Charles H. Herndon

A COMPARATIVE STUDY OF THE HEALING PROCESS FOLLOWING DIFFERENT TYPES OF BONE TRANSPLANTATION.

A controlled comparative study was made of the osteogenic properties of various types of bone grafts in dogs. A rating scale was applied to the histological criteria used for the evaluation of the grafts, and a tabular and statistical evaluation of the results was carried out. Fresh autogenous bone was clearly superior; freezedried homogenous bone was the next highest in rating. The rest of the grafts tested rated in the following order: frozen homogenous, decalcified homogenous, frozen irradiated homogenous, freeze-dried irradiated homogenous, fresh homogenous, deproteinized heterogenous, and deproteinized homogenous. An indication of the approximate level of significance of this ranking was given. The deficiencies in the data related to the great variability in the response of the animals and the small numbers of animals at each test interval are discussed.

Acute Slipped Capital Femoral Epiphysis

The experience at University Hospitals of Cleveland and Childrens Hospital of Akron with fifty cases of acute slipped capital femoral epiphysis is reviewed. In forty-seven hips treated by manipulative reduction and epiphyseodesis, pin fixation, or both, seven cases of avascular necrosis occurred (15 per cent). In nineteen hips treated by manipulative reduction, epiphyseodesis, and plaster immobilization, one case of avascular necrosis occurred (5 per cent), and seventeen (90 per cent) satisfactory functional results were obtained. In sixteen hips treated by manipulative reduction and pin fixation, three cases of avascular necrosis occurred (25 per cent), and twelve (75 per cent) satisfactory functional results were obtained. No case of avascular necrosis occurred in eight patients treated by manipulative reduction within twenty-four hours of the onset of acute symptoms. No case of avascular necrosis occurred in a female patient.

Pulmonary Function in Paralytic and Non-Paralytic Scoliosis before and after Treatment

The results of pulmonary-function studies done on sixty-three patients with paralytic and non-paralytic scoliosis are presented. The results confirm the concept that angular deformities of the spine cause impairment of pulmonary function. The results also demonstrate that the application of the preoperative corrective device further reduces pulmonary function except when the halo apparatus is used as the corrective device. There is no significant improvement of pulmonary function following spine fusion. The importance of blood-gas and diffusion-capacity studies is discussed.

The Effect of Corrective Surgery on Pulmonary Function in Scoliosis

Pulmonary function was studied in thirty-five patients before, during, and immediately after major orthopaedic operations. One group of twenty patients had corrective procedures for idiopathic scoliosis. Fifteen patients had operations involving the extremities. In the patients with scoliosis were found that pulmonary mechanics, as expressed by flow resistance and elastic compliance, deteriorated during the operation; that pulmonary right-to-left shunting increased and arterial oxygen tension on air decreased immediately postoperatively; and that vital capacity was greatly reduced after the operation. No significant changes took place in the rest of the patients. We concluded that corrective operations for idiopathic scoliosis are associated with major reductions of pulmonary function in the immediate postroperative period, so that postoperative respiratory failure would be a risk in patients who had compromised pulmonary function preoperatively. We therefore recommend pulmonary function testing preoperatively and outline one approach to this problem.

Osteogenic Induction by Osteosarcoma and Normal Bone in Mice

1. Osteogenic induction across a Millipore filter barrier by normal mouse calvarias and mouse osteosarcoma was demonstrated in mice. 2. The amount of external bone induction was considerably greater with two-week and eight-week-old mouse calvarias than with newborn calvarias, but the incidence of bone induction dropped sharply with eight-week calvarias. 3. The amount of external bone induction by the mouse osteosarcoma was from fifteen to seventy-five times greater than that by the normal bone. 4. External induction did not occur with any chamber in which bone was not growing or with any chamber containing rat calvaria or human osteosarcoma.

A Critical Evaluation of Processed Calf Bone

The commercial availability of processed bovine boric has provided the surgeoni with a convenient, readily available, arid almost unlimited supply of boric-graft material. In addition to these obvious advantages, data have been published itt support of claims that processed bovine bone is well tolerated by the host, manifests negligible antigeniicity of the immediate type, arid undergoes remodeling as rapi(lly as autogenous bone i,2,3,4,5.6,s,I2,i3 From these data arid an extended clinical trial it has been concluded by its proponents that the quality of processed calf boric as a graft material “compares favorably to that of human autogenous bone grafts” . The experimental models in which this material has been tested have been al most exclusively designed as window defects in either cortical or cancellous boric. Under these conditions practically all grafting materials will be incorporated anicl the defect obliterated. Indeed, data from our own studies indicate that, given a vascular defect surrounded by boric, an empty hole will be filled with woven boric more rapidly than one containing a plug of fresh autogenous cancellous borne. Iii fact, this same observation was made iii one of the studies on processed calf bone . Data drawn from experiments of this design indicate principally the degree to which a material may be inicorl)orated arid remodeled in the normal healing process. They tell us very little about the ability of a graft to initiate arid support osteogeniesis under circunistan(’es in which osteogeniesis in the host bed is less active. In general, siicli studies will tend to minimize differences between bone-grafting materials rather t han t o emphasi ze them. Any stage of the healing Pr (’css iii boric is always the sum of the contributions from both the transplanted material and the recipient site. If we wish to see (‘learly the contribution of the graft material, then the contribution of the recipient site must he reduced to where it is unIv a fraction of that of the graft. However, non-osseous, minimally reactive, soft-tissue sites are riot satisfactory either because they will riot allow us to evaluate the stiniulatinig effect of a graft upon an indolent osteogeriic bed. In a previous stud ’ three of us (K.G.H., S.W.C., arid C.H.H.) assessed the healinig process in eight types of boric grafts compared with aut.ogenious controls. An experimental niodel vas used which we believe nieets most of the criteria indicated above. Briefly, it consists of creating a standard segmental defect iii the nIna t\Vice as long as the dianieter of the diaphysis. This will result in non-union in most instances if the defect does riot receive a graft., arid iii some cases riot even fresh autogenous cancellous boric will heal the defect. The purpose of the present stud ’ ‘as to evaluate processed heterogenious calf bone in our standardized test system. By using the identical system anid time * Read at the Annual Meeting of The American Academy of Orthopaedic Surgeons, San Francisco, California, January 18, 1967. t This investigation was supported iii part by Public lTealth Service Grants, Nos. Ti AM 5437 and AM 06075 from the National Institute of Arthritis arid i\Iet.aholic Diseases arid the Rainbow hospital Research Fund. 2065 Adelbert Iload, Cleveland, Ohio 44106.

Treatment of Coxa Vara in Children by Means of a Modified Osteotomy

1. A technique of subtrochantric osteotomy to correct coxa vara employing end-to-side apposition and fixation with an infant-size blade-plate has been presented. 2. This method is technically easier than methods used previously. 3. Adequate, controlled correction has been obtained and maintained in all cases. In view of the short time these patients have been followed, no conclusions concerning long-term results can be drawn. Further clinical and roentgenographic follow-up is indicated.

IMMUNOLOGIC FACTORS IN HOMOGENOUS BONE TRANSPLANTATION. I. SEROLOGICAL STUDIES

The successful use of relatively small amounts of hom3genous preserved bone has been repeatedly demonstrated both experimentally and clinically. The use of massive homogenous bone grafts, with rare reported exceptions, has not met with the same success. In previously reported experiments on whole kneejoint transplants in dogs by one of the authors,‘ marked, consistent, gross, and microscopic differences were noted in the homogenous as compared with the autogenous joints. The former showed no retention of living cells, slow osteogenesis, and ultimate severe degenerative changes similar to those seen in avascular necrosis. The work reported here was done in an attempt to determine if these daerences in the behavior of autogenous and homogenous whole joints could be explained on the basis of an immunologic response to homogenous whole bone acting as an antigen. It has been reported as a clinical observation in the literature dealing with bone transplantation that incompatibility of blood types between the donor and recipient has no bearing on the success or failure of the graft. The authors, however, have been unable to find any experimental work that tends to prove or disprove this assumption in regard to bone transplantation. The presence of the A and/or B group specific substance as a source of potential incompatibility was an obvious starting point for experimental observations on the possible antigenicity of whole bone grafts, as bone transplants invariably contain varying amounts of blood. There is the additional possibility that bone tissue per se contains the A and/or B substance that is widespread in the tissues of persons of those types. The reports by Young et al?, on the determination of “blood groups” in dogs suggested a potentially suitable research animal. They have described five “types” occuring in dog red blood cells that were antigenically distinct, the most potent of which was the “canine A factor” which wasable to produce high titer “anti-A” antibodies capable of hemolysing A positive red cells rapidly both in vivo and in vitro. Through the kindness of Doctor Lawrence E. Young and Doctor William A. O’Brien of the University of Rochester Medical School, a supply of “anti-A” serum was obtained which was used to type and classify dogs into “A positive” and “A negative” groups. The demonstrated ability of the “A” antigen to produce a potent “anti-A” antibody was the basic research tool used in the serological experiments reported here and in the histological experiments to be reported a t a later date.