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The preparation of autogenous bone grafts with osteotomes
THE PREPARATION
OF AUTOGENOUS
WITH
OSTEOTOMES*
WALTER G. STUCK, SAN
BONE GRAFTS
ANTONIO,
E
VEN though the first successfu1 bone grafting operation was described by Jobi Meekren of Amsterdam in I 682, t the modern utihzation of transpIanted bone dates from AIbee’s pioneer operations which were reported in 1913. At the end of the nineteenth century Barth, Radzimowsky and others had studied the pathoIogy of bone transpIants in animaIs but to AIbee credit is due for initiating the use of bone grafts in cIinica1 surgery. In the ensuing twenty-five years autogenous bone grafts have been found to be indispensabIe in the repair of bony defects, in the heaIing of ununited fractures and in producing soIid fusion of certain diseased joints. The usua1 operation of bone grafting invoIves the remova of a portion of the tibia1 cortex by means of a circuIar motor saw and transpIantation of the piece of bone to another part of the body. Henderson and CampbeII have shown that “massive onIay ” grafts, which are Iarge pieces of cortica1 bone Iaid on a prepared area with wide meduIIary contact, are more successfu1 than the origina “inIay” type of grafts which are fitted into a carefuIIy sawed groove. During the past two years I have been removing autogenous bone grafts from the tibia by means of sharp thin osteotomes instead of the customary saws and have been impressed with their superior efhciency. In twenty-eight bone graft operations performed in this way on patients of a11 ages, the one faiIure was in a chiId with t Meekren transpIanted a piece of bone from the skuII of a dog into the defect in a soldier’s cranium produced by injury in battle. It heaIed we11but when the church heard of this infamy they required Meekren to remove the foreign bone under ban of excommunication.
M.D.
TEXAS
tubercuIosis of the spine with marked kyphosis. In this case the graft did not conform properIy to the curve and hence did not hea soIidIy in its new position. The foIlowing advantages of this osteotome technique make it worth consideration in certain instances : I. High speed motor saws, when improperly used, burn the edges of the graft. UnIess the saw is kept coo1 with a stream of water or is swept aIong the bone in short strokes, much heat is generated. This sears the tiny bIood vesseIs along the edges of the graft, poIishes the surfaces and consequently deIays revascuIarization in the new bed. In 1932 GhormIey and I performed a number of bone grafts to the spine in dogs and studied among other things the effects of burning the graft with an uncooIed high speed saw. This inhibited bone growth in severa instances. Of course, when orthopedic surgeons use a motor saw properIy and eschew overheating there is no interference with heaIing of the graft. 2. Grafts removed with osteotomes have raw irregular edges which heal quickly in their new locations. If revascuIarization can take pIace rapidIy a11 the bone ceIIs do not die and the compIete repIacement of the graft by new ceIIs is not necessary. Thus in this group of twenty-eight cases there seemed to be more rapid cIinica1 union of the transpIanted bone, which I assume to be due to more rapid re&stabIishment of norma bIood suppIy to the bone. 3. The best motor saws sometimes break down in the midst of an operation and a substitute method for removing a graft ensures no delay in the operation. It is not uncommon also when operating in more than one hospita1 to find a defective
* Presented before the Texas Railway Surgeons Association,
340
May 8, 1939.
Stuck-Bone
NEW SERIESVOL. LI. No. 2
or outmoded saw which cannot be used efficientIy at the time it is needed. 4. The massive onlay graft as developed
Grafts
American Journd of Surgery
35’
which hasten heaIing and stimuIate the formation of new bone. If the bed where the graft is to be transpIanted has been pre-
by Henderson and Campbell is eminently successful in the repair of bone defects and since it does not need to be fitted accurately into a perfect groove, its edges can be quite irregular. Therefore a “carpenter’s fit” which can be achieved by saws is not necessary and a comparativeIy irreguIar graft is entirely suitable. OPERATIVE
TECHNIC
A Iong incision is made over the anteromedia1 surface of the upper haIf of the tibia which divides skin, fascia, and periosteum down to the cortex of the bone. The tissues are then retracted so that the media1 face of the tibia is exposed. (In aduIts it is not important to preserve the periosteum with the graft and even in chiIdren the presence or absence of periosteum seems to make IittIe difference in the rate of heaIing of the graft.) With caIipers or a meta ruIer the size of the required graft is determined and is then outlined on the tibia with a sharp knife. (Fig. I .) Cuts are made around the graft with sharp thin osteotomes and with onIy one bIow of the maIIet at each point. PreviousIy muItipIe driI1 hoIes were made around the graft but this has been found to’ be unnecessary. The graft begins to come Ioose after the bIows are made on the osteotome a second time and can usuaIIy be removed during the third cutting. (Fig. 2.) If instruments are sharp and the maIIet bIows are of moderate force this can be performed in patients of a11 ages without d&cuIty and with no great danger of splitting the tibia. If the graft is to be anchored with vitaIIium screws or bone pegs, it is we11 to determine the sites of the hoIes in the graft and driI1 them before removing it from the tibia. After the graft is removed it is pIaced in a warm saIine sponge whiIe scraps of canceIIous bone are curetted from the upper end of the meduIIary space in the tibia. (Fig. 3.) This soft highIy vascuIar bone possesses great ceIIuIar growth powers
FIG. I. Method of measuring and marking outline of graft on the inner face of the tibia.
pared in advance the bone can be placed in position without deIay and the cancehous bone scraps packed around it. While bone grafts can be kept out of the body as Iong as necessary during such operations, they succeed better if they are transplanted with reasonabIe ceIerity. Except in spina fusions it is advantageous to anchor bone grafts secureIy to the adjacent fragments and to protect the extremity with a cast which immobiIizes the Iong bone and the contiguous joints. Since VenabIe and I have demonstrated the eIectroIytic effects of metaIs in bone and have introduced the passive aIIoy
352
American
Stuck-Bone
Journal of Surgery
FIG. 2. Freeing the graft from the tibia by the use of thin sharp osteotome (see inset) and malIet.
A
Grafts
FIG. 3. which from cavity
Curettement of cancellous bone is used to pack about the graft the upper half of the meduIlary of the tibia.
B
FIG. 4. A, H. C., age 51. Fracture of the left humerus six years previously. Complete nonunion with we11 developed pseudarthrosis in the middle of the shaft of the bone. B, false joint removed, ends trimmed and Iarge cortical bone graft anchored to fragments with four vitallium screws.
NEW SERIES VOL.LI, No. 2
Stuck-Bone
Grafts
American Journal of Surgery
353
vitaIIium into bone surgery, it is admirabIy suited for fixation of grafts. Sometimes I have used vitaIIium screws aIone to anchor a graft (Fig. 4.) and at other times I have recessed the graft in the bone ends and pIaced a Iong vitaIIium pIate over it. No matter what type of interna fixation is used it is quite important that the member shouId be immobiIized in a cast or brace for severa months or unti1 the graft is soIidIy heaIed in its new Iocation. Patients sometimes compIain of gnawing pain in the Ieg months after a graft has been removed from the tibia. In this series of twenty-eight patients there was the compIication of pain in the Ieg for eight months in a boy of 14 and pain and Iimp for six months in the case of a man of 32. In the other cases there were no unusua1 compIaints referabIe to the tibia from which the graft was removed.
As stated before there was one faiIure of union, in the case of a chiId with Pott’s disease and marked dorsa1 kyphosis. Two of the patients compIained of persistent pain in the Iegs for six months or Ionger. The others recovered UneventfuIIy.
TABLE I BONE GRAFT OPERATIONS Spinal fusion for paraIytic scoliosis. .............. Spinal fusion for Pott’s disease ................... LumbosacraI fusion for spondyIoIisthesis. ......... Fusion of flail joints (shotrIder, ankle). ........... Old ununited fractures .......................... Humerus ................................. Clavicle .................................. Tibia .................................... Femur ................................... Radius ..................................
ALBEE, F. H. An experimental study of bone growth and the spinal bone transplant. J. A. M. A., 60: 1044, 19’3. BARTH, ARTHUR. Ueber histoligische Befunde nach Knochenimplantationen. Arch. f. klin. Cbir., 46:
Totat.....................................
6 5
z 4 II 3 3 2 I 2
28
The group of patients in which the afore. mentroned techniaue was used comprised persons of a11 a’pes and with &ious pathoIogic Iesions requiring a bone graft. (TabIe I.)
SUMMARY
Sometimes it is preferabIe to remove bone grafts from the tibia without the customary bone saw. This can be readiIy accompIished by the use of thin sharp osteotomes and maIIet. In twenty-eight operations of a11 types in which such bone grafts were used resuIts were successfu1 in g6 per cent of the cases and there was onIy one faiIure of union of the bone graft. This method can be used on many occasions when more traditiona equipment is not avaiIabIe. REFERENCES
409, 1893.
RADZIMOWSKY.Quoted by Berg, A. A., and Thalhimer, WiIliam. Regeneration of bone. Ann. Surg., 67: 331, 1918. HENDERSON. M. S. Massive bone araft in ununited fractures. J. A. M. A., 107: I ro4rrg36. Bone grafts in ununited fractures. J. Bone IT Joint Surg., 20: 635, 1938. CAMPBELL, W. C. Ununited fractures.
Arch. Surg., 24:
R. K. and STUCK, W. G. Experimental bone transplantation. Arch. Surg., 28: 742, 1934. VENABLE. C. S. and STUCK. W. G. Recent advances in fracture treatment with non-eIectroIytic metal appbances. J. Indiana State M. A., 31: 335. x938. EIectroIysis controlling factor in the use of metals in treating fractures. J. A. M. A., I I I : I 349. 1938.
GHORMLEY,
OF AUTOGENOUS
WITH
OSTEOTOMES*
WALTER G. STUCK, SAN
BONE GRAFTS
ANTONIO,
E
VEN though the first successfu1 bone grafting operation was described by Jobi Meekren of Amsterdam in I 682, t the modern utihzation of transpIanted bone dates from AIbee’s pioneer operations which were reported in 1913. At the end of the nineteenth century Barth, Radzimowsky and others had studied the pathoIogy of bone transpIants in animaIs but to AIbee credit is due for initiating the use of bone grafts in cIinica1 surgery. In the ensuing twenty-five years autogenous bone grafts have been found to be indispensabIe in the repair of bony defects, in the heaIing of ununited fractures and in producing soIid fusion of certain diseased joints. The usua1 operation of bone grafting invoIves the remova of a portion of the tibia1 cortex by means of a circuIar motor saw and transpIantation of the piece of bone to another part of the body. Henderson and CampbeII have shown that “massive onIay ” grafts, which are Iarge pieces of cortica1 bone Iaid on a prepared area with wide meduIIary contact, are more successfu1 than the origina “inIay” type of grafts which are fitted into a carefuIIy sawed groove. During the past two years I have been removing autogenous bone grafts from the tibia by means of sharp thin osteotomes instead of the customary saws and have been impressed with their superior efhciency. In twenty-eight bone graft operations performed in this way on patients of a11 ages, the one faiIure was in a chiId with t Meekren transpIanted a piece of bone from the skuII of a dog into the defect in a soldier’s cranium produced by injury in battle. It heaIed we11but when the church heard of this infamy they required Meekren to remove the foreign bone under ban of excommunication.
M.D.
TEXAS
tubercuIosis of the spine with marked kyphosis. In this case the graft did not conform properIy to the curve and hence did not hea soIidIy in its new position. The foIlowing advantages of this osteotome technique make it worth consideration in certain instances : I. High speed motor saws, when improperly used, burn the edges of the graft. UnIess the saw is kept coo1 with a stream of water or is swept aIong the bone in short strokes, much heat is generated. This sears the tiny bIood vesseIs along the edges of the graft, poIishes the surfaces and consequently deIays revascuIarization in the new bed. In 1932 GhormIey and I performed a number of bone grafts to the spine in dogs and studied among other things the effects of burning the graft with an uncooIed high speed saw. This inhibited bone growth in severa instances. Of course, when orthopedic surgeons use a motor saw properIy and eschew overheating there is no interference with heaIing of the graft. 2. Grafts removed with osteotomes have raw irregular edges which heal quickly in their new locations. If revascuIarization can take pIace rapidIy a11 the bone ceIIs do not die and the compIete repIacement of the graft by new ceIIs is not necessary. Thus in this group of twenty-eight cases there seemed to be more rapid cIinica1 union of the transpIanted bone, which I assume to be due to more rapid re&stabIishment of norma bIood suppIy to the bone. 3. The best motor saws sometimes break down in the midst of an operation and a substitute method for removing a graft ensures no delay in the operation. It is not uncommon also when operating in more than one hospita1 to find a defective
* Presented before the Texas Railway Surgeons Association,
340
May 8, 1939.
Stuck-Bone
NEW SERIESVOL. LI. No. 2
or outmoded saw which cannot be used efficientIy at the time it is needed. 4. The massive onlay graft as developed
Grafts
American Journd of Surgery
35’
which hasten heaIing and stimuIate the formation of new bone. If the bed where the graft is to be transpIanted has been pre-
by Henderson and Campbell is eminently successful in the repair of bone defects and since it does not need to be fitted accurately into a perfect groove, its edges can be quite irregular. Therefore a “carpenter’s fit” which can be achieved by saws is not necessary and a comparativeIy irreguIar graft is entirely suitable. OPERATIVE
TECHNIC
A Iong incision is made over the anteromedia1 surface of the upper haIf of the tibia which divides skin, fascia, and periosteum down to the cortex of the bone. The tissues are then retracted so that the media1 face of the tibia is exposed. (In aduIts it is not important to preserve the periosteum with the graft and even in chiIdren the presence or absence of periosteum seems to make IittIe difference in the rate of heaIing of the graft.) With caIipers or a meta ruIer the size of the required graft is determined and is then outlined on the tibia with a sharp knife. (Fig. I .) Cuts are made around the graft with sharp thin osteotomes and with onIy one bIow of the maIIet at each point. PreviousIy muItipIe driI1 hoIes were made around the graft but this has been found to’ be unnecessary. The graft begins to come Ioose after the bIows are made on the osteotome a second time and can usuaIIy be removed during the third cutting. (Fig. 2.) If instruments are sharp and the maIIet bIows are of moderate force this can be performed in patients of a11 ages without d&cuIty and with no great danger of splitting the tibia. If the graft is to be anchored with vitaIIium screws or bone pegs, it is we11 to determine the sites of the hoIes in the graft and driI1 them before removing it from the tibia. After the graft is removed it is pIaced in a warm saIine sponge whiIe scraps of canceIIous bone are curetted from the upper end of the meduIIary space in the tibia. (Fig. 3.) This soft highIy vascuIar bone possesses great ceIIuIar growth powers
FIG. I. Method of measuring and marking outline of graft on the inner face of the tibia.
pared in advance the bone can be placed in position without deIay and the cancehous bone scraps packed around it. While bone grafts can be kept out of the body as Iong as necessary during such operations, they succeed better if they are transplanted with reasonabIe ceIerity. Except in spina fusions it is advantageous to anchor bone grafts secureIy to the adjacent fragments and to protect the extremity with a cast which immobiIizes the Iong bone and the contiguous joints. Since VenabIe and I have demonstrated the eIectroIytic effects of metaIs in bone and have introduced the passive aIIoy
352
American
Stuck-Bone
Journal of Surgery
FIG. 2. Freeing the graft from the tibia by the use of thin sharp osteotome (see inset) and malIet.
A
Grafts
FIG. 3. which from cavity
Curettement of cancellous bone is used to pack about the graft the upper half of the meduIlary of the tibia.
B
FIG. 4. A, H. C., age 51. Fracture of the left humerus six years previously. Complete nonunion with we11 developed pseudarthrosis in the middle of the shaft of the bone. B, false joint removed, ends trimmed and Iarge cortical bone graft anchored to fragments with four vitallium screws.
NEW SERIES VOL.LI, No. 2
Stuck-Bone
Grafts
American Journal of Surgery
353
vitaIIium into bone surgery, it is admirabIy suited for fixation of grafts. Sometimes I have used vitaIIium screws aIone to anchor a graft (Fig. 4.) and at other times I have recessed the graft in the bone ends and pIaced a Iong vitaIIium pIate over it. No matter what type of interna fixation is used it is quite important that the member shouId be immobiIized in a cast or brace for severa months or unti1 the graft is soIidIy heaIed in its new Iocation. Patients sometimes compIain of gnawing pain in the Ieg months after a graft has been removed from the tibia. In this series of twenty-eight patients there was the compIication of pain in the Ieg for eight months in a boy of 14 and pain and Iimp for six months in the case of a man of 32. In the other cases there were no unusua1 compIaints referabIe to the tibia from which the graft was removed.
As stated before there was one faiIure of union, in the case of a chiId with Pott’s disease and marked dorsa1 kyphosis. Two of the patients compIained of persistent pain in the Iegs for six months or Ionger. The others recovered UneventfuIIy.
TABLE I BONE GRAFT OPERATIONS Spinal fusion for paraIytic scoliosis. .............. Spinal fusion for Pott’s disease ................... LumbosacraI fusion for spondyIoIisthesis. ......... Fusion of flail joints (shotrIder, ankle). ........... Old ununited fractures .......................... Humerus ................................. Clavicle .................................. Tibia .................................... Femur ................................... Radius ..................................
ALBEE, F. H. An experimental study of bone growth and the spinal bone transplant. J. A. M. A., 60: 1044, 19’3. BARTH, ARTHUR. Ueber histoligische Befunde nach Knochenimplantationen. Arch. f. klin. Cbir., 46:
Totat.....................................
6 5
z 4 II 3 3 2 I 2
28
The group of patients in which the afore. mentroned techniaue was used comprised persons of a11 a’pes and with &ious pathoIogic Iesions requiring a bone graft. (TabIe I.)
SUMMARY
Sometimes it is preferabIe to remove bone grafts from the tibia without the customary bone saw. This can be readiIy accompIished by the use of thin sharp osteotomes and maIIet. In twenty-eight operations of a11 types in which such bone grafts were used resuIts were successfu1 in g6 per cent of the cases and there was onIy one faiIure of union of the bone graft. This method can be used on many occasions when more traditiona equipment is not avaiIabIe. REFERENCES
409, 1893.
RADZIMOWSKY.Quoted by Berg, A. A., and Thalhimer, WiIliam. Regeneration of bone. Ann. Surg., 67: 331, 1918. HENDERSON. M. S. Massive bone araft in ununited fractures. J. A. M. A., 107: I ro4rrg36. Bone grafts in ununited fractures. J. Bone IT Joint Surg., 20: 635, 1938. CAMPBELL, W. C. Ununited fractures.
Arch. Surg., 24:
R. K. and STUCK, W. G. Experimental bone transplantation. Arch. Surg., 28: 742, 1934. VENABLE. C. S. and STUCK. W. G. Recent advances in fracture treatment with non-eIectroIytic metal appbances. J. Indiana State M. A., 31: 335. x938. EIectroIysis controlling factor in the use of metals in treating fractures. J. A. M. A., I I I : I 349. 1938.
GHORMLEY,