Bone Growth after Spine Fusion

Bone
Growth
after
A
BY
J.
T.
H.
WAYNE
Al)out
1783,
of a youmig
John
pig.
University
Humster
Whets
the
placed
pig
msew
matter
beitig
imsterposed
in the
niammy years
the mechanism
subject
i)elieved
that
all
growth,
and
that
skeletal
growth.
The
svidetmed
the
diaphyses
of
of
bomse
lonsg
epiphyses-or
fiat
botmes.
Lacroix
After
were
of bomse
after
true
fusiots
by
mioted
that
tissue
skeletoti
growth
beets
at
the
fusion
solidly
down
fusion
in
fused
all
children
and
time
firm
this
lomsgitudinsal
botme
bridge
resulted.
bonme
bridge
became
growth
Haas
of the
determimse
imifer
foumid
but
in
young
that
at
ansd
against
this
the
inmtervelstiots
experinsetital
mean
one
or there
As
growth
They
of two
was
theory,
of
to
of
amiimmsals.
things
insterstitial
: cit het’
growth
of intrimssic
year,
Haas,
“fusions
the
time
of
was
firm”.
spine
coistinsued,
accommodate
itself
that
certaimm
they
to
the
eireintmmfmnsiotis
its
was firm in the spinmous
processes.
the growimsg
forces
of the bodies.
the
grafted
in almost
area
exploratiotms,
Therefore,
when
under
growth
in letmgth.
after
perfortssitmg
spinse
roentgenograms,
of sacrifice,
performmsed
lateral
miterthat
its every
instammce
the
to
concluded
lengthening
no serial
of
elongated
vertebrae.
defimsite
he had
the
when
was
ins
periosteunms
isesv observations
arose
the apparemmt
lemsgthehiimmg
it would
puppies,
tsot.ed
that
just
as soon as the fusion
there
was no yielding
in the fused
Spine
to
experiments,
the
grow’tlm
plate.
statmces,
transplamsted
bomie is capable
0mm the other
hamsd, in the same
Hos’ever,
and
denyimsg
experimental
plane,
Bisgard
and Musselman
ots the spines
of young
goats
and
reported
a
have
prohiferatiomi-as
for
or another
1947,
of
whereas
immthe
argunsetsts
a
fortsm
its
mmmi(roseopy
cartilages,
of arguments
intact”.
nornsal
its length
hyalimme-cartilage
spume,
at one
amid
proliferation-as
of
beets
lotsgitudinal
in
the
grow’th
epiphyseal
through
survey
all
by
Havers
Hellstaohius
alid
subject,
place
was
w’ere
has
Cloptotm
pam’t
l)otie
its 1930,
that
as
shot
eloligated
of l)onie
took
of
growth
of boise.
roemmtgetmography
has
the
aim authority
of the
Policard
its time diaphysis
not
old.
grow’th
of itmterstitial
especially
as
occurs
spine
broke
ins the
Ots the
body
fusion
ensitmemit
apart
slaughtered,
bommes are
the argument
seemed
settled,
Various
investigators
reported
in the
area
fusiots
as
picture.
segmensts
If this
the
just
the
that
As
that:
“The
structure
botse growth
remains
However,
inches
believe
fibrous-tissue
a careful
two
anmd was
to
1929,
takes
through
immterst.it.ial
fused
hotses
dimensiotss
coiscluded
confuse
the
shot
Haten
New
grow’nm
interstitial
in
type
of
AND
(‘ONNECTI(’UT
interstices
of the
of lotmgitudimial
bomse
opitmion,
its other
the
ammy
sonse
study
him
sO-(alled
Kortmew
majority
lead
literature.
of the
this
all defeisded
isave
led
its the
parts
HAVEN,
of Medicine,
fully
itmches
of
This
was
two
comstroversial
MARYLAND,
NIW
School
still
For
apart.
BALTIMORE,
M.D.,
of Surgery,
Divisions
o,f Orthopaedic
Surgery.
Univer&ity
School
of Medicine,
Baltimore,
Yale
and
Fusion
SURVEY
M.D.,
SOUTHWICK,
the Departments
Johns
Hopkina
Pros’s
CLINICAL
JOHNSON,
0.
Spine
the
the
aiminsal
or other
nsost
was
lie
could
altmsost
fully
all of his
ways
to
logically
growls,
there
was gemmerally
solid fusions
amid that
grow’th
had I)eems sotmsewhat
suppresseol
at sonse time.
He noted
that. whets the markers
were attached
to time graft,
there
was
based
iso
on
separatiots
two
dogs
of
the
markers.
However,
this
imsiportant
oi)s(’rvatioms
was
only.
1396
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THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
GR0\vrH
BONE
( )delhetg-.Johmssotm
AFTE1t
perfot’tms(’ol
14
S1’INF
spimm(’
1397
FUSION
fusiotis
rahlnts,
on
1)111
tioteol
gtos5
I )5(’il(ht it Ii is ses
a t a I mis( )st
(‘\‘(‘t’\’
i t5 t el’sj)a(’e
I le (‘01 5 (‘1 1t( le( 1 1ha I I Ise gt’ )wt ii i t
let mgtlm l I hiP 51)1 1 I(’ i t I I h1(’s(’ a 1 1i 11511 Is I ) )k la,(’e
at
I hese
( I(l((t
s. I I )\\(V(’t’,
t hi(’s(’
.
\VC1’e
(‘ii
t S 1(111
lv
ol
I lets(’(’,
granms.
its (‘hil(lt’els
t lie
itls
(1himmieal
.Jomnes,
atid
tmoted
thst&t
fimsditsgs
solid
soli(1
report
Hisser
the
Immu(’is
fusioit
s
Rt(’
ill
115
its(hi(ILt(?d
finsiots
tistiss
1 It
)fI (‘1 5 \\I
I hiese
ill
ItJ)l)ILF(’mstlV
1)t’O\’(’Ol
gettimtg
(
mnot lots \I55
tail to thmtov
(‘xp(’rilsmelsls
s,
(l(’fe(’t
)V i( )115
w’ith ettt’tilage, amid gross
often
a I nine
amsumials
spitle
are
as
)tn(Iit ionss
(1(’scril
time
(‘onntrol
of tIme ftnsioms
is elomngated
:trea
I)Iflt(
hoslies
10.
fronms
verts’h)ral
vitls
gm)\vthm
..
ws’rs’
utnsls’r
tIns
tmiass
of
..
Iraticis,
(10(5
tise
42-A,
NO.
8, DECEMBER
1980
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bool’
atsd
Measured
2Itenate
Measured
A4ea
8
:.
)s’sI ia’re
.
FIG.
Tsvo
atmd
Hisser
O(’(ltF.
vem’t(’l)ral
.
10)1
)sh’asitrs’nmsenits
of t lie ison’nmsal vs’rt(’h)ral
in(’hm(Ie(I
vithmins time fusionm \oul(I
l)e tms:uh’
plats’
1 to
vs’rt(’I)ral
Ph:tIs’
4 annd
fronmm vert(’h)ral
l)late
7 to vo’rteh)ral
l)lats’
10.
:\I (‘asurenm(’nmt S of t his’ nsornsal
)sterior
s’lenmetnt s,
t his’ is’(Iicl(s,
\‘5)ttld
be I15a(.i(’ its a sinmiilar
fa&liiotn
betves’ns
poinmts
..l ansd B and between
l)OiIitS
(‘ anmd
1) onm the pedicles.
VOL.
h t hose
of the (lifh(’mmltV js
is illmlst n’at(’d.
‘Tins’ P mit s
5Sf rs’fs’rensrs’ ars’ tii(’ censts’rs of tise Isdies
s)f tIne
ss’venst Ii :unsl nsint ii t inoracis’
vs’rt s’l irac.
Ni t s’ that
four
vertebral
1)ltt(’s
are
ils(’hin(Is’(I
ins t ins’ (‘olnt rol
:)r(’a Imeinsg Immeasul’(’d.
2. 13v t lie nmmetiis)(I of Ilalli
s’k, 1t’anm(’is, :nnn I .h ons’s,
if t he fusionm ars’a 5’Xt(’tids’(I
fronms t his’ ts’nnt In t ho in:scic
t) I I lie t hird
litlmmbar verts’h u’:t, t lie 1)00115
of ns’fs’rsno’s’
for time Isi(’asttt’(’Imis’tst
5)1 tims’ ls’tsgthm of tIne mino1s’
fusion
mvould
I e vcrteI)ral
plate
I :snns 1 en’t shr:n I
5’)
5(’(!
spitme-fusioti
Ihtilock,
otses.
expem’itmu’tmtal
grovth
v(’n’teh)ras’
Is’:tSUI’eniU’lst
vit
timem’efot’e,
lit
roenstgetso-
atsiismals.
cotsftnsitsg
that
(‘l,’
(‘Otsll)l(’t
cotsmpat’able
s(’areely
light oti 1110!l)rol)lelss because
youtsg
vs’rt.s’i)ra.
\Is’asurs’nmms’tmt. of
I. (‘a \i I V
Its getset’al,
fusiotss.
I.
ittt
nssct in( )( I t Inc (‘(‘nnt(rs
ot t Inc cnt ci )ral
I)O(hi(s
stol timid-l)Oinsts
of t ins’ l)c(ii(’l(s
(l(’
1151(1
as l)OiIstS
of r(’f(’r(’ts(’(’
for
all nis(’aitmr(’tnm(’nnt 5. his
S V() t.’ti&l v(’n’t(’h)ra(’
of I Inc fused
anets
\v(’r(
tn(’V(n
itn(’llt(.Ie(I
in atn nmm(’asitr(’nms(’tnt.
Tints,
if ths(’ fusionn
(‘Xt(’ls(le(l
fn’onmm t ln(’ tenst is I im()ra(’i(’
I ( ) 1 Inc t imin’ I
linnishar
v(’rt(’i)ra,
thse (Iistannc(’
bet w(’etn t h(’ c(’nnt(’n
I )f
t ims’ (‘leV(’tnt 11 timortt(’ic
v(’t’tei)n’a
015(1 the ((‘Inter
I )f t hse
55(011(1
lunmsbar
v(’rt(’I
ra voul( I be nm’asinr’
1.
SilmmilarlV,
if I hm(’ fmnsiots
extensded
onne segtmsets(
farther
dovts
to this’ foinrtls
lutmibar
vertebra,
this
distanice
1)(t (‘(‘ti
tine
cennter
of tins’ lsd\
of t he
(‘IeV(’Iitisthsoras’ic:tti(Itimat. of tue tisird linnimbar
vs’rtebra
vomnld I e ils(’5I as ref(’r(’ts(’e
l)oilnt S ( Sf nims’asinretmmennt
I f l)seuslart
Isrosis
m:ss f )ilti( I l)s’t 555
I his’ I slit hi
annd
elevetit
hi thnoras’is’
v(’rts’I )ras’,
ann :tltennn:nt e
nmm(’asur(’nsetlt.
osilsl
hs’ 115551.
SmtS(’s’ t ho’ ns’st it mt 0 In
1 )f
t he (liss’ask’(l
area
its 1his’ uper
1)5)11 0 )11 ( )f I his
lssIv of tii(’ first linnmmbar hod
is I)rOt)aI)lY
5(IiliVaIennt I ) t Iss’ s’nns’r )as’hsnlmennt
5)1 t his inifs’ni
1’ stnrfas’s
( )f
I lie I imird
hsnnsml air
vert(’l)n’a
mnnto I his’ :o Ijas’slnt.
i I 1 1s’rvs’rt(’h)ral
5 liss’,
I lie shist anns’s I )st mvs’s’t n I Ins esn nI ral
l)5)itmt of thns’ i)s)5I\
of tine fit’st lutmmh)an’ to the
(‘(Istral
1)oitst of tIme bosly of tine third hittnmbar rtsImn:s (‘0111(1 be 1155(1 as ant :Llt(’I’tlat(’
tims’:tsut’etsisnnt
Finnallv,
if 1 ins’ fusion
(‘xts’ts(lesl
sIovnm 5)115’ liii ins’
s(’gnn(’tnt.
t 5 ) 1 Ins fifth
lunmml ar vsrt el )n’a , Ism(’:nsi 115tmmsnts (‘0(1151bs’ Imia(I(’its tine N5155C fasisiotn frotss tins
rs’tnter
(of this’ (‘ls’V(’tmtlI or t’,(’Iftis
tisOra(’ic
or fronsm
t his ce’nster
of I Iss’ first 5)1’ ss’s’otnsl htnsmbar
body
sh 5I1
15) thss’ cs’tmter
of t his bod
s)f tine fourth
hinnimhan
\\his’nsevs’r
I)oSsiI)ls’,
(Iis(’aS(’(l
inss’d as 1)5)itits of refen’enscs’
for
j Oitm
oI(’tmiotsst
ral)lo’ itt betiditig
IsmetimOds
of
1
measurement.
1398
3. T. H. JOHNSON
AND
W.
0.
SOUTHWICK
2-A
FIG.
Fle.
2-B
Hot’tntgennogransis
of Case
C. C., otm mvhmotmmani Albee
fusionn
was l)s’rforlmse(I,
s’xts.nn(Iinsg
frons
tine
tiurd
to tim fifth
lunmibar
vertebra.
Pscudartimrosis
betweeni
the third
:mnn(l fourth
lunmsbar
vertebrae
aI)IXan’ed
six nmsontiss after
olxrationm
atn(! ws’ still visible
ott a roentgetiogranms
made
on Mmiv 4, 1951,
four
years
after
operatiotm
(Fig.
2-A).
l)espite
150 treatnisetit
of ansy kinnd,
thmis I)sell(lart.lmrosis
was
l)ridge(l
by boise,
May
9, 1952,
five years
after
operatioti
(Fig.
2-B).
(‘Oni(llnd(’d
that
this
was
possible
I I alloc k aisd assoei ates
carefully
that.
fusions
1iseso’
tue
foutsd
l)Osteri5)t’
fom’
yoittig
ill
imm all
tttiol
associates
ol)l)Os(’d
niade
categori(’ally
l)otse
spimme
after
immimsimal
time
of
the
occur
cansimot.
cireunmstamsces
of
by
thmrougls
time
and
the
paper
by
gradual
grafts
on
Friedman
bent,
tuberculosis
area
fusions
mssass
surgical
also
even
the
tsoted
when
of the
follow-imp
‘‘
(
adult.
life.
ammo!
amstel’R)r
fiisdiisgs
of
least
the
elmatiges
fused
h
1i,
paraspihsal
in
segmemst,
state(I
He
the
then,
s(’oliotic
mdl or
was
developed
not.
mmrecemit
explained
of tIme spinse.
that
betmdinmg
is overcorre(’ted
to
straigistennsg
of
sustaimmed
of deficiemit
ins the
at’ea
growl
()delben’g-,Joistsson
Isummiani heitsgs.
iii
spine
fused
its lemsgtim of time s’ho1e
portiotms
but
I Ise
1 he
1(15(1
of
oily
st
of
b’omvth
imsehes
grafts
observed
a
negative
of
but
fused
curve
a localized
:
pseudarthrosis
restored
imssmature
repeated
Ponseti
that
l)e
itito
botls
its diseussitig
growths
Miller
prinssary
tlsese
proved
earlier
if the
t lie
ittcrease
raised
and
;t.re
Friedimsani,
w’hich
itt
em’ni
tlmat
of Albee
solidly
Laekutss
‘Oti
tn’unsk
extetit
Time
“
cases
of apparemstly
oeeasiommally
and
the
:
o’ommfusimsg questioim,
will
tms(Ier
wrote
its
scoliosis,
fusioms
miot observed
except
bemsdimtg
for
lie had
aiiol
statcol
tunt Isors
follow-up
fusioms,
Another
to timese
tmsa.ms. 1)tiSeti
its
followed
ii of
omse amid omse-hmalf
a lomsg-termmi
timat
i)ridg(’
a. lotsg-t
atmol
rioted,
time average
grovth
being
being tht’ee-qsnarters
of atn itich’’.
(otsmpletely
were
gromvt
\‘eFtO’bt’tto’.
l)reSetstO’(l
\\.ILS
m’hso also
who
cotititsttc(l
mm chmildnemt
I ubei’ctnlosis
the l)iologi(’al
plasticity
of l)Olse.
roen t gemmogm’a Isis of lift ccii 11 i bbs
of
t he
childremm
pa.tiemits
of time fuseol
eletsmetsts
( ‘levelatsol
fusiomis
perforlned
\\‘(‘t’O’
autlmoms
I)ecause
mmm(’asureol
After
or
spine
givimsg
fusioms
way
time extent
that
is
of the
balaisre
time conspensatory
curves.
loss
occurs;
fusion,
absemsee
literatitre,
of
but
of
correction
oftets
atsv
throughout
the
pseudartimn’osis,
as
exploratiotss.
that
correctioti
appareistly
spine,
solid.
noted
THE
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its seohiosis
that
JOURNAL
Hallock
:
“
OF
was
and
Forward
DONE
oftens
Jones,
bending
AND
JOINT
lost
ins an
with
SURGERY
1400
J. T. H. JOHNSON
AND
W.
0.
SOUTHWICK
Case
S. S. , tuhs’rs’ulosis
of this’ siitse
itsvolvinng
time t.velftis
timoracic
:511(1 first
lunmhar
vertebras’.
( )n Jutme
20, 193 1 , a nmmassive Hibbs
fission,
usinmg i)anmk boise,
was l)(’rfs)rI(’(1
fronms tIme zsint.h timoracic
to time timir(I litnibar
vertebra.
1’xplorations
of the grtmft. with
repair
of l)SetldartiirosiS
betweeni
the eleventh
anmd tw(’lftlm
tlsoracic
vertebrae
was carried
out on .Janmimarv 9, 1952.
(its \Iav
21 , 1952,
the fusion
was re’-(’xl)ls)rs’(I
:115(1 fomumd to be solid
throughout
its whole
(‘xt(’Imt.
Roentgeniogranmss
))f the spinn’
were
OI)tailsed
at least
otice
a year,
frsins
1952 to 1958.
The
l)est
were
those
ma(Ie
015 l)eccnmber
16, 1952,
whenm the patienst
was five years
of age (Fig.
4-A), aimd 5)15
Aitgitst
9. 1958,
win(’ns the (‘imild as
ten 1515(1 a half (Fig.
4-B).
Noto’ tinat. 501555’ straigimteniinsg
of this’
kypisosis
isad s)s’(’ltrr(’(l
(Iltritng
this interval
of five anmd a half years.
t’sitmg tlsese
roenmt gs’nmogranims,
we deternsinmed
the inmcrease1inheight
of t iso’ fus.esl
ansd
the imnifinss’d
nns)rnmal verto’h)ra(’,
(‘nssployitsg
first our method
anmd timen that
of Hallock,
IEratn(’is,
anal Jon(’s.
1’). our tsiethsod
tue fuss’d area
(the
six tmtm(lafliaged
epipisyseal
l)latcs)
betweeli
ths(’ t(’tmth tinor:u’ie
ati(l sscOti(l
ltmtmshar vs’rts’hrae
inscrease(I
as follows:
12, 16, 52
I )istatnre
betmveetn
Immid-bo(lies
J)istance
betweens
Imii(1-pe(Iicles
:tniol time unfused
sacral
vertei)rae
area
(six
iincnease(l
uimdamaged
as follows:
e)i)hiyseal
6 . 9 clii.
7.2 cm.
1)lates)
between
7, 9, 58
time
12,16/52
Itnerease
(lid’ cent
7 . 5 (‘tim.
9
7.9 cnmm.
10
third
lunmhasr
anmd this’
7, 9, 55
Inicreas(’
( per
cent
8 . 7 cm.
30
8.0 ens.
33
By the
Franmcis,
and Jones,
vertebrae,
Imseasured
fronmm t lie
top of the nilmtlm thot’acic
to tise h)ottom
of the eleventh
thoracic
vertebra
alm(l from
time top Of tine
se(’Oii(l
lumbar
to tise l)Ottofl1
of the third
lunmihar
vertebra.,
illcreased
1(5 follows:
12 16/52
7/9/58
Inicrease
(per cermt
‘I’9 to ‘FL 1
4.7 ens.
5.6 ‘nmm.
1k.)
L2 to L;
4 . 0 ens.
4 . 9 (‘1mm.
22
anid time unfusesi
hmealthiv
vertebrae,
nseasured
frons
time top of tine fourth
lunmmhan veltebra
ts
tins’
hottons
of the first sacral
vertel)ra,
iflcrease(l
1(5 follows:
144 to Si
6.0 cm.
8.0
(‘Iii.
33 (per (‘dm1
Similarly,
by their
metho(l,
time total
fusion
area,
immeasured
1)0th fronmm the top of time ninth
thoracic
to the bottonmm
of time tisird
lumbar
vertebra
anmd fronm time superior
marginm
of time pedicle
of
the nintls
tlsora(’ic
to the inmferior
margin
of the pedicle
of time third
lunmbar
vertebra,
iimcrease(1
as
follows:
Distance
i)etweeis
1)istaisce
between
nmet.ho(1
mid-bo(Iies
mid-pedicles
of Hallork,
first
6 . 7 cm.
6.0 cm.
tIsefused
healthy
12/16/52
Bodies,
Pedicles,
T9 to L3
T9 to L3
12 . 0 cm.
13 . 7 ens.
12.2
13.5
TIlE
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Inscrease
7/9/58
cm.
JOURNAL
OF
BONE
cnm.
AND
(rer
cenmt)
14
11
JOINT
SURGERY
1400
J. T. H. JOHNSON
AND
W.
0.
SOUTHWICK
Case
S. S. , tuhs’rs’ulosis
of this’ siitse
itsvolvinng
time t.velftis
timoracic
:511(1 first
lunmhar
vertebras’.
( )n Jutme
20, 193 1 , a nmmassive Hibbs
fission,
usinmg i)anmk boise,
was l)(’rfs)rI(’(1
fronms tIme zsint.h timoracic
to time timir(I litnibar
vertebra.
1’xplorations
of the grtmft. with
repair
of l)SetldartiirosiS
betweeni
the eleventh
anmd tw(’lftlm
tlsoracic
vertebrae
was carried
out on .Janmimarv 9, 1952.
(its \Iav
21 , 1952,
the fusion
was re’-(’xl)ls)rs’(I
:115(1 fomumd to be solid
throughout
its whole
(‘xt(’Imt.
Roentgeniogranmss
))f the spinn’
were
OI)tailsed
at least
otice
a year,
frsins
1952 to 1958.
The
l)est
were
those
ma(Ie
015 l)eccnmber
16, 1952,
whenm the patienst
was five years
of age (Fig.
4-A), aimd 5)15
Aitgitst
9. 1958,
win(’ns the (‘imild as
ten 1515(1 a half (Fig.
4-B).
Noto’ tinat. 501555’ straigimteniinsg
of this’
kypisosis
isad s)s’(’ltrr(’(l
(Iltritng
this interval
of five anmd a half years.
t’sitmg tlsese
roenmt gs’nmogranims,
we deternsinmed
the inmcrease1inheight
of t iso’ fus.esl
ansd
the imnifinss’d
nns)rnmal verto’h)ra(’,
(‘nssployitsg
first our method
anmd timen that
of Hallock,
IEratn(’is,
anal Jon(’s.
1’). our tsiethsod
tue fuss’d area
(the
six tmtm(lafliaged
epipisyseal
l)latcs)
betweeli
ths(’ t(’tmth tinor:u’ie
ati(l sscOti(l
ltmtmshar vs’rts’hrae
inscrease(I
as follows:
12, 16, 52
I )istatnre
betmveetn
Immid-bo(lies
J)istance
betweens
Imii(1-pe(Iicles
:tniol time unfused
sacral
vertei)rae
area
(six
iincnease(l
uimdamaged
as follows:
e)i)hiyseal
6 . 9 clii.
7.2 cm.
1)lates)
between
7, 9, 58
time
12,16/52
Itnerease
(lid’ cent
7 . 5 (‘tim.
9
7.9 cnmm.
10
third
lunmhasr
anmd this’
7, 9, 55
Inicreas(’
( per
cent
8 . 7 cm.
30
8.0 ens.
33
By the
Franmcis,
and Jones,
vertebrae,
Imseasured
fronmm t lie
top of the nilmtlm thot’acic
to tise h)ottom
of the eleventh
thoracic
vertebra
alm(l from
time top Of tine
se(’Oii(l
lumbar
to tise l)Ottofl1
of the third
lunmihar
vertebra.,
illcreased
1(5 follows:
12 16/52
7/9/58
Inicrease
(per cermt
‘I’9 to ‘FL 1
4.7 ens.
5.6 ‘nmm.
1k.)
L2 to L;
4 . 0 ens.
4 . 9 (‘1mm.
22
anid time unfusesi
hmealthiv
vertebrae,
nseasured
frons
time top of tine fourth
lunmmhan veltebra
ts
tins’
hottons
of the first sacral
vertel)ra,
iflcrease(l
1(5 follows:
144 to Si
6.0 cm.
8.0
(‘Iii.
33 (per (‘dm1
Similarly,
by their
metho(l,
time total
fusion
area,
immeasured
1)0th fronmm the top of time ninth
thoracic
to the bottonmm
of time tisird
lumbar
vertebra
anmd fronm time superior
marginm
of time pedicle
of
the nintls
tlsora(’ic
to the inmferior
margin
of the pedicle
of time third
lunmbar
vertebra,
iimcrease(1
as
follows:
Distance
i)etweeis
1)istaisce
between
nmet.ho(1
mid-bo(Iies
mid-pedicles
of Hallork,
first
6 . 7 cm.
6.0 cm.
tIsefused
healthy
12/16/52
Bodies,
Pedicles,
T9 to L3
T9 to L3
12 . 0 cm.
13 . 7 ens.
12.2
13.5
TIlE
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Inscrease
7/9/58
cm.
JOURNAL
OF
BONE
cnm.
AND
(rer
cenmt)
14
11
JOINT
SURGERY
BONE
GRO\VTH
iFTER
sn’IxF:
.
FIG.
1401
FUSION
5-A
‘
‘
Ftc..
5-B
I ). 1{.., tuhei’culosis
of I Ins’ sminne ilnvolvinmg
tine lift ii :tlnd sixt is I iiI:teir
vs’nts’I n:ns.
( )tn Junme I 6, 1 950, a nimassive
I Iihhs
fusiotm,
m’einmfon’ced with
l’ibl)OIs grafts
frotmm t hie tibia,
(ase
as
Pt”fornmmed fronmm t ime fourt h to 1 ime t enst Im t hmoracic
vertel
na.
l(oentgenogranss
:mt yearly
inntenvals
thereafter
inmdis’ated
timat time graft
:ss
solid
I hnroughnsntt
its
enmt ire extent
. TIme
l’oetntgennogranmss
us(’d
for nmeasurenmenst
were
obtained
onm I )es’enmsi er
12, 1
mvimens time 1)atielit
\:ts
eight
years
olsI (Fig.
.5-A),
and on Juime 2, 1955,
whets
tine (mull
\\05
t\V5lV(’
:115(1 a half (Fig.
5-B).
Using
these
roenntgelsogranmms,
ve (leterninne(l
time iticrease
in height
of tue fused
annsl tIne unnftnsed
Imornmsal vertebrae
ensmmdoyiisg
first.
our
nmethod
atsd then
that
of Ilallock,
Fralseis,
atnd .Jomses.
By our nmethod
time fused area (six undani:mged
epipinysea.1
1)lates)
betweelm
tine fifth
:Lfl(I nninnthi
I hmoracic
vertei)rae
ilss’rease(i
as fi )llows:
12/12,50
I )ist ann’s’ I st (‘(‘nn
J)ist.anns’c
anm(I tue
ven’tehras’
1550 1-1 iodies
ls’t
tmmi)l-l)e(lis’les
unnfused
area (six tmornsal
ini(’Ie:nse)I
:ns foIlovs:
epipiisea1
1)lates)
62/55
7 . 3 (‘1mm.
7 . 5 ens,
betweemm
time tennth
12/1250
Inncreasc
( 1s’r
edit
I 1
S . 0 (nm.
7
thmom’acic 011(1 tine first
S
.
1 elms.
6/2/55
hetweenm
h)ettveeIs
immid-bodies
mmiid-pesliels’s
7 . 1 (‘niL
7. . S (nm.
an
Innrr(’asc
( i’n
1)ist.almce
1)istanss’e
lunml
10 . 4 c.Imm
1 1 . 0 (‘lit.
s’emmt
-11
1I
t lie nii(’t Ii 1(1 s)f I I aIls ck , I’I:n l1(i5,
:1.1)5 1 .Js ons’s,
t he fusesl
hiealt hny vent ci )n:tc, Iim(’:nsInl(’ I fn uin I I
of t ise sevennt
ii t monaco’
I 5) t lie hot t onmm of t inc tenit is I hiOIa(’i(’
ventei)ra,
inmcreas(’sI
as follomvs
T7 to T10
7 . 8 (‘nfl.
9 . 1 sImm,
21 (per c(’tnt
Ln5(L t Ins’ unnfusesl
niortisal
vert (‘lmr:se, nsmeasure(l
frons
t he 15)1) of time eleveimt h 1 isoracis
1 o I lie I ot t onnm
s)f t lie first
hurts) etn vs’rtehn’a,
inoneasesl
as follows:
‘l.’l
I Is) L I
7 . 2 cnmm.
10 . 2 cnn.
12 (pet (‘(‘nit
ts)1)
Sitmmihatly,
1iy t heir
thmoras’ic
to tine bottonis
of the fourt
hi t hmor:ncic
:is follows:
nnethmod,
t lie
of tise tenth
to the inferior
total
fusion
area,
mmmeasured
thoracic
vertei)ra
and from
n:mrgin
of t lie pe(li(’le
of the
I2/h2/.(1
both
froni
t Inc t op
the superior
margits
teimth I lmon:u’ic ventel
sf
i, 255
Imncrease
I inc
(mxn’(‘CIII
Boslis’s,14 l o ‘1’ 1 (1
vs )L.
42-A.
N)
0.
12
Tl0
Pedis’les, ‘l’I to
0
Dt
.
12.5
i:mn tiER
l)6()
Downloaded From: http://jbjs.org/ by a SERIALS/BIOMED LIB 0699 User on 05/15/2014
6 sims.
(nm.
15
14.1
.
1 clii.
(‘lii.
fount
of the peslis’le
rtt, inm(neasesl
20
1
in
1402
J.
T.
H.
JOHNSON
AND
W.
0.
SOUTH\VICK
(‘ase
B. A. S., tuberculosis
of the spine irmvolviimg the third and fourth
lunshar
vertebrae.
(mm Fehm’uan’v
17, 1950,
a 5l)ilme fusion
from
the first lunsh)ar
to the fifths lunmhar
vertebra
was attensmpte(l,
lout l)seu(lartlsroses
developed
between
the tlsird
aImd fourths
anmd hetwecim
time fourths
amnsl
fifth
lunimbar
vertebrae.
Oni Februan’v
9, 1951 , these
pseudarthroses
were
repaired
su(’s’essfully.
Iloweven’,
a l)seu(Iarthmrosis
timat hind beens overlooked
iii scvei’al
roemntgelms)granms
was
sUbseqU(’Iitly
seen
betweens
tise first amnd seconmsl lumbar
vertel)rae.
\earlv
roelltg(’nis)granms
timereafter
revealed
that
time graft
was solid
frons
the se(’olmd
lunmmbar to
time se(’ond
sacral
vertebra.
Time roentgenograms
used
for Imieasurenmelst
by both
our nmetiiod
alnsl
that
of Ilallock,
Fn’aimcis,
and Jones
were
oI)tairmed
omi Julie
15, 1951,
when
the (‘hmild was seveim years
01(1 (Fig.
6-A), 1Usd on April 11, 1958, mhens time child wa.s fourteen
(Fig. 6-B).
B:’ OUr nmmetiso(I
tine
ani(l first sacral
vertebrae
area
ili(’rease(l
fused
(four
as
unn(Ianmaged
epi)Isysea1
I)lates)
betwcenm
time fourth
lunmsbar
follows:
6
15
51
4
1 1 58
Inms’reass’
(‘elst
5 . 7 cnmm.
6 . 2 (Iii.
9
4 . 9 cmii.
5 . 3 (‘1mm.
S
hetweeim
I lie s’levent
Is I hmor:ncic amnd I lie
( l)(’r
1)istamnce
1)istaisce
betweens
hetveeis
Immi(I-bO(lies
nmmid-pedicles
hme unfinsed
area (four
v(’1t &‘lt’:u’ itms’n’ease(I
anmsl
t
luimml
1:5 n
tmornmal epiphsvseal
as
plates
)
15
(‘I
Distance
1)istannce
1.
to1)
the
of
betweemi
between
Immi(l-h)odies
immid-pediches
nmetho(l
of ilallock,
lumbar
to
time
se(’ommd
Fraiscis,
amid Jones,
time fused
the 1)ottons
of the third
lumbar
of
T12
time
unfused
first
nsornmal
lunmbar
vertebrae,
vertebra,
measured
increased
:ts
from
the
met mod,
of the
of
to
secon(I
lutmsbar
time
tine
first
inmferioi’
limcrease
(‘dm1)
7 . 3 ctms.
7 . 3 (‘1mm.
top
(‘oS
.f . S clii.
Siimmilamly,
I y t ineir
lutsmbar
15) tine bottons
1 1 55
( Pr”
follows:
to Li
time
4
33
healtimy
vertebrae,
mmieasured
fronm time
vertebra,
increased
as follows:
cm.
6.2 cm.
29 (per cemmt)
of the twelfth
timora(’ic
to time bottom
4.8
time
51
5 . 2 cmmm.
5 . .5 cnm.
L2 to L3
alm(l
first
follomvs
.
ctmm.
42 (per
(‘emit
total
sacral
fusioim
are:n , isme:nsured
both
fronmm tue
t op sf 1 ha’ second
vertel)ra
and
from
time superior
immamgimm of tine
I)edi(’le
mmsam’gimm of time l)edi(’ls’ of time first
sacral
vertebra,
incrs’as(’sl
as
follows:
(‘1
13
i1
4
1 1, ‘55
lnl(’re:nse
(per
Bo(Iies,
Pedicles,
L2 to Si
L2
to
Si
12.5
cm.
11 .5 cm.
THE
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JOURNAL
OF
cenit)
15.0
ens.
20
13.5
ens.
17
BONE
AND
JOINT
SURGERY
BONE
GROWTH
AFTER
SPINE
1103
FUSiON
FIG. 7-A
FIG.
7-B
Case
tuberculosis
of time spine
involving
the timir(I, foiirtim,
:115(1 fifth
lunmbar
vertebrae.
AIn Albee
fusions
fronm
time first
lumbar
to time first
sa(’ral
vertebra
was attenmpte(I
5)15 August
14,
1942,
msiien
tue Iatiellt
as
four
years
old.
PSeU(1:trtiiroses
(levelol)esl
betw(’els
tine se(’onnd
almd
third
and
between
time thmin’d anm(l fourths
lulmmh)am’ vertebrae.
These
pseudartlmroses
were
repaired
on
.Jatmuarv
26, i943.
Year1’
roenmtgenogranmms
thereafter
revealed
tue fusionn
to be solid
frstmm time first
lunmmhar to time
S(’(’5)Ii(1
sacral
of Ilallock,
(Fig.
7-A),
Jh
s)ur
anid
Time rs)entgenogralmms
vertebra.
Frans(’is,
ali(l Jonnes
anisl onm August
25,
niietins)5I,
first
area
inscr(’ased
time
sas’ral
were
1949,
fusesl
vertebrae
used
for Immeasurenmemnt l)y h)otis our netisod
the patient
was five
obtaume(I
015 .July 1, 1943,
mimen
when
time s’iiilsi
was elevens
(Fig.
(four
as
uisdanmm:mgesi
follows:
epipisvseal
plates)
hetweenn
time second
S 25-19
1)istannee
hetws’emn
hetweeni
1)istance
isornmal
of
the
first
lumbar
Li to 142
anid
time UIifUse(l
twelfths
thmorasic
TlO to Fi2
to
imormal
vertebra,
Francis,
tIme
bot.tonm
vertel)rae,
innereased
ansi
of
Jones
time
nseasured
as follows:
time
second
froni
of the
itmferior
time
to . 8 ens.
; . clii.
tenth
amid
S 25 #{149}.19Immcrease
4 . 2 eni.
4 . 3 cm.
3 . 9 cnmm.
5 . 8 (nm.
fused
lumbar
( ler
Isealtisy
vertebrae,
vertebra,
4.5 clii.
time top
of
dim.
6.0
the
temmth
Li
Pedicles,
VOL.
42-A.
35
as
cnms.
to
the
fronis
the
follows:
33 (per cent)
bottom
of time
S. 5 elms.
42 (per
ceist)
nmmetimod, tue total
fusions
area,
nmmeasured
bothm fI’olmm the to1) of time first
lttnmmbar
first sacral
vertebra
and fronim the superior
niargini of the pedicle
of tue first
niargini
of time pecli(’le
of time first sacral
vertebra,
increased
as follows:
7143
8. 25/49
Increase
to Si
Li to Si
NO.
cent.)
nmeasuned
nmcreased
tinom’acic
40
(per
Bodies,
(‘emit)
hO
10
twelfth
7,. 1 , .13
6.0
timeir
Sinsmilarly,
to time bottonm
lunmibar to time
Plates)
nmid-bsxlies
Issi(1-I)edicles
1fr. time nmmetiiod of hiallock,
ts)1)
el)iI)iivseal
6 . 2 (nm.
6 .:
bet.mveemm
lunsmI)ar
Itmcrease
( per
het.weens
nmid-bodies
betweenm
nmi(l-I)edicles
tmnnfused
area
(four
inns’reased
as follows:
old
7-B).
7, 1, 43
1)istanmre
1)istannce
and
this’
vs’rtehras’
aln(I that
years
8, DECE%IBER
10.5
ens.
12.3
ens.
cezmt)
17
10.0
cm.
11.5
cm.
15
1900
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1404
J.
Case
U.N.,
A two-stage
tuberculosis
T.
of
H.
time
JOHNSON
spine
AND
inmvolvimmg
(tue first otm 1)ecember
8, 1950,
thss)racie to the t.ms’elfth t.horacic
the third
\VtS SOli(I fn’otms time third
inn April
1951 , but. there
fronsm
our
nimetimod,
thoracic
the
fused
vertebrae
had
the
time
0.
SOUTHWI(’K
sixths,
and the
vertebra
sevelsth,
eighth
amid
thiorarir
vertei)mae.
fusioni
secolm(I olm J:umuam’y 26, 1951 ) Ilihhs
was attempted,
usinmg bansk honne.
Fusions
thoracic
vertel)ra,
as evidelm(’ed
by a roelmtgelms)gm’almm
nsia(Ie
was pseudarthrosis
betmveen
time eleveisth
anmd twelfths
timora(’ic
vem’tehmae.
1(oenstgennogm’anmss
were
obtained
frequently
during
the follosvinmg
two years.
Flowever,
there
\V:LS
thenn a two-year
l:tpse;
the next
roentgenogram
was not made
until
1955.
At timis tinme timere was
evi(Ience
t ina1. time pseudartlmrosis
had healed
spoistaneously,
without
treatnsent
.
\Ieasur(’nmseimts
1y
both
or
nmmethod mumd that
of Hallock,
Franmeis,
and Jones
vere
niade
on time I)asiS of time inmitiallv
solid
fusioni
extenmding
fronm time third
to time eleventh
thoracic
vertebra.
Time roelstgelsoglams
us(’sI
svere
oh)tainned
015 August
6, 1951, wheis the patienmt was five years
01(1 (Fig.
8-A ), :115(1 011 JUI1(’ 7,
1955,
vlmets
(lie (‘Imild was
tsine (Fig. 8-B).
In time interval
l)etweens
these
roenitgenmognanmms
tIne
kyphosis
had dinmmilsishmed slightly.
By
tenmth
to
W.
eleventh
area
(eight
increased
undamaged
epi)hmysea1
plates)
hetmveemn
S 6 51
l)istance
betweeni
Distance
between
and the unfused
isad
increased
as
nornmal
epiphyseal
6
7
35
8 . 5 ciii.
8 . 7 cist
10 . 0 cnmm.
10 . 2 elms.
betweeim
time first alnd fifths
Immid-i)odies
nmid-pedicles
area
(eiglmt.
follows:
thi(’ fountin
plates)
8
6 51
6
7
Ilicrease
(iei
edit.)
2
2
lunsmhar
vertebrae
55
lnncne:tse
(leI
l)istansce
1)istansce
By
to1)
of
bet.weems
betweels
10 . 5 sImm.
#{182}
. 9 (‘Iii,
nmid-bodies
nmid-pedicles
to
tine
hottons
of time fifth
thoracic
vertei)ra,
inn(’rease(I
8 6 51
T9toTil
5.3cm.
T3toT5
and the unfused
the third lunmbar
Li to L3
4.7cm.
Sinsilarly,
thioracic
I)edi(’le
itss’reased
by
nornsal
vertebra,
vertel)t’ae,
increased
12
nmeasured
as follows:
fronmm time
tot)
11
method,
the
2 s’nms.
6/7
total
fusion
area,
to time bottom
of the elevenmth
thmoracic
of time third thon’acic
to the insferior
margin
as follows:
55
Insenease
(per edit)
13
6.0cm.
5.2eiss.
of
the
first
nmeasured
vertebra
and
of the pediele
S. 1
both
11
lunmmbar
tue
ts
(I)5.
from
time
top
fronms time superior
of the
elevemmthm
S 6 51
6
7 f5
T3 to Ti I
T3
to Ti!
12 . 0 cmmm.
1 2 . 9 clii.
14.0
clii.
13.
THE
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1 cims.
JOURNAL
OF
BONE
hottonns
14 (per
(elit
of
timird
time
vertebra,
thoracic
lnncrease
ANI)
of
mimargimi of time
(ix’r
Bodies,
Pedicles,
(‘emnt )
16
.
:ts follows:
7. 1 cm.
thmeir
.
0 (‘155.
1 I
a.Imd ,Jommes, time fused imealtimy vettehi:ne,
nme:nsulesl from t lns’
of the eleventim
thiora(’i(’ vertel)ra
annsl fnonmi the ts)1) of tlninsl
time nmethod of Hallock,
Francis,
the tiiimtim timora(’ic to the bottom
timor:tcic
alnd
as follows:
cent)
7
7
J5)INT
5(.)((;y
GISOWTH
h3()Nh
AFTER
SPINE
1405
FUSION
( ‘ase \\ . H .. t ui)erculosis
of I he spinse
ilsvolvinmg
t lie fourths
timid fift It lunsl)ar
vert ehrae.
( )tn 1ehruarv
.1, 1949,
a I Iihhs
fusionm, reiniforced
mvith tibial
honie,
mas perfornmed
fronim tue first
limnmhar
ts) t Ine ses’s)nsd saen’al
vertebra.
Fusiolm
becanmie
solid
from
time secommd lunsbar
to tine se’onnsl
sas’ral
vertel)ra,
vitim pseudartimrosis
bet.weenm
the first anm(I Se(’OIid
lunmbar
vertebrae.
Thereafter,
roenntgenogranmms
were
obtainmed
at least. once
yearly
uist ii I 955. The
roent gelsogranms
usesi for nmmeasuretmmetmt
I)y both
our method
anmd that. of hiahlock,
Frals(’is,
tusd ,Joties
were
Ol)taitls’(I
slIm .Juime
7, 1949,
mvlmeim t lne pat ienmt was seven
years
old (Fig.
9-A ), atsd On June
6, 1 955,
winels
1 hns’
rhnild was t hsirteeti
(1ig.
(J_I ).
I:t
the
VCItel)Iae
fusesl
area
inm(’rs’asesl
5)1I’ Immetle)d,
:tnisl
first.
sact’:il
unnslatnmags’sl epiphmyseal
(fstr
as
1)1:515’s ) l)(’t\v((’nn
tIne
tlnirsl
6
7
6 6 ‘55
P.)
IltCl(’:ns(’
(per
I )ist.atnee
between
I)etweens
unfused
ins’re:ue(I
1)istanmce
the
vertel)l’ae
:511(1
7 ens.
6 . 2 ctn.
nssid-hodies
nmi(l-pe(licl(’s
area
(four
as follows:
(‘I
tss)rlmsal
lunishar
fshlsmvs
(pi)hnVseal
tlates)
7.1 einm.
6..! ens.
tent Ii lund
.
l)etweenm
the
67,49
s’ennt
6
:
twelfth
6 6, 55
tisoras’i(
Increase
cent)
(per
I )ist alice
1)etweens
I )ist :mnsre I iet.ws’eii
nmmisl-bodies
nmmid-1)esh(’les
lh’ time nmmethmod of Hallock,
tot)
of
time
lumbar
second
5.1
5:3
Fralmeis,
alid Jones
the
bottonmm of the timird
fused
lumbar
tue
to
6.5
(i.8
cnsm.
imealthy
vertebra,
s’nmm.
25
cnn.
28
vertebrae,
increased
6/7/49
nsea.sure(1
from
as follows:
66/55
Increase
(per
L2
to
:05(1 the
unfusesi
nnorlmmal vertebrae,
of tue twelftlm
tiioracic
vertebra,
‘I’ 10 ts) T12
Sinmilarly,
I)y
their
nmetimO(I,
nseasured
frons
inmcrettseol
as follows:
time
Bodies,
Pedicles,
42-A,
I2
Si
to
L2
NO.
to
Si
8, DECEMBER
total
sacral
tnargins
fusions
area,
vertebra
and
of
pedicle
the
measured
frons
time
telith
of
tue
timoraci(’
9
hotim
the
sacral
vertebra,
11.7cm.
12.8cm.
10.3cm.
11.0cm.
the
botts)nml
30 (pet’
time top
nmargin
66’55
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to
I sm.
fronm
superior
first
.
6, 7/49
tYOO
(‘ent)
22
6 . 7 cnsm.
7 . 0 enms.
lumbar
to the l)ottOnsm of the first
the seeotmd lunshar
to time inmferior
follows:
VOL.
5 . 5 ens.
time top of
[43
tine
of
(‘ennt
time secolid
of time pedicle
increase(I
Increase
(per cent)
9
7
of
as
1406
.r.
Epiphyseal
more
growth
active
allowing
lolsg
fusions
causes
area
law.
i)eyonsd
the
isot
botse
Weinmann
also
with
be
or excessive
true
pressure,
due
sufficient
to
loss
of continuity,
Ths
thems
allow
cause
consequent
bending
stated
overcorrection
or betsditsg
CLINICAL
This
study
requiritmg
culosis,
was
long spine
poliomyelitis,
subjecting
effects
of
Such
child
effects
is essential
the
of fusion.
Although
be
the
that
seensed
Therefore,
to
were
the
were
solidity
of a fusiomm
rotationt
the
area
is extremely
Hibbs
years
anmd
of
with
age
In
especially
plate
could
almost
fusioms
ansd
These
defects
culosis,
follow-up
such
This
“.
Could
to
produce
growth,
resorption
graft
in one area?
it what
you will
problem
of
as idiopathic
is certainly
know
possible
the
young
long-terns,
amid,
itt
a slower
but
spine
Childremm,
of clinical
with
accurate
as well
effects.
perhaps,
the
as
of bone
growth
the desirable
the
type
literature,
seetsss
a substamstial
to the basic
laws
the clitsical
material
Crippled
A wealth
tuberbefore
umsdesirable
extemit
as expressed
at
children
scoliosis,
importatst,
long-terns
the
fusiotm,
is contrary
evaluate
significant,
rate,
it
of bomse physiology.
at the
Childremi’s
both
its Baltitssore,
Immaterial was available
to
imsass after
spinme fusioti
for
to judge
by roemst.gemiogram
scohiosis.
Furthernmore,
nmeasuremssent
of
if the
the
lemmgth
of
difficult.
fusions
for
tsext
studied.
of the
spine
but
be
clearly
75
per
they
seen,
cent.
tuberculosis
of
the
Roentgenograms
were
often
did
different
the
spine
ins childrenm
of the
available
healed
not
incidence
Often,
seem
they did interfere
roentgenograms
genograms-twenty
of
its
in
the
spines
two
ummder
of 400
hospitals,
tent
childrems
yet
it
was
how few could
be properly
evaluated
with
respect
to bomme growth
after
mammy cases,
it was extremely
difficult
to judge
the solidity
of the fusiots,
the Hibbs
fusion
in the thoracic
region.
In spinmes its which
the fusion
amazing
was
botie
or t.ensiont
due
accurate
knowledge
its a givemi situatiotm,
opinion,
after
are
Albee
were
tuberculosis
fusions.
to
any
mm a t.horacic
ansd
may
clinical
determinimmg
Icermman Hospital
for
in actual
situatiomis.
curvature
fusiomi
the
many
lotsg-term
follow-ups.
to determimie
the growth
of the fusion
unn’esvardiiig.
It is almost
impossible
Attemmmpts
s(’OhiOSiS
persists
the
is, however,
anseurysnss.
tetisiomm,
a
graft.
operation,
majority
this concept
decided
to
amid the
there
recent
and
excessive
diverse
reasotss
anomalies.
It
an
in
still
happemied
of
outweigh
vital
growth
hospital
amid
will
us that
it was
see
what
to such
is also
of
resorption
of continuity
of the
or stress
fracture-call
of the procedure.
An
to evaluate
whether,
operation
knowledge
by
or
INVESTIGATION
because
fusions
for such
atmd congenital
a small
the short-term
after
fusions
to
initiated
borne
of pressure
tumors
and
pressure
There
of boise
of the
a lomig
increased
occur.
of scoliosis,
loss
of
stretmgth
not
certain
pressure
Hueter-Volkmann
that
“Increase
its which
an actual
pseudarthrosis,
shaft
greater
does
that:
by
fusions,
stretching
the
states
to destruction
caused
to
of increased
to the
which
that
leads
in spine
area
But
law,
and
Sicher
pressure
of bone
-may
result
and
SOUTHWICK
in an
growth.
Wolff’s
of tolerance
occurs
this
the
0.
pressure-according
through
to
W.
suppressed
formation
with
limits
ol)viously
be
AND
of decreased
responds
of stress,
another
JOHNSON
bending
plate
inicreased
the
H.
will
in an area
law-thus
T.
years
technique
of pseudart.hrosis
these
pseudarthroses
spontaneously,
to
as
interfere
showis
by
with
the
greatly
with growth
and records.
evaluation.
Finally,
the
or more
fusion-seemed
that
after
it
was
its otse
were
extremely
near
or nsore
the
later
ends
areas
of
the
roetstgenogrammss.
healing
of the
tuber-
Many
cases had incomplete
long-term
follow-up
roemstso grossly
difficult
to
magnified
make
and
accurate
comparisons.
TEE
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JOURNAL
OF DONE
AND
JOINT
SURGERY
BONE
these
problems
amid Jommes more
With
F’ramicis,
criteria
and
additiotsal
rate
bUt
were
bone
grafts
or if the
metits
tiisse
made
after
Their
of the
above
l)ody
and
the
cud
1, 1)
normal
diseased
of the
omme of the
other
etsd
grams
of
of the
four
area,
bottom
fusiomi.
fusions
lumbar
patients,
areas.
thus
was
criteria
by
surgical
exploration.
but
vertebrae
area.
The
included
normal
plates
by the
beiisg
inscluded
within
of the
exact
top
of the top
1 to 4 in Fig.
in the
region
(Fig.
1,
narrowed,
occurs
4)
,
the
disc
of the
disc
immdividual
ammd does
not
extetit
two
vertebral
1). Thus,
measured
fusion,
and hence
at least
nseasured
could
be expected
segments
the
usually
(Fig.
25 per cent
to occur.
space
in the
of the
At the
roentgeno-
as noted
by Hallock,
Francis,
because
of bone
replacement
vertebral
growth
the
was
accu-
the
vertebrae,
would
Sl5OW
of
in
Measure-
roentgenograms,
space
is largely
replaced
by
using
the vertebral
end-plate
expemise
nmade
Kyphosis
making
disc nsat.erial.
At any
rate,
the disc
vertebral
bodies
and any measurement
the
is
were
successful
in all patients
were used to determine
were measured
from the
vertebral
body
(as from
epiphyseal
measured
normal
fusion
older
patients
is markedly
amid this narrowing
probably
Jones,
spine
Seven
fusion
“
by Hahlock,
in detail
the
mso mentiotm
areas.
verified
of the
whole
completely
unaffected
growth
of the segments
is
other
postoperative
were
of the
or below
the
to the bottom
after
paper
gives
mmot stated.
tsieasuremetsts
fusions
was
the
that
fusion;
in thoracolumbar
or
in thirteen
of fifteen
“early
was
to review
only one
Hibbs
from
of fusion
1407
FUSiON
measurements
They
stated
that
what
roentgenographic
from
operation
SPINE
by
taken
were
severe
presence
were
growth
treated
being
difficult.
mention
AVFER
it was decided
since
this is the
for
all
area,
and eight
to moderately
measurensent
they
did iiot
this,
used
patients
thoracic
nioderate
in mind,
closely,
techniques
Their
GROWTH
body,
imidicate
but
growth
this
of the
the adjacemmt
its this way
growth
fused
amid
of the
may
be
segmetmt
at.
as
a
ss’hole.
Measurement
the
of
whole
fused
area
dependitig
oms the length
of fusion)
tets or twelve)
that
are not restricted
the mmormal growth
of these
msot its the least
itsfluemmced
time pedicles
uppermost
adjacent
area
rrh
presetmce
Fratscis,
found
bone
six or seven
by the fusion.
of the
on
of
pedicle
fused
vertebrae
Measurement
may
subsequenst.
pseudarthrosis
amid Jones.
In
close examinatiomm.
especially
genograns,
the
roenstgenogranss.
roemitgeisogranss,
t511ti5(’t’OUS
sary
the
to 10 or from
1
expand
1 to
12,
out
cent
of
of
plates
(two
15 to 20 per
will take
place
of the distammce
atsyway,
between
to a lesser
degree.
rfhie
width,
especially
if the
of the pedicles
with
it.
somewhat
at
the
expense
of
ligaments.
Ilallock,
were
1, from
is subject
to the same
consideration,
although
or lowermost
pedicles
are free to grow
in
vertebral
body
grows
and pulls
the periosteum
Ins a fused
aolj aceist
(Fig.
will immclude two growth
by the fusion.
Hetsce,
to rule
omme made
Ins
but
subsequeistly
roemstgenogranms
of the
out
adequately
was
either
never
our series,
Sometimes,
early
other
the
after
immstatices
same
memstioised
numerous
these
operation,
they
a
(Fig.
period
founmd
itm the
2). A
of time
of defects
bY
fusion
plates
iii omse roemmt-
were
presemst
or the absensce
possibility
its the
visible
l)ut
were
healed
spotst.ammeously
fusiotm over a long
presetice
as
defects
were tsot
on
early
study
of
is neces-
its the fusioms.
Fimsally,
the ages of the childrets
in the early
postoperative
roetstgenograms
are not given
by Hallock,
Francis,
and Jones.
Presumably,
these
children
were
frons four to six years
old ansd probably
weighed
about
fifty pounds.
The average
follow-up
was
comparisoms
magnification
were
VOL.
the
42-A,
twenty-onme
were
of
factor
same
NO.
8,
years;
adults
to be
(thirty-six
DECEMBER
hensce,
the
who
presunmably
expected
from
inches),
would
be
follow-up
roent.genograms
used
weighed
these,
if the
about
150
tube-to-target
pounds.
The
distatsces
17 per
1900
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cent
(Fig.
3).
for
1408
J.
To
2.8
illustrate,
to 3.4
let
and
are
JOHNSON
an
enlarged
AND
that
W.
area
whets the
correction
1 1 per
0.
a fused
unfused
made
first
uSinsg the
By
measurements
H.
us suppose
centimeters
by roentgetmograms
he was an adult.
T.
SOUTHWICK
area
from
patient
factors
cetst
growth
to 4.1
iticreases
centimeters,
frons
as showti
was a small
child
atmd later
whets
shown
its Figure
3, the childisood
Whets
.
during
2.4
corrected,
these
will
be
chaniged
from 2.8 to 2.52 centimeters
and from 2.4 to 2.16 centimeters.
Th
adult
measurememits
are emmiarged
28 per ceist and hensce,
whets
corrected,
will be chamsged
from
3.4
to 2.65 ceimtimet.ers
and from 4.1 to 3.2 cemitinseters.
Thus,
after
corre(’tiomm
for
tmsagisification,
we find that
nseters,
or 4 per cemst growth,
or 45 per cemit growth.
inssignmificant
atsd well
purposes
no sigmsificant
per
cent
growth
Using
fusion
area
grew
170
calculated
50 per
has
the fused
amid the
Now,
0.13 centimeter,
or 4 per cemst growth,
is statistically
within
the limits
of error
in measurememmt,
so for practical
growth
has taken
place
iii the
fused
area,
amid about
45
taken
these
same
grew
120
place
in the
figures
Hallock,
cent,
a change
per
per cent,
a change
of 70
the growth
by subtracting
cent.
real
these
evidence
figures
fused
area.
less
area
has growns
frotms 2.52
to 2.65
cetstiunifused
area from
2. 16 to 3.2 cemmtitmseters,
growth
in the
unfused
area.
Framscis,
of 20
per
one
fusion
Jotses
estinmated
cemmt., amid
that.
cent..
Using
these
value
from
the
area;
that
the fusion
area
grew
is that
the unfused
portion
aisd
per
whereas,
values,
other.
imm point
that
the
the
mmornmal
these
The
area
authors
result.
of fact,
was
there
is iso
at all. The only
evidence
provided
grew somewhat
its comparisotm
with
by
the
METHOD
1mm our
tioned
fusion
Hibbs
series
lumbar
and
pseudarthroses
sidered
thoracolumbar
in the
unless
until
the
fusion
itscorporated;
particular,
may
Spine
measured
on
both
the
interval.
The
third
sets
getiograms,
that
tut.ed
plate
made
criterion
before
at least
and
these
all
port.n)lt
beimsg
of
tine
mmseasure(1
urememst
would
itselude
the
Furthermore,
iso measurements
this
surgery
again
yet
have
patients
the
entire
found
spontaneously
showed
no
had
the
5J)1h1(
variable
factors
just
mmsets-
cases
were
with
comm-
nseasured
immterval.
may
years
area.
Aim Albee
break
later
numerous
should
have
period
of measurensemst
its
pseudart.hroses
had
its
numerous
also because
whereas
other
roentto he sinre
requirememmt
pseudarthroses
was insstihad
ole-
sonme roemstgemmoroetstgemsograimms
defects.
area to he measured
should
plates,
all well vithims
the
fused
area
he eotsspat’(’(l
atm equal
isutisbet
no)t. comstaims an emsd vertel)ra
of
with
gnosvtls
THE
JOURNAL
OF
BONE
ANt)
itmelude
hinsits
of
that
of ams
1)Iat(’s. ‘Elms’
sitsee
growth
of an end-plate
ummrestraimmed
should
be made
from
the end-plates
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graft,
dow’ts later.
A
may
look solid
had
and
defects,
the fusion
epiphyseal
of this
but
many
coistaimsitig
should
All
cases
the
time.
This
in which
demonstrated
letsgt.h
evaluated.
aisd no
throughout
during
during
was that
vertebral
fusiomm msmass, amid that
area
that
a year,
healed
reasons
Visible
after
and
and
was
after
the
first
measurement
should
imot. be made
A graft
takes
several
motmths
to heconse
occur
had remained
solid
the
a number
of cases
were
had
avoid
the most.
easily
were
discarded,
clearly
may
once
fourth
criterion
four umidamaged
snufused
to
that
the
surgery.
solid
shortly
after
surgery
preferably
and
then
for techtiical
The
were
area
was
was
after
growth
look
shortly
made
of roentgenograms
the fusion
because
‘e1oped
grams
fused
was
set of criteria.
First
to be itmcluded
was
that
a solid
visible
on the roentgenograms.
This ruled
out. immost
new bone had beets added.
Albee
operatiomss
its the
area
measured
The
second
criterion
at least
four months
solidly
the
atm attempt
by setting
up a rigid
plate
had to be clearly
fusions,
unless
extensive
smelt
by
a
incus-
time fusiomm.
since
mmseas-
JoINT
5URGERY
BONE
tti’(’nii(’tsts
5 )f
hi(’ t 5 #{176}l
:1.i I S 1 1s
I
ulj
t liese
frons
I
asi’n
tmsi(l-l)(
s )l
‘ I nI 5
(‘xl)(’(’t (‘(I t 0
discs
I
relat
amid
((.)iIst
eemstral
the
spamsmied
of the
of
pedicles,
as
the
unrestraitseol
I)Iit(’(’
at.
I h(’
t 5 sh(BiI(l
bo(lies
ii boise
si
t’el)laeetiietst
i)eing
about
area,
but
area,
rather
I
equal
the
t ls(’
of
frotis
I ISP
1s \‘oul(1
1)(‘
he irit (‘rv(’rteb)ral
(Fig.
1). These
disease
than
I5(’
tItit(IP
1)011)
of
disease
grow’th
(‘xp(’i
he
I h(’s(’
ttd(’
poitnts
iimvolved
posterior
visualized
amid losver
were
elensemmts
its the
borders
imseasurensmemsts
of the
grossly
lateral
‘as
quiescemit
destructiomi,
further
shosv
the
significant
growth
of t he
physique
tmiagmiificationt
may
the
1940)
(sitmce
in
ehild
of
Its the
atsd
as those
that
the
used
mid-points
than
from
the
rather
of markers
these
other
measurements
of
the
posterior
between
the
the cenmters of the vertebral
bodies.
period
should
be lommg enmough
to
areas,
but
tiot
too long,
because
the
radically
and
Only
to
frons
betweems
follow-up
roetstgenograms.
w’ere
nsade
absetmce
even
uimfused
change
were
roentgenogram
pedicles.
itiaccurate,
pe(1i(’Ies
s’ere isot so accurate
‘l’he fifth
criterion
was
era
s’it
the
I a kes
(}5
(‘brat
rust
include
ti5(’ItSltt(’t5i(’i)
‘ert
I ( )tti
tlieso’
restitutiomi
M(’asurelssemsts
ttpper
ively
ivlsi
,
1409
FUSION
rule.
time
the
I iist (‘IRI
I )( )t
I #{176}P1115(1
SPINE
nsight.
(‘I m’al I)111t (5
(lisds.
sometinses
cases
s’as
us’
AFTER
referemsce
of
\‘(‘l’t
1115(1 i)eloW’
al)ove
all
01,55
ei)ral
i’(’tiittiti
msseasurememits
its
points
)t t
i is t (‘i’\’(’it
GROWTH
make
cause
gross
differences
roetmtgenograms
sure
that
the
made
in
its the
the
roentgenographic
modern
techniques
Were fairly
well stammdardized.
Spimses
with
excessive
kyphoses
or scolioses
were
avoided,
sinmee these
deformities
make
measurement
difficult.;
omsly omie of the
cases
finally
ac(’epted
for study
had
more
than
a mild
kyphosis.
A range
of
of frons
four
nsade
duritsg
follow-up
genograrns
of the
spimme amid thus
miificatiots
occurred
patiemmt
s’ere
comparal)le
cenmtinmseter
ss’ill
be
with
reasomm
or
COlle(’t.
otsly
for
These
such
the
(‘ases
cases
associates.
the
standardized,
obtainmed
embedded
hut
from
system
svere
The
results
reprodinctioms
majority
the
the
roetmt.growth
some
degree
posit.iomiitsg
of magof the
roetstgenogranss
to
it
were
reviewed.
hospitals
which
roentgenograms
the
variable
necessary
was
of cases
two
avoid
to
It was
fulfilled
measured
by our owms system
of these
measurements
of the
and
with
yearly
the gradual
as
nearly
without.
some
commstant
factor,
such
as
its the graft..
It is hoped
that.
future
a marker
great
sitmce,
to follow
Undoubtedly,
techniques
so difficult
at presetit.
were
so exactimig
that
another,
six
approved
possible
unmdue distortiotm.
roemmtgetmographic
msot (‘otsspletely
dOtidll(ted
tiotied.
avoid
amid the
as could
be
issetal
marker
remmoi(’r imsterpretatiomi
These
criteria
amid
to eight
years
was
this interval,
it was
used
all
factors
discard,
the
its this
study.
that
for
possible
ansd also by
are recorded
of the roemstgemmograimss
were
made
at. the same
dist.ammce
each
pair
so that
measurensenmts
of these
photographs
percemstage
d ifferems (Cs as t he original
roentgen
ograms.
a omseseries
one
finally
to
criteria
that
iii
men-
of Hallock
the legemmds
photographs
rfhe
and
magnification
should
give
the
for
same
RESULTS
Time
percentages
average
time six cases
studied
1. Our
criteria:
issid-body
measurements
nsent.s
area,
of the
30
fusion
per
time top
bottom
V5)L.
42-A,
area,
amid
top
ummfttsed
of the
NO.
7 per
Francis,
of the
(‘enmt. ; imorimsal
time
of
the
fused
amid
umsfused
vertebrae
in
methods.
of
32
the
fusiomm area,
per (‘emit ; mid-pedicle
cemmt ; ansd niid-pedicle
nieasurememits
8 per cetmt;
measureof the
normal
ceimt.
2. Hallock,
from
of growth
were det.ermimied
by two
mid-body
measuremetmts
of the isormal
area,
S.
DECEMBER
Jomses’
vertebra
vertebrae,
bottom
vertebra,
to
criteria:
the
nseasitred
:34 per
msornsal
bottommm
frons
cent
1900
Downloaded From: http://jbjs.org/ by a SERIALS/BIOMED LIB 0699 User on 05/15/2014
fused
vertebrae,
of time bottom
the
; total
top
fusioti
of
nseasured
vertebra,
the
area,
top
21
per
vertel)ra
nmseasured
to
frons
1410
J.
T.
H.
JOHNSON
the
atsd
top of the top vertebra
to
total
fusions
area
measured
top
vertei)flt
to t lie inferior
AND
W.
the bottom
from
the
tisargims
0.
SOUTHWICK
of the
superior
of the
bottom
margins
pedicle
vertebra,
of the
of I he
loot I out
14 per cent;
pediele
of the
1 2 i)em
vertebra.
(‘emst.
it. is apparemit
tort.ionm,
the
by
mid-body
the
that
growth,
measurements
and
vertebrae
outside
the
without
the
included
fusions.
areas
used
for
the
in the fusion
The whole
the
area
fused
the vertebral
vertebral
grew
tsormal.
be made
direct
We believe
to reduce
by
Hahlock
shorter
(for
reasons
should
When
growth
the
and
cent
as much
much
inference,
63 per
vertebral
bodies
and 77 per cent
as the
and
Jones.
ss’as
definitely
these
smaller
Although
tiomm for
excluded
cent
in
of normal.
that
this
difference
in our cases.
criteria
the
of
miormal
imormal
vertebrae
grew
-11 per cemit
normal
vertebral
the
follow-up
However,
37 per cent less
bodies
within
bodies.
Similarly,
23 per cent
less thamm
was 77 per cent of the
every
and
should
make
a
still persists.
those
its the series
period
the
effort
then
in
our
percetstage
series
Similarly,
the
is five or fifteems years.
measuremetst
of vertebral
of the vertebral
bodies
in
amount
of growth
area was 62 per cent
in the series
studied
are not too
that
in the
cases
Hallock
was, by
of the
mmormal
of normal
in our series
by Hallock,
Francis,
far apart,
the rate of growth
other
series.
We believe
that
is that
intercurrent
Among
the fifteen
is
of growth
of normal.
In the series
reported
by
in the fused
area of their
patients
in the fusion
by inference,
results
than
as much
mid-pedicle
the
spines,
degree
of inaccuracy
comparable
with
previously).
41 per cent
of growth
included
of normal,
the
fusion
area grew
that
the vertebral
studies
of vertebral
growth
magnification
to a minimum
associates
area was
the amount
same
(Its-
or
censt
With
as much
as the
top to bottom
be relatively
comparable,
whether
the follow-up
Hallock,
Francis,
and Jones’
technique
for the
was used
in this series,
the amount
of growth
whole
fusion
associates,
per
by
areas.
the fusion
area
grow
is that
their
growth
that
a certain
are not directly
mentioned
25
bodies
and 35 per cent
as much
its the regiotm
unfused
areas.
did not specifically
state
that
the rate of growth
percentage
of the normal
rate.
However,
their
that
in future
distortion
and
and
as
of these
62 per cent
area
from
bodies
within
the inference
comparisoms,
admitting
The cases
its this series
studied
cent
nnagmiificatioii
only
unfused
bodies
of the entire
bodies
seems
to imply
63 per
if the normal
vertebral
imormal
vertebral
bodies,
per
the
for
was
measurement
grew
fusion
much
anteriorly
in the vertebral
of the pedicles
as did the adjacent
Hallock,
Francis,
and Jones
in the fused
area
was a certain
that
normal
in
correction
criteria,
23
as
as
statement
than
the
our
and
fused
associates
atsy
by
measurements
in
Hallock
even
as measured
pseudart.hroses
studied
by
have
Hallock
its our series
the explansabeen
carefully
and associates,
the amount
of growth
of the fused
normal
vertebrae
was 100 per cent
of normal
its two,
less than
50 per cent
in three,
and between
50 and
100 per cent
in the
remaining
cases.
This rather
wide variation
in the amount
of growth
in otse series
suggests
some
difference
that.
difference
could
in
well
the
restraining
be explained
SUMMARY
exerted
AND
magnification
small
suggests
amount
some
and
of
growth.
bending
other
technical
The
of the
the
fusion
plate-a
pseudarthroses.
CONCLUSIONS
factors,
slight
decrease
fusion
mass.
Downloaded From: http://jbjs.org/ by a SERIALS/BIOMED LIB 0699 User on 05/15/2014
by
transitory
It was concluded
from these
cases that
when
a spine
and fairly
massive,
there
is little
increase
in length
increase
that
most
of the cases
we studied
showed
solid
sniall
by
force
by unrecognized
but
in
fusion
is unquestionably
of the fused
area.
could
be accounted
it. is impossible
the
No
definite
THE
JOURNAL
kyphos
in
to
two
rule
of
pseudarthroses
OF
BONE
AND
The
for
out
our
could
JOINT
a
cases
SURGERY
be
BONE
SPCI5
the
0mm
imot. be
roemstgenograms
ruled
out..
AF1ER
the
nsechatsismss
occurs.
Iii
that
from
bonie
defects
and
perhaps
grafts
were
childhood
the ends of the segment
plate.
Pseudarthroses
opinion,
growing
immipression
spitse growth
of a fused
or at the site
in spitme fusions
than
is generally
suspected
epiphyseal
cartilages,
as
pseudarthroses
rfhe
or stress
under
the
stress
govern
bone
opinion
no
of growth
growth
such
thing
as
feniora
that
of
they
methods.
associates
amid
of
younmg
could
is valuable
what
will
that
coissiderable
happems
may
degree.
spine
can
occur
rnotiotm.
apply
interstitial
the
growth
of spume
by the
motion.
or grossly
believe
we
bone
that
visible;
The
break
the
fusions.
at
fusioms
in our
forces
exerted
caused
by
microscopic
Fimsally,
to
only
defects
in the
more
frequent,
tension
stresses
be
occurs
etscouraged
on the basis
spine
fusiomms its yoummg
completely
solid fusion
its
of gross or microscopic
its children
are much
because
of the
well as theusual
growth
we believe,
to allow
all that
is kmsowmm about
at any time
and heal
spotmtatseously.
less chance
there
will be that
it will
in general
us
t rite
losses
nsiCroscopic
,
l)e umifortunate,
familiar
with
to a significant
segmetmt
of the
fractures
they
may
occur
spotmtatseously
tmsassive
the fusiots
plate,
the
or any
fusioms its early
childhood.
However,
their
data
authors
previously
meistioned
commvey an its-
segmetst.
It would
since surgeotss
not
will impair
that
growth
We believe
by
comssidered
poimmt of view,
growth
of the spitse
after
spine
fusion
might
be falsely
of published
data
to perform
longer
and
more
massive
children.
Our study
suggests
that
a long,
massive,
and
early
could
are
its the distal
of such
a nature
clitsical
uimintemstiommal
a solidly
fused
spine
this impressioms
to persist
lIt
pseudarthroses
in lengths
or roentgenographic
of Hallock
and his
practical,
to the average
pat.iemmt after
spitme
anmd the observations
of the other
accurate
or more
pseudarthroses
by which
amiy real itserease
our experimetmt.aI
studies
clinical
study
the
1411
FUSION
of one
tratnsiemit
by standard
the end-result
it indicates,
SPINE
presence
atsd
comstitmuity
its trammsepiphyseal
were detnonstrated.
These
msot be demonstrated
Ins our opinion,
itt
but
Microscopic
I 5) be time nsost likely
(‘isamige
its atsgulatiomm
I)Otie
rabbits
GROWTH
nsore
dowms
laws
There
that
is in
our
of bomme.
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the
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05551155’.
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l’r(’sS(’
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.Fhe
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