Calcaneal donor bone grafts

Bone Graft Harvesting From the Calcaneus Using Lateral Wall Corticotomy Technique by an Osteotome

Background: The aim of this study was to evaluate the complications following calcaneal autologous bone graft harvesting using an osteotome in patients who underwent foot and ankle surgery with follow-up of at least 1 year. Methods: In a cohort study, all consecutive patients underwent forefoot or midfoot surgeries in conjunction with harvesting bone graft from the calcaneus using lateral wall corticotomy technique by an osteotome from 2015 till 2018 were asked to follow. The outcome and morbidity were assessed by visual analogue scale (VAS) pain, numbness in territory of the sural nerve, surgical site numbness or tenderness, infection, hematoma formation, or pathologic fracture. Also any possible restrictions on wearing desired shoes were asked. Results: Totally, 50 patients (11 males, 39 females; 29 right foot, 21 left foot) with the mean age of 48.2 ± 13.8 years (range 8-66 years) were assessed. There were no major complications on donor site such as infection, hematoma formation, or pathologic fracture. The following results were seen; 90% without any pain (VAS 0/10), 96% without numbness at the incision site, 96% without point tenderness on lateral of heel, 98% without paresthesia or numbness in the sural nerve territory, and 84% were able to wear their favorite shoes. Forty-one (82%) cases said if they need another foot surgery, they would permit to harvest bone graft from their heel. Conclusions: Autologous bone graft harvesting from the calcaneus using lateral wall corticotomy technique by an osteotome could be a useful method with very low complications.Levels of Evidence: Therapeutic, level IV: cohort, case series.

Surgical Reconstruction of Nonunion after Iatrogenic Scarf Osteotomy

We present the case of a young patient, 32 years old, with nonunion in the diaphysis of the first metatarsal after scarf osteotomy for correction of hallux valgus. After removal of the failed osteosynthesis material and preparation of the bone fragments, a calcaneal bone autograft, previously extracted from the patient, was placed in the nonunion area. The new physiological position of the first metatarsal in the three planes was checked intraoperatively, and autograft and fragment fixation was performed using a combination of a low-profile plate with six screws and two interfragmentary screws. The advantage of using an autogenous graft is that it provides corticocancellous bone and great osteogenic capacity with little antigenic capacity. This makes it an excellent option in many situations in foot and ankle surgery. Regarding the fixation method, we used the two most commonly used techniques for osteosynthesis of bone grafts in cases of bone nonunion, combining plates with locking screws and two interfragmentary screws. This provides greater stability of the bone fragments in the three planes and makes it possible to bring forward when the patient starts postsurgical loading.

Bone Grafts, Bone Substitutes, and Orthobiologics: Applications in Plastic Surgery

As reconstructive needs often extend past the soft tissue alone, a plastic surgeon must also be well versed in the methods of bony reconstruction. Understanding of the basic science of fracture healing and the biochemical mechanisms of the different bone grafts, bone substitutes, and orthobiologics is essential to selecting among the many different options available to the modern plastic surgeon. This review provides a broad overview of these different options and the specific applications for plastic surgeons based on anatomic location.

Calcaneal Bone Graft Procedures: An Analysis of Postsurgical Complications

The purpose of this article is to examine complications in patients who underwent bone grafting from the calcaneus between December 2001 and June 2010. This retrospective, single-practice study included 247 procedures in 242 patients, including 200 (82.64%) female and 42 (17.36%) male patients, ranging in age from 13 to 89 (median 49) years. Overall, the incidence of experiencing any form of complication was 2.43% (6 of 247); these included 5 (2.02%) feet that displayed donor site sural neuritis and 1 (0.41) that displayed a painful, hypertrophic scar at the donor site. The only statistically significant risk factor associated with the development of a calcaneal donor site complication was white race (being African American was protective). These findings indicate that procurement of autogenous bone graft from the calcaneus, as described in this report, is safe and dependable with a low incidence of complications, and irritation of the sural nerve is the most common complication associated with the procedure. Further clinical and long-term follow-up studies controlling for confounding variables need to be performed to fully determine the overall safety and efficacy of this procedure.

Mechanical Stress Redistribution in the First Metatarsal Bone After Autologous Bone Harvesting

BACKGROUND

The first metatarsal bone is a viable source for autologous bone grafting in foot and ankle surgery and may serve as another convenient graft site to correct a flail toe deformity. We aimed to determine how progressive bone removal from the first metatarsal affects the mechanical redistribution of the foot and whether this bone removal increases the risk of fracture.

METHODS

A three-dimensional finite element model developed from computed tomographic images obtained from a healthy man were used to evaluate traction stresses on the first metatarsal bone as a function of applied loads on the talus and Achilles tendon at two phases of the gait cycle (and according to the depth of bone removal).

RESULTS

Simulations indicated that when maximum load was applied to the Achilles tendon, tensile stress increased from 2.049 MPa in the intact foot to 5.941 MPa in the area of maximum bone harvest during the stance phase. Furthermore, as the volume of bone extracted from the first metatarsal increased, there was a redistribution of stress that differed significantly from that of the intact foot.

CONCLUSIONS

Although the maximum stress on the first metatarsal was not significantly affected by increasing the volume of bone harvested, the ankle should be splinted in plantarflexion during the postoperative period to eliminate the stance phase of gait and reduce the risk of metatarsal fracture.

Morbidity and complications following percutaneous calcaneal autograft bone harvest

BACKGROUND

Autogenous bone grafting is commonly used as an adjuvant in foot and ankle procedures. The iliac crest and tibia are common sources of autogenous bone graft but require a separate operative site and have been reported to have significant morbidity including pain, fractures, and prolonged hospitalization. Bone grafting from the posterolateral calcaneus offers advantages such as a single operative field, ability to be done under an ankle block, and a theoretical low complication rate. We report our morbidity and complications of percutaneous calcaneal autograft bone harvest in patients undergoing foot operations.

METHODS

Between 2006 and 2010, 6 foot and ankle surgeons performed a calcaneal bone graft on 393 patients undergoing foot procedures. Outcomes were measured through the use of a 4-question survey evaluating pain, subjective sensitivity at the incision site, numbness at the incision site, and limitation of shoe wear at a minimum of 1 year following the operation. Patient records were also examined for any additional complications that may have been reported.

RESULTS

Of the 393 patients eligible for this study, 210 patients responded at an average of 2.8 years (range, 1.2-5.8 years) after the operation (minimum 1 year). Of those, 181 patients (86.2%) reported no problems. Minor complications included 6 patients (2.9%) who experienced only incisional nerve sensitivity, 4 patients (1.9%) with only incisional pain, 4 patients (1.9%) who reported some degree of incisional numbness only, 2 patients (1.0%) who reported only shoe wear limitations, and 10 patients (4.8%) who had a combination of symptoms. Three patients (1.4%) had more significant complications, which consisted of a pathological fracture through the graft site, a calcaneal stress fracture, and 1 patient with permanent numbness along the distribution of the sural nerve.

CONCLUSION

Calcaneal bone graft was an easily accessible source of local autogenous bone graft for foot and ankle procedures. Despite the simplicity of the procedure, minor complications are not infrequent, with 13.8% of patients reporting some residual symptoms along the lateral border of the calcaneus when bone graft was obtained through an oblique incision.

LEVEL OF EVIDENCE

Level IV, case series.

Tarsometatarsal joint arthrodesis with trephine joint resection and dowel calcaneal bone graft

Arthritis of the tarsometatarsal joints is a challenging problem to treat. It can cause chronic foot pain and functional disability. We present a surgical technique for tarsometatarsal joint arthrodesis using a trephine to resect the articular surfaces and a dowel plug of an autogenous calcaneal graft with locking plate fixation. The procedure has been shown to result in osseous fusion, and it is technically relatively simple to complete.

Bone graft from the distal medial tibia in foot and ankle surgery

Autogenous bone graft is the ideal substrate for primary and revisional foot and ankle surgery. The distal medial tibia is an easily accessible site that provides both cancellous and corticocancellous autograft. Thirty cases of distal tibial bone graft with a minimum follow-up of 1 year are presented. There was an 86% union rate, and there were no stress fractures, persistent pain, or reported nerve injuries at the donor site. An efficient and versatile technique for harvesting both cancellous bone graft and corticocancellous graft is described. The use of distal tibial bone graft eliminates the need for a second surgeon and more lengthy harvest procedure and offers sufficient autograft material for foot and ankle applications with a low rate of complications.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

Mechanical stress redistribution in the calcaneus after autologous bone harvesting

The calcaneus is a desirable site for harvesting autologous bone for use in foot surgery. However, fracture of the calcaneus is a serious complication associated with bone harvesting from this site. Currently it is unknown how much bone may be safely harvested from the calcaneus without inducing a fracture. The purpose of this study was to investigate the effect of progressive bone removal from the calcaneus onto the mechanical stress redistribution of the foot, and therefore on the increase in fracture risk. Different loads were applied on the talus to evaluate the calcaneus stress distribution at different situations. Because of the potential increase in mechanical stress in the calcaneus, secondary to contraction of the Achilles tendon, we also evaluated the mechanical behavior properties of the foot with increasing traction force in the Achilles tendon. A three-dimensional (3D) finite element (FE) model developed from CT images obtained from a healthy individual was used to compute displacement, tension and compression stresses in six situations, including intact foot, and five depth of the bone block removed, with a maximum depth of 7.5 mm. The results from these simulations indicated that when the maximum load was applied at the Achilles tendon, the tension stress increased from 42.16 MPa in the intact foot to 86.28 MPa with maximum bone harvesting. Furthermore, as the volume of bone extracted from the calcaneus increases, there is a redistribution of stresses that differs significantly from the intact foot. In fact, although the maximum stress was not significantly affected by increasing the volume of bone harvested-except when increasing the Achilles tendon force-, stresses did increase in areas of the calcaneus is vulnerable to injury, leading to an increase in fracture risk.

Technique and pearls in performing the first metatarsal phalangeal joint arthrodesis

When there is a considerable loss of first metatarsal phalangeal joint (MTPJ) motion and/or ankylosis is apparent then a joint preservation procedure may not be feasible. For end-stage degenerative change within the MTPJ, nonreducible joint incongruity, or instability of the first MTPJ, an arthrodesis can provide the most predictable and, arguably, the most definitive correction of the deformity, especially in patients with higher functional demands. This article discusses principles of techniques with an emphasis on the procedure to prepare a successful arthrodesis, and expounds on technical nuances including those associated with fixation devices.

Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study

The purpose of this article is to report the complications associated with autogenous bone marrow aspirate harvested from the lower extremity (ie, tibia and/or calcaneus) for soft tissue and/or osseous healing augmentation. This is a multisite, multisurgeon, observational cohort study involving retrospective review of prospectively collected data of 548 autogenous bone marrow aspirate harvests from the lower extremity of 530 consecutive patients between August 2000 and March 2009. Each patient underwent autogenous bone marrow aspirate harvest from the proximal medial tibial metaphysis, distal medial tibial metaphysis, medial malleolus, lateral calcaneus, medial calcaneus, or a combination of both the proximal tibial metaphysis and lateral calcaneus for application to split-thickness skin graft application sites or for mixture with allogeneic bone graft material for osseous defects or arthrodesis. Patients were kept non-weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 324 female and 206 male patients with a mean age of 54.7 +/- 14.1 years (range: 14 to 84 years). There were 276 left feet/ankles and 272 right feet/ankles undergoing operative interventions with 18 harvests occurring from the proximal medial tibial metaphysis, 183 from the distal medial tibial metaphysis, 11 from the medial malleolus, 325 from the lateral calcaneus, 3 from the medial calcaneus, and 8 from both the proximal tibial metaphysis and lateral calcaneus. All procedures were deemed successful with no nerve-related injury, infection, wound-healing complications, or iatrogenic fracture occurring. When properly performed, autogenous bone marrow aspirate harvest from various locations about the lower extremity as described here represent safe and minimally invasive techniques useful for soft tissue and osseous healing augmentation.

LEVEL OF EVIDENCE

4 (Case Series; Therapeutic Study).

Reconstruction of the first metatarsophalangeal joint following post-cheilectomy avascular necrosis of the first metatarsal head: a case report

Avascular necrosis of the first metatarsal head is a well-known, albeit rare, complication associated with hallux abductovalgus surgery. In this report, we describe the case of a 51-year-old male who developed osteonecrosis of the first metatarsal head 1 year after undergoing an isolated cheilectomy for the treatment of hallux rigidus. To our knowledge, this is the first published report of osteonecrosis following isolated cheilectomy used for the treatment of hallux rigidus. A bone graft substitute with undifferentiated stem cells was used to pack the medullary canals of the first metatarsal and the proximal phalanx. A section of autogenous calcaneal graft was used to perform a bone block distraction arthrodesis of the first metatarsophalangeal joint.

LEVEL OF CLINICAL EVIDENCE

4.

Percutaneous bone marrow aspirate and bone graft harvesting techniques in the lower extremity

Autogenous bone marrow aspirate and cancellous bone graft represent a useful adjuvant to enhance soft tissue and osseous healing in high-risk patients. The authors present a review of the pertinent literature and step-by-step guidelines for performing reliable, simple, and reproducible percutaneous surgical techniques to harvest autogenous bone marrow aspirate and cancellous bone graft from the proximal medial tibial metaphysis and lateral calcaneus. In addition, these techniques are associated with low morbidity and financial cost.

Tricortical calcaneal bone graft and management of the donor site

The clinical outcomes of 19 patients requiring autogenous grafts for foot surgery were followed up until healing at the donor site occurred. In all cases, tricortical bone was extracted from the calcaneus for use at another pedal site. The first cohort of 9 patients had the calcaneal deficit replaced with allogenic cubes. The second cohort received no tissue replacement. Patients were reviewed postoperatively with a questionnaire and clinical examination to evaluate the outcome of the operations. Radiographic outcomes were observed at the donor and recipient sites in both groups until healing was confirmed as bridging trabeculation. Incorporation of the graft at the donor site was also reviewed. Clinical outcomes, namely pain, local sensory function, and return to footwear, were satisfactory in all patients and were not significantly different between groups. One patient from each group sustained a heel fracture. The donated autogenous grafts at the recipient sites were all incorporated uneventfully at 6 months. In the first cohort, allogenic graft incorporation in the calcaneus was complete in only 2 patients at the 12-month stage. The remaining 7 cases showed reduction of the deficit by new bone formation arising from the calcaneus. Donor sites with allogenic bone replacement healed at a median of 18 months (interquartile range, 18-18 months). In the group without replacement, healing occurred at a median of 6 months (interquartile range, 6-12 months), a highly statistically significant difference (P < .001). In the second cohort without allogenic graft replacement, radiographic filling at the donor site was complete within a 12-month period. Tricortical bone can be successfully harvested from the calcaneus, but there may an associated risk of heel fracture. The role of replacement allogenic bone in assisting healing at the donor site is unclear.

Complications of iliac crest graft and bone grafting alternatives in foot and ankle surgery

The ability to harvest iliac crest bone is a well-established skill in the surgical armamentarium of the orthopedic surgeon. As with any surgical procedure, this operation has its own set of complications. The surgeon must be aware of these potential problems in an effort to avoid them when possible. Other autologous sites for bone harvest are available to the surgeon, and s/he should be aware of these in terms of location, limitations of use, harvest technique, and potential pitfalls. The foot and ankle surgeon almost always needs less bone graft than our colleagues in spine surgery or joint revision surgery, so these other sites may be more suitable than the iliac crest for obtaining bone graft. Nonautogenous alternatives are becoming increasingly available to the orthopedist as a way to decrease morbidity and operating times. Scranton recently published an article about his success with several different bone substitute products that are used in foot and ankle reconstructive cases. As these options become more varied, it becomes more difficult to know which product to select. Understanding the biology of bone grafting with respect to osteoconduction, osteoinduction, and osteogenesis provides the surgeon with the knowledge that is needed to make an informed choice when selecting a bone grafting option. Before choosing an alternative graft material, the surgeon should also investigate how the graft material has performed in cases similar to his or her patient's needs. In the future, with continued research, the fields of tissue engineering and gene therapy will provide even better options for nonautogenous bone graft material.

Bone cyst of a fishy origin: from an old catfish spine puncture wound to the foot

A rare first metatarsal unicameral-type bone cyst with a deceptive radiographic appearance and size and an unusual pathological etiology was identified in a female patient. This eccentric cyst was observed only postoperatively by radiograph. Review of the patient's history documented a foot injury from a catfish spine as the etiology of this chronically inflamed cyst.

Radiographic evaluation of bone grafts

Autogenous and allogenic bone grafts are frequently used in foot and ankle surgery. Indications may include treatment of nonunions, acute fractures, arthrodesis procedures, and reconstructive osteotomies. Proper perioperative management of these procedures requires a through understanding of the radiographic changes that occur after bone grafting. This article describes normal and abnormal radiographic presentations in both the recipient and donor sites after bone graft surgery.

Different forms of bone grafts

Successful incorporation of a bone graft depends on a number of factors. The source, size, function, and form of the bone graft necessary will influence decision making. This article presents the various forms of bone grafts, along with their applications in foot and ankle surgery.

Autogenous bone grafting

Complex, out-of-the-ordinary problems are often encountered when evaluating patients for reconstructive foot and ankle surgery. Salvage of these complex problems in the foot and ankle often requires the use of autogenous bone grafts. This article provides a brief overview of autografts including indications, healing, graft types, and perioperative management.