Modern operative bone surgery, with special reference to the treatment of fractures

Preface

The great demand for a comprehensive, yet abridged, book on "Plastic Bone Surgery" suitable for the busy surgeon, presenting clearly the modern methods and mechanical means for perfecting such work, has been firmly impressed upon the mind of the author in the last three years by the great number of inquiries from this and foreign countries for a book dealing with this subject. It was with a keen appreciation of this demand that the present volume was undertaken.

Following these ideas, the author has endeavored to give the facts in autoplastic bone work and the modern instruments used in such work as briefly as is compatible with clearness.

It has been a difficult task, because there is no similar work on this subject published up to the present time. All previous publications on bone surgery are largely composed of reports of cases.

The transplantation of bone is not an entirely new procedure, and the advent of asepsis and the development of the electro-operative motor instruments have made possible its extensive application. The dependable methods of obtaining asepsis in bone surgery must withstand the closest detailed scrutiny.

vj PREFACE.

Bone being a connective tissue, lends or gives itself favorably to transplantation, and to the repair of defects and deficiencies of the skeleton. It is the only safe and reliable internal fixation. By the use of autogenous material the surgeon follows nature's own method, and is thereby able to overcome mechanical surgical defects which hitherto he was unable to deal with successfully.

The application of external fixation-braces, and the uncertain extemporizing methods, cannot compare with the autogenous bone-graft accurately and directly implanted.

The reader will recognize, after a careful review of the voluminous literature of the last few years, the difficulty of justly estimating the value of conflicting opinions; therefore, a judicial and careful selection from the vast material is the most important duty of the writer.

The author is deeply indebted to the late John B. Murphy for the privilege of selecting from his extensive library valuable rontgenograms, many of which are used in this volume, and also for his many suggestions.

The author is also obligated to Dr. Arthur H. Hertzler for his most valuable criticisms and corrections.

C. G.

Contents

CHAPTER PAGE

I. Histology of Chondrin. Cartilage 1

II. Histology of Periosteum and Bone 5

Introduction

In the Library at Leipsic is the celebrated hieratic medical papyrus which was discovered by George Moritz Ebers, a German Egyptologist and f novelist, born in Berlin in 1837. While travelling in Egypt in 1872 he discovered the hieratic medical papyrus which is now known as the "Papyrus Ebers," which dates back one thousand and fifty-five years B.C. It is one of the best preserved Egyptian papyri in existence, and forms the chief source of information in regard to the medical knowledge of the ancient Egyptians.

It is evidenced by these ancient records that rhinoplastic operations were performed then by the flap method. The ancient Hindoo specialists made new noses from the frontal tissues long before the time of the noted Italian surgeon, Taliacotius. The Hindoos replaced the cartilage portion, cut oft" as a punishment for adultery or other reasons, by a cutaneous flap, turned down from the forehead. Taliacotius, in the sixteenth century, made noses and lips from the tissues of the. arm ; he thus improved the features resulting from disfigurement in war, or by disease, many years before the days of Dieftenbach.

Plastic or reconstructive surgery has made wonderful strides since its revival, in the first half of the nineteenth century, by Dieftenbach and

(xiii)

xiv INTRODUCTION.

his contemporaries in Europe, and Muetter and his followers in America.

The development and history of this branch of our art is as attractive as that of aviation. Both would easily evoke in one's mind a pleasure akin to that responding to the touch of a novelist's pen.

Wolff, the noted Scotch surgeon, was able to convince a few of his profession that a free flap or graft of skin taken from a distant portion of the body could be successfully transplanted to correct eversion of the eyelid.

His method of dissecting up the ectropion, replacing the eyelid, and filling the raw gap with a piece of detached skin, was often tried, but this operation failed too frequently to become a standard procedure.

Then came another celebrated Scotchman, Lord Lister, who died but a few years ago, and who did so much to improve surgical operative technic by developing and demonstrating the importance of asepsis in surgical work.

Krause, of Germany, then came forward, who developed the usefulness of the free flap or graft of Wolff, by using it in general surgery, and safeguarding it with an antiseptic technic.

Experimental research and clinical observation have proved that all tissues are governed by physiological laws, the same as those regulating* the cell-life and cell-death of the skin. Thoughtful men with broadened minds during the past half century have demonstrated fully that all tis-

INTRODUCTION. xv

sues — teeth, tendons, blood-vessels, nerves, fascias, cartilage, and bone — may be removed from one portion of the body and transplanted to another, and live and grow and become a part of the tissue in which it is transplanted. The patient's own tissue is far superior to that of any other individual for these operations. The tissue from a young person lives and grafts more readily than from the aged.

To Dr. Oilier, of France, should be given great credit in the field of orthopedic surgery, for it was his work, and the stimulus which he gave to the profession, that established the possibility of using bone in plastic operations. It is almost fifty years since Oilier first gave special attention to this branch of surgery.

The wonderful development now seen in osteoplastic work exceeds the march of progress found in other branches of surgery. The methods of Oilier have been modified by the result of increasing knowledge and the invention of modern electro-operative instruments suitable for such work.

Honorable mention, since Ollier's time, is due Tomita, Grohe, Morpurto, Macewen, Axhausen, Murphy, Janeway, Hibbs, Albee, and others, who have done much clinical and experimental work in osteoplastic surgery.

In this volume, only the autogenous bone transplant will be considered, for it is the safe and sound procedure.

Charles Geiger.

Chapter I

Histology of Chondrin. Cartilage.

Ix studying the histogenesis of cartilage and bone, the fact is revealed to us that there are still a number of disputed points in regard to the formation and structure of these tissues.

I shall deal as lightly as possible with the minute cellular changes that take place in the regeneration of cartilage and bone; however, there are certain fundamental points that must be described.

Both of these tissues, cartilage and bone, when fully developed, are very easily distinguished from one another, and there is nothing to suggest that they have a close developmental relationship. Cartilage is flexible, smooth, cuts easily, and has a glistening surface and a homogeneous structure; bone is firm, very difficult to cut, and has a tough, irregular surface, with a complex architecture. Microscopically, cartilage cells are situated in a uniform ground substance, of a singular type, varying only in size and shape; large and round in the center, small and flat towards the periphery, where they gradually pass into a surrounding membrane, called the perichondrium.

Microscopically, bone-cells are of various types; in the center is the complex marrow, beyond which is the cortex, made up of characteristic bone-cells, lying in a uniform ground substance.

The entire structure is surrounded by a thin membrane, called the periosteum.

The embryological origin of cartilaginous bone, its close relation to cartilage, is apparent, as it arises from a blastemal-syncytium of white fibrous tissue, and it passes through an intermediate cartilaginous stage.

The chief problems to be considered are, the relative importance of the original cartilage, and the perichondrium in forming the new cartilage.

The histogenesis of bone reveals the fact that there are a number of disputed points regarding the method or methods of its formation; in this, the chief problems to be considered are the relative importance of the original bone and the periosteum in forming the new bone. In the transformation of cartilage into bone the perichondrium takes a very active part in the endochondral ossification. Following the penetration of the perichondria! buds into the cartilage, changes take place by which the marrow cavity and cancellous bone are formed. The exact manner in which the cartilage is formed into bone has not been fully ascertained. Some investigators think that there is a direct change of cartilage-cells into bone-cells; others believe that the new bone is formed outside the old cartilage, which only acts as a direct framework for the new bone. However, with the change within the center of the cartilage co-incidentally there is a direct deposition of bone beneath this perichondrium.

After the bony stage has been reached, the

HISTOLOGY OF CHOXDRIX. CARTILAGE. 3

perichondrium becomes the periosteum, and the chondroblasts become the osteoblasts. Thus, it is believed that there is a very close relation between the perichondrium and the periosteum, between the chondroblasts and the osteoblasts, between the cartilage and the bone; and it would only be natural to expect a certain parallelism in the methods of regeneration of two tissues so closely related in their development.

The perichondrium is the thin membrane which can be separated from the underlying cartilage, providing the exact line of cleavage is found at or near the chondro-osseous junction. It becomes thicker and more adherent, and so continues with the periosteum. Without the microscope it is impossible to make out any separation between the perichondrium and the true cartilage.

The outer layer of the perichondrium consists of a loosely arranged fibrous tissue, beneath which are longitudinally placed plate-like nuclei. In the next layer the nuclei are large, oval in shape, and, when stained, lighter in color, and are not so close together. These latter nuclei shade off gradually into a group which are slightly larger, and have a more vascular appearance; many of the latter are in pairs, as though they were divided.

There is a general idea that cartilage possesses only slight power of regeneration, and it is even held by some that this power is entirely lacking. The greater number of investigators admit that cartilage has the property of regeneration, but there is no uniformity of opinion as to the exact manner.

The consensus of opinion is that the regeneration takes place from the perichondrium; the transformation from the fibrous connective tissue to the simple cartilage and the complex bone involves as intricate a developmental problem as is met with in any of the developmental changes within the body.

In the study of cartilage and bone it will be noticed that certain cells possess the inherent tendency to produce these specific types of tissue; and although we cannot hope to determine what that stimulating factor may be, we should at least be able to arrive at a uniform interpretation of the various steps of the process.

Here, as in all other regenerative and developmental changes, some unknown factor or forces initiate the transformation that takes place. This influence is often referred to as the inherent organization of the germs, but as yet no one has any definite conception as to what that organization is.

In the early development of the foetus, many of the cells of the somatic and splanchnic mesoderm are transformed into what is known as the mesenchyme. The mesenchyme is the forerunner of connective tissue. These tissues are intimately associated with the formation of all the organs of the body, and also become definite membranes, cords, or solid masses, etc., i.e., fascia, tendons, ligaments, cartilage, and bone.

CHAPTER II. Histology of Periosteum and Bone

Bone may form either from fibrous tissue, in which case it is known as intramembranous bone, or it may develop from cartilage, as in intermedial stage, and then it is known as intercartilaginous, or endochondral, bone. In either case, it is developed from mesenchyme, but differs from other mesenchymatous derivatives in that bone is never of primary formation, either developing in preformed fibrous tissue or cartilage.

In. the intramembranous development, when the inherent organic power of the organism stimulates the fibrous tissue to become differentiated into osseous tissue, certain cells, known as osteoblasts, deposit calcium salts in the fibrous tissue matrix, forming a network of bone spicula. These spicula, as development continues, increase in thickness, and extend farther, radiating in all directions, into the connective tissue matrix.

Later on, the cells of the mesenchyme, which are directly adjacent to the reticular plate of bone, previously produced, are seen to condense, and form "a stout membrane". This membrane becomes what is known as the periosteum. By the time the periosteum becomes recognizable as a distinctly condensed membrane, a layer of osteoblasts arrange themselves in a more or less definite manner between the periosteum and developing bone.

Being limited externally by the fibrous tissue membrane, the osteoblasts deposit a lamella of compact bone. The histological structure of the periosseous layer is intimately associated with the function of the periosteum; its component cellular elements increase or decrease, numerically, directly with the physiological or pathological variation of its function.

In adult bone, its function is slightly different from that of young bone, and extremely variant from that of irritated bone.

Bone is not a simple crude mass resulting from the calcification of cartilage or fibrous tissue. It is a highly developed form of connective tissue. It is in reality a white fibrous tissue, calcified and structurally modified until it becomes osseous tissue. It is distinctly a different structure, the constituent parts of which are arranged systematically.

Two distinct varieties of bone exist; compact, or dense bone, and loose, spongy or cancellous bone. Dense bone is compact, and is always found upon the exterior part of the bone-tissue. Even this apparently compact bone is porous. It differs from spongy bone only in its greater density, and in the arrangements of its osseous substances into lamellae. It particularly forms the shafts of the long bones, and constitutes the outer portion of their extremities, and of the short, flat and irregular bones. Excepting the dentine and enamel, it represents the hardest substance of the body. It is elastic and tough, and much force is required to break it. All bones possess two membranes; the covering or periosteum, and the lining or endosteum. The periosteum is a dense tissue, which is firmly attached to the bone by trabecular of fibrous tissue (Sharpey's fibers), which penetrate the bone at right angles to its surface, and carry blood-vessels into the dense bone. They do not directly enter the Haversian system, but only circumferential and intermediate lamellae — parts' that are formed by periosteal action. Some of these vessels, however, communicate with the Haversian canal, and even with the endosteum and marrow indirectly, and play a most important part in the result of a transplant. There are no Haversian canals in the outer layer, but here are found in the large channels Volkmann's canals. The interstitial or intermediate lamellae occupy the spaces between the Haversian systems. They represent the remains of peripheral lamellae. They are usually short, and very irregular, but possess lacunae and canaliculi, and are arranged as in the Haversian system, and with which they connect.

The Haversian or concentric lamellae are circular layers, arranged around a center space or canal, known as "a Haversian canal". There is no fixed number of these layers, there being usually from five to ten. The layers of each system are parallel to one another, but the layers of the different systems cross at various angles. Between these layers are small irregular spaces called lacunae. These lacunae are connected by small canals or canaliculi, and the lacunae nearest the Haversian canal communicate therewith, by canaliculi; in other words, there is a perfect network of small and large lakes and canals in the shaft of long bones.

The Haversian canal contains blood-vessels and nerves; the vessels in the canals are covered with endosteal cells, and the canals themselves are lined with the same cells. The space thus formed is the lymph channel, and into these canals the canaliculi empty. Thus, an indirect connection in the periosteum and endosteum is formed. In each lacuna is a bone-cell, or osteoblast — the 'important part of the bone-graft.

The spaces between the Haversian systems are occupied by the interstitial lamellae, which are short and very irregular, but possess lacunae and canaliculi, which are arranged as in the Haversian system. The lamellae that surround the marrow cavity are irregular, they also possess lacunae and canaliculi and the all-important osteoblasts, which are just outside of the endosteum.

The osteoblasts are irregular, flattened, stellate masses of protoplasm, possessing a number of processes. The protoplasm is granular, and each cell contains a large and distinct nucleus. Osteoblasts are met with in greatest number in the deep layers of the periosteum, and in the endosteum. Cancellous bone is found in irregular and in flat bones, and it forms the bulk of the

HISTOLOGY OF PERIOSTEUM AXD BOXE.

o o o % extremities of the long bones. Its anastomosing spicula form a network for the marrow. It contains lacunae, and canaliculi, and the spicula have a fibrillar structure. In the ends of the long bones the spicula are placed, as a rule, at right angles to the planes of articular surface (the line of greatest pressure). They are bound together by other spicula that correspond in direction to the planes of the articulation (the line of greatest tension). The nearer the marrow cavity, the heavier and stronger these spicula are.

The blood-vessels that supply the cancellous bone are fewer and larger than those that supply the compact bone. The supply for both is derived from the periosteum, whereas the marrow derives it principally from the nutrient artery. This artery enters through the nutrient foramen, usually located near the center of the shaft, which passes obliquely through to the medullary canal. There the artery gives oft" branches towards both extremities, thus forming capillary plexus in the marrow, and communicates with the periosteal vessels. The walls of the blood-vessels in bone are very thin, and the current very slow ; the veins are given exit in three places : from the long bone, with the nutrient artery, and at the articulating extremities, and from the compact substance. The latter two do not accompany arteries, but immediately after emerging from the bone they have numerous valves. In the flat and cranial bone the veins are numerous and large. The nerve supply to bone is very complete. The nerves are freely distributed to

Fig. 2.— Skiagraph of elbow showing fracture of the internal and external condyles of humerus ; with ordinary 6-penny finishing nail driven through each condyle into lower portion of humerus, holding condyles in position; also, brachial artery (injected with lead) with its many branches around elbow- joint. (/. B. Murphy.)

MODERN OPERATIVE BONE SURGERY.

Fig. 3. — Illustrating circulation of forearm, wrist, and part of hand. (/. B. Murphy.)

HISTOLOGY OF PERIOSTEUM AND BOXE. 13

Fig_ 4.— Beautifully illustrating circulation of pelvis and hip. (/. B. Murphy.)

MODERN OPERATIVE BONE SURGERY.

Fig. 5. — Posterior view of the lower portion of leg and foot. Also illustrating the posterior tibial and peroneal arteries, their position, and the branches given off from them.

the periosteum, and some of the fibers terminate in this structure as pacinian corpuscles. Nerves accompany the nutrient arteries into the interior of the bone, and also reach the marrow from the periosteum by way of Volkmann's and Haversian canals. They very thoroughly supply the coats of the arterials, and ramify about the osteoblasts. Articulating surfaces, as well as bone-tissue, are most completely supplied with nerves. In severe injury to bone or joint, great shock follows, on account of the destruction of nerve-tissue.

In studying the elements histologically of the periosteum, it must be studied in its proper relation to the compact bone, as well as when it is stripped from said member. Not only is it necessary to examine the periosteum intact, and that stripped from said member, but much depends upon the method used in separating it from the bone. If removed with a quick stroke of the periosteotome, and likewise a similar strip from the same location, but with a slow raising motion of the periosteotome, and each strip examined microscopically, the variation in the line of separation can easily be demonstrated. This variation becomes more marked when bones of different stages of development are studied.

The periosteum is a membranous coat of fibrous tissue. It consists of an outer layer, made up of interlacing bundles of dense fibrous tissue, and large blood-vessels, the branches of which penetrate into the underlying compact bone. Directly beneath this, and in contact with this outer-

Fig. 6. — Skiagraph of the knee-joint showing the popliteal artery with its numerous branches. Star indicates a large artery entering the bone near the upper epiphyseal junction. (/. B. Murphy.)

most layer, is a firm fibro-elastic stratum, which varies with the age of the individual. In adult bone it is closely attached and firmly adherent to the surface of the bone; beneath this latter stratum there is a periosseous or cambium layer of tissue consisting of small vessels, numerous small cells, and fine connective tissue fibrils — the subperiosteal areolar tissue of Macewen.

The cellular elements are profuse in young or developing bone, and are easily divided into two distinct types — an outer layer of cells, with plate-like nuclei closely packed together, and an inner layer, consisting of small oval nuclei. These cells with plate-like nuclei are similar to those found in the perichondrium of true cartilage.

These two types of cells are probably dormant osteoblasts (Haas).

Microscopically, there is no demonstrable line of separation between the periosteum and compact bone.

The histological components of the stripped periosteum vary with the method of stripping, as previously stated, definitely proving that there is no distinct line of cleavage.

Again repeating, one specimen stripped slowly with a blunt instrument will contain cellular elements not present in a specimen stripped quickly, or with a sharp osteotome.

About 1740 Duhamel brought forth the first systematic work on the role that the periosteum plays in the repair of bone, and was the originator of the generally accepted modern theory.

It was his belief that the periosteum, intact, proliferated and became thickened about a fracture, and formed the callus by throwing out new tissue. He was also the first to define and use the term "cambium layer", of the periosteum, which, since the writing of Macewen, has become recognized as the all-important bone-growing element of that member, possessing as it does, when removed in a certain manner, a great many osteoblasts.

Over 1 20 years later appeared the great and important work of Oilier (1865), which has withstood the test of time, and remains today the principal foundation of all exact knowledge of the growth of bone. His work was so thorough that his conclusions have attained an almost unassailable position. He proved the regeneration of bone from periosteum intact, in every possible way, and ever since his day this membrane, in its normal position, has been regarded as one of the most important vital tissues of bone. Nearly half a century has elapsed since Oilier' s treatise, and during this period practically the whole of modern surgery has arisen.

As previously stated, it is evident that the periosteum is a direct derivative of the chondroblasts; in the regeneration of bone the osteoblasts tend to revert to the chondroblastic type, which is shown by the formation of cartilage and bone at the same time in the early stages.

In the regeneration of cartilage there is a reversion of the chondroblasts to the connective-tissue type of the cells. After the periosteum has proliferated into cartilage, it is rapidly transformed, either directly or indirectly, by some specific influence, perhaps of a chemical or physical nature, into bone. The cartilage, on the other hand, some of it, continues to grow as cartilage, but it also may later be changed into bone, as in old age. The growing and determining force is the same as that which is fundamental to all growing conditions, and is dependent upon a specific property of the cell, which determines the character of the tissue to be formed.

By carefully studying the voluminous literature, and reviewing the methods of experimentation, the question arises whether all the investigators have included or excluded the same components, and what constitutes the periosteum.

Are the constituent components of the periosteum constant, or are they subject to extensive variations, either numerically or in type and arrangement of cellular elements?

On account of the utter confusion which has arisen concerning the exact components of the periosteum, I shall give a concise description of its histological activity and change of same.

The histological structure of the periosteum differs in its component constituents at different stages of development of the body. During the stage of developing and growing bone the periosteum apparently contains an active third layer, or a periosseous layer, in which is found the fine connective-tissue fibrils, numerous small blood-vessels, and rows of small cells, the osteoblasts.

The term periosteum, as generally used, is understood to be the periosteum from a surgical standpoint. As such, it is considered as the membrane which remains after a careful subperiosteal resection of the underlying bone, special care being exercised that no bone elements are left behind. Moreover, it is definitely known that the periosteum, in different stages of bone development, contains special cellular elements in greater or lesser number. These cellular elements are also increased by toxic, chemical, or mechanical causes. Therefore, it will be expected that in experiments produced with such a varying structure as the periosteum, although all other details were identically carried out, the results would be at a greater or lesser variance with each other, even so far as absolutely contradictory results.

The gross anatomy of the periosteum is a dense fibrous tissue membrane, completely surrounding and adhering to the surface of the bone, except at the ends or articulating surfaces, where the bone is covered by cartilage. At the location of the tendon attachment, the periosteum becomes a part of structure. Many blood-vessels traverse the periosteum, and enter the compact bone through Yolkmann's canals. "When it is stripped from the living bone many bleeding-points are seen, which mark the site of the entrance of these blood-vessels.

Blood-vessels from the periosteum penetrate compact bone, and reach the marrow substance, communicating with branches from the nutrient artery. The periosteum also furnishes the blood supplied to the cancellous bone, branches of which ramify in the cavities of the spongy part or parts of the bone.

After a thorough investigation, the author has come to the following conclusion:

i. That the periosteum in itself has no osteogenetic power, outside of the adhering osteoblasts.

2. By the removal of the periosteum from a bone-graft, a great number of osteoblasts on the surface of the bone are removed and destroyed, thereby reducing the osteogenetic function of the graft very greatly.

3. That if the periosteum is left intact on the transplant, it supplies nourishment by the blood supply to the osteoblasts that come in contact with, and just beneath, the periosteum, and cause them to live, thereby stimulating osteogenesis.

4. That the endosteum supplies nutrition to the osteoblasts on the inner surface of the bone, or that are nearby, or that come in contact with the endosteum, because of the thorough blood supply of the endosteum.

5. That if the endosteum is removed from the transplant, a number of osteoblasts on the inner surface of the bone are destroyed, with the blood supply, thereby reducing the osteogenetic function of the graft.

6. That by leaving intact both periosteum and endosteum we preserve the blood supply, thereby giving nutrition to the cells' that are responsible for the regeneration of bone and nutrition which is responsible for the apparent life of the graft or transplant.

7. Bony protuberances, condyles, etc., detached from all tissue save the periosteum, unite like free autogenous grafts covered with periosteum.

8. Detached bone, protuberances, or condyles, with healthy periosteal covering, and attached more or less to other tissues, continue to live.

9. By using autogenous bone-grafts, if good apposition is obtained, we have a very small callus, as small as in simple fractures, with good apposition.

10. The autogenous graft seems to live, but in reality it does not; the trabecular are gradually replaced by bone growing inward from the vascular spaces between them, while the cartilage continues to live, and to a limited extent aids in the formation of the new bone adjacent to it.

11. The principal replacement of bone in the trabecular takes place directly from the bone-cells, without the preliminary formation of cartilage; and the dead portion of the trabecular are absorbed in a line immediately adjacent to the new growing bone, without the addition of special cells.

CHAPTER III. General Considerations

functions of the periosteum.

It is very evident that the periosteum has four distinct functions: (i), nutrition; (2), protection; (3), a limiting membrane; (4), that of strengthening and fortifying.

In an article in the "Journal of Surgery, Gynecology and Obstetrics," of May, 19 13, Murphy stated: "The bone-graft, per se, does not possess any osteogenetic power, and merely serves as an osteogenetic purpose. The regenerative force is supplied by osteogenetic cells found normally in the Haversian canal and lacunas of living bone."

One of the important recent contributions is that of Auxhausen (1898). It is readily seen that he assumes the position that neither bone alone, nor the periosteum, per se, is osteogenetic: some of the bone dies, but a portion of it retains its vitality; the periosteum and marrow substance remain alive, and produce new bone.

Macewen summarizes the function of the periosteum as follows: "The periosteum is of great use in limiting within specific boundaries the distribution of the osteoblasts, and preventing them, during the evolutionary period, from being scattered into soft tissues, where their presence would be prejudicial to the functions of these parts. In the loose areolar tissue existing between the periosteum and the bone, the osteoblasts find nutriment for their growth, and space to regenerate."