BONE GRAFTS

An End-Result Study of the Healing Time

¹ Medical Corps, Army of the United States

This study of the end results in the various types of bone-graft operations has permitted a follow-up as to the healing time of 358 of the 580 bone-graft procedures which came under our observation from June 1942 to September 1946. Approximately one-third of the patients studied were transferred from other hospitals, and came under observation during the healing period. No attempt was made to separate the two groups, and the statistical tables represent a composite study.

There were 40 failures (11.2 per cent.). Of the remaining 318 cases, there were 34 inlay grafts with an average healing time of twenty-seven weeks, 121 onlay grafts with union in an average of twenty weeks, and 163 dual-type grafts that had union by an average of the nineteenth week. Of this group, 180 (56.6 per cent.) had delayed union beyond the sixteenth week. The distribution as to type and percentage of the grafts with delayed union was as follows (Table V): inlay, thirty-one (91.2 per cent.); onlay, seventy (57.8 per cent.); and dual, seventy-nine (48.4 per cent.). These end-result figures are particularly significant in view of the different types of clinical conditions for which the three types of grafts were usually employed.

Delayed union of bone grafts, used for the bridging of defects, occurred in five of eight cases in which the inlay type of graft had been used, and also in five of eight cases in which the onlay type of graft had been used; there were three instances of non-union in each group (Table VII). However, of the 112 dual grafts used for the bridging of defects, there were only twenty delayed unions and no failures without complicating factors. Failure of union near joints was treated very successfully by the dual-type graft, there being only four cases of delayed union and no non-unions without other cause among fifty-four cases (Table VII). All inlay grafts resulted either in delayed union or non-union; and onlay grafts were unsuccessful in four cases and united after delay in six of sixteen cases of non-union near a joint.

Sclerosis of one or both of the fracture fragments was present in forty-seven cases. Of the five inlay grafts used in this type of case, there were four delayed unions and one failure of union. Seventeen such cases had onlay grafts, with ten delayed unions and five non-unions. However, of the twenty-five dual-type grafts employed in the presence of sclerosis, eighteen resulted in delayed union and one in non-union.

Severe decalcification of the fracture fragments was present in forty-nine of the cases studied. Four inlay grafts resulted in three cases of delayed union and one of non-union; nineteen onlay grafts resulted in delayed union in fifteen and failure in four; and, of the twenty-six dual-type grafts used in this condition, there were twenty-two delayed unions and one non-union.

A second or subsequent graft after an initial failure also resulted in slow union. In this group, there were ten onlay grafts with six delayed unions and four repeated nonunions. However, of the twenty-two dual grafts used after a previous failure, there were only nine delayed unions and no non-unions.

Fracture of the graft occurred in twenty-five of the cases. Of these, fourteen appeared to be the direct cause of non-union, and eleven healed in an average of twenty-seven weeks from the time of the fracture.

Postoperative infection was encountered in thirty-nine cases. In thirteen of these, there was sequestration of the graft; and failure of union occurred in all but one. In the twenty-six cases without sequestration, delayed union occurred in thirteen cases, and in one other case a fracture of the graft failed to unite.

Short grafts are seldom, if ever, indicated. Of the twenty-one grafts which were three inches or less in length, twelve resulted in delayed union and five in non-union.

Failure to provide a flat surface for the reception of the graft was obvious in thirty-five cases, there being thirteen delayed unions and two failures in the series.

The use of plates in conjunction with bone grafts was employed in three inlay grafts, twenty-three onlay grafts, and twelve grafts of the dual type. The healing time was the same, with or without the use of the plate. There were no fractures in this group of thirty-eight cases, and early mobilization was possible in all instances.

Adequate fixation of the graft with screws will permit early mobilization of the adjacent joints. When this routine was followed, it resulted in marked reduction of the length of the convalescent period, and often in reduction of the proportion of patients with permanent disability, as compared to similar cases treated by other methods.

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