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Tibial autogenous cancellous bone as an alternative donor site in maxillofacial surgery: A preliminary report
J Oral Maxillofac 50:1256-1263.
Surg 1992
Tibia/ Autogenous Cancellous Bone as an Alternative Donor Site in Maxillofacial Surgery: A Preliminary Report GUY A. CATONE, DMD,* BARRY L. REIMER, MD,t DANA McNEIR, DMD,* AND RICHARD RAY, MD5 This preliminary report reviews the use of the proximal tibia1 metaphysis as an alternative to other bone graft donor sites. A series of 21 cancellous grafts were procured from 20 patients using a predictable orthopedic approach. A singular finding was the overall lack of morbidity at the donor site and the apparent favorable quality and quantity of the procured bone. Data describing the use of tibia1 cancellous bone grafting in a wide range of maxillofacial reconstructive procedures are presented.
Cancellous bone grafting to the maxillofacial region has long been an accepted procedure in oral and maxillofacial surgery. Well-recognized donor sites have included the anterior and posterior iliac crest, rib, and more recently intercalvarial diploic bone. Procurement of cancellous bone from any site is not without relative biologic insult to the patient, including 1) an additional surgical site, 2) possible increased postoperative morbidity, 3) weakened donor sites, and 4) potential serious complications from these conditions.’ These factors led us to explore the proximal tibia as an alternative donor site that had the potential to yield viable cancellous bone with a minimum of morbidity. The impetus for this study was based on the efficacy, available donor bone volume, and lack of morbidity observed in a group of 206 orthopedic trauma patients reported by O’Keefe et al2 in whom 230 proximal tibia1 cancellous procurements were performed. O’Keefe et al reported excellent results with such grafts with lower Received from the Division of Oral and Maxillofacial Surgery, Department of Surgery, Allegheny General Hospital, Pittsburgh, PA. * Senior Attending, Associate Professor, Department of Medicine (Dental), Medical College of Pennsylvania. t Senior Attending, Department of Orthopedic Surgery. 4 Former Senior Resident. 0 Senior Attending, Department of Orthopedic Surgery. Address correspondence and reprint requests to Dr Catone: Division of Oral and Maxillofacial Surgery, Physicians Office Bldg, Suite 104,2566 Haymaker Rd. Monroeville, PA 15146-3594. 0 1992 American
Association
0278-2391/92/5012-0002$3.00/O
of Oral and Maxillofacial
Surgeons
extremity fractures or nonunions requiring cancellous grafting. The orthopedic study and our own observations since 1989 have supported our view that the lateral proximal tibia1 metaphysis offers a promising alternative source of cancellous bone for grafting in reconstructive oral and maxillofacial surgery. ProcurementTechnique The patients were placed in a supine position with a roll under the ipsilateral hip to elevate the anterolatera1 tibia (Fig 1). After preparation of the leg with iodine or a povidone-iodine solution, a stockinette bandage was placed on the leg. After appropriate sterile draping, access was gained to the donor site by cutting the stockinette bandage over the area. A major portion of the tibia is subcutaneous and, at its cephalad extent, the tibia1 condyles can be palpated immediately below the knee. On the anterior surface of the proximal end of the tibia between the condyles, an oval protuberance, the tibial tuberosity or Gerdy’s tubercle, can be felt. Palpation of this tubercle is essential to avoid violation of the articular surface of the tibial plateau and damage to the articulation of the knee. Moreover, maintaining this anatomic position avoids involvement of the head of the fibula, which is also located subcutaneously at this level, and prevents injury to the articular surface of the tibia.3 Small blood vessels in the immediate vicinity of the lateral proximal tibia include branches of the medial 1258
CATONEET AL
lncisidn
FIGURE1. Small roll placedunder ipsilateralhip flexesthe knee and facilitates access to proximal tibia. superior and inferior genicular arteries passing under cover of the patellar ligament; branches of the lateral inferior genicular, fibular, and the anterior recurrent tibial; and branches of the anterior tibia1 arteries (Fig 2). Bleeding from these vessels has not presented a problem and is easily controlled with diathermy. The tibialis anterior muscle is located on the lateral surface of the tibia and in the caudal extent of the dissection is thick and fleshy. Its fibers course vertically caudad overlapping the anterior tibia1 vessels and deep peroneal nerve in the proximal tibial region. This nerve arises from the bifurcation of the common peroneal nerve between the fibula and the peroneus longus muscle, and continues deep to the extensor digitorum longus to the anterior surface of the interosseous membrane. Injury to this structure is avoided by appropriate placement of the incision. A 2- to 3-cm oblique incision is made with a no. 10 scalpel, with the center of the incision directly over Gerdy’s tubercle. The incision is angled with its cephalad limit just above and medial to the origin of the tibialis anterior muscle and its caudal extent lateral to the patellar ligament (Fig 2). It is made through skin, subcutaneous tissue, and fascia of the iliotibial tract of the fascia lata down to the periosteum, which is incised in a U-shaped fashion with the base of the U inferior. Drill holes are then made with a surgical bur along the base between the most superior arms of the U (Fig 3). This creates an osteoperiosteal flap or “trapdoor” based superiorly which can be elevated from the underlying metaphyseal cancellous bone using osteotomes according to the method of Ray.4 The technique of inclusion of the bone window with the cancellous graft material, as performed by Reimer,2 also has been used extensively with excellent results, especially in orthopedics. After elevation of the cortical window, the appropriate quantity of cancellous bone can be obtained with straight and curved orthopedic curettes (Fig 4). In the majority of instances, the bony trapdoor can be sutured back if the surgeon so chooses or if the cortical bone is not being used. There is no attempt to fill the metaphyseal dead space with an alloplastic material in the
Lat. inf. genicular
a.
Gerdy’s tubercle
genicular
a.
Med. inf. genicular
a.
Ant. tibia1 recurrent a.f
FIGURE2. Diagramof articulationof kneeandassociatedarterial distributionshowingrelationshipof incisionto Gerdy’stubercle. manner described by Bucholz et al for the management of tibial plateau fractures.5 The wound is not drained, and can be closed in layers in the usual fashion using skin staples or a continuous subcuticular suture. The latter method produces better esthetic results. As with any surgical approach, constant revision of the technique has occurred. In some cases, we have obviated the need for a large incision and trapdoor approach. Cases in which small amounts of cancellous bone are necessary (< 15 mL) may be performed
FIGURE3. Diagram showing delineation of bone window #byholes made with a rotary instrument.
1260
FIGURE 4.
IIJ3lAL AUIUbtNUUY
m___._
Diagramshowingsuperiorlybasedosteoperiosteai flap.
through a stab incision made with a no. 10 blade and perforation through the lateral cortex with a trephine or curette. This variation has been found to save operating time, and has further improved the esthetics of the healed incision. Following application of an antibacterial ointment and a nonsticking dressing over the wound, the immediate area of the donor site is wrapped with a Kerlex bandage (Johnson & Johnson, New Brunswick, NJ) and the knee and leg are wrapped with an Ace bandage (Conco Med, Bridgeport, CT). Postoperatively, ambulation was begun the same day or, more often, the following morning. All patients received an intravenous course of antibiotics for the primary surgery, which theoretically should cover the donor site procedure. Material and Methods Twenty patients who had required bone grafting as an adjunct to their surgical management were evaluated retrospectively. All patients were administered a general anesthetic except one in whom an intravenous conscious sedation technique and local anesthesia at the donor site were used. The operations included grafting of a nonunion of a Le Fort I osteotomy, antroplasty with sinus grafting, repair of mandibular nonunions, secondary cleft palate repair combined with calvarial bone strips, salvaging of several mandibular staple implants, and major reconstruction of a mandible lost as a result of a gunshot wound. The inpatient and outpatient records were used to ascertain information about age, sex, past medical history, the primary maxillofacial procedure, the specific donor site(s), the amount of cancellous bone procured (recorded as noncompressed and rounded off to the nearest whole number), the recipient site, any additives to the graft, earliest time of weight-bearing on the ipsilateral leg,
._._^^_..^T.^
CANCbLLUUS ^.__^__
_
___^
BUNE --__-
-
_
__.-_
AS DUNUK
SITE
and early or delayed complications at the donor and recipient sites, as well as any residual gait disturbances. Cancellous bone was procured from the proximal tibia1 metaphysis after ruling out contraindications related to age (lack of closure of the epiphyseal growth center), the presence of ipsilateral infection, metabolic or metastatic bone disease, or ipsilateral trauma to the extremity that would further compromise the integrity of the leg. The cancellous tibial bone was obtained in some instances concomitantly with the initiation of the maxillofacial procedure. However, in those cases in which excessive movement of the patient caused by the graft procurement would disturb the maxillofacial surgery, the procedures were performed separately. Maxillofacial dissection before graft procurement was ideal because of the ability of the oral and maxillofacial surgeons to assess volumetric need or to choose an alternative donor site, if necessary. Those cases in which volumetric requirements could be assessed preoperatively allowed simultaneous maxillofacial dissection and graft procurement, decreasing anesthesia time. A single tibial donor site was anticipated in each case. If, however, the volume of cancellous bone required exceeded what could be obtained from the tibia, the contralateral tibia was also used or the ilium was selected instead. Results Patients were observed during the period of April 1990 through February 199 1 (Table 1). Twenty patients underwent 21 cancellous tibia1 graft procurements as part of their maxillofacial reconstructive procedure. Their age averaged 43.3 years (median, 44 years). There were 13 females (7 1.4%) and 5 males. All patients had mild to moderate temporary ecchymosis and edema postoperatively. The average follow-up period was 5.2 months. An average amount of noncompressed cancellous bone obtained from the 2 1 donor sites was 25 mL, with a range of 10 to 42 mL. A bilateral tibia1 procurement, which yielded 40 mL, was used to reconstruct an entire mandible that necessitated a large volume of cancellous bone. Ten patients (50%) received an additive to the primary tibia1 graft. These included Interpore 200 (Interpore International, Irvine, CA), 1 patient; Bio-oss (anorganic bovine hydroxylapatite, Walter Lorenz, FL), 5 patients; cortical bone from the tibia and ilium, 2 patients; lyophilized rib, 1 patient; and calvarial strips, 1 patient. The majority of patients were able to bear weight on the ipsilateral donor leg on the second postoperative day. The exception was patient E.B., in whom weight bearing was delayed for 6 weeks because of head, thoracic, and extremity trauma. Five patients required the use of a cane for 2 to 3 weeks postoperatively, and one patient for 1 week after surgery. Seven patients underwent antroplasty and tibial
Osteopenia GSW
51
44
50 58 60 53
70
67
24 58
50 17
29
24
60
24
60
E.B. C.P. K.A.
S.F. N.M.
M.L. A.B. R.H. G.D.
S.G.
M.L.
L.H. M.R.
GM. J.F.
T.F.
A.V.
M.S.
L.L.
D.R.
NJ)
Debridement dacron/Luhr reconstruct (Luhr. Howmedica,
Antroplasty (2) Branemark X 6 Closure of clefts
LeFortI
Schuhardt (2)
Osteotomy Antroplasty (2) implants Antroplasty (2) C-osteotomy
Osteotomy
Debridement, place FM1
Antroplasty (1) ReC0llStNct mandible AntropIasty (1) Antroplasty (1) Debridement Debridement
ORIF mandible Redo Le Fort I Antroplasty
Primary Surgery
Tibia
Tibia
Tibia
Tibia
Tibia
Tibia Tibia
Tibia Tibia
Tibia
Tibia
Tibia Tibia (2), ilium (1) Tibia Tibia Tibia Tibia
Tibia Tibia Tibia
Donor Site
Mandible
Maxilla-antra, palate
Maxilla-antra
Maxilla
Maxilla
Maxilla-antra Vertical rami
Maxilla Maxilla-antra
Vertical rami
Mandibular symphysis
Maxilla-an&urn Entire mandible w/ titanium tray Maxilla-antrum Maxilla-antrum Mandibular symphysis Mandibular symphysis
Mandible, alveolus Maxilla Maxilla-antra
Recipient Site
Graft
42
10 40
25 40
20
10
15 15 20 20
25 20,20
30 20 35
0 0 0
0 0 0
POD-l POD-l POD1 POD- 1
POD- 1
0 0
0
Calvarial
Bio-oss 5 g
0
Bio-ass 5 g 0 0 Lyophilized block rib 0
0
Pain 2wk 0
POD-l POD-l
0
Infection
Cane 3wk Limp 2wk Cane 2wk
0
0
0 0
0 0
0
6
7 7
11 10 8
Cm)
FollowUP
staple bone plate; VME, vertical maxikwy
POD- 1
0 POD-l
OphY
0 0
POD-4
0
0
0
OP &Y OphY POD-3
0
0 0 0 0
POD-2
Bio-oss 2.5 g Cortical strips (ilium) 0 Bio-ass 2.5 g 0 0
Limp 3d 0 Cane 1 wk 0 0 0 Cane 3wk Cane 3wk
0 0
0 0 0
0 0 0 0 0
>6 wk POD-2 POD- 1
Gait
Recipient
Donor
Complications
POD-l POD-2
Hydroxylapatite Cortical chips Bio-oss 5g
Additives
Earliest WeightBearing
IN); MS3P, mandibular
Volume (mL)
Abbreviations: GSW, gunshot wounds: FMI, fixed mandibular implant (Zimmer, Warsaw, excess; CA, carcinoma; VMH, vertical maxillary hypertrophy; POD, postoperative day.
Clefi alveolus palate Nonunion postCA
Osteopenia Class II microgenia Horizontal maxillary exceSS VMH/ microgenia Osteopenia
MSBP failure (MSBP, Hall International, Carpenteria, CA) Pagets disease, class III VME, class III Osteopenia
Osteopenia Osteopenia FMI failure FMI failure
Acute trauma Nonunion Osteopenia
31 24 31
Patient
History
Age (yr)
Table 1. Characteristics of 20 Patients Receiving Proximal Lateral Tibia1Grafts
1262
TIBIAL
cancellous bone transplants to one or both maxillary sinuses. Five of these patients had tibia1 bone mixed with Bio-ass and three had only tibial bone transplanted to a single sinus. In those patients who received Biooss, the amount used ranged from 2.5 to 5 g. In this subset of patients, the amount of noncompressed cancellous tibial bone procured averaged 23.75 mL per patient. All patients included in this study had minimal leg pain, which could be easily controlled in the majority of instances with nonsteroidal anti-inflammatory medications and occasionally with oral narcotic analgesics. Moreover, there were no complaints of cosmetic problems associated with the incision over the proximal tibia. Of the 21 donor sites evaluated, there were no complications such as long-term pain, neuropathy involving the ipsilateral leg, wound infection, hematoma or seroma formation, or fracture of the proximal tibia, even in older patients in whom weight bearing commenced within the first 24 hours after surgery. Furthermore, there was no local donor site wound breakdown or superficial or deep infections. None of the patients experienced deep vein thrombophlebitis. However, this possibility should be considered and the patient observed carefully in the immediate postop erative period. There were no long-term gait disturbances in those patients observed beyond 6 months. Discussion A review of the literature shows that few authors in either orthopedics or oral and maxillofacial surgery have advocated or studied the application of cancellous bone grafts from the proximal tibia1 metaphysis. This may be the result of a general opinion that there is an inadequate volume of cancellous bone at this site. In view of the fact that the iliac crest, which is the most popular and well studied donor site for maxillofacial procedures, has well documented major and minor complications, alternative donor sites should be explored. In all of our patients, with the exception of the subtotal replacement of the mandible and the cleft patient, the proximal tibia1 metaphysis provided more than an adequate volume of cancellous bone. Although the cancellous procurement yielded up to 42 mL of bone, the volume of donor bone from a single site was based on need and not the total amount that potentially could be procured. In the exceptions cited above, the bone from the ilium was felt to be suboptimal in the mandibular reconstruction case and surgical philosophy dictated the use of calvarial strips in the cleft patient. In all cases except the subtotal mandibular reconstruction, only one proximal tibia was used as a donor site. Thus, from a preliminary standpoint, the proximal tibia is useful for a variety of maxillofacial procedures and
AUTOGENOUS
CANCELLOUS
BONE AS DONOR
SITE
would appear an easily obtainable source of viable cancellous bone. The consistency and character of the cancellous tibia1 bone is much like that from other donor sites and compares favorably from the histologic standpoint. Although a single site tibia1 graft harvest is volumetrically less than that generally obtainable from the ilium, for a large range of maxillofacial procedures the volume of cancellous bone procured is adequate. It would thus be appropriate to use the proximal tibia for those maxillofacial procedures in which less than 40 mL is required, realizing the potential of a significantly greater procurement if the contralateral tibia is used. Patients were clinically healed and able to ambulate early, but postoperative radiographs of the tibia were consistent with the observations of DaEner in which he noted long-term radiographic visibility or radiolucency of the donor site6 (Fig 5). As a result of this finding, and in view of the suggestion that iatrogenic processes are usually not considered by the radiologist when an osteolytic area is discovered and the radiologist may be unable to rule out an infectious or neoplastic process, Daffner cautions that a full history of prior graft harvest from the surgeon is essential. Further, knowledge on the part of the radiologist of newer alternative donor sites would be important to avoid a misdiagnosis. O’Keefe et al are anecdotally aware of three patients who were considered for surgical biopsy of the proximal tibia by physicians unaware of the surgical history.2 Also supportive of the proximal tibia as a donor site is the lack of complications relating to deep vein thrombophlebitis, pulmonary problems, or peritoneal or genitourinary system injury. Significantly, there were no immediate or delayed fractures of the tibia1 plateau or articular compromise of the knee in the 10 patients
FIGURE 5. Immediate postoperative radiographs of proximal tibia from which cancellous bone has been procured.
1263
CATONE ET AL
observed for 6 to 10 months. However, a greater number of cases must be followed up for at least 6 months before definitely advocating routine weight-bearing immediately after surgery. The disadvantages of proximal tibia1 bone harvest relates are similar to those with any bone graft.’ Moreover, in view of the potential radiographic visibility of the donor site in the proximal tibia, for years, it would not be advisable at this time to consider this site for a repeated harvest. Additionally, the lack of correlation between the radiographic appearance and the quality or quantity of bone present in the distal radius in humans and the ilium in the canine model, further supports caution and the need for future studies to advocate reuse of the proximal tibial donor site.8,9
References 1. Burchardt H: Biology of bone transplantation. Orthop Chn North Am 18:187, 1987 2. O’Keefe RM, Reimer BL, Butterfield SL: Harvesting of autogenous cancellous bone graft from the proximal tibia1 metaphysis: A review of 230 cases. J Orthop Trauma 5:469, 199 1 3. Gray H: Anatomy of the Human Body. Philadelphia. PA, Lea & Febiger, 1959 4. Ray R: Personal communication, June 1988 5. Bucholz RW, C&ton A, Holmes R: Interporous hydroxylapatite as a bone graft substitute in tibial plateau fractures. Chn Orthop Rel Res 24053, 1989 6. Daffner RH: Case report 592. Skeletal Radio1 19:73, 1990 7. Younger EM, Chapman MW: Morbidity at bone graft donor sites. J Orthop Trauma 3~192, 1989 8. McGrath MH, Watson K: Late results with local bone graft donor sites in hand surgery. .I Hand Surg 6:234, 198 I 9. Montgomery DM, Moed BR: Cancellous bone donor site regeneration. J Orthop Trauma 3:290, 1989
Surg 1992
Tibia/ Autogenous Cancellous Bone as an Alternative Donor Site in Maxillofacial Surgery: A Preliminary Report GUY A. CATONE, DMD,* BARRY L. REIMER, MD,t DANA McNEIR, DMD,* AND RICHARD RAY, MD5 This preliminary report reviews the use of the proximal tibia1 metaphysis as an alternative to other bone graft donor sites. A series of 21 cancellous grafts were procured from 20 patients using a predictable orthopedic approach. A singular finding was the overall lack of morbidity at the donor site and the apparent favorable quality and quantity of the procured bone. Data describing the use of tibia1 cancellous bone grafting in a wide range of maxillofacial reconstructive procedures are presented.
Cancellous bone grafting to the maxillofacial region has long been an accepted procedure in oral and maxillofacial surgery. Well-recognized donor sites have included the anterior and posterior iliac crest, rib, and more recently intercalvarial diploic bone. Procurement of cancellous bone from any site is not without relative biologic insult to the patient, including 1) an additional surgical site, 2) possible increased postoperative morbidity, 3) weakened donor sites, and 4) potential serious complications from these conditions.’ These factors led us to explore the proximal tibia as an alternative donor site that had the potential to yield viable cancellous bone with a minimum of morbidity. The impetus for this study was based on the efficacy, available donor bone volume, and lack of morbidity observed in a group of 206 orthopedic trauma patients reported by O’Keefe et al2 in whom 230 proximal tibia1 cancellous procurements were performed. O’Keefe et al reported excellent results with such grafts with lower Received from the Division of Oral and Maxillofacial Surgery, Department of Surgery, Allegheny General Hospital, Pittsburgh, PA. * Senior Attending, Associate Professor, Department of Medicine (Dental), Medical College of Pennsylvania. t Senior Attending, Department of Orthopedic Surgery. 4 Former Senior Resident. 0 Senior Attending, Department of Orthopedic Surgery. Address correspondence and reprint requests to Dr Catone: Division of Oral and Maxillofacial Surgery, Physicians Office Bldg, Suite 104,2566 Haymaker Rd. Monroeville, PA 15146-3594. 0 1992 American
Association
0278-2391/92/5012-0002$3.00/O
of Oral and Maxillofacial
Surgeons
extremity fractures or nonunions requiring cancellous grafting. The orthopedic study and our own observations since 1989 have supported our view that the lateral proximal tibia1 metaphysis offers a promising alternative source of cancellous bone for grafting in reconstructive oral and maxillofacial surgery. ProcurementTechnique The patients were placed in a supine position with a roll under the ipsilateral hip to elevate the anterolatera1 tibia (Fig 1). After preparation of the leg with iodine or a povidone-iodine solution, a stockinette bandage was placed on the leg. After appropriate sterile draping, access was gained to the donor site by cutting the stockinette bandage over the area. A major portion of the tibia is subcutaneous and, at its cephalad extent, the tibia1 condyles can be palpated immediately below the knee. On the anterior surface of the proximal end of the tibia between the condyles, an oval protuberance, the tibial tuberosity or Gerdy’s tubercle, can be felt. Palpation of this tubercle is essential to avoid violation of the articular surface of the tibial plateau and damage to the articulation of the knee. Moreover, maintaining this anatomic position avoids involvement of the head of the fibula, which is also located subcutaneously at this level, and prevents injury to the articular surface of the tibia.3 Small blood vessels in the immediate vicinity of the lateral proximal tibia include branches of the medial 1258
CATONEET AL
lncisidn
FIGURE1. Small roll placedunder ipsilateralhip flexesthe knee and facilitates access to proximal tibia. superior and inferior genicular arteries passing under cover of the patellar ligament; branches of the lateral inferior genicular, fibular, and the anterior recurrent tibial; and branches of the anterior tibia1 arteries (Fig 2). Bleeding from these vessels has not presented a problem and is easily controlled with diathermy. The tibialis anterior muscle is located on the lateral surface of the tibia and in the caudal extent of the dissection is thick and fleshy. Its fibers course vertically caudad overlapping the anterior tibia1 vessels and deep peroneal nerve in the proximal tibial region. This nerve arises from the bifurcation of the common peroneal nerve between the fibula and the peroneus longus muscle, and continues deep to the extensor digitorum longus to the anterior surface of the interosseous membrane. Injury to this structure is avoided by appropriate placement of the incision. A 2- to 3-cm oblique incision is made with a no. 10 scalpel, with the center of the incision directly over Gerdy’s tubercle. The incision is angled with its cephalad limit just above and medial to the origin of the tibialis anterior muscle and its caudal extent lateral to the patellar ligament (Fig 2). It is made through skin, subcutaneous tissue, and fascia of the iliotibial tract of the fascia lata down to the periosteum, which is incised in a U-shaped fashion with the base of the U inferior. Drill holes are then made with a surgical bur along the base between the most superior arms of the U (Fig 3). This creates an osteoperiosteal flap or “trapdoor” based superiorly which can be elevated from the underlying metaphyseal cancellous bone using osteotomes according to the method of Ray.4 The technique of inclusion of the bone window with the cancellous graft material, as performed by Reimer,2 also has been used extensively with excellent results, especially in orthopedics. After elevation of the cortical window, the appropriate quantity of cancellous bone can be obtained with straight and curved orthopedic curettes (Fig 4). In the majority of instances, the bony trapdoor can be sutured back if the surgeon so chooses or if the cortical bone is not being used. There is no attempt to fill the metaphyseal dead space with an alloplastic material in the
Lat. inf. genicular
a.
Gerdy’s tubercle
genicular
a.
Med. inf. genicular
a.
Ant. tibia1 recurrent a.f
FIGURE2. Diagramof articulationof kneeandassociatedarterial distributionshowingrelationshipof incisionto Gerdy’stubercle. manner described by Bucholz et al for the management of tibial plateau fractures.5 The wound is not drained, and can be closed in layers in the usual fashion using skin staples or a continuous subcuticular suture. The latter method produces better esthetic results. As with any surgical approach, constant revision of the technique has occurred. In some cases, we have obviated the need for a large incision and trapdoor approach. Cases in which small amounts of cancellous bone are necessary (< 15 mL) may be performed
FIGURE3. Diagram showing delineation of bone window #byholes made with a rotary instrument.
1260
FIGURE 4.
IIJ3lAL AUIUbtNUUY
m___._
Diagramshowingsuperiorlybasedosteoperiosteai flap.
through a stab incision made with a no. 10 blade and perforation through the lateral cortex with a trephine or curette. This variation has been found to save operating time, and has further improved the esthetics of the healed incision. Following application of an antibacterial ointment and a nonsticking dressing over the wound, the immediate area of the donor site is wrapped with a Kerlex bandage (Johnson & Johnson, New Brunswick, NJ) and the knee and leg are wrapped with an Ace bandage (Conco Med, Bridgeport, CT). Postoperatively, ambulation was begun the same day or, more often, the following morning. All patients received an intravenous course of antibiotics for the primary surgery, which theoretically should cover the donor site procedure. Material and Methods Twenty patients who had required bone grafting as an adjunct to their surgical management were evaluated retrospectively. All patients were administered a general anesthetic except one in whom an intravenous conscious sedation technique and local anesthesia at the donor site were used. The operations included grafting of a nonunion of a Le Fort I osteotomy, antroplasty with sinus grafting, repair of mandibular nonunions, secondary cleft palate repair combined with calvarial bone strips, salvaging of several mandibular staple implants, and major reconstruction of a mandible lost as a result of a gunshot wound. The inpatient and outpatient records were used to ascertain information about age, sex, past medical history, the primary maxillofacial procedure, the specific donor site(s), the amount of cancellous bone procured (recorded as noncompressed and rounded off to the nearest whole number), the recipient site, any additives to the graft, earliest time of weight-bearing on the ipsilateral leg,
._._^^_..^T.^
CANCbLLUUS ^.__^__
_
___^
BUNE --__-
-
_
__.-_
AS DUNUK
SITE
and early or delayed complications at the donor and recipient sites, as well as any residual gait disturbances. Cancellous bone was procured from the proximal tibia1 metaphysis after ruling out contraindications related to age (lack of closure of the epiphyseal growth center), the presence of ipsilateral infection, metabolic or metastatic bone disease, or ipsilateral trauma to the extremity that would further compromise the integrity of the leg. The cancellous tibial bone was obtained in some instances concomitantly with the initiation of the maxillofacial procedure. However, in those cases in which excessive movement of the patient caused by the graft procurement would disturb the maxillofacial surgery, the procedures were performed separately. Maxillofacial dissection before graft procurement was ideal because of the ability of the oral and maxillofacial surgeons to assess volumetric need or to choose an alternative donor site, if necessary. Those cases in which volumetric requirements could be assessed preoperatively allowed simultaneous maxillofacial dissection and graft procurement, decreasing anesthesia time. A single tibial donor site was anticipated in each case. If, however, the volume of cancellous bone required exceeded what could be obtained from the tibia, the contralateral tibia was also used or the ilium was selected instead. Results Patients were observed during the period of April 1990 through February 199 1 (Table 1). Twenty patients underwent 21 cancellous tibia1 graft procurements as part of their maxillofacial reconstructive procedure. Their age averaged 43.3 years (median, 44 years). There were 13 females (7 1.4%) and 5 males. All patients had mild to moderate temporary ecchymosis and edema postoperatively. The average follow-up period was 5.2 months. An average amount of noncompressed cancellous bone obtained from the 2 1 donor sites was 25 mL, with a range of 10 to 42 mL. A bilateral tibia1 procurement, which yielded 40 mL, was used to reconstruct an entire mandible that necessitated a large volume of cancellous bone. Ten patients (50%) received an additive to the primary tibia1 graft. These included Interpore 200 (Interpore International, Irvine, CA), 1 patient; Bio-oss (anorganic bovine hydroxylapatite, Walter Lorenz, FL), 5 patients; cortical bone from the tibia and ilium, 2 patients; lyophilized rib, 1 patient; and calvarial strips, 1 patient. The majority of patients were able to bear weight on the ipsilateral donor leg on the second postoperative day. The exception was patient E.B., in whom weight bearing was delayed for 6 weeks because of head, thoracic, and extremity trauma. Five patients required the use of a cane for 2 to 3 weeks postoperatively, and one patient for 1 week after surgery. Seven patients underwent antroplasty and tibial
Osteopenia GSW
51
44
50 58 60 53
70
67
24 58
50 17
29
24
60
24
60
E.B. C.P. K.A.
S.F. N.M.
M.L. A.B. R.H. G.D.
S.G.
M.L.
L.H. M.R.
GM. J.F.
T.F.
A.V.
M.S.
L.L.
D.R.
NJ)
Debridement dacron/Luhr reconstruct (Luhr. Howmedica,
Antroplasty (2) Branemark X 6 Closure of clefts
LeFortI
Schuhardt (2)
Osteotomy Antroplasty (2) implants Antroplasty (2) C-osteotomy
Osteotomy
Debridement, place FM1
Antroplasty (1) ReC0llStNct mandible AntropIasty (1) Antroplasty (1) Debridement Debridement
ORIF mandible Redo Le Fort I Antroplasty
Primary Surgery
Tibia
Tibia
Tibia
Tibia
Tibia
Tibia Tibia
Tibia Tibia
Tibia
Tibia
Tibia Tibia (2), ilium (1) Tibia Tibia Tibia Tibia
Tibia Tibia Tibia
Donor Site
Mandible
Maxilla-antra, palate
Maxilla-antra
Maxilla
Maxilla
Maxilla-antra Vertical rami
Maxilla Maxilla-antra
Vertical rami
Mandibular symphysis
Maxilla-an&urn Entire mandible w/ titanium tray Maxilla-antrum Maxilla-antrum Mandibular symphysis Mandibular symphysis
Mandible, alveolus Maxilla Maxilla-antra
Recipient Site
Graft
42
10 40
25 40
20
10
15 15 20 20
25 20,20
30 20 35
0 0 0
0 0 0
POD-l POD-l POD1 POD- 1
POD- 1
0 0
0
Calvarial
Bio-oss 5 g
0
Bio-ass 5 g 0 0 Lyophilized block rib 0
0
Pain 2wk 0
POD-l POD-l
0
Infection
Cane 3wk Limp 2wk Cane 2wk
0
0
0 0
0 0
0
6
7 7
11 10 8
Cm)
FollowUP
staple bone plate; VME, vertical maxikwy
POD- 1
0 POD-l
OphY
0 0
POD-4
0
0
0
OP &Y OphY POD-3
0
0 0 0 0
POD-2
Bio-oss 2.5 g Cortical strips (ilium) 0 Bio-ass 2.5 g 0 0
Limp 3d 0 Cane 1 wk 0 0 0 Cane 3wk Cane 3wk
0 0
0 0 0
0 0 0 0 0
>6 wk POD-2 POD- 1
Gait
Recipient
Donor
Complications
POD-l POD-2
Hydroxylapatite Cortical chips Bio-oss 5g
Additives
Earliest WeightBearing
IN); MS3P, mandibular
Volume (mL)
Abbreviations: GSW, gunshot wounds: FMI, fixed mandibular implant (Zimmer, Warsaw, excess; CA, carcinoma; VMH, vertical maxillary hypertrophy; POD, postoperative day.
Clefi alveolus palate Nonunion postCA
Osteopenia Class II microgenia Horizontal maxillary exceSS VMH/ microgenia Osteopenia
MSBP failure (MSBP, Hall International, Carpenteria, CA) Pagets disease, class III VME, class III Osteopenia
Osteopenia Osteopenia FMI failure FMI failure
Acute trauma Nonunion Osteopenia
31 24 31
Patient
History
Age (yr)
Table 1. Characteristics of 20 Patients Receiving Proximal Lateral Tibia1Grafts
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TIBIAL
cancellous bone transplants to one or both maxillary sinuses. Five of these patients had tibia1 bone mixed with Bio-ass and three had only tibial bone transplanted to a single sinus. In those patients who received Biooss, the amount used ranged from 2.5 to 5 g. In this subset of patients, the amount of noncompressed cancellous tibial bone procured averaged 23.75 mL per patient. All patients included in this study had minimal leg pain, which could be easily controlled in the majority of instances with nonsteroidal anti-inflammatory medications and occasionally with oral narcotic analgesics. Moreover, there were no complaints of cosmetic problems associated with the incision over the proximal tibia. Of the 21 donor sites evaluated, there were no complications such as long-term pain, neuropathy involving the ipsilateral leg, wound infection, hematoma or seroma formation, or fracture of the proximal tibia, even in older patients in whom weight bearing commenced within the first 24 hours after surgery. Furthermore, there was no local donor site wound breakdown or superficial or deep infections. None of the patients experienced deep vein thrombophlebitis. However, this possibility should be considered and the patient observed carefully in the immediate postop erative period. There were no long-term gait disturbances in those patients observed beyond 6 months. Discussion A review of the literature shows that few authors in either orthopedics or oral and maxillofacial surgery have advocated or studied the application of cancellous bone grafts from the proximal tibia1 metaphysis. This may be the result of a general opinion that there is an inadequate volume of cancellous bone at this site. In view of the fact that the iliac crest, which is the most popular and well studied donor site for maxillofacial procedures, has well documented major and minor complications, alternative donor sites should be explored. In all of our patients, with the exception of the subtotal replacement of the mandible and the cleft patient, the proximal tibia1 metaphysis provided more than an adequate volume of cancellous bone. Although the cancellous procurement yielded up to 42 mL of bone, the volume of donor bone from a single site was based on need and not the total amount that potentially could be procured. In the exceptions cited above, the bone from the ilium was felt to be suboptimal in the mandibular reconstruction case and surgical philosophy dictated the use of calvarial strips in the cleft patient. In all cases except the subtotal mandibular reconstruction, only one proximal tibia was used as a donor site. Thus, from a preliminary standpoint, the proximal tibia is useful for a variety of maxillofacial procedures and
AUTOGENOUS
CANCELLOUS
BONE AS DONOR
SITE
would appear an easily obtainable source of viable cancellous bone. The consistency and character of the cancellous tibia1 bone is much like that from other donor sites and compares favorably from the histologic standpoint. Although a single site tibia1 graft harvest is volumetrically less than that generally obtainable from the ilium, for a large range of maxillofacial procedures the volume of cancellous bone procured is adequate. It would thus be appropriate to use the proximal tibia for those maxillofacial procedures in which less than 40 mL is required, realizing the potential of a significantly greater procurement if the contralateral tibia is used. Patients were clinically healed and able to ambulate early, but postoperative radiographs of the tibia were consistent with the observations of DaEner in which he noted long-term radiographic visibility or radiolucency of the donor site6 (Fig 5). As a result of this finding, and in view of the suggestion that iatrogenic processes are usually not considered by the radiologist when an osteolytic area is discovered and the radiologist may be unable to rule out an infectious or neoplastic process, Daffner cautions that a full history of prior graft harvest from the surgeon is essential. Further, knowledge on the part of the radiologist of newer alternative donor sites would be important to avoid a misdiagnosis. O’Keefe et al are anecdotally aware of three patients who were considered for surgical biopsy of the proximal tibia by physicians unaware of the surgical history.2 Also supportive of the proximal tibia as a donor site is the lack of complications relating to deep vein thrombophlebitis, pulmonary problems, or peritoneal or genitourinary system injury. Significantly, there were no immediate or delayed fractures of the tibia1 plateau or articular compromise of the knee in the 10 patients
FIGURE 5. Immediate postoperative radiographs of proximal tibia from which cancellous bone has been procured.
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CATONE ET AL
observed for 6 to 10 months. However, a greater number of cases must be followed up for at least 6 months before definitely advocating routine weight-bearing immediately after surgery. The disadvantages of proximal tibia1 bone harvest relates are similar to those with any bone graft.’ Moreover, in view of the potential radiographic visibility of the donor site in the proximal tibia, for years, it would not be advisable at this time to consider this site for a repeated harvest. Additionally, the lack of correlation between the radiographic appearance and the quality or quantity of bone present in the distal radius in humans and the ilium in the canine model, further supports caution and the need for future studies to advocate reuse of the proximal tibial donor site.8,9
References 1. Burchardt H: Biology of bone transplantation. Orthop Chn North Am 18:187, 1987 2. O’Keefe RM, Reimer BL, Butterfield SL: Harvesting of autogenous cancellous bone graft from the proximal tibia1 metaphysis: A review of 230 cases. J Orthop Trauma 5:469, 199 1 3. Gray H: Anatomy of the Human Body. Philadelphia. PA, Lea & Febiger, 1959 4. Ray R: Personal communication, June 1988 5. Bucholz RW, C&ton A, Holmes R: Interporous hydroxylapatite as a bone graft substitute in tibial plateau fractures. Chn Orthop Rel Res 24053, 1989 6. Daffner RH: Case report 592. Skeletal Radio1 19:73, 1990 7. Younger EM, Chapman MW: Morbidity at bone graft donor sites. J Orthop Trauma 3~192, 1989 8. McGrath MH, Watson K: Late results with local bone graft donor sites in hand surgery. .I Hand Surg 6:234, 198 I 9. Montgomery DM, Moed BR: Cancellous bone donor site regeneration. J Orthop Trauma 3:290, 1989