The purpose of this report is to describe our experience with performing the tibial bone graft procurement procedure under intravenous sedation and local anesthesia as an in-office procedure and to quantify the amount of bone graft material that can be harvested from the tibia.
AN IN-OFFICE TECHNIQUE FOR HARVESTINGTIBIAL BONE: OUTCOMES IN 8 PATIENTSCLINICALCameron Y. S. Lee, DMD, MDKEY WORDSTibiaAutogenous cancellous boneMaxillary sinusMorbidityCameron Y. S. Lee, DMD, MD, is in theprivate practice of oral, maxillofacial, andreconstructive surgery. Address correspondenceto Dr Lee at 98-1247 Kaahumanu Street, Suite314, Aiea, Hawaii 96701 (CLee555294@aol.com).The purpose of this report is to describe our experience with performing thetibial bone graft procurement procedure under intravenous sedation and localanesthesia as an in-office procedure and to quantify the amount of bone graftmaterial that can be harvested from the tibia.INTRODUCTIONlinicians are frequentlychallenged to develop surgicaltechniques that areminimally invasive, arecost-effective, and haveminimal postoperative morbidityand mortality. Office surgeryhas the advantage of cost containmentwithout compromising the standardsof patient care. When the atrophic bilateralposterior maxilla are augmentedusing the sinus lift elevation procedure,the amount of cancellous intraoralbone available for bone grafting is usuallyinadequate. Because only a limitedamount of autogenous intraoral bone isavailable for grafting the bilateral maxillarysinuses, clinicians have used variousgraft materials, such as xenografts,allografts, and alloplastic materials.These bone substitutes have been usedalone or in combination with autogenousbone. In contrast, cancellous boneharvested from the lateral proximaltibia provides the surgeon with satisfactoryamounts of bone to graft bothsinuses without the need to incorporateother graft materials.The tibial bone harvest technique iswell described in the surgical literature.In 1992, Catone and colleagues1published the results of a study of 20patients who had bone harvested fromthe tibia for various oral and maxillofacialreconstructive surgery procedures.All patients were admitted tothe hospital and surgery was performedin the operating room. Generalanesthesia was administered to 19 patientsand 1 patient was under intravenoussedation when the procedurewas completed. In 1999, Alt et al2 reportedthe results of 54 trauma patientswho underwent bone reconstructionwith bone harvested from the tibia.They concluded that patient morbiditywas low (1.9%) and all patientswere able to ambulate immediately aftersurgery. Garg3 reported a complicationrate of 1.3% to 3.8%, which iscomparable to the complication rate forthe iliac crest harvesting procedure.The purpose of this report is to describethe tibial bone graft procurementin an office setting using intravenoussedation and local anesthesia.The bone, which was harvested to graftbilateral maxillary sinuses, was quantified.METHODSEight patients underwent bilateralmaxillary sinus lift elevation proce-Journal of Oral Implantology 181HARVESTING TIBIAL BONETABLE 1Average bone graft volumeharvested per patientBone Volume(mL)* PatientR.T.H.I.M.I.G.V.J.A.Y.F.3935253937313833Y.I.S.H.*Average bone volume was 34.6 mL.dures with bone harvested from theleft tibia under intravenous sedationand local anesthesia. The graft was allowedto heal for 4 months beforeplacement of endosseous implants. Thesurgeon administered the intravenousanesthesia, prepared the platelet-richplasma, harvested the tibial bone, andperformed the sinus grafting procedure.A complete medical history wasperformed preoperatively, and all thepatients were nonsmokers and did nothave a history of knee surgery or disease.Intraoperative and postoperativeexperiences of the clinician were documented.None of the patients receivedpreoperative antibiotics. Postoperatively,every patient was prescribed a cephalosporinantibiotic for a period of 5days. The recipient site is usually preparedfor grafting before harvestingthe donor bone. This allows the surgeonto determine the amount of donorbone needed to reconstruct the osseousdefect. However, the experienced surgeoncan reliably predict the amount ofbone volume needed to reconstruct themaxillary sinus before exposing the recipientsite. To avoid surgical contaminationof the lower-extremity donorsite with oral flora, the bone was harvestedbefore preparing the maxillarysinuses. Because the entire surgicalprocedure is performed under sterileconditions, harvesting the donor bonefirst eliminates the need for the surgeonto regown and redrape the patient.The patients were instructed towear shorts on the day of surgery for182 Vol. XXIX/No. Four/2003TABLE 2Morbidity 2 weeks after surgeryClinical ObservationNo. of Patients(N 5 8) (2 wk)DiscomfortEdemaEcchymosisAbnormal sensationParesthesiaDifficulty ambulatingFractureKnee joint perforationUnsightly scarInfection/wound breakdownease of surgical access. All patientswere seated in the surgical chair, andthe left leg was elevated into a flexedposition using a towel roll that wasplaced under the knee. The area of theknee was prepared in sterile fashionusing an iodine preparation and thendraped to view the entire knee, theproximal tibia, and the femur directlyabove the knee. Using a marking pen,key anatomic landmarks were identi-fied and labeled. Gerdy's tubercle wasidentified and 1.8 mL of lidocaine, 2%with 1:100 000 epinephrine, was infiltratedinto the surgical site. A 2-cmlongsoft tissue incision was made directlyover the tubercle using a No. 15scalpel. The incision was carriedthrough the skin, subcutaneous tissue,and iliotibial tract. The surgeon identifiedthe periosteum and, using sharpand blunt dissection, reflected it to exposethe bony surface of the tibia.An ovoid-shaped bone windowwas made with a No. 701 fissure burin a high-speed handpiece. The cap ofbone was then removed and approximately0.5 mL of local anesthetic wasdirectly infiltrated into the cancellousbone of the tibia. Using orthopedic curettesof varying size, the surgeon harvestedthe cancellous bone mediallyand inferiorly down the tibial shaft untilsufficient amounts of bone were procuredto graft both maxillary sinuses.After harvesting the bone, the surgeonclosed the surgical site in layers. Theperiosteum and iliotibial tract wereclosed with 3-0 resorbable suture, andthe skin was closed with 5-0 nylon su-No. of Patients(N 5 8) (2 mo)10000000208832050021ture in an interrupted fashion. The skinincision was covered with an adhesivestrip bandage. The knee was notwrapped in a pressure dressing. Postoperatively,all patients were instructedto apply ice directly over the surgicalsite during a 24-hour period and to elevatethe knee while at rest for 2weeks. Each patient was allowed tobear weight on the left leg immediatelyafter surgery.RESULTSAll 8 patients were followed up formore than 2 months. Of the 8 patients,6 were women and 2 were men. Thepatients ranged in age from 32 to 71years. The average age was 64.3 years.The average time for procurement ofthe tibial bone was 31 minutes (range,25-59 minutes) from the time of skinincision to skin closure. Blood loss averaged60 mL (range, 45-150 mL). Theaverage volume of cancellous bone obtainedfrom the tibia was 34.6 mL(range, 25-39 mL). The results aresummarized in Table 1.Healing was evaluated on the basisof clinical observation and questionsregarding discomfort, swelling, ecchymosis,and abnormal sensation (Table2). All patients reported experiencingsome degree of postoperative discomfort(pain or tenderness). Localizededema immediately after surgery wasreported by all patients. Two patientsreported abnormal sensation that wasdescribed as itching over the skin. Fivepatients reported discomfort walking.Ecchymosis was observed in 3 patients.The ecchymosis was observed justabove the ankle and not at the harvestsite. Two female patients commentedthat the scar was unsightly. None ofthe patients developed an infection.However, 1 patient experienced woundbreakdown at the incision line that wastreated with local wound care and adhesivestrips over the incision line. Follow-up observation at 2 months revealedthat 1 patient still experiencedmild discomfort and 2 patients stillcomplained that the scar was unsightly.The patient who had the woundbreakdown was one of the patients thatbelieved that the scar was unsightly.No significant complications, such asprofuse bleeding or fracture, were observedin this patient series. Althoughunreported, intraoperative and postoperativefracture is possible. To avoidthis potential complication, an ovoidosteotomy is recommended to decreasethe chances of stress fracturealong the tibia.DISCUSSIONClinicians have reported on the use ofxenografts, allografts, and alloplasticmaterials either with or without autogenousbone to augment the posteriormaxilla.4-8 Because autogenous bone isosteogenic, osteoconductive, and osteoinductive,it is considered the goldstandard in grafting the oral and maxillofacialregion.9 Bone harvested fromthe maxillary tuberosity or mandible(ascending ramus and symphyseal region)will yield approximately 2 to 5mL of cortical and cancellous bone,which is sufficient to reconstruct smallosseous defects such as extraction sitesand periodontal defects. When thejaws cannot provide sufficient volumesof autogenous bone to reconstruct atrophicareas, such as the bilateral maxillarysinuses, the most commonly usedextraoral harvest sites are the calvarium,ilium, and tibia. The parietal areaof the cranium cam provide approximately40 mL of cortical bone.10 Verylittle cancellous bone is available forbone grafting. The posterior and anterioriliac crest of the hip can provideapproximately 40 mL of corticocancellousbone but requires significant dissectionof soft tissue that has signifi-cant morbidity.11 These procedures cancause pain and bleeding. Prolongedgait disturbances and lengthy hospitalstays are not uncommon with iliaccrest bone grafts. Subdural hematomaformation has been reported as a complicationof the cranial bone graft procedure,which is an emergency that requiresprompt neurosurgical intervention.10 In contrast, the tibial bone graftprocedure can be performed in the of-fice, which reduces overall cost and caneasily provide up to 40 mL of cancellousbone. There is minimal morbiditywith this in-office surgical proceduredue to the limited amount of soft tissuedissection. All patients were able towalk out of the office without assistanceafter the surgical procedure.In bone grafting of the maxillary sinusfloor, there is great variability inmaxillary sinus volume among individuals.In an anatomic study of 59 sinusesfrom 32 cadavers, Uchida et al12determined that the average sinus volumewas 30.01 mm in length, 34.6 mmin height, and 25.4 mm in width. In allspecimens, the distance between themost inferior points of the antral floorand ostium of the middle meatus was20 mm or more. Garg and Quinones13determined that the average sinus volumeis 15 mL. In our series, all patientswere of Asian ethnicity and requiredapproximately 8 to 10 mL of compactedautogenous bone to increase thevertical bone height in preparation fordental implant placement in the unilateralmaxillary sinus. For a bilateralsinus grafting procedure, we recommendharvesting 20 to 25 mL of cancellousbone for implant surgery. Likeall procedures, there is a definite learningcurve associated with the procedure.In the earlier cases, more bonewas harvested than was needed to reconstructthe bilateral posterior maxilla.If the clinician plans on incorporatingother graft materials with the autogenousbone, then less donor boneshould be harvested. In all 8 cases,Cameron Y. S. Leeplatelet-rich plasma was added to thegraft to promote and accelerate woundhealing of the graft.CONCLUSIONKnowledge of the anatomy of the maxillarysinuses and the amount of bonevolume required for the sinus graftingprocedure is useful in determiningwhere to harvest donor bone. Eventhough this study is limited by thesmall number of patients, it can be concludedthat the tibia is a good sourceof autogenous cancellous bone that canbe harvested in the office with predictableresults. The benefits of this donorsite are low morbidity and sufficientquantities of cancellous bone. The disadvantagewith tibial grafts is the lackof cortical bone available for grafting.With the abundance of bone that canbe harvested from the tibia, we havenot had to incorporate other graft materialswith the donor bone or use theiliac crest or calvarium as a donor site.For a unilateral grafting procedure ofthe maxillary sinus, the tibia is not recommendedas a donor source becausesufficient quantities of intraoral boneare available for grafting. As healthcare trends continue to restrict the cliniciandue to reductions or denial ofreimbursement, the practitioner mustcontinue to develop other means of reducingcost while maintaining standardsof health care.REFERENCES1. Catone GA, Reimer BL, McNeirD, Richard R. Tibial autogenous cancellousbone as an alternative donorsite in maxillofacial surgery: a preliminaryreport. J Oral Maxillofac Surg.1992;50:1258-1263.2. Alt V, Nawab A, Seligson D.Bone grafting from the proximal tibia.J Trauma. 1999;47:555-557.3. Garg AK. Lateral proximal tibiabone harvest for use in augmentationprocedures. Dent Implant Update. 2001;11:33-37.4. Froum SJ, Tarnow DP, WallaceSS, et al. Sinus floor elevation using anorganicbovine bone matrix (Osteo-Journal of Oral Implantology 183HARVESTING TIBIAL BONEgraf/N) with and without autogenousbone: a clinical, histologic, radiographicand histomorphometric analysis-part 2 of an ongoing prospective study.Int J Periodontics Restorative Dent. 1998;18:529-543.5. Scher ELC, Day RB, Speight PM.New bone formation after a sinus liftprocedure using deminalized freezedriedbone and tricalcium phosphate.Implant Dent. 1999;8:49-51.6. Chanavaz M. Sinus graft proceduresand implant dentistry: a reviewof 21-years of surgical experience(1979-2000). Implant Dent. 2000;9:197-203.7. Wheeler SL. Sinus augmentation184 Vol. XXIX/No. Four/2003for dental implants: the use of alloplasticmaterials. J Oral Maxillofac Surg.1997;55:1287-1293.8. Hurzeler MB, Kirsch A, AckermannKL, Quinones CR. Reconstructionof the severely resorbed maxillawith dental implants in the augmentedmaxillary sinus: a 5-year clinical investigation.Int J Oral Maxillofac Implants.1996;11:466-475.9. Block MS, Kent JN. Sinus augmentationfor dental implants: the useof autogenous bone. J Oral MaxillofacSurg. 1997;55:1281-1286.10. Lee CYS, Mohammadi H. Oraland maxillofacial reconstruction withcranial bone grafts. Hawaii Dent J. 1996;24:8-10.11. Marx RE, Morales MJ. Morbidityfrom bone harvest in major jaw reconstruction:a randomized trial comparingthe lateral and posterior approachesto the ilium. J Oral MaxillofacSurg. 1988;48:196-203.12. Uchida Y, Goto M, Katsuki T,Akiyoshi T. A cadaveric study of maxillarysinus size as an aid in bone graftingof the maxillary sinus floor. J OralMaxillofac Surg. 1998;56:1158-1163.13. Garg AK, Quinones CR. Augmentationof the maxillary sinus: a surgicaltechnique. Pract Periodontics AesthetDent. 1997;9:211-219.