BONE REGENERATION

Ax EXPERIMENTAL STUDY OF BONE-GRAFTING MATERIALS

BY ROBERT D. RAY, M.D., PH.D., JAMES DEGGE, M.D., PARK GLOYD, M.D.,
AND GARTH MOONEY, M.D., SEATTLE, WASHINGTON

From tile Division of ()rihopaedic Surgery, University of 1I’ashington School of Medicine, Seattle

INTRODUCTION

There are tis’o schools of thought today regarding bone regeneration. Proponents of
the first theory hold that bone formation is governed by local humoral changes, including
changes in circulation, hydrogen-ion concentration, and possibly the presence of a specific
osteogenctic substance 27.17,18,19,27#{149} Claims for isolation of the latter have been made20,
and it has been named “ osteogenin “. However, others have not been able to confirm the
presence of such a substance 13.23 Supporters of the second theory believe that the os-
teoblast-s d!erivcd from the primitive connective tissue, the cnd!ostcum, the periosteum, or
the Havcrsian canals may survive transplantation and are capable of reproducing 8,I221

During 1948 a ness’ substance is-as called to the attention of the author by Dr. Arthur
Ward. The substance, a synthetic hydroxyapatite, was developed during the War by
Elliott Barrett of the Mellon Institute, Pittsburgh, Pennsylsania, as a component of a
granular adlsOrl)cnt to replace bone chat- in sugar-refining. These basic calcium phosphat-c
crystals behave physically and chemically like bone. They has-c the same x-ray diffraction
pattern and almost the same chemical composition as natural bone .

An attempt is-as made to study the physiological properties of the compound and to
compare it w’ith fresh autogenous and frozen bone in filling skeletal defects created sur-
gically in the long bones and iliac is-ings of dogs and burr holes in the crania of cats and
monkeys. It is-as concluded from these experiments that the synthetic hydroxyapatite
crystals could be replaced by neiv bone, but the crystals is-crc not so effective as autogcnous
bone grafts in repairing the defects25. The problem as to w’hether their presence stimulated
or induced neis’-bone formation remained unsolved.
In order to approach this problem, a second series of experiments ivas undertaken to
determine suitable sites for studlying ectopic bone formation. The results of these expcri-
ments confirmed! the fact that autogenous grafts of canccllous bone can survive and grosv
is-hen transplanted to skeletal musculature, to the ventricle of the brain, and to the an-
tenor chamber of the eye in rats, guinea pigs, and! rabbits.** The anterior chamber of the
eye selected
is’as for subsequent studies, since the fate of the grafts COuld! he followedi is-ith
a slit lamp and since the incidence of spontaneous new-bone formation resulting from
trauma alone ivould! be loss’.
The purpose of the present experiment is-as to determine: (1) si-hat isoiild be the
response of the anterior chamber of the eye to injections of basic calcium phosphate
apat-ite crystals; (2) whet-her or not bone graft-s would sursive fi-cezing or lyophilizing and!
subsequently gross’ is’hcn implanted in the eye; and (3) if they did not sursisc, ishcther
the dead! transplants isould “induce” bone formation in the recipient tissues.

METHOD

Transplant-s to the eye has-c been carried out in t-hirty-fis’e guinea pigs and eighteen
rats, as summarizedi in Table I.
* Read at the Annual Meeting of The American Orthopaedic Association, White Sulphur Springs,
\\rest Virginia, June 20, 1951.
t This project is’as supported in part b)- Initiative 171 Funids froln the State of Washington.
4* These experiment-s ivere (!escril)ed in a paper read at the meeting of the Western Orthopedic Associa-
tion, Portlandi, ()regon, October 4, 1930.

638 rHE JOURNAL OF HONE AND JOINT SURGERY

 BONE REGENERATION 639

TABLE I
S1-MMARY OF ANIMAL GROUPS

Type of Graft Treatment before Implantation Number of Animals

Basic Calcium Phosphate None 6

Emhronic Femur Frozen 24 hours 7
Lyophilized 24 hours 6
None 3

lracture Callus Frozen 24 hours 5

Lvophilized 24 bout-s 6
None 4

A(lult Cortical amid! Cancellous Bone Frozen 24 hours 3

L)ophilized 24 hours 6
None 3

The aninals is-cie (!isi(!e(! intd) four groups : six guinea pigs in is’hich basic calcium
phosphate Crystals \5’CFC inje(tcdl intd) the anterior chamber of the eye; eighteen adult rats
ili ii’liid’h the femora froni eighteen-dirty tat embryos ivere implanted! into the anterior
chamber; fifteen guinea pigs in ivhicli ivere implanted fragments from the callus deposited
atotind fiaet-tii-es of the tibia OI1C si’eck after fracture ; and! fourteen guinea pigs in ishich
is’cre implanted fragments of cortical and! cancellous bone from the iliac crest. All groups
except the first ivcrc further subdivided! in the follois’ing fashion : In one group the grafts
ivere frozeti at -18 degrees centigrade for tis’cnty-four hours prior to implantation; in the
second! the graft-s iicre frozen in liquid! carbon dioxide at - 73 degrees centigrade an(! w’hilc
frozen is’ere (lesiccat-cdi under a s-acuum of 0. 1 millimeter of mercury for tsvcnty-four hours
before implantation ; and in the last the graft-s is-crc implant-ed directly. Except for the

Fn. 1
Photomnicrograph (X 95) of the 5)rithetiC hydroxvapatite six sseeks after implantation in the anterior
chamber of the eye of a guinea pig, showing the nature of the r(’action of the recipient site.

VOL. 34-A, NO. 3. JULY 1952

640 R. D. RAY, JAMES DEGGE, PARK GLOYD, AND GARTH MOONEY

basic calcium phosphate and the embryonic implants, all grafts w’ere aut-ogdnous. The
grafts is-crc implanted by making a small nick in the sclerocorncal juncture and the bone
( or callus) is-as inserted is-it-h a fine sterile is-ire as gently as possible. The basic calcium

phosphate crystals is-crc suspended in isotonic saline solution arid injected! ivith a fine
hypodlermic needle. To control the technique, a similar prOcc(hlrc ivas carried! out- on the
opposite eye, except that- no graft is-as implant-cd!. In none of the controls in this series is’as
spontaneous bone formation obscrscd. Tiso of the eyes in which grafts ivere implanted
became infected!. In these no evidence of the graft-s could be foulid! at. autopsy. A post opera-
t-is’c period of six weeks is-as select-ed for dletcrmining the results since, according td)

Wickstrom and Mosiman’s experiments, six is’ccks after grafting appears to I)c the critical
time for determining the viability of the graft.

RESU LTS

Basic C’a-lciu m Phosp/i a Ic

Of the six guinea pigs in which the basic calcium phosphate ivas injected into the
anterior chamber, tii’o shoiicdl, at the end of six weeks, no evidence of the crystals or
cellular reaction histologically; two revealed a mod!crate cellular reaction but no crystals;
and in tis-o scattered! crystals remained. The cellular react-ion consisted! predominantly of
fibroblastic proliferation, small round-cell (plasma cell) infiltration, and! the appearance of
multinucleated giant cells (Fig. 1). In no instance was bone formation obscrs’ed. In many
respects the histological picture was similar to that seen around! fragments of bone tinder-
going aseptic necrosis.

Embryo iiic Transplants

All of the embryonic femora subjected to freezing and all of those subjected! to lyo-
philizing surs’is’cd is-hen transplanted to the anterior chamber. With re-establishment of

FIG. 2
Photomicrographi ( X 28), six iveeks after implantation, of the femur of an eighiteemi-day rat embr)-o
subjected to freezing at - 18 (1(’greer) centigrade for twemity-four hours and themi imnplamited in thle au-
tenor chamber d)f the eve of ami ad!ult rat, shoss’ing survival of the graft amid re-estal)lishmnemit of endlodhioli-
dral ossification.
THE JOURNAL OF BONE AND JOINT SURGERY
 BONE REGENERATION 641

1i

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Phiotomicrograph ( X 2), six ss-eeks after operation, of the femur of an eighteen-day rat emhr)-o sub-
je(’ted to lvophiilizimig umider a vacuum of 0.1 millimeter of mercury for twenty-four hours prior to im-
plamitation in the anterior chamh)er of the eye of an adult rat.

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FIG. 4
Phot-omicrograph (X 28), six weeks after implantation, of the femur of an eighteen-day rat embryo
implanted direct!)’ into the anterior chamber of an adult rat.

VOL. 34.A, NO. 3, JULY 1952

642 B. D. HAY, JAMES DEGGE, P.\RK GLOYD, AND d;.RTH MOONEY

:
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FIG. 5
Photoniicm’ogm’aphi (X
sveeks after 28), six inplantatiomi, of ami autogemious graft of fracture callus otw
sveek old, sul)jected t freezingat - 18 dlegrees (‘emltigra(h’ for tssenlt)--four houm’s aml(! thiemi imnl)lamited ill the
e,in’ of a guinea pig, shioisinig survival of the callus but :lsej)tic necrosis of the spicules of (-ortid’al homie.

circulation, the l)roccss of endochondral ossification continued, aiR! lones of (lefinitivc

shape could be rccogliized! (Figs. 2 and! 3). Howcvei, the groivthi ol)sers’cdl following freez-
ing or lyophilizing ivas not nearly as actis’c as in f-hose grafts is’hich isere I ranspla.nted
(IircctlV isithout intervening treatment. (Fig. 4).

IiracIarc Callus
Among the gmoup of guinea pigs in ishichi fracture callus was subjected! to freezing
I)riOr td) implantation, there ivas one instance of survival of the callus at. the endl of six
is’ecks (Fig. 5). It is interesting to note that seseral chips of cancellous bone transplanted
at the same time apparently underivent aseptic necrosis. Callus treated by lyophilizing
prior to transplantation did not survive. On the other hand, in the group in which t.rans-
plantation is-as carried out immediately, spicules of cortical bone ivere still sia-blc aft-cr
six weeks, and there ‘was evidence of limited new-bone formation (Fig. 6).

..1 dult Cortical and Cancellous Bone

The autogenous grafts of mature cancellous and cortical bone Sllbjectedi to freezing
for tis’enty-four hours and those subject-ed to lyophilizing failedl to survive. All showed
es’idence of aseptic necrosis at the end of the six-week period. Around some of the grafts
there is-as a fibroblastic reaction similar to that seen around the basic calcium phosphate
crystals. In some cases capillaries had invaded the Haversian canals, but. there is-as no
evidence of new-bone format-ion (Figs. 7 and 8). However, in the group in which trans-
plantation was carried out without intervening treatment, the grafts did survive and in
t.svo instances there w’as histological evidence of limited new-bone formation (Fig. 9).

DISCUSSiON

The reaction of the skeleton to implantation of basic calcium phosphate crystals

resembled in many respects the reported reaction to implants of boiled bone 91015 and os

THE JOURNAL d)I- BONE ANI) JOINT s(JRd;ERY

 BONE REGENERATION 643

Fnc.. C)
Phiotomiiicm-ogm’aphi (X 28), six ised’ks after inil)Ianlt at ion, of an autogemious graft of (‘Om’ti(’a! honie, fron a
fracture O1ld sVd’ek Oldl, imisl)lamlted imi tin (‘y(’ of a guima’a pig, shois-imig survival of the l)Omie.

. w
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FIG. 7
Phiotoniicrograph (X 28), six sveeks aftem imuplantation, of ami autogetious graft of adult cortical bone
suhjected freezing
td) :tt - 18 (legrees cemitigm’ade for tisent)’-four hours andi then transplanted to the
amitem-ior chamber, shioss-ing aseptic necrosis of the fragment.

VOL. 34-A, NO. 3. JUI.\’ i9.52

644 R. D. RAY, JAMES DEGGE, PARK GLOYD, AND GARTH MOONEY

FIG. 8
Phot-omicrographi ( X 28), six ss-eeks after implamitatiomi, of ami autogenous graft of cand-ellous bone
subjected! to lyophilizimig for tis-emsty-four hours ami(1 then implantedi in the anterior chamber, showing
aseptic mi-rOsis of the graft. The react-ion of the re(-ipient site is similar to that observed around the
implanted! smit.het.ic :ul)atit.(’ d’r:s’stals.

purum 22 Apparently these non-living substances act as scaffolds into ivhich ness’ bone
can grow . When the crystals ivere implant-cd in the anterior chamber of the eye, the
reaction of the recipient- site was in essence a forcign-bod!y reaction. A similar reaction ‘was
observed! aIotind! fiagrncnts of frozen or lyophi!ized bone ivhich failed to survive. It is’ould
appear that a high local concentration of calcium phosphate, either alone or combined
ivith the organic matrix of d!es’italizcd! l)onc, is not capal)le of indlueing the connective-
tissue cells to Iind!crgo metaplasia into chondrocytes and-! osteocytes. This conclusion is in
agreement. ii’ith that. reached by Huggins and! his co-workers and by Urist 26

\Vhule (hinica.llv there is a question regardling the fat-c of hone grafts L5J124, the cx-
periment here dlcscribedl, as is-cl! as the preliminary studies, confirm the findings of Iclinker-
fuss, I.rist and McLean 27, Widkstrom and! i\Iosiman, and others, that homogenous
embryonic hone and! aut-ogenous grafts of fracture callus an(l adlUlt cancellous and cortical
l)oflc can survive in a suitable cct.opic site. Since the survival of the cells is dlircct-ly de-
pendlent on (lifiusion of tissue fluidls through the ground substance, both the nat-tire of
the grotindl sul)sta-nec an(! the thickness of the graft should be important. Hoises’cr, this
is a problcni for fut-um-e st-u(!y.
The prcced!ing experiment also demonstrates that- embryonic bone will survisc frccz-
ing (om- lyophilizing) for limited! periods of time and! subsequently grow si-hen transplanted
into the anterior chaml)cr of the eve. Accord!ing td) our results, hois’ever, grafts of fracture
callus and! mature cancellous and! cortical bone are less able to withstand such treatment.
Furthermore, it should! he emphasized that freezing or lyophilizing the embryonic trans-
plants d!clavedl subsedluent growth as compaicd with transplants ishich had had no prior
treatment. These results can be explained if lis-ing cells are responsible for the propagation
of bone. On the other hand!, such results arc (hiffidult to explain on the basis of a specific
chemical ostcogcnetic organizer.
The factors responsible for mct.aplasia of the primitive connective-tissue cells remain

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 BONE REGENERATION 645

FIG. 9
Photomicrograph (X 28) of an autogenous graft of cancellous and cortical bone implamlted! mi the eye
svithout intervening treatment; six weeks after im!)lamitatiOli survival of the graft is cvk!elit.

obscure. Genetic patterns, trauma is’ith or without necrosis, and an autocatalytic reaction
to living chondroblasts or osteoblasts are some of the possibilities ass’aiting future in-
vest.igation.

51’MMARY

Studies of histological sections of implants in the anterior chamber of the eye in

thirty-fise guinea pigs and eighteen rats, made six is’ecks after implantation, res’caled the
follois’ing:
1. Injection of synthetic basic calcium phosphate apatite crystals resembling the
inorganic crystals from natural bone resulted in a foreign-bodly reaction in four out of six
guinea pigs.
2. Grafts of the femora of eighltecn-dlay rat cml)ryos frozen at - 18 d!cgrccs centigrade

for tis-enty-four hours and then the anterior

transplanted! (Ilamber of the eye of adult
to
rats survived in sesen out of seven cases. Endochondra! ossification si-as re-established.
Similar grafts lyophilized under a s’acuum of 0.1 millimeter of mercury for tis’enty-four
hours also survis’cd in six out of six instances. Embryonic fcmora transplanted directly
svithout intcrsening treatment riot only survived in fise out of five animals, with re-
establishment of cndochondral ossification, but gross-th isas much more active than in
either of the two preceding groups.
3. Autogenous implants of fracture callus frozen at - 18 degrees centigrade for
tiventy-four hours and implanted one week after fracture, survived in the anterior cham-
ber of the eye for six ‘weeks in one out of five guinea pigs. Fracture callus treated by
lyophilizing for twenty-four hours prior to implantation failed to survive in six out of six
cases. Fracture callus andi spicuics of ac!ult bone transplanted ii-ithout intervening treat-
ment sursised in four out of fout’ instances.
4. Autogenous grafts of adult canccllous and cortical bone treated by freezing in five

VOL. 34-A, NO. 3, JULY 1952

 646 R. D. RAY, JAMES DEGGE, PARK GLOYD, AND GARTH MOONEY

guinea pigs and by lyophilizing in six animals failed to survive in all instances. However.
grafts transplanted directly survived in three out- of three guinea pigs.
These studies, therefore, confirm the fact- that homogenous grafts of embryonic bone
aIldi atitogcnotts graft-s of fracture callus and adult canccl!ous and cortical bone can survive
and proliferate in a suitable ectopic sit-c. Furthermore, embryonic bone frozen att 18 -

degrees centigrade or lyophihizec! under a s-acuum of 0. 1 millimeter of mci-cury for tis-enty-

four hours isill survive and gross- sshcn implanted in an ectopic location. Fracture callus
and adult cancellous and cortical bone are less al)lc to survis’e in an ectopic site following
freezing or lyophilizing.

REFE RENC ES

1. ABBOTT, 14. C.; SCHOTTSTAEDT, E. R.; SAUNDERS, J. B. DEC. M.; and! BOST, F. C.: The Evaluation of
Cortical and Cancellous Bone as Grafting Material. A Clinical and! Experimental Study. J. Bone 1111(1

Joint- Surg., 29: 381-422, Apr. 1947.

2. ANNERSTEN, S. : Bone Regemierat-ion by Hormonie Ina!uctiomi. Nord. Kir. Forenings Forhamidhingar, Oslo,
1939.
3. BAlKois’, A.: tlber Transplantation von Kmlod-henmark. Cemitralbl. f.d. Med. Wiisscuischi., 8: 371-373,
1870.
4. BARRErr, E. P. ; BROSVN, J. M. ; and OLECK, S. M. : Some Granular Carbonaceous Adisorbemits for Sugar
Refining. Indust. and Engin. Chem., 43: 639-654, 1951.
5. BARTH, ARTHUR: t)lJer histologische Befunde nach Knochenimplantationen. Arch. f. Khin. Chir., 46: 409-
417, 1893.
6. BARTH, ARTHUR: Ueber Osteoplastik. Arch. f. Khin. Chir., 86: 859-872, 1908.
7. BERTELSEN, ARNE: Experimental Investigations into Post-Foetal Osteogenesis. Acta Orthop. Scan-
dinavica, 15: 139-181, 1944.
8. BRUNS, PAUL: Ueber Transplantation von Kmioclienmark, Arch f. KIm. Chir., 26: 661-668, 1881.
9. CARRELL, Vi. B.: Cois’ Horn Fixation in Bone Surgery. Surg., Gynec., and! Obstet., 63: 636-639, 1936.
10. Fois’mER, E. B. : The Use of Cois”s Horn in a Simplified )4I(’tho(l of Internal Fixation of Fractures. Ilhimiois
MedI. J., 65: 56-57, 1934.
11. GALLIE, W. E., amid! ROBERTSON, D. E.: The Repair of Bomie. British J. Surg., 7: 211-261, 1920.
12. GOUJON, E. : Recherches exp#{233}rimentales sur les proprit(s physiologiques dIe Ia moelle des os. J. (IC
l’Anat. et de Ia Physiol., 6: 399-412, 1869.
13. HE1NEN, J. II.; DABBS, G. H.; and MASoN, H. A.: The Experimental Prod!uction of Ectopic Cartilage
and Bone in the Muscles of Rabbits. J. Bone and Joint Surg., 31-A: 765-775, Oct. 1949.
14. HUGGINS, C. B.; MCCARROLL, H. R.; and BLOCKSOM, B. 11.: Experimenit-s on the Theory of Osteogenesis.
The Influence of Local Calcium Deposits on Ossification ; the Osteogemiic St.imiiulus of Epithehium. Arch.
Surg., 32: 915-931, 1936.
15. HUGHES, C. W. : Rate of Absorption and Callus Stinnulatimig Properties of Cosv horn, Ivor)’, Beef Bone
and! Autogenous Bone. Surg., Gynec., and Obstet., 76: 665-671, 1943.
16. KLINKERFUSS, G. H. : A Study of the Grois-ing Pois-er of Periosteal Callus \\‘heui Transplanted to Costal
Cartilages. Surg., Gynec., and Obstet., 38: 625-631, 1924.
17. LACROIX, PIERRE: Organizers and the Grois’th of Bone. J. Bomie atidi Joint Surg., 29: 292-296, Apr. 1947.
18. LERICHE, R., and POLICARD, A. : The Normal and Pathological Ph)-siolog)- of Bone. It-s Problems.
Translated by Sherwood Moore and J. A. Ke). St. Louis, The C. V. Mosh)v Co., 1928.
19. LEVANDER, GusTAv: A Stud)’ of Bone Regeneration. Surg., Gvnec., and Obstet., 67: 705-714, 1938.
20. LEVANDER, (I., arid! WILLSTAEDT, H. : Alcohol-Soluble Osteogenetic Substamice from Bone Marrow.
Nature, 157: 587, 1946.
21. MIY.t.t’CHI, K. : I)ie autoplastische Kmiochenmarkstramisplamitation mi Experinwmit. Arch. f. Khini. Chir.,
106: 273-292, 1914.
22. ORELL, S. : Interposition of Os Purumn imi Osteosynthesis after Osteotoni)-, Itesections of Bones arid Joints
(Interpositiomi-Osteosynt.hesis) . Surg., Gynec., and Obstet-., 59: 638-643, 1931.
23. PFEIFFER, C. A. : Effects of Bone Extract Injected into the Mouse Testis. Conference on Metabolic
Aspects of Comivalescence, Seventeenth Meeting, pp. 175-187. New York, Josiah Macy Jr. Foundation,
1948.
24. IHEMISTER, 1). B. : The Fate of Transplamited Bone and Regenerative Poiver of It-s Various Constituents.
Surg., Gvnec., and Obstet., 19: 303-333, 1914.
25. RAY, R. D., audi \\ARJ), A. A., JR. : A Preliminary Report on Stu(Iies of Basic Calcium Phosphate in Bone
Replacememit. In Surgi(al Forum, American College of Surgeons, 195!, pp. 429-434. Philadelphia, W. B.
Saunders Co., 1952.
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 BONE REGENERATION 647

26. URIST, M. R. : Calcification and Ossification. III. The Role of Local Transfer of Bone Salt in the Cal-
cification of the Fracture Callus. J. Bone and Joint Surg., 24: 47-67, Jan. 1942.
27. URIST, M. R., and MCLEAN, F. C. : Osteogenetic Potency and New-Bone Formation by Induction in
Transplants to the Anterior Chamber of the Eye. J. Bone and Joint Surg., 34-A : 443-476, Apr. 1952.
28. WARD, ARTHUR: Personal communication.
29. WICKSTROM, JACK, and MOSIMAN, R0SC0E: Observation of bone implants in the anterior chamber of the
guimica-pig e)’e. Scientific Exhibit-, The American Academy of Orthopaedic Surgeons, Chicago, Illinois,
January 27-February 1, 1951.

ILI()PSOAS TRANSFER FOR WEAKNESS OF THE HIP ABI)CCTOIIS

A PRELIMINARY REPORT*

BY W. T. MUSTARD, M.D., TORONTO, ONTARIO, CANADA

From The hospital for Sick Children, Toronto

Paralysis or ‘weakness of the hip abductor muscles alloiss the pelvis to tilt to the
opposite side ss’hcn the body ss’eight is borne on the affected limb. A compensatory lurch
of the body to the affected side in order to regain balance produces a characteristic gait.
Accompanying this fatiguing and! disfiguring limp is an external rotational deformity of
the extremity. Several muscles have been transferred in an attempt to restore pelvic
stability. It has been the author’s experience that none of the muscles selected, either alone
or in combination, is capable of replacing the stabilizing poss’er of the hip abductors.
The author became interested in the iliopsoas for a number of reasons. The iliopsoas,
lying as it d!ocs on the inside of the pelvis, has the necessary muscle bulk to equal the hip
ahd!uctor muscles, and the short fibers of the iliacus suggest that it ‘would add to the
pois’er of stabilization rather than increase the range of motion. The innervation of the
muscle is such that-, in pohiomyelit-is, it-s anterior horn cells are often spared ivhen those
of the hip abductors are involved!.
Anatomically, its origin and insertion are s’ery similar to those of the hip abductor
muscles, except-, of course, is reversed. that
The originthe situation
of the iliacus inside
the pelvis is almost identical of the abductors ‘with
outside the origin
the pelvis; the
lesser trochanter is about the same distance from the iliac crest- as is the greater trochanter.
When the iliopsoas is tested elcetromyographically, with a needle electrode in the iliacus,
muscle contractions are recorded! if one bears weight on the side being tested. This result
is indicative that the iliopsoas is a hip stabilizer.
After considering these factors, the author attempted a surgical approach on a
cadaver. It is-as demonstrAted! that. through an anterolateral incision, such as the one
* Rea(1 at the Annual Meeting of The American Orthopaedic Association, White Sulphur Springs,
West Virginia, June 23, 1951.

VOL. 34.A, NO. 3, JULY 1952