FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS

m FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS By STEWART H. HARRISON, F.R.C.S., L.D.S.R.C.S.(Ed.) From the Windsor Group of Hospitals and the Mount Vernon Centre for Plastic Surgery, Northwood, Middlesex A COMPOUND fracture of the lower limb complicated by skin loss can be one of the more difficult problems in traumatic surgery. Failure to obtain early closure of the wound inevitably leads to established infection with the well-known sequelm of sequestration and non-union. Many months and often years are spent in hospital. Frequent and extensive procedures to eliminate infection "and establish skin cover may be required TABLE I Closed Fractures 3 treated by open reduction Io treated by nail or plate 3 treated by manipulation Compound Fractures 6 treated by nail or plate x I treated by manipulation and suture Compound Fractures with Skin Loss 2 treated by nail or plate r 7 treated by manipulation Total number of fractures Total number treated primarily by nail or plate. 16 17 19 52 18 The end-result may be amputation often deferred for too long. The object of this presentation is to assess some of the reasons for failure in the treatment of fractures of the tibia with skin loss, and in the light of this knowledge to evolve a plan of treatment which may prevent or minimise the poor results we have experienced. Fifty-two cases are presented all of which had fractures of the tibia with skin loss necessitating the provision of skin grafts of various kinds to obtain healing. Table I shows the initial treatment of the fractures. In some cases skin loss was obvious at the first examination. In others, however, no skin deficiency was noted initially, but later it became apparent that an area of skin was non-viable. The majority of legs were treated in closed plaster of Paris casts and it is possible either that devitalised skin was not recognised at the time, or that partially devitalised skin progressed to full thickness skin loss by swelling of the leg within a rigid case. Skin loss becoming apparent after the treatment of compound fractures by manipulation and skin suture may be the result of suture under tension. In those cases in which skin loss was present at the time of injury it was possible to prevent infection by early skin cover. Delay in treatment led to established infection and many months of hospitalisation. 262

FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS 263 Primary Internal Fixation (Table II).--In this series 18 cases were treated by primary internal fixation (Table II). All were complicated by skin loss. Of these : 2 cases treated by Kuntschner nail were successfully treated, one by a free graft and one by delayed primary suture. 3 were treated with primary nail fixation and primary cross leg flap. All healed without complication. i plate became exposed and was removed. The defect was covered with a trailsposition flap and the leg healed without complication. 9 became infected. 3 cases nailed were later treated by bone graft for delayed union and all subsequently developed infection with skin loss. TABLE II Primary Nail or Screw Fixation (Total 18) Results : Persistent infection 9 Healed 9 The number of cases treated by primary metal fixation which subsequently broke down and became infected does not warrant an evaluation of the correctness or otherwise of this method of treatment. Internal fixation of a compound fracture is a calculated risk which often must be taken by the orthopmdic surgeon. It makes the task of the plastic surgeon easier and it is physiologically desirable to reduce the sequelae of pain, ha:matoma and oedema which accompany an unstable fracture. It does, however, accent the need for close co-operation in the provision of skin cover as the need to prevent infection by early closure is more important in the fracture treated by internal fixation than in the compound fracture treated by manipulation and external splint fixation. Should infection occur the problem will then arise as to whether it is better to remove the metal fixation or to leave it in place and proceed with skin cover. Our experience would favour the former course and would particularly apply to plates and screws. Skin loss may be due to any one of the following : direct trauma as a result of the accident ; hmmatoma ; suture under tension ; suture of partially devitalised skin; pressure ; pressure from swelling within a rigid case ; infection. When skin is abraded from trauma it is partially devitalised and subsequent infection may precipitate skin loss. The methods used to provide skin cover in this series fall into four distinct groups : cross leg flaps ; abdominal tube pedicles ; transposition or local flaps ; free skin grafts frequently associated with either decortication or sequestrectomy. Cross Leg Flaps.--The cross leg flap is a convenient method of providing skin cover to a defect on the opposite leg. By this method skin cover can be obtained quickly. The improved blood supply over the fracture site will assist in controlling mild infection. The method has been fully described in medical literature by Jayes (I95I), Stark (I952) and others. The cross thigh flap is an alternative procedure similar in principle. The particular application of these flaps is in cases where : early closure is essential to prevent infection ; replacement of unstable skin cover is necessary ; replacement of adherent scar or previous skin graft is desired because of delayed union or as a preliminary to inserting a bone graft.

264 BRITISH JOURNAL OF PLASTIC SURGERY The disadvantages are : the technical difficulty of this procedure in compound fractures of the upper and lower ends of the tibia ; the difficulty of controlling a recent unstable fracture without recourse to internal fixation ; the secondary defect on the back of the good leg is often unsightly. Abdominal Tube Pedieles.--This method of skin replacement is applicable to long linear defects of the tibia usually presenting as an unstable scar. It is used to avoid secondary deformity on the opposite limb as occurs with cross leg flaps. In fractures of the upper end of the tibia it is used to provide cover after split skin grafting. The disadvantages are : five stages are necessary at not less than three week intervals; the procedure is hazardous in terms of survival of the tube; it is generally necessary to have 9 0 of flexion at the knee joint. The open jump flap recommended by Cannon et al. (1947) reduces the number of procedures and can be used with benefit, but requires very accurate fixation. Transposition Flaps.--Local flaps are hazardous on the leg as it is geometrically difficult to transpose or rotate on a curved surface. The relaxing incision or strap flap can only be used for very small defects. It is important to remember when using strap flaps that the point of maximum tension is the centre of the flap where bone cover is required, and this is the area where necrosis of the flap is most likely to occur. A sliding transposition flap is useful for small defects, and has been used on a number of cases in this series. Occasionally a transposition flap "is used in conjunction with a cross leg flap in defects which are too large for a single procedure. An example of this is shown in Figures I and 2, which show the initial skin c~efects, and in Figure 3, which shows the delayed primary transposition flap. Later a small area of bone was decorticated and the defect covered with a cross leg flap (Fig. 4). Carefully planned transposition flaps have proved a useful method for immediate skin cover. Free Skin Grafts.--Free skin grafts will take over soft tissue, periosteum and cancellous bone, but will not take over cortical bone or tendon. Indications : for soft tissue defects without bone exposure ; over cancellous bone after decortication ; after separation of a sequestrum. Free grafting may be used as temporary cover. The graft becomes adherent and tends to be unstable. It often requires replacement by a flap. REVIEW OF CASES A total of 52 cases have been reviewed. The skin defects were repaired as follows : 27 cross leg flaps ; 6 abdominal tube pedicles ; IO transposition flaps ; 9 free grafts following decortication. The method selected was the one considered to be the treatment of choice for that particular case. However, more than one method was frequently necessary in the same case. For instance, in 17 cases ultimately treated by a cross leg flap a preliminary decortication and free grafting procedure was done.

FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS 265 FIGS. I and 2. Size and site of skin defect. FIG. 3 FIG. 4 Delayed transposition flap. Cross leg flap. Cross Leg Flaps (Total 27) Ten cases were treated by nail or plate on the day of injury and later by a cross leg flap. The end-result of these was as follows : 2 were amputated at 2½ and 3 years after the cross leg flap. 4 required bone grafting and three became infected after bone grafting. I healed after 2½ years. 2 primary metal fixation combined with an immediate cross leg flap healed without complication. I delayed primary cross leg flap at 19 days in which the plate and screws were discarded at the time of the flap healed without complication in a female patient, aged 60. The average time for the cross leg flap was 13 months and IO days after fracture. Seventeen cases were treated primarily by toilet and suture and external splint fixation, and later by cross leg flap as follows : 3 required bone grafting following the flap and all became infected after the bone graft. I a gunshot wound of eight years' duration which failed to heal after a cross leg flap was finally amputated.

266 BRITISH JOURNAL OF PLASTIC SURGERY 13 cases were treated by decortication or sequestrectomy and free grafting prior to cross flap and nine finally healed. Four remained with persistent infection. The average time of transfer of the cross leg flap after fracture in 13 cases was nine months and ten days ; of the remaining four cases the cross leg flaps were used many years after the accident and three of these failed to control infection. TABLE III Cross Leg Flap (Total 27) Primary Treatment : b 7 nailed or plated.. 2 nailed or plated with primary cross-leg flap I delayed primary plate and cross-leg flap. 17 toilet and suture Results : Persistent infection Amputations Healed Average time of f/ap I3iI2. IO 3 14 Abdominal Tube Pedicles (Total 6) (Table IV) Primary treatment of the fracture : 3 were treated by metal fixation. 3 were treated by external splinting. Secondary treatment : 5 were treated by free grafting prior to the attachment of a tube pedicle. I was bone grafted seven months after the tube pedicle and healed without complication. TABLE IV Abdominal Tube Pedicle (Total 6) Primary Treatment : 3 primary nail or plate 3 primary toilet and suture Results : Healed Failures Average healing time 2" years'. Average time of pedicle inset II 2/12. 6 Average time of the tube pedicle procedure was I 1.2 months and the average healing time after fracture was two years. All cases remained healed without complication.

FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS 267 Figure 5 shows a compound fracture of the proximal tibia treated by sequestrectomy and free grafting. Definitive cover was provided by an abdominal tube pedicle. Figures 6, 7 and 8 show the process of cover. FIG. 5 Sequestrectomy and free grafting in compound fracture of tibia. FIG. 6 FIG. 7 FIG. 8 Figs. 6, 7 and 8.--Steps in tubed pedicle cover.

268 BRITISH JOURNAL OF PLASTIC SURGERY Transposition Flaps (Total 20) (Table V) The IO cases in this group are summarised as follows : I transposition flap was used on a male, aged 78, seven months after fracture. Infection with the discharge of sequestra continued for four years. 5 cases of compound fracture of the tibia with skin loss were treated by transposition flaps at an average of 5"8 days after the accident and all healed. I preceded by decortication and free grafting on two occasions was finally covered by a transposition flap eight months after the accident. A small sinus through which sequestra discharged continued to persist. I was treated by a transposition flap for an unstable scar and healed without incidence. I fracture treated primarily by a Kuntschner nail subsequently developed a four and a half inch sequestrum ~vhich was removed. Three operations, in which the bone was decorticated and free grafted failed to heal. A transposition flap was finally used; but infection continued and the leg was amputated, one year after the accident. I female aged 64. Tibia plated. The plate became exposed, and was removed at four months and the skin defect covered by a transposition flap. This healed without incident. Primary Treatment : 3 primary nail or plate. 7 primary toilet. TABLE V Transposition Fl@s (Total Io) Results : Healed without complication Amputation. Persistent infection Average time of flap : 5 delayed primary, average 5'6 days 5 late 6"7 months i at one year for unstable scar TABLE VI Decortication and Free Skin Grafting (Total 9) treated by primary nailing--secondary decortication--grafting. Average healing time--i yr. treated by primary toilet and suture--secondary decortication-- grafting. Average healing time Io/I2. treated by primary strap flap--delayed primary excision and grafting. Healed in 1/12. Failures from recurrent infection 2

FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS 269 Free Grafting associated with Decortication and/or Sequestrectomy (Total 9) (Table VI) Summary : 2 fractures were treated by primary metal fixation. Both healed in I2 months after a series of operations for decortication and grafting. 4 healed in an average of IO months after decortication and grafting. I treated by decortication and grafting ultimately healed ; but subsequently re-fractured with exposure of the tibia. Ten decortication and grafting procedures failed to obtain healing or control infection. I closed fracture was later treated by a bone graft for delayed healing. The bone graft became exposed and was treated on four occasions by decorticafion and grafting. Healing was eventually obtained. I compound fracture of the tibia with skin loss was treated by raising a flap and then incising the base ; as a result there was massive skin necrosis. The patient was seen two days after the procedure by Mr F. G. Ward. He inserted a Kuntschner nail and immediately transferred the patient for skin cover without any other fixation. On admission the dead skin was excised, and a viable muscle transplant was used to cover the fracture site. A large graft covered the defect. The leg healed in io days and the fracture healed without any further fixation. Delay in this case might have resulted in amputation. Figures 9 and IO show the area of skin loss ; Figures II and 12 the leg after grafting and Figure 13 the X-ray. In these nine cases only four healed with one decortication and grafting. Amputations (Total 4 : incidence 7"7 per cent.) (Table VII) Lottes, Hill and Key (1952) reported IO per cent. amputations following plate fixation. i TABLE VII Amputations i old gun shot wound. Failed decortication and cross leg flap. Amputated at 8 years. 3 treated by primary nailing. Time of amputation I yr. 2½ yrs. B yrs. 2 failed after cross leg flap. I failed after decortication and transposed flap. Summary : I was a gunshot wound seen some years after the accident with discharging sinuses and infected bone. After decortication and grafting followed by a cross leg flap, amputation was performed eight years after the accident, because of failure to control infection. This case is mentioned merely to emphasise the particular difficulties associated with this type of injury when complicated by chronic infection. Three cases treated by primary metal fixation were amputated at one year, two and a half years, and three years respectively, two after cross leg flaps and one after a transposition flap. In all cases chronic infection with skin loss failed to respond to treatment.

270 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 9 FIG. 1o Figs. 9 and Io.--Site and size of skin loss. FIG. II FIG. 12 Figs. II and i2.--after free grafting. FIG. 13 Position of bone fragments on X-ray.

FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS Bone Grafts (Total 8) (Table VIII) Summary : 4 were treated by metal fixation, cross leg flap and bone graft. 3 were treated by primary toilet and suture, cross leg flap and bone graft. I was treated by nail fixation, abdominal tube pedicle and bone graft. Results : 2 healed without complication. 5 were complicated by infection. I complicated by infection led to amputation of the leg. 27x Primary Treatment of Fracture : 5 internal fixation 3 external fixation Results after Bone Grafting : Persistent infection Amputation HeEled TABLE VIII Bone Grafts (Total 8) Average time of bone grafting procedures after accident I yr. Relation of Grade of Infection to Time of Grafting Cross Leg Flaps (Total 27) Infection : Time of graft : IO early : 5 nil 3 Grade I 2 Grade 2 Abdominal Tube Pedicles (Total 6) 2 early : I nil I Grade I Transposition Flaps (Total IO) 7 early : 5 nil 2 Grade I 2 Grade 2 Free Grafts (Total 9) 8 early : 4 Grade I 2 Grade 2 2 Grade 3 Grade I Grade 2 Grade 3 Early Late 17 late : 2 nil 4 Grade I 5 Grade 2 6 Grade 3 41ate: 2 Grade2 i Grade 3 I nil 31ate: 2 Grade 2 I Grade 3 ilate: I Grade I slight moderate severe 3/12 or under over 3/12

272 BRITISH JOURNAL OF PLASTIC SURGERY Results of Primary and Delayed Primary Skin Grafting in Compound Fractures of Tibia (Total I I) (Table IX) Summary : I compound fracture treated by primary free skin graft healed without complication. 2 primary Steinman pin fixation of fractures and primary cross leg flap healed by first intention. I in which both legs were fractured, a plate and screws were inserted into the right leg. At I9 days the plate was discarded and a cross leg flap applied. Healing proceeded normally. I compound fracture with skin loss was treated by the insertion ofa Kuntschner nail and the limb elevated on a Braun's frame. Delayed primary closure was performed at seven days. Healing was uncomplicated. 5 fractures of the tibia complicated by extensive skin loss were treated by delayed primary transposition flaps at 1% 3, 3, 7, 7 days respectively. All healed without complication except one in which the skin loss was so extensive that an additional cross leg flap was required. In this case healing also proceeded normally. I failed strap flap treated by Kuntschner nail, muscle transplant and free graft at ten days, healed without complication. TABLE IX Results of Primary and Delayed'Primary Grafting (Total II) Primary Grafting-- 3 Free graft... Steinman pin and cross-leg flap. Delayed Primary Grafting--8 Delayed primary suture. Muscle transplant and free graft. Skin flaps Results : All healed without complication. A male aged I9 was involved in a road accident and both legs were fractured. Mr G. P. Arden inserted a Kuntschner nail into the left leg and excised the wound (Fig. I4). The right leg presented a large wound with bone exposure and skin loss (Fig. I5). The skin was undermined from subcutaneous stripping. The primary procedure performed by Mr Arden consisted of manipulation of the fractures and excision of wound edges. Traction was provided by a Steinman pin through the os calcis and the leg was elevated on a Braun's frame. Five days after the initial operation the wound of the left leg was closed by suture (Fig. I6). The wound of the right leg was excised to create one large defect and the whole area covered by a transposed flap. Instillation of an antibiotic solution and suction drainage was instituted (Fig. I7). The leg was elevated on a Braun's frame with traction. Recovery was uneventful and no infection occurred (Fig. i8). When wound healing had been established the patient was referred for further orthopaedic care. Eleven cases treated by primary or delayed primary skin closure healed without complication. On the recommendation of the Consultant Orthopaedic Surgeon, Mr G. P. Arden, no plaster fixation was used in these cases.

FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS 273 FIG. 14 Excision of wound in left leg and insertion of Kuntschner nail. FIG. 15 Size and site of wound in right leg. FIG. 16 Closure of wound in left leg. FIG. 17 Wound in right leg closed by transposition flap. FIG. I8 Healing by first intention. 30

274 BRITISH JOURNAL OF PLASTIC SURGERY Pathologieal Considerations.--The immediate result of an injury to the leg severe enough to produce a compound fracture implies damage to all tissues and involves skin, muscle, bone, vessels and nerves. Widespread damage of this kind produces a relative state of devitalisation similar in pattern to the effect of crush injuries elsewhere in the body. The skin is contused and less likely to withstand the further effect of surgical trauma such as suture under tension. Extravasation in muscle is frequently widespread and the blood supply of the bone ends at the fracture site is reduced in variable degree by the extent of periosteal stripping. Two cases illustrate the effect of periosteal stripping on the subsequent treatment. In Case I there occurred a compound fracture with skin loss. The leg was elevated on FIG. I9 Extent of periosteal stripping. a Braun's frame and a simple dressing applied. The soft tissues surrounding the exposed bone became adherent to the bone and after a few weeks it was possible to decorticate the exposed bone and do a cross leg flap at the same time. Healing was uneventful. In this case periosteal stripping was minimal and infection remained local. In contrast, Case 2 is the leg of a patient who sustained a closed fracture of the tibia and fibula complicated by a h~ematoma. The latter was incised and the fracture site became infected. Periosteal stripping in this case was extensive and the infection created a lake of pus around the bone. As a result of gravity pus collected posterior to the fracture finally creating a discharging sinus posteriorly. Figure 19 is the X-ray and shows the extent of periosteal stripping. After removal of a 4½ in. squestrum, the wounds healed rapidly~ It is this type of case which presents the greatest problem in treatment, as an early decision should be made in terms of radical surgery and the choice usually lies between amputation or the removal of a large segment of bone. Temerity in treatment will lead to failure and late amputation or many months of hospitalisation involving many operations. DISCUSSION Treatment falls into three categories : control of the fracture ; provision of skin cover ; control of infection. Control of the Fractures.--Compound fractures of the tibia are potentially infected. Metal fixation may be considered necessary by the orthopmdic surgeon; but should not be used in the presence of skin loss unless adequate steps are provided to ensure

FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS 275 early closure. Accurate assessment of skin damage is not always easy. If any doubt exists metal fixation of the fracture should be accompanied by limb dressings which are not rigid and can be readily removed for inspection. In the event of skin loss appearing subsequent to the primary treatment, steps should be taken to provide skin cover, and it may be deemed advisable to discard the metal fixation. Provision of Skin Cover.--In this series four different methods have been used to provide skin cover, namely : cross leg flaps ; abdominal tube pedicles ; transposition flaps ; free grafting. The choice of cover depended on : the time after injury ; the extent of the loss ; the state of the wound. In those cases referred immediately after injury every effort was made to provide full thickness cover. If the loss was so extensive that full cover could not be provided then the objective was to cover the fracture with full thickness skin and to free graft the remainder ; the free graft being used as a physiological dressing. The limb was kept elevated until such time as further full thickness skin could be provided. In those cases referred late in which infection had already become established, skin cover has to be deferred until the infection has been eliminated. Control of Infection.--When infection has become established an attempt is made to bring this under control by drainage, irrigation, sequestrectomy, decortication and free grafting. Many operations may be required and delayed union is inevitable. If the periosteum has been stripped there is the risk of a lake of pus forming deep to the fracture. Should this occur either a large segment of bone should be excised or the leg amputated. The more one studies the history of these cases, the more one is impressed with the need to control infection early. The means are available but the time is limited. Once infection becomes established bone fixation must be delayed, skin cover is contraindicated, osteomyelitis is imminent and amputation may have to be considered. Success depends on accurate assessment of skin damage and the provision of early skin cover. Primary wound toilet should consist of removal of devitalised tissue and trimming of wound edges. Suturing should be avoided. Suction should eliminate haematoma and tube installation of an antibiotic should be considered. Tight dressings and plaster of Paris should not be used and the leg should be elevated on a splint with simple traction to maintain some degree of immobilisation. The stage is now set for the provision of skin cover when necessary. This can be provided as a primary procedure by cross leg flap, but is often a hazardous procedure and the skin defect is not always suitable for this type of procedure. Defects over soft tissue can be free grafted and even over bone a free graft is good physiological cover. Many cases, however, present extremely difficult problems in terms of skin cover and nothing is lost by deferring a decision for a delayed primary repair about seven days. At this stage every effort must be made to cover the exposed bone, and every case presents its own particular problems. In regard to primary metal fixation, there is no doubt that intramedullary nailing will materially assist the plastic surgeon in his efforts to provide skin cover and at the same time will relieve the patient of considerable pain and discomfort. It is, however, a calculated risk, and should be employed only in compound fractures with skin loss when there is a reasonable expectation of closing the fracture with full thickness skin. Finally, a decision on amputation should not be deferred for too long. In older patients factors such as varicose ulceration and poor peripheral pulses should initiate an early decision. CONCLUSION This investigation has shown that the results following fractures of the tibia with skin loss are poor, except in those cases where early skin cover has been secured. Open

276 BRITISH JOURNAL OF PLASTIC SURGERY fractures tend to become infected and once established may takc many months or years to eradicate. The results following bone grafts in such cases would suggest that the infection is still latent long after apparent healing has been obtained. The cases treated by primary or delayed primary skin cover prove the value of early cover in the prevention of sepsis. The objective should be early recognition of skin loss and early provision of skin cover. There arc three possible lines of treatment : primary skin cover ; delayed primary skin cover ; elevation of the limb until the wound is suitable for grafting. Expectant treatment in plaster of Paris with ambulation is a definite step to failure. Therc is a need for reappraisal of this problem and in the face of a rising accident rate a need for co-operation between the services concerned. SUMMARY J. Fifty-two cases of compound fracture of the tibia have been reviewed. Skin loss either was present at the time of the injury or appeared subsequent to the primary treatment. The methods of repair have been described, and appear under four main headings. There were 27 cross leg flaps and failure to obtain healing occurred in 13 cases ; four of these were subsequently amputated. There were six cases of abdominal tube pedicles, all of which healed. There were io transposition flaps with three failures. There were nine cases treated by free grafting accompanied by either sequestrectomy or decortication. Two cases failed to heal. The total failure rate was 34"6 per cent.' Eleven cases treated by primary or delayed primary full thickness skin cover all healed without complication. Delay in providing skin cover allowing infection to become established was the commonest cause of failure. Recommendations are made in regard to early treatment which might help to reduce the high incidence of f~ilure. My thanks are due to the orthopaedic surgeons of the Windsor area, Mr Arden, Mr Hershell and Mr Maudsley for referring their cases. Mr Arden has participated in this study. His advice and co-operation have been essential in the treatment of the patients. My thanks are also due to Miss Norah Walker of Mount Vernon Hospital, Mr Peter Fisk of the Canadian Red Cross Memorial Hospital, and Miss Bannister of King Edward VII Hospital, Windsor, for the photographic records. A summary of this paper was read at the S.I.C.O.T. meeting in Paris in September x966. REFERENCES CANNON~ Bo LISCHER~ C. E., DAVISj W. B.~ CHASKO~ S.~ MOORE, A.~ MURRAY, J. E.~ and McDoWELL, A. (1947). Plastic reconstr. Surg., 2, 336. JAY,S, P. H. (1951). Br.. plast. Surg., 3, I. LOTTES, J. O., HILL, L. J., and KEY, J. A. (1952). J. Bone Jt Surg., 34 A, 861. STARK, R. B. (1952). Plastic reconstr. Surg., 9, 173.