Georg Karl Felix Preiser: The Idea and Misinterpretation of a Genius

Life and Professional Career

Dr. Georg Karl Felix Preiser (1876–1913) was a German surgeon who lived in Hamburg. He worked as an orthopaedic surgeon, mostly on cases involving trauma and joint diseases. His publications include the monograph “Static Joint Diseases” and journal articles such as “A Case of So-called Idiopathic Juvenile Osteoarthritis Deformans Coxae (a Congenital Dysarthritis?)” and “The Tennis Elbow.” He was interested in anatomy of the bones, particularly the normal and disturbed perfusion to the bones in fractures and in the development of osteonecrosis.

 

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Scientific Innovation

In 1910, Preiser published an article in the journal Fortschritte auf dem Gebiet der Röntgenstrahlen [1] in which he described 24 patients with scaphoid fractures and five case histories he considered to be of different morphology than the fracture types. He referred to these entities as “rarefying osteitis” of the scaphoid and assumed a posttraumatic osteonecrosis of the scaphoid without a causative fracture. Unfortunately, his publication did not include radiographic images.

A year later, Preiser compared his findings on the scaphoids with the osteonecroses of the lunate, as described by Robert Kienböck a few months earlier, and with Köhler's disease, a rare disorder of the navicular bone of the foot.[2] Preiser favored the theory of a “vascular and nutritional disorder” of the bone with initial ligament tears and vascular injuries that lead to a fracture via focal bone demineralization. He proposed the term “traumatic nutritional disorders of the short bones of the hand and foot” for this new entity.

Preiser's theory was based on experimental radiographic images that he produced together with his surgeon friend Erich Lexer. Both surgeons visualized the nutritional arteries feeding the scaphoid on cadaver specimens in angiograms after injecting a contrast medium. They found branches from the radial artery as the main vessels supplying the scaphoid with a central entry via the dorsal side ([Fig. 1]).

Fig. 1 Preiser's original angiographies. (a) Mainly the radial artery was found to provide the vascular supply to the scaphoid. (b) Branches of the radial artery enter dorsally at the midpoint of the scaphoid. (Reproduced with permission of SAGE publications from Kallen AM, Strackee SD. On the history and definition of Preiser's disease. J Hand Surg Eur 2014;39:770–776.)

 

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Diagnostic Misinterpretation

As early as 1911, Dr. George Fedor Haenisch (Hamburg) argued that the osteitis cases must have been caused by fractures. Preiser strongly disagreed, emphasizing that vascular insufficiency was the cause.

We must credit the Amsterdam hand surgeons A. Marlot Kallen and Simon D. Strackee,[3] who undertook intensive research into Preiser's work and brought to light the previously unknown radiographs. In their retrospective analysis of the images, Kallen and Strackee uncovered pathologies that indicate primary scaphoid fractures ([Fig. 2]).

Fig. 2 Dorsopalmar radiograph of Preiser's case number 3. There is obviously a fracture-related zone of demineralization in the middle third of the scaphoid. (Reproduced with permission of SAGE publications from Kallen AM, Strackee SD. On the history and definition of Preiser's disease. J Hand Surg Eur 2014;39:770–776.)

Preiser's five patients were men between 17 and 45 years of age who had fallen on their wrists. His radiographs, dorsopalmar projections, were performed between week 1 and month 7 after the accidents. Three of the fractures detected by Kallen and Strackee[3] were in the middle third of the scaphoid, one in the distal third, and one questionably distally at the level of a sclerotic zone. Therefore, it was assumed that Preiser had misinterpreted the radiographs at the time.

 

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Current State of Knowledge

Preiser assumed a nonfracture injury was the cause for the subsequent osteosclerosis of the scaphoid. However, during the following decades, the pathogenesis remained a matter of debate with controversial opinions in the literature.

The current understanding is that a fracture or nonunion of the scaphoid must be excluded in Preiser's disease. It is an avascular scaphoid necrosis that can be triggered by a wrist injury without fracture, prolonged steroid medication, systemic diseases, chemotherapy, alcohol consumption, and smoking. In most cases, however, the etiology remains unclear, so an idiopathic osteonecrosis of the scaphoid is assumed.

Pathoanatomically, an occlusion of the nutritional vessels to or in the scaphoid initially leads to ischemia of the bone marrow and later also of the bone. This scenario leads to osteonecrosis with cystic inclusions and volume loss of the affected bone. Secondarily, a pathologic fracture can occur. Due to retrograde vascularization of the scaphoid, the proximal segment is first affected; the middle and distal segments are involved later.

 

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Critical Appraisal

Preiser was certainly far ahead of his time when he visualized the vascular supply of the scaphoid using angiographic techniques. He demonstrated the retrograde course of the intraosseous arteries in the scaphoid. From this unique vascularization, Preiser consistently concluded that the proximal scaphoid pole should be regarded as a vascular terminal zone. His theory is still used today to explain the poor healing of fractures and the frequent osteonecrosis in the proximal scaphoid third.

Despite his excellent bone angiographies and theory of the vascular risk to the proximal scaphoid pole, Preiser's scientific contribution was unfortunately stigmatized by the radiologic misinterpretation of probably overlooked scaphoid fractures. What remains after more than 100 years of Preiser's work is his excellent theory of vascularization of the carpal bones.

 

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Conflict of Interest

None declared.

• References

• 1 Preiser G. Eine typische posttraumatische und zur Spontanfraktur führende Ostitis des Naviculare carpi. Fortschr Röntgenstr. 1910; 15: 189-197
• 2 Preiser G. Zur Frage der typischen traumatischen Ernährungsstörungen der kurzen Hand- und Fußwurzelknochen. Fortschr Röntgenstr. 1911; 17: 360-362
• 3 Kallen AM, Strackee SD. On the history and definition of Preiser's disease. J Hand Surg Eur Vol 2014; 39 (07) 770-776

Publication History

Article published online:
20 May 2024