Treatment of Ununited Fractures by Bone Grafting without Resection of the Bone Ends

Abstract

in the longer fragment remote from the site of fracture. The wire is then passed into the nmedulla from the fractured end and pulled out to the requisite amount through the window, by means of a loop of salmon gut or silver wire; the other fragment is placed in position and the wire pushed into it, leaving 2 in. protruiding through the window and wound. A supination plaster is then applied incorporating the wires. This metho(d will be found to have its uses but it also has its limitations. It is designed to prevent lateral displacement, but if the fracture is transverse it also prevents shortening, for at least half the diameter of the fragments maust always be in apposition, and the splint controls angulation. In a long spiral fracture the method prevents lateral displacement only, and cannot prevent telescoping. It is, howrever, applicable to fractuires of two bones if one of them is fractured transversely, for, if this latter is stabilized by means of a wire, the fragments cannot become displaced; and the other bone, which is fractured spirally, cannot telescope without angulation. Fortunately, in fractures of the radius and ulna one of them, usually the ulna, is fractured transversely, an(d a well-applied plaster prevents angulation.THIS paper is confined to the consideration of one method of treatment of a single type of ease of' non-union of a fracture of the shaft of a long bone that in which there is a fibrous intersection rather than a really wide gap between the fragments.The treatment under investigation is that of autogenous bone grafting with minimal disturbance of the bone ends or the intervening tissue. It is usually advised that a graft operation should be accompanied by clearing and resection of the bone ends. Some surgeons remove all sclerotic bone others are more conservative, and the procedure is then sometimes referred to as "freshening " the bone endls. (Mr. Naughton Dunn has used the same term for his highly successful subeortical procedure, but this involves no removal of bone and does not therefore enter into the considerations of' the present paper.) It has long been Mr. R. C. Elmslie's teaching that the customary resection of the bone ends as a supplement to grafting is unnecessary and therefore undesirable. To test the validity of this contenltion the results of a consecutive series of cases treated by Mr. Elmslie and two of his pupils have been investigated and are here reported. Unfortunately no series of' control cases treated by the more extensive procedure is available, because this has not been used by us in recent years.In the cases under review the graft adopted was an osteo-periosteal inlay from the tibia, except in two instances: an intramedullary tibial graft to the humerus, a,nd a fibular peg to the femoral neck. Tibial grafts w"ere always taken from the uninjured tibia and never from the fractured one. In operations on the leg, osteoclasis or osteotomy of the fibula was performed only if necessary for good general alignment.There are difficulties in assessing, the resul...