A modification of the tibial bone-graft-harvesting technique

Int. J. Oral Maxillofac. Surg. 1996; 25:346-348 Printed in Denmark. All rights resented

Copyright © Munksgaard 1996

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Oral &,_ MaxJllofacial Surgery ISSN0901-5027

A modification of the tibial bone-graft-harvesting technique

Philip A. van Damme, Matthias A. W. Merkx Department of Oral and MaxillofacialSurgery, University Hospital St Radboud,Nijmegen, The Netherlands

Ph. A. van Damme, M. A. IV. Merlcr: A modification of the tibial bone-graft-harvesting technique, bit. J. Oral Maxillofac. Surg. 1996; 25: 346-348. © Munksgaard, 1996 Abstract. A modified method of tibial bone-graft harvesting is presented. A hollow, cylindric, hand-driven instrument is used to harvest the graft at the medial slope of the tibial tuberosity. Satisfactory amounts of autogenous cancellous bone graft are available to bridge osteotomy gaps and facial fractures, fill smaller defects, and even obliterate a frontal sinus. There is minimal donor-site morbidity, and complications have not been seen in a series of nine consecutive patients.

Key words: tibia; bone graft; cancellous; autogenous. Accepted for publication 9 April 1996

In oral and craniomaxillofacial surgery, bone-grafting procedures are common 1'5"6'8'14'16. Various indications, donor sites, and techniques have been reported 6"12. The tibial plateau has seldom been recommended as a harvest

site despite good accessibility and availability 4,9,1s. The reasons for this may be fear of epiphysial and potential growth disturbances in growing patients; the expected quantity, quality, and fatty bone-

marrow content of the graft; and, possibly, unawareness of the simplicity and low morbidity of the technique. We would therefore like to report our experience with a modification of the tibial bone-graft-harvesting technique.

Fig. 1. Location of incision at medial slope of tibial tuberosity.

Fig. 2. Placement of Wagner instrument perpendicular to bony surface.

F/g. 3. Cancellous tibial bone rod of 5 cm (patient 5, Table 1).

Tibial bone graft

347

Patients

To date, nine patients have been treated with this modified technique. Their data are summarized in Table I. Results

a

Fig. 4. Radiographs of tibia of patient 6 (Table 1) after harvesting of graft: A) lateral view; B) anterior-posterior view. Material and m e t h o d s Technique

With the patient in a supine position during general anesthesia, without the need of a tourniquet, the tibial tuberosity is palpated, and the medial and lateral joint spaces are marked. With a sterile technique, a 1.0-1.5cm vertical incision is made through the skin, subcutaneous tissue, and periosteum on the medial slope of the tuberosity, where the overlying soft tissues are thinnest (Fig. 1). The pcriosteum is elevated to enable a Wagner® 10-12-ram-diameter, hollow, cylindric instmment with trocar to be introduced. This instrument is rotated perpendicular to the surface of the bone until the cortical plate has been passed, and further to obtain the cancellous content of the tibial plateau (Fig. 2). The trocar is then

removed. By choosing various angles of insertion, several rods of cancellous bone with a length of up to 5 cm can be harvested by rotating the instrument until the cortical surface of the opposite side is reached (Fig. 3). This can be felt quite easily and is noticed as an increased resistance to easy insertion through the cancellous bone. When this instrument produces no more bone, a sharp curette can be used to harvest the residual cancellous bone. If this bone is still insufficient, the same procedure can be performed on the other leg. The wound is closed in layers; the periosteum is approximated with Vicryl® 3-0, and the skin with Ethylon® 4-0, without the need for drainage. A small pressure bandage is applied for 24 h. No restrictions to normal movement or weight bearing are necessary. The sutures can be removed after 7 days.

There were no complications attributable to this technique in any patient. The procedure lasts about 20 min. Blood loss is minimal, and the technique allows about 40 cc of bone to be harvested per side. The cancellous bone rods are malleable, although rigid enough to support any contour. Postoperatively, the patients had minimal pain and dysfunction. They could walk immediately after recovery from the general anesthesia, without additional support. Apart from slight bruising, no hematomas were seen, and there were no signs of infection. Postoperative radiographs showed no perforations of the articular surface or other boundaries (Fig. 4A and B). Healing was uneventful, and the scars were unremarkable and did not mar the appearance of the female leg. The take of the graft at the acceptor site was good in all cases. No signs of rejection, infection, necrosis, or sequestration were noticed. Discussion

Depending on the indications for bone grafting, the best site for harvesting the graft must be chosen. Important cofactors are the age and condition of the patient, the characteristics of the

Table 1. Consecutive patients with autogenous tibial bone grafts Age Patient no. (years)

Sex

Diagnosis

Indication

1

43

F

Fractured fibular bone graft after mandibular resection Bridging fractures within free vascularized bone graft and radiotherapy for squamous cell carcinoma

2

22

F

Angle Class II deformity anterior mandibular segmental osteotomy, genioplasty

Bridging osteotomy gaps

3

35

M

Fronto-naso-ethmoidal fracture

Obliteration of frontal sinus

4

29

M

Tertiary post-traumatic periorbital reconstruction

Bridging zygoma osteotomy gaps and filling contour defects

5

67

M

Pathologic mandibular fracture after enucleation of follicular cyst

Bridging fracture and filling defect

6

37

F

Angle Class II deformity anterior mandibular segmental osteotomy, genioplasty

Bridging osteotomy gaps

7

34

F

Tertiary post-traumatic mandibular reconstruction

Bridging nonhealing fracture and filling contour defects

8

22

F

Angle Class II deformity anterior mandibular segmental osteotomy

Bridging osteotomy gaps

9

28

M

Angle Class II deformity anterior mandibular segmental osteotomy, genioplasty

Bridging osteotomy gaps

348

van

Damme and Merkr

acceptor site, the type and amount of bone needed, and the characteristics of potential donor sites. When cancellous bone can be used, e.g., for bridging gaps in orthognathic surgery (patients 2, 6, 8, and 9), trauma (patients 3 and 5), or post-traumatic and oncologic reconstructive surgery (patients I, 4, and 7), tibial grafts may be very suitable (Table I). Particulate cancellous bone grafts do not have the mechanical strength desired for reconstruction of large defects without additional support. On the other hand, because of the large open areas in these grafts, (re)vascularization usually takes place rapidly, thereby bringing cellular regeneration, remodeling, and gradual substitution with new bone formation where old bone has disappeared 2"3'l°'n't3. The complication rates of tibial graft harvesting are reported to range from 1.3% to 3.8%, which compares favorably with the complication rate of iliac crest harvesting of 8.6-9.2% 7,9. The nine patients of this series do not allow us to give a meaningful complication rate, although a complication rate of 0% is encouraging. The fact that the bone grafts tend to be oily did not cause any morbidity in the early follow-up period. Because of possible growth-center interference, the use of the tibia as donor site is contraindicated in children and adolescents. In questionable situations (e.g., an 18-year-old man), preoperative radiographs should be made to verify closure of the epiphysial plates and cessation of growth. This modified graft harvesting technique is simple, is not time-consuming, and produces reasonable amounts of

cancellous bone with a simple, handdriven instrument. Other techniques need drilling equipment, tourniquets, and osteotomes 4"9"15, and may cause weight-beating limitations. This modification allows weight bearing immediately postoperatively, needs neither a bloodless field nor drainage, and does not appear to cause complications or morbidity. The tibial plateau can be considered a suitable donor site for defined indications in bonegrafting procedures in oral and craniomaxillofacial surgery. Acknowledgments. We thank Dr A. C. Vlantis and Dr E. N. Robertson for their linguistic and editorial expertise, and Petra van Veelen for typographic assistance.

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