Abstract
Background:
Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognized minor and major complications. The proximal tibia is one such potential site and is particularly suited to foot and ankle surgery, because it is within the operative field and under tourniquet control.
Methods:
A retrospective review was performed of 148 procedures using bone graft from the proximal tibia performed over a period of 5 years. Minimum followup was 3 months. Data were obtained from operative notes and patient interviews to establish pain, morbidity, and overall satisfaction.
Results:
Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately after surgery. At followup, 96% had no pain and 4% had very mild pain with certain activities such as kneeling. There were no major complications. Four patients (2.7%) had persisting areas of paresthesia at followup, but none were troubled by it. One patient had a superficial wound infection that resolved. The period of nonweightbearing, usually 2 to 3 weeks, was dictated by the primary procedure. There were no complications related to early weightbearing
Conclusions:
The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restrictions in weightbearing after this procedure.
Keywords
INTRODUCTION
Autogenous cancellous bone graft remains the gold standard for use in reconstruction and fusion procedures. Although there have been advances in the use of other materials, such as alloplastics, ceramics, and polymers, fresh autograft continues to demonstrate superior results over these and allografts, 4,6,7,8,11,12 with proven osteoinductive, osteoconductive, and osteogenic capability. There is no universally accepted donor site for bone graft. Possibilities include the iliac crest, ribs, distal radius, distal femur, proximal tibia, distal tibia, and calcaneus, each of which has significant minor and major complications 1,5,14 . In foot and ankle surgery, the ideal donor site is on the ipsilateral limb distal to the tourniquet (Figure 1); this site allows easy harvest and produces few postoperative mobility problems beyond those imposed by the primary procedure. In our department the proximal tibia has become the preferred site for autogenous cancellous bone harvest during foot and ankle arthrodesis procedures. Although this procedure has been reported previously, 2,3,9,13 the ability and safety of postoperative weightbearing have not been fully investigated.
The aim of this study was to perform a retrospective review of procedures involving bone graft harvest from the proximal tibia in a regional orthopaedic center to determine morbidity, complications, and acceptability to patients.
MATERIALS AND METHODS
A retrospective review identified 151 procedures (133 patients) between December, 1999, and January, 2005. The procedures were mainly elective arthrodesis of the hindfoot, midfoot, and ankle (Table 1). Primary and revision surgeries were included. Data on patient demographics, date of surgery, consultant, procedure (primary or revision), donor site for bone graft, and period of limited weightbearing were obtained from patient charts and operative notes.
Harvest site for proximal tibial bone graft harvesting.
Procedures identified in study population
Two patients had died since their surgeries. The remaining 131 patients (148 procedures) were contacted by telephone by the first author and questioned using a predetermined protocol to establish pain levels and the presence of paresthesia or numbness around the donor site scar in the immediate postoperative period and at the time of review, any complication related to the donor site, and the level of overall satisfaction with the procedure. The 78 women and 53 men had an average age of 53 (range 20 to 82) years. Of the 148 procedures, 15 were revisions. Few ankle arthrodeses were included because at our institution, they usually are done arthroscopically without bone grafting. If complications were identified, the full hospital notes were examined to obtain further details. Those who did not have a satisfactory outcome were offered further consultation. Followup ranged from 3 to 69 (mean 28) months.
The most common procedure was triple arthrodesis. Most of the other procedures were hindfoot or midfoot arthrodeses (Table 1). In all patients, local graft was used where this was sufficient. Proximal tibial bone harvest was only used in those patients in whom this was not sufficient; these were the patients identified for inclusion in the study. The amount of graft harvested from the site was sufficient for the main procedure in all patients (Figure 2); the actual amount of graft harvested was not formally measured.
Pain scores were measured on a verbal rating scale for ease of use over the telephone (1-no pain, 2-very mild pain, 3-mild pain, 4-moderate pain, 5-severe pain). The common reference point for the degree of pain was the pain from the main operative procedure. The point of reference for the pain score used by the patient was the pain from the main operation site.
Operative Technique
The lower limb was prepared and draped, leaving the proximal tibia exposed. A thigh tourniquet was used unless contraindicated. For graft harvest a longitudinal or oblique incision was made just lateral to the tibial tuberosity (Figure 1). The fascia was incised, the muscle separated by blunt dissection, and a periosteal elevator used to expose the underlying bone. A 1-cm osteotome was used to cut a rectangular window measuring approximately 2 × 1 cm (Figure 3). Cancellous bone was harvested using curettes. The bone window was replaced, and the wound was closed without requiring drainage (Figure 4).
The period of postoperative nonweightbearing ranged from 1 to 8 weeks with a mean of 3 weeks. The period of partial weightbearing after this varied from 2 to 11 weeks with a mean of 5.5 weeks. These periods were determined by the nature of the primary procedure rather than the bone graft donor site.
RESULTS
The mean initial postoperative donor site pain score was 1.25 (range 1 to 3, no pain to mild pain). At the time of followup, the mean score was 1.04 (range 1 to 2) (Table 2).
Nine-centimeter bowl demonstrating amount of cancellous graft easily harvested from one site.
Harvest site showing removal of cortical window with 1-cm osteotome.
Operative site showing relation of bone graft harvest site to primary operative field.
Pain score from donor site
Of those reporting any pain at followup, pain on palpation, minor direct trauma, or kneeling was typical.
Immediate postoperative paresthesia was reported in eight limbs (5.4%), four of which had resolved by the time of followup. Most areas of paresthesia were less than 1 cm 2 . Two patients reported areas larger than this, one lateral to the scar, and the other a 10-cm long narrow area inferior to the scar. Neither of these had completely resolved at followup, but they had improved, and neither patient found it to be a problem.
One patient (0.7%) reported an early superficial wound infection at the donor site. With an oral antibiotic, the infection resolved within a week. Wound swabs taken were negative. No other complications were reported, in particular, no cases of hematoma or fracture.
Eight patients (6.1%) requested further followup at the time of interview. One was for a problem thought initially to be related to the donor site, a persistent uncomfortable swelling that had developed 6 months postoperatively. Ultrasound examination demonstrated an unrelated pes anserinus bursitis, and a satisfactory outcome was obtained with injection of local anesthetic and steroid. The other seven patients requesting followup had problems related to their foot surgery, including requests for removal of implants and problems with persisting symptoms, none of which were related to the bone graft donor site.
DISCUSSION
Autogenous cancellous bone graft remains preferable to allograft or synthetic substitutes because of its beneficial effects, avoidance of risk of infection transfer, immune stimulation and cost. The use of the proximal tibia as a graft donor site in foot and ankle surgery allows access to a site already under tourniquet control within the operative field and requires no change in patient position or additional draping.
Several previous studies have reported the feasibility of bone graft harvest from the proximal tibia. O'Keeffe et al. 13 examined 230 cases in a retrospective study of bone grafting of acute lower extremity fractures and nonunions 13 . All had a minimum of 6 weeks of nonweightbearing. Alt et al. 2 reported a series of 54 cases in a retrospective study using proximal tibial bone graft for unspecified fresh fractures and nonunions. Weightbearing as tolerated was permitted postoperatively. Geiderman et al. 9 reported a mixed cohort of 155 acute fractures and reconstructions. All patients were nonweightbearing for 6 weeks. This study involved a particular patient population, those who had elective reconstructions or fusions of the hindfoot, midfoot, or ankle whose ability to bear weight was dictated by their primary procedure; nonweightbearing averaged 3 weeks.
Younger and Chapman, 14 in a series of mainly iliac crest bone grafts, reported 8.6% major complications and 20.6% minor complications. If the graft was obtained through the same incision as the primary procedure the major complication rate was 17.9%. Later studies have shown lower but still significant complication rates for the iliac crest as a donor site 1,10 .
The studies of proximal tibial bone harvest reported complication rates from 1.3% to 2.5% 2,9,13 . Each study reported one postoperative hematoma. Alt et al. 2 reported no other complications. O'Keefe et al. 13 reported one nondisplaced tibial eminence fracture and one superficial infection. None reported sensory loss, and altered sensation was not mentioned. Geiderman et al. 9 reported three patients with sensory changes postoperatively, all of which resolved by 3 months, but this study was a retrospective chart review only, with no direct contact with the patients.
Healed bone harvest site scar at 1 year followup.
We had no major complications in our 131 patients. One patient (0.7%) had wound erythema successfully treated with oral antibiotics. Eight patients (5.4%) reported altered sensation immediately after surgery. Four of these (2.7%) had altered sensation when questioned at followup but only one (0.7%) had noticed the problem before questioning. Of 131 patients, 126 (96%) had no pain from the donor site at the time of followup; the remainder had occasional mild symptoms. No patient had delayed rehabilitation due to the donor site and none were concerned about the cosmetic appearance. Many respondents had forgotten about their graft harvest site until reminded (Figure 5).
The proximal tibia is a reliable and safe site for bone harvest in patients undergoing elective foot and ankle surgery. A sufficient quantity of bone is available. Complication rates are low and the procedure is very acceptable to patients. There is no need to restrict weightbearing to allow donor site healing beyond the time imposed by the primary procedure.