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`NUVASIVE 1018
`NuVasive, Inc. v. Warsaw Orthopedic, Inc.
`IPR2013-00206
`
`

`

`Clinical Orthopaedics
`and Related Research
`
`MARSHALL R. URIST
`Editor-in-Chief
`
`With the Assistance of
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`THE ASSOCIATE EDITORS
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`THE BOARD OF ADVISORY EDITORS
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`THE BOARD OF CORRESPONDING EDITORS
`
`Number One Hundred Sixty-Five
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`J. B. LIPPINCOTT COMPANY
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`Philadelphia
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`Toronto
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`CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
`GUIDELINES FOR AUTHORS
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`Congenital Pseudarthroses of the Tibia
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`Operative Arthroscopy
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`Copyright ©1982. av J. B. LI'PPI‘NCOTT COMPANY
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`Library of Congress Catalog Card Number 53-7647
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`

`

`Contents
`
`SECTION I: SYMPOSIUM
`
`INVESTIGATIVE ORTHOPAEDICS TRIBUTE TO
`
`HAROLD B. BOYD
`
`Rocco A. CALANDRUCCIO, M.D.
`Guest Editor
`
`Editorial Comment:
`Tribute to Harold B. Boyd
`Rocco A. Calandruccio, M.D.
`
`Harold Buhalts Boyd 1904-1981
`Rocco A. Calandruccio. MD.
`
`The Classics
`
`Orthopaedic Philosophy
`Harold B. Boyd. M.D.
`
`Our Orthopaedic Personality: Harold B. Boyd, M.D.
`Hugh Smith, MD.
`
`I Consulted With an African Witch Doctor
`Harold B. Boyd, MD.
`
`Congenital Pseudarthrosis of the Tibia
`H. B. Boyd, M.D., and R. P. Sage, M.D.
`
`Final Results Obtained in the Treatment of Bone Cysts with Meth-
`ylprednisolone Acetate (Depo-Medrol) and a Discussion of Re-
`sults Achieved in Other Bone Lesions
`0. Seaglietti. P. G. Marchetti. and P. Bartolozzi
`
`Treatment of Bone Cysts by Intracavity Injection of
`Methylprednisolone Acetate: A Message to Orthopedic
`Surgeons
`Oswaldo P. Campbs. M.D.
`
`Arthroplasty by Osteocartilaginous Graft in Primates
`Guilluame T. du Toit, F.R.C.S., and M. B. E. Sweet. B.Sc.. M.B.. Ch.B..
`PhD.
`
`The Role of Polytomography in the Diagnosis and Treatment of
`Cervical Spine Injuries
`Lewis D. Anderson, M.D., Bruce L. Smith. Jr.. M.D., James DcTorre,
`M.D., and Jesse T. Littleton, M.D.
`
`Fat Embolism Syndrome: A Review of the Pathophysiology and Phys-
`iological Basis of“ Treatment
`Harry R. Gossling. M.D., and Vincent D. Pellegrini. Jr., MD.
`
`V
`
`10
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`14
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`16
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`33
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`43
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`49
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`64
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`68
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`

`Ctlnlcal Orthopaedics
`Vi
`and Related Research
`——-—————.___.—_._.—,—_—___________
`
`Home Traction in the Management of Congenital Dislocation of
`the Hip
`Keenan Joseph, M.B., BS, MS, (Orth). G. Dean MacEwen, MD,
`and Marilyn L. Boos, B.S.N.
`
`Displaced, Unstable Ankle Fractures: Classification, Incidence, and
`Management of a Consecutive Series
`George D. Purvis, M.D.
`
`Chondrolysis Complicating Slipped Capital Femoral Epiphysis
`Alvin J. Ingram, M.D., Michael S. Clark, M.D., Charles S. Clark, Jr..
`M.D., and William R. Marshall. M.D.
`
`Instability of the Lumbar Spine
`W. H. Kirkaldy-Willis, M.A., M.D., F.R.C.S. (E. and C.), and H. F.
`Farfan, M.Sc., M.D., C.M., F.R.C.S. (C)
`
`Congenital Pseudarthrosis of the Tibia: Treatment With Pulsing Elec-
`tromagnetic Fields: The International Experience
`J. S. Kort, M.D., M. M. Schink, B.S., R.N., S. N. Mitchell, 13.8., R.N.,
`and C. A. L. Bassett, M.D., Sc.D.
`
`Boyd Amputations in Children
`Craig E. Blum. M.D., and Ali Kalamchi, M.D.
`
`Mobilizations and Transfer of the Intrinsics of the Great Toe for
`Hallux Valgus
`Hanes H. Brindley, M.D.
`
`Vascular Complications in Injuries About the Knee Joint
`Carlos E. Ottolenghi, M.D.
`
`SECTION II: GENERAL ORTHOPAEDICS
`
`Anterior Lumbar Interbody Fusion: Indications for its Use and
`Notes on Surgical Technique
`H. v. Crock, M.D., M.s., F.R.C.S., F.R.A.C.S.
`
`The Results of 150 Anterior Lumbar Interbody Fusion Operations
`Performed by Two Surgeons in Australia
`Arihisa Fujimaki, M.D., Henry V. Crock, M.D., M.S.. F.R.C.S,
`F.R.A.C.S., and Sir George M. Bedbrook, M.D., M.S., F.R.C.S.,
`F.R.A.C.S.
`
`83
`
`91
`
`99
`
`110
`
`124
`
`138
`
`144
`
`148
`
`157
`
`164
`
`Correction with 3 Transverse Loading System in the Operative Man- 168
`agement of Scoliosis
`William A. Herndon. CDR., M.C., U.S.N.R., Ronald D. Ellis. M.D., John
`E. Hall, M.D., and Michael B. Millis, M.D.
`
`Surgical Treatment After Chemonucleolysis Failure
`C. C. Carruthers, F.R.C.S.(C). and K. N. Kousaie, M.D., F.R.C.S.(C)
`
`Femoral Stem Failures in Total Hip Arthroplasty: An Unusual
`Causal Mechanism
`Merrill A. Ritfer, M.D., and P. Douglas Kiester, M.D.
`
`172
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`176
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`Number 165
`vii
`May, 1882
`
`
`Anterolateral Compared to Posterior Approach in Total Hip
`Arthroplasty: Difi'erences in‘ Component Positioning, Hip
`Strength, and Hip Motion
`.
`Donald R. Gore, M.D., M. Pat Murray. Ph.D., Susan B. Sepic, B.S..
`and Gena M. Gardner, BS.
`
`The Results of Early Clinical Trials with a Microporous Coated
`Metal Hip Prosthesis
`Hugh U. Cameron, M.D., M.B.. Ch.B.. F.R.C.S.(C)
`
`Hip Replacement in a Charcot Joint: A Case Report and Historical
`Review
`Thomas R. Sprenger, M.D., and Charles J. Foley. M.D.
`
`Renal Transplant Infarction During Total Hip Arthroplasty
`Clarence E. Zimmerman, M.D., and Harris S. Yett, MD.
`
`The Patella in Total Knee Arthroplasty
`Hugh U. Cameron. M.D., M.B., Ch.B., F.R.C.S.(C) and Donna M. Fe-
`dorkow. MD.
`
`A New Orthopedic Fixation Method in the Treatment of Bladder
`Extrophy
`Henri HOroszowski, M.D., Amnon Israeli, M.D., Michael Helm, M.B.,
`Ch.B.. Paul Jonash. M.D., and Itzhak Farine, M.D.
`
`Slipped Capital Femoral Epiphysis in a Hypothyroid Adult Male
`Michael J. Hennessy, M.D., and Kenneth Lee Jones, M.D.
`
`Capitate Fractures: A Long-term Follow—up
`James A. Rand, M.D., Ronald L. Linscheid. M.D., and James H.
`Dobyns. M.D.
`
`Current Uses of Open Phenol Nerve Block for Adult Acquired
`Spasticity
`.
`Douglas E. Garland, M.D., R. Stephen Lucie, M.D., and Robert L.
`Waters, M.D.
`
`IntraoperatiVe 99'“ Technetium Bone Imaging in the Treatment of
`Benign Osteoblastic Tumors
`Jack Sty, M.D., and George Simons', M.D.
`
`Intraoperative Nerve Fascicle Identification Using Choline Acetyl—
`transferase: A Preliminary Report
`A. Ganel, M.D.. I. F'arine. M.D., Z. Aharonson, M.D., H. Horoszowski.
`M.D., R. Melamed, and S. Rimon, Ph.D.
`
`Radical Radiotherapy as Primary Treatment for Ewing’s Sarcoma
`Distal to the Elbow and Knee
`Michael Kliman, M.D., Andrew R. Harwood. M.B., Ch.B..
`F.R.C.P.(C), R. Derek Jenkin, M.B., Ch.B., F.R.C.P.(C), Bernard J.
`Cummings, M.B., Ch.B., F.R.C.P.(C), Frederick Langer, M.D.,
`F.R.C.S.. Ian Quirt. M.D., F.R.C.P.(C), and Victor L. Fornasier, M.D.,
`F.R.CrP.(C)
`
`On Aging Bone Loss
`Richard B. Mazess, Ph.D.
`
`Bone Morphometry in Alcoholics
`O. Johnell. B. E. Nilss'on, M.D., and P. E. Wikland. MD.
`
`180
`
`188
`
`191
`
`195
`
`197
`
`200
`
`204
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`209
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`217
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`223
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`228
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`233
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`239
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`253
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`

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`Pramadtngs of the 42nd AnaflALMefiting 0f flu: American Fracture
`Assnciatinn
`
`303
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`

`
`
`SECTION 11
`
`GENERAL ORTHOPAEDICS
`
`Anterior Lumbar Interbody Fusion
`Indications for its Use and Notes on Surgical Technique
`
`H. V. CROCK, M.D., M.S., F.R.C.S., F.R.A.C.S.
`
`surgical
`Looking back on the major
`achievements of the 19708,
`the technical
`feats of cardiovascular surgeons and the
`range of application of microsurgical tech-
`niques in plastic, reconstructive and neu-
`rosurgery are impressive. Moreover in or-
`thopedic surgery, remarkable improvements
`occurred in operations for joint replace-
`ments. However,
`in the surgery of spinal
`disorders technological improvements have
`been confined largely to precedures for the
`correction of deformities, as introduced by
`Harringtonlo in the United States and by
`Dwyer et al.‘5 in Australia.
`While knowledge of problems caused by
`spinal stenosis increased dramatically during
`this period, reflecting the wider use of water
`soluble myelography and computerized to-
`mography, spinal surgery per se has failed
`to reach the heights of achievement as seen
`in the other special fields.
`The purpose of this paper and the one fol-
`lowing by Fujimaki et al.’ is to draw atten-
`tion to anterior lumbar interbody fusion as
`a major operation in spinal surgery. It de-
`
`
`Senior Orthopaedic Surgeon. St. Vincent’s Hospital,
`University of Melbourne. MerOurne. 3000, Australia.
`Reprint requests to H. V. Crock. St. Vincent's Hos-
`pital, Melbourne. 3000. Australia.
`Received: September [0. 1980.
`
`serves to be included in the range of surgical
`procedures that any surgeon who regularly
`Operates on the spine offers to his patients.
`This article describes the indications for its
`
`use and the techniques that have proved safe
`and effective with 20 years of use.
`
`INDICATIONS FOR ANTERIOR
`LUMBAR INTERBODY FUSION
`
`The operation of spinal fusion was intro-
`duced first by Albeel for the treatment of
`spinal
`tuberculosis. Its use was then ex-
`tended by the application of anterior inter-
`body fusion methods, as popularized in Hong
`Kong by Hodgson and Stock (1956).” In
`selected cases with spinal tuberculosis, an-
`terior interbody fusion still enjoys an undis-
`puted and favored plaCein treatment.
`The role of spinal fusionin the treatment
`of disorders of the lumbar spine has re-
`mained vexed and Confused. Apart from a
`general agreement on the possible applica-
`tion of spinal fusion in the treatment of spon-
`dylolisthesis, there are no published or clear-
`cut statements for the use of spinal fusion
`techniques. Wtih the decline in the use of
`fusion operations for major joints in the
`limbs, there has been a corresponding fall
`in the number of these procedures as applied
`
`OOO9-92lX/82/0500/157 $00.35 © J. B. Lippincott Co.
`
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`

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`Ditties] O
`Crock
`158
`and Related Research
`
`to spinal problems. In particular, a number
`of the degenerative disorders of the lumbar
`spine now can be more effectively treated by
`some form of spinal Canal or spinal nerve
`root canal decompression.
`In the author's opinion, the present indi—
`cations for the use of anterior lumbar inter-
`
`body fusion operations are as follows: (1) for
`the treatment of other failed spinal opera-
`tions; (2) for the treatment of certain disc
`lesions;4 (3) in the management of Selected
`cases of spondylolisthesis; (4) for the treat-
`ment of certain Spinal infections; (5) follow-
`ing some vertebral fractures; (6) for the cor-
`rection of selected spinal deformities; and
`(7) for the treatment of rare miscellaneous
`cases, e.g., vertebral body tumors and nu-
`cleus pulposus calcification.
`
`MATERIALS AND METHODS
`
`The lumbar interbody fusion operation cannot
`be performed safely without the aid of two com-
`petent assistants. Until the orthopedic surgeon is
`thoroughly familiar with every aspect of the pro-
`cedure, he would be wise to work with a senior
`general surgeon who has special competence in
`vascular surgery.
`When Sir John Charnley2 first introduced his
`operation of total hip joint replacement in the
`early 19605, he provoked an angry response from
`many surgeons by refusing to allow them to buy
`the recommended instruments until they had been
`specially instructed in their use. The wisdom of
`his early cautiOn d0ubtlessly served a good pur-
`pose inasmuch as total hip joint replacement op-
`erations, as performed by otherwise untrained sur-
`geons, can mairn. But when anterior lumbar
`in terbody fusion is attempted by surgeons who are
`not specially trained the results can be far higher;
`the patient may lose his life.
`
`PRELIMINARY PREPARATIONS
`
`Patients arrive at the operating room with an
`intravenous set pre-inserted. Two or three liters
`of compatible blood should be available for use
`during the operation; blood loss at the tim¢ of
`surgery is usually about 300-500 ml, varying with
`single or double level fusions.
`The patient’s X-rays, including lumbar disco-
`grams when appropriate, should be clearly dis-
`played. Facilities should be available for taking
`control X—rays on the theater table when fusions
`
`above the lumbosacral junction are to be per-
`formed; the quality of such films is often clear.
`Good quality films of the patient’s spine must be
`available in the theater fer comparison with those
`taken at the time of surgery.
`
`POSITIONING
`
`For approaches to the lower three lumbar in-
`tervertebral discs, patients are placed supine on
`the operating table. For rarer upper lumbar fu-
`sions. they are placed in the lateral position with
`the left loin uppermost. The stirgeon should pay
`particular attention to the placing of restraining
`devices and arm supports, ensuring that the pa-
`tient’s trunk is held in a stable position and that
`undue pressure is not exerted on the peripheral
`nerves or veins in the legs. Electric calf stimulators
`are applied.
`
`ABDOMINAL INCISIONS
`
`In the lower lumbar region, oblique, left-sided
`incisions are made, commencing at the midline
`between the umbilicus and symphysis pubis and
`extending upwards and laterally, parallel to the
`level of the iliac crest. The anterior rectus sheath
`is divided in the line of the skin incision, extending
`out into the fibers of the external oblique muscle
`and over the length of the skin incisiOn. At the
`lateral border of the rectus abdominus muscle, the
`internal oblique muscle and transversah's fascia
`are divided to identify the extraperitoneal space.
`The peritoneum is separated from the inner aspect
`of the abdominal wall, and these two muscles are
`further divided laterally in the line of the main
`incision. In obese patients, it is wise to retract the
`lateral border of the left rectus abdominus muscle,
`to identify the inferior epigastric vessels. These
`should be divided between ligatures and the rectus
`abdominus muscle then divided across trans-
`versely to the level of the midline; such an incision
`will allow wide extraperitoneal approach to the
`lower lumbar spine.
`The skin incision should be placed nearer the
`umbilicus if the LH disc is to be approached.
`Midline transperitoneal approaches may be in-
`dicated for operations at the Ls-Sl level in some
`cases of spondylolisthesis or in very obese patients
`with high Ferguson angle meaSurernents at the
`lumbosacral junctiou.’
`incision has been
`When the abdominal wall
`completed, the peritoneum is separated from the
`posterior abdominal wall and the psoas major
`muscle. A small raytec pack is inserted into the
`paracolic gutter and pushed upwards for some
`distance. The ureter can be seen lying adherent
`
`
`
` 9
`
`
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`

`

`Number 185
`May, 1982
`Anterior Lumbar lnterbody Fusion 159
`
`
`
`to the peritoneum. It is carried forward when a
`large modified Deever type retractor is inserted,
`resting on the anterior surface of the lumbosacral
`disc or on the anterolateral edge of the L”. or
`L34 discs at the anterior edge of the left psoas
`major muscle, depending on the level to be fused.
`
`VESSEL LIGATION
`
`The techniques of vessel ligation are vital to the
`success of exposing the disc spaces at various lev-
`els in the lumbar spine and essential for the safe
`performance of these operations.
`Vascular sutures, including 5/0 suture material
`on atraumatic needles, are required. In addition,
`long handled instruments and right angled artery
`fOICeps must be available for use.
`When the median sacral vessels have been li-
`gated and divided, small gall bladder dissecting
`swabs mounted on long-handled forceps are used
`to clear the loose tissues from the front of the disc
`space; thus, clearly exposing the anterior longi-
`tudinal ligament. in retroperitoneal approaches
`to the LFS. disc space, the filaments of the pre-
`sacral sympathetic plexus are rarely scan (the
`danger of damaging these nerves in the male has
`been exaggerated by opponents of this method of
`spinal fusion'). The thin, anterior, longitudinal
`ligament is then divided transversely across the
`middle of the disc Space and the ends are swept
`upwards and downwards to expose the junction
`of the vertebral end-plate and the disc. on either
`side of the disc space. The cufi‘ of tissue formed
`by its rolled ledges helps to protect the wall of the
`great veins at the side of the disc space.
`To expose the disc between the L. and L, ver-
`tebral bodies it may be necessary to ligate and
`divide the left ascending lumbar vein. The sym-
`pathetic trunk is first identified where it lies along
`the anterior margin of the psoas majOr muscle,
`on the side of the vertebral body. The fibers of the
`fibrous arcade, which attach the psoas muscle to
`the superior and inferior vertebral margins at the
`disc space, are divided and the psoas muscle is
`retracted laterally.
`The ascending lumbar vein is often quite large.
`with a diameter at its entry point into the lateral
`wall of the left common iliac vein of between 3
`and 5 mm. The techniques for the safe handling,
`dissection and ligation of this vessel are among
`the most critical maneuvers to be performed in
`the whole of this operation. Whether or not ll-
`gation is required depends on the length of the
`vessel and its site of entry into the left common.
`ih'ac vein. This vein is usually surrounded by fatty
`tissues from which it must be dissected free. This
`can be done by using a blunt probe and a smooth
`ended fine sucker.
`
`
`
`FIG. 1. A photograph showing a modified Hud-
`son brace and three dowel cutting instruments,
`with the starter center pieces and one graft‘ ejec-
`tor. On' the right side, note the special gouges
`which are used with the cutters (Trewavis Sur-
`gical Melbourne Pty. Ltd., Nunawading, Victo-
`ria).
`
`The vessel is ligated with sutures of 3/0 black
`silk, just beyond its entry point into the left com-
`mon iliac vein and again. further along its course,
`deep to the psoas muscle, it is essential to lock
`these black silk sutures Onto the wall of the as-
`cending lumbar vein with 5/0 sutures. transfixing
`its wall and encircling the vessel adjacent to each
`suture. The vessel is then divided between these
`locking sutures with a fine scalpel blade, mounted
`on a long handle. With these precise maneuvers
`safely completed, the great vessels may then be
`retracted towards the midline from the antero-
`lateral surface of the L4,, disc space.
`Exposure of the L3-.. disc space can often be
`achieved satisfactorily without division of any sig-
`nificant vessels; although, on occasions the lumbar
`Vessels lying on the side of the body of L4. may
`need to be separately ligated near the anterior
`margin of the psoas major muscle beforethe great
`vessels can be safely retracted from the antero-
`lateral surface of this disc.
`Exposure of upper lumbar discs is best done
`with the patient in the lateral position on the op-
`erating table and with the incision running through
`the bed of the twelfth rib to allow extraperitoneal
`exposure of the upper lumbar vertebral column.
`
`
`
`10
`
`
`
`

`

`160
`
`
`
`FIG. 2. Lower lumbar dowel cavities. (l) The
`use of a dowel cutting instrument in the lumbar
`spine. (2) The anteroposterior orientation of two
`dowel cavities in the lower lumbar area. (3) The
`use of the special gouge to displace the disc and
`adjacent fragments of the vertebral bodies. (4)
`The use of the ring curette for the removal of
`vertebral end plate and disc tissue remnants from
`the interbody space.
`
`PREPARATION or THE INTERSPACE FOR
`GRAFl' INSERTION
`
`The preparation of dowel cavities in the inter-
`vertebral space is carried out with the use of spe-
`cial cutters supplied in six sizes for use at any
`vertebral level. Each cutting cylinder has circum-
`ferential markings clearly visible on its external
`surface. These rings are separated from each other
`by 5 mm (Fig. l). DOWel cavities are cut across
`the vertebral interSpace with a cutting cylinder
`of appropriate size (Figs. 2 and 3).
`in due course, grafts are cut using the cutting
`cylinder that is one size larger than that used 10
`cut the inlervertebral dowel cavities. When the
`cutting instr’uments are in use in the disc spaces,
`the surgeon must at all times have the undivided
`attention of his two assistants. to ensure that the
`great vessels are protected from injury. Specially
`modified Deever’s retractors, (Trewavis Surgical
`Melbourne Pty. Ltd., Nunawading, Victoria)
`
`area.
`
`FIG. 3. A lateral
`illustration of the ori-
`entation of dowel cav-
`ities
`transversely in
`the
`intervertebral
`space
`suitable
`for
`interbody grafting in
`the
`upper
`lumbar
`
`molest Orthopaedla
`and Related Rm
`
`which have smooth excavated ends, are held in
`place with loose raytec swabs positioned beneath
`them to prevent herniating the edge of the great
`vessels or adjacent soft tissues from herniating
`beneath them.
`The surgeon must be thoroughly familiar with
`the measurements of the intervertebral space in
`esch patient when preparing the dowel cavities.
`Measurements of the vertical height of the disc
`space and the anteroposterior depth should be
`available from preoperative roentgenograms. In
`addition it is to be noted that the anteroposterior
`measurements vary, being greatest in the midline
`and smallest laterally because the shape of the
`disc bearing surface of the vertebral body is oval,
`not rectangular.
`When the parallel plugs.of the adjacent ver-
`tebral body fragments and the intervening inter-
`vertebral disc have been displaced from the in-
`terspace using a gouge specially tooled to match
`the size of the cutter (Fig. l). the disc remnants
`are then removed from the intei'space with ron-
`geurs. In addition, vertebral end-plate remnants
`should be removed with ring curettes. Aided by
`the use of a vertebral spreader. it is possible to
`remove the bulk of disc tissue and vertebral end-
`plates from the interspaces. However, during
`these maneuvers the surgeon must avoid pene-
`trating the spinal canal or damaging the great
`vessels, which may have slipped out from beneath
`the retractors.
`The graft beds prepared by this method are well
`vascularized. Indeed one of the great advantages
`of this operation is that the blood supply of the
`vertebral bodies is not disturbed; thus, vascular-
`ization of appropriately placed grafts is assured.’
`
`CRAFT PREPARATION
`
`The use of autogenous bone grafts is strongly
`recommended. The left iliac crest is exposed by
`retracting the inferolateral edge of the abdominal
`incision. A supplementary incision is then made
`running along its upper border. Dowel cutting in-
`struments of one size larger than those used to
`prepare the dowel cavities in the intervertebral
`space, are then used to cut grafts from (he iliac
`grest, passing vertically downwards to the re-
`quired depth. Grafts of 2.5 cm to 2.8 cm in depth
`are? of satisfactory size in most patients. On oc-
`casion, cancellous chips may be cut from the bony
`fragments of vertebral bodies obtained from the
`dowel cavities. These fragments may be used to
`supplement the iliac crest grafts in larger patients.
`The iliac crest grafts have three cortical faces
`
`
`
`11
`
`
`
`

`

`Number 165“
`May. 1932
`Anterior Lumbar Interbody Fusion 161
`
`
`
`and two “tooled" cancellous faces. They are de-
`signed to be impacted parallel to each other with
`the cortical faces orientated laterally in the disc
`space and the cancellous surfaces facing the ver-
`tebral bodies. Purely cancellous grafts inserted
`into the intervertebral disc space have been shown
`by Crock3 to be liable to imiasion by disc rem-
`nants; thus, predisposing to nonunion. This com-
`plication has been largely obviated by the use of
`grafts cut from the anterior iliac crest in the man-
`ner just described (Fig. 4).
`
`GRAFT IMPAC'I‘ION
`
`In the last phase of this operation the interver-
`tebral disc space is again carefully exposed by the
`assistants. A vertebral spreader is inserted into
`one of the dowel cavities and opened to allow for
`a final inspection of the interspace. The depth of
`the dowel cavity is checked with a depth gauge
`and ruler and the first graft then impacted. This
`is a potentially dangerous maneuver as the edge
`of a great vessel may become trapped between the
`graft and the wall of the intervertebral space
`dowel cavity. Successful retraction at this critical
`stage of the operation calls for strict attention to
`detail.
`Following impaction of the first graft, the ver.
`tebral spreader is removed from the second dowel
`cavity and the second graft is impacted. Some
`hemorrhage will occur from the site; but, this is
`never severe and usually ceases in two or three
`minutes (Figs. 5, ‘6, 7A and 7B).
`Attention is finally focused on the donor site.
`If two grafts have been cut from the iliac crest
`then the bouy defect is filled with orthopedic bone
`cement befOre the Wounds are cloSed in layers with
`suction drainage.
`
`DISCUSSION
`
`The method of operation described in this
`paper has been used by the author at St.
`Vincent‘s Hospital, Melbourne, since 1961.
`Of approximately 1000 operations per-
`formed in 20 years, three patients have died.
`Two of these died in the postoperative period
`of acute coronary occlusion; the third com-
`mitted suicide four months postoperation.
`No significant urologic complications have
`been encountered with this method of spinal
`fusion. Retention of urine occurs in some
`
`
`
`PK}. 4. Method of cutting grafts from the an-
`terior third of the iliac crest. The graft has
`“tooled" cancellous surfaces and stout cortical
`faces on three sides. Reprinted with permission
`from: Crock, H. V.: Observation on the manage-
`ment of failed spinal operations. J. Bone Joint
`Surg. 58le93, 1976.
`
`patients, but its management only rarely in-
`volves the use of a catheter for one or two
`
`days. In most cases bladder function is re-
`stored after the use of one or two doses of
`
`Urecholine (Merck Sharp & Dohme).
`
`years after operation.
`
`FIG. 5. A lateral
`view roentgenogram
`showing 1...,
`inter-
`body fusion in' a 46-
`year’old woman,
`ten
`
`
`
`12
`
`
`
`

`

`Clinical Orthnpaadlce
`Crock
`162
`and Related Research
`
`
`
`FIG. 6. A lateral
`view reentgenogram
`showing L4,, and L,—
`S,
`interbody fusions
`in a 48-year-old man,
`.five years after oper-
`ation.
`
`In exposing the lumbosacral intervertebral
`disc space in the male, the use of diathermy
`in the presaeral area has been avoided. The
`author is aware of complaints of sterility in
`only two patients, both of whom were psyi
`chiatrically disturbed and both of whom had
`complained of impotence before operation.
`
`POSTOPERATIVE CARE
`
`Patients are nursed supine with one or two
`pillows, and rolled from side to side several
`times a day with a pillow placed between
`their legs. We recommend the use of beds
`
`which can be tilted vertically to allow pa-
`tients to stand and to get out of bed with
`little assistance from the nursing staff. In-
`travenous therapy is continued until bowel
`sounds are heard or flatus has been passed.
`Urine retention is not a common problem
`after this operation.
`Prophylactic anticoagulant therapy with
`subcutaneOus calciparine (Heparin, Difrex
`Australian Laboratories Pty. Ltd., Glebe,
`N.S.W.) is administered until patients have
`become fully mobile. Spinal Supports are fit-
`ted within a few days of operation and worn
`for three or four months afterwards.
`
`SUMMARY
`
`A technique using dowel cutting instru-
`ments for anterior lumbar interbody fusion
`operations is recommended for the treatment
`of other failed spinal operations; certain disc
`lesions; in the management of selected cases
`of spondylolisthesis; certain spinal
`infec‘
`tions;
`folloWing some vertebral fractures;
`correction of selected spinal deformities and
`in the treatment of rare miscellaneous cases,
`e.g., vertebral body tumors and nucleus pul-
`posus calcification. Extra peritoneal ap-
`proaches to the lumbar vertebral column are
`recommended. Dowel cavities are cut to pre-
`determined depths with specially designed
`cutters of appropriate size. The greater bulk
`of disc tissues and vertebral end plate car—
`tilages are then removed using ring curettes
`and pituitary rongeurs. Autogenous grafts
`are cut from the iliac crest using a cutter
`one size larger than that used to prepare the
`intervertebral dowel cavities. With the depths
`of the dowel cavities having been checked
`with a depth gauge, the grafts are duly im-
`pacted after careful retraction of all adjacent
`structures away from the cavities.
`
`.
`
`
`
`mum. a
`
`'
`
`"
`
`FIGS. 7A AND 73. (A) Lateral view roentgen-
`ogram of the lumbar spine in a 45-ye