A NEW MODIFIED TECHNIQUE FOR HARVEST OF CALCANEAL BONE GRAFT IN SURGERY ON THE FOOT AND ANKLE
September 3rd, 1997
Kent R. Biddinger, MD; Gregory A. Komenda, MD;
Lew C. Schon, MD; and Mark S. Myerson, MD
Abstract
Reported sites for retrieval of cancellous bone for grafts include the iliac crest, greater trochanter, proximal tibia, and distal tibia. A new lateral technique for retrieval of cancellous bone from the calcaneus is evaluated through anatomic review, quantitative analysis, and retrospective clinical assessment. Of 22 patients managed with this technique over a 2-year period, 17 returned for an evaluation by questionnaire, physical examination, and radiographic follow-up at an average of 7 months after surgery (range, 4 to 16 months). Complaints/complications were minor: three had minor incisional symptoms, five had medial heel pain (three caused by plantar fasciitis), and one had unchanged preoperative heel pain secondary to club foot deformity. Compared to more extensive bone-grafting procedures, this procedure offers the advantages of bone harvested under local anesthesia, a readily accessible ipsilateral extremity, and minor complications.
Introduction
The practice of surgery on the foot and ankle commonly relies on the use of corticocancellous or cancellous bone in grafting for arthrodesis and for the repair of nonunions or malunions. Published reports describe multiple sources for such grafts of autogenous bone graft, including the iliac crest, greater trochanter, proximal tibia, and distal tibia, as well as for allograft bone.4,6,7,9,13 There has, however, been little reported focus on the use of cancellous bone harvested from the calcaneus. Calcaneal bone for grafting can be harvested an ankle-block anesthesia, and it does not require a separate operative field. The incisions are small, and complications are rare. Theoretical disadvantages include calcaneal fracture, neurovascular injury, injury to the subtalar joint, insufficient quantity of bone, and incisional irritation from wearing shoes. Since 1991, the senior authors (LCS and MSM) have developed a technique for harvesting cancellous bone from the calcaneus to augment various procedures performed on the foot and ankle. This report describes and provides a clinical analysis of that technique.
Materials and Methods
Operative Technique
To avoid the medial calcaneal branches of the tibial nerve, bone to be grafted is harvested from the lateral aspect of the calcaneus. The patient is turned into the semilateral or lateral position and a 1.0- to 1.5-cm incision is made obliquely over the lateral aspect of the calcaneus centered on a point 2 cm anterior to the posterior aspect of the calcaneus and 2 cm superior to the plantar surface of the foot (Fig. 1). Care is taken to ensure that the incision is only through the skin, and then blunt dissection is used to advance down to the lateral calcaneal wall. The periosteum is elevated off the lateral wall of the calcaneus. An 8-mm round-core biopsy trephine is then inserted through the wound onto the lateral wall of the calcaneus with the surgeon's dominant hand; the surgeon's nondominant hand is positioned along the medial wall of the calcaneus for counterpressure. The position of this hand medially further improves the proprioception and prevents overinsertion of the trephine. A bicortical cylinder of bone is then harvested perpendicular to the lateral calcaneal wall and including the medial cortex and periosteum, taking care not to penetrate the medial soft tissues. If the periosteum is left intact medially, the bone plug is not loose and is not delivered with the trephine. The cylinder of bone is then removed and assessed for quantity and quality. Up to three full cylinders of bone can safely be harvested from the calcaneal tuberosity. One cylinder of bone and additional curettage of cancellous bone is usually sufficient for most procedures on the mid- and forefoot. The wounds are then irrigated, and the skin is closed either with 4.0 nylon or with staples. Sterile compressive dressing is then applied after completion of the primary surgical procedure. A tourniquet is not routinely used.
Patient Population
We retrospectively reviewed the records of 22 patients for whom this technique had been used between 1991 and 1993. These 22 patients were contacted and asked to return for a follow-up analysis, including evaluation by questionnaire, a physical examination, and a weight-bearing lateral radiograph of the heel. The 17 patients who returned for evaluation formed our study population. The average age of the 12 women and 5 men was 46.5 years (range, 17 to 70 years). The average time of follow-up was 7 months (range, 4 to 16 months).
Anatomic Investigation
To demonstrate the medial and lateral neurovascular structures at risk, we dissected cadaveric specimens during and after the operative technique described above. With the trephine in place, the medial and lateral nerves were exposed and the proximity of the trephine to the nerves was recorded (Fig. 2). Next, to determine the quantity of bone that would be harvested for grafting, the trephine was reinserted until retrieval was minimal. The number of bone plugs was then recorded.
Follow-up Analysis
The questionnaire documented the age and sex of the patient, the preoperative diagnosis, the procedure performed, and whether or not fusion or healing was obtained; it did not evaluate the clinical outcomes of the primary procedure. The questionnaire was designed to document the morbidity of the donor site by focusing on incisional, neurovascular, or shoe-wear difficulties and complications relative to the bone. Specifically, we evaluated patients for the presence of incisional pain, neuritis, numbness, reflex sympathetic dystrophy, wound infection, delayed healing, problems with wearing shoes, and heel pain.
The physical examination focused on heterotopic ossification, formation of hypertrophic scars, and neurovascular evaluation, including posterior tibial pulse, tibial nerve, sural nerve and its lateral calcaneal branch, subtalar arc of motion compared to the nonoperative side, heel pain, plantar fasciitis, and documentable presence of numbness, neuromas, or hypersensitivity.
The weight-bearing lateral radiographs were then evaluated for evidence of fracture or collapse, presence of subtalar arthritis, or persistent radiographic defects.
Data from the questionnaire, physical examination, and radiographs were then tabulated to evaluate the frequency of morbidity at the donor site.
Results
Clinical
Five patients had mild, subjective complaints that did not limit physical activity or work: three experienced mild intermittent incisional discomfort, one complained of local numbness along the distribution of the lateral calcaneal nerve, and one needed minor shoe-wear modifications (a band-aid over the incision for strapped shoes only). Three patients complained of plantar-medial heel pain consistent with plantar fasciitis. We could not identify any correlation between the donor site and the cause of the plantar fasciitis, which may have been due to associated premorbid pathology.
There was no difference in subtalar motion as compared to that on the opposite side unless the subtalar joint had been fused in the primary procedure. There were no cases of hypertrophic scarring, heterotopic ossification, reflex sympathetic dystrophy, or vascular injury. No patient felt that postoperative pain was increased because of this procedure.
All radiographs showed persistent lucency, of varying degrees, at the donor site, but there was no instance of fracture, collapse, or new subtalar arthritis. Radiographic fusion was evident in 15 of 17 patients. The patients with nonunions included one patient with fixation failure of an acute sesamoid fracture that reruptured during a fall and one patient with a talonavicular fusion for a nonunion of a navicular stress fracture.
Anatomic Investigation
The dissection of two cadaveric specimens indicated that when the graft is taken perpendicular to the lateral wall, the trephine exits the medial wall approximately 3.5 cm posterior and inferior to the neurovascular bundle. On the medial side of the heel, there were several terminal branches of the medial calcaneal nerve in the subcutaneous tissues superficial to the exit point of the trephine. On the lateral side of the heel, the sural nerve was identified anterior to, but within 1 to 2 cm of, the incision site. Small branches of this nerve were not found in these two specimens. Using this approach, three plugs of bone could be obtained safely (Fig. 3)
Discussion
Although previous reports have described various sources for obtaining cancellous bone to be grafted graft for procedures on the foot and ankle, the calcaneus has, in general, been overlooked. Harvesting bone graft from the calcaneus has been described previously, but not as outlined above, and for different indications and circumstances. Bordelon2,3 described the technique of obtaining a bicortical or unicortical block of bone from the superior or superolateral calcaneus. He recommended this graft in children, particularly for interposition of a lengthening osteotomy of the calcaneus for flatfoot. He did not note fracture of the calcaneus when a larger quantity of bone graft was harvested.
Bone from the iliac crest is probably the most common source for autogenous graft. It offers many advantages, including an abundant source of both cortical and cancellous bone and an inherent strength that enables it to be used as a structural graft. However, it also has several disadvantages: harvest requires an additional procedure, necessitating more equipment, an increase in operative time or number of surgeons required, and the necessity for spinal/epidural or general anesthesia rather than the ankle block that is usually sufficient for procedures on the foot and ankle. Iliac crest bone harvest often increases postoperative pain, resulting in increased length of hospital stay, increased use of narcotic analgesics, and delayed ambulation.13,15 Specific complications of using bone from the iliac crest include: a 15% incidence of donor site pain for longer than 3 months; a rate of injury to the lateral femoral cutaneous nerve as high as 10%; injury to the superior cluneal and ilioinguinal nerve; occasional injury to the superior gluteal artery, which can result in postoperative hematoma, blood loss requiring transfusion, and formation of an arteriovenous fistula; rates of wound hematoma of 4% to 10%; and an incidence of abduction lurch as high as 3%.13,15 Other complications include muscle hernias, iliac fractures,1,8,11,12 and problems with wound healing.5,9,15
The greater trochanter has also been recommended as a site for cancellous bone harvest during surgery on the foot and ankle. In a study using cadavers, Lindberg et al10 demonstrated that at least as much bone can be harvested from this site as from the anterior iliac crest. Reported complications from this site include pain (31%), bursitis, avulsion fractures (2%), intertrochanteric fractures, snapping iliotibial bands, and wound infections (2%).1,4,7 Although this may be a reasonable alternative to a graft from the iliac crest, general or spinal anesthesia is still necessary, and delayed ambulation may be prudent to avoid catastrophic hip fracture and to minimize postoperative pain.
Graft from either the proximal or the distal tibia may be another alternative. The average volume of tibial graft is 8.6 ml, whereas that from the anterior iliac crest or the greater trochanter region is 6.0 or 6.5 ml, respectively. The complications associated with tibial graft are few. One study6 reported no complications at recipient or donor site6 and another14 reported one tibial stress fracture (1%), 13% minor complications, 3% nonunion, and no neurologic problems or wound infections.
Of the 17 patients in our study group, three had incisional symptoms and five had medial heel pain. The incisional symptoms were all mild, and only one had numbness over in the distribution of the lateral calcaneal nerve. None of these complications in any way limited work or recreational activity, and only one required protecting the wound when wearing strapped shoes. None of these three patients viewed their heel incisions as a negative outcome.
Five patients complained of medial heel pain. Three of these had mild or moderate plantar fasciitis believed to be related to the primary pathology and not the bone graft. The two remaining patients complained of pain in the medial calcaneal wall. One, still in the early postoperative phase, was evaluated at 4 months after surgery. The second person had medial heel pain unchanged from that before surgery for her residual clubfoot deformity.
With the exception of mild incisional difficulties, no other identified problems could be directly related to the bone-grafting procedure. From a biomechanical standpoint, the calcaneus is ideally suited to harvesting these dowel-type grafts. As has been noted with extensive experience relating to the defects associated with calcaneus fractures, these fill in over time. Furthermore, we have not identified any stress fracture of the calcaneus in these not subsequently treated patients.
Conclusion
Using the calcaneus as a donor site for grafts of cancellous bone is a safe alternative to using the proximal tibial, distal tibial, or iliac crest for procedures on the foot and ankle. The procedure offers the advantages of minimal additional pain, a single operative field, utilization of ankle-block anesthesia, and few, relatively minor, complications.
References
1. Blakemore, M.E. Fractures at cancellous bone graft donor sites. Injury, 14:519-522, 1983.
2. Bordelon, R.L. Bone graft. In Atlas of Adult Foot and Ankle Surgery, Lutter, L.D. (ed.). St. Louis, Mosby-Year Book Inc, 1997, pp. 11-16.
3. Bordelon, R.L. Flatfoot in children and young adults. In Surgery of the Foot and Ankle, Ed. 6. Mann, R.A. and Coughlin, M.J. (eds.). St. Louis, Mosby-Year Book Inc, 1993, pp. 717-756.
4. Chapman, M.W. Bone grafting. In Operative Orthopaedics, Ed. 2. Chapman, M.W. (ed.). Philadelphia, JB Lippincott Co, 1993, pp. 139-149.
5. Cowley, S.P., and Anderson, L.D. Hernias through donor sites for iliac-bone grafts. J. Bone Joint Surg. 65A:1023-1025, 1983.
6. Danziger, M.B., Abdo, R.V., and Decker, J.E. Distal tibia bone graft for arthrodesis of the foot and ankle. Foot Ankle Int. 16:187-190, 1995.
7. Hayes, W.R., Jr., and Smith, R.W. Trochanteric bone grafts in foot and ankle surgery. Foot Ankle Int. 17:402-405, 1996.
8. Kuhn, D.A., and Moreland, M.S. Complications following iliac crest bone grafting. Clin. Orthop. 209:224-226, 1986.
9. Kurz, L.T., Garfin, S.R., and Booth, R.E., Jr. Harvesting autogenous iliac bone grafts. A review of complications and techniques. Spine, 14:1324-1331, 1989.
10. Lindberg, E.J., Katchis, S.D., and Smith, R.W. Quantitative analysis of cancellous bone graft available from the greater trochanter. Foot Ankle Int. 17:473-476, 1997.
11. Marx, R.E., and Morales, M.J. Morbidity from bone harvest in major jaw reconstruction: a randomized trial comparing the lateral anterior and posterior approaches to the ilium. J. Oral Maxillofac. Surg. 46:196-203, 1988.
12. Medina, A., and Ebraheim, N.A. Pelvic fractures on harvesting iliac crest bone graft: case reports. Contemp. Orthop. 29:414-416, 1994.
13. O'Keeffe, R.M., Jr., Riemer, B.L., and Butterfield, S.L. Harvesting of autogenous cancellous bone graft from the proximal tibial metaphysis. A review of 230 cases. J. Orthop. Trauma, 5:469-474, 1991.
14. O'Malley, D.F., Jr., and Conti, S.F. Results of distal tibial bone grafting in hindfoot arthrodesis. Foot Ankle Int. 17:374-377, 1996.
15. Younger, E.M., and Chapman, M.W. Morbidity at bone graft donor sites. J. Orthop. Trauma, 3:192-195, 1989.
Figure Legends
Fig. 1. The position of the sural nerve is marked and the trephine is inserted through a 1-cm incision inferior to the path of the nerve (A). Note the position of the opposite hand applying counterpressure on the medial heel (B).
Fig. 2. Anatomic dissection on the medial foot surface demonstrates the trephine (arrow) inferior to the calcaneal branch of the tibial nerve.
Fig. 3. In this cadaveric specimen, note the location of the three trephine holes that can be made through a slightly larger incision.
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