The Journal of Bone and Joint Surgery, Vol 62, Issue 7 1039-1058, Copyright © 1980 by Journal of Bone and Joint Surgery, Inc
Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects
WF Enneking, JL Eady and H Burchardt
The results of using segmental cortical autogenous bone grafts to
reconstruct defects created by resection of tumors were analyzed in forty
patients. Thirty-three patients had dual grafts while seven had a single
fibular graft. Dual grafts were used for major bones (humerus, femur, and
tibia without fibula) while single grafts were used for the radius and for
the tibia when the ipsilateral fibula was intact. Thirty patients had good
or excellent results; seven, fair; and three, poor results. In twenty-five
patients primary union was achieved within tweleve months and in two, in
twenty months, while twelve patients required a second, supplementary
cancellous graft at the site of non-union to obtain stability. One patient
required removal of an infected graft and had a poor result. Stress
fractures of the grafts occurred in eighteen of the forty patients after
union had occurred. The stress fractures healed in fifteen of these
patients: in six with no treatment (the fracture was identified
retrospectively), in seven with external immobilization, and in two after
bone-grafting of the ununited fracture. There were three persistent
non-unions of stress fractures despite bone-grafting, internal fixation,
and electrical stimulation, and these account for two of the three poor
results. The length of the defect did not affect the incidence of non-union
but it did affect the number of fatigue fractures. The shorter grafts (7.5
to twelve centimeters) were associated with a 33 per cent incidence of
non-union (four non-unions of twelve grafts) while the longer grafts
(twelve to twenty-five centimeters) had a 32 per cent rate of non-union
(nine non-unions of twenty-eight grafts). The incidence of fatigue
fractures in the longer grafts (58 per cent) was much greater than that in
the shorter grafts (17 per cent). The grafts decreased in density during
the first six months but gradually regained their mass and were generally
comparable to normal cortical bone at two years. As the patients became
functiona, most (55 per cent) of the the grafts became more dense than
normal, some (34 per cent) remained the same, and a few (11 per cent)
became less dense. Similarly, some (32 per cent) hypertrophied, most (58
per cent) remained the same size, and a few (9 per cent) atrophied. There
was little morbidity (three of forty patients) associated with graft
procurement. In twelve patients an additional graft was implanted
experimentally, labeled with tetracycline, and subsequently removed at the
time of a secondary procedure. These grafts were analyzed to determine if
human grafts were repaired in the same fashion as grafts in experimental
animals. The studies showed that human grafts are repaired in the same
fashion, but that the sequence takes approximately twice as long as it does
in the dog.
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