NECROSIS OF THE FEMUR, 
WITH IMPLANTATION OF DECALCIFIED BONE CHIPS. 
UY WILLIAM 15. VAN LENNEP, A.M., M.D., PHILADELPHIA 
In the September number of the American Journal of the Medical 
Sciences there appeared an article by Dr. Nicholas Senn “on the* 
healing of bone cavities by implantation of antiseptic decalcified 
bone.” While reading this paper I saw a case I had operated on over 
two years ago, where a large cavity in the tibia had taken nearly 
eight months to heal by the slow process of granulation. The result 
is a deep depression and a weak cicatrix, which breaks down and 
ulcerates after every bruise. The attempt had been made to fill the 
cavity with a blood clot, as had been suggested by Schede a short 
time before, but this failed. Senn says that the blood clot is too 
good a culture soil for germs; that the loss of blood, if a large clot 
is required, may be dangerous; that it may be insufficient, on the 
other hand, to fill the cavity. He also very justly criticizes the 
proposition of Neuber to turn down and tack flaps of the soft parts 
into bone cavities, because the flaps are apt to slough, and in certain 
cases much healthy bone has to be removed to allow of their being 
turned in. He proposes to fill the cavity, in place of the clot or the 
sponge, with chips of decalcified bone. These he prepares as fol- 
lows : The fresh tibia of an ox is taken and cut across into sections 
about two inches thick. The medulla is cleaned out and the bone 
decalcified in dilute muriatic acid, which is frequently changed. 
The acid is then washed out and neutralized by a weak solution of 
caustic potash. Thin sections are made in the long axis of the bone, 
which are kept in sublimated alcohol, 1 to 500. 
I immediately prepared a tibia in this manner, and Gemrig & Co. 
have since obtained for me some specimens like those used in Senn’s 
experiments. They are not quite as completely decalcified as those 
I prepared and used. 2 
I was about to operate on a young man for extensive necrosis of 
the femur, and, with his consent, determined to give this method a 
trial. There were two sinuses just above the knee, a large one on 
the inside and a small one on the outside, through both of which 
rough bone could be readily felt. A number of bits had been dis- 
charged, and one large sequestrum seemed loose. Higher up, on the 
outer side of the thigh, was a deeply depressed, long, adherent cica- 
trix, resulting from a former similar trouble of several years’ dura- 
tion. The abscess had been incised, and nature allowed to complete 
the cure. The scar is weak and tender. 
Operation, September 23, 1889, at the Camden Homoeopathic 
Hospital. After the usual antiseptic precautions, the limb having been 
rendered bloodless by the Esmarch bandage, an incision was made up 
and down from the internal sinus, freely exposing the bone. Two 
‘large sequestra and a number of small pieces were removed, leaving a 
deep groove running from the internal condyle upward for about six 
inches, and ending in a pocket. Just below the latter was an open- 
ing through the bone to the sinus on the outer side. The rough 
places were rendered smooth with gouge and chisel, the whole sup- 
purating area carefully and thoroughly scraped, and the inflamed 
soft parts freely excised with curved scissors. After washing out 
with hot water, strongly sublimated, twelve per cent, solution of 
chloride of zinc was applied with a brush ; the irrigation was re- 
peated, and iodoform blown in. The chips, previously soaked in 
weak sublimate and dusted with iodoform, were taken from a disin- 
fected towel and tightly packed into the whole cavity. There 
being no periosteum available with which to cover the chips, the soft 
parts over both openings were drawn together by buried catgut and 
superficial silk sutures. This was accomplished with difficulty, pro- 
ducing considerable tension, and a small aperture was therefore left 
on the inner side of the thigh for drainage. lodoform dressings 
were applied, and the limb done up on a posterior metal splint. 
The Esmarch tubing was then removed. 
There was a smart fever the next day (103°) and good deal of 
oozing, the dressings becoming saturated with blood. They were 
changed, and the drainage opening slightly enlarged to relieve ten- 
sion. The bone chips could be seen entangled in a dark clot. The 
wounds closed per primarn, except at this point, which suppurated 
subsequently. He went to his home in the country on the twelfth 
day, returning to have the opening washed and dressed from time to 
time. 3 
The bone chips have evidently done their work, as the contour of 
the limb is well preserved and the cicatrix only depressed at the point 
mentioned. There must have been a new formation of bone, for a 
hard elevated lump can be felt instead of the deep groove. In its 
centre is a crater-like depression where the wound suppurated. Only 
a couple of chips were discharged and found in the dressings. 
The case was anything but favorable for implantation, and re- 
quired most scrupulous scraping and disinfection, especially in the 
pocket at the upper end and the opening through the bone. There 
was no periosteum with which to cover the chips, and the soft parts 
were drawn together with great difficulty. The tension and the sep- 
tic cavity caused me considerable anxiety, and when the temperature 
shot up, I feared that I would have to open the wound and allow 
healing to take place by the slow and deforming process of granula- 
tion. While the blood clot is used in the interstices between the 
chips, it is supported by them, aud breaking down is further prevented 
by their being not only aseptic but antiseptic. For this reason they 
also tend to counteract the effects of any shortcomings in disinfection. 
The result is certainly very satisfactory, healing being rapid 
and without deformity or tender scar. I feel that the case should 
be reported as one of the first since Senn’s publication. Besides, 
it is our duty to put on record successes and failures with any 
new method in order to help define its value.