The Use of Plaster of Paris to Fill Large Defects in Bone

Abstract

Leonard F. Peltier (Fig 1) was born on January 8, 1920 in his grandmother’s home in Wisconsin Rapids, WI. He grew up in Lincoln, NE where his father was a professor at the university. After graduating from Lincoln High School, Peltier attended the University of Nebraska, and received his AB degree in 1941. He then went to the University of Minnesota Medical School in Minneapolis, and graduated in 1944. After 9 months of surgical internship and 9 months of surgical residency, Peltier was called to active duty in the army. He was sent to the 120th Station Hospital in Bayreuth, Germany, and after a short time he was made chief of the surgical service. After serving overseas for 28 months, Peltier returned to Minneapolis to finish his surgical residency. As a part of this program, he spent 1 year as a fellow of the National Foundation for Infantile Paralysis studying the respiration of patients with poliomyelitis in iron lungs. For this work, he received his PhD degree in 1951. On finishing his surgical residency, Peltier became an instructor in the department of surgery. Encouraged by Dr. Owen H. Wangensteen to become an orthopaedic surgeon, he then completed the necessary residency requirements for board certification in this specialty. He gained board certification in general surgery in 1954 and in orthopaedic surgery in 1956.Fig 1.: Leonard F. Peltier, MD, PhD. (Photograph courtesy of the University of Arizona Health Sciences Center, Tucson, AZ).During this period, Peltier began his research of fat embolism, the use of plaster of Paris to fill defects in bone, the study of pelvic fractures, and eponymic fractures. All of these subjects continued to interest him for the remainder of his career. From 1952 to 1956, Peltier was designated as a John and Mary R. Markle Foundation Scholar in Medical Science. In 1957, he was given the Kappa Delta Award for his work on fat embolism and in 1960 he won the Nicolas Andry Award for his work on the use of plaster of Paris to fill defects in bone. On July 1, 1956, Peltier became the Associate Professor of Orthopedic Surgery and Acting Head of the Section of Orthopedic Surgery at the University of Minnesota. There was much opposition from the local orthopaedic community to this appointment; the impression was that Peltier was a general surgeon. For this reason, he accepted the position of Professor of Orthopedic Surgery and Head of the Section of Orthopedic Surgery at the University of Kansas Medical Center on January 1, 1957. At the University of Kansas, Peltier strengthened the residency program and continued his work on fat embolism, pelvic fractures, and plaster of Paris. On July 1, 1971, he moved to the new medical school at the University of Arizona. There he began a new residency program, serving as chief of orthopaedics until his retirement in 1985. After his retirement, Peltier was called on to assume the position as Acting Head of the Department of Surgery at the Arizona College of Medicine, a position he held for 4 years. He now resides in Albuquerque, NM. Peltier did not believe the reports that he read about the use of plaster of Paris to fill bone defects until he tested it in his laboratory. Because of the problems with Ostamere and Boplant, it did not seem like a good time to try to promote the use of plaster of Paris. Ethicon Laboratories produced sterile pellets for a short time and then abandoned the project. The use of the plaster had a widespread underground use through the years. Recently, the use of plaster of Paris to fill defects in bone has been revived by Wright-Orthopaedics. The use of plaster of paris to fill defects in bone is by no means a new procedure. In 1892 Dreesmann [1], from Trendelenburg’s Clinic in Bonn, reported on eight patients in whom cavities in a variety of bones were filled with a mixture of plaster of paris and a 5 per cent solution of phenol. Two years later Martin [7] described experiments on two dogs in which plaster of paris had been placed in cavities made in bone. This paper caught the eye of Bradford in Boston, and on December 12, 1894, Harvey Cushing, then a medical student, wrote to his father that Bradford had asked him to repeat Martin’s experiments [3]. No report of these experiments was ever made. During the ensuing fifty years there has been occasional mention of this procedure, in all instances with approbation [2,5,9,10,15]. The recent papers of Häuptli [4] and Kovacevic [6] clearly demonstrate the value of plaster of paris in filling cavities in bones of patients. Our initial reaction to the suggestion that plaster of paris could be used to fill cavities in bone was one of skepticism. The documentation, however, was too plentiful to be brushed aside. As a result we embarked upon a series of experiments in animals which for the most part have been described elsewhere [11–14]. From this work it has been possible to draw the following conclusions: 1. The implantation of plaster of paris into the bone or soft tissue does not produce a foreign body reaction characterized by the formation of foreign body giant cells, or the infiltration of polymorphonuclear leukocytes or lymphocytes. The material is accepted well by the tissue. 2. Plaster of paris, by itself, does not stimulate bone formation. New bone formation occurs only when periosteum or bone is also present. 3. The presence of plaster of paris in the wound does not inhibit bone formation. 4. The plaster of paris is regularly absorbed and removed from the site of implantation regardless of whether or not new bone formation occurs. 5. Infection in wounds containing plaster of paris is not complicated by sequestration of the plaster. It drains out with the pus or is absorbed. None is retained at the site of implantation. These conclusions are fully supported by a recent paper by Nikulin and Ljubovic [8]. Following these observations in the laboratory we were encouraged to use plaster of paris to fill some defects in human bone. Patients were selected primarily because they presented large defects and were challenging problems in reconstructive surgery. The immediate results have been exciting enough to prompt this early preliminary report, not to encourage the use of this material but to promote interest in its possibilities. The plaster of paris used was of a commercial grade and was made into small tablets prior to sterilization by dry heat (300°F. for four hours). There has been much clinical experience in Europe with the use of plaster of paris to fill small defects created by the excision of benign bone tumors. The first case is typical of this. (not shown). COMMENTS In our initial experiments with dogs we noted a rise in serum calcium levels during the immediate postoperative period. Such a rise could not be demonstrated in any of these patients. Although the plaster of paris is absorbed quickly, if the patient has an adequate fluid intake and output and is mobilized rapidly, hypercalcemia and its attendent complications do not appear to be a hazard. The outstanding feature of these cases is the speed with which the plaster is removed from the site of implantation and the new bone is formed in the defect. Progress can be seen in a matter of weeks in contrast to the long periods of time usually involved when bone grafts, autogenous or homogenous, or other types of bone substitutes are employed in a similar manner. The use of the plaster of paris did not adversely affect the healing in any of these defects. It appears to have contributed significantly to the rapid healing in all of them. Does the plaster function by supplying a local source of calcium for bone formation? Does it act only passively as a space-occupying material whose absorption rate is comparable to the optimum rate of bone regeneration? Further experimental studies may supply the answers. Will the use of plaster of paris supplant the many various forms of preserved or prepared homogenous or heterologous bone grafts being used at the present time to fill cavities in bone? Further clinical trials will tell.