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TIBIAL BONE GRAFT FIARVEST - The Podiatry …

CHAPTER 4 PROXIMAL TIBIAL bone GRAFT FIARVESTJ ustin Fleming, DPMINTRODUCTIONThe need for cancellous bone grafting is quite apparent infoot and ankle reconstruction. Despite all of the expandingtechnology in the field of orthobiologics, no commerciallyavailable bone GRAFT or bioengineered GRAFT substitutes havebeen proven to be superior or equal to autoiogous donor sites for GRAFT harvest include the iliac crest,fibula, distal tibia, and calcaneus. These sites often yieldinadequate quantities and are associated with donor sitemorbidity such as pain and secondary fracture. The authorwill illustrate the previously described surgical technique ofbone GRAFT harvest from the proximal TIBIAL metaphysis andprovide the authors' experience with this technique.','INDICAIIONSThe primary need for cancellous bone GRAFT in foot andankle reconstruction is to augment arthrodesis in additionto filling bony voids.

CHAPTER 4 PROXIMAL TIBIAL BONE GRAFT FIARVEST Justin Fleming, DPM INTRODUCTION The need for cancellous bone grafting is quite apparent in foot and ankle reconstruction.Despite all of the expanding technology in the field of orthobiologics, no commercially available bone graft or bioengineered graft substitutes have been proven …

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Transcription of TIBIAL BONE GRAFT FIARVEST - The Podiatry …

1 CHAPTER 4 PROXIMAL TIBIAL bone GRAFT FIARVESTJ ustin Fleming, DPMINTRODUCTIONThe need for cancellous bone grafting is quite apparent infoot and ankle reconstruction. Despite all of the expandingtechnology in the field of orthobiologics, no commerciallyavailable bone GRAFT or bioengineered GRAFT substitutes havebeen proven to be superior or equal to autoiogous donor sites for GRAFT harvest include the iliac crest,fibula, distal tibia, and calcaneus. These sites often yieldinadequate quantities and are associated with donor sitemorbidity such as pain and secondary fracture. The authorwill illustrate the previously described surgical technique ofbone GRAFT harvest from the proximal TIBIAL metaphysis andprovide the authors' experience with this technique.','INDICAIIONSThe primary need for cancellous bone GRAFT in foot andankle reconstruction is to augment arthrodesis in additionto filling bony voids.

2 Autoiogous bone is the gold standardin bone grafting and "optimizes" the environmenr forhealing by providing both osteoconductive and osteogenicproperties. Although pladet gels, bone marrow aspirates,and other technologies (BMP) have reduced the needfor autologous bone , their cost is substantial and nocomparison long term studies are currently available. Theauthor began to utilize this technique when hospitaladministration would no longer allow for the use oforthobiologics and implantable bone stimulation becauseof their financial drawbacks. Specifically, the author findsthe most frequent procedures performed in conjunctionwith proximal TIBIAL bone GRAFT harvest are arthrodesisprocedures involving the ankle and subtalar joint in cases ofpost-traumatic arthritis.

3 These injuries often leave largeavascular cystic changes in the talus and more commonlyin the distal tibia which require grafting (Figure 1). Inaddition, those cases of revisional fusions or high riskfusions (smokers, open fractures) and extended midfootfusions ( , neuroarthropathy) may benefit or requiresupplement grafting. Contraindications include thosepatients with an open physis, total knee arthroplasqz, orprior anterior cruciate ligament reconstruction. Thegraft harwested in this region in not intended to bestructural in 1A. Subtotal AVN of the distal tibia with cysticchange secondary to post-traunatic arthritis. Sagitralplane image through prior regiotr olt A\Nfollowing bone grafting and tibio-talo-calcaneala rth 4 PROXIMAL TIBIAL bone GR\I'T FIARVESTJ ustin Fleming, DPMINTRODUCTIONThe need for cancellous bone grafting is quite apparent infoot and ankle reconstruction.

4 Despite all of the expandingtechnology in the field of orthobiologics, no commerciallyavailable bone GRAFT or bioengineered GRAFT substitutes havebeen proven to be superior or equal to autologous donor sites for GRAFT harvest include the iliac crest,fibula, distal tibia, and calcaneus. These sites often yieldinadequate quantities and are associated with donor sitemorbidity such as pain and secondary fracrure. The authorwill illustrate the previously described surgical technique ofbone GRAFT harvest from the proximal tibiai metaphysis andprovide the authors' experience with this technique.','INDICAIIONSThe primary need for canceilous bone GRAFT in foot andankle reconstruction is to augment arthrodesis in additionto filling bony voids. Autologous bone is the gold standardin bone grafting and "optimizes" the environment forhealing by providing both osteoconductive and osteogenicproperties.

5 Although platlet gels, bone marrow aspirates,and other technologies (BMP) have reduced the needfor autologous bone , their cost is substantial and nocomparison long term studies are currently available. Theauthor began to utilize this technique when hospitaladministration would no longer allow for the use ofonhobiologics and implantable bone stimulation becauseof their financial drawbacks. Specifically, the author findsthe most frequent procedures performed in conjunctionwith proximal TIBIAL bone GRAFT harvest are arthrodesisprocedures involving the ankle and subtalar joint in cases ofpost-traumatic arthritis. These injuries often leave largeavascular cystic changes in the talus and more commonlyin the distal tibia which require grafting (Figure 1). Inaddition, those cases of revisional fusions or high riskfusions (smokers, open fractures) and extended midfootfusions ( , neuroarthropathy) may benefit or requiresupplement grafting.

6 Contraindications include thosepatients with an open physis, total knee arthroplasq., orprior anterior cruciate ligament reconstruction. Thegraft harvested in this region in not intended to bestructural in 1A. Subtotal AVN of the distal tibia wjth cysticchange secondarv to post-traumatic arthriris. Sagittalplane image through prior region of AVNfollowing bone grafting and 4 SURGICAL TECHNIQUEP rior to surgery, a complete radiographic analysis of theproximal tibia and knee should be obtained in addition tothe studies appropriate for the index procedure. Pre-existing clinical or radiographic abnormalities in the regionofharvest should be evaluated by an orthopedic surgeon oranother source of bone should be proximal tibia can usually be accessed with thepatient in any position (supine, prone, lateral decubitus,etc.)

7 And the procedure can be carried out with or with-out tourniquet control. If tourniquet time is not available,retraction of the soft tissues generally provides adequatehemostasis much like dissection on the plantar the patient is obese and the typical subcutaneouslandmarks are not readily palpable, fluoroscopy may beutilized and is encouraged to avoid violation of the kneejoint or entrance into the diaphyseal region of the incision is created over the lateral flare of the tibialplateau. Gerdyt tubercle, the TIBIAL tubercle and theanterior TIBIAL crest serve as landmarks for incisionplacement (Figure 2).A 4-5cm oblique incision over the anteriorcompartment begins just inferior to the Gerdyt tubercleand terminates slightly distal to the inferior pole of thetibial tubercle.

8 ' The lateral flare of the tibia is usuallyFigure 2A'fypical landmarks for incision placement fbr GRAFT hanest includeGerdy's tubercle (circle), thc TIBIAL tubercle and anterior TIBIAL crest and thelateral flare ofthe TIBIAL plateau. The incision is drawn with a hatched and is helpful in gaining orientation. There areno named neurovascular structures in this region anddissection can be carried sharply to the crural fasciaoverlying the anterior musculature. This fascia is incisedjust lateral to the TIBIAL crest allowing adequate repair ofthis structure upon closure (Figure 3).The tibialis anterior muscle belly is bluntly elevatedoff the lateral tibia leaving the periosteum intact. Thiswill serve as a hinge for the cortical window. The tip ofthe Homann retractor is placed on the posterior aspect ofthe tibia and serves as the primary source of retraction.

9 Cm by 1 cm oval shaped cortical window is thencreated in the lateral metaphysis of the tibia'(Figure 4). mm drill is used to outline the window and the drillholes are connected with an osteotome. The long axis ofthe cortical defect is made paraliel to the long a-xis of thetibia. The cortex is then rotated posteriorly on a periostealhinge and GRAFT procurement can begin. Various curvedcurettes are necessary to reach the medial and lateral flaresof the plateau. Following GRAFT harvest, the cortical windowis returned to its position. Repair of the periosteum is notnecessary. The metaphyseal defect may be filled withallograft as the surgeon desires although this is not foam may be placed in the access hole to decrease theincidence of hematoma. The fascia is then closed with2-0 28.

10 Typical landmarksCHAPTE,R 4I3F-igure 3. Fascial incision overlying the anterior O STO PERAITVE MANAGEMENTP ostoperatively the wound is evaluated lvithin the firstweek and the patient is encouraged to perform range ofmotion as tolerated. tWeightbearing is dictated by theprimary procedure and usually occurs between 6 and 72weeks, although previous authors'have allowed immediateweightbearing on the extremiq/ without documentedfractures occurring through the GRAFT site.' Periodicradiographs should be obtained to document complications of this technique are similar to othertechniques of bone GRAFT harvest. Major complicationsinclude fracture, persistant dysthesias, infection, chronicpain, wound breakdown, compartment syndromes andknee instability.'z A medial approach was originallyadvocated, however transient neuropraxias involving thesaphenous nerve were identified and the recommendapproach is from the lateral side as described.


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