THE CLASSIC: Transplantation of a Portion of the Tibia Into the Spine for Pott's Disease

Heterotopic bone transplantation for defects in the human skeleton had been attempted since the beginning of surgery. In the modern period experimental attempts at bone transplanting or grafting go back to Meekren in the seventeenth century, and then to John Hunter, Flourens, Wolff, Ollier, MacEwen and many others. However, these reports describe only occasional experimental attempts to place heteroplastic bone or replace autoplastic bone splints in fractures. Bone graft surgery as a planned, carefully designed procedure started with this 1911 paper by Fred Houdlett Albee (1876-1945) of New York City (Fig. 1, not shown). His method was immediately recognized and very quickly adopted by orthopedic and trauma surgeons throughout the civilized world. E.M.B. The following is a final development, from a series of studies, on the application of osteoplasty in the treatment of Pott's disease of the spine. I was induced to undertake this experimental work on the spine, on account of the excellent operative results obtained in tuberculosis of joints elsewhere in the body where bony union with its perfect support and immobilization has caused the tuberculous process to disappear so rapidly, although only a fractional part of the tuberculous tissues was removed. This has been especially exemplified in my ankylosing operation on the hip, when applied to tuberculous ostitis of that joint, and also in erasion of the knee under similar circumstances. The fact that it is only necessary to secure bony stiffening in tuberculous joints, by operation or otherwise, in order to get a rapid disappearance of the tuberculous process has been emphasized very strongly in the recent writings of Ely, both in his clinical and his pathologic studies. Previous to the herein reported cases, five patients were operated on and 3 or 4 spinous processes were split with a chisel or bone forceps for from 1 to 1⅓ inches from their tips, into equal halves, either through a plane approximately parallel with the long axis of the trunk or at right angle to it. The tip of the lower half of the superior vertebra was then brought into approximation with the tip of the superior half of the next lower vertebra after green-stick fractures of each and fastened with heavy kangaroo tendon. Chips of bone from the spinous processes were then placed in between so as to insure further bone union between these vertebrae. Mechanically this event (the union of spinous processes of neighboring vertebrae) acts in two ways: First, if we consider each vertebra a lever (as it properly is) with the fulerum at the lateral processes, its short arm, the body of the vertebra and the long arm of the lever, the spinous process, then by causing a bony union of the posterior part of the lever, we shall prevent by leverage a crushing together or approximation of the bodies or the anterior arm of the lever. Nature has done this, i.e., a fusing together of the posterior portions of the vertebrae involved, but unfortunately rarely, as pointed out by Brackett. This prevents absolutely any crushing of the bodies of the vertebrae and thus any further progress of the kyphosis or deformity. Secondly, and possibly not least, this formation of a bony bridge, connecting firmly the diseased vertebrae with the healthy ones on either side, acts directly as an internal splint on the vertebrae involved and furnishes more perfect support than any mechanical apparatus could possibly accomplish. These assumptions are based, of course, on bony union of vertebra to vertebra as well as union of the green stick fractures of the vertebral halves. This union has been satisfactory so far as can be ascertained, but on account of its uncertainty and the large amount of cartilage in the vertebrae of small children, with its slowness of union and early lack of support, it has seemed best to devise a procedure which would be possibly more reliable and also give support from the beginning. These requirements can be fulfilled in no other way except by a strong bone-graft. The different sources from which to secure a strong bone-graft for an internal splint, which would give immediate support to the spine, were considered and the crest of the tibia was selected as by far the most desirable and accessible. CASE REPORTS Case 1. History. With this in view, R.C., a child aged 4, referred to me by Dr. E. H. Johnston, of Waterbury, Conn., was admitted to the Post-Graduate Hospital. The past history was negative up to the time the trouble with the spine began. Several months before, the child had begun to have night “cries and sweats,” and coincidentally began to support herself with her hands on her knees. The mother thought that there had been a loss of weight and that the child was getting pale. There had been pain in the region of the stomach for the past 2 months. About 3 weeks before examination, the lump on the child's back was first noticed. Examination. This was negative except for a considerable kyphosis at the first and second lumbar vertebrae. The child stooped to pick up things from the floor with difficulty. The spine was rigid to passive and active motion in the region of the kyphosis. Operation. The patient was operated on June 9, 1911. Under ether, with the patient in the ventral position, an incision was made, directly over the tips of four spinous processes, with the kyphosis in the center. Each process was then split longitudinally for about one inch and a quarter into two portions with one-third of the process on the left and two-thirds on the right. The soft tissues between the processes were then merely separated by blunt dissection or by a scalpel, parallel with the muscles. Green-stick fractures were then produced at the base of the one-third portions of each of the processes. A wedge-shaped cavity was thus produced, ready to receive the bone graft. A compress of hot saline was then placed over the wound. The left leg which had been prepared for operation was then flexed on the thigh, so that an incision over the crest of the tibia anteriorly could be made. A prism-shaped piece of the tibia from its anterior-internal aspect was then removed by means of a chisel, with the periosteum intact on two of its surfaces. The graft taken was about 4 inches by 1 inch, by ½ inch. It was quickly removed and immediately placed in the interval between the portions of the spinous processes. The dense fascia over the tips of the processes was then approximated by interrupted sutures of No. 3 chromic catgut, thus holding the bone-graft very firmly in place. The skin was closed by a continuous suture of No. 1 plain catgut. The leg wound was treated in a similar way. The time of operation was fifteen minutes. There was no shock. Result. The child made a fine recovery from the anesthetic. The wounds healed by primary union. The child was discharged from the hospital July 17, 1911. The convalescence has been extremely satisfactory thus far. Muscular spasm of the spinal muscle has diminished very materially. However, it is obvious that it is too early to draw any definite conclusion concerning the final results of any of the cases herein reported, and this is a record of progress only. Case 2. History. The patient, J.M.C., male, was a carpenter, aged 28. His family history was negative to tuberculosis. His present trouble began eight months ago with pain in his back which started in the lumbar region and shot into the thighs. He had night sweats all last winter, but no cough. There was a little pain in his right side when the patient walked and later there was pain in the left side also. There was a mass in the right groin for six months previous to the examination. Examination. This was negative except for moderate kyphosis involving the eleventh and twelfth dorsal vertebrae and the right psoas abscess, the size of a fist, just below Poupart's ligament. The spine was very rigid to all motion, both passive and active, in the lower dorsal and lumbar regions. The patient bent the spine with pain and difficulty. Operation. June 27, 1911, the Post-Graduate Hospital. Precisely the same operation was done as described in the previous case. The bone-graft from the tibia was much larger, however. It measured about 6 inches by 1⅛ inch by ½ inch. Both wounds healed by primary union. This case was discharged from the hospital July 15, 1911. The patient has gone back to work, wearing a Taylor spinal brace. Case 3. History. The patient, W.D., was a boy aged 4½ years. His past history was negative except for measles and typhoid fever one and two years ago. He began to rest his chin in his hand eight months before examination. There was pain in the neck, which grew progressively worse, and which was complained of at about the same time. A lump on his back was noticed about six months ago. Examination. This was negative except for the spinal condition. There was a large angular kyphosis including the last cervical and first two dorsal vertebrae. There was a marked muscular spasm from passive motion. The patient bent with difficulty to pick things from the floor. Operation. July 14, 1911. Post-Graduate Hospital. This operation differed from the preceding ones only in reference to the bonegraft. On account of the angularity of the kyphosis, the bone-graft had to be molded into the segment of a circle in order that the corners would not project beyond the tips of the spinous processes distal from the kyphosis. The graft was about 4 inches by 1 inch by ¾ inch, and included four spinous processes. Both wounds healed by primary union. This patient is still on a modified Bradford frame. The convalescence has been very satisfactory thus far. We have at present two cases on reversely bent Bradford frames for the purpose of securing a recession of the kyphosis before operating, and feel confident of holding the correction by the bone-graft. SUMMARY The inefficiency of present methods in the treatment of dorsal Pott's disease was tersely expressed by Schapps in 1905 as follows: “It is universally admitted that the forms [of portative apparatus] in general use and described in the standard text-books on orthopedics do not, even in the most skilled hands, control the deformity.” A firm bony splint with bony union to the vertebra involved and the healthy vertebrae on each side is supplied by this method, which assures not only the prevention of further deformity in two mechanical was as stated above (leverage and splint action) but should also cause the immediate disappearance of the tuberculous process. This method is believed to be preferable to any, where breaking or cutting of the spinous processes destroys entirely, or for the time being, until union takes place, the desired leverage of the spinous processes and their muscles and ligaments. Union is also uncertain where motion from breathing is present. If bony union should not occur the same mechanical effects would still be largely obtained from the union of the internal bone splint to the ligamentous structures. Perfect immobilization of the few involved vertebrae in the respiratory area of the spine is secured, which is a mechanical impossibility by means of any external apparatus, on account of the constant movement of the ribs, and the vertebrae attached. Fortunately, on account of the anatomy of the part it is not necessary to enter the focus of disease; therefore primary union of soft tissues with immediate bone union can be expected. The normal leverage action of the spinal muscles and the supporting ligaments on spinous processes is not interfered with. The operation is by no means a formidable one. The technic is very simple. When possible it is well to secure a recession of a kyphosis by long recumbency on a reversely bent Bradford frame. This method offers great promise of holding the correction obtained. A bone-graft is far superior to an internal metal splint, because, by following Wolff's law it will become thicker and stronger if necessary to hold the weight or strain brought to bear on it, whereas in the case of an internal metal splint, suture or screw applied to the bone, no dependence can be placed on them to hold weight or strain, because of the bone atrophy and absorption which takes place directly around the metal. This occurs even when no strain is present. I have found silver wire and screws which were placed through bone only a few months before, in the soft tissues where they had fallen through or out of the bone without being influenced by strain. For this reason and the always present danger of sepsis about buried metal, it would seem that bone-grafting will prove preferable to the internal metal spinal splint of Lange.