Low Donor Site Morbidity Associated With Tricortical Calcaneal Bone Graft

Introduction

The use of bone graft in orthopedic surgeries is widespread to fill cavities, bone defects, and pseudoarthrosis, as well as to correct deformities, among other indications.^3,7,9,20

When bone grafts are from the patient’s own body (autologous), they are usually harvested from the tibia, fibula, or iliac crest. ⁸ These 3 bones provide structured cortical grafts. Bone grafting is common; in the United States alone, it is estimated that 200 000 grafting procedures are performed each year. ¹⁹

In 2012, Sanhudo ¹⁵ described the technique of harvesting an autologous bone block graft from the posterior-superior calcaneal tuberosity. The study shows some advantages of this technique, such as preparation in the same operative field and the possibility of using the same anesthesia as that of the primary procedure. Additionally, the bone structure at the calcaneal tuberosity is especially useful in surgeries that require a rigid and tricortical graft.

This study aims to evaluate the donor site complications observed in a consecutive series of patients undergoing autologous graft harvesting from the posterior-superior calcaneal tuberosity.

Materials and Methods

This is a retrospective case series study based on data collected from patients’ medical records and on a prospective face-to-face clinical evaluation. The sample included 22 patients consecutively, and 2 case was not included due to loss of follow-up. The study was approved by the local ethics committee and followed the Declaration of Helsinki and the Guidelines for Good Clinical Practice.

Participants underwent operative treatment using the posterior-superior tuberosity as the autologous graft donor site between January 2017 and January 2020. All procedures were performed by the same medical team, at the same medical center. The graft was used at the same operative time to treat foot and ankle disorders.

The inclusion criteria were as follows: (1) patients who underwent operative treatment using the technique of autologous graft harvesting from the posterior-superior calcaneal tuberosity and (2) patients who agreed with and signed the study informed consent form at the time of follow-up.

The exclusion criteria were as follows: patients with neuropathy, previous or current skin lesions in the graft region, previous degenerative lesions, and surgeries or sequelae of fractures in the foot or ankle.

Outcome Measures

This study assessed clinical and imaging outcomes. The clinical evaluation was performed at the last consultation using the visual analog scale (VAS) directed at the graft donor as well as by evaluating the healing process and complications.

In cases where patients reported pain at the donor site, a magnetic resonance imaging (MRI) was ordered and independently evaluated by 2 radiologists specialized in the musculoskeletal field (G.D., J.P.B.C.L.). Feet radiograph was ordered according to routine consultations (Figure 1).

OPEN IN VIEWER

Figure 1.

(A) Preoperative radiograph. (B) Radiograph of the posterior-superior calcaneal tuberosity graft harvesting site 1 year after the surgery.

Operative Technique and Postoperative Care

The patients underwent the operative procedure in the supine position, with lateral tilt after placing a cushion below the ipsilateral gluteus. Spinal anesthesia was performed with sedation in all cases.

After setting up the sterile fields, a tourniquet was inflated. The technique consists of making a vertical incision of approximately 3 cm, in most cases in the lateral region, in the topography of the posterior-superior calcaneal tuberosity (Figure 2).

OPEN IN VIEWER

Figure 2.

Vertical incision in the topography of the posterior-superior calcaneal tuberosity.

The Achilles tendon is identified with care not to detach it. The graft harvest area is then marked with the electrocautery, and a bone saw is used to perform the osteotomy (Figure 3).

OPEN IN VIEWER

Figure 3.

Graft identification and preparation for osteotomy.

A delicate chisel is used to harvest the graft; then, the region must be cleaned with a saline solution (Figure 4). The subcutaneous tissue was closed using a 3-0 Vicryl suture, whereas the skin was closed using a 4-0 nylon suture.

OPEN IN VIEWER

Figure 4.

Autologous bone graft from the posterior-superior calcaneal tuberosity.

Postoperative care was the same as for any other surgery. Immediate weightbearing restrictions varied according to the primary procedure to which the patient was submitted.

Results

The participants were mostly female (95%), with a mean age of 67.35 and a standard deviation of 6.82, ranging from 48 to 77 years. The left side was most commonly affected (55%), 18 of 20 (90%) patients were nonsmokers, 4 of 20 (20%) had diabetes mellitus, and 2 of 20 (10%) had rheumatoid arthritis (Table 1.)

OPEN IN VIEWER

Table 1.

Sample Characteristics and Postoperative Results.

Outcome	Postoperative
VAS score, mean ± SD (range)	0.55 ± 1.70 (0-6)
Follow-up, mo, mean ± SD (range)	17.95 ± 4.51 (12-26)
Operative approach, %
Lateral	85
Medial	15

Abbreviation: VAS, visual analog scale.

Table 2 shows the primary operative procedures that required graft harvesting, as well as the diagnoses and postoperative protocol.

OPEN IN VIEWER

Table 2.

Diagnoses and Procedures Performed Using Bone Block Graft.

Diagnosis	Procedure	Postoperative Protocol	n (%)
Adult acquired flatfoot	Lateral column lengthening	Weightbearing after 4 wk	12 (60)
Subtalar osteoarthritis	Subtalar arthrodesis	Weightbearing after 2 wk	1 (5)
Hallux valgus	Revision of arthrodesis of the metatarsophalangeal joint in the hallux (Pseudoarthrosis)	Immediate weightbearing	2 (10)
Mueller-Weiss syndrome (navicular osteonecrosis)	Talonavicular arthrodesis	Weightbearing after 2 wk	1 (5)
Adult acquired flatfoot	Cotton osteotomy	Weightbearing after 4 wk	1 (5)
Adult acquired flatfoot	Talonavicular arthrodesis revision (Pseudoarthrosis)	Weightbearing after 2 wk	1 (5)
Hallux valgus	Treatment of sequelae of resection arthroplasty of the hallux	Immediate weightbearing	1 (5)
Hallux valgus	Lapidus procedure revision (pseudoarthrosis)	Immediate weightbearing	1 (5)

Two patients (10%) reported pain in the graft region. In both cases, the pain was not exclusive to the donor site, but a diffuse pain in the foot, including that region. Both patients underwent a magnetic resonance imaging (MRI) examination: one showed mild insertional tendinopathy with no sign of rupture and edema in the graft donor bed; the other, on the other hand, showed no inflammatory changes in the Achilles tendon and its region, except for a slight thickening.

In this series, 1 patient developed a superficial operative wound infection, which resolved with oral antibiotic therapy. We had no deep infections requiring operative debridement, no Achilles tendon ruptures or intra- or postoperative calcaneal fracture.

Discussion

Autologous bone graft is considered the gold standard of bone grafting because it contains osteogenic, osteoinductive, and osteoconductive properties. Further, there is a complete histocompatibility, with no risk of disease transmission.^9,12

One of the most common sites for autologous bone graft harvesting is the iliac crest region with varying reports of complication rates. Shin et al ¹⁶ found good long-term results, with low complication rates. However, Kim and colleagues ¹⁰ reported 16.5% of patients reporting more severe pain at the iliac crest graft harvesting site than at the primary operative site after 1 year of follow-up.

In a case series involving 19 patients, Feeney described the harvesting of a tricortical graft from the calcaneus. Unlike this study, the 1.5 × 1.5 × 3-cm bone block was harvested from a region close to the halfway point between the calcaneal tendon insertion and the subtalar joint. No patient developed symptoms at the donor site at the end of the follow-up, but they had 2 calcaneal fractures requiring treatment with cast immobilization. ⁶ By harvesting the graft from the tuberosity very close to the Achilles tendon insertion, similar to a calcaneoplasty, we obtained a much shorter lever arm, thus reducing the fracture risk. In this procedure, the concern is the risk of avulsion, but no patient had this complication. Similarly, studies in which calcaneoplasty has been performed to treat Haglund’s Syndrome, Achilles avulsion is rare and typically only after tendon manipulation for insertional tendinopathy was performed during the procedure.^4,18

In our study, 2 of 20 (10%) of patients reported continued pain. These patients did not report pain exclusively at the graft harvesting site, but a diffuse pain in the foot, probably from the primary operative procedure. The MRI examinations did not show any specific injury to the Achilles tendon or to other local structures that could have been affected by the graft harvesting procedure. Only 1 of the cases involved mild tendinopathy, with no substantial injuries.

Our sample presented a patient with a superficial infection at the operative site, which was resolved using oral antibiotic therapy. When comparing it with the complications already described on iliac graft harvesting, such as gait abnormalities, infection, sensory changes, and cosmetic dissatisfaction, ¹¹ it appears that calcaneal graft harvesting is a less morbid procedure.

Another advantage of using autologous bone graft from the posterior-superior calcaneal tuberosity is that the procedure is performed in the same operative field. Two studies have shown that postoperative pain is less common when using a graft from the same area as that of the primary procedure, especially in foot and ankle surgeries; moreover, anesthetic blocks can be performed to control the postoperative pain.^2,14

The tibia region is another common region for autologous bone graft. Low complications in this area have substantial evidence in the literature; however, a major disadvantage is the recommendation to prevent local weightbearing and postpone walking until the tibia defect is partially consolidated in order to prevent a possible fracture.^1,5,13 In our small case series, we did not restrict weightbearing based on the harvesting of a graft from the calcaneus.

The size of bone grafts from the posterior-superior calcaneal tuberosity is restricted. The maximum dimension that can be harvested is up to the region of the Achilles tendon’s insertion, so as to avoid the risk of disinsertion. In cases where large amounts of graft are needed, another donor site should be deemed a safer option.

The study has some limitations. Our sample size is relatively small, and the follow-up time is short. Graft harvesting was performed by a team specialized in foot and ankle surgery and may have a steep learning curve for orthopedic surgeons unfamiliar with the anatomy of the area. The grafts were used exclusively in procedures in the same foot, and not in other areas, favoring a confusing factor in the results. Finally, the autologous graft used in this study was not compared with other classic autologous graft donor sites, such as the iliac crest or the tibia region.

Supplemental Material