About Bone

What happens when a segment of bone is missing after a severe fracture or removal of a tumor? The bone ends try to grow into one another as they do after routine fractures, but the gap and lack of immobilization are usually insurmountable despite how hard the world’s best building material tries to repair itself. The gap instead fills with fibrous scar tissue; this gristle-like material does not restore stability, and a false joint forms. Orthopedists can overcome this situation by bringing in new bone from afar. To help you understand bone grafts, consider the analogy of borrowing money.

If you find yourself just a couple of dollars short, searching under the sofa cushions and raiding the piggy bank may produce the necessary cash. Nobody misses the money, and there is no pressing need to pay off the loan. If you need a substantial amount of money, perhaps you can borrow from your retirement account or from your kid’s educational fund. Doing so solves the immediate gap in your finances but leaves a deficit elsewhere, which may or may not recover over time. Finally, if you cannot fund it yourself, you could go to the bank, and as strange as it might seem, ask for a gift.

The concepts are the same for bone grafting. If surgeons only need some hearty bone cells to stimulate new bone formation, maybe to supplement local bone for spinal fusion, then they can temporarily open the hard outer surface of the pelvis and scrape spongy bone from the pelvis’s interior. Several tablespoons of bone can be obtained in this manner without changing the outer contour of the pelvis. The crumbly graft offers no mechanical stability, but it is full of bone-forming osteoblasts that quickly overcome the small debit in the recipient bone. At the same time, the donor site fills with new bone and could be re-excavated later if necessary.

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Sometimes a surgeon needs a short section of structurally sound bone to fill a gap at the site of a nonhealing fracture or to span a gap after removal of a bone tumor. In these instances, a chunk of full-thickness bone from the patient’s own pelvis works well.

It comes from the rim of the pelvis, near where your thumb rests when you put your hands on your hips. Unless the owner is quite thin or the chunk is bigger than an inch square, the withdrawal is harmless and invisible. Otherwise there is permanent, but manageable evidence of the loan.

If a long, straight bone graft is needed, attention often turns to the leg. Of the two bones between the knee and the ankle, the sturdy one that transmits weight is the robust shinbone, aka tibia. Just to its outside is the half-inch-in-diameter fibula. Except for a short portion near the ankle, the fibula is expendable because it is mainly an attachment site for ankle and toe muscles, which are fully functional even if the fibula had been borrowed. Hence the fibula is a mainstay in the orthopedist’s “long-bone lumberyard.” Depending on the patient’s height, a six-to-ten-inch strut is available to span a large gap in a critical bone.

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The fibula strut is far more slender than most of the bones it replaces, so it will need support from a sturdy internal plate and an external brace for at least a year. This bridging graft is “seed money” and will grow stronger over time allowing it to resist the limb’s normal bending, twisting, and compression forces. The complete conversion of a grafted fibula from scrawny to robust and from muscle anchor to body-weight resister usually takes several years.

In the next post I will describe jumbo loans.

Here is an item you may want to acquire—the fossilized skeleton of a baby Tyrannosaurus rex. Yes, you can “Buy It Now” (May 2019) for $2.95 million, which might seem a bit steep, but shipping is included, and you can get frequent flyer miles if you pay by credit card.

Regardless of the deal’s value, the offering is making professional paleontologists’ skin crawl. The upsetting issue started in 1990 with a flat tire. While the rest of the team from the Black Hills Institute (BHI), the world’s largest commercial fossil dealer, went to town to get the flat fixed, experienced amateur paleontologist Sue Hendrickson decided to have a look at a previously unexplored cliff. Along its base, she found several small fossilized bones. Looking up, she discovered the end a large fossil sticking out. On return, the team, led by BHI owner Peter Larson, recognized her find as a Tyrannosaurus rex, the top-of-the-food-chain carnivore of the late dinosaur era 66 million years ago. In honor of the discoverer and his then-girlfriend, Larson named the beast Sue, although the sex of this or any other dinosaur has never been determined.                                                                                      

On a handshake deal, Larson paid land owner Maurice Williams $5000 to extract the entire find, which proved to be 90% intact and therefore by far the largest and best-preserved T rex skeleton ever discovered. Larson removed the fossils to the BHI lab in Hill City, South Dakota, for cleaning and eventual display or sale, but ownership of Sue was in dispute between Larson, Williams, and the federal government, to whom Williams had leased his land. In the end, the court awarded ownership of Sue to Williams.

Williams then contacted Sotheby’s to sell Sue. At the auction in 1997, some private collectors were in competition with several natural history museums for ownership, yet all but one of each were priced out as the bids passed an astounding $7 million mark within ten minutes. The representatives for Chicago’s Field Museum of Natural History had reached their predetermined bidding limit, and it looked like Sue would fall into private ownership. On a hunch that one more offer would work, the Field rep bid again. The auctioneer’s gavel came down. “Sold to the Field Museum for $7.6 million.” Sotheby’s got an extra 10% for its troubles.

The Field then invested an additional $2 million building a custom support frame for Sue, one that allows removal of any individual bone for study without disturbing the remainder of the display. And on its opening in 2000, what an impressive display it was. Sue, lunging with mouth open and sharp teeth exposed, greeted museum visitors in the main atrium for 17 years. Surely the Field Museum has recouped their hefty investment with ticket, book, and gift shop sales as well as museum memberships and international visibility as an institution dedicated to research and education. In 2018, the Field Museum moved Sue to her own exhibition hall and replaced her in the main reception atrium with a much larger and much older herbivorous dinosaur for the tune of $16.5 million. Sue’s replacement will have to work hard to prove its financial investment.

Coincidentally, publicity surrounding Sue occurred within several years of the debut of Jurassic Park, the fanciful, frightening computer-animated movie portraying dinosaurs in modern times. If dinosaur mania needed its flames fanned, this combo did the trick. Fossil hunting intensified as collectors saw million-dollar figures swirling around the discovery and retrieval of Sue-like specimens.

Many land owners began selling their property’s fossil rights to the highest bidder regardless of the digger’s method or intent. Those interested in fossils’ commercial value do not necessarily recognize or care much from which layer of rock their treasures were found. They have no incentive to consider the context of their find, for example, what other plant and animal fossils were present in the same layer.

By contrast, trained and disciplined paleontologists excavate methodically and respect the fossils’ scientific and educational import far above any sense of their commercial value. The pros take pains to carefully record the exact location of any finds in three dimensions and meticulously search the surrounding stratum for other deposits that will aid placing the fossil in context of the world as it then existed.

Furthermore, when a commercially mined fossil goes up for sale, cash-strapped universities and museums typically lose out. If the new owners display their treasures at home, their scientific and educational value plummets, much to the chagrin of professional paleontologists. A writer for Slate commented, “There is no more need for self-styled paleontologists than there is for amateur gynecologists.” Commercial enterprises counter that the exposed fossils they retrieve would otherwise crumble and weather away, useful to no one. I guess they are saying that an amateur gynecologist is better than none. You decide; but if you do buy Baby Rex, please donate it to a public institution, take a tax deduction, and keep the frequent flyer miles.  

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If $2.95 million is too steep for your budget, consider bidding on a nearly complete dodo skeleton that Christie’s in London is auctioning on May 24. It is expected to go for somewhere between $500,000 and $700,000.

Comments: “Love it, but it is bigger than my apartment.” “I already have one.” “I’ll take two.”

Bones have not only infiltrated the arts and popular culture, they also flavor place names. For some, the derivation is obvious, for example, Bone Creek, Saskatchewan; Bone Valley, Florida; Bone River, Washington; Bowlegs, Oklahoma; Bay of Bones, Macedonia; and Bone, Indonesia. Bone Cabin Quarry is a rich fossil field in Wyoming that was named for a nearby sheepherder’s cabin made out of stacked dinosaur bones.

For other locations, the connection is obscure. The Place of the Skull (Golgotha in Greek, Calvary in Latin) is the site near Jerusalem where Jesus was crucified. The exact location is disputed, as is the source of the name. Perhaps the name denoted a skull-shaped hill or the site where Adam’s skull was buried or maybe a site rich in skeletal remains.

Undisputed in both name origin and location is the Calaveras River in California. An early explorer came upon skeletal remnants of Native Americans on the bank of a then-unnamed river and exclaimed in Spanish, “Calaveras” (“Skulls”). Later the surrounding county received the same name, which makes the title of Mark Twain’s short story much more rhythmic than if it had been The Celebrated Jumping Frog of Skulls County.

By the way, skullduggery and Marylebone have nothing to do with bones, although bonfire does. It is a condensation of bone fire and comes from the time when the marrow fat of bone fueled open cremation pyres.  

In the Middle Ages, surnames emerged, first usually describing a location (e.g., Hill, Rivers) or an occupation (e.g., Miller, Shepherd). I guess when they ran out of those, along came Bone, Smallbone, Boner (no kidding), Bonebreak, and Brisbane. I will leave it to your imagination how the Boner family got its name, but Brisbane is rooted in old English where brise meant break and ban meant bone; but your imagination is again required, because nobody knows whether this family suffered broken bones, broke the bones of others, or set broken bones.

What is clear, however, is that hundreds of years later, one Thomas Brisbane was governor of New South Wales, Australia, and he shared his name with the local river and government seat.

“City of Bones” is the nickname for Derry, Northern Ireland, and its coat of arms includes a seated skeleton. How this came about is lost in time. Some wag said that the skeleton was that of a citizen waiting for a decision from the city council.

Perhaps the first person with a bone nickname was Ivar the Boneless, about whom I have previously blogged. Other folk with osseous nicknames include Sawbones (historically, any surgeon), Billy Bones (character in Treasure Island), and Brother Bones (mid-20^th century musician, known for his rendition of Sweet Georgia Brown). There are also Ebony Bones (British actress), Bonebreaker (Marvel comic character), BONES (rapper), and the hip hop group BoneThugs-N-Harmony, consisting of Bizzy Bone, Wish Bone, Layzie Bone, Krayzie Bone, and Flesh-n-Bone.

What is it about bone? Why aren’t any people or places named Kidney or Skin or Nerve? Bone rules!!

In the last half of the 19th century, quickly following the advent of general anesthesia and the discovery of bacteria, some surgeons began specializing in treatments of the brain, eye, or other body parts. Fracture treatment, however, remained within the domain of the generalist in cities and at times left to the care of bone setters in rural and impoverished areas.

This changed with the Industrial Revolution and specifically with the building of the Manchester Ship Canal in England, which remains the world’s longest river navigation canal at 36 miles.

Rather than war, which historically has been the usual catalyst for rapid advances in surgery, it was this massive peace-time project involving hundreds of cranes, locomotives, and excavators, thousands of trucks and wagons, and tens of thousands of construction workers. The mix produced a great number of skeletal injuries over the six-year construction period.

A few years earlier and because of hard times at home in London, Robert Jones, then a teenager, moved to Liverpool to live with his uncle, Hugh Owen Thomas. Thomas was an orthopedist. His father, grandfather, and great grandfather had been bone setters.

Thomas made multiple contributions to the management of skeletal diseases that included published treatises on tuberculosis and on femur fractures. He encouraged his nephew, Robert, to attend medical school and then to join him in practice, which Robert did. Together Thomas and Jones developed a unique interest in fracture management whereas most orthopedists at the time dealt primarily with children’s skeletal deformities. 

In 1888 there was a fortuitous turn of events. Jones became Surgeon-Superintendent of the Manchester Ship Canal construction project and took advantage of this opportunity to develop the world’s first comprehensive accident service. He spaced three hospitals at intervals along the canal with intervening first aid stations and a railroad connecting them all. Jones trained and staffed the hospitals with personnel skilled in fracture management, and he operated on many of the injured workers himself. This intense operative experience, along with great proficiency in the non-operative management of fractures, markedly improved fracture care techniques.

Soon after, these advances proved invaluable during the Great War when Jones became Inspector of Military Orthopaedics and oversaw a 30,000-bed organization. Knighthood followed.

In the course of their work, Thomas devised a splint for temporary immobilization of broken legs, and Jones devised a bulky bandage to be used after knee surgery. Both of these advances bear their innovator’s name and are still used today.

The most significant and lasting mark that these two orthopedists made on medicine, however, was that they defined a new specialty. Canal building and then a war ended a decades-long discussion about the nature of the specialty of orthopedics. Should it include surgical procedures or just focus on straightening crooked children with casts and splints? From 1920 on, the specialty has been appropriately called orthopedic surgery.

Antarctica. The first image that comes to most people’s mind is probably not one of bones, and looking for them is not why I went. For years I had dreamed of seeing the glaciated terrestrial landscape and the iceberg-laden waters described over 100 years ago during the “Age of Heroic Exploration.” I also wanted to experience a bit, just a bit, of the weather that made the early explorations heroic.

As whalers and sealers of the 19^th and early 20^th centuries discovered, the waters surrounding Antarctica were and are surprisingly rich with wildlife. Near the bottom of this food pyramid are trillions of krill, which are inch-long shrimp-like critters that whales, seals, and penguins find delectable and life-sustaining. Whales and seals take huge gulps of krill-dense sea water, close their mouths part way, and expel the water while retaining the krill against their baleen filters (whales) or interdigitated teeth (seals). Penguins swallow some krill for themselves and once back on land regurgitate the rest for their demanding, ever-hungry chicks. Once the chicks are fledged, the penguins spend the rest of the year at sea.

So logically there are lots of bones scattered on the surrounding ocean floor, likely well preserved due to low temperatures. They are tantalizingly close, yet invisible and inaccessible to casual observers. In several bays the whale bones must be stacked deep, since factory ships would anchor in protected areas during the hunting season, process blubber, and discard the rest.

Before whalers drove their prey to near extinction, they realized that the bones as well as the blubber had value. They began boiling the skeletons to extract fat and then grinding the bones for fertilizer. (At about the same time, bison bones, bleaching on the prairies of the Great Plains, were found to have commercial value for the same reason. See blog post When Bone Piles Became Cash Cows.)

Local penguins number in the millions, and not all die at sea. I came across several of their bones on rocky areas, which ignited my interest, and I began to search for more Antarctic bones. Scavenging birds (skuas, sheathbills) can quickly strip a fresh carcass clean. Because of the low temperature (30-35^oF in coastal areas during the summer) and low intensity sunlight (or no sunlight during the winter), the bones erode slowly, especially the larger, harder ones. Also, on Antarctica there are no calcium-seeking rodents, which on temperate terrain gnaw and recycle fallen bones and antlers.

Here are some pictures of penguin bones I found. I did not bring any of my discoveries home, because it is against international agreements for tourists to remove anything from Antarctica much less eat, drink, or go to the bathroom there. And consider this: Antarctica is the first non-smoking continent!

Once I had my bone-seeking adrenaline racing, I came across some scattered seal and whale bones and was directed to an intriguing, semi-reconstructed whale skeleton. Apparently some enterprising bone lover roughly assembled vertebrae and ribs in line with a massive and likely unmovable skull.

On the way home, I stayed overnight in Punta Arenas, Chile, at the tip of South America. My beachcombing continued. Two long strolls along the shore turned up a fascinating assortment of bones. A handful were two-inch long segments of bovine skeletons, apparently sawn to this dimension for ships’ soup pots.

My best finds were the fierce-looking jawbone of a sizable creature (dog?) and a finger or toe bone of a behemoth (sea lion?). I will let you know when a zoologist has positively identified these for me. In the meantime, keep your eyes open for bones. You may be surprised where they turn up. I was, and happy about it.

Antwerp, Belgium’s second largest city, started as a river port during Roman times and grew to become the world’s diamond center.

Local legend tells of a giant who would extract tolls from boatmen navigating the river. He cut off the hands of those resisting his tax. A Roman legionnaire ended this nonsense by slaying the ogre and flinging his huge hand into the river. Hantwerpen was the spelling of the city for centuries and means throwing the hand.

Some huge bones, unearthed years later, substantiated the legend. The local museum displayed these remains as belonging to the giant until somebody realized that the bones were a fossilized rib and shoulder blade from a two-million-year-old right whale. Scholarly research ensued and turned up aanwerp—soil deposited in a river delta—as the more likely source of the city’s name. Did this create a municipal identity crisis? Momentarily, perhaps.

Undaunted by the bare-bone facts, the locals have commemorated the brave legionnaire’s fictional heroism with a bronze sculpture, which is the main plaza’s centerpiece. (A stream of water courses from the amputated hand.) Also, hands remain on the city’s coat of arms, sweet shops sell hand-shaped cookies and chocolates, and the hallmark for locally produced gold and silverware is, naturally, a hand.

The notorious whale bones, now accurately labeled, are still on display at the local Museum aan de Stroon. 

It may have started with primitive man clacking a couple of charred mastodon rib bones together. He smiled. Clack-clack. Fellow cave dwellers looked up. Then with a flip of the wrist, clackity-clackity-clack. Music was born.

In several forms, “playing the bones” has continued to the present time. Various museums display pairs of ancient Egyptian bone clappers in the shape of forearms and hands. I have never seen two pairs of these displayed together, so I am uncertain whether the clappers were played with a set in each hand, like castanets and finger cymbals, or if a complete set was a single pair and held in just one hand, like spoons.

Shakespeare knew of the art. In A Midsummer Night’s Dream, Bottom commands, “I have a reasonable good ear in music; let us have the tongs and the bones.”

William Sidney Mount, well-known for his depictions of everyday life, painted The Bone Player in 1856. A New York art agent commissioned the painting along with The Banjo Player in order to make lithographs from them to sell in Europe.

Illustrator Henry Holiday penned a number of cartoons to illustrate Lewis Carrol’s The Hunting of the Snark, published in 1876. This drawing accompanies the verse that follows and are from Fit the Seventh, The Banker’s Fate:

Down he sank in a chair—ran his hands through his hair— and chanted in mimsiest tones. Words whose utter inanity proved his insanity, while he rattled a couple of bones.

Interest continues today. Here is an example of a virtuoso on YouTube playing the bones; and at Amazon you can purchase your own set made of beechwood, ebony, rosewood, or maple. If you want the osseous originals, however, just ask for a doggie bag after you have feasted on barbecued spare ribs. Then clack away as your ancestors did 40,000 years ago.

The word orthopedic was coined in 1741 by Nicolas Andry, a French physician who wrote the first book on the topic. The book’s title was Orthopédie. Ortho- is Greek for straight or correct, as in orthodoxy (correct belief) and orthodontics (straight teeth).

The pédie is also Greek and stems from child. In his book, Andry described how families and physicians could prevent and correct skeletal deformities in children. Of course, the means were entirely non-surgical because it would be another 100 years before general anesthesia and the concept of elective surgery came about. The graphic that Andry chose for the frontspiece of his book to illustrate his concept of straightening a child remains iconic.

In his 1828 monumental treatise, An American Dictionary of the English Language, Noah Webster simplified the spelling of Old World entries including colour, programme, cheque, and encyclopaedia. He probably would have also objected to aeroplane, had it been around then. Despite the lexicographer’s best efforts, we still have two spellings for bone surgery:  orthopedic and orthopaedic.

Some stuffed shirts are reluctant to give up that “a” in orthopaedic because they say that pedo also means foot. These purists insist that orthopaedic means straight children, which was Andry’s intent, whereas orthopedic might mean just straight feet.  Somehow, American paediatricians long ago became pediatricians without apparent loss of professional standing.

To my mind, Wikipedia brings the debate to an end.  It says that pedo- relates to 1) children, 2) feet, 3) soil, and 4) flatulence. Or should it be flaetulence?

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Other posts at www.aboutbone.com of particular interest to orthopedic surgeons:

Giant public works project spawns new surgical specialty.

The spine surgery will help your child breathe.

The human hand. Not really that good for anything.

To flavor soups and sauces, many cooks traditionally use broth derived from simmered bones of fish, fowl, or four-footed critters. In recent years, bone-broth bars have appeared and offer patrons a non-caffeinated, nutritious alternative to coffee or tea. In the more health-conscious of these establishments, the proprietors tout these elixirs for their filling, cleansing, and de-toxing capabilities.

I wanted to decide whether a daily cup of bone broth should be part of my annual January resolution for a healthy life. On the internet, I found four broth-serving establishments within a bike-friendly five-mile radius of home. Within the same range there were three Vietnamese cafes that serve pho, a traditional soup of spiced bone broth, rice noodles, and meat. Off I went.

I started at a broth “bar” that was an eight-foot square kiosk in a country mart’s passageway. The cheerful teenage attendant offered me a sample, which she poured straight from a refrigerated bottle. I was her only customer, so we chatted while I sipped. With my game face on, I thought, “Definitely don’t drink this stuff cold.” She touted broth’s virtues, which on the business’s website include increased energy, sharpened focus, optimization of vital functions, and body fat reduction.  She also explained how the owner obtained the bones and prepared the broth. Having picked her brain, I felt it only decent to buy a pint bottle of beef broth. She heated several ounces on a hotplate but had to go to a coffee shop down the way to get a paper cup. I took the rest home for my wife to taste. We shared our doubts about the long-term viability of this particular bone broth business.

A week later I decided to have pho for lunch preceded by visits to two bone broth bars and followed by a stop at another. The first was a store large enough to walk into. It had both chicken and beef bone broths that were already hot. There were also frozen packets for take-home. Again, I was the only customer, and the clerk was helpful although mistaken in her belief that broth contains collagen. In fact, bone is collagen-rich, but heating it degrades the collagen into gelatin. Then when swallowed, digestive enzymes break gelatin into its constituent amino acids before they are absorbed. It is beyond belief that our bodies would then reassemble these molecules into gelatin, much less collagen. (Consider this analogy: bald men eating hair.) This store’s website, in addition to repeating the kiosk’s claims, indicates that “collagen and gelatin found in bone broth build and help repair the GI tract” and are also good for immune support and joint pain relief. The vegetable soups I sampled tasted better than the broths, which I considered bland and certainly not a substitute for coffee. Maybe their bone broth blendies (hot) and collagen smoothies (cold) would be better, but I had miles to go.

The next stop was a burger café, which also had frozen whole chickens, quarts of refrigerated broth, and two urns of hot broth: traditional (beef/pork) and poultry (duck/chicken/turkey). The latter was as bland and unappealing as my previous tastings. The traditional blend was delicious. It was if I was gnawing the last crispy bits of steak off a T-bone. The cook explained that he roasted the bones for about an hour before simmering them for 48 more. Condiments enhanced the pleasure. My favorite was a stirred-in spoonful of parsley-garlic pesto. 

Lunch time! I found a counter seat at a bustling hole-in-the-wall Vietnamese café. The meatball pho came in a huge bowl with cilantro, onion, and bean sprouts garnishing the rice noodles and broth. Good, and certainly filling, but since all the ingredients complicated my quest for tasting bone broth, I decided to pass on the other nearby Vietnamese eateries that day.  

I next cycled to a health food café. In addition to “Classic Chicken or Beef Broth” I could order either one with added ingredients such as turmeric, ghee, schizandra berry, cabbage, and jalapeno to produce “Anti-Inflammatory Broth,” “Butter Broth,” “Immunity Broth,” “Gut Broth,” or “Skinny Broth.” They all cost $10-$12 for 12 ounces, and for $2 more, I could “add collagen with 10 grams of protein.”

While sipping my Classic Beef, I browsed the foyer bookshelf and flipped through Dr. Kellyann’s Bone Broth Diet, which claimed I could lose up to 15 pounds,  4 inches (didn’t say from where), and my  wrinkles in 21 days. Despite those remarkable claims on the cover, inside Dr. Kellyann did note that boiling bone converts collagen to gelatin. She went on, however, to extol the purported health benefits of gelatin. Like many other advocates, she cherry-picked research results that supported her claims while ignoring the abundance of literature that has found no significant benefits of bone broth over eating a generally healthy diet. Also, I am typically wary of products claiming to cleanse and detox. How did these health trendistas let themselves get soiled and toxed in the first place?

Now at the end of my bone broth adventure, I had an uneasy feeling, perhaps caused by sudden weight loss or immunity gain. I knew for sure, however, that a whole class of taste buds had gone unstimulated all day. Before hopping back on my bike and heading to the office, I stopped at Burger King for a soothing Oreo milkshake.

In the 1950s, about the same time that John Charnley was perfecting total hip replacement surgery in England (see previous blog posts), American Paul Harrington addressed a vexing spine problem. To understand the problem, consider that a snake slithers along by curving its spine repeatedly from side to side. By comparison, a human’s spine is not as flexible. It can bend a little from left to right but is normally straight when its owner stands tall. If a human spine develops a curve to the side that does not go away when standing at attention, the bend is unbalanced and tends to progress. Untreated, the spine can collapse to the side and cause shortened stature, an unsightly humpback, and in some conditions even compression of the heart and lungs inside a twisted ribcage. A compromised life ensues. Read more