NON VASCULARIZED BONE NON VASCULARIZED BONE GRAFTSGRAFTS

INTRODUCTIONINTRODUCTION• Contemporary oral and maxillofacial Contemporary oral and maxillofacial

surgeons need bone grafting techniques to surgeons need bone grafting techniques to satisfy patient needs in trauma, pathology, satisfy patient needs in trauma, pathology, reconstructive surgery, and dental reconstructive surgery, and dental implantology. implantology.

• The "gold standard" for bony reconstruction The "gold standard" for bony reconstruction of the jaws is the use of autogenous bone of the jaws is the use of autogenous bone grafts. grafts.

ADVANTAGESADVANTAGES

Viable osteocytes can be carried to the Viable osteocytes can be carried to the graft site, and active bone regeneration graft site, and active bone regeneration or osteogenesis can occur. or osteogenesis can occur.

Autogenous bone grafts act by Autogenous bone grafts act by osteoinduction when bone osteoinduction when bone morphogenetic proteins stimulate bone morphogenetic proteins stimulate bone formation. formation.

Finally, autogenous bone grafts act as a Finally, autogenous bone grafts act as a scaffold for vascular ingrowth, which is scaffold for vascular ingrowth, which is known as osteoconduction known as osteoconduction

we have a wide choice of we have a wide choice of autogenous bone donor sites, autogenous bone donor sites, including jaws, iliac crest, calvarium, including jaws, iliac crest, calvarium, rib and tibia. By expanding the donor rib and tibia. By expanding the donor sites to the free flap arena, surgeons sites to the free flap arena, surgeons can expand the donor sites to include can expand the donor sites to include the scapula, radius, and fibula.the scapula, radius, and fibula.

GENERAL PRINCIPLESGENERAL PRINCIPLES

All non-vital grafts harvested without a All non-vital grafts harvested without a blood supply must gain this from recipient blood supply must gain this from recipient bed in order to maintain their viability.bed in order to maintain their viability.

The larger the volume of grafted tissue, the The larger the volume of grafted tissue, the more difficult it is for ingrowth of capillaries more difficult it is for ingrowth of capillaries in sufficient time to prevent necrosis.in sufficient time to prevent necrosis.

Any fluid collections at the recipient site, Any fluid collections at the recipient site, such as seroma or haematoma, will prevent such as seroma or haematoma, will prevent direct contact between the recipient bed direct contact between the recipient bed and the graft, with likely graft failure. and the graft, with likely graft failure.

The graft must be held rigidly at the The graft must be held rigidly at the recipient site, otherwise capillary ingrowth recipient site, otherwise capillary ingrowth will be prejudiced and graft failure will will be prejudiced and graft failure will ensue.ensue.

The most appropriate donor site material The most appropriate donor site material should be chosen. Harvested bone may be should be chosen. Harvested bone may be solid or particulate or combined with solid or particulate or combined with cartilage. Solid bone may be cortical alone cartilage. Solid bone may be cortical alone or cortical and cancellous in combination. or cortical and cancellous in combination.

In younger patients it is prudent to avoid In younger patients it is prudent to avoid donor sites where interference in growth donor sites where interference in growth may produce either a cosmetic or functional may produce either a cosmetic or functional disability.disability.

How to minimize donor site How to minimize donor site morbidity……morbidity……

Incisions should be sited so that they are Incisions should be sited so that they are barely visible.barely visible.

Motor and sensory nerves in the area must Motor and sensory nerves in the area must be preserved.be preserved.

Musculoskeletal complexes in the area Musculoskeletal complexes in the area should be kept intact; for example, the should be kept intact; for example, the anterosuperior iliac spine and iliac crest anterosuperior iliac spine and iliac crest should be preserved if at all possible.should be preserved if at all possible.

COSTOCHONDRAL RIB COSTOCHONDRAL RIB HARVESTINGHARVESTING

Principles and indicationsPrinciples and indications There are 12 ribs on each side of the thorax.There are 12 ribs on each side of the thorax. The rib have a pronounced curve from posterior The rib have a pronounced curve from posterior

to anterior, changing direction through 180°. to anterior, changing direction through 180°. They are also angled downwards from back to They are also angled downwards from back to front except fifth rib.front except fifth rib.

The rib cage protects the intrathoracic contents The rib cage protects the intrathoracic contents including the lungs and heart. The neurovascular including the lungs and heart. The neurovascular intercostal bundles run in a groove along the intercostal bundles run in a groove along the lower surface of the rib.lower surface of the rib.

When more than one rib is harvested, alternate When more than one rib is harvested, alternate ribs are removed rather than adjacent ribs, to ribs are removed rather than adjacent ribs, to prevent cosmetic and functional chest-wall prevent cosmetic and functional chest-wall problems. problems.

A sub periosteal approach is used for A sub periosteal approach is used for non-vital rib harvest.non-vital rib harvest.

With the periosteum remaining With the periosteum remaining in situ in situ in the chest wall, new bone will form in the chest wall, new bone will form in the subperiosteal pocket. This new in the subperiosteal pocket. This new bone can sometimes be harvested in bone can sometimes be harvested in future if it is of sufficient bulk. future if it is of sufficient bulk.

Rib can provide cartilage alone, bone Rib can provide cartilage alone, bone alone or a combination of both cartilage alone or a combination of both cartilage and bone on the same strut. and bone on the same strut.

Cartilage is a relatively inert tissue and Cartilage is a relatively inert tissue and therefore resorbs slowly. It does not therefore resorbs slowly. It does not integrate readily with adjacent bone at the integrate readily with adjacent bone at the recipient site which can be used to recipient site which can be used to advantage in temporomandibular joint advantage in temporomandibular joint ankylosis.ankylosis.

It also retains its growth potential and can It also retains its growth potential and can therefore be used to replace the therefore be used to replace the secondary growth centre of the secondary growth centre of the mandibular condyle in children.mandibular condyle in children.

Cartilage has inherent stresses which are Cartilage has inherent stresses which are not manifest immediately but take from 30 not manifest immediately but take from 30 minutes to one hour to develop. minutes to one hour to develop.

When cartilage is used as a subcutaneous When cartilage is used as a subcutaneous strut (e.g. along the nasal bridge) this strut (e.g. along the nasal bridge) this property may cause deformation of an property may cause deformation of an initially satisfactory reconstruction with initially satisfactory reconstruction with time. time.

The cartilage should be carved then left The cartilage should be carved then left out of the body for 30 minutes to deform, out of the body for 30 minutes to deform, prior to final carving and placement in its prior to final carving and placement in its recipient site. recipient site.

The natural curve of the rib lends itself The natural curve of the rib lends itself readily to combined orbital floor and medial readily to combined orbital floor and medial orbital wall, or zygomatic arch and body orbital wall, or zygomatic arch and body reconstruction. reconstruction.

Rib bone or cartilage is used to reconstruct Rib bone or cartilage is used to reconstruct the nasal bridge. the nasal bridge.

Segments of rib may also be used as Segments of rib may also be used as interpositional grafts in mandibular or interpositional grafts in mandibular or maxillary Le Fort 1, 11 and III osteotomies. maxillary Le Fort 1, 11 and III osteotomies.

The combination of bone with a small The combination of bone with a small amount of chondral cartilage is an ideal amount of chondral cartilage is an ideal reconstruction for the mandibular condyle reconstruction for the mandibular condyle after freeing temporomandibular ankylosis.after freeing temporomandibular ankylosis.

Split rib is used for brain coverage Split rib is used for brain coverage and protection when part of the and protection when part of the cranium has been lost.cranium has been lost.

The rib can also be used as an onlay The rib can also be used as an onlay graft in the malar prominence, graft in the malar prominence, superior and inferior orbital rims, chin superior and inferior orbital rims, chin and the bridge of the nose.and the bridge of the nose.

A combination of costal cartilages can A combination of costal cartilages can be carved to reconstruct the whole be carved to reconstruct the whole auricle.auricle.

Preoperative preparationPreoperative preparation When one or two ribs are to be harvested, an When one or two ribs are to be harvested, an

incision is made in the submammary crease. incision is made in the submammary crease. This should be marked when the patient is This should be marked when the patient is

awake and erect as the submammary crease awake and erect as the submammary crease is no longer readily visible when the patient is no longer readily visible when the patient is supine and asleep on the operating table. is supine and asleep on the operating table.

A preoperative chest X-ray is mandatory to A preoperative chest X-ray is mandatory to exclude intrathoracic abnormalities and any exclude intrathoracic abnormalities and any unusual rib pattern. unusual rib pattern.

The patient is warned about the siting of the The patient is warned about the siting of the scar and immediate postoperative problems scar and immediate postoperative problems of discomfort and pneumothorax. of discomfort and pneumothorax.

Incision and procedureIncision and procedure A 5 cm long incision is A 5 cm long incision is

made in the made in the submammary crease, submammary crease, starting approximately 4 starting approximately 4 cm from the midline. The cm from the midline. The incision is carried through incision is carried through skin and subcutaneous skin and subcutaneous fat to the muscles of the fat to the muscles of the anterior chest wall.anterior chest wall.

The muscle encountered The muscle encountered first is the lower edge of first is the lower edge of pectoralis major. pectoralis major.

In the lateral part of the In the lateral part of the wound, slips of serratus wound, slips of serratus anterior can be seen anterior can be seen inserting onto the rib.inserting onto the rib.

Following wide undermining in the Following wide undermining in the plane superficial to the muscle, the plane superficial to the muscle, the rib to be harvested is palpated.rib to be harvested is palpated.

If two ribs are required the rib in the If two ribs are required the rib in the centre of the operative field is not centre of the operative field is not used and the ribs above and below used and the ribs above and below this rib are chosen.this rib are chosen.

An incision with cut diathermy is An incision with cut diathermy is made through the muscle onto and made through the muscle onto and through the periosteum of the rib to through the periosteum of the rib to be harvested.be harvested.

The periosteum is elevated from the anterior The periosteum is elevated from the anterior and superior aspects of the rib using Howarth and superior aspects of the rib using Howarth elevator.elevator.

No attempt is made at this juncture to push No attempt is made at this juncture to push posteriorly as the elevator may perforate posteriorly as the elevator may perforate the pleural cavity. the pleural cavity.

Instead the periosteal elevator is run along Instead the periosteal elevator is run along the superior surface of the rib from medial the superior surface of the rib from medial to lateral and the periosteum then falls to lateral and the periosteum then falls away from the rib at its posterosuperior away from the rib at its posterosuperior aspect.aspect.

The same procedure is followed with the The same procedure is followed with the anteroinferior periosteum until the lower anteroinferior periosteum until the lower border of the rib is reached. border of the rib is reached.

Care is taken here because the intercostal Care is taken here because the intercostal neurovascular bundle runs in a groove on neurovascular bundle runs in a groove on the under surface of the rib. the under surface of the rib.

Once the Once the subperiosteal plane subperiosteal plane on the posterior on the posterior surface of the rib has surface of the rib has been started, it is been started, it is then relatively easy then relatively easy to free a small strip to free a small strip of periosteum from of periosteum from superior to inferior superior to inferior with the use of the with the use of the Howarth raspatory, Howarth raspatory, on the posterior on the posterior surface of the rib.surface of the rib.

The curved Doyen's The curved Doyen's rib raspatory is then rib raspatory is then inserted into this inserted into this channel and the channel and the sharp edge of the sharp edge of the resparatory is used resparatory is used to strip off the to strip off the posterior periosteum posterior periosteum from this point from this point laterally and laterally and medially.medially.

Once sufficient bone has been cleared the Once sufficient bone has been cleared the Tudor Edward's rib shears are introduced Tudor Edward's rib shears are introduced to make the lateral cut first. Then the rib to make the lateral cut first. Then the rib shears are used to make the anterior cut.shears are used to make the anterior cut.

A examination is made of the deep A examination is made of the deep periosteal surface to see whether there periosteal surface to see whether there are any pleural tears. Water is then placed are any pleural tears. Water is then placed in the wound and the anaesthetist asked in the wound and the anaesthetist asked to exert positive pressure ventilation to to exert positive pressure ventilation to see whether there is any bubbling in the see whether there is any bubbling in the wound which indicates a pleural tear.wound which indicates a pleural tear.

If there is an air leak it is wise to use a If there is an air leak it is wise to use a temporary chest drain inserted low in the temporary chest drain inserted low in the anterior axillary line through a separate anterior axillary line through a separate stab incision in the skin. stab incision in the skin.

• When cartilage is harvested in continuity with rib then a diamond of periosteum and perichondrium is left attached to the anterior surface of the adjacent rib and costal cartilage to prevent disarticulation of the bone and cartilage

• The lateral cut is made The lateral cut is made first and the rib elevated first and the rib elevated with the left hand whilst with the left hand whilst the requisite amount of the requisite amount of cartilage is cut with a no. cartilage is cut with a no. 15 blade 15 blade

Bupivacaine 0.5% is injected proximally into Bupivacaine 0.5% is injected proximally into intercostal bundles of the harvested rib and intercostal bundles of the harvested rib and the rib the rib above and below this. above and below this.

AnAn epidural cannula and suction drain are epidural cannula and suction drain are inserted through two separate puncture inserted through two separate puncture wounds.wounds.

The periosteum and theThe periosteum and the muscle muscle surfaces are surfaces are closed with a continuous 2/0 chromic suture. closed with a continuous 2/0 chromic suture. The subcutaneous fat is closed as a separate The subcutaneous fat is closed as a separate layer with resorbable sutures and the skin is layer with resorbable sutures and the skin is closed wit subcuticular 3/0 Prolene suture. closed wit subcuticular 3/0 Prolene suture.

ComplicationsComplications

Wound infectionWound infection Loss of fixationLoss of fixation Exposure or fracture of the graftExposure or fracture of the graft Chest wall instabilityChest wall instability Pleural laceration and pneumothorax Pleural laceration and pneumothorax

SKULL BONE SKULL BONE HARVESTINGHARVESTING

Principles and indicationPrinciples and indication The skull bone vary in thickness at different The skull bone vary in thickness at different

sites, at different ages in the same sites, at different ages in the same individual and between individuals.individual and between individuals.

However, posterior part of the skull,However, posterior part of the skull,in the region of the parietal and occipital in the region of the parietal and occipital bone is relatively thick. bone is relatively thick.

The outer and inner table of skull boneThe outer and inner table of skull bone is separated by the vascular diploe.is separated by the vascular diploe.

In young children and the elderly the diploe In young children and the elderly the diploe may be non-existent so that it proves may be non-existent so that it proves impossible to separateimpossible to separate inner and outer inner and outer tables of skull bone. tables of skull bone.

The skull bone is curved in two dimensions The skull bone is curved in two dimensions and therefore fits neatly into defects such as and therefore fits neatly into defects such as the orbital floor and zygomatic prominence. the orbital floor and zygomatic prominence.

Preoperative preparationPreoperative preparation On the evening prior to operation, the On the evening prior to operation, the

patient's scalp should be shampooed with an patient's scalp should be shampooed with an antiseptic shampoo containing povidone-antiseptic shampoo containing povidone-iodine 4%. iodine 4%.

Only sufficient hair to gain access to the Only sufficient hair to gain access to the incision line and for later suturing is shaved incision line and for later suturing is shaved from the affected scalp. from the affected scalp.

The patient is warned about possible dural The patient is warned about possible dural tears, venous haemorrhage and tears, venous haemorrhage and cerebrovascular accidents. cerebrovascular accidents.

CT scans of the skull at 5-7 mm intervals will CT scans of the skull at 5-7 mm intervals will help in deciding on the thickest areas of help in deciding on the thickest areas of bone for donor site material.bone for donor site material.

Incision and ProcedureIncision and Procedure If a bicoronal flap is used for the If a bicoronal flap is used for the

recipient site then the posterior flap is recipient site then the posterior flap is elevated in the subgaleal plane until elevated in the subgaleal plane until the area of bone chosen for harvest is the area of bone chosen for harvest is encountered encountered

The scalp flap is turned back with The scalp flap is turned back with rake retractors and the periosteum is rake retractors and the periosteum is incised. incised.

The periosteum is retracted and if the The periosteum is retracted and if the bone is thick enough a burr is used to bone is thick enough a burr is used to cut through the outer table of the cut through the outer table of the skull around the proposed donor site. skull around the proposed donor site.

A curved osteotome is inserted into A curved osteotome is inserted into the diploe and gently tapped to free the diploe and gently tapped to free the outer table from the inner table.the outer table from the inner table.

With larger With larger segments of bone segments of bone a formal a formal craniotomy is craniotomy is carried out carried out

Once the burr hole has been made a Once the burr hole has been made a periosteal elevator is used to periosteal elevator is used to separate dura from the overlying separate dura from the overlying cranial bone cranial bone

This bone is taken to a side table and split This bone is taken to a side table and split into inner and outer table using power into inner and outer table using power saws. One bone surface can be used to saws. One bone surface can be used to cover the exposed brain using wires or cover the exposed brain using wires or plates and the other is used as donor plates and the other is used as donor material.material.

All dural tears are repaired with a All dural tears are repaired with a continuous suture technique. continuous suture technique.

If a significant section of dura has been If a significant section of dura has been then fascia lata is harvested to cover this then fascia lata is harvested to cover this area and a combination of human fibrin area and a combination of human fibrin glue and continuous suture should seal any glue and continuous suture should seal any potential defects in the dural layer.potential defects in the dural layer.

ComplicationsComplications

Intracranial complications- extradural Intracranial complications- extradural haematoma, direct intracerebral haematoma, direct intracerebral trauma or counter-coup injuries.trauma or counter-coup injuries.

Cranial bone that is completely Cranial bone that is completely removed and replaced may develop removed and replaced may develop osteomyelitis.osteomyelitis.

ILLIAC CREST ILLIAC CREST HARVESTINGHARVESTING

ANATOMY OF REGIONANATOMY OF REGION

Principles and Principles and indicationsindications

The ilium is curved anteroposteriorly and The ilium is curved anteroposteriorly and superoinferiorly. This is advantageous for superoinferiorly. This is advantageous for reconstruction of curved mandibular defects.reconstruction of curved mandibular defects.

The ilium provides excellent The ilium provides excellent corticocancellous struts which may be used corticocancellous struts which may be used as solid interpositional grafts to replace as solid interpositional grafts to replace continuity defects in the mandible.continuity defects in the mandible.

It also be used to replace orbital floor and It also be used to replace orbital floor and wall defects.wall defects.

Iliac bone is currently in use with Iliac bone is currently in use with osseointegrated implants in the maxilla osseointegrated implants in the maxilla (sinus lifts). (sinus lifts).

In maxillofacial surgery, the patient In maxillofacial surgery, the patient will usually be lying supine on the will usually be lying supine on the operating table and so the common operating table and so the common site of harvest is from the anterior site of harvest is from the anterior part of the illium.part of the illium.

Three approaches to harvest bone-Three approaches to harvest bone- a lateral approach stripping tensor a lateral approach stripping tensor

fascia lata and gluteus muscle.fascia lata and gluteus muscle. a medial approach stripping iliacusa medial approach stripping iliacus a crestal approach splitting a a crestal approach splitting a

portion of iliac crest. portion of iliac crest.

IncisionIncision The incision must not be sited over the crest The incision must not be sited over the crest

as this will result in widening of the scar and as this will result in widening of the scar and tethering to the crest.tethering to the crest.

The maximum width of the bone to be The maximum width of the bone to be harvested should be used as a guide to the harvested should be used as a guide to the length of the incision (e.g. if the bone to be length of the incision (e.g. if the bone to be harvested measures 8 X 5 cm, then the skin harvested measures 8 X 5 cm, then the skin incision need only be 5 cm long). Where the incision need only be 5 cm long). Where the harvest is only of particulate cancellous harvest is only of particulate cancellous bone, the incision need only be 2-3 cm long.bone, the incision need only be 2-3 cm long.

All incisions should lie in skin crease lines. All incisions should lie in skin crease lines. The lateral scar should therefore lie parallel The lateral scar should therefore lie parallel

to the crest whilst the medial scar lies at an to the crest whilst the medial scar lies at an angle of approximately 30-45° to the crest.angle of approximately 30-45° to the crest.

The incision is carried down through The incision is carried down through skin, subcutaneous fat, Scarpa's fascia skin, subcutaneous fat, Scarpa's fascia to the muscular aponeurosis.to the muscular aponeurosis.

The incision is carried obliquely The incision is carried obliquely through internal oblique and through internal oblique and tranversus abdominis muscles to strike tranversus abdominis muscles to strike the ilium approximately 1 cm below the ilium approximately 1 cm below the crest in young patients and 5 mm the crest in young patients and 5 mm below the crest in adults. below the crest in adults.

ProcedureProcedure Osteotome cuts are made across the iliac Osteotome cuts are made across the iliac

crest andcrest and these are angled to create a these are angled to create a dovetail joint hinged laterally. The anterior dovetail joint hinged laterally. The anterior osteotome cut must be at least 1 cm osteotome cut must be at least 1 cm posterior to the anterosuperior iliac spine. posterior to the anterosuperior iliac spine.

The periosteum on the The periosteum on the medial aspect of the medial aspect of the ilium is elevated ilium is elevated inferiorly from the point inferiorly from the point of incision on the crest of incision on the crest using Farabeuf rougine. using Farabeuf rougine. Profuse bleeding may be Profuse bleeding may be encountered at this encountered at this stage when the deep stage when the deep circumflex iliac artery circumflex iliac artery and vein are divided. and vein are divided. this can be dealt with this can be dealt with diathermy.diathermy.

A curved osteotome is A curved osteotome is then inserted and crest then inserted and crest is then fractured out.is then fractured out.

The proposed The proposed corticocancellous corticocancellous graft is then graft is then marked out.marked out.

Once medial cut Once medial cut is outlined, a is outlined, a broad osteotome broad osteotome is inserted in the is inserted in the cancellous bone cancellous bone just medial to the just medial to the lateral cortical lateral cortical plate and plate and intended volume intended volume of bone is of bone is harvested.harvested.

The iliac crest is sutured back in position The iliac crest is sutured back in position using an absorbable suture such as Vicryl using an absorbable suture such as Vicryl or 1/0 chromic catgut through the or 1/0 chromic catgut through the periosteum or cartilage. The dovetail joint periosteum or cartilage. The dovetail joint will aid this.will aid this.

The anterior abdominal wall muscles are The anterior abdominal wall muscles are closed in layers. closed in layers.

The subcutaneous tissues The subcutaneous tissues and Scarpa's and Scarpa's fascia are fascia are closed with interrupted closed with interrupted absorbable sutures and the skin is closed absorbable sutures and the skin is closed with a subcuticular 2/0 or 3/0 Prolene with a subcuticular 2/0 or 3/0 Prolene suture.suture.

Postoperative carePostoperative care

The Redivac drain should be left The Redivac drain should be left in in situ situ until drainage is minimal - until drainage is minimal - usually 48 hours.usually 48 hours.

Antibiotics and analgesics cover.Antibiotics and analgesics cover. 0.25% bupivacaine should be 0.25% bupivacaine should be

administered through the epidural administered through the epidural cannula on a regular basis every 8 cannula on a regular basis every 8 hours.hours.

The patient should be encouraged to The patient should be encouraged to walk as soon as possible (ideally walk as soon as possible (ideally from 24 hours after the operation).from 24 hours after the operation).

ComplicationsComplications

Anesthesia or paresthesia of upper Anesthesia or paresthesia of upper lateral thigh, if lateral cutaneous lateral thigh, if lateral cutaneous nerve is damaged.nerve is damaged.

Postoperative illeus.Postoperative illeus. Perforation of abdominal viscus.Perforation of abdominal viscus. Herniation of intra-abdominal Herniation of intra-abdominal

contents.contents.

HARVESTING OF HARVESTING OF FIBULA GRAFTFIBULA GRAFT

Principles and Principles and indicationsindications

The fibula lies on the The fibula lies on the lateral surface of the lateral surface of the to limb below the to limb below the knee and articulates knee and articulates with the superiorly with the superiorly and inferiorly. It is and inferiorly. It is connected to the connected to the tibia along its length tibia along its length by the interosseous by the interosseous membrane and is membrane and is covered laterally by covered laterally by peroneal muscles.peroneal muscles.

The common peroneal nerve, which can The common peroneal nerve, which can often be palpated and which runs often be palpated and which runs anteroinferiorly around the neck of the anteroinferiorly around the neck of the fibula to course under the peroneal fibula to course under the peroneal muscles, must always be protected when muscles, must always be protected when harvesting this bone. harvesting this bone.

The ankle joint and lower quarter of the The ankle joint and lower quarter of the fibula must not be disturbed. fibula must not be disturbed.

It is therefore advisable to harvest the It is therefore advisable to harvest the middle third or the middle half of the fibula middle third or the middle half of the fibula leaving the upper and lower quarters leaving the upper and lower quarters intact.intact.

Incision and ProcedureIncision and Procedure

A vertical incision is made along the A vertical incision is made along the lateral edge of the lower leg overlying lateral edge of the lower leg overlying the fibula. The incision is carried through the fibula. The incision is carried through skin and subcutaneous tissue until the skin and subcutaneous tissue until the fascia overlying the leg muscles is fascia overlying the leg muscles is encountered.encountered.

The plane between the peroneal muscle The plane between the peroneal muscle and the soleus muscle is identified and and the soleus muscle is identified and the peroneal muscles are retracted the peroneal muscles are retracted anteriorly and soleus is retracted anteriorly and soleus is retracted posteriorly.posteriorly.

A totally A totally subperiosteal subperiosteal approach is used approach is used around the required around the required segment of fibula. segment of fibula. CareCare is taken is taken superiorly to remain superiorly to remain in the subperiosteal in the subperiosteal plane so that no plane so that no damage occurs to damage occurs to the anterior tibial the anterior tibial vessels which lie vessels which lie between the neck of between the neck of the fibula and tibia the fibula and tibia

After the medial aspect of the fibula has been After the medial aspect of the fibula has been protected with malleable retractors, saw cuts are protected with malleable retractors, saw cuts are made through the segment of fibula required and made through the segment of fibula required and any remaining medial attachment of the any remaining medial attachment of the interosseous membrane is then divided to free interosseous membrane is then divided to free the fibula graft. the fibula graft.

Suction drainage is used and the wound is closed Suction drainage is used and the wound is closed in layers with a continuous resorbable suture in layers with a continuous resorbable suture loosely reapposing the peroneus and soleus loosely reapposing the peroneus and soleus muscles. muscles.

The subcutaneous tissues are closed with a The subcutaneous tissues are closed with a resorbable suture and the skin is closed with a resorbable suture and the skin is closed with a subcuticularsubcuticular 2/0 or 3/0 Prolene.2/0 or 3/0 Prolene.

The patient is rested with the leg elevated for the The patient is rested with the leg elevated for the first 24 hours postoperatively but after that is first 24 hours postoperatively but after that is rapidly mobilized. rapidly mobilized.

Postoperative complications Postoperative complications

Damage to the ankle joint will cause Damage to the ankle joint will cause severe disability requiring extensive severe disability requiring extensive reconstructive surgery.reconstructive surgery.

Damage to the common peroneal nerve Damage to the common peroneal nerve will result in foot drop, loss of arches of the will result in foot drop, loss of arches of the foot and a flaccid foot with loss of control. foot and a flaccid foot with loss of control.

In older patients with peripheral vascular In older patients with peripheral vascular disease the incision line may heal slowly or disease the incision line may heal slowly or break down.break down.

TIBIA BONE GRAFT TIBIA BONE GRAFT HARVESTHARVEST

Principles and indicationsPrinciples and indications

The tibia graft is performed on skeletally The tibia graft is performed on skeletally mature patients who want the benefit of mature patients who want the benefit of autogenous bone grafting without the risk autogenous bone grafting without the risk and pain associated with other favorite and pain associated with other favorite donor sites, such as the iliac crest or donor sites, such as the iliac crest or calvarium. calvarium.

The surgeon easily can obtain 25 cc of The surgeon easily can obtain 25 cc of cancellous bone, which is more than cancellous bone, which is more than adequate for procedures such as bilateral adequate for procedures such as bilateral sinus lifts and grafting fracture nonunions.sinus lifts and grafting fracture nonunions.

Review of anatomyReview of anatomy The primary bony landmark in the proximal tibia The primary bony landmark in the proximal tibia

is Gerdy's tubercle. Gerdy’s tubercle is a bony is Gerdy's tubercle. Gerdy’s tubercle is a bony protuberance between the patellar ligament protuberance between the patellar ligament (midline) and the head of the fibula. which is (midline) and the head of the fibula. which is palpable 90° laterally. There is thin skin over this palpable 90° laterally. There is thin skin over this area and no vital anatomic structures located area and no vital anatomic structures located over Gerdy's tubercle.over Gerdy's tubercle.

The area over Gerdy's tubercle is devoid of any The area over Gerdy's tubercle is devoid of any major anatomic structure, which is a key feature major anatomic structure, which is a key feature in the simplicity of the surgery and the low in the simplicity of the surgery and the low complication rate.complication rate.

The only anatomic structure one encounters The only anatomic structure one encounters during the dissection is the iliotibial tract, a dense during the dissection is the iliotibial tract, a dense fascial band that runs from the anterior iliac crest fascial band that runs from the anterior iliac crest to the lateral surface of the tibia.to the lateral surface of the tibia.

Surgical techniqueSurgical technique Gerdy's tubercle is Gerdy's tubercle is

palpated and diagrammed palpated and diagrammed with a surgical marking with a surgical marking pen.pen.

A 3 to 4 cm incision is A 3 to 4 cm incision is made directly over Gerdy's made directly over Gerdy's tubercle. The incision is tubercle. The incision is carried sharply through the carried sharply through the skin, subcutaneous tissues skin, subcutaneous tissues (including the iliotibial (including the iliotibial tract), and periosteum. The tract), and periosteum. The periosteum is elevated in periosteum is elevated in preparation for making a preparation for making a cortical window through cortical window through the cortical bony plate at the cortical bony plate at Gerdy's tubercle. Gerdy's tubercle.

A cortical window is A cortical window is made with surgical made with surgical bur and is removed.bur and is removed.

The cancellous bone The cancellous bone is harvested with is harvested with orthopedic curettes orthopedic curettes by going across the by going across the tibia plateau and tibia plateau and down the shaft of down the shaft of the tibia the tibia

Once the bone harvest is completed, Once the bone harvest is completed, hemostasis is checked.hemostasis is checked.

The wound is closed in layers, with The wound is closed in layers, with the iliotibial tract being the iliotibial tract being reapproximated with 2-0 or 3-0 vicryl reapproximated with 2-0 or 3-0 vicryl sutures and 4-0 nylon suture for skin sutures and 4-0 nylon suture for skin closure.closure.

Only major complication seen with Only major complication seen with tibia harvest is fracture of tibia tibia harvest is fracture of tibia plateau. plateau.

ReferencesReferences1.1. Iain Hutchinson. Reconstructive surgery- bone and Iain Hutchinson. Reconstructive surgery- bone and

cartilage grafts. Operative maxillofacial surgery; 93-cartilage grafts. Operative maxillofacial surgery; 93-114.114.

2.2. G.M Kushner. Tibia bone graft harvest technique. Atlas G.M Kushner. Tibia bone graft harvest technique. Atlas oral and maxillofacial surg clin N Am 13 (2005); 119-oral and maxillofacial surg clin N Am 13 (2005); 119-126.126.

3.3. Ruiz, Timothy et al. Cranial bone grafts: Ruiz, Timothy et al. Cranial bone grafts: Craniomaxillofacial applications and harvesting Craniomaxillofacial applications and harvesting techniques. Atlas oral and maxillofacial surg clin N Am techniques. Atlas oral and maxillofacial surg clin N Am 13 (2005); 127-137.13 (2005); 127-137.

4.4. Randall Wilk. Bony reconstruction of the jaws. Randall Wilk. Bony reconstruction of the jaws. Principles of oral and maxillofacial surgery, Peterson, Principles of oral and maxillofacial surgery, Peterson, 39; 784-798.39; 784-798.

5.5. John, Bernard et al. Costocondral Rib Grafting. Atlas John, Bernard et al. Costocondral Rib Grafting. Atlas oral and maxillofacial surg clin N Am 13 (2005); 139-oral and maxillofacial surg clin N Am 13 (2005); 139-149.149.

6.6. Mehrara et al. Repair and grafting of bone. Mathes Mehrara et al. Repair and grafting of bone. Mathes Plastic Surgery; 639-718.Plastic Surgery; 639-718.