of of bone in upper part fragments.
case herewith reported, it was most easiIy applied. ShouId the tensiIe strength of a periostea1 suture suffice, periosteum from the site of the osseous graft is often readiIy available. In operations involving the knee the fibrous tissue necessary may be obtained by the incision exposing the invoIved parts as iIIustrated by Ober’s technique.2 In certain spina cases, erector spinae fascia has been successfuIIy used by the author to anchor spina grafts. In addition to the choice of correct structures to facilitate permanent repair, a definite effort shouId be made to obtain the maximum strength of interna fixation. For this reason it is necessary to possess at Ieast a fair working knowIedge of the tensiIe strength of fibrous tissues,3 and the seIection shouId be guided not onIy by the type but by the size of the suture necessary. It is my beIief that the operative procedure frequentIy used has not afforded the greatest strength of interna fixation
Sutures
American
~~~~~~~ Of
surgery
363
because of the insufficient attention given to the anchoring of the fascia1 transpIants. A very carefu1 study of the technique as
FIG. 3. X-rays
May 16, 1933. End-result.
reported in the literature wouId seem to indicate that this may account for some of the faiIures reported. If the transpIants themseIves depend for anchorage on absorbabIe or non-absorbabIe sutures, this technique would seem to be Iess advantageous than one in which the entire strain is borne by the sutures themseIves.4 The uItimate fate of Iiving sutures is aIways of extreme interest and the opportunity to examine them cIinicaIIy after they have been in pIace many years is unfortunateIy rare. The observations of BunneII,b based on records of 461 free grafts of fascia and tendon are of great interest. BunneII states : “A tendon or fascia1 graft which is given the function of resisting repeated tension wiI1 hypertrophy in response to the demand. If, however, the force to which it is subjected is too great and too constant, the tissue, whether natura1 or a graft, wiI1 atrophy and yieId.” The dividing Iine between these two extremes: hypertrophy and atrophy, is in a11probabiIity the safe working Ioad of the transpIanted tissues used. PhysioIogicaIIy,
364
Journal of Surgery American
Gratz
& Robison-Living
if the transplant has to bear a Ioad in excess of this, the behavior of the tissues under tension wouId appear to indicate a dis-
Sutures
NOVEMBER,
In the case report which foIIows two fascia Iata sutures, 3$ inch in width, were used to suppIement a bone peg. By the
FIG. 4. Technique. I. Anteroposterior view showing re-alignment of fragments; site for reception sectiona view. II. Anteroposterior view showing site of Gallie pins (sectional view). III. Lateral views showing technique. IV. Anteroposterior view of compIeted technique.
integration of the fibers. This wouId account for the phenomena of atrophy as noted.
ISIM
caIcuIations previousIy aIone shouId withstand 64.4 Ibs.3 Enumeration
of graft with and sectional
made the sutures a safe tension of of these factors
NEW SERIES VOL. XXVI,
No. 2
Gratz
may cIarify a few probIems this type of work. CASE
& Robison-Living
to be met in
Sutures
American ~~~~~~~of
surgery 365
We considered that this method in conjunction with the sIing was the simpIest and most effective in getting satisfactory results on this
REPORT
stock L. F., male, aged forty-nine yesrs, , broker, was first seen in Broad Street HospitaI on September zg, 1931. The patient had been picked up by the ambuIance after falIing two stories. He was unconscious and semi-moribund. There were a11 the signs of compound fracture of the lower third of the right femur; exquisite pain over the peIvis, particuIarIy over the crest of the iIium; marked sweIIing of the Ieft ankle; a Iaceration s inch Iong over the Ieft eyebrow. The heart sounds were very faint, the reflexes sIuggish. BIood pressure 60/35. Emergency treatment for shock was given and the area of compound fracture thoroughry cIeaned with temporary spIinting of the involved areas. It was noted that there was a 13s inch shortening of the right Ieg as compared with the left. The working diagnosis, after indicated consultations and x-ray examinations, was as foIIows : (I) Compound supracondyIar fracture of the Iower third of the? right femur; (2) muItipIe fracture of the peIvis; (3) fracture of both maIIeoIi of the Ieft ankIe; (4) cerebra1 concussion. DetaiIs of the first tw-o are shown in Figures I and 2. The muItiplicity of the fractures and the fact that they were a11 invoIved in weight bearing necessitated a carefuIIy pIanned sequence of treatment. The peIvis received first consideration. Very fortunateIy, in spite of the fact that there was a 3 cm. separation of the symphysis pubis and a compIete fracture of the pubis and ischium, there was no invoIvement of the bIadder. A linen hammock about 14 inches wide was pIaced beneath the peIvis, extending from the Iower Iumbar region of the spine to beneath the buttocks; each side of this sling was fastened by means of a puIIey to a BaIkan frame and 20 Ib. traction used on either side. The resuIt obtained is shown in Figure 3. The next in order was the femur. The area of compound fracture had been thoroughIy cleaned and prepared when the patient was first seen, and infection was avoided. RusseII traction was seIected and the foot of the bed eIevated.
FIG. 5. X-rays December 17, 1931. LateraI view showing contour of femur and bone peg.
case as it avoided any countertraction against the injured pelvis. The bi-maIIeoIar fracture of the left ankIe was reduced and heId in suitabIe position by a cast and good result obtained. Of the three groups of fractures, satisfactory resuIts had been obtained by conservative methods in two, but further work was necessary on the third, i.e. the femur. Open operation was decided upon. Inasmuch as this treatment wouId necessitate the use of a pIaster spica until heaIing was compIeted, operation was deIayed unti1 satisfactory reduction of the fracture of the pelvis was obtained.
366
American Journal of Surgery
Gratz
& Robison-Living
examination discIosed Tho Irough medica three abscessed teeth which were removed before operation.
FIG. 6. X-rays
NOVEMBER , 1934
reception in the femur. To counteract must :uIar puI1, which might cause anguIation of the graft, GaIIie bone pins were placed thrc>ugh
May 16,
The operation of choice was an autogenous by living tibia1 bone peg, suppIemented sutures, The Iatter were obtained from the thigh of the same Ieg and the technique used for the operation is graphicaIIy iIIustrated in Figure 4. The operation was done under genera1 anesthesia on November 4, 1931. The patient was pIaced on the AIbee tabIe with sufficient traction to reduce the fracture. A IateraI incision exposed the fascia Iata; two sutures about 34 inch in width removed; the incision deepened to expose the osseous structure; spicule of bone and fibrous tissue found between the fragments removed and the fracture approximated and heId in position by suitabIe clamps. The reamer designed by AIbee for his bone peg operation was used to driI1 a hoIe through the centra1 portion of the fractured area. The bone peg taken from the crest of the tibia of the same side was prepared by using the Atbee miI1 and fitted accurately for
Sutures
1933.
End-resuIt.
each end of the graft. The fascia Iata sutures were pIaced one above and one beIow the bone peg and tied with a reinforced square knot, sutured to the periosteum and the ends which had been traumatized in their transpIantation carefuIIy removed. The suture threader was of assistance in pIacing the living sutures.6 CIosure was made in the usual manner and a pIaster spica appIied. The postoperative course was uneventful. The immediate postoperative x-rays showed good reduction. Later x-rays showed an upward dispIacement of the distal fragment with a sIight sIipping of the bone graft. Whether this was due to the prepared bone peg breaking or shear through the graft of the autogenous bone, is pureIy a matter of conjecture. However, the clinica course of the case wouId seem to indicate that the living sutures heId and prevented further overriding of the fragments. X-rays taken December 17, 1931 when the first spica was removed are shown (Fig. 5). The second spica was removed and weight
NEW SERIES VOL.XXVI, No. 2
Gratz
& Robison-Living
bearing with the aid of a brace started
January 20, 1932. Physiotherapy was instituted and the convalescence was uneventful. The endresult is shown in Figure 6. The downward dispIacement due to the fracture of the pelvis compensated for the slight overriding at the site of operation of the right femur, with the result that there was no functional shortening. May 19, 1933, the patient was able to walk without a limp and without the aid of any support.
SUMMARY
I. Living sutures in the case reported and in previous cases reviewed have been successfuhy used as a supplement to pIastic bone surgery. 2. The operation was accomphshed by a comparativeIy simpIe technique and the living sutures were obtained from the incision exposing the site of operation. 3. The technique was so devised that the fuII strength and eIasticity of the sutures were utilized and they were used within their safe working load. The cIinica1 course of the case indicates that ahhough the bone peg gave the Iiving sutures were sufficientIy strong to prevent further overriding of the fragments.
Sutures
American
~~~~~~~ ofsuraery
36;
4. CaIIus formation may have been assisted by using one autogenous bone peg and two autogenous sutures, the Iatter being tied in a Ioop which actuaIIy gave five scaffoIds of autogenous mesodermic materia1 bridging the area of fracture. Comment: The strength of interna fixation may be definiteIy increased by anatomica and mechanica study of the structures invoIved, and by so doing the operation may be planned so that the safe working Ioad of the transpIant is considered and the danger of atrophy CorrespondingIy decreased. I wish to acknowIedge with thanks H. Albee’s consuhation and advice.
Dr. Fred
REFERENCES I. PATTERSON, R. H. InternaI fixation of fractures
and dislocations by use of human fascia Iata. Am. Surg., 88: 879-84, 1928. 2. OBER, F. R. Fracture of patella: a new operation. J. Bone H Joint Surg., 14: 640-643, 1932. 3. GRATZ, C. M. TensiIe strength and eIasticity tests on human fascia Iata. J. Bone Ed Joint Surg., 13: 334-340,
193’.
4. GRATZ. C. M. The use of fasciae in reconstructive and pIastic surgery - _ with specia1 reference to opera&e technique. Ann. Surg., gg: 241-245, 1934. r;. BUNNELL. S. Discussion of Haas. S. L. Free fascia1 grafts; union with muscIe; cases. Cafij. @Y Western Med., 32: 387-93, 1930. 6. GRATZ, C. M. New instruments for living sutures. AK J. SURG., n.s. 13: 81-82, 1931.
TO PLASTIC BONE SURGERY*
CHAS. MURRAY GRATZ,M.D. NEW
T
AND RICHARD YORK
HE successful transpIantation of Iibrous tissues has resulted from basicaIly sound research and wide
FIG. I. X-ray of peIvis October I, 193I. Note separation of symphysis pubis; downward displacement of right side of pelvis; fracture at junction of ramus of ischium and ramus of pubis; fracture at junction of ramus of ischium with tuberosity of ischium.
cIinica1 observation. The abihty of these tissues when used in the form of sutures
P. ROBISON,
M.D.
CITY
to grow soIidIy to bone, muscIe and fascia, coaptated, has been fairly ij properly definiteIy estabIished and makes unnecessary further reiteration of their advantages over absorbabIe and non-absorbabIe sutures in selected cases. It wouId, therefore, seem IogicaI to assume that physioIogicaIIy Iiving sutures should be a vaIuabIe suppIement in certain cases requiring pIastic bone surgery, where by forming a scaffoId over or through the component host and scion tissues, a more expeditious bony union might resuIt. In going over the Iiterature, Patterson’ reports the use of fascia Iata in 14 cases of fractures and dislocations; 5 cases are reported in fuI1 and good resuIts were obtained in the entire series. In one case infection occurred, but the suture survived the infection for over two weeks. In the 5 cases fuIIy reported fascia Iata from the thigh was used and in one case a fragment of bone was used as a modified graft with good resuIts. The use of a maximum amount of autogenous tissue with an equabIe decrease in foreign material is indicative of the present trend in surgery. In devising a technique, however, the exponents of this principle encounter obstacIes. The primary diffrcuIty is the frequent necessity of two extra incisions, one to secure the osseous graft and the other to obtain the fascia1 transpIant . By virtue of the extra incisions the severity of the operation is increased; the patient may take exception to too many and unIess care is exercised incisions, may become unduIy the technique compIicated.
* From the Departments of Orthopedic Surgery, New York Post-Graduate HospitaI-Columbia University. (Case report from Broad Street Hospital.) Presented before the Section on Orthopedic Surgery, N. Y. Academy of Medicine.
362
NEW SERIES VOL. XXVI, No. z
Gratz & Robison-Living
The ehmination of one incision is possibIe in many cases by a careful study of the anatomica structures involved, and in the
FIG. 2. X-ray October I, 1931. with marked overriding and fragments with large spicuIe of fracture wideIy separating
Supracondylar fracture lateral dispIacement of of bone in upper part fragments.
case herewith reported, it was most easiIy applied. ShouId the tensiIe strength of a periostea1 suture suffice, periosteum from the site of the osseous graft is often readiIy available. In operations involving the knee the fibrous tissue necessary may be obtained by the incision exposing the invoIved parts as iIIustrated by Ober’s technique.2 In certain spina cases, erector spinae fascia has been successfuIIy used by the author to anchor spina grafts. In addition to the choice of correct structures to facilitate permanent repair, a definite effort shouId be made to obtain the maximum strength of interna fixation. For this reason it is necessary to possess at Ieast a fair working knowIedge of the tensiIe strength of fibrous tissues,3 and the seIection shouId be guided not onIy by the type but by the size of the suture necessary. It is my beIief that the operative procedure frequentIy used has not afforded the greatest strength of interna fixation
Sutures
American
~~~~~~~ Of
surgery
363
because of the insufficient attention given to the anchoring of the fascia1 transpIants. A very carefu1 study of the technique as
FIG. 3. X-rays
May 16, 1933. End-result.
reported in the literature wouId seem to indicate that this may account for some of the faiIures reported. If the transpIants themseIves depend for anchorage on absorbabIe or non-absorbabIe sutures, this technique would seem to be Iess advantageous than one in which the entire strain is borne by the sutures themseIves.4 The uItimate fate of Iiving sutures is aIways of extreme interest and the opportunity to examine them cIinicaIIy after they have been in pIace many years is unfortunateIy rare. The observations of BunneII,b based on records of 461 free grafts of fascia and tendon are of great interest. BunneII states : “A tendon or fascia1 graft which is given the function of resisting repeated tension wiI1 hypertrophy in response to the demand. If, however, the force to which it is subjected is too great and too constant, the tissue, whether natura1 or a graft, wiI1 atrophy and yieId.” The dividing Iine between these two extremes: hypertrophy and atrophy, is in a11probabiIity the safe working Ioad of the transpIanted tissues used. PhysioIogicaIIy,
364
Journal of Surgery American
Gratz
& Robison-Living
if the transplant has to bear a Ioad in excess of this, the behavior of the tissues under tension wouId appear to indicate a dis-
Sutures
NOVEMBER,
In the case report which foIIows two fascia Iata sutures, 3$ inch in width, were used to suppIement a bone peg. By the
FIG. 4. Technique. I. Anteroposterior view showing re-alignment of fragments; site for reception sectiona view. II. Anteroposterior view showing site of Gallie pins (sectional view). III. Lateral views showing technique. IV. Anteroposterior view of compIeted technique.
integration of the fibers. This wouId account for the phenomena of atrophy as noted.
ISIM
caIcuIations previousIy aIone shouId withstand 64.4 Ibs.3 Enumeration
of graft with and sectional
made the sutures a safe tension of of these factors
NEW SERIES VOL. XXVI,
No. 2
Gratz
may cIarify a few probIems this type of work. CASE
& Robison-Living
to be met in
Sutures
American ~~~~~~~of
surgery 365
We considered that this method in conjunction with the sIing was the simpIest and most effective in getting satisfactory results on this
REPORT
stock L. F., male, aged forty-nine yesrs, , broker, was first seen in Broad Street HospitaI on September zg, 1931. The patient had been picked up by the ambuIance after falIing two stories. He was unconscious and semi-moribund. There were a11 the signs of compound fracture of the lower third of the right femur; exquisite pain over the peIvis, particuIarIy over the crest of the iIium; marked sweIIing of the Ieft ankle; a Iaceration s inch Iong over the Ieft eyebrow. The heart sounds were very faint, the reflexes sIuggish. BIood pressure 60/35. Emergency treatment for shock was given and the area of compound fracture thoroughry cIeaned with temporary spIinting of the involved areas. It was noted that there was a 13s inch shortening of the right Ieg as compared with the left. The working diagnosis, after indicated consultations and x-ray examinations, was as foIIows : (I) Compound supracondyIar fracture of the Iower third of the? right femur; (2) muItipIe fracture of the peIvis; (3) fracture of both maIIeoIi of the Ieft ankIe; (4) cerebra1 concussion. DetaiIs of the first tw-o are shown in Figures I and 2. The muItiplicity of the fractures and the fact that they were a11 invoIved in weight bearing necessitated a carefuIIy pIanned sequence of treatment. The peIvis received first consideration. Very fortunateIy, in spite of the fact that there was a 3 cm. separation of the symphysis pubis and a compIete fracture of the pubis and ischium, there was no invoIvement of the bIadder. A linen hammock about 14 inches wide was pIaced beneath the peIvis, extending from the Iower Iumbar region of the spine to beneath the buttocks; each side of this sling was fastened by means of a puIIey to a BaIkan frame and 20 Ib. traction used on either side. The resuIt obtained is shown in Figure 3. The next in order was the femur. The area of compound fracture had been thoroughIy cleaned and prepared when the patient was first seen, and infection was avoided. RusseII traction was seIected and the foot of the bed eIevated.
FIG. 5. X-rays December 17, 1931. LateraI view showing contour of femur and bone peg.
case as it avoided any countertraction against the injured pelvis. The bi-maIIeoIar fracture of the left ankIe was reduced and heId in suitabIe position by a cast and good result obtained. Of the three groups of fractures, satisfactory resuIts had been obtained by conservative methods in two, but further work was necessary on the third, i.e. the femur. Open operation was decided upon. Inasmuch as this treatment wouId necessitate the use of a pIaster spica until heaIing was compIeted, operation was deIayed unti1 satisfactory reduction of the fracture of the pelvis was obtained.
366
American Journal of Surgery
Gratz
& Robison-Living
examination discIosed Tho Irough medica three abscessed teeth which were removed before operation.
FIG. 6. X-rays
NOVEMBER , 1934
reception in the femur. To counteract must :uIar puI1, which might cause anguIation of the graft, GaIIie bone pins were placed thrc>ugh
May 16,
The operation of choice was an autogenous by living tibia1 bone peg, suppIemented sutures, The Iatter were obtained from the thigh of the same Ieg and the technique used for the operation is graphicaIIy iIIustrated in Figure 4. The operation was done under genera1 anesthesia on November 4, 1931. The patient was pIaced on the AIbee tabIe with sufficient traction to reduce the fracture. A IateraI incision exposed the fascia Iata; two sutures about 34 inch in width removed; the incision deepened to expose the osseous structure; spicule of bone and fibrous tissue found between the fragments removed and the fracture approximated and heId in position by suitabIe clamps. The reamer designed by AIbee for his bone peg operation was used to driI1 a hoIe through the centra1 portion of the fractured area. The bone peg taken from the crest of the tibia of the same side was prepared by using the Atbee miI1 and fitted accurately for
Sutures
1933.
End-resuIt.
each end of the graft. The fascia Iata sutures were pIaced one above and one beIow the bone peg and tied with a reinforced square knot, sutured to the periosteum and the ends which had been traumatized in their transpIantation carefuIIy removed. The suture threader was of assistance in pIacing the living sutures.6 CIosure was made in the usual manner and a pIaster spica appIied. The postoperative course was uneventful. The immediate postoperative x-rays showed good reduction. Later x-rays showed an upward dispIacement of the distal fragment with a sIight sIipping of the bone graft. Whether this was due to the prepared bone peg breaking or shear through the graft of the autogenous bone, is pureIy a matter of conjecture. However, the clinica course of the case wouId seem to indicate that the living sutures heId and prevented further overriding of the fragments. X-rays taken December 17, 1931 when the first spica was removed are shown (Fig. 5). The second spica was removed and weight
NEW SERIES VOL.XXVI, No. 2
Gratz
& Robison-Living
bearing with the aid of a brace started
January 20, 1932. Physiotherapy was instituted and the convalescence was uneventful. The endresult is shown in Figure 6. The downward dispIacement due to the fracture of the pelvis compensated for the slight overriding at the site of operation of the right femur, with the result that there was no functional shortening. May 19, 1933, the patient was able to walk without a limp and without the aid of any support.
SUMMARY
I. Living sutures in the case reported and in previous cases reviewed have been successfuhy used as a supplement to pIastic bone surgery. 2. The operation was accomphshed by a comparativeIy simpIe technique and the living sutures were obtained from the incision exposing the site of operation. 3. The technique was so devised that the fuII strength and eIasticity of the sutures were utilized and they were used within their safe working load. The cIinica1 course of the case indicates that ahhough the bone peg gave the Iiving sutures were sufficientIy strong to prevent further overriding of the fragments.
Sutures
American
~~~~~~~ ofsuraery
36;
4. CaIIus formation may have been assisted by using one autogenous bone peg and two autogenous sutures, the Iatter being tied in a Ioop which actuaIIy gave five scaffoIds of autogenous mesodermic materia1 bridging the area of fracture. Comment: The strength of interna fixation may be definiteIy increased by anatomica and mechanica study of the structures invoIved, and by so doing the operation may be planned so that the safe working Ioad of the transpIant is considered and the danger of atrophy CorrespondingIy decreased. I wish to acknowIedge with thanks H. Albee’s consuhation and advice.
Dr. Fred
REFERENCES I. PATTERSON, R. H. InternaI fixation of fractures
and dislocations by use of human fascia Iata. Am. Surg., 88: 879-84, 1928. 2. OBER, F. R. Fracture of patella: a new operation. J. Bone H Joint Surg., 14: 640-643, 1932. 3. GRATZ, C. M. TensiIe strength and eIasticity tests on human fascia Iata. J. Bone Ed Joint Surg., 13: 334-340,
193’.
4. GRATZ. C. M. The use of fasciae in reconstructive and pIastic surgery - _ with specia1 reference to opera&e technique. Ann. Surg., gg: 241-245, 1934. r;. BUNNELL. S. Discussion of Haas. S. L. Free fascia1 grafts; union with muscIe; cases. Cafij. @Y Western Med., 32: 387-93, 1930. 6. GRATZ, C. M. New instruments for living sutures. AK J. SURG., n.s. 13: 81-82, 1931.