Bone-graft surgery

Front matter

' HEALTH SCIE

""'""" HX64b59677 RD118AI1 Bone-graft surgery

RECAP

Preface

The author has been induced to write this book in order to answer as far as possible the many inquiries in regard to bone grafting and to present the technique of the apphcation of the bone graft in the widening field for its use, which is covered in no other work yet published. The greater portion of this book presents the author's original applied technique with ample illustrations.

Bone, being one of the simple connective tissues, lends itself favorably to transplantation and to the repair of skeletal deficiencies and is the most reliable means of internal bone fixation. Instead of antagonizing Nature by attempting to introduce a foreign substance, the surgeon, by using autogenous material is following Nature's own method, being thereby able to overcome mechanical surgical defects which he has hitherto been unable to cope with. The use of uncertain extemporizing methods and the application of external fixation braces cannot compare with the accurate, direct internal implantation of an autogenous bone graft contacting corresponding structures of graft and host bone, i.e., periosteum to periosteum, compact bone to compact bone, endosteum to endosteum and marrow to marrow.

As improved machinery and tools have made the skilled artisan more efficient, so likewise has the introduction of rontgenography and electrically driven tools augmented the skill and accuracy of the surgeon in arresting bone diseases and restoring bone defects and has opened ways of dealing with bone and joint conditions such as have never been attempted with the cruder hand tools. Though the author considers the use of the motor-driven tools as more nearly approaching the ideal conditions yet there are instances where their use is not absolutely essential.

14 PREFACE

Bone and joint work is a difliciilt surji;i('al specialty, involving ^pjt.ionly the surgical management of soft tissues but bone tissue as well. The successful outcome of any procedure to restore the skeletal architecture depends not only upon a proper operative techni(iue but in many cases in a greater degree upon the skill with which the post-oix^-ative external fixation dressing is applied and in the convalescent management of the case.

The author wishes to express his deep obligation to his associate Dr. Robert E. Soule for his cordial collaboration. He is also indebted to Dr. Penn-Gaskell Skillern, Jr., for his most valuable criticisms, corrections and suggestions.

Fred H. Albee.

40 East 41st Stkeet,

New York City.

October, 19L5.

Chapter I

THE FUNDAMENTAL PRINCIPLES UNDERLYING THE USE OF THE BONE GRAFT IN SURGERY

Cellulai' life may be quite independent of organic or somatic life and, under favorable conditions, tissue cells may retain their viability long after being detached from the living organism. ''The remarkable viability of transplanted periosteum has been demonstrated by Grohe and Morfurgo, the former showing that it is capable of preservation for 100 hours and yet able to be implanted and exert its osteogenetic powers. The latter (Morfurgo) has shown the periosteum of a corpse kept at 15° can produce new bone when implanted after 168 hours." — Janeway. The duration of this cellular life depends largely upon the means of preservation of the detached parts or, in the case of organic death, the preservation of the whole cadaver, and also upon the amount of disintegration from the cause of death. It is on account of this phenomenon that detached portions of living tissues can be successfully transplanted from a corpse to a living organism. The higher the specialization ol the cell the less marked are its resisting and proliferating powers. This is especially well illustrated in the case of tissue grafts. The lower order of tissues, which need less nutrition, continue to live for days on their own substance which is contained in the serum that permeates them, but the more highly specialized ones are liable to necrosis in a short time unless nourished by a blood circulation. This viability varies with the individual tissue, as the higher the development of the cell — such as the ganglion or parenchymatous cells — and the richer the tissue is in blood-vessels, the less likely it is to survive. 2 17

The most favorable tissues for grafting i)urposes are the simpler connective tissues, such as bone, fat, fascia, etc., which are endowed with the capacity of extracting nuti'ition from the soil into which they are planted and at the same time are able to regenerate so that the portion of the graft which disintegrates is replaced. Muscles and nerves are most unfavorable.

Bone has been successfully transplanted since 1809, when ]\Ierrem obtained successful healing of bone plates in the skulls of animals after trephining. Subsecjuently, Walther, in applying this technique to the human subject, secured partial healing of the graft, in spite of the co-incident suppuration. In 1858, Oilier, after extensive investigations in the use of the bone graft in both animals and man, concluded that fresh bony tissue, covered with periosteum, remains viable. Autogenous grafts, or those derived from the same individual into which they are engrafted, are by far the most trustworthy. The fluids, albumins, and tissues of every individual vary in degree from those of every other, and while this incompatibility may be slight, it is sufficient cause for using, whenever feasible, the individual's own tissue for the repair of his defects.

With primary union and in the absence of infection, autogenous bone grafts, properly contacted, are always successful, and even infection does not necessarily indicate failure. "The vegetative capacity of the bone cell is as great as that of the epithelial cell, and if one grants not only the viability of the transplanted epithelium but also its power of extensive proliferation, then, judging by analogy, the bone cell ought to show, as it has bone in this instance, equal capabihty of living and growing when transplanted. In proportion to the size of the graft, the smaller the graft the greater the proliferation." — Macewen.

The knowledge of the exact histological role which the bone graft plays is, fortunately, immaterial to its clinical usefulness, whether it serves as an osteoconductive scaffold or as an active osteogenetic force. The extensive experiments and histological studies of Oilier, Macewen, Frangenheim, Cotton and Loder, McWilliams, Mayer, Phemister, and the author (see Chap. Ill), have proved the viabiUty and osteogenesis of the grafts when inserted by the proper technique.

Cotton states: ''Our specimens show a practically uniform survival of the transplant when the technique is adequate. The articular transplant of the cartilage usually shows no gross change in color or texture from that of the surrounding undisturbed joint surface. The fragment very rapidly becomes firmly fixed in place. Histological preparations obtained at varying intervals show a series of changes in the bony portions of the grafts, the more important of which are constant and very definite. The essential picture shown is briefly: (1) the early disappearance of the bone corpuscles in the transplanted trabeculse and in the trabeculse of the host bone for a short distance from the wound surface; (2) without any loss of substance in (or any marked foreign body reaction around) the bone from which the corpuscles have disappeared, this bone was rapidly and completely covered by a layer of new^ endosteal bone, which unites with endosteal bone of the host; (3) the new bone is laid down by the activity of end-osteoblasts in all portions of the grafts, centre as well as periphery. It has not yet been proved that some of the end-osteoblasts which are active in the graft may not have originated from the endosteum of the host and extended, or even emigrated, from it to the graft; but no one, after study of our sections, can doubt that in part, at least, these osteoblasts represent the actively proliferating covering membrane of the transplanted trabeculse; (4) practically no changes, either of degeneration or proliferation in transplanted articular cartilage, at least up to 4 weeks,"

McWilliams concludes in a recent pubUcation: "Living bone grafts have life inherent in themselves, and the theory that contact with living bone is necessary for subsequent life of the graft must be given up,"

''As important as the properties of the transplant are the pualities of the "wound soil" which serves the function of supplying as quickly as possible nutrition to the graft. The first step in the establishment of the lymph flow and the circulatioii is tlie early adhesion between wound edges and the transplant. The more quickly and surely this takes place, the more promptly is nourishment assured. Should the cells of the wound he injured because of antiseptic applications, or should they be abnormal because of the presence of scars or hsematomata, or the seat of previous disease, as tuberculosis, necessary nutrition will be delayed. Very important contributing factors to failure are errors in operative technique, causing infection with a very slight transudate, which is instrumental in destroying the first intimate contact, thus preventing nutrition, partially or absolutely, and predisposing to partial or total necrosis due to suppuration. By means of strict asepsis, this element of failuie can be eradicated. Most important, however, is a second factor, which prevents the early intimate adhesion of the wound edge, namely, imperfect hsemostasis. The presence of the slightest amount of blood is dangerous, as it interferes with the nutrition. That this factor has been heretofore disregarded is apparent from the literature. It is the general belief that a smooth, uninfected wound is a sign of perfect technique. This is not true in connection with transplantation. In this instance, perfect technique is recognized by a complete gumming and coaptation of the wound edges. For this reason, every experimenter in recording the results of his transplantations should convince himself that the transplant is really grafted as it should be, in order that his operation be perfect." — Lexer.

Homoplastic grafts are those which are derived from another individual of the same species, and when composed of the lower order of tissues, such as bone or fascia, they may be employed successfully, though not with the same certainty as autogenous grafts; when they consist of the more highly specialized tissues, they result in failures. Homoplastic grafts are often difficult to obtain, and there always exists the danger of transmitting disease from the donor to the host, even when the greatest care has been exercised. Fibrous encapsulation occurs more frequently in homoplasty than in autoplasty. This, as Lexer has pointed out, is probably due to the irritation of a foreign proteid, which varies most with difference in race, next with distant relatives, near relatives, and least with the individuals of one family. This variation prevents proper nourishment of many tissues and, as a result, substitution in the regenerative process occurs very slowly while degeneration takes place rapidly.

Heteroplastic grafts are those which are obtained from an individual of another species. Living grafts from different species may die when implanted into man or the higher animals. The graft in these cases acts as a foreign body, and if there is even mild infection it is liable to ulcerate out. In the event of no infection, it either becomes encapsulated or disappears, and is slowly substituted by the proliferation and migration of the tissues in which it is embedded.

This process may require months in the case of the bone graft, and thus it follows that the graft may be a success clinically, though histologically it undergoes partial or even com- two^g^rafi^^a^cr^rrionTin! plete absorption, or, in other words, '"r''^''^ , ^y the author for a

_ . tibial defect from the removal

it acts as an osteoconductive scaffold, of two-thirds of its shaft for

sarcoma. It was necessary to amputate the leg just 4 weeks after the insertion of the grafts, on account of the recurrence of the sarcoma, and in this short time the grafts had become firmly united (at C) by solid bone, although the diameters of the grafts both above and below the union remained the same as when implanted. These proliferating callus bone cells could have originated from no other source than the two graft ends, thus proving conclusively the active osteogenesis of these free grafts. The efficiency of the bone graft could not be better demonstrated than by this specimen. A, indicates where firm union has occurred between the upper graft and the upper remaining end of the tibia; B, where the lower graft has become united to the lower fragment of the tibia; C, indicates firm bony union between the two graft ends which were contacted in the centre of the leg far away from any other possible source of new bone.

The principixl dilliculty witli heteroplastic grafts is that the albumins of different individuals are not alike. Successful experiments are reported as under way in Lexer's clinic, with the object of changing the blood by preliminary treatment. Kutt-

FiG. 2. — By the kindness of Mr. Robert Jones. Tibial graft AB, placed to restore the tibia lost from osteomyelitis. The graft has broken at C. (See Fig. -3.)

ner has been partially successful in grafting tissue from the ape to man. The cellular mass necroses, as it may in homoplasty. Clinical success in the repair of large denuded bony cavities can be secured only by the use of living autogenous bone covered with periosteum.

Just what happens to the autogenous bone graft from a microscopical standpoint, is still a matter of discussion. Whether the boue graft lives as such, or whether the cells wander into it from the bone with which it is connected, is still sub judica.

Fig. 3.— By the kindness of Mr. Robert Jones. AB indicates firm union and callus thrown out by the graft fragments.

In the author's experience both with human beings and with animals, perfect union of the autogenous aseptic bone graft with the bone into which it was placed has been secured in 100 per cent, of cases, and, after all is said, this is the important consideration.

The subject of the bone graft is being widely (.liscussed, and the men who are studying this problem may be divided into two schools: those who claim that a certain portion of the cells in the graft live and that the graft is a distinct and separate osteogenetic force; and those who claim that the cells of the graft do not per se have any osteogenetic power and that the graft merely serves an osteocondiicti\'e purpose. There are at present, however, very few who continue to uphold the latter view, especially since Earth, its originator, has been convinced that his former position was wrong and that the cells of a portion of an autogenous periosteum-covered bone graft live and play an important osteogenetic role (see Figs. 1 and 3).

One should not be too dogmatic concerning the exact role that every graft must play. Individual conditions or individual environment determine the exact role of each particular graft. There may be a considerable blood -clot, or tissue shreds, which interfere with the nourishment of the graft, preventing an immediate and perfect union; or there may be a sHght or severe infection, or other disturbances to deal with, and these conditions determine the exact histology in each individual case or, in other words, how many of the graft cells have received sufficiently early nutrition and remain viable, and how much of the graft dies and serves in an osteoconductive role. It fortunately does not matter, from a surgical standpoint, what happens histologically, so far as the exact role of the graft is concerned. It is known that an autogenous bone graft always "takes" and becomes permanent, if it is put in under aseptic conditions; and, if it has function to perform, it stays there and adapts itself in structure, size, contour, and in strength to the new environment.

Boiled bone has been used by Kausch and others for years as a substitute for the bone graft. From a recent discussion of this matter, one would gather that this material had never been used before. Boiled bone is far inferior to an autogenous bone graft, and Kausch, in 1910, from an extensive experience prepared a table illustrating the scale of value of dilTerent material for bone substitution and made the following statement: Boiled bone and bone from the cadaver are not adapted for implantation in a bed free from periosteum, and foreign substances are still less suitable for this purpose.

Fig. 4. — An antero-posterior longitudinal section of a spine 2 years after the tibia bone graft had been implanted into its split spinous processes to ankylose the tuberculous infected vertebrce present between A and B.

The drawing was made from an actual specimen and represents the alteration which has taken place in the character of the graft and its bed.

The area A to 5 has been so changed that it presents the characteristics of a single bone with a distinct cortex enclosing cancellous bone structure throughout or in other words it has become identical in its anatomical structure to the spinous processes to which it has become amalgamated.

This is a fortunate characteristic of the bone graft, i.e., it adapts itself to its environment.

KAUSCH'S TABLE OF VALUE OF DIFFERENT MATERIALS FOR BONE

TRANSPLANTATION

1. Pedunculated soft parts with periosteum-covered bone flap.

2. Free transplanted periosteum-covered autoplastic bone.

3. Free transplanted periosteum-covered homoplastic bone.

4. Fresh boiled bone.

5. Fresh preserved bone.

6. Cadaver or fetal bone, obtained under sterile conditions.

2G BONE-GRAFT SURGERY

7. The same bono, boiled.

8. Ivory.

9. Foreign bodies, sucli as metal.

10. Fresh animal bone, living or l)oiled.

Lexer states: ''Boiled bone, obtained fi-oin a cadaver, or fresh bone which has been sterilized, acts as does a foreign body which slowly undergoes substitution; it is rapidly destroyed by \'igorous gi'anulations. Foreign body suppuration with extrusion of the dead graft, long after primary union, occasionally occurs."

Barth {Verhandlung der Deutsch. Gesell. fur Chir., xxxviii, 1909) makes this statement in reference to boiled bone for transplantation purposes: "Personally, I (Barth) have had nothing but failures. Absorption follows in these cases, or secondary suppuration if the patients are allowed to use their limbs, and the bone must be removed. I therefore believe that it would be going backward to make use of dead bone as a routine measure in osteoplastic work. Accordingly it can no longer be doubted that in the substitution of very large defects, only the living bone covered with periosteum furnishes trustworthy results."

Baum reported five cases of intramedullary graft for ununited fractures. Four were homoplasty grafts (taken from amputated limbs and fetal bones). The fifth graft was an autogenous graft and was the only one which resulted in solid union, thereby proving the value of live autogenous bone grafts and possibly the disadvantage of the intramedullary technique.

In this connection. Bier claims that most bone regeneration comes from the endosteum and bone- marrow and that no regeneration occurs in a scraped (or reamed-out) medullary cavity. This undoubtedly explains in part, at least, failures from the intramedullary technique of inserting the graft in ununited fractures.

Implanted ivory is merely absorbed, without any substitution formation of new bone.

Autogenous live bone is the only material which can be implanted with safety in a bed free of periosteum.

Laewen made histological studies of bone grafts which had been transplanted 11 weeks, and by injecting the blood-vessels of the amputated arm found that there had been a complete vascularization of the transplant which had been obtained from the tibia of the same patient. The graft was being gradually absorbed and replaced by new bone which proliferated from the osteogenetic bone-cells in the periphery of the Haversian canals of the graft itself; and also the periosteum lived and was active in proliferating new bone from its deep osteogenetic layer. The new bone always took on the contour of the part which it replaced.

After extensive experimental investigations and a large amount of human work, the author is convinced that the best transplant is a live piece of autogenous bone in-

FiG. 5. — A diagram

eluding all its elements, namely, periosteum, illustrating the method

, 1 , 1 used most frequently in

compact bone, endosteum, and marrow grafting fruit trees, it substance; that the periosteum which is j:^'^:}:^l^Z separated from attached muscles should be three elements of the

graft or scion (namely,

-incised in numerous places to provoke a the bark, alburnum (sap)

, i-ij- 11 n uiJ and wood) are closely

greater stimulation and also a ireer blood coapted mth their corsupply; it lets out osteogenetic cells and lets J-P^^f^^^jf of "dplnt in nourishment, that the bone is best taken branch. This contact of

individual tissue layers

from the same individual or, if this is im- is most essential in tree practicable, from another individual of the ueved to be analogous to nearest kin, preferably a brother or sister; J;°;^^\ °;:^f°;;g;" ''"""''^" that the bone should never be obtained from an animal, because its viability or replacement is uncertain or, at best, delayed, and according to Axhausen its periosteum does \ \ (not proliferate.

There are certain fundamental I'ules which should always be observed in the transplantation of all tissues. These rules must be adhered to as closely in the animal as in the vegetable kingdom. The science of grafting in the plant kingdom is centuries old. The most important rule of the process of grafting in the vegetable kingdom is the contacting of the alburnum of the scion or graft

Fig. 6.- — -Note increased density of the graft in (Fif^. 7). This rontgenogram was taken 5 weeks after the implantation.

(which, in a way, corresponds to the periosteum) to the alburnum of the stock, or the part grafted. (See Fig. 5.) The contacting of the corresponding histological layers is not of such paramount importance in the grafting of bone as it is in vegetable life, but the importance of its observance is unquestionable.

The more closely these rules are adhered to, the greater will be the percentage of clinical successes. In the case of the bone transplant, nature is confronted wdth the following problems: (1) the rapid establishment of cellular nutrition and blood supply, which is brought about by the extension of blood-vessels, and by the cellular assimilation of the serum in which the graft is immersed; (2) the union of the graft to the contacted bones or fragments of bones by osteogenesis on the part of the graft or recipient bone, or both; (3) through Wolff's law, which is the adaptation in form and increased strength of the graft to its mechanical requirements. If nature is to succeed in accomplish-

N

Fig. 7. — Rontgenogram of a case of Pott's disease showing a tibial graft spanning three vertebral spinous processes and although this graft is considered to be too short, yet it has held the diseased vertebrte hyperextended and arrested the progress of the disease. The principal interest of this rontgenogram is that it shows a marked increase of density of the graft (6 months after implantation) from functional stimulation. (Wolff's law.)

ing this, it is quite essential that both the graft and the recipient bone should be favorable to cellular life and proliferation.

The surgeon can do much in aiding nature by strict asepsis, by minimizing the trauma to all the tissues involved, by avoiding cellular death through either bruising or comminuting with hand tools, or by frictional heat from motor-driven instruments; by the avoidance of traumatism, thus guarding against necrosis of portions of the graft and lessening the danger of wound infection; by the proper protection and preservation of the graft bed and the graft itself from drying and possible infection; b}^ so arranging his skin incision that it will not come directly over a superficially placed transplant, as this lessens the danger of skin necrosis and infection; by excising, if possible, extensive scars from the field of operation, as their poor blood supply is likely to interfere with the establishment of nutrition to the graft; by closely fitting and contacting bone surfaces which should, whenever possible, include the accurate coaptation of periosteum of graft to periosteum of recipient bone, of cortex to cortex, of endosteum to endosteum, and of marrow to marrow; by properly suturing muscle origins and insertions to the suitable mechanical locations on grafts which replace skeletal bones or portions of them (this is important if muscle control is to be reestablished) ; by securing sufficient hsemostasis in the graft bed by means of repeated applications of hot saline solutions, and by careful tying of blood-vessels. (A hsematoma not only favors the development of infection, but also interferes with the early nutrition of the transplant by the permeating serum; a small amount of blood-clot, however, may be desirable); by including in the graft the periosteum, endosteum, and marrow, which not only contain active osteogenetic elements but, on account of their loose structure, are more favorable than compact bone to a rapid reestablishment of the blood supply with the recipient tissues of the graft bed, from whence nourishment rapidly reaches the compact part of the graft through the numerous blood-vessels passing from these enveloping membranes into the compact bone. In other words, a bone graft consisting of all its elements approaches more closely a complete physiological unit — especially in refeience to nutritional distribution — which is obviously an advantage.

Stohr, in his text-book on Histology, states: ''The blood-vessels of the bone, the marrow, and the periosteum are in the closest connection with one another and also with the surrounding structures. Small branches (not capillaries) of the numerous arteries and veins of the periosteum enter the Haversian and

PLATE I

Fig. 1. — Sixty-four day Exp. No. 153. One-half of the shaft .split longitudinally; periosteum and endosteuni on: «, Old dead cortex; b, new bone from periosteum; c, extensive new bone from endosteuni; d, filjrous intermediary callus above; e, bony union lower end. This specimen emphasizes the importance of the endosteum in the production of new Ijone.

Fig. 2. — Forty-six day Exp. No. 176. Periosteum and endosteum Ijoth removed: a, Callus formed on transplant from surviving cells; b, dead cortex; c, fibrous intermediary calluses. This specimen proves that a cortical bone transplant will produce new bone from its " marrow canals," although all its periosteum and endosteum has been removed.

Fig. 3. — Forty-six clay Exp. 161 R. Showing rapid bony union — a fracture through a transplant with periosteum and endosteum on: a, Bony periosteal callus; b, bony endosteal callus: c, bony intermediary callus; d, cortex with colls dead. The rapid bone formation and union in this specimen emphasizes the importance of coaptating like layers of bony parts, whether they are fracture fragments or bone-grafts. There is an important correlation between these layers (viz., periosteum, compact bone, endosteum, and marrow) in the formation of bony callus, and a bone-graft should always, when possible, be inserted by the inlay method, which brings all its layers in coaptation with the corresponding ones of the host bone. According to Ely the periosteum furnishes connective tissue from which the osteoblasts of the marrow tissue build new bone.

(D. B. Phemister in "Surgery, Gynecology and Obstetrics.")

Volkmann's canals, which on the inner surface of the bone are in communication with the blood-vessels of the marrow. The latter is supplied by the nutrient artery, which on its way through the compact substance gives off branches to the same, and in the marrow breaks up into a rich vascular network."

The bone contact should be of generous extent and always with healthy vascular osteogenetic bone — the more unfavorable the bone, the greater should be the area of contact. Careful suturing as well as accurate coaptation should be secured when early use is to be made of the part, in order to obtain the benefits of functional irritation. In many instances where close contact and exact coaptation cannot be secured, early bony union may be accelerated by the interposition of numerous small grafts or fragments of bone. In early ununited fractures, it is the practice of the author to remove most of the fibrous union and substitute for it (after the inlay has been fixed in position) numerous bone chips between the ends of the fragments. These coalesce with each other and also with the graft and recipient fragments.

The proper contact of these bone elements can be secured only by the employment of the author's inlay principle of procedure, which should always be carried out as carefully as circumstances permit. Examples of the various modifications of this principle are the inlay spinal giaft for Pott's disease, the bone-graft wedge for the correction of deformities, and the inlay bone graft for fresh and ununited tractuies. In many of the lattei type of cases, the callus formation is so meagre that it may well be compared to the cabinet-maker's glue, which will not hold unless the wood is exactly fitted and coaptated. It will not bridge space. The same holds true in a long-existing ununited fracture. The surgeon must execute cabinet bone work in order to approximate 100 per cent, of successful results, and this can be accomplished only by employing the inlay method with the author's bone mill.

Bone grafts have been successfully applied by other means, but the following are some of the obvious advantages of the author's inlay method, besides the approximation of correspond-

32 BONE-GRAP^T SURGERY

ing bone elements of "raft to recipient l)one which this procedure makes possible. In the repair pi-ocess, especially in fractures, new bone appears from both the periosteum and the endosteum on both sides of the cortex, possibly more markedly on the concave side of the fracture. The space between an inlay bone graft and its host bone becomes filled by cells arising from both the endosteum and the periosteum. Cotton and Loder consider the endosteum as the more important factor in the formation of bone about the transplant. In view of these facts, the inla\ method of inserting a bone graft is apparent, in that it affords the coaptation of both these structures of the graft to the corresponding ones of the host bone.