CHAPTER 55
Proximal Tibial Bone Graft

Nathan Steele¹ and J. Michael Ray²

¹Private Practice, Cheyenne Oral and Maxillofacial Surgery, Cheyenne, Wyoming, USA

²Private Practice, DFW Facial and Surgical Arts, Dallas, Texas, USA

A surgical procedure for harvesting cancellous bone from the proximal tibia.

Indications

1. The need for autogenous bone in a quantity greater than can be harvested intraorally
2. Hard tissue maxillofacial defects requiring 30 mL or less of cancellous bone

Contraindications

1. Reconstruction of maxillofacial defects requiring more than 30 mL of cancellous bone
2. Severe peripheral vascular disease
3. Total knee arthroplasty
4. Skeletally immature patient

Anatomy

• Gerdy's tubercle: The lateral tubercle on the proximal metaphysis of the tibia, which serves as the insertion of the iliotibial tract superiorly and the anterior tibialis muscle inferiorly

Technique: Lateral Approach to the Proximal Tibia

1. Preoperative intravenous antibiotics are recommended. The procedure may be performed with general endotracheal intubation or with intravenous sedation dependent on the patient's anxiety level and the invasiveness of the coinciding reconstructive procedure.
2. The patient is positioned supine with a knee bump (i.e., towels, a sand bag, or an intravenous fluid bag) placed under the ipsilateral knee, providing a medial rotation of the tibia.
3. The surgical site is prepped and draped in a sterile fashion. Pertinent anatomy is marked to include the patella, the patellar tendon, Gerdy's tubercle, the tibial tuberosity, the fibular head, and the planned incision (Figure 55.1).
4. Local anesthetic containing a vasoconstrictor is infiltrated subcutaneously and deep to the periosteum.

5. A 2–3 cm length oblique incision is placed overlying Gerdy's tubercle. The incision initially extends through skin and subcutaneous tissue (Figure 55.2). A Weitlaner retractor may be placed to assist in the retraction of the supraperiosteal tissues (Figure 55.3).

6. The periosteum is incised, and a subperiosteal dissection is performed to expose Gerdy's tubercle. A 701 bur with copious irrigation is used to remove the cortical bone overlying Gerdy's tubercle. The cortical bone should be removed en bloc so that it may be used at the recipient site (Figure 55.4).
7. Gouges or curettes are used to remove cancellous bone from the tibial plateau and the proximal portion of the shaft. The amount of cancellous bone harvested is dependent on the size of the proximal tibia. Typically, 10 to 30 mL of uncompressed cancellous bone can be harvested (Figure 55.5).
8. Once the graft harvest is complete, the surgical site is irrigated with normal saline (Figure 55.6), and microfibrillar collagen is placed within the surgical site to aid in hemostasis.
9. The incision site is closed in a layered fashion (Figure 55.7). The periosteum is reapproximated with 3-0 polylactic acid sutures. The subcutaneous tissues are reapproximated with 4-0 polylactic sutures. The skin can be closed with either a running subcuticular or standard skin-suturing technique.
10. Antibiotic ointment is applied to the wound, and a sterile compressive dressing is placed (Figure 55.8).

Figure 55.1. Preoperative surgical markings include the patella, the patellar tendon, Gerdy's tubercle, the tibial tuberosity, the fibular head, and the planned incision. Gerdy's tubercle is palpated between the tibial tuberosity and fibular head. The incision is marked obliquely from Gerdy's tubercle to the tibial tuberosity.

Figure 55.2. Incision through skin and subcutaneous tissue.

Figure 55.3. The periosteum overlying Gerdy's tubercle is exposed. Self-retracting devices (i.e., a Weitlaner retractor) aid in tissue reflection.

Figure 55.4. A 1 × 2 cm block of cortical bone is removed from Gerdy's tubercle to expose the marrow space of the proximal tibia. The cortical bone may be used as a small onlay graft or may be milled into particulate bone.

Figure 55.5. Cancellous bone is removed from the proximal tibia with curettes and gouges. The proximal tibia typically yields 10–30 mL of uncompressed marrow.

Figure 55.6. Defect after bone harvest. Local hemostatic agents (i.e., microfibrillar collagen) may be placed to enhance hemostasis.

Figure 55.7. The incision site is closed in a layered fashion.

Figure 55.8. Antibiotic ointment is applied over the incision site, and a compressive dressing is placed.

Postoperative Management

1. Opioid analgesics are recommended for pain control.
2. Antibiotics are generally not required.
3. Patient may begin to ambulate as tolerated the day after surgery.
4. Although typically not necessary, ambulation may be assisted with a rolling walker or cane as needed.

Complications

1. Seroma or hematoma formation: Rare, but possible in patients with peripheral vascular disease and especially in the obese patient.
2. Infection: Typically caused by not adhering to sterile technique or by poor postoperative Management. Treatment consists of drainage, cultures, and oral antibiotics.
3. Wound dehiscence: Caused by inappropriate closure technique (i.e., not performing a layered closure, or closure under tension).
4. Pain and gait disturbance: Common during the first 2 weeks after surgery. Typically resolves with time.

Key Points

1. A thorough understanding of the pertinent anatomy and proper patient selection are vital in minimizing potential intraoperative and postoperative complications.
2. This procedure can be predictably performed in an office setting with intravenous sedation and local anesthesia.
3. A medial approach to the proximal tibia may also be performed. Both the lateral and the medial approaches to the proximal tibia have thin overlying tissue with a relative lack of neurovascular structures.

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Case Report

Case Report 55.1. A 68-year-old male presents with a chief complaint of loss of numerous maxillary teeth. On examination and on review of the patient's cone beam computed tomography scan, the patient has posterior left maxillary edentulism and moderate sinus pneumonization. The patient also exhibited a large anterior maxilla defect. The patient was treated with a tibial cortical onlay graft to the anterior maxillary defect and a left-sided sinus augmentation using cancellous bone from the proximal tibia. Implants were placed after 5 months of graft consolidation. (See Figures 55.1 through 55.8.)

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References

1. Galano, G.J. and Greisberg, J.K., 2009. Tibial plateau fracture with proximal tibia autograft harvest for foot surgery. American Journal of Orthopedics (Belle Mead, NJ), 38 (12), 621–3.
2. Herford, A.S. and Dean, J.S., 2011. Complications in bone grafting. Oral and Maxillofacial Surgery Clinics of North America, 23 (3), 433–42.
3. Mazock, J.B., Schow, S.R. and Triplett, R.G., 2004. Proximal tibia bone harvest: review of technique, complications, and use in maxillofacial surgery. International Journal of Oral and Maxillofacial Implants, 19 (4), 586–93.
4. Michael, R.J., Ellis, S.J. and Roberts, M.M., 2012. Tibial plateau fracture following proximal tibia autograft harvest: case report. Foot Ankle International, 33 (11), 1001–5.