The use of vitallium appliances in compound fractures

THE USE OF VITALLIUM APPLIANCES IN COMPOUND FRACTURES CHARLES S. VENABLE, M.D. AND WALTER G. STUCK, M.D. SAN ANTONIO, TEXAS

I

N the first World War there were, of course, many severe com-

pound fractures with gross infections, osteomyelitis or gas gangrene which resuIted in great loss of Iife and limb. To combat these infections, the debridement technic of Baron Larry was revived, the Orr method of adequate drainage was perfected and the CarreII-Dakin plan of wound sterilization was evoIved. Since the War, highway accidents have increased in frequency and severity, and fractures in industry have become so common that the treatment of compound fractures has become a major probIem of traumatic surgery. In the past few years two new principIes of treatment have been deveIoped which suppIement the earher methods and which offer hope of constantIy improved results. These factors are: I. The proof that suIfaniIamide acts as a Iocal bacteriostatic agent when pIaced in compound wounds. 2. The fact demonstrated by us in 1936 that metals which are eIectricaIIy passive (inert) in body Auids (eIectroIyte) can be used with safety in the interna fixation of fractures. I. LOCALLYAPPLIED CRYSTALLINE SULFANILAMIDE The discovery that suIfaniIamide is an effective bacteriostatic agent has produced revoIutionary changes in a11 fields of medicine and its use has become widespread. ShortIy after it became availabIe in this country, BohIman tried giving the drug oraIIy in cases of compound fracture to reduce the IikeIihood of secondary infection.lv2 This prophyIactic measure met with such success that it gained wide popuIarity. Later Bohlman,1~2 SincIair,12 ChandIer,4 Nelson, Johnsrud and Johnson,l experimented with the introduction of pure crystaIIine suIfaniIamide into compound wounds to enhance the bacteriostatic effects. This was found to produce high IocaI concentrations of the drug in the wounds which prevented the development of OsteomyeIitis or gas gangrene. SuIfaniIamide in a wound acts as a chemical deterrent to bacterial growth which thus permits the norma body defenses to overcome invading organisms. 757

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In our series there have been fifty-six compound fractures which were treated with IocaI apphcation of crystaIIine suIfanilamide with infection of the bone in onIy two cases.14 One of these patients had received a severe crushing injury of both bones of the leg, and the other had an extensive compound fracture-dislocation of the ankIe, yet even in these osteomyelitis was not extensive. As is we11 known, the exposed surfaces of wounds quickIy become seaIed so that bacteria are retained within the tissues at the wound site. Hence it is important that the infecting organisms must be prevented from growth in such wounds. A saturated solution of suIfaniIamide in serum in a wound is nearIy fifty times as concentrated as the amount of the drug which can reach the wound through the bIood stream and is correspondingIy more powerfu1. For that matter in spite of Iarge amounts of the drug in a wound reIativeIy IittIe is absorbed into the bIood stream. Since the body quickIy buiIds a barrier against bacteria1 invasion the IocaIIy impIanted suIfaniIamide reaches the area where it is needed more rapidIy than it does when given by mouth and is consequentIy more effective. The use of x-ray therapy to prevent the deveIopment of gas gangrene infection seems to be of vaIue if it is used soon after the accident.5*10 LocaIIy applied suIfaniIamide seems to be far more effective against the gas-forming anerobes. II. VITALLIUM

FOR

INTERNAL

FIXATION

In a11 cases of compound fracture, thorough dkbridement of dvmaged tissues is of course essentia1 and this incIudes changing of gIoves, drapes and instruments when necessary during the operation. The wound must be flushed with Iarge quantities of saIine soIution to remove scraps of foreign materia1 and dead tissues and the fracture must be supported with casts, spIints, skeIeta1 traction or some other form of immobiIization. Since we had observed in rg37 that ununited fractures often heaIed folIowing fixation with nonirritating vitaIIium plates, we began to appIy them to fresh compound fractures through dCbrided wounds. The wounds were then packed open with 5 per cent xeroform gauze after the manner of Orr. Subsequently, the extremities were supported in the usua1 pIaster casts or spIints to immobilize the invoIved bone and the adjacent joints. (Figs. I, 2, 3 and 4.) We found that these wounds fiIIed in rapidIy with healthy granuIation tissue whiIe the bone heaIed normaIIy. However, they often heaied by scar formation which resulted in skin adherent to

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the bone. Therefore, about two years ago we undertook to insert the plates and screws through a clean incision away from the contaminated area and to treat the wound sites separately. This caused

FIG. I. Compound cornminuted fractures of both tibiae. Right treated by appIication of vitaIlium plate. Left treated by skeletal traction which resuIted in much less satisfactory result.

better healing at the operative site while the bone united and t;he open wound filled with healthy granulation tissue. The end results have been much better because fractures have healed with a minimum of delay or deformity: Total compound fracture cases ..................... Treated by x-ray (prophyIactic) ..... ............... Developed gas infections ........................... Gas gangrene cases treated by x-ray. ............ ........... Subsequent amputation. ..................... Death ..................................................... Treated by crystaIIine sutfanilamide. ........................ ............ Bone infections. .............................. ........ Delayed unions. ........................ Nonunions ...................................................

IOZ 28

o 3

I o 56 2

...

2

o

In a recent study of 1,227 cases of all types in which vitallium appliances were used by sixty-one surgeons, we found that severa others had been using vitallium plates and screws in compound fractures with equally good results. 3*6,21Of all fractures of a11 types

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B

A

FIG. 2. A, compound

comminuted fracture of left pateIIa. B, wound debrided and fracture secured with singIe vitaIIium screw. A simple and effective method of treating patelIar fractures.

A

FIG. 3. A, compound

B

fracture of both bones of the Iower third of the leg. B, fracture fixed with two vitaIIium screws. Wound packed open with xeroform gauze.

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treated with vitaIIium apphances 92.6 per cent gained soIid union, 3.8 per cent showed deIayed union and 3.6 per cent resuIted in nonunion. If infections deveIoped or if the fractures faiIed to heaI

A

B

FIG. 4. A, compound cornminuted

fracture of both bones of the Ieg at the junction of the middIe and Iower thirds. B, wound dkbrided; fragments anchored with vitalhum screws and wound cIosed. SoIid union and perfect alignment four months Iater.

the surgeons invariably reported “the meta was not at fauIt.” Two and three-tenths per cent of the faiIures were due to technica troubIes in the operation. Therefore, we find once more that the presence of an inert assive) meta does not interfere with the heaIing of damaged or ?fected tissue or cause any “foreign body reaction.” In the very few instances in which OsteomyeIitis deveIoped about screws it seemed to be due to the bacteria carried into the bone by them, because healthy bone heakd in about the appIiances after the infection subsided. To be sure we do not favor the indiscriminate pIating of a11 compound fractures since many can be adequateIy immobiIized with

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Kirschner wire traction or other forms of fixation. The need for interna fixation depends upon the type of fracture, the diffIcuIty of reduction, the severity of the injury, the condition of the wound, etc. In this, as in a11 decisions, conservative surgical judgment is a prerequisite. SuIfaniIamide pIaced directly in compound wounds provided a powerfu1 deterring effect against growth of the contaminating organisms. VitaIIium aIIoy has made it possibIe to use interna fixation in compound fractures so that the bones are heId in the best possible position for good union. These deveIopments by themseIves or in combination with others offer invaIuabIe aid in the modern treatment of compound injuries. ELECTROLYTIC

EFFECTS

OF METALS

IN BONE

Since we demonstrated four years ago that eIectroIysis must be eIiminated from metaIs used in bone surgery this fact has become wideIy accepted. 17--20 Even the proponents of other aIIoys are beginning to speak of “pacification” of them by the creation of a protective moIecuIar vei1 or the addition of moIybdenum to “ 18-8” stee1 to inhibit the passage of eIectrons. Sherman expIained in a recent articIe that when his vanadium stee1 pIates are applied to fractures a sinus may persist which requires remova of the pIates and screws. l1 He added that the meta he used in spIinting compound fractures “compIicates the massive osteomyeIitis.” Moreover, “ . . . the objections to vanadium stee1 have been overcome recentIy by the production of a new stainIess stee1 (18-8 with moIybdenum) . . . which wiIl not corrode in the presence of sodium chIoride. . . . ” He was opposed to vitaIlium because he said it was a brittIe cast meta “and contains air bubbIes.” Even though he stated that mone1 meta and duraIumin corrode and “efFIoresce” in the presence of saIine soIution, Sherman denied that eIectroIysis cotiId occur “when Iike metaIs are used.” And finaIIy he describes how infected wounds “usuaIIy cicatrize Ieaving one or more sinuses Ieading to the stee1 screws” and “this is due to corrosion or oxidation of the steel.” The sinuses Ieading to the stee1 screws indicate that an aIIoy is being used which has sufhcient eIectro-activity to irritate tissues. Since eIectroIysis accompanies corrosion it is this action which erodes bone and causes chronic drainage. The abandonment of the highIy eIectroIytic vanadium steel removed a great source of irritation of tissue and erosion of bone. The “ 18-8” stainIess stee1 to which

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moIybdenum has been added is far Iess irritating than vanadium steel but it is incorrect to say a “Iike meta1” is being used. Instead four metaIs (iron, chromium, nicke1 and moIybdenum) are in combination and unti1 they are more perfectIy united to resist the passage of eIectrons there wiI1 continue to be some eIectroactivity about them. UhIig and WuIff at the Massachusetts Institute of TechnoIogy have studied passivity of metaIs and have apparentIy found Iimitations of the oxide fiIm theory.15 They reported that the addition of moIybdenum to “ 18-8” stainIess stee1 tended to complete the atomic Iattice and so increase the resistance to corrosion. However, this did not produce a compIeteIy passive aIIoy. Hudack, in coIIaboration with Darrach and Murray, has pointed out that vanadium stee1 causes IocaI irritation and erosion of bone which often requires its remova1.’ As a substitute he proposed the use of high chromium-low nicke1 stee1 as recommended by Jones and Lieberman.” He remarked that if this stee1 is highIy poIished and is “ passivated ” in nitric acid it may gain a moIecuIar chromic oxide coating which resists corrosion. NevertheIess, in the forty-one cases he reported pIates and screws were removed in tweIve because of persistent sinuses, insecure fixation, IocaI irritation, puIIing out of screws or corrosion of the meta1. He concIuded that this meta wiI1 be adequate when “certain requirements” are fuIfiIIed. THE

IDEAL

METAL

FOR

INTERNAL

FIXATION

The “ certain requirements ” which must be fuIfiIIed in any metal are passivity in body ffuids and hence freedom from eIectroIytic irritative tissue effects. As we have frequentIy stated, a positive proof of eIectroIytic action (or “non-passivity”) in the body is the abiIity to recover constituent metaIs of an aIIoy from the tissues adjacent to it. ChemicaI examination of tissues and fluids which have been in contact with the meta wiI1 revea1 the presence of metaIIic ions corroded from the aIIoy. Thus far onIy vitaIIium is suffIcientIy passive in body ffuids to cause no disintegration or reIease of metaIIic ions into the tissues. We have stated before that tbe amount of electrolytic disintegration of metals and consequent erosion of bone seems to be related to the current jlow recorded in a microammeter when the metaIs are combined with a third meta as an anode in sodium chIoride. In other words, an aIIoy which produces many microamperes of current wiI1 produce much erosion of bone and the meta itseIf wiI1 disintegrate in the tissues. Thus the metaIs vanadium steel, duraIumin, Dow

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metaI, etc., which cause destructive changes in the body produce of current in sahne. StainIess stee1 more than 200 microamperes (“ 18-8”) which is better toIerated by the body produces a reading of

FIG. 5. Diagram showing contact being made between stainless steel screws in Ieg of experimenta animaI. Micro-ammeter shows relatively Iarge amount of current produced.

FIG. 6. Diagram showing contact being made between vita&urn screws in leg of experimenta animal. No current flow demonstrable on the micro-ammeter.

50 to 100 microamperes. “ 18-8” stainIess stee1 which has been “passified” with nitric acid causes stiI1 Iess irritation of tissue and a reading of IO to 20 microamperes. VitaIIium which causes no reaction in the tissues produces a reading of I to 2 microamperes momemtariIy and then o amperes. (Figs. 5 and 6.)

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While vitaIIium is the most inert ahoy now used in bone surgery, we are experimenting with a recently deveIoped aIIoy which seems to be approaching it in passivity. Our main interest has aIways been to discover an aIIoy which is compIeteIy noneIectroIytic and hence nonirritating in the body and at the same time maIIeabIe enough to be machined. Experiments with “ ‘g-15 ” stee1 in which the nickeLchromium proportion is aItered and molybdenum added seem to point the way toward the uItimate hope of a maIIeabIe yet passive aIIoy. More than a year ago we experimented with pIates and screws of this new materia1 and found that they produced onIy 3 to 5 microamperes of current. Screws and pIates of this aIIoy were pIaced on the bones of dogs whiIe simiIar vitahium pIates were pIaced in opposite Iegs for controjs. At the end of sixty days there were no evidences of corrosion of either metal or irritation of the tissues. NevertheIess, traces of nickeI and chromium were recovered from the tissues adjacent to the “ 19-15” meta which shows that even this is not compIeteIy passive in the body fluids. Two simiIar cases of patients with maIunited fractures of the shaft of the femur were operated upon and vitaIIium pIates and screws pIaced in one whiIe plates of the new meta were pIaced in the other. After a year there has been no appreciabIe cIinica1 or x-ray difference between the two cases. The time seems near that a material wiI1 be deveIoped which is sufhciently passive to be used safely in the body and which, unIike vitallium, can be machined. Such deveIopments shouId be cIosely foIIowed but we must reemphasize that no aIIoy is universaIIy adaptabIe to bone surgery unIess it is compIeteIy passive in body Auids. This is especiahy important in the treatment of compound fractures, for here of a11 pIaces irritation must be reduced to an absoIute minimum. Absence of eIectroIytic irritation makes it possibIe to use vitaIIium plates and screws in compound fractures without such corrosive manifestations as erosion of bone or sinus formation. For the time being this is the onIy aIIoy that can be used in compound wounds with perfect safety. BIBLIOGRAPHY I. 2. 3. 4. 5. 6.

BOHLMAN, H. R. Am. J. Surg., 42: 824, 1938. Ibid. J. A. M. A., 109: 254, 1937. CAMPBELL, W. C. Personal communication. CHANDLER, F. A. Cited by Bigler and Haralambie. Am. J. Dis. Cbild., 57: I I IO, 1939. COLEMAN, E. P. and BENNETT, D. A. Am. J. Surg., 43: 77, 1939. DICKSON, F. A. Personal communication.

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7. HUDACK,S. Arch. Surg., 40: 867, 1940. 8. JENSEN,N. K., JOHNSRUD, L. W. and NELSON, M. C. Surgery, 6: I, 1939. g. JONES,L. and LIEBERMAN,B. A. Arch. Surg., 32: ggo, 1936. I o. KELLY, J. F., et al. Radiology, 3 I : 608, 1938. I I. SHERMAN,W. 0. Arch. Surg., 40: 838, 1940. 12. SINCLAIR,J. A. J. Canad. Dent., 3: 571, 1937. 13. STUCK,W. G. J. Bone e? Joint Surg., Ig: 1077, 1937. 14. STUCK,W. G., MAXWELL, E. A. and MONSALVO,R. N. 0. Texas State M. J., JuIy, 1940. UHLIG, H. H. and WULFF, J. Metals Technology, June, 1939; Oct., 1939. VENABLE,C. S. Soutb M. J., 31:501, 1938. VENABLE,C. S., STUCK,W. G. and BEACH,A. Ann. Surg., 105: 917, 1937. VENABLE,C. S. and STUCK.J. Indiana State M. Ass., 31: 335, 1938. Ibid. J. A. M. A., I II: 1349, 1938. Ibid. Surg., Gynec. & Obst., 70: 964, 1940. 21. Ibid. Ann. Surg. (In press.)

15. 16. 17. 18. 19. 20.

DISCUSSIONS

OF

PAPERS

OF

DR.

MURRAY,

DR. CAMPBELL

AND DR. VENABLE KELLOGG SPEED: My discussion really covers onIy two of the papers. The first is that of Dr. Campbell Assuming that the only autogenous graft is used for a fracture faihng to unite and which has been opened, pared down or guttered for the purpose of attaching the graft, we can conclude that the beId of the fracture has been reduced, as much as Iies in our power, to conditions resembhng those of a fresh fracture. To obtain bony healing there must foIIow fixation and immobilization of the part unti1 bony union has developed. In my experience I have never found in shaft fracture of Iong bones an idea1 method of attaching the bone graft onto the host to estabIish rea1 fixation. AbsorbabIe material certainly wiI1 not hold it. Wedging beneath guttered edges may hold in some instances. OIdfashioned meta screws of doubtful metallic origin and producing eIectroIytic reaction, have faiIed and bone pegs or screws have Iacked in tensiIe strength and Iasting qualities. With the advent of a noneIectroIytic reacting meta aIIoy, firm apposition and fixation, as great as that obtained in appIying a metal pIate, can be obtained. Our choice for this fixation must Iie in meticuIous boring of the transplant and its transfixation with cortex-to-cortex fixation into the host bone as in applying a meta pIate. VitaIlium, eIectroIyticalIy inert, may we11 be used. I have seen a few vitaIlium pIates and screws which became broken during cIinica1 use and cannot be sure whether those breaks were caused by the brittIeness of the meta or the presence in it of air bubbIes, as claimed by Sherman. Sherman favors stainIess steel, an ahoy made of high chrome, IOU nickel, and moIybdenum, which has a high tensiIe strength and which, when properIy machined, affords no eIectroIytic reaction to sodium chIoride or hydrochIoride soIution. In practice I have been using either vitaIlium

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or the stainless steel screws, in a few instances mixing them. Observation on these patients to date shows no untoward reaction. In addition to considering the chemical reactions about screws, we must not forget the mechanical necessity for adequate external splint fixation to guard the screws against cross- and rotation-strain and absorptive atrophy of bone along these tracks from continued or overgreat pressure until bony union has occurred. As for Dr. Murray’s paper, “operative treatment of fractures” may be a misnomer. Could we not say “operation in the treatment of fractures,” because the operation often enters into at the most only two requirements in the care of fractures, namely, apposition of fragments and Fixation. Fixation acquired by operation is, however, often inadequate to support limb weight, and must be supplemented by external splintage and fixation of a high degree of excellency, because in case of failure of the method, the blame may quite wrongfully be shifted back to the operative portion of the case, when it really lies in inadequate aftercare. We must look at operation in treatment from a broader standpoint, not merely as surgeons working in the protected cloister of our own too attentive hospital, but from the standpoint of treatment everywhere throughout the country, in order that we may set a proper pace and a good example. In general, then, more care should be exercised, and better attempts made by all physicians in the care of fractures, without the intervention of the factor of operation. There remain many instances and some well recognized types of fractures which require operative help from the very start. These I am sure you can readily call to mind. Operation is, in my experience, required more frequently in the neglected fracture often seen Iate after injury, than it is in recent fracture. FaiIure to gain proper apposition and subsequent immobilization, particuIarIy after shaft fractures in aduIts, require operation. We should not deIay in giving this help. Some instances in chiIdhood, especiaIIy near the joint surfaces of long bones, simiIarly may be offered operation early, and their progress after mishandIing may be hastened and bettered by operation. One virtue the surgeon must cuItivate is patience in his handling of the fracture after operation, and not fee1 that simpIy because he has operated, cure wiI1 sureIy follow. I beIieve there is an undue amount of fear about immobiIizing fractures around joints, but it is far better to keep them quiet a Iong time and minimize the amount of rebeIIious reaction and detrimental new bone formation about the joint than to attempt too earIy motion with disastrous results. I had no more idea of what Dr. Murray was going to say than you had, but you see that I know him we11 and that I understand his thoughts, and I concur very heartily in what he has said. GUSTAV F. BERG (Pittsburgh, Pa.): I was especiaIIy interested in the summary just given by Dr. VenabIe, because I beIieve he is delving into a

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fieId that has been comparativeIy unexpIored from the standpoint of electroIysis and corrosion. It is true that we have used metaIs of various types for a considerable number of years, in achieving the fixation of compound fractures, but it is aIso true that the last word has not been said. Dr. VenabIe has very IearnedIy and IogicaIIy set forth his bases for the use of vitaIIium pIates and appIiances, and his findings are of untold worth to the profession. We wiI1 a11agree that the end resuIt desired in the reduction and heaIing of compound fractures is threefold: (I) A strong fixation which insures perfect weight-bearing ahgnment and good function; (2) the eIimination of the dangers of infections and their end resuIts; and (3) a Iifetime use of the injured part. In my experience in the use of pIates, screws or naiIs, resort has been made to various types of steel pIates and screws; chief among these are the ones designed by Dr. Sherman, of Pittsburgh, in 1910, the Lane plate, the pioneer Lambotte appliances, and an appIiance which I use occasionaIIy in types of compound fractures, known as the Smith cIamp. In using the Sherman vanadium aIIoy pIate for a period of twenty-nine years, I have found that the vanadium stee1 pIates achieved a rigid fixation. It does not submit to the vibrations of the body. It does not interfere with the formation of reparative caIIus, nor does it produce an electrolysis or corrosion, sufficient in character to become the basis of a biochemica1 or corrosive change. MetaIIurgicaI constituents of the vanadium pIates are that the stee1 for both pIates and screws shaI1 be chromium-vanadium stee1, conforming to the following requirements as to chemica1 compositions: Carbon........... Manganese............. Chromium.... Phosphorous not over. Sulfur ,.,,.,........... Vanadium not under. Desired..............

.._._.....

.._.._...

..::111::::::::‘:::“1111::::

,.

,_ .,,,

Per Cent 0.45-0.55 .5o- .80 .8+1. to 0.040 -045 *‘5 .18

The plates and screws, after forming, shaI1 be heat treated to a hardness of not Iess than 43 or more than .53, as determined by the Rockwell hardness tester using the C scaIe and the ISO kiIogram Ioad on the diamond cone penetrator. Ch rommm, ’ Nickel...................................... MoIybdenum................................ RockweII hardness..

18 per cent 8percent 1-V-38 I-C scaIe 35.3 per cent

Here are two screws that have been in the solution for a certain period of time, and they are presented for your inspection. The dates are on these.

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One is dated December 26, 1939, and the other is dated February 6, 1939. I would like you to show me where there is any evidence of corrosion on the screws. The end resuIts achieved with the Sherman plate have been most successfu1, and I, therefore, beIieve that the use of the vitalhum aIIoy pIate appliances adds another efficient means of assistance in the treatment of compound fractures. It is my beIief that the matter of desired fixation is due Iess to the type of pIate used and due more to the method of application of a pIate to the fractured ends of the bone. I beIieve that suficient care is not used in hoIding the bone fragments immobile, and in hoIding the pIate just as immobiIe, driIIing the correct size of the hoIe. The one I use is the standard Brown and Sharpe onethirty-second of an inch driI1, and the screw which is to be used shouId be a tapping screw one-thirty-second of an inch oversize, and shouId be properIy countersunk into the bone plate which has been used. That is very important, the driIIing of the hoIe and the proper pIacing of the screw. When a11 the screws are in pIace, they must be firmIy snugged up so that there is no pIay between the bone and the plate and the pIate and the screws. There must be no stripping of bone thread, and at no time is rough handling of the bone permitted. I should Iike to see the surgeon who has the mechanica abiIity to pIace properIy a hoIding forcep on a bone, then hand it to his assistant, and his assistant be abIe absoIuteIy to immobiIize the same, whiIe the surgeon driIIs the necessary number of hoIes. By the time this is done, how much of the bone that wouId fit the screw has been destroyed? What is the resuIt? As the resuIt of mechanics used in driIIing and inserting the screws, considerable bone has been devitalized, and as the resuIt of this devitalization, there is an absorption of bone which takes place around the screws, and as the resuIt of this absorption the meta of which the screw is composed is accused of causing an eIectroIysis. It is not permissibIe to overheat the bone in the act of driIIing the holes by the use of high speed motors. I have found in my own experience that a combination bone cIamp must be used in order to meet the above requirements. Without any attempt to appear immodest, I must say that I have achieved this compIete immobilization with a bone cIamp which I designed. This is a combination cIamp which comes apart and these are individua1 clamps, use one on one fragment and one on the other. After your bone is gripped by the instrument, the cross-bar is inserted. This is put on and it makes no difference where your fragment is. Your traction screw is then appIied, and you start your correction of your overriding. Any IateraI deviation and mispIacement is corrected in the handIe. If any one is interested in the clamp, I present it for your inspection. I understand that our coIIeague, Dr. James H. Jackson, has designed a clamp with which he is abIe to secure the same result.

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You can see that it is my thought that it is not mu&h the type of pIatc used, as the manner in which it is used, that determines whether or not a perfect fixation shaII be achieved. If, after a period of twenty-nine years, I have not been troubled with the danger of sufficient corrosion caused by the use of the Sherman pIate, then I beheve the proponents of the vitallium plate must admit that we have not suffered from the eIectroIysis or corrosion sufficient in character to bring about a destructive corrosion by the materia1 used, and have had no interference with the union of fractures, as the resuIt of the material used. The absence of absorption of bone after the use of vanadium plates, in many thousand cases, during the past twenty-nine years, aIso must draw an admission that the vitaIIium pIate, screw and appliances are not aIone in the fieId. I have not been very much interested in the use of vitaIIium appliances, because of the uniform good fortune with the materiaIs at hand. It has come to my attention that there has been some criticism of the vitaIlium pIate, and this criticism has as a basis certain metaIIurgica1 deficiencies. Dr. T. A. Carnes, of MassiIIon, Ohio, surgeon to the Republic SteeI Company, has taken x-ray films of vitaIIium plates and screws, and has found conceaIed gases and air bubbIes in both pIates and screws. Some of these bubbles have been Iocated at the head of screws, making shearing of the head a great hazard. It is admitted by anyone familiar with metaIIurgy that air bubbles are not desirabIe, and, further, that a11 metaIs are eIectroIytic or corrosive to some extent. In cIosing, may I again congratuIate Dr. VenabIe for his invaIuabIe aid to the profession. I wiI1 add that after the cIose of the meeting I would be pIeased to demonstrate x-ray films of a patient operated upon twenty-nine years ago for a compound fracture of the right humerus, x-ray fiIms and pictures of a patient operated upon for a supracondyIar fracture of the right humerus twenty-one years ago, the bone pIate stiI1 being in proper position; and the patient having absoIuteIy no discomfort or interference with norma function. This patient was operated upon at the age of thirteen. This was not a compound fracture, however, a case demonstrating the use of the Smith clamp in compound fracture. I shouId also Iike to demonstrate the combination clamp which is, I feeI, of great assistance in the treatment of fractures. I aIso wish to present two test tubes containing the new type of moIybdenum stainIess stee1 screws which have been immersed in hypochIoride .05 since December 26, 1939. GORDON M. MORRISON (Boston, Mass.): Very briefly I should like to mention one or two points regarding the discussion of cIosed versus open treatment of compound fractures. It seems to me that there is a certain class of case where the patient is badIy shocked, and we know shock and sepsis go hand in hand. In that type of case, or that classification, the cIosed treatment, foIIowing irrigation, should be definitely out.

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One other factor that has given me troubIe in the past and which I see other men getting into trouble with reguIarIy, is that of the pinpoint compound fracture. Spinning an iodine gauze swab into pinpoint compound fractures wil1 take care of some of them, but there is an awfuIIy Iarge percentage that go rankIy septic, and then you have rea1 troubIe on your hands. It seems to me that we ought to keep after the men who do not attend meetings of this sort and educate them up to that simpIe fact. The manner of irrigation is important; it has a technic. Dr. Griswold brought out what I think is a mighty exceIIent point, namely, that the tip of the irrigating apparatus should be pIaced in the bottom of the wound and the wound shouId be ffushed from the inside out and not from the outside in. That is so self-evident that it hardly seems worth whiIe to bring up, but in going around, occasionaIIy one sees someone mereIy sIopping soap and water or saIt soIution into the wound. In those cases in which we have used vitaIIium screws for fixation, cortex-to-cortex, or used vitaIIium pIates, we have not had any trouble with their becoming Ioose. It has seemed to me that there is an added factor of hoIding security with the vitaIIium screws. This hoIding security is mighty important in the cIean cases, more so in the septic cases. I beIieve that Dr. VenabIe has made a great contribution to bone surgery. KENNETH M. LEWIS (New York City): I just want to show one sIide iIIustrating an onlay bone graft in a compIicated case, but before showing that, I.cannot heIp but think that some of this discussion takes some of the New York men back to a trip that we made to Pittsburgh about five years ago. Dr. Murray wiI1 remember that trip very weI1, and I am rather convinced that there are many roads that Iead to Rome. I remember at that time Dr. Sherman was very enthusiastic, as he had been for many years about the routine pIating of fractures of the shafts of the Iong bones. We men in New York did not beIieve it could be done. Dr. Murray at that time did not think it couId be done. Dr. Murray decided when he got back to New York, that he wouId try to dupIicate Dr. Sherman’s work and, needIess to say, he has done a very exceIIent job. I shouId like to say that at BeIIevue, where we are working in a Iarge city hospita1, where we cannot possibIy have the set-up that Dr. Sherman has and that Dr. Murray has at Presbyterian Hospital, we beIieve that some of the thoughts Dr. Murray has been expressing this morning shouId reaIIy be given a great dea1 of serious attention. A Iot of open bone work on fractures, when necessary, can be done, and can be done with safety, if the proper organization and the proper care of detaiIs are taken care of. A specia1 operating room for bone cases and a modified type of Lane technic are essential. Since we have adopted that on practicaIIy a11 services at BeIIevue, we have found our incidence of infection has been Iess,_that the

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job can be done, and I think the thing Dr. Murray wanted to get across, and that many of us ought to try to appreciate, is the fact that it can be done and is not so much the question of who operates on the fracture as it is the invariabIe attention to details and organization which Dr. Sherman over many years has aImost made classical. I want to show this slide because it happens to be a compIicated case. This man had his arm projecting out of a bus window and sustained a fracture of the humerus, together with an anterior disIocation of the head of the radius, a muscuIar spira1 paraIysis and a compound fracture of the upper third of the uIna. He was treated with traction. His humerus united. It was impossibIe to reduce the disIocation of the head of the radius. The head of the radius was excised, and subsequentIy, in about two months, there was a pseudarthrosis which developed at the site of the fracture in the uIna. The uIna was operated upon. The eburnated bone was quite extensive, which Ieft a defect that can be seen. The upper fragment of the ulna was in two pieces. I noticed in many of the fiIms shown with Dr. CampbeII’s paper the number of screws used in the pIates. I wiI1 admit here we have onIy one above and one beIow, which are too few. I am wondering whether two above and three beIow, provided they go right through to the cortex, are necessary. OnIy two screws were used here because the upper fragment was in two pieces, and because of this we were afraid that in putting in two screws we might spIit it and spoi1 our end resuIt. Even so it was simpIe to use an onIay graft with one screw above and one below. It has been retained and the patient has an exceIIent end result. An inIay graft wouId not have been satisfactory; a medullary graft couId not have been used because the medullary cavity did not run up into the upper fragment. DERYL HART (Durham, N. C.): I will say only a few words. I beIieve that in our work, and I think we have concIusiveIy proved in our hospita1, that the air is an important source of infection in any open wound, particuIarIy in those invoIving bones and joints. For a period of four to five years we had a great dea1 of troubIe with infections in cIean operative incisions and these couId not be eIiminated by the most rigid technic as we then understood aseptic technic to be. We had a number of carriers of the StaphyIococcus aureus in the nose and throat (at times as high as 80 per cent of the genera1 popuIation, and also the operating personne1). This organism caused the greatest troubIe, both as regards number and severity of infections. By January 15, 1936, we had carried out preliminary tests on bacteria and animals to prove the efficiency of certain wave Iengths of uItra vioIet for kihing bacteria floating in the air or on a petri dish, had demonstrated on animaIs that wound heaIing was not impaired, and had equipped an operatingrroom!for aifsteriIization of this method. I wouId like to give you certain statistics, which I have just finished compiling.

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From JuIy, 1930, unti1 January 15, 1936, out of a tota of over 15,000 operations, we had eIeven deaths from infections in cIean primary incisions, a11 of these patients having operations of great magnitude. There were four thoracopIasties, three bone and joint operations, one radica1 mastectomy, two craniotomies and one radical dissection of the gIands of the neck for carcinoma. AI1 these patients except three had a septicemia with the same organism that caused the wound infection. The two cases of brain surgery did not have a septicemia but had an associated meningitis, so there was onIy one death without an associated septicemia or meningitis. Since January, 1936, we have performed large cIean operations (Iaminectomies, craniotomies, thoracotomies, radica1 mastectomies, arthropIasties, hernioplasties, etc.) in a fieId where the air is steriIized. Out of a total of 25,000 operations, we have had 2,500 performed in reIativeIy steriIe air, and out of this group of cases we have had not one death from infection. Our deaths from infections in cIean operations stopped sharpIy when we reduced the contamination of the air as a source of infection. At the same time, we reduced our infection rate in genera1 surgery, and the surgica1 specialties, from approximateIy 4 per cent, most of them miId but with an associated severe septicemia and fatalities as I have indicated, to Iess than one-haIf of I per cent, most of which have been stitch abscesses. Furthermore, our postoperative temperature reactions, both in duration and eIevation, have been reduced by from 30 to 70 per cent, being greatest for procedures of the magnitude of an extrapIeura1 thoracopIasty and least in the operations of Iess magnitude such as herniopIasties. Furthermore, the amount of temperature reduction has also corresponded to the amount of reduction in the air contamination. From January unti1 June the air contamination is reIativeIy high, dropping quite Iow during the summer months and rising against during the faI1. In the case of thoracopIasties without radiation the curves found by plotting the average eIevation of temperature or duration of temperature by months foIIows roughIy a similar form. With radiation, however, the greatest reductions both in temperature elevation and duration, have been during the colder months so that the former curves are reversed, being Iowest in the cooler and highest in the warmer months. During the summer months when the air contamination is Iow, we have obtained IittIe reduction in the temperature reaction, and it is our impression that contamination of the wound with bacteria-Iaden perspiration is one important factor in the production of this reaction. I might say further that a11 members of the SurgicaI Staff (incIuding the Surgical SpeciaIties) have been given compIete freedom of choice as to the use of ultra violet radiation. It is used by a11 of them with the exception of those on the nose and throat service who do not perform operations in which radiation is indicated. We have three of our five larger operating

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rooms equipped for air steriIization and the demands for its use are so great that we are now having the fourth room equipped. GROVERC. WEAL (Pittsburgh, Pa.): I can not heIp but take the opportunity of subscribing to some of the very exceIIent remarks in the papers presented, having come from Pittsburgh in an industria1 center where we have Iong practiced and pioneered in the work of open reduction. However, it must not be thought that all fractures are reduced by the open method. We have Iong since, of course, reaIized the importance of instituting proper surgica1 measures or methods in each individua1 case. Dr. Murray, I do believe, rather minimizes his own particuIar abiIity. He is rather timid about it, nevertheless; he has played the great rBIe in effecting his organization, which is most important and which has brought about his marveIous resuIts. Just a word about compound fractures, going back to Dr. Speed’s dictum of fixation, retention and return of function. We have aIways beIieved in the great importance of this. It represents a major surgical procedure, and the time period from the injury to the institution of your method is of the highest importance. In times past I have seen many tragic deaths from gas baciIIus infection; and when one considers the potentiahy dangerous effect of this organism within such a relativeIy short period of time, one can reaIize the importance of the institution of earIy treatment. We consider as one of the most important phases of the treatment of the compound fractures, the institution of earIy surgica1 interference. We carried out the open method Iong before Orr popularized it. In fact, of course, he made a rea1 contribution. With the cases Ieft open with proper drainage folIowing debridement-what we caI1 sensibIe debridement after fixation-with, as a ruIe, the Sherman bone plate, it has been our observation that severe infections have been reduced to a minimum where the wound was suppIied with ampIe drainage and dressings are deIayed for weeks, foIIowed, of course, Iater by secondary cIosure and granulation. I have become very much impressed with the use of sulfathiazole. Dr. Venable brought out the use of suIfaniIamide, but we have found sulfathiazole, particuIarIy the suIfamethyIthiazoIe, which we used first, was perhaps the most marveIous chemica1 agent we have ever used. We insufffate it in the wound, diffuse it about thoroughly, and, as Dr. Venable brought out, its application in the wound brings about a very low bIood Ievel; but its character and nature is that it is bacteriostatic, has a bacteriostatic effect, which is certainly of great importance, and we have recently been able to cIose up compound fractures after introducing perhaps anywhere from IOO to ISO grains. We have been abIe to cIose up these wounds without evidence of any infection. It is too early as yet to speak of it with authority but, nevertheless, in our hands, it has certainIy given great promise.

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ARNOLD GRISWOLD (Louisvihe, Kentucky): I shouId like to say a few things on sulfanilamide and sulfathiazole impIantation in wounds, which may be somewhat at variance with one statement of Dr. Venable and Dr. WeiI. We have found that we can raise the blood concentration with both of these drugs to quite high levels by direct implantation of 5 to I 3 Cm. of the drug in the wound. Taking a curve of bIood concentration every two hours, foIIowing implantation in muscuIar structures, the bIood concentration hits a peak of six to nine in about twelve hours and dies off in about forty-eight hours. When the drug is used in the peritonea1 cavity, the absorption is much more rapid, and the bIood peak occurs in about four hours. Our highest concentration has been a peak of fourteen, four hours after operation, and we have seen cyanosis foIIowing impIantation of sulfaniIamide in the wound. CLAY RAY MURRAY (cIosing) : I have very Iittle to say in closing except that I shouId like to comment on something said by Dr. Speed and referred to again by Dr. Berg, as emphasizing my own persona1 convictions. In my opinion the majority of the criticisms directed at the metals commonIy used in the fixation of fractures as being responsibIe for failure to hea and for irritation in the tissues shouId be directed toward the technic with which these metaIs are appIied and the lack of absolute fixation, rather than toward the chemica1 composition of the meta1. Any meta put into tissues which undergoes excessive strain because of Iack of rigidity in fixation, or which is Ioose in the tissues, or which is appIied in tissues which as a preliminary are badIy traumatized, is going to cause troubIe, not because it is meta but because it is a foreign body in an area of infiammation. The tissue fluid changes which occur as a result of that inflammatory process are per se sufficient at times to prevent bone formation at the site of a fracture. In fact, some fracture cases resuIt in nonunion, as we a11 know, without the use of any metal. The inflammatory reaction at the fracture site, if it produces sufficient change in the tissue IIuids to cause prolonged marked acidity, wiI1 cause deIay or failure in calcification of the heaIing tissue. I agree with Dr. Berg that it is probabIy not necessary to have complete passivity of the meta introduced. It is ideaI, unquestionabIy, but from my point of view in the operative treatment of fractures as the method of choice, it is not onIy necessary to have a meta which in itseIf does not cause any appreciable disturbance, but it is aIso necessary that that metal be abIe to stand the strain of function postoperativeIy. Vanadium steel in our hands has not been abIe consistentIy to withstand the strain of function. The breakages were few, but they were very, very disturbing. VitaIIium has no reaction in the tissues. It is a cast meta and it would appear from what work we have done with the metal that it wiI1 not stand the strain of active function postoperativeIy in the form in which it has now, or up to now, been put out. In other words, I think Dr. VenabIe

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and I, whiIe I taIk in terms of stainIess steel of a certain type, and he talks in terms of vitaIlium, are taIking the same Ianguage, and have the same ideal, and I think he will admit if ever a meta is discovered which produces no physiologica change, and which at the same time has the flexibility and the toughness of the stainIess steeIs, we will have the meta which fuIfiIIs a11 requirements. VitaIIium is not that metal in my opinion. One other thing I think is of importance: I do not beIieve we have a satisfactory criterion of tissue reaction unless it is checked by physioIogica1 results. The reactions caused by meta in saline and other solutions are not adequate evidence. As to use in the body, I think one has to produce evidence that a meta is not onIy eIectroIytic, but that the amount of eIectroIysis produced actuaIIy produces changes in a tissue. Changes in ammeters do not affect fracture heaIing. On the other hand, this is partIy an academic question because of the amount of eIectroIysis induced wiI1 depend IargeIy on what tissue is invoIved. Furthermore, it is into freshIy traumatized tissue, further traumatized necessariIy by whatever operative procedure is used, no matter how carefully it is done, that metals are pIaced. It is, therefore, necessary to have a t&t fluid of a very low PH. Experimentally we have been abIe to determine the PH of the tissues in vivo. A PH as Iow as 4.5 twelve hours after injury has been recorded. In that PH any meta is much more active eIectroIyticaIIy than in normaI saline. For that reason I believe the approach to the idea1 compIete passivity is a very necessary thing, and I think the investigation which Dr. VenabIe has done is therefore of paramount importance; but if the principle of optional operation, based on the purpose of cutting convaIescence time and Iessening the economic cost of injury-if that principIe is to be used-a meta must be deveIoped which wiI1 both stand the strain of active function and remain inert. IncidentaIIy, I think that covers aIso in a way the question which Dr. Speed raised, in which he said that postoperative fixation must be appIied. We can Iay down as a definite ruIe for Iong bone fractures in aduIts that rigid fixation must be secured at operation if functional activity is to be aIIowed postoperatively. No case shouId be subjected to operation as the method of choice unIess we are convinced that such fixation can be secured. We believe we have demonstrated that rigidity can be secured by a twopIane fixation, and that with such two-plane fixation postoperative immobilization in plaster is not needed provided the patient is kept in balanced suspension, adequateIy supervised. This does not mean a resident testing the apparatus at eight o’clock in the morning and again at eight in the evening; it means apparatus adequateIy supervised a11 day. In any fracture in which the pIate or screws or other fixation materia1 gives inadequate fixation, external immobilization becomes necessary. If that case has been operated upon as the method of choice rather than by necessity, and postoperativeIy it is found necessary to incorporate the part

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in plaster, it was a mistake to operate on the patient provided any more conservative measure wouId have secured adequate position. The fixation problem is a very major one. Postoperative care of the patient is a very major thing. Dr. Lewis, I think, expressed in very concise terms exactly my point in reading this paper; that is, that if in the hospitals of the United States the men who are doing fracture work will devote as much time, effort and money in developing the organization and equipment of their hospitaIs to a point at which this work can be safely done as they now devote to the devising of ways and means and apparatus to avoid operation on cases, the use of the operative treatment of fractures can become much more wideIy spread, with a great deal of economic gain and without any increased risk of either infection or death for the patient. HAROLD B. BOYD (Memphis, Tenn., cIosing): I wish to thank Dr. Speed and Dr. Lewis for their discussions of our paper. In regard to the possibiIity of breaking the screws, in this series of sixty patients, we broke two screws. This may occur due to two factors: First, a defect in the screw may occur in the process of casting. Second, the hole driIIed in the bone may be too smaI1 for the screw. With this in mind, we are carefu1 to have the proper size driI1 for the screw to be used. A sIightIy smaller drill is used where the screw is pIaced in canceIIous or osteoporotic bone than when it is placed in normal cortical bone. Dr. Speed has iIIustrated how the transpIant may puI1 away from the shaft of the grafted bone. This occurred in a few of our cases in which autogenous bone pegs were used, but has not occurred in any case in which the vitaIlium screws were employed. Since the vitaIIium screws hoId the graft securely, one should take specia1 care not to apply the transpIant under tension. Undue tension on the graft may cause it to absorb or break at the fracture site. The vitahium screws do not permit sIight readjustment of the position of the graft, as seen in some cases fixed with autogenous bone pegs. Dr. Lewis’ criticism of the number of screws used is we11 taken. In our more recent cases, we have been using four screws in most grafts; however, we stiI1 use six screws when applying a graft to the femur. I do not beIieve that the use of two screws, as shown by Dr. Lewis, is adequate. CHARLES S. VENABLE (closing): I do not think I made my point quite clear concerning suIfaniIamide. What I said was “proportionately” and by “proportionateIy” I mean that if you give a patient 150 Gm. of sulfanilamide by mouth, that is a much more serious thing than if you put I 30 mg. in a wound, and, of course, there is a proportionate change as it is taken up by the bIood. What I intended to say was that proportionately it may be used in Iarge quantities with reasonable safety. I think that Dr. Berg and Dr. Murray, Dr. Sherman-in fact, I think we have a11 come around to talking exactIy the same Ianguage. I have shown

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you today the expectancy in using a material that is passive. I have been working just as hard to find, in testing many materiaIs that couId be miIIed, a stee1 that wouId have all of the things in point of strength that Dr. Murray requires, that is aIso as passive as vitaIlium. It is impossibIe and impractica1 to taIk about whether a metal is electroactive or not by putting it in a bottIe of saIt soIution. I have some that have been in three or four years and stiI1 Iook pretty good, but you can probabIy recover the constituent metaIs after a certain length of time. Remember that the body fluids are different from just pIain salt solution. You have other eIements that have effect and more effect than plain saIt. The crucial test of whether or not there is any irritation or any eIectroIytic action can only be had by the method of recovering one or more constituents of the materia1, so that your chemist may teI1 you what the meta is made of from his examination of the body or other fIuid acting as the eIectroIyte. What we are a11 trying to do, in attempting to reach the same end, is to have material that can be cheaper, that can be miIIed, that can be machined and which wil1 be consistentIy toIerated by bone and tissue. I think there wiI1 aIways be a place in surgery for vitaIlium. Under the stress and strain of hip cups, in the first pIace it wouId have to be a cast object and not one machined; there are variations in the mechanics of creating the appliances we need. We are a11 taIking the same Ianguage and a11 I hope is that we taIk it so pIainIy that everyone understands we are striving toward the passivity of the materia1 and trying on that basis to find the materia1 that wiI1 then serve both purposes of strength and passivity without any fear of irritation, so that we can go to bed and go to sIeep and not worry about what is going to happen.