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The proximal tibia donor site in cleft alveolar bone grafting
Journal of Cranio-Maxillofacial Surgery (2002) 30, 17 r 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved. doi:10.1054/jcms.2002.276, available online at http://www.idealibrary.com on
Discussion
The proximal tibia donor site in cleft alveolar bone grafting The authors assess the morbidity of the donor site when using cancellous bone from the tibia. For this purpose, retrospective questionnaires were sent to the patients and their family physicians. The medical records were reviewed. The pie`ce de resistance of this publication is the report of two fractures of the tibia in the area of bone removal. This is very important, even if it is not the first time that such a complication has been reported (van Damme, 1998). Further results should be judged with reserve, even if the size of the series is considerable. The study, going back 7 years, the memory of the patients and their parents concerning the postoperative period might not be very clear in all cases. Patients also quite often have different ideas about the quality of a scar from physicians. Furthermore, the poor information from the family doctor seems to indicate, that although the basic idea appears logical, the particulars should have been sought elsewhere. The comparison with another, a small series from our department (van Damme and Merkx, 1996) reveals some differences. In that report, all the patients were 22 years or older; and it was considered advisable not to use the technique in children and adolescents because of the possible growth-centre interference. Only a precise prospective study could decide on this issue, although the present paper suggests, that the risk is minimal. Hughes and Revington use a lateral one, while van Damme uses a medial approach. The latter seems easier and more direct. In the Dutch study, the (few, adult) patients ‘could walk immediately after recovery from general anaesthesia without additional support’, while in the British about 20% of the children used some support up to three weeks after the operation. So, van Damme advises 4–6 weeks abstention from sport, even though allowing full weight bearing, whilst Hughes and Revington recommend initial partial weight bearing and 3-months’ avoidance of contact sports. While the British authors correctly state that the significance of the fracture occurring after 3 months is questionable, the other three fractures must without doubt be attributed to the bone harvesting. All of them were caused by minor inadequate trauma (running, fall, tennis-playing) within the first 10 postoperative days. This indicates that the approach of Hughes and Revington is more prudent, especially in children. It should be borne in mind that the procedure causes little or almost no pain at all. This seduces the patient to underrate the risks of damage to the donor site. Patient information must stress this point.
Finally, let us consider breifly the choice of the donor site. It is most evident that the function and the shape of the graft, and the amount of bone needed are important factors in this choice. Since the requirements in alveolar cleft grafting are not extremely stringent, it is permitted to question the iliac crest as the gold standard. A comparison of bone from the iliac crest, rib and chin in about 300 cases has shown that the best results by far were obtained using chin transplants (Freihofer et al., 1993). The drawbacks of this material are the limited volume that can be harvested in children and the increased risk of pulp obliteration and crown damage (Hoppenreijs et al., 1992). Rib and iliac crest show comparable overall results. Enough bone can easily be harvested, but this must be seen in relation to a second operating field, considerable postoperative pain and a long, not always inconspicuous scar. These disadvantages are not seen with the tibia donor site. Still, the fractures reported demand strict postoperative guidance. On the other hand, this bone is very easy to handle and therefore an attractive alternative to chin. However, a comparative study with chin emphasizing the amounts of resorption, and the final form of the alveolar process after eruption of the canine seems mandatory. Prof. Dr. H. P. Freihofer, MD, DMD, PhD Luciaweg 33, 6523 NK Nijmegen, The Netherlands E-mail: [email protected] References Freihofer HPM, Borstlap WA, Kuijpers-Jagtman AM, Voorsmit RACA, van Damme PhA, Heidbu¨chel KLWM, BorstlapEngels VMF: Timing and transplant materials for closure of alveolar clefts. A clinical comparison of 296 cases. J CranioMaxillofac-Fac Surg 21: 143–148, 1993 Hoppenreijs ThJM, Nijdam ES, Freihofer HPM: The chin as a donor site in early secondary osteoplasty. A retrospective clinical and radiological evaluation. J Cranio-Maxillofac Surg 20: 119–124, 1992 Van Damme PhA: Fracture of the tibia after the modified tibial bone-graft-harvesting technique. A report of two cases. Abstract of the congress of the European Association of Cranio-Maxillofacial Surgery, Helsinki, 1998. J CranioMaxillofac Surg 26 (Suppl. 1): 197, 1998 Van Damme PhA, Merkx MAW: A modification of the tibial bone-graft-harvesting technique. Int J Oral Maxillofac Surg 25: 346–348, 1996
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Discussion
The proximal tibia donor site in cleft alveolar bone grafting The authors assess the morbidity of the donor site when using cancellous bone from the tibia. For this purpose, retrospective questionnaires were sent to the patients and their family physicians. The medical records were reviewed. The pie`ce de resistance of this publication is the report of two fractures of the tibia in the area of bone removal. This is very important, even if it is not the first time that such a complication has been reported (van Damme, 1998). Further results should be judged with reserve, even if the size of the series is considerable. The study, going back 7 years, the memory of the patients and their parents concerning the postoperative period might not be very clear in all cases. Patients also quite often have different ideas about the quality of a scar from physicians. Furthermore, the poor information from the family doctor seems to indicate, that although the basic idea appears logical, the particulars should have been sought elsewhere. The comparison with another, a small series from our department (van Damme and Merkx, 1996) reveals some differences. In that report, all the patients were 22 years or older; and it was considered advisable not to use the technique in children and adolescents because of the possible growth-centre interference. Only a precise prospective study could decide on this issue, although the present paper suggests, that the risk is minimal. Hughes and Revington use a lateral one, while van Damme uses a medial approach. The latter seems easier and more direct. In the Dutch study, the (few, adult) patients ‘could walk immediately after recovery from general anaesthesia without additional support’, while in the British about 20% of the children used some support up to three weeks after the operation. So, van Damme advises 4–6 weeks abstention from sport, even though allowing full weight bearing, whilst Hughes and Revington recommend initial partial weight bearing and 3-months’ avoidance of contact sports. While the British authors correctly state that the significance of the fracture occurring after 3 months is questionable, the other three fractures must without doubt be attributed to the bone harvesting. All of them were caused by minor inadequate trauma (running, fall, tennis-playing) within the first 10 postoperative days. This indicates that the approach of Hughes and Revington is more prudent, especially in children. It should be borne in mind that the procedure causes little or almost no pain at all. This seduces the patient to underrate the risks of damage to the donor site. Patient information must stress this point.
Finally, let us consider breifly the choice of the donor site. It is most evident that the function and the shape of the graft, and the amount of bone needed are important factors in this choice. Since the requirements in alveolar cleft grafting are not extremely stringent, it is permitted to question the iliac crest as the gold standard. A comparison of bone from the iliac crest, rib and chin in about 300 cases has shown that the best results by far were obtained using chin transplants (Freihofer et al., 1993). The drawbacks of this material are the limited volume that can be harvested in children and the increased risk of pulp obliteration and crown damage (Hoppenreijs et al., 1992). Rib and iliac crest show comparable overall results. Enough bone can easily be harvested, but this must be seen in relation to a second operating field, considerable postoperative pain and a long, not always inconspicuous scar. These disadvantages are not seen with the tibia donor site. Still, the fractures reported demand strict postoperative guidance. On the other hand, this bone is very easy to handle and therefore an attractive alternative to chin. However, a comparative study with chin emphasizing the amounts of resorption, and the final form of the alveolar process after eruption of the canine seems mandatory. Prof. Dr. H. P. Freihofer, MD, DMD, PhD Luciaweg 33, 6523 NK Nijmegen, The Netherlands E-mail: [email protected] References Freihofer HPM, Borstlap WA, Kuijpers-Jagtman AM, Voorsmit RACA, van Damme PhA, Heidbu¨chel KLWM, BorstlapEngels VMF: Timing and transplant materials for closure of alveolar clefts. A clinical comparison of 296 cases. J CranioMaxillofac-Fac Surg 21: 143–148, 1993 Hoppenreijs ThJM, Nijdam ES, Freihofer HPM: The chin as a donor site in early secondary osteoplasty. A retrospective clinical and radiological evaluation. J Cranio-Maxillofac Surg 20: 119–124, 1992 Van Damme PhA: Fracture of the tibia after the modified tibial bone-graft-harvesting technique. A report of two cases. Abstract of the congress of the European Association of Cranio-Maxillofacial Surgery, Helsinki, 1998. J CranioMaxillofac Surg 26 (Suppl. 1): 197, 1998 Van Damme PhA, Merkx MAW: A modification of the tibial bone-graft-harvesting technique. Int J Oral Maxillofac Surg 25: 346–348, 1996
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