The iliac crest is the standard site for harvesting bone; however, this
procedure may require another specialist and a general anaesthetic. The
proximal tibial bone harvest has gained popularity for harvesting autogenous
bone. An analysis of the clinical literature regarding the various regions
for harvesting bone demonstrates that the use of the proximal tibia led to
shorter hospital stays, lower morbidity rates, and a shorter learning curve
for the surgeon. The purpose of this study was to analyze the clinical
anatomy of a proximal tibial bone harvest graft to provide the anatomical
architecture supporting a safe procedure.
Materials and Methods
Dissection of 58 lower limbs from embalmed cadavers was conducted to
determine the anatomy of a proximal tibial bone harvest (PTBH).
Results
Dissection revealed that the medial approach has fewer clinically relevant
neurovascular structures in harms way, and a larger surface area, providing
the clinician a confident surgical window to perform the procedure.
Conclusions
The anatomical basis of this study suggests that the medial proximal tibial
bone harvest approach would have fewer serious structures in harm's way
compared to the lateral; however, the lateral approach may be preferred for
a subgroup of patients.
bones and bone tissueaugment bone grafttibiabone transplantation.INTRODUCTION
In 1682, the first documented case of bone grafting was recorded in the Anecdotal
Case History of Church Literature [1].
Harvesting bone techniques and grafts are used to treat a myriad of pathologies
including skeletal trauma, congenital defects, infectious diseases, and conditions
associated with cancer. Harvesting techniques and grafts can also be used in
reconstructive and restorative surgery, in particular in the head and neck region by
Oral Maxillofacial and Plastic surgeons. Bone grafts provide a honeycombed matrix
for in-growth by host bone and provide osteogenic cells and growth factors to the
host. There are three classic harvesting areas conducted on bone: 1) cortical, 2)
cancellous, and 3) cortical-cancellous [2-5]. Approximately 200,000
autogenous bone grafts are harvested annually within the United States [6,7]. In
1992, Catone, et al. [8] described a bone
harvesting technique from the proximal tibia published in the Journal of Oral
Maxillofacial Surgery. There have been modifications since the technique was
described [5-14].
The "gold standard" for harvesting cancellous bone has long been the iliac
crest site [15,16]. For procedures requiring a bone graft involving head and
neck pathologies, multiple clinicians may be needed to coordinate bone harvesting
and final graft placement [2-6].
The proximal tibial bone harvest site is becoming a popular alternative to the iliac
crest harvest site [3-5,15,16]. There are two recognized approaches or
techniques used at the anterior proximal tibial region: lateral and medial [5]. This study focused on comparing the clinical
anatomy of the two approaches.
In other countries (United Kingdom, Germany, Sweden, etc.), the proximal tibial
harvest is now being conducted in clinical trials as an outpatient procedure [15-18].
The morphology of the anterior aspect of the tibia has it positioned so that the
most anterior structure is a sharp and well-defined border. There are two flat
surfaces that angle posteromedially and posterolaterally, which allow access for
collection of cancellous bone. These two flat surfaces have been referred to in
clinical studies as the medial and lateral approaches to the anterior proximal
tibial bone harvest [11,12,18-23]. There are no studies to date that compared
the detailed anatomical structures encountered from the two approaches.
The purpose of this study was to analyze the clinical anatomy of a proximal tibial
bone harvest graft to provide the anatomical architecture supporting a safe
procedure.
MATERIAL AND METHODS
A literature search of proximal tibial bone graft/harvest techniques was conducted
and the anatomy was analyzed. Fifty radiographic images (roentograms of the proximal
tibia) and dry tibial bones were examined to assess the epiphyseal line. Thirty
cadavers (58 sides, 30 right and 28 left, age 45 – 89, average: 76.3) were dissected
to reveal the anatomy witnessed during a proximal tibial bone harvest. Exclusion
criteria included below knee amputation and/or severe trauma to the proximal tibia.
Both the medial and lateral approaches consisted of placing the cadaver in a supine
position with the knee flexed between 30 - 45 degrees. Surface anatomy palpation was
performed to identify bony landmarks, which were highlighted with a skin marker pen.
Prior to incision palpated surface bony landmarks of the medial approach were as
follows: patella, medial border of patella tendon, apex of a single tibial
tuberosity or the distal prominence of a double apex tibial tuberosity (ATT), medial
tibial condyle and medial tibiofemoral space. Using a calliper, a measurement point
of 1.5 cm proximal to the ATT (p-ATT) was identified and 1.5 cm medial (m-ATT) to
the p-ATT point was marked with an 'X' ('X' represents the
midpoint of the 1 to 2 cm oblique incision). Prior to incision palpated surface bony
landmarks of the lateral approach were as follows: patella, lateral border of
patella tendon, tibial tuberosity (TT), Gerdy's tubercle (GT), fibular head,
lateral condyle of tibia and lateral tibiofemoral space. Classically, the midpoint
between the TT and the fibular head reveals Gerdy's tubercle. An oblique
incision from GT was made towards the ATT. The medial and lateral incisions were
made through connective tissue from skin down to periosteum (Figure 1 and Figure 2).
Deep dissection was then conducted to identify any connective tissue layers and/or
neurovascular structures (Figure 4). Trephine
needle was used to penetrate the cortex and a 1cm window was created within the
cortex. Spoon spatula was used to harvest cancellous bone.
Surface markings of left proximal tibial region: PB = body of patella; PT =
patella tendon; fh = head of fibula, PIP = inferior pole of patella; MI =
medial approach incision; LI = lateral approach incision; ATT = apex of
tibial tuberosity, g = gerdy's tubercle.
Surface and osseous proximal tibial anatomy: PB = body of patella; PT =
patella tendon; PIP = inferior pole of patella; MI = medial approach
incision; LI = lateral approach incision; ATT = apex of tibial tuberosity; g
= gerdy's tubercle; fh = head of fibula, fn = neck of fibula.
RESULTS
In previous studies, the primary focus was based on techniques and morbidity of the
above procedures. No single study adequately integrated detailed anatomy with these
techniques. Radiographic images and dry tibial bone examination revealed that the
proximal tibial epiphyseal line remained within 2 cm of the medial and lateral
plateaus of the tibia. Prior to dissection, all palpable landmarks were identified.
The medial approach incision (tibial tuberosity 1.5 cm x 1.5 cm grid incision)
successfully allowed entry through the cortex to harvest cancellous bone avoiding
the epiphyseal line (Figure 3). Dissection
from this incision revealed (superficial to deep connective tissue) dermis,
subcutaneous tissue, pes anserinus tendon, and the medial collateral ligament (Figure 4, Figure 5 and Figure 6).
Neurovascular structures encountered were the infrapatellar branch and medial crural
cutaneous branch of the saphenous nerve, the saphenous nerve; the saphenous branch
of the descending genicular artery and the medial inferior genicular artery; the
great saphenous vein and branches from the infrapatellar region (Figure 7). The lateral approach using an
oblique incision from Gerdy's tubercle to ATT (GT-ATT incision) successfully
allowed entry through the cortex to harvest cancellous bone avoiding the epiphyseal
line. Dissection from this incision revealed (superficial to deep) dermis,
subcutaneous tissue, iliotibial tract or band (anterolateral ligament), anterior
tibialis muscle, and extensor digitorum longus muscle. Neurovascular structures
encountered were the lateral sural cutaneous nerve, recurrent deep peroneal nerve,
common fibular nerve, superficial fibular nerve, and deep fibular nerve; anterior
tibial artery and its recurrent branch; anterior tibial vein.
X-ray of anterior proximal tibia and fibula landmarks prior to harvest: p =
patella; fc = femoral condyle; tp = tibial plateau; curved line = epiphyseal
line; g = gerdy's tubercle; tt = tibial tuberosity; fh = head of
fibula; fn = neck of fibula.
Superficial dissection of the proximal tibial bone graft: medial approach. TT
= tibial tuberosity; PA = pes anserinus; GS-v/n = Great saphenous vein and
nerve.
Superficial dissection of proximal tibial bone graft: lateral approach. TA =
Tibialis anterior muscle; ATT = apex of tibial tuberosity.
Deep dissection of proximal tibial bone graft: lateral appraoch. Tibialis
anterior muscle and extensor digitorum longus muscle reflected. TA =
tibialis anterior muscle; EDL = extensor digitorum longus muscle; ATA =
anteiror tibial arterior; ATV = anterior tibial vein; ATA mb = anterior
tibial artery muscular branches; ATRA = anterior tibial recurrent artery;
DFN = deep fibular nerve.
Deep dissection of proximal tibial bone graft: lateral approach. Tibialis
anterior muscle and extensor digitorum longus muscles reflected and
separated displaying the deep fibular nerve between the forceps. TA =
tibialis anterior muscle; EDL = extensor digitorum longus muscle; ATA =
anteiror tibial arterior; ATV = anterior tibial vein; ATA mb = Anterior
tibial artery muscular branches; ATRA = anterior tibial recurrent artery;
DFN = deep fibular nerve.
DISCUSSION
Proximal tibial bone harvesting is a recognized, important surgical procedure,
harvesting bone for acute and chronic pathological defects. Anatomical structures
from superficial to deep of the proximal medial and lateral regions of the tibia are
not described or illustrated comprehensively in contemporary anatomy texts or
atlases [24-39]. Although the majority of these structures appear within texts
individually, they are generally dispersed amongst multiple chapters and may have
some of the smaller structures omitted completely.
Several investigations describe two techniques for harvesting cancellous bone from
the proximal tibia [12,17]. In general, the proximal tibial bone harvest was
considered as an acceptable alternative to the previous "gold standard"
iliac crest harvest [3,16]. The proximal tibial bone harvest technique demonstrated
some benefits that make it preferable to the iliac crest. Benefits include:
decreased hospitalization, potentially fewer required clinicians, lower morbidity,
and adequate harvest volume. As such, it could stimulate clinicians to opt for this
approach, rather than the iliac crest. Nevertheless, individual investigations have
focused on technique and inadequately addressed the detailed anatomy for the
surgeon.
Comparing the medial to the lateral approach can aid surgeons in their choice of
approach regarding structures that potentially could be compromised or for specific
patient sub groups. The medial approach consistently had fewer structures
demonstrated from cadaveric dissection, specifically, a small surface-supplying
artery (branch of descending genicular) and cutaneous nerves (saphenous branches of
the infrapatellar and medial crural) (Table
1). The lateral approach has significant arterial structures and motor nerves
potentially in harm's way.
Anatomy of proximal tibial bone harvest. Medial vs. lateral
approaches
Medial approach
Lateral approach
Nerve
Infrapatellar branch of saphenous nerve;Medial crural cutaneous
branch of saphenous nerve;
Saphenous nerve
Lateral sural cutaneous nerve; Recurrent deep peroneal nerve;
Common fibular nerve; Superficial fibular nerve;
Deep fibular nerve
Artery
Saphenous branch of descending genicular artery; Medial inferior
genicular artery
Using the lateral approach, it could be postulated that the anterior tibialis (+/-
extensor digitorum longus) muscle will cover the harvest site defect, which may
increase healing and decrease morbidity in diabetic or compromised patients. It is a
known fact that the moderate to severe diabetic patient has compromised arterial
supply, therefore an approach where a highly vascular structure, such as a muscle,
covering the defect, would expedite healing. Thus, it may be the approach of choice
for this group of patients. Studies of the medial harvest procedure reveal that the
"trap-door" from the extraction can result in an aesthetic
depression-deformity and demonstrates insignificant morbidity [20]. Further, compartment syndrome would not be an issue with
the medial approach whereas it could be problematic with the lateral approach. The
architecture of the compartment(s) of the anterolateral aspect of the proximal leg
can be compromised from the surgical insult due to increased pressure within the
investing fascia. This study is not suggesting that one approach is better than the
other. Rather, each approach can benefit different patient sub-groups and each have
unique anatomical considerations.
CONCLUSIONS
The medial approach would have fewer serious structures in harm's way compared
to the lateral approach; however, the lateral approach would have the benefit of
muscle coverage and therefore healing might be expedited in particular patient
sub-groups. From an anatomical point of view, this study suggests that the novice
clinician might prefer the medial approach, while the more experienced clinician may
choose to use the lateral approach when appropriate. However, the approach may be
more specific to patient sub-groups and/or co-morbid factors. For example, the
lateral approach may be more prudent for diabetic patients, whereas the medial
approach may be preferable for a person whose healing is not compromised.
ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS
Internal Review Board (IRB) approval was granted for this study. There was not
any external funding for this study. The authors did not have any conflict of
interest with this study. Authors retain all rights to images.
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