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2. Techniques for obtaining autogenous bone graft
S-AS
2. Techniques for obtaining autogenous bone graft
P.-J. Meeder,
M.D.1 and Ch. Eggers, M.D.2
1 Head of the Dept. of Trauma
and Reconstructive
2 Head of the Dept. of Trauma, Reconstructive
The following areas are donor cancellous and cortico-cancellous 1. Anterior superior the ilium 2. Greater
trochanter
Surgery, University Clinic Heidelberg,
and Hand Surgery, St. George’s Hospital, D-20099 Hamburg
sites for autogenous bone graft:
iliac crest and posterior
crest of
of the femur
3. Femoral condyle 4. Proximal
tibia1 metaphysis of the tibia
5 C.
Olecranon,
D-69120 Heidelberg
and medial malleolus
distal radius
111 general, autogentjus bone graft is taken from the ventral and dorsal areas of the ilium. The other donor sites should be regarded as supplementary areas if the main source, namely the ilium, should not be sufficient or if it ullexpectrdly becomes apparent during the operation that only a small amount of graft is required. In exceptional cases, cortical strips, ribs and fibular graft can be used. In clinical practice, the amount nf bone obtainable from both anterior iliac crests is almost always adequate for the treatment of fresh fractures of the limbs. In the case of extensive, secondary, reconstructive procedures for multiple fracture defects, it is recommended that graft be taken from the posterior iliac crest. This involves placing the patient in the lateral or prone position which may be difficult, depending on the injury. Further considerations when determining the pelvic donor site, i.e. ventral/dorsal, left/right, are previous extraction of cancellous bone, existing scars and the position of the injury on the lower limbs. If possible, autograft should be taken on the same side of the body as the injury so that the intact
contralateral limb can function (Riiter and Lob, 19X5).
freely and painlessly
The donor sites on the pelvis are dictated by its anatomy: The iliac wing faces forward and at the end of the anterior superior iliac spine an obvious prominence runs laterally as a palpable ridge as far as the roof of the acetabulum. In the central part of the wing of the ilium the bone is very thin as it approaches the internal and external cortical laminae. The ilium widens out dorsally towards the sacroiliac joint. The main reserves of cancellous bone are to be found in this area and in the ventral portion of the ilium where three to four times the amount of bone is found dorsally as ventrally (Fig. la and b).
Fig. la and b: Transverse section of the iliac wing. a) Position of the saw cuts.
S-A6
Extraction of graft from the iliac wing: ventral approach Anatomical sites
b) The cut surface of the segments. (Courtesy of A. Riiter and c. Lob, 1985).
The attachments of the internal and external oblique muscles and the transversus abdominis muscles are found on the iliac crest; the inner side of the ilium is covered and filled out by the iliacus muscle. On the outer side of the ilium are the origins of the iliotibial tract and those of the gluteus Animus and gluteus medius muscles. When exposing the anterior iliac crest, attention must be paid to the lateral femoral cutaneous nerve. This nerve lies close to the anterior iliac spine, but its exact position varies. As a branch of the lumbar plexus, it supplies skin sensation to the lateral aspect of the thigh. It passes over the iliacus muscle which covers the inner surface of the iliac wing and exits medial to the anterior superior iliac spine, deep to the inguinal ligament and crosses superficial to the sarto&s muscle. This nerve may pierce the inguinal ligament or lie above it; however, it will rarely iie above the iliac spine (Fig. 2). Position In order to facilitate access to the pelvic donor site, the patient lies in the supine postion and a sandbag is placed under the ipsilateral buttock to raise it slightly. The lateral femoral cutaneous nerve is protected by positioning the leg in slight adduction and bending it at the hip joint (Fig. 3).
Fig. 2: The lateral femoral cutaneous nerve can easily be damaged by the elevators which are inserted very deep and manoeuvered vigorously. Prophylaxis: Bending and adduction at the hip joint, the elevator should not be inserted too far ventrally but directed towards the sacrococcyx as much as possible.
Meeder: Obtaining autogznous bone graft
Fig. 3: Raising the hip to facilitate graft from the-anterior iliac wing.
extraction
S-A7
of the
Operative procedure The standard skin incision is made at a distance of 1 cm superior and parallel to the iliac crest so that the postoperative scar will not be on the prominent bone and easily irritated (Riiter and Lob, 1986). The alternative is to place the incision 2 cm caudally from the iliac crest. This position can easily be determined by pressing on the abdomen with the palm of the hand so that the skin is pulled taut over the iliac crest which is then easily visible and palpable (Fig. 4) (Daniaux and Seykora, 1990). To avoid damage to the lateral femoral cutaneous nerve, the incision should be 2-3 cm from the iliac spine. After dividing the subcutaneous tissue, the lateral edge of the iliac.crest is exposed and the perinsteum and the aponeuroses of the trunk and gluteal, and the iliotibial tract dissected in the intermuscular interval to expose the bone (Fig. 5a).
Fig. 4: Incision over the iliac crest. It is important to maintain a wide per&teal border laterally in order to have enough material for subsequent reinsertion (Daniaux and Seykora, 1990). Using the curved periosteal elevator the insertions or origins of the abdominal muscles are detached en bloc subperiosteally and the medial edge of the ilium exposed (Fig. 5b). With the blunt elevator or the wide Garre spa&la, the iliacus muscle can be detached with the periosteum from the concave inner wall of the ilium. A broad retractor, or even better, an additional narrow one can be used to maintain exposure of the operative field. The tips are carefully pressed into the medial cortex of the iliac wing dorsally and towards the sacroiliac joint.
Obtaining cancellous and monocortical cancellous bone for grafting
cortico-
There are two procedures for obtaining pure particled cancellous bone whereby the medial cortex remains intact so that there is no loss of functional stability.
lnjuy 1994,Supplement2
S-A8
Fig. 5a: Division of the aponeuroses
Fig. 5b: Subperiosteal
in the muscle interval to expose the iliac crest.
stripping of the gluteal muscles to expose the interior edge of the iliac crest.
A flat, 10 mm chisel is placed on and parallel to the iliac crest and driven into the inner table at an obtuse angle. With a narrow chisel, two oblique osteotomies are carried out oblique to the first ostcotomy and the media1 cortex is opened wide. With the bone curettc, the cancellous bone is scooped out from between the cortical lamellae. The osteotomy is closed by reinsertion of the window in the cortex on the medial side and bv transosseous suhlres (Fig. ha and b).
If large quantities of autngenous graft are required, then it is removed from below the lower edge of the iliac crest beginning with a flat chisel at the inner cortex of the iliac wing and then harvesting all the canccllous bone from the anterior iliac wing using hollow chisels and bone curettes. The outer table of the ilium must be carefully preserved during this must be avoided. Large procedure; perforation amounts of monocortical cortico-cancellous graft can be obtained in the same way. The operative field must be thoroughly irrigated and bleeding from the exposed areas of cancellous bone can be stopped using a haemostyptic. No deep vacuum drains are inserted. After insertion of a subcutaneous drain, the wound is closed in layers. Obtaining cancellous
bicortical and bone for grafting
tricortical
cortico-
The continuity of the iliac crest should not be affected in any way by the extraction of bicortical corticocancellous graft or bone blocks from the iliac wing. Incision of the skin, aponeurnses and periosteum is performed as for cancellous bone. The periosteum on the lateral side, along with the attached gluteal muscles, is retracted several centimetres from the outer wall of the pelvis in a caudal direction. The required size of bone block can then be cut from the pelvic wall with an oscillating saw, beginning laterally and just below the iliac crest (Fig. 7). After harvesting the bicortical cortico-cancellous bone block, the canccllous bone can be scooped out of the bony window as required.
Fig. ha and b: Obtaining tricortical cortico-cancellous graft and rcconstructicrn of the iliac crest.
Fig. 7: Obtaining bicortical corticn-cancellous graft whilst leaving the iliac crest intact.
bone for
S-Al0 To close the defect and to arrest the bleeding, the gluteal and iliac musculature are sutured across the window over the deep vacuum drains. Subsequent closure of the wound is as described above following extraction of cancellous or monocortical corticoExtensive tricortical corticocancellous graft. cancellous bone grafts (“U-shaped”) involving the iliac crest itself are very rarely needed (H. Daniaux and P. Seykora, 1992). In these situations, a local sliding graft can be used to reconstruct the contours of the i!iac crest in order to avoid a visible defect and subjective dissatisfaction (Fig. 8a and b). The sliding graft is fixed using transosseous sutures. If a small ticortical graft is required with a maximum base of 1 cm (correction osteotomy), then extraction of a wedge is possible without reconstruction of the iliac crest.(Fig. 9).
Fig. 9: Position of the skin incision vertically on the posterior iliac crest.
which is made
Extraction of graft from the iliac wing: dorsal approach Anatomical
sites
The gluteal region is bordered by the Sulcus glutaeus below and by- the iliac crest above which runs from the anterior superior iliac spine to the posterior superior iliac spine. The tensor fasciae latae muscle originates on the anterior aspect of the iliac crest, the gluteus medius on the external aspect of the ilium and the gluteus minimus on the outer aspect of the ilium; the gluteus maximus originates at the posterior gluteal line of the ilium. The piriformis muscle divides the greater sciatic foramen into supra and infrapiriform regions. The following emerge in the suprapiriform region: the superior nerve, artery and vein; and in the infrapiriform region: the sciatic nerve, the inferior gluteal nerve, .artery and vein. The superior cluneal nerve supplies sensation to the gluteal region around the iliac crest. Position The patient is placed in the prone position hip raised.
Figs 8a and b: Harvesting a tricortical cortico-cancellous graft and reconstruction crest.
(U-profile) of the iliac
Operative
with the
technique
The standard skin incision starts alongside the vertebral column at the posterior superior iliac spine and extends laterally and cranially to the dorsal iliac
crest. An alternative would be to make an incision vertical to the posterior iliac crest in order to avoid the superior cluneal nerves which lie about 5 cm to the lateral side of the posterior superior iliac spine and run from the cranial/medial side in a dorsal/lateral direction (Fig. 10). The subcutaneous tissue is divided, the lateral border of the posterior iliac crest exposed and, having cut the periosteum and the fasciae, the gluteal muscles are lifted in a single layer subperiosteally from the outer surface of the posterior iliac wing using the sharp elevator. One or two narrow retractors are introduced with their tips pointing towards the greater sciatic notch and pressed into the cortex so that the operative field is clearly visible. It is important to avoid damage to the superior gluteal neurovascular bundle which exits from the greater sciatic notch. Harvesting cancellous and monocortical, and tricortical cortico-cancellous graft
bicortical
Cancellous bone is taken as for the anterior iliac wing: Small quantities can be obtained through a window in the cortex which is then closed on completion. To obtain large quantities, the outer cnrtex is chiselled away and the cancellnus bone gouged out with hollow chisels and bone curettes.
To obtain monocortical cortico-cancellous graft, the cuts are made into the outer table across or parallel to the edge of the ilium using the chisel or oscillating saw. The broad chisel is inserted and the bone scooped out. Bicortical and tricortical grafts can be removed dorsally as described above. Perforation of the inner table or discontinuity of the pelvic girdle at the level of the greater sciatic notch must be avoided at all costs and the sacroiliac joint must be treated with great care. Bleeding is stopped by application of a haemostyptic. Closure of the wound in layers and insertion of subcutaneous vacuum drains.
Obtaining graft from the Trochanter major femoris, Condylus femoris, Caput tibiae, Malleolus intemus tibiae, olecranon and distal radius. Autogenous cancellous bone suitable for grafting is to be found in the femoral intertrochanteric region, the femoral condyles, the proximal tibia, the distal tibia, the olecranon and the distal radius. These areas are to be regarded as atypical donor sites. They are reserved for use in those situations in which small amounts of graft suddenly become necessary during the operation or when the reserves of the anterior and posterior iliac crest have been exhausted.
Greater trochanter
Fig. If): Harvesting a wedge-shaped tricortical graft with a maximum base of 1 cm without reconstruction of the iliac crest.
of the femur, femoral condyle
Cancellous bone suitable for grafting is to be found in the proximal part of the femur in the area of the greater trochanter and on the distal side of the condyle. Cortico-cancellous graft should not be taken from these donor sites, but rather only small amounts of cancellous bone. When removing bone, the great loads placed on the femur must be taken into consideration and its stability must not be impaired. For this reason, it is recommended that round windows be made with a drill. Access is by means of a longitudinal incision on the distal side of the major trochanter. The iliotibial tract is split in the direction of its fibres and the major trochanter exposed. The cancellous bone is taken through a lateral bone window and along the axis of the femoral neck with the aid of a bone curette. The bony attachments for the iliopsoas and gluteus medius muscles should not be completely hollowed out because of the risk of avulsion fractures. The bone window is repaired using a haemostyptic and the wound closed in layers after insertion of the drains (Fig. 11).
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Fig. 11: Obtaining bone graft from the major t&chanter and the distal tibia. A bone curette is used to remove pure cancellous bone from the major trochanter or the distal tibia.
Fig. 12: Obtaining proximal tibia.
cancellous
bone graft
from the
Extraction of cancellous bone from the femoral condyle is also by means of a lateral approach. The iliotibial tract is divided in the direction of its fibres and a window in the bone is drilled. The cancellous bone is removed obliquely using the bone curette. A thickness of at least 2 cm of subchondral bone must remain if a collapse of the articulating surface is to be avoided. Application of a haemostyptic in the area of the drill hole and wound closure in layers after insertion of the drain. Proximal tibia1 metaphysis, olecranon and distal radius
medial
malleolus,
Relatively little cancellous bone is to be found in these areas and extraction of bone may cause instability. Therefore, these donor sites are of secondary importance. An interval of 2 cm to the joint surface must remain in order to retain stability (Fig. 12). The approach is usually dependent on the position of the main operative field. The bone windows should be small and rounded if possible. If the windows in the cortex are square or rectangular, there is a danger of fissure formation, starting at the corners of the corticotomy.
Fig. 13a: Special plane driven by the universal and used to obtain cortical graft.
Obtaining cortical strips for grafting Cortical strips are useful for cortical defects in multifragmentary diaphyseal fractures of long bones. These avital fragments are made into strips which are 2-3 mm long and 80-100 pm thick. This is done with a special plane (Fig. 13a and b). The graft is then transplanted into the defect.
Fig. 13b: Replaceable
surfon plane.
drill
MredLT: OhtairlinX
autopous
S-Al3
bow p-aft
Rib grafting With the patient in the lateral position and under insufflation anaesthesia, the skin is incised over the rib to be resected, preferably the 5th to 10th ribs. Ttwse ribs arc preferred for anatomical reasrjns: They approach an angle of %P close to the costal angle, but tltherwise they run more or less straight, or curve llnly slightly towards the bony attachment (Meeder, l’fK6). The skin and subcutaneous fat is divided. The muscles arc incised using the ordinary or the electric knife - the electric knife is strongly recommendc*d frjr longitudinal division of the periostcum elf the rib. After stripping the pericrstrum down to the edge of the rib with the aid of a straight periosteal elevator and after dissecting the muscle attachment:, iIf the outer intercnstal muscles from the edge of the rib, the lclwer surfacr is stripped from the perinsteum with a Doyne elevator. Rib shears are used to resect the rib. to check that the pleura have It is imperative stopped the remained intact (Fig. 14). Having bleeding and inserted the drains, the wound is closed in layers and carefully sutured. Rib sections up to 20 cm in length can be obtained using this technique.
Fig. 14a-e: a: Following longitudinal incision over the rib, the pericateum is best divided longitudinally using; the electric knife.
Fig. 14b: The periosteum is pushed the rib using the straight rasp&q.
Fig. 14~: Initial stripping raspa tory.
aside to expose
of the rib using the angled
Fig. 14d: The periosteum can then be completely stripped from the inner rib using the Doyen rib raspatory.
Fig. 14~: Rib resection is performed l>r Sauerbruch-Frey rib shears.
using the Brunner
e
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Obtaining
fibula graft
If the fibula is to be obtained as an isolated graft, the length of the anterolateral skin incision over-the tibia will be determined by the amount of graft required. In practice, as much as 4/5 of the fibula may be removed. In children and adolescents, the proximal and distal fifths should be left intact in order to avoid secondary complications involving the adjacent joints, such as progressive valgus deformity of the ankle. The insertion of a stabilizing screw combined with a bone block placed between the remaining fibula and the tibia provides a bony synostosis and prevents valgus deformity and/or instability of the upper ankle. After incision of the fasciae and exposure of the peroneal nerve, the fibula is stripped subperiosteally and osteotomies are performed proximally and distally using the oscillating saw (Fig. 15). Having ensured that the peroneal nerve has not been damaged and that the upper ankle joint is stable, the wound is closed in layers over the vacuum drains.
Fig. 15a-d: a. Longitudinal incision over the fibula showing the pen&al nerve and longitudinal division of the fasciae immediately adjacent to the intermuscular septum,
Fig. 15b: Stripping of the peroneal musculature from the lateral anterior surface of the fibula; the perinsteum is retained.
Fig. 15~: Proximal and reiuired length of fibula oscillating saw. The soft Langenbeck and Hohmann
distal osteotnmy for the is carried out using the tissue are retracted with hooks.
Fig. 15d: The section of bone graft is then rotated o&vards using bone forceps and separated from the interosseous membrane.
a
b
C ---
S-Al6 Intraoperative
treatment
of autogenous
graft
The biological value of a graft considerably depends on how much time elapses between extraction and reinsertion of the graft. Puranen 0966) looked into this issue thoroughly. If the graft is kept for only one hour exposed to the air at room temperature, such extensive alteration takes place that the results of grafting would be similar to those obtained with deep-frozen autogenous or homologous graft. If the autogenous graft is kept in ph&&@ical saline solution for up to two hours, it remains eiuivalent to fresh graft. Schweiberer et al. (1981, 1982) maintain that leaving the graft exposed to the air for as little as 20 minutes. leads to a reduction in the vitality of the graft. They reject preservation of the graft in saline solution and prefer to keep it in blond-soaked compresses. Berggren et al. (1982) reported dissimilar survival periods for osteocytes and osteoblasts when the graft was stored in Collins solution at 5 “C. In animal experiments, they observed healthy survival of the bone cells in microvascular pedicled bone grafts after a period of 25 hours. In practice, it is recommended that the graft be explanted immediately before transplantation. If it needs to be temporarily stored, then cancellous graft, cortical strips or cortico-cancellous blocks should be placed in blood or in a moist chamber but not in physiological saline solution. Complications
during graft extraction
Follow-up of 10(K)patients by Miiller (7983) indicated a complication rate of 4.2%. There were 32 haematomas, 7 encroachments on the lateral femoral cutaneous nerves, 2 cases of infection and 1 pertrochanteric fracture following extraction of cancellous bone from the greater trochanter. 25% of patients complained of pain after grafting from the iliac crest, some of them having pain for a relatively long period. Laurie et al. (1984) observed 5 cases of damage to the lateral femoral cutaneous nerve in 104 patients, all of whom experienced pain, sometimes over a long period, at the iliac crest. In those cases in which an abdominal hernia developed through the iliac wing, as described by Campbell (1980) and Reid (1968), large portions of the iliac crest had been removed. Stress fractures of the ilium following the extraction of cortico-cancellous bone blocks fro& the anterior iliac wing were reported by Guha and Polle (1983) in two patients. In a follow-up study of our own patients (St. George’s Hospital, Hamburg), involving 769 cases of bone grafting between 1. Jan., 1979 and 30. July, 1985,. we found only six complications (0.8%): 1 case of damage to the lateral femoral cutaneous nerve, 2 infections, 2 cases of postoperative haemorrhage and 1 haematoma requiring revision treatment.
Acknowledgement: The authors wish to express their gratitude to the School of Art and Design, Zurich, for preparing the artwork for this chapter. The drawings were made by the Special Class for Scientific Drawing under the supervision of Mr. Chr. Gijldlin, namely,.by C. Gantenbein, S. Heusser, H. Hromadka, and M. Moser who was also responsible for the layout.
References Berggren A., Weiland A.J. and Lkrfmann, H. (1982) The effect of prolonged ischemia time on osteocyte and osteoblast survival in composite bone grafts revascularized by microvascular anastomoses. Plnst. P&onstr. Surg., 69 (2), 290.
Campbell W. C. (1980) Campbell’s Mosby, Toronto.
operative
orthopaedics.
Daniaux H. and Seykora, P. (1990) Technik der Knochenentnahme am Becken, 213-221. In: Beck E. (ed.) Breitner Chirurgische Operationslehre Band Xl, Traumatologie 4. - Untere Extremitat, Urban and Schwarzenbeck, Munich, Vienna, Baltimore. Guha S.C. and Polle M.D. (1983) Stress fracture of the iliac bone with subfascial femoral neuropathy: Unusual complications in a bone graft donor. Case Report, Rr. J. Plast. Surg., 36,305-306.
Laurie S. W. S., Kaban L.B., Mulliken J.B. et al. (1984) Donor site morbidity after harvesting rib and iliac bone, Plnst. Rccorrstr. Surg., 73, 933-938. Meeder, P.-J. (1986) Die autologe Rippenspanplastik zur Defektiiberbriickung an Rohrenknochen - eine klinische und experimentelle~Studie, postdoctoral thesis, University of Tubingen. Miiller G.W. (1983) Beschwerden und Komplikationen nach Spongiosaentnahme am Becken - Klinische Studie an 1000 Patienten. Doctoral thesis, Universitat Ulm. puranen J. (1966) Reorganization of fresh and preserved bone transplants, Acfa Orthop. Stand. (Suppl.) 92. Reid R.L. (1968) Hernia through site, j. Ronc It Surg., 50,757-760.
an iliac bone graft donor
Ruter A. and Lob, G. (1986) Die Entnahme Knochentransplantate, Orthopde, 15,10-15.
autologer
Schweiberer L., Brenneisen R., Dambe L.T. et al. (1981) Derzeitiger Stand der auto-, hetero- und homoplastischen Knochentransplantation, 115-127. In: Cotta H. and Martini A.K. (eds) Implantate und Transplantate in der plastischen und Wiederherstellungschirurgie, 17. Jahrestagung der Deutschen Gesellschaft fiir plastische und Wiederherstellungschirurgie 1979, Springer Verlag, Heidelberg. Schweiberer L., Eitel, F. and Betz giosatransplantation, Chirurg, 53,195.
A.
(1982)
Spon-
2. Techniques for obtaining autogenous bone graft
P.-J. Meeder,
M.D.1 and Ch. Eggers, M.D.2
1 Head of the Dept. of Trauma
and Reconstructive
2 Head of the Dept. of Trauma, Reconstructive
The following areas are donor cancellous and cortico-cancellous 1. Anterior superior the ilium 2. Greater
trochanter
Surgery, University Clinic Heidelberg,
and Hand Surgery, St. George’s Hospital, D-20099 Hamburg
sites for autogenous bone graft:
iliac crest and posterior
crest of
of the femur
3. Femoral condyle 4. Proximal
tibia1 metaphysis of the tibia
5 C.
Olecranon,
D-69120 Heidelberg
and medial malleolus
distal radius
111 general, autogentjus bone graft is taken from the ventral and dorsal areas of the ilium. The other donor sites should be regarded as supplementary areas if the main source, namely the ilium, should not be sufficient or if it ullexpectrdly becomes apparent during the operation that only a small amount of graft is required. In exceptional cases, cortical strips, ribs and fibular graft can be used. In clinical practice, the amount nf bone obtainable from both anterior iliac crests is almost always adequate for the treatment of fresh fractures of the limbs. In the case of extensive, secondary, reconstructive procedures for multiple fracture defects, it is recommended that graft be taken from the posterior iliac crest. This involves placing the patient in the lateral or prone position which may be difficult, depending on the injury. Further considerations when determining the pelvic donor site, i.e. ventral/dorsal, left/right, are previous extraction of cancellous bone, existing scars and the position of the injury on the lower limbs. If possible, autograft should be taken on the same side of the body as the injury so that the intact
contralateral limb can function (Riiter and Lob, 19X5).
freely and painlessly
The donor sites on the pelvis are dictated by its anatomy: The iliac wing faces forward and at the end of the anterior superior iliac spine an obvious prominence runs laterally as a palpable ridge as far as the roof of the acetabulum. In the central part of the wing of the ilium the bone is very thin as it approaches the internal and external cortical laminae. The ilium widens out dorsally towards the sacroiliac joint. The main reserves of cancellous bone are to be found in this area and in the ventral portion of the ilium where three to four times the amount of bone is found dorsally as ventrally (Fig. la and b).
Fig. la and b: Transverse section of the iliac wing. a) Position of the saw cuts.
S-A6
Extraction of graft from the iliac wing: ventral approach Anatomical sites
b) The cut surface of the segments. (Courtesy of A. Riiter and c. Lob, 1985).
The attachments of the internal and external oblique muscles and the transversus abdominis muscles are found on the iliac crest; the inner side of the ilium is covered and filled out by the iliacus muscle. On the outer side of the ilium are the origins of the iliotibial tract and those of the gluteus Animus and gluteus medius muscles. When exposing the anterior iliac crest, attention must be paid to the lateral femoral cutaneous nerve. This nerve lies close to the anterior iliac spine, but its exact position varies. As a branch of the lumbar plexus, it supplies skin sensation to the lateral aspect of the thigh. It passes over the iliacus muscle which covers the inner surface of the iliac wing and exits medial to the anterior superior iliac spine, deep to the inguinal ligament and crosses superficial to the sarto&s muscle. This nerve may pierce the inguinal ligament or lie above it; however, it will rarely iie above the iliac spine (Fig. 2). Position In order to facilitate access to the pelvic donor site, the patient lies in the supine postion and a sandbag is placed under the ipsilateral buttock to raise it slightly. The lateral femoral cutaneous nerve is protected by positioning the leg in slight adduction and bending it at the hip joint (Fig. 3).
Fig. 2: The lateral femoral cutaneous nerve can easily be damaged by the elevators which are inserted very deep and manoeuvered vigorously. Prophylaxis: Bending and adduction at the hip joint, the elevator should not be inserted too far ventrally but directed towards the sacrococcyx as much as possible.
Meeder: Obtaining autogznous bone graft
Fig. 3: Raising the hip to facilitate graft from the-anterior iliac wing.
extraction
S-A7
of the
Operative procedure The standard skin incision is made at a distance of 1 cm superior and parallel to the iliac crest so that the postoperative scar will not be on the prominent bone and easily irritated (Riiter and Lob, 1986). The alternative is to place the incision 2 cm caudally from the iliac crest. This position can easily be determined by pressing on the abdomen with the palm of the hand so that the skin is pulled taut over the iliac crest which is then easily visible and palpable (Fig. 4) (Daniaux and Seykora, 1990). To avoid damage to the lateral femoral cutaneous nerve, the incision should be 2-3 cm from the iliac spine. After dividing the subcutaneous tissue, the lateral edge of the iliac.crest is exposed and the perinsteum and the aponeuroses of the trunk and gluteal, and the iliotibial tract dissected in the intermuscular interval to expose the bone (Fig. 5a).
Fig. 4: Incision over the iliac crest. It is important to maintain a wide per&teal border laterally in order to have enough material for subsequent reinsertion (Daniaux and Seykora, 1990). Using the curved periosteal elevator the insertions or origins of the abdominal muscles are detached en bloc subperiosteally and the medial edge of the ilium exposed (Fig. 5b). With the blunt elevator or the wide Garre spa&la, the iliacus muscle can be detached with the periosteum from the concave inner wall of the ilium. A broad retractor, or even better, an additional narrow one can be used to maintain exposure of the operative field. The tips are carefully pressed into the medial cortex of the iliac wing dorsally and towards the sacroiliac joint.
Obtaining cancellous and monocortical cancellous bone for grafting
cortico-
There are two procedures for obtaining pure particled cancellous bone whereby the medial cortex remains intact so that there is no loss of functional stability.
lnjuy 1994,Supplement2
S-A8
Fig. 5a: Division of the aponeuroses
Fig. 5b: Subperiosteal
in the muscle interval to expose the iliac crest.
stripping of the gluteal muscles to expose the interior edge of the iliac crest.
A flat, 10 mm chisel is placed on and parallel to the iliac crest and driven into the inner table at an obtuse angle. With a narrow chisel, two oblique osteotomies are carried out oblique to the first ostcotomy and the media1 cortex is opened wide. With the bone curettc, the cancellous bone is scooped out from between the cortical lamellae. The osteotomy is closed by reinsertion of the window in the cortex on the medial side and bv transosseous suhlres (Fig. ha and b).
If large quantities of autngenous graft are required, then it is removed from below the lower edge of the iliac crest beginning with a flat chisel at the inner cortex of the iliac wing and then harvesting all the canccllous bone from the anterior iliac wing using hollow chisels and bone curettes. The outer table of the ilium must be carefully preserved during this must be avoided. Large procedure; perforation amounts of monocortical cortico-cancellous graft can be obtained in the same way. The operative field must be thoroughly irrigated and bleeding from the exposed areas of cancellous bone can be stopped using a haemostyptic. No deep vacuum drains are inserted. After insertion of a subcutaneous drain, the wound is closed in layers. Obtaining cancellous
bicortical and bone for grafting
tricortical
cortico-
The continuity of the iliac crest should not be affected in any way by the extraction of bicortical corticocancellous graft or bone blocks from the iliac wing. Incision of the skin, aponeurnses and periosteum is performed as for cancellous bone. The periosteum on the lateral side, along with the attached gluteal muscles, is retracted several centimetres from the outer wall of the pelvis in a caudal direction. The required size of bone block can then be cut from the pelvic wall with an oscillating saw, beginning laterally and just below the iliac crest (Fig. 7). After harvesting the bicortical cortico-cancellous bone block, the canccllous bone can be scooped out of the bony window as required.
Fig. ha and b: Obtaining tricortical cortico-cancellous graft and rcconstructicrn of the iliac crest.
Fig. 7: Obtaining bicortical corticn-cancellous graft whilst leaving the iliac crest intact.
bone for
S-Al0 To close the defect and to arrest the bleeding, the gluteal and iliac musculature are sutured across the window over the deep vacuum drains. Subsequent closure of the wound is as described above following extraction of cancellous or monocortical corticoExtensive tricortical corticocancellous graft. cancellous bone grafts (“U-shaped”) involving the iliac crest itself are very rarely needed (H. Daniaux and P. Seykora, 1992). In these situations, a local sliding graft can be used to reconstruct the contours of the i!iac crest in order to avoid a visible defect and subjective dissatisfaction (Fig. 8a and b). The sliding graft is fixed using transosseous sutures. If a small ticortical graft is required with a maximum base of 1 cm (correction osteotomy), then extraction of a wedge is possible without reconstruction of the iliac crest.(Fig. 9).
Fig. 9: Position of the skin incision vertically on the posterior iliac crest.
which is made
Extraction of graft from the iliac wing: dorsal approach Anatomical
sites
The gluteal region is bordered by the Sulcus glutaeus below and by- the iliac crest above which runs from the anterior superior iliac spine to the posterior superior iliac spine. The tensor fasciae latae muscle originates on the anterior aspect of the iliac crest, the gluteus medius on the external aspect of the ilium and the gluteus minimus on the outer aspect of the ilium; the gluteus maximus originates at the posterior gluteal line of the ilium. The piriformis muscle divides the greater sciatic foramen into supra and infrapiriform regions. The following emerge in the suprapiriform region: the superior nerve, artery and vein; and in the infrapiriform region: the sciatic nerve, the inferior gluteal nerve, .artery and vein. The superior cluneal nerve supplies sensation to the gluteal region around the iliac crest. Position The patient is placed in the prone position hip raised.
Figs 8a and b: Harvesting a tricortical cortico-cancellous graft and reconstruction crest.
(U-profile) of the iliac
Operative
with the
technique
The standard skin incision starts alongside the vertebral column at the posterior superior iliac spine and extends laterally and cranially to the dorsal iliac
crest. An alternative would be to make an incision vertical to the posterior iliac crest in order to avoid the superior cluneal nerves which lie about 5 cm to the lateral side of the posterior superior iliac spine and run from the cranial/medial side in a dorsal/lateral direction (Fig. 10). The subcutaneous tissue is divided, the lateral border of the posterior iliac crest exposed and, having cut the periosteum and the fasciae, the gluteal muscles are lifted in a single layer subperiosteally from the outer surface of the posterior iliac wing using the sharp elevator. One or two narrow retractors are introduced with their tips pointing towards the greater sciatic notch and pressed into the cortex so that the operative field is clearly visible. It is important to avoid damage to the superior gluteal neurovascular bundle which exits from the greater sciatic notch. Harvesting cancellous and monocortical, and tricortical cortico-cancellous graft
bicortical
Cancellous bone is taken as for the anterior iliac wing: Small quantities can be obtained through a window in the cortex which is then closed on completion. To obtain large quantities, the outer cnrtex is chiselled away and the cancellnus bone gouged out with hollow chisels and bone curettes.
To obtain monocortical cortico-cancellous graft, the cuts are made into the outer table across or parallel to the edge of the ilium using the chisel or oscillating saw. The broad chisel is inserted and the bone scooped out. Bicortical and tricortical grafts can be removed dorsally as described above. Perforation of the inner table or discontinuity of the pelvic girdle at the level of the greater sciatic notch must be avoided at all costs and the sacroiliac joint must be treated with great care. Bleeding is stopped by application of a haemostyptic. Closure of the wound in layers and insertion of subcutaneous vacuum drains.
Obtaining graft from the Trochanter major femoris, Condylus femoris, Caput tibiae, Malleolus intemus tibiae, olecranon and distal radius. Autogenous cancellous bone suitable for grafting is to be found in the femoral intertrochanteric region, the femoral condyles, the proximal tibia, the distal tibia, the olecranon and the distal radius. These areas are to be regarded as atypical donor sites. They are reserved for use in those situations in which small amounts of graft suddenly become necessary during the operation or when the reserves of the anterior and posterior iliac crest have been exhausted.
Greater trochanter
Fig. If): Harvesting a wedge-shaped tricortical graft with a maximum base of 1 cm without reconstruction of the iliac crest.
of the femur, femoral condyle
Cancellous bone suitable for grafting is to be found in the proximal part of the femur in the area of the greater trochanter and on the distal side of the condyle. Cortico-cancellous graft should not be taken from these donor sites, but rather only small amounts of cancellous bone. When removing bone, the great loads placed on the femur must be taken into consideration and its stability must not be impaired. For this reason, it is recommended that round windows be made with a drill. Access is by means of a longitudinal incision on the distal side of the major trochanter. The iliotibial tract is split in the direction of its fibres and the major trochanter exposed. The cancellous bone is taken through a lateral bone window and along the axis of the femoral neck with the aid of a bone curette. The bony attachments for the iliopsoas and gluteus medius muscles should not be completely hollowed out because of the risk of avulsion fractures. The bone window is repaired using a haemostyptic and the wound closed in layers after insertion of the drains (Fig. 11).
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Fig. 11: Obtaining bone graft from the major t&chanter and the distal tibia. A bone curette is used to remove pure cancellous bone from the major trochanter or the distal tibia.
Fig. 12: Obtaining proximal tibia.
cancellous
bone graft
from the
Extraction of cancellous bone from the femoral condyle is also by means of a lateral approach. The iliotibial tract is divided in the direction of its fibres and a window in the bone is drilled. The cancellous bone is removed obliquely using the bone curette. A thickness of at least 2 cm of subchondral bone must remain if a collapse of the articulating surface is to be avoided. Application of a haemostyptic in the area of the drill hole and wound closure in layers after insertion of the drain. Proximal tibia1 metaphysis, olecranon and distal radius
medial
malleolus,
Relatively little cancellous bone is to be found in these areas and extraction of bone may cause instability. Therefore, these donor sites are of secondary importance. An interval of 2 cm to the joint surface must remain in order to retain stability (Fig. 12). The approach is usually dependent on the position of the main operative field. The bone windows should be small and rounded if possible. If the windows in the cortex are square or rectangular, there is a danger of fissure formation, starting at the corners of the corticotomy.
Fig. 13a: Special plane driven by the universal and used to obtain cortical graft.
Obtaining cortical strips for grafting Cortical strips are useful for cortical defects in multifragmentary diaphyseal fractures of long bones. These avital fragments are made into strips which are 2-3 mm long and 80-100 pm thick. This is done with a special plane (Fig. 13a and b). The graft is then transplanted into the defect.
Fig. 13b: Replaceable
surfon plane.
drill
MredLT: OhtairlinX
autopous
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bow p-aft
Rib grafting With the patient in the lateral position and under insufflation anaesthesia, the skin is incised over the rib to be resected, preferably the 5th to 10th ribs. Ttwse ribs arc preferred for anatomical reasrjns: They approach an angle of %P close to the costal angle, but tltherwise they run more or less straight, or curve llnly slightly towards the bony attachment (Meeder, l’fK6). The skin and subcutaneous fat is divided. The muscles arc incised using the ordinary or the electric knife - the electric knife is strongly recommendc*d frjr longitudinal division of the periostcum elf the rib. After stripping the pericrstrum down to the edge of the rib with the aid of a straight periosteal elevator and after dissecting the muscle attachment:, iIf the outer intercnstal muscles from the edge of the rib, the lclwer surfacr is stripped from the perinsteum with a Doyne elevator. Rib shears are used to resect the rib. to check that the pleura have It is imperative stopped the remained intact (Fig. 14). Having bleeding and inserted the drains, the wound is closed in layers and carefully sutured. Rib sections up to 20 cm in length can be obtained using this technique.
Fig. 14a-e: a: Following longitudinal incision over the rib, the pericateum is best divided longitudinally using; the electric knife.
Fig. 14b: The periosteum is pushed the rib using the straight rasp&q.
Fig. 14~: Initial stripping raspa tory.
aside to expose
of the rib using the angled
Fig. 14d: The periosteum can then be completely stripped from the inner rib using the Doyen rib raspatory.
Fig. 14~: Rib resection is performed l>r Sauerbruch-Frey rib shears.
using the Brunner
e
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Obtaining
fibula graft
If the fibula is to be obtained as an isolated graft, the length of the anterolateral skin incision over-the tibia will be determined by the amount of graft required. In practice, as much as 4/5 of the fibula may be removed. In children and adolescents, the proximal and distal fifths should be left intact in order to avoid secondary complications involving the adjacent joints, such as progressive valgus deformity of the ankle. The insertion of a stabilizing screw combined with a bone block placed between the remaining fibula and the tibia provides a bony synostosis and prevents valgus deformity and/or instability of the upper ankle. After incision of the fasciae and exposure of the peroneal nerve, the fibula is stripped subperiosteally and osteotomies are performed proximally and distally using the oscillating saw (Fig. 15). Having ensured that the peroneal nerve has not been damaged and that the upper ankle joint is stable, the wound is closed in layers over the vacuum drains.
Fig. 15a-d: a. Longitudinal incision over the fibula showing the pen&al nerve and longitudinal division of the fasciae immediately adjacent to the intermuscular septum,
Fig. 15b: Stripping of the peroneal musculature from the lateral anterior surface of the fibula; the perinsteum is retained.
Fig. 15~: Proximal and reiuired length of fibula oscillating saw. The soft Langenbeck and Hohmann
distal osteotnmy for the is carried out using the tissue are retracted with hooks.
Fig. 15d: The section of bone graft is then rotated o&vards using bone forceps and separated from the interosseous membrane.
a
b
C ---
S-Al6 Intraoperative
treatment
of autogenous
graft
The biological value of a graft considerably depends on how much time elapses between extraction and reinsertion of the graft. Puranen 0966) looked into this issue thoroughly. If the graft is kept for only one hour exposed to the air at room temperature, such extensive alteration takes place that the results of grafting would be similar to those obtained with deep-frozen autogenous or homologous graft. If the autogenous graft is kept in ph&&@ical saline solution for up to two hours, it remains eiuivalent to fresh graft. Schweiberer et al. (1981, 1982) maintain that leaving the graft exposed to the air for as little as 20 minutes. leads to a reduction in the vitality of the graft. They reject preservation of the graft in saline solution and prefer to keep it in blond-soaked compresses. Berggren et al. (1982) reported dissimilar survival periods for osteocytes and osteoblasts when the graft was stored in Collins solution at 5 “C. In animal experiments, they observed healthy survival of the bone cells in microvascular pedicled bone grafts after a period of 25 hours. In practice, it is recommended that the graft be explanted immediately before transplantation. If it needs to be temporarily stored, then cancellous graft, cortical strips or cortico-cancellous blocks should be placed in blood or in a moist chamber but not in physiological saline solution. Complications
during graft extraction
Follow-up of 10(K)patients by Miiller (7983) indicated a complication rate of 4.2%. There were 32 haematomas, 7 encroachments on the lateral femoral cutaneous nerves, 2 cases of infection and 1 pertrochanteric fracture following extraction of cancellous bone from the greater trochanter. 25% of patients complained of pain after grafting from the iliac crest, some of them having pain for a relatively long period. Laurie et al. (1984) observed 5 cases of damage to the lateral femoral cutaneous nerve in 104 patients, all of whom experienced pain, sometimes over a long period, at the iliac crest. In those cases in which an abdominal hernia developed through the iliac wing, as described by Campbell (1980) and Reid (1968), large portions of the iliac crest had been removed. Stress fractures of the ilium following the extraction of cortico-cancellous bone blocks fro& the anterior iliac wing were reported by Guha and Polle (1983) in two patients. In a follow-up study of our own patients (St. George’s Hospital, Hamburg), involving 769 cases of bone grafting between 1. Jan., 1979 and 30. July, 1985,. we found only six complications (0.8%): 1 case of damage to the lateral femoral cutaneous nerve, 2 infections, 2 cases of postoperative haemorrhage and 1 haematoma requiring revision treatment.
Acknowledgement: The authors wish to express their gratitude to the School of Art and Design, Zurich, for preparing the artwork for this chapter. The drawings were made by the Special Class for Scientific Drawing under the supervision of Mr. Chr. Gijldlin, namely,.by C. Gantenbein, S. Heusser, H. Hromadka, and M. Moser who was also responsible for the layout.
References Berggren A., Weiland A.J. and Lkrfmann, H. (1982) The effect of prolonged ischemia time on osteocyte and osteoblast survival in composite bone grafts revascularized by microvascular anastomoses. Plnst. P&onstr. Surg., 69 (2), 290.
Campbell W. C. (1980) Campbell’s Mosby, Toronto.
operative
orthopaedics.
Daniaux H. and Seykora, P. (1990) Technik der Knochenentnahme am Becken, 213-221. In: Beck E. (ed.) Breitner Chirurgische Operationslehre Band Xl, Traumatologie 4. - Untere Extremitat, Urban and Schwarzenbeck, Munich, Vienna, Baltimore. Guha S.C. and Polle M.D. (1983) Stress fracture of the iliac bone with subfascial femoral neuropathy: Unusual complications in a bone graft donor. Case Report, Rr. J. Plast. Surg., 36,305-306.
Laurie S. W. S., Kaban L.B., Mulliken J.B. et al. (1984) Donor site morbidity after harvesting rib and iliac bone, Plnst. Rccorrstr. Surg., 73, 933-938. Meeder, P.-J. (1986) Die autologe Rippenspanplastik zur Defektiiberbriickung an Rohrenknochen - eine klinische und experimentelle~Studie, postdoctoral thesis, University of Tubingen. Miiller G.W. (1983) Beschwerden und Komplikationen nach Spongiosaentnahme am Becken - Klinische Studie an 1000 Patienten. Doctoral thesis, Universitat Ulm. puranen J. (1966) Reorganization of fresh and preserved bone transplants, Acfa Orthop. Stand. (Suppl.) 92. Reid R.L. (1968) Hernia through site, j. Ronc It Surg., 50,757-760.
an iliac bone graft donor
Ruter A. and Lob, G. (1986) Die Entnahme Knochentransplantate, Orthopde, 15,10-15.
autologer
Schweiberer L., Brenneisen R., Dambe L.T. et al. (1981) Derzeitiger Stand der auto-, hetero- und homoplastischen Knochentransplantation, 115-127. In: Cotta H. and Martini A.K. (eds) Implantate und Transplantate in der plastischen und Wiederherstellungschirurgie, 17. Jahrestagung der Deutschen Gesellschaft fiir plastische und Wiederherstellungschirurgie 1979, Springer Verlag, Heidelberg. Schweiberer L., Eitel, F. and Betz giosatransplantation, Chirurg, 53,195.
A.
(1982)
Spon-