- Email: [email protected]
Fractures at cancellous bone graft donor sites
lnju~,14.519-522
Printed in Great Britain
519
Fractures at cancellous bone graft donor sites M. E. Blakemore Birmingham General Hospital Summary
Two cases of fracture, which followed removal ofbone for grafting are presented. One affected the femur and one the ilium. The implications of this complication are discussed. CASE REPORTS Case 1
A woman aged 63 was admitted following a fall from a height of about 3 feet in which she sustained a comminuted fracture of the upper end ofthe right tibia with separation of the tibia1 plateaux and avulsion of the insertion of the anterior cruciate ligament (Eg. I ). It was decided to operate to reconstruct the tibia1 articular surface, recognizing that the osteoporosis might preclude stable fixation of the articular fragments to the shaft of the tibia. This proved to be the case. The articular fragments and the attachment of the anterior cruciate ligament were reduced and internally fixed (Fig. 2) and a supporting bone graft was taken from the opposite greater trochanter. The right lower limb was then splinted in a plaster-of-Paris cast at first, and later the patient was allowed to walk with crutches, bearing full weight on the left leg, with a non-weight-bearing brace hinged at the knee applied to the right lower limb. Thirteen days after operation, having been walking without pain for 6 days, the patient suddenly developed pain in the upper part of the left thigh. Radiography showed a crack fracture, apparently orieinatina at the bone graft donor site (Fip. 3). This was treated with simple-traction for 8 weeks and the patient was then allowed to walk again. By I2 weeks from the original injury, the tibia1 and femoral (Fig. 4) fractures were clinically and radiologically united, and the patient could flex the knee to 90” and walk unaided. Case 2 A 57-year-old man was admitted for operation for severe cervical spondylosis with associated compression of the nerve roots. A Cloward type of anterior decompression and dowel fusion was performed at 2
Fig. I. Case I. Comminuted upper tibia1 fracture with separation of the tibia1 plateaux and some depressed central fragments levels (Fig. 5), dowels being obtained from the left ilium close to the crest. His post-operative course was uneventful and he went home after 8 days. When seen 28 days later he complained that he had experienced a sudden increase of pain at the bone graft donor site while climbing stairs at home. There was no evidence of sepsis and radiography showed a fracture through the dowel hole defects in the ilium (Fig. 6). The pain was treated with analgesics and gradually subsided.
Injury: the British Journal of Accident Surgery Vol. 1~/NO. 6
520
Fig. 2. Case I. Open reduction articular fragments.
and internal fixation of
F(y. 3. Case I. Fracture of the left upper femur cxtending from the bone graft donor site to the subtrochanteric region.
DISCUSSION
Various complications relating to bone grafts’ donor sites have been observed, ranging from common and minor symptoms such as pain, haematoma, infection, hypersensitivity and anaesthesia ofthe buttock (Cockin, 197 1) to rare and more serious complications including instability of the pelvis (Coventry and Tapper, 1972) herniation of viscera (Bosworth, 1955; Challis et al., 1975; Oldfield. 1945; Reid, 1968) arterio-venous fistula and injury to the ureter (Escalas and DeWaId, 1977). Whilst fracture due to weakening of the donor site has been shown to be a complication in 12 per cent of tibias from which large cortical grafts had been taken (Belcher and Janes, 1975), this does not seem to have been reported as a complication of donor sites used to obtain cancellous or mainly cancellous bone for grafting. These 2 cases seem to emphasize that care should be taken about how much bone is taken from sites which may be subjected to early weight bearing or the forces of muscular action. In the first case it would clearly have been better
Fig. 4. Case I. Healing of the upper femoral fracture.
Blakemore.
Fractures at Cancellous Sites
521
l.‘r,q.5. Case 2. Post-operative appearance of 2 level anterior cervical decompreasoon and fusion using dowjel grafts.
to have taken the bone graft from a site other than one which was to be subjected to full weight bearing forces immediately after operation. particularly as generalized osteoporosis was thought to contribute to the original injury. This should be balanced against the difficulties of obtaining bone grafts from other sites: for example the inaccessibility of the posterior ilium when the patient is supine; the reduced accessibility ofthe ipsilateral greater trochanter when a pneumatic tourniquet is used: the possibility of producing further stiffness of the knee when the ipsilateral femoral condyle is chosen as the donor site. The alternative might be the use of ‘Kiel Bone’ as an inert replacement for crushed cancellous bone. but that might be impregnated with potentialI> osteogenic cells obtained by aspiration of the iliac crest’s marrow (Salama and Wcissman. 1978). Perhaps when taking the dowels for the Cloward type of cervical fusion. only I dowel should be taken from each ilium or. to avoid 2 donor sites. if 2 dowels are taken from the same iliac wing they should be as widely separated from each other as possible. Acknowledgements F&T 6. Case 2. Displacement of part of the iliac crest following fracture of the iliac wing through the dowel holes.
My thanks are due to Mr M. H. M. Harrison. Consultant Orthopaedic Surgeon, Birmingham General Hospital, and to Mr W. J. Whatmore. Consultant Neurosurgeon, Walsgrave Hospital,
522
Injury: the Brltlsh Journal
Coventry, for allowing me to report these 2 cases. I am grateful for the help of the Department of Clinical Illustration, Birmingham General Hospital, which produced the photographs. REFERENCES
Belcher D. C. and Janes J. M. (1975) Tibia1 donor site morbidity; 500 consecutive cases with long follow-up. J. Bone Joint Surg. 57A, 1032. Bosworth D. M. (1955) Repair of herniae through iliac crest defects. J. Bone Joint Surg. 37A, 1069. Challis J. H., Lyttle J. A. and Stuart A. E. (1975) Strangulated lumbar hernia and volvulus following removal of iliac crest bone graft. Acta Orthop. &and. 46,230.
Requem /ix repprinl.r .shoutdhe addressed
RX Dr M. E. Blakemore,
of Accident
Surgery Vol. 1 ~/NO. 6
Cockin J. (I 97 I) Autologous bone grafting-Complications at the donor site. J. Bone Joint Surg. 53B, 153. Coventry M. B. and Tapper E. M. (1972) Pelvic instability. A consequence of removing iliac bone for grafting. J. Bone Joint Surg. 54A, 83. Escalas F. and DeWald R. L. (1977) Combined traumatic arterio-venous fistula and ureteral injury: A complication of iliac bone-grafting. J. Bone Joint Surg. 59A, 270. Oldlield M. C. (1945) Iliac hernia after bone grafting. Lancet. 1,810. Reid R. L. (1968) Hernia through an iliac bone-graft donor site. J. Bone Joint Surg. 50, 757. Salama R. and Weissman S. L. (1978) The clinical use of combined xenografts of bone and autologous red marrow. J. Bone Joint Surg. 60B, I I I.
Birmingham
General Hospital. Birmingham.
Printed in Great Britain
519
Fractures at cancellous bone graft donor sites M. E. Blakemore Birmingham General Hospital Summary
Two cases of fracture, which followed removal ofbone for grafting are presented. One affected the femur and one the ilium. The implications of this complication are discussed. CASE REPORTS Case 1
A woman aged 63 was admitted following a fall from a height of about 3 feet in which she sustained a comminuted fracture of the upper end ofthe right tibia with separation of the tibia1 plateaux and avulsion of the insertion of the anterior cruciate ligament (Eg. I ). It was decided to operate to reconstruct the tibia1 articular surface, recognizing that the osteoporosis might preclude stable fixation of the articular fragments to the shaft of the tibia. This proved to be the case. The articular fragments and the attachment of the anterior cruciate ligament were reduced and internally fixed (Fig. 2) and a supporting bone graft was taken from the opposite greater trochanter. The right lower limb was then splinted in a plaster-of-Paris cast at first, and later the patient was allowed to walk with crutches, bearing full weight on the left leg, with a non-weight-bearing brace hinged at the knee applied to the right lower limb. Thirteen days after operation, having been walking without pain for 6 days, the patient suddenly developed pain in the upper part of the left thigh. Radiography showed a crack fracture, apparently orieinatina at the bone graft donor site (Fip. 3). This was treated with simple-traction for 8 weeks and the patient was then allowed to walk again. By I2 weeks from the original injury, the tibia1 and femoral (Fig. 4) fractures were clinically and radiologically united, and the patient could flex the knee to 90” and walk unaided. Case 2 A 57-year-old man was admitted for operation for severe cervical spondylosis with associated compression of the nerve roots. A Cloward type of anterior decompression and dowel fusion was performed at 2
Fig. I. Case I. Comminuted upper tibia1 fracture with separation of the tibia1 plateaux and some depressed central fragments levels (Fig. 5), dowels being obtained from the left ilium close to the crest. His post-operative course was uneventful and he went home after 8 days. When seen 28 days later he complained that he had experienced a sudden increase of pain at the bone graft donor site while climbing stairs at home. There was no evidence of sepsis and radiography showed a fracture through the dowel hole defects in the ilium (Fig. 6). The pain was treated with analgesics and gradually subsided.
Injury: the British Journal of Accident Surgery Vol. 1~/NO. 6
520
Fig. 2. Case I. Open reduction articular fragments.
and internal fixation of
F(y. 3. Case I. Fracture of the left upper femur cxtending from the bone graft donor site to the subtrochanteric region.
DISCUSSION
Various complications relating to bone grafts’ donor sites have been observed, ranging from common and minor symptoms such as pain, haematoma, infection, hypersensitivity and anaesthesia ofthe buttock (Cockin, 197 1) to rare and more serious complications including instability of the pelvis (Coventry and Tapper, 1972) herniation of viscera (Bosworth, 1955; Challis et al., 1975; Oldfield. 1945; Reid, 1968) arterio-venous fistula and injury to the ureter (Escalas and DeWaId, 1977). Whilst fracture due to weakening of the donor site has been shown to be a complication in 12 per cent of tibias from which large cortical grafts had been taken (Belcher and Janes, 1975), this does not seem to have been reported as a complication of donor sites used to obtain cancellous or mainly cancellous bone for grafting. These 2 cases seem to emphasize that care should be taken about how much bone is taken from sites which may be subjected to early weight bearing or the forces of muscular action. In the first case it would clearly have been better
Fig. 4. Case I. Healing of the upper femoral fracture.
Blakemore.
Fractures at Cancellous Sites
521
l.‘r,q.5. Case 2. Post-operative appearance of 2 level anterior cervical decompreasoon and fusion using dowjel grafts.
to have taken the bone graft from a site other than one which was to be subjected to full weight bearing forces immediately after operation. particularly as generalized osteoporosis was thought to contribute to the original injury. This should be balanced against the difficulties of obtaining bone grafts from other sites: for example the inaccessibility of the posterior ilium when the patient is supine; the reduced accessibility ofthe ipsilateral greater trochanter when a pneumatic tourniquet is used: the possibility of producing further stiffness of the knee when the ipsilateral femoral condyle is chosen as the donor site. The alternative might be the use of ‘Kiel Bone’ as an inert replacement for crushed cancellous bone. but that might be impregnated with potentialI> osteogenic cells obtained by aspiration of the iliac crest’s marrow (Salama and Wcissman. 1978). Perhaps when taking the dowels for the Cloward type of cervical fusion. only I dowel should be taken from each ilium or. to avoid 2 donor sites. if 2 dowels are taken from the same iliac wing they should be as widely separated from each other as possible. Acknowledgements F&T 6. Case 2. Displacement of part of the iliac crest following fracture of the iliac wing through the dowel holes.
My thanks are due to Mr M. H. M. Harrison. Consultant Orthopaedic Surgeon, Birmingham General Hospital, and to Mr W. J. Whatmore. Consultant Neurosurgeon, Walsgrave Hospital,
522
Injury: the Brltlsh Journal
Coventry, for allowing me to report these 2 cases. I am grateful for the help of the Department of Clinical Illustration, Birmingham General Hospital, which produced the photographs. REFERENCES
Belcher D. C. and Janes J. M. (1975) Tibia1 donor site morbidity; 500 consecutive cases with long follow-up. J. Bone Joint Surg. 57A, 1032. Bosworth D. M. (1955) Repair of herniae through iliac crest defects. J. Bone Joint Surg. 37A, 1069. Challis J. H., Lyttle J. A. and Stuart A. E. (1975) Strangulated lumbar hernia and volvulus following removal of iliac crest bone graft. Acta Orthop. &and. 46,230.
Requem /ix repprinl.r .shoutdhe addressed
RX Dr M. E. Blakemore,
of Accident
Surgery Vol. 1 ~/NO. 6
Cockin J. (I 97 I) Autologous bone grafting-Complications at the donor site. J. Bone Joint Surg. 53B, 153. Coventry M. B. and Tapper E. M. (1972) Pelvic instability. A consequence of removing iliac bone for grafting. J. Bone Joint Surg. 54A, 83. Escalas F. and DeWald R. L. (1977) Combined traumatic arterio-venous fistula and ureteral injury: A complication of iliac bone-grafting. J. Bone Joint Surg. 59A, 270. Oldlield M. C. (1945) Iliac hernia after bone grafting. Lancet. 1,810. Reid R. L. (1968) Hernia through an iliac bone-graft donor site. J. Bone Joint Surg. 50, 757. Salama R. and Weissman S. L. (1978) The clinical use of combined xenografts of bone and autologous red marrow. J. Bone Joint Surg. 60B, I I I.
Birmingham
General Hospital. Birmingham.