Bone grafting is an essential component of restoring
three-dimensional osseous architecture. Surgical correction of
hard tissue deficiencies presents challenges in both the
functional and aesthetic realms.
Autogenous bone harvested from secondary surgical sites
provides great utility in reconstructing defects, augmenting healing, treating
nonunions, arthrodesis and lengthening bones. While a number of options are
available in allograft, autograft and
bone graft substitutes, the benefits of osteogenesis and
osteoinduction in autografts, as well as its mechanical and handling
characteristics, make it the gold standard.
Bone grafting procedures are used in an estimated 200,000 surgeries each
year in the United States. The cellular and molecular elements that accompany
the bony autograft serve multiple purposes. First, the osteoconductive scaffold
recruits osteoprogenitor cells that make the grafting procedure more reliable
and predictable. Second, a host of molecular growth factors that accompany
autologous bone grafts have been evaluated and demonstrate osteoinductive
qualities. These include fibroblast growth factor, transforming growth factor
ß-1, vascular endothelial growth factor and the
bone morphogenic proteins (BMPs). These factors are expressed
at various times in the healing process and play an important part in fracture
repair and new bone formation.
The most frequently used site of harvest is the iliac crest. Although
bone from this area offers both cortical and cancellous bone, the procedure
carries with it significant pain as well as risks of hematoma and paresthesia.
With this in mind, other sites have been shown to be advantageous in terms of
similar bone quantity, but less postoperative morbidity. Studies have shown
that approximately 10 cm3 to 15 cm3 can be harvested from
the proximal lateral tibia with low morbidity and easy accessibility.
This surgical technique addresses a method for harvesting cancellous
bone from the lateral proximal tibia metaphysis.
Figure 1. The anatomy of the proximal lateral tibia is
identified showing Gerdys tubercle marked in the center with the planned
incision also marked.
Figure 2. The initial incision is placed over Gerdys
tubercle with extension performed inferomedially.
Figure 3. Shown is the lateral metaphysis with retractors in
place demonstrating access to the bone graft.
Figure 4. The drill holes are placed using a 2-mm drill.
Images: Mauffrey C
The anatomy of the proximal lateral tibia facilitates access to the
graft site. Critical areas to avoid are the tibialis anterior muscle, which
will lie inferior to the harvest site. The incision is ideally placed between
the delineation of the tibialis anterior muscle and the anterior subcutaneous
surface of the tibia. Although the cutaneous branches of the lateral sural
nerve and fibular nerve are in proximity to the graft site, one main advantage
of the procedure is there are no major nerves over the harvest site. The main
blood supply to possibly be encountered in the harvest area is the anterior
tibial artery; however, experience shows this is rarely the case. We use the
osseous anatomy to determine major landmarks and plan the incision. We
highlight the lateral tibiofemoral joint line, the tibial tuberosity, the
fibular head and Gerdys tubercle. The midpoint of a line that joins the
fibular head to the tibial tuberosity approximates the location of Gerdys
tubercle (Figure 1). Gerdys tubercle is where we start the incision and
then carry the incision inferiorly and medially (Figure 2).
The positioning of the patient is determined by the graft recipient
site. The optimal patient positioning is supine with a sand bag placed under
the homolateral buttock to elevate and internally rotate the lateral aspect of
the proximal tibia metaphysis. The patient may also be placed in a prone
position with the leg flexed; however, this position makes the procedure much
Intravenous antibiotics are given at induction before the tourniquet is
inflated. The leg is prepared up to the mid-thigh with povidone-iodine
(betadine) solution and draped in a sterile manner. Infiltration of
approximately 0.25% marcaine (bupivicaine, AstraZeneca) with 1/200,000 of
adrenaline is infiltrated into the area of the incision down to the periosteum
to reduce postoperative pain and intraoperative bleeding.
Curette selection is critical
A linear incision of 2 cm to 3 cm is directed superolaterally to
inferomedially through the skin and subcutaneous tissue directly over
Gerdys tubercle. This assures the patellar tendon is medial, and the
tibialis anterior muscle is inferior. This is continued through the skin and
the subcutaneous tissue down to the periosteum, using care not to enter the
muscle fibers of the tibialis anterior. The periosteum is then sharply incised
and retracted to expose the lateral surface of the metaphysis at about the
level of the tibial tuberosity. Care must be taken to make an incision long
enough to avoid excessive traction on the skin while allowing enough access to
begin the lateral bony window (Figure 3).
West retractors are applied, and a series of drill holes are made with a
2-mm drill bit forming a 1-cm2 area (Figure 4). The drill holes are
joined together using a 0.25-inch osteotome removing a 1-cm2 window
of bone. It is usually easiest to define the lateral osteotomies first,
followed by the inferior osteotomy and then the superior osteotomy. Once the
osteotome is driven past the cortex, the cortical bone can be easily
out-fractured, aiding easy visualization of the inner cancellous bone. Usually
we incorporate the crest of the tubercle, which allows us to reference an
anatomic landmark for avoiding the articular surface of the tibia while
maintaining access to the best metaphyseal bone. The cortical window is placed
in a sterile sponge soaked in normal saline. The entire cancellous bone of the
metaphysis is available to collect using a curette (Figure 5). We find that
using the largest curette possible allows for easy harvesting of the cancellous
bone, maintains integrity of the surgical site and makes perforation less
likely. Ideally, the integrity of the bone window is kept intact while
harvesting the cancellous bone (Figure 6). As stated, approximately 15 mL to 25
mL of cancellous bone can be harvested from this site (Figure 7). Depending on
preoperative planning, the bone graft can be mixed with antibiotic powder. In
general, one half to two thirds of a 1.2-g vial of tobramycin powder is mixed
with the graft.
Figure 5. The surgeon collects the cancellous bone using a
Figure 6. Seen is the bone window created during the
Cancellous bone is harvested in the amount needed.
The wound at the harvest site is closed.
The incision is closed in two layers, and a sterile compressive dressing
applied before leaving the operating room (Figure 8). This dressing is usually
removed 24 hours after the procedure.
Following the procedure, we allow weight bearing as tolerated. Alt and
colleagues demonstrated in cadaveric studies where eight cadaver proximal
lateral tibias were decancellated and compression studies were carried out with
eight control lateral tibias. No difference was found, which supports the
clinical findings that a sufficient amount of cancellous bone can be harvested
from the tibia and the risk of postoperative fracture is not increased. We find
that as the patients are allowed to function, their complaints of pain are
minimal and generally resolve within 2 weeks to 4 weeks. Sutures are removed at
10 days, and the patients are instructed on local wound care.
The proximal lateral tibial metaphysis provides a useful site for
autogenous bone harvesting. When compared to other sites, we find this approach
preferable because of its relatively simple anatomy. The dissection is
straightforward, even in obese patients. There is ample cancellous bone that
may be harvested, which is comparable in quality and quantity to the anterior
iliac crest. The patients tolerate it and recover well.
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- Cyril Mauffrey, MD, FRCS, is Assistant Professor, Denver Health
Medical Centre. He can be reached at 502-712-9819; email:
- Matthew J. Madsen, MD, DMD, is a resident in oral and maxillofacial
surgery at the University of Louisville. He can be reached at 501 S. Preston
St., Louisville, KY 40202; 502-852-5401; email:
- David Seligson, MD, is Professor, Chief of Orthopedic Surgery,
University of Louisville Hospital. He can be reached at 210 E. Gray St., Suite
1003, Louisville, KY 40202; 502- 852-0923; email:
- Disclosures: Mauffrey, Madsen and Seligson have no relevant