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Retrospective review of donor site complications after harvest of cancellous bone from the anteriomedial tibia
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British Journal of Oral and Maxillofacial Surgery 47 (2009) 20–22
Retrospective review of donor site complications after harvest of cancellous bone from the anteriomedial tibia Tom W.M. Walker ∗ , Prince C. Modayil, Luke Cascarini, Luke Williams, Simon Miles Duncan, Peter Ward-Booth Department of Oral & Maxillofacial Surgery, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex, RH19 3DZ, United Kingdom Accepted 1 May 2008 Available online 3 August 2008
Abstract Donor site morbidity is important in deciding the site for harvest of cancellous bone for alveolar bone grafts. Many studies have supported the view that tibia is safe with few complications in the short term. We know of no studies on the long-term complications to the donor site after tibial bone grafting in children with alveolar clefts. The casenotes of 40 children who had had tibial bone grafts for alveolar clefts were studied retrospectively, and parents or patients were contacted by telephone and a standardised questionnaire was used to assess any long term complications at the donor site. We found none. We found no evidence of long-term complications at the donor site in children who had had proximal tibial bone grafting for secondary repair of alveolar clefts. We conclude that the proximal tibia is a safe site from which to obtain cancellous bone graft for alveolar clefts in children. This study is preliminary, and highlights the need for a randomised trial. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Cleft; Alveolar Bone Graft; Tibia
Introduction Autogenous bone grafts are commonly used to bridge alveolar clefts. The bone stabilises the dental arch, allows teeth to erupt, and improves bony healing and growth. The ideal time for grafting is just before eruption of the permanent canine teeth.1–3 Donor sites of choice are the calvarium, mandibular symphysis, rib, ilium, and proximal tibia. Studies support the view that tibial harvesting is a safe procedure with low complication rates.4–6 However, there have been anecdotal reports that there may be pain and poor scarring at this donor site. The senior author has been harvesting bone from the proximal tibia through a medial approach using a 5 mm trephine for alveolar bone grafting in cleft children for over 15 years.4 We did a retrospective analysis of 40 sets of casenotes and ∗
Corresponding author. Tel.: +44 01342414300. E-mail address: [email protected] (T.W.M. Walker).
sent a questionnaire to patients or their parents to find out if there was any evidence of long-term complications at the tibial donor site.
Patients and methods We made a comprehensive search of the hospital coding system and theatre records to trace the notes of children who had had a tibial bone graft under the care of the senior author. All the cases of tibial bone grafting in children under 16 years old had been done for children with clefts. All patients fewer than 6 months postoperatively were excluded. We also excluded anyone who was over 16 years old at the time of operation. The search was stopped when 40 patients had been identified who met the inclusion criteria. The patient’s casenotes were used to collect details of the procedure and any record of early or late complications.
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.05.014
T.W.M. Walker et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 20–22
Parents or patients were contacted by telephone and a standardised questionnaire was used to enquire about any late complications, which included pain, reduced function, unacceptable scarring, attendance at any other hospital or medical practice, and whether the procedure had been repeated for any reason. The telephone call was made by same person each time and he always introduced himself as ‘someone who works in the hospital’, and he did not suggest that he was a surgeon or that he worked for the senior author. This was to reduce the likelihood that the results would be biased.
Surgical technique The patient is positioned supine with the knee flexed to about 45◦ . The landmarks are: the patella, the patellar ligament extending to the tibial tuberosity, the medial and lateral condyles, and the head of the tibia, which critically identifies the approximate level of the epiphyseal cartilage. Local anaesthetic (0.25% bupivacaine with 1/200 000 adrenaline) is infiltrated at the site, and access is through a stab incision placed medial to the midline tibial tuberosity. Medial access is favoured, as it avoids stripping the tibialis muscle. Bone is exposed only sufficiently to allow a single penetration of the cortex using a serrated cutting-end trephine (5 mm internal diameter with a 27 mm depth stop) (Martin Medizin, Tuttingen, Germany). Several cores of cancellous bone are harvested in a fan-like pattern and, if required, further bone can be removed with a curette. The wound is closed with two deep resorbable sutures to approximate the periosteum, and completed with skin sutures. A gauze dressing is placed with a light pressure bandage, and left on for 24 hours. Postoperative care included analgesia with paracetamol or non-steroidal analgesics, and early mobilisation is encouraged on the evening of operation.
Results Of the 40 patients included in the study, 15 had bilateral clefts (38%) and 25 unilateral clefts (63%). Twenty-six patients were male and 14 female (ratio 1.9:1). The mean age at operation was 10 years and 6 months, range 7 years 1 month to 15 years 7 months. Among the boys the range was 7 to 15.5 years (mean 10.5) and among the girls 7 to 14 years (mean 11). The follow up interval was 8 months to 10.5 years, with a mean of 4 years and 4 months. The bone was harvested from the right tibia in 29 cases (73%) and from the left in 11 (27%). The recipient site was the right in 19 cases (47.5%), left in 12 cases (30%), and bilateral in 9 cases (23%).
21
Review of casenotes Casenotes showed 6 recordings of short term complications relating to the donor site. These were pain or discomfort (n = 3), unsightly scarring (n = 2), and one wound infection. There were no recordings of long-term complications. Telephone Questionnaire Thirty-two parents answered the telephone questionnaire; the remaining 8 were answered by patients. They reported 4 postoperative complications, all of which were short-term. One patient had two weeks of pain at the donor site. Another had two hours of post operative pain. A third had minor discomfort on walking for a week. A fourth patient had a purulent discharge from the site. This was the same patient that was identified by a review of the casenotes with a wound infection one week postoperatively. The wound infection was treated with a course of antibiotics given orally. There was one exceptional case of persistent knee pain, which was referred to an orthopaedic surgeon, and a diagnosis of Osgood Schlatter disease was made.7 It was felt that this was probably coincidental and not related to the bone harvesting. This particular patient had the operation repeated three times because the cleft was large but all three grafts failed. However, he had had no long term complications at the tibial donor site on 6-year follow up. We have not mentioned radiographic follow-up of the recipient site as it is only complications at the donor site with which we are concerned. As far as long term complications were concerned, however, we found none at the donor site and scars were acceptable in all the cases.
Discussion Fresh autogenous cancellous bone supports the survival of the maximum amount of transplanted bone, and the number of pluripotential cells therefore provides the necessary raw material to enable osteoconduction, osteoinduction, and osteogenesis.8 There are intraoral and extraoral donor sites for autogenous bone grafts. The intraoral sites such as the mandibular symphysis, ramus, and palatine tori have been used for alveolar cleft repair with favourable results, but the amount of available bone is limited.9 The extraoral sites are iliac crest, rib, calvarium, and tibia. Among these, iliac and tibial bone grafts have become the choice for grafting of alveolar clefts. The use of proximal tibia as the donor site for reconstruction of cleft alveolus became popular in the United Kingdom in the late 1990s.4,10 There are many studies4–6,8,9 that have supported the use of the tibial graft because of the low morbidity at the donor site postoperatively. The speed at which children mobilise postoperatively, the time to discharge, and the low pain scores all
22
T.W.M. Walker et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 20–22
add to the attractiveness of this donor site. The same quality and quantity of cancellous bone can be obtained as from iliac crest grafts. Besly and Ward-Booth reported that the mean postoperative hospital stay was one day for those in the tibial group compared with three days for those in the iliac group. Patients in the tibial group were all able to walk from the first postoperative day.4 Short term complication rates reported for proximal tibial grafting range from none described by Catone et al.8 to a postoperative fracture risk of 2.7% described by Hughes and Revington.6 It could be argued that patients may have different ideas about the quality of a scar from surgeons, and a scar judged acceptable by a patient may differ from that judged acceptable by the surgeon, but we think that it is the patient’s perception that is most important. None of these studies focused on the long-term complications to the donor site, particularly in children. This study is, to the best of our knowledge, the only study of long-term complications at the tibial donor site in children. It is, however, preliminary, and highlights the need for a randomised trial to find the best donor site.
References 1. Amanat N, Langdon JD. Secondary alveolar bone grafting in clefts of the lip and palate. J Craniomaxillofac Surg 1991;19:7–14. 2. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal defects. J Oral Surg 1972;30:87–92. 3. Paulin G, Astrand P, Rosenquist JB, Bartholdson L. Intermediate bone grafting of alveolar clefts. J Craniomaxillofac Surg 1988;16:2–7. 4. Besly W, Ward-Booth P. Technique for harvesting tibial cancellous bone modified for use in children. Br J Oral Maxillofac Surg 1999;37:129–33. 5. O’Keeffe Jr RM, Reimer BL, Butterfield SL. Harvesting of autogenous cancellous bone graft from the proximal tibial metaphysis: a review of 230 cases. J Orthop Trauma 1991;5:469–74. 6. Hughes CW, Revington PJ. The proximal tibia donor site in cleft alveolar bone grafting: experience of 75 consecutive cases. J Craniomaxillofac Surg 2002;30:12–7. 7. Flowers MJ, Bhadreshwar DR. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop 1995;15:292–7. 8. Catone GA, Reimer BL, McNeir D, Ray R. Tibial autogenous cancellous bone as an alternative donor site in maxillofacial surgery: a preliminary report. J Oral Maxillofac Surg 1992;50:1258–63. 9. Chen YC, Chen CH, Chen PL, Huang IY, Shen YS, Chen CM. Donor site morbidity after harvesting of proximal tibia bone. Head Neck 2006 Jun;28(6):496–500. 10. Ilankovan V, Stronczek M, Telfer L, Peterson J, Stassen LFA, WardBooth P. A prospective study of trephined bone grafts of the tibial shaft and iliac crest. Br J Oral Maxillofac Surg 1998;36:434–9.
British Journal of Oral and Maxillofacial Surgery 47 (2009) 20–22
Retrospective review of donor site complications after harvest of cancellous bone from the anteriomedial tibia Tom W.M. Walker ∗ , Prince C. Modayil, Luke Cascarini, Luke Williams, Simon Miles Duncan, Peter Ward-Booth Department of Oral & Maxillofacial Surgery, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex, RH19 3DZ, United Kingdom Accepted 1 May 2008 Available online 3 August 2008
Abstract Donor site morbidity is important in deciding the site for harvest of cancellous bone for alveolar bone grafts. Many studies have supported the view that tibia is safe with few complications in the short term. We know of no studies on the long-term complications to the donor site after tibial bone grafting in children with alveolar clefts. The casenotes of 40 children who had had tibial bone grafts for alveolar clefts were studied retrospectively, and parents or patients were contacted by telephone and a standardised questionnaire was used to assess any long term complications at the donor site. We found none. We found no evidence of long-term complications at the donor site in children who had had proximal tibial bone grafting for secondary repair of alveolar clefts. We conclude that the proximal tibia is a safe site from which to obtain cancellous bone graft for alveolar clefts in children. This study is preliminary, and highlights the need for a randomised trial. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Cleft; Alveolar Bone Graft; Tibia
Introduction Autogenous bone grafts are commonly used to bridge alveolar clefts. The bone stabilises the dental arch, allows teeth to erupt, and improves bony healing and growth. The ideal time for grafting is just before eruption of the permanent canine teeth.1–3 Donor sites of choice are the calvarium, mandibular symphysis, rib, ilium, and proximal tibia. Studies support the view that tibial harvesting is a safe procedure with low complication rates.4–6 However, there have been anecdotal reports that there may be pain and poor scarring at this donor site. The senior author has been harvesting bone from the proximal tibia through a medial approach using a 5 mm trephine for alveolar bone grafting in cleft children for over 15 years.4 We did a retrospective analysis of 40 sets of casenotes and ∗
Corresponding author. Tel.: +44 01342414300. E-mail address: [email protected] (T.W.M. Walker).
sent a questionnaire to patients or their parents to find out if there was any evidence of long-term complications at the tibial donor site.
Patients and methods We made a comprehensive search of the hospital coding system and theatre records to trace the notes of children who had had a tibial bone graft under the care of the senior author. All the cases of tibial bone grafting in children under 16 years old had been done for children with clefts. All patients fewer than 6 months postoperatively were excluded. We also excluded anyone who was over 16 years old at the time of operation. The search was stopped when 40 patients had been identified who met the inclusion criteria. The patient’s casenotes were used to collect details of the procedure and any record of early or late complications.
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.05.014
T.W.M. Walker et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 20–22
Parents or patients were contacted by telephone and a standardised questionnaire was used to enquire about any late complications, which included pain, reduced function, unacceptable scarring, attendance at any other hospital or medical practice, and whether the procedure had been repeated for any reason. The telephone call was made by same person each time and he always introduced himself as ‘someone who works in the hospital’, and he did not suggest that he was a surgeon or that he worked for the senior author. This was to reduce the likelihood that the results would be biased.
Surgical technique The patient is positioned supine with the knee flexed to about 45◦ . The landmarks are: the patella, the patellar ligament extending to the tibial tuberosity, the medial and lateral condyles, and the head of the tibia, which critically identifies the approximate level of the epiphyseal cartilage. Local anaesthetic (0.25% bupivacaine with 1/200 000 adrenaline) is infiltrated at the site, and access is through a stab incision placed medial to the midline tibial tuberosity. Medial access is favoured, as it avoids stripping the tibialis muscle. Bone is exposed only sufficiently to allow a single penetration of the cortex using a serrated cutting-end trephine (5 mm internal diameter with a 27 mm depth stop) (Martin Medizin, Tuttingen, Germany). Several cores of cancellous bone are harvested in a fan-like pattern and, if required, further bone can be removed with a curette. The wound is closed with two deep resorbable sutures to approximate the periosteum, and completed with skin sutures. A gauze dressing is placed with a light pressure bandage, and left on for 24 hours. Postoperative care included analgesia with paracetamol or non-steroidal analgesics, and early mobilisation is encouraged on the evening of operation.
Results Of the 40 patients included in the study, 15 had bilateral clefts (38%) and 25 unilateral clefts (63%). Twenty-six patients were male and 14 female (ratio 1.9:1). The mean age at operation was 10 years and 6 months, range 7 years 1 month to 15 years 7 months. Among the boys the range was 7 to 15.5 years (mean 10.5) and among the girls 7 to 14 years (mean 11). The follow up interval was 8 months to 10.5 years, with a mean of 4 years and 4 months. The bone was harvested from the right tibia in 29 cases (73%) and from the left in 11 (27%). The recipient site was the right in 19 cases (47.5%), left in 12 cases (30%), and bilateral in 9 cases (23%).
21
Review of casenotes Casenotes showed 6 recordings of short term complications relating to the donor site. These were pain or discomfort (n = 3), unsightly scarring (n = 2), and one wound infection. There were no recordings of long-term complications. Telephone Questionnaire Thirty-two parents answered the telephone questionnaire; the remaining 8 were answered by patients. They reported 4 postoperative complications, all of which were short-term. One patient had two weeks of pain at the donor site. Another had two hours of post operative pain. A third had minor discomfort on walking for a week. A fourth patient had a purulent discharge from the site. This was the same patient that was identified by a review of the casenotes with a wound infection one week postoperatively. The wound infection was treated with a course of antibiotics given orally. There was one exceptional case of persistent knee pain, which was referred to an orthopaedic surgeon, and a diagnosis of Osgood Schlatter disease was made.7 It was felt that this was probably coincidental and not related to the bone harvesting. This particular patient had the operation repeated three times because the cleft was large but all three grafts failed. However, he had had no long term complications at the tibial donor site on 6-year follow up. We have not mentioned radiographic follow-up of the recipient site as it is only complications at the donor site with which we are concerned. As far as long term complications were concerned, however, we found none at the donor site and scars were acceptable in all the cases.
Discussion Fresh autogenous cancellous bone supports the survival of the maximum amount of transplanted bone, and the number of pluripotential cells therefore provides the necessary raw material to enable osteoconduction, osteoinduction, and osteogenesis.8 There are intraoral and extraoral donor sites for autogenous bone grafts. The intraoral sites such as the mandibular symphysis, ramus, and palatine tori have been used for alveolar cleft repair with favourable results, but the amount of available bone is limited.9 The extraoral sites are iliac crest, rib, calvarium, and tibia. Among these, iliac and tibial bone grafts have become the choice for grafting of alveolar clefts. The use of proximal tibia as the donor site for reconstruction of cleft alveolus became popular in the United Kingdom in the late 1990s.4,10 There are many studies4–6,8,9 that have supported the use of the tibial graft because of the low morbidity at the donor site postoperatively. The speed at which children mobilise postoperatively, the time to discharge, and the low pain scores all
22
T.W.M. Walker et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 20–22
add to the attractiveness of this donor site. The same quality and quantity of cancellous bone can be obtained as from iliac crest grafts. Besly and Ward-Booth reported that the mean postoperative hospital stay was one day for those in the tibial group compared with three days for those in the iliac group. Patients in the tibial group were all able to walk from the first postoperative day.4 Short term complication rates reported for proximal tibial grafting range from none described by Catone et al.8 to a postoperative fracture risk of 2.7% described by Hughes and Revington.6 It could be argued that patients may have different ideas about the quality of a scar from surgeons, and a scar judged acceptable by a patient may differ from that judged acceptable by the surgeon, but we think that it is the patient’s perception that is most important. None of these studies focused on the long-term complications to the donor site, particularly in children. This study is, to the best of our knowledge, the only study of long-term complications at the tibial donor site in children. It is, however, preliminary, and highlights the need for a randomised trial to find the best donor site.
References 1. Amanat N, Langdon JD. Secondary alveolar bone grafting in clefts of the lip and palate. J Craniomaxillofac Surg 1991;19:7–14. 2. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal defects. J Oral Surg 1972;30:87–92. 3. Paulin G, Astrand P, Rosenquist JB, Bartholdson L. Intermediate bone grafting of alveolar clefts. J Craniomaxillofac Surg 1988;16:2–7. 4. Besly W, Ward-Booth P. Technique for harvesting tibial cancellous bone modified for use in children. Br J Oral Maxillofac Surg 1999;37:129–33. 5. O’Keeffe Jr RM, Reimer BL, Butterfield SL. Harvesting of autogenous cancellous bone graft from the proximal tibial metaphysis: a review of 230 cases. J Orthop Trauma 1991;5:469–74. 6. Hughes CW, Revington PJ. The proximal tibia donor site in cleft alveolar bone grafting: experience of 75 consecutive cases. J Craniomaxillofac Surg 2002;30:12–7. 7. Flowers MJ, Bhadreshwar DR. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop 1995;15:292–7. 8. Catone GA, Reimer BL, McNeir D, Ray R. Tibial autogenous cancellous bone as an alternative donor site in maxillofacial surgery: a preliminary report. J Oral Maxillofac Surg 1992;50:1258–63. 9. Chen YC, Chen CH, Chen PL, Huang IY, Shen YS, Chen CM. Donor site morbidity after harvesting of proximal tibia bone. Head Neck 2006 Jun;28(6):496–500. 10. Ilankovan V, Stronczek M, Telfer L, Peterson J, Stassen LFA, WardBooth P. A prospective study of trephined bone grafts of the tibial shaft and iliac crest. Br J Oral Maxillofac Surg 1998;36:434–9.