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The classic: repair of bone in the presence of aseptic necrosis resulting from fractures, transplantations, and vascular obstruction.

Phemister DB - Clin. Orthop. Relat. Res. (2008)

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, The University of Chicago, Chicago, IL, USA.

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Axhausen was perhaps the first to systematically examine the repair of dead bone [3], and described the process of “simultaneous absorption of dead bone and incomplete, irregular replacement by new bone. ” [7] Phemister extended those observations and coined the term, “creeping substitution. ” “By the process of creeping substitution the old bone is gradually absorbed and replaced by new bone, so that in the course of months or occasionally years the necrotic area is more or less completely transformed into living bone ... the amount of new bone formed ... depends largely on the extent of the living bone with which it (the dead bone) is in contact. ” At the time, necrosis was believed mostly related to fractures, transplants, or infection (septic necrosis)... Phemister commented, “Aseptic necrosis of bone, the result of proven thrombosis or embolism, is a condition that has been rarely reported in man. ’ He did not mention what we would today consider idiopathic aseptic necrosis or osteonecrosis. (The term, “avascular necrosis” first appears in PubMed in 1949 in relation to fractures [4]... Repair of bone in the presence of aseptic necrosis resulting from fractures, transplantations, and vascular obstruction... However, mild inflammatory reactions, particularly when associated with embolic or thrombotic processes and due to low grade micro-organisms, may sometimes result in necrosis which is followed by simultaneous absorption of dead bone and incomplete, irregular replacement by new bone, as first pointed out by Axhausen... I implanted radium needles into an undifferentiated round-cell sarcoma of the ischium, producing aseptic bone necrosis, and after subsequent x-ray treatments saw healing of the sarcoma with repair of the bony defect without evidences of sequestration of the necrotic bone after the lapse of seven years... Cornil and Coudray found that in experimental fractures there is necrosis of the cortex for a variable distance back from the fragment ends which is gradually replaced by new bone ingrowing from the living cortex with which it is continuous and to a less extent from the adjacent callus... This occurrence does not interfere with the process of healing... The vessels of the ligamentum teres may supply adequate blood to keep the head alive even in the aged... Death of the proximal fragment predisposes to non-union, but union occurs in a considerable percentage of the cases with a dead head in which there is impaction of fragments or in which there is efficient reduction and fixation of fragments, the best results apparently being obtained from the closed abduction method of Whitman... A roentgenogram taken 274 days after the injury (Fig.  12) showed union of the fractures in both astragalus and os calcis but the body of the os calcis had undergone extensive change... There was irregular increase in density of the distal and inferior portion of the proximal fragment, which was due to newly formed bone, but the superior and posterior portions bordering on the ankle joint were reduced in volume and irregularly in density,’ and the shadow of articular surface was lost in almost its entire extent... If the transplant is in the soft parts, disconnected with the skeleton and serving no supporting function, the surviving unossified osteogenic elements about the ends may proliferate temporarily,—as in the healing of a fracture of a bone graft as shown by Haas, or in closing the open end of the medullary cavity of the graft as shown by Phemister... But soon resorptive activities are found to exceed proliferative activities and the fragment begins to decrease in volume... The so called necrosing lesions of the center of ossification of certain epiphyses in children and the os lunatum in young adults have been variously attributed to injury to the blood vessels, vascular obstruction from embolism or thrombosis, and infection... Thus Legg-Perthes’ disease sometimes follows reduction of congenital dislocation of the hip which points to vascular injury and the experiments of Nussbaum show that cutting epiphyseal vessels results in necrosis followed by reorganization and deformity of the bony center.

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Case 1. Two hundred and fifty days after operation. Head extensively reduced in density from invasion and replacement from the living bone of base of neck.
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Fig5: Case 1. Two hundred and fifty days after operation. Head extensively reduced in density from invasion and replacement from the living bone of base of neck.

Mentions: CASE 1. Male, age twenty-eight, entered the University of Chicago Clinics May 7, 1929, because of bony ankylosis of the left hip resulting from acute hematogenous pyogenic arthritis two and one-half years previously (Fig. 1). At operation on May 9, through a goblet incision the greater trochanter was reflected, the soft parts reflected from the neck, and the head detached from the acetabulum with a chisel. After roughly rounding it off and deepening the acetabulum, a cap of free fascia lata was placed over the head and tied about the neck with a purse-string suture of chromic catgut. The head was then restored to acetabulum, the muscles and greater trochanter were sutured in place, the wound closed, and a body and leg cast applied. There was slight postoperative febrile reaction, but the temperature returned to normal at the end of ten days and the wound healed with only a slight superficial serous discharge. The cast was removed after two weeks and weight extension applied for ten days. A roentgenogram taken twenty days postoperatively (Fig. 2) showed the reduced head of the femur with its sharply outlined chisel cuts resting in the acetabulum. Movement was begun and after five weeks the patient was allowed to walk with crutches. In a roentgenogram taken thirty-six days postoperatively (Fig. 3) the head and neck showed their outline and density unchanged, but there was a slight reduction in density in hone at the junction of neck and shaft and slight atrophy of disuse of the shaft. A fair range of mobility persisted in the hip but it remained painful so that the patient continued to walk on crutches. A roentgenogram taken 151 days postoperatively (Fig. 4) showed the head retaining its original density and sharp outline of its cut surface. The adjacent innominate bone and the trochanters and shaft of the femur showed marked atrophy of disuse. The zone of reduced density at the base of the neck had broadened to include almost the entire neck of the femur. A diagnosis was made of necrosis of the head and neck of the femur with retention of the original density of the head and atrophy of disuse of the surrounding living bone. The extension of the rarefaction in the neck was interpreted as evidence of beginning invasion of the necrotic portion by tissue from the living portion with absorption of the dead bone and replacement by a less dense living bone. The hip improved slowly and the patient began to bear a small amount of weight on it. A roentgenogram 250 days postoperative (Fig. 5) showed persistence of the atrophy of the shaft and innominate bone and a very marked reduction in the density of the shadow cast by the head as compared with the previous roentgenograms. The cortex at the inferomesial and superolateral portions of the base of the head retained its old density but the cancellous bone of the interior and articular surfaces of the head had been reduced to practically the same density as the trochanters and upper end of the shaft. This was interpreted as evidence of extensive invasion of the head with absorption of the dead bone and a certain amount of replacement by new bone. The patient then made greater use of the limb in weight-bearing but continued to assist it with a crutch. A roentgenogram taken 350 days after operation showed slight increase in density of all of the atrophic living bone in the region and slight further reduction in the dense areas of the head. The patient then walked with the assistance of a cane, and a roentgenogram taken 404 days postoperatively (Fig. 6) showed little change except for evidence of cavitation in the inferomesial part of the head, indicating absorption of the necrotic bone with failure of replacement by new bone.Fig. 1


The classic: repair of bone in the presence of aseptic necrosis resulting from fractures, transplantations, and vascular obstruction.

Phemister DB - Clin. Orthop. Relat. Res. (2008)

Case 1. Two hundred and fifty days after operation. Head extensively reduced in density from invasion and replacement from the living bone of base of neck.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2311466&req=5

Fig5: Case 1. Two hundred and fifty days after operation. Head extensively reduced in density from invasion and replacement from the living bone of base of neck.
Mentions: CASE 1. Male, age twenty-eight, entered the University of Chicago Clinics May 7, 1929, because of bony ankylosis of the left hip resulting from acute hematogenous pyogenic arthritis two and one-half years previously (Fig. 1). At operation on May 9, through a goblet incision the greater trochanter was reflected, the soft parts reflected from the neck, and the head detached from the acetabulum with a chisel. After roughly rounding it off and deepening the acetabulum, a cap of free fascia lata was placed over the head and tied about the neck with a purse-string suture of chromic catgut. The head was then restored to acetabulum, the muscles and greater trochanter were sutured in place, the wound closed, and a body and leg cast applied. There was slight postoperative febrile reaction, but the temperature returned to normal at the end of ten days and the wound healed with only a slight superficial serous discharge. The cast was removed after two weeks and weight extension applied for ten days. A roentgenogram taken twenty days postoperatively (Fig. 2) showed the reduced head of the femur with its sharply outlined chisel cuts resting in the acetabulum. Movement was begun and after five weeks the patient was allowed to walk with crutches. In a roentgenogram taken thirty-six days postoperatively (Fig. 3) the head and neck showed their outline and density unchanged, but there was a slight reduction in density in hone at the junction of neck and shaft and slight atrophy of disuse of the shaft. A fair range of mobility persisted in the hip but it remained painful so that the patient continued to walk on crutches. A roentgenogram taken 151 days postoperatively (Fig. 4) showed the head retaining its original density and sharp outline of its cut surface. The adjacent innominate bone and the trochanters and shaft of the femur showed marked atrophy of disuse. The zone of reduced density at the base of the neck had broadened to include almost the entire neck of the femur. A diagnosis was made of necrosis of the head and neck of the femur with retention of the original density of the head and atrophy of disuse of the surrounding living bone. The extension of the rarefaction in the neck was interpreted as evidence of beginning invasion of the necrotic portion by tissue from the living portion with absorption of the dead bone and replacement by a less dense living bone. The hip improved slowly and the patient began to bear a small amount of weight on it. A roentgenogram 250 days postoperative (Fig. 5) showed persistence of the atrophy of the shaft and innominate bone and a very marked reduction in the density of the shadow cast by the head as compared with the previous roentgenograms. The cortex at the inferomesial and superolateral portions of the base of the head retained its old density but the cancellous bone of the interior and articular surfaces of the head had been reduced to practically the same density as the trochanters and upper end of the shaft. This was interpreted as evidence of extensive invasion of the head with absorption of the dead bone and a certain amount of replacement by new bone. The patient then made greater use of the limb in weight-bearing but continued to assist it with a crutch. A roentgenogram taken 350 days after operation showed slight increase in density of all of the atrophic living bone in the region and slight further reduction in the dense areas of the head. The patient then walked with the assistance of a cane, and a roentgenogram taken 404 days postoperatively (Fig. 6) showed little change except for evidence of cavitation in the inferomesial part of the head, indicating absorption of the necrotic bone with failure of replacement by new bone.Fig. 1

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, The University of Chicago, Chicago, IL, USA.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Axhausen was perhaps the first to systematically examine the repair of dead bone [3], and described the process of “simultaneous absorption of dead bone and incomplete, irregular replacement by new bone. ” [7] Phemister extended those observations and coined the term, “creeping substitution. ” “By the process of creeping substitution the old bone is gradually absorbed and replaced by new bone, so that in the course of months or occasionally years the necrotic area is more or less completely transformed into living bone ... the amount of new bone formed ... depends largely on the extent of the living bone with which it (the dead bone) is in contact. ” At the time, necrosis was believed mostly related to fractures, transplants, or infection (septic necrosis)... Phemister commented, “Aseptic necrosis of bone, the result of proven thrombosis or embolism, is a condition that has been rarely reported in man. ’ He did not mention what we would today consider idiopathic aseptic necrosis or osteonecrosis. (The term, “avascular necrosis” first appears in PubMed in 1949 in relation to fractures [4]... Repair of bone in the presence of aseptic necrosis resulting from fractures, transplantations, and vascular obstruction... However, mild inflammatory reactions, particularly when associated with embolic or thrombotic processes and due to low grade micro-organisms, may sometimes result in necrosis which is followed by simultaneous absorption of dead bone and incomplete, irregular replacement by new bone, as first pointed out by Axhausen... I implanted radium needles into an undifferentiated round-cell sarcoma of the ischium, producing aseptic bone necrosis, and after subsequent x-ray treatments saw healing of the sarcoma with repair of the bony defect without evidences of sequestration of the necrotic bone after the lapse of seven years... Cornil and Coudray found that in experimental fractures there is necrosis of the cortex for a variable distance back from the fragment ends which is gradually replaced by new bone ingrowing from the living cortex with which it is continuous and to a less extent from the adjacent callus... This occurrence does not interfere with the process of healing... The vessels of the ligamentum teres may supply adequate blood to keep the head alive even in the aged... Death of the proximal fragment predisposes to non-union, but union occurs in a considerable percentage of the cases with a dead head in which there is impaction of fragments or in which there is efficient reduction and fixation of fragments, the best results apparently being obtained from the closed abduction method of Whitman... A roentgenogram taken 274 days after the injury (Fig.  12) showed union of the fractures in both astragalus and os calcis but the body of the os calcis had undergone extensive change... There was irregular increase in density of the distal and inferior portion of the proximal fragment, which was due to newly formed bone, but the superior and posterior portions bordering on the ankle joint were reduced in volume and irregularly in density,’ and the shadow of articular surface was lost in almost its entire extent... If the transplant is in the soft parts, disconnected with the skeleton and serving no supporting function, the surviving unossified osteogenic elements about the ends may proliferate temporarily,—as in the healing of a fracture of a bone graft as shown by Haas, or in closing the open end of the medullary cavity of the graft as shown by Phemister... But soon resorptive activities are found to exceed proliferative activities and the fragment begins to decrease in volume... The so called necrosing lesions of the center of ossification of certain epiphyses in children and the os lunatum in young adults have been variously attributed to injury to the blood vessels, vascular obstruction from embolism or thrombosis, and infection... Thus Legg-Perthes’ disease sometimes follows reduction of congenital dislocation of the hip which points to vascular injury and the experiments of Nussbaum show that cutting epiphyseal vessels results in necrosis followed by reorganization and deformity of the bony center.

Show MeSH