This document discusses non-vascularized bone grafts. It notes that autogenous bone grafts are the gold standard for bony reconstruction of the jaws. Costochondral rib harvesting is described as a technique for obtaining bone grafts. The document outlines the advantages of autogenous bone grafts and principles of non-vital grafts, such as needing a blood supply from the recipient site. It provides details on harvesting and using costochondral rib grafts, including preoperative preparation, incision and procedure steps.

1. NON VASCULARIZED BONENON VASCULARIZED BONE
GRAFTSGRAFTS

2. INTRODUCTIONINTRODUCTION
• Contemporary oral and maxillofacialContemporary oral and maxillofacial
surgeons need bone grafting techniques tosurgeons need bone grafting techniques to
satisfy patient needs in trauma, pathology,satisfy patient needs in trauma, pathology,
reconstructive surgery, and dentalreconstructive surgery, and dental
implantology.implantology.
• The "gold standard" for bony reconstructionThe "gold standard" for bony reconstruction
of the jaws is the use of autogenous boneof the jaws is the use of autogenous bone
grafts.grafts.

3. ADVANTAGESADVANTAGES
 Viable osteocytes can be carried to theViable osteocytes can be carried to the
graft site, and active bone regeneration orgraft site, and active bone regeneration or
osteogenesis can occur.osteogenesis can occur.
 Autogenous bone grafts act byAutogenous bone grafts act by
osteoinduction when bone morphogeneticosteoinduction when bone morphogenetic
proteins stimulate bone formation.proteins stimulate bone formation.
 Finally, autogenous bone grafts act as aFinally, autogenous bone grafts act as a
scaffold for vascular ingrowth, which isscaffold for vascular ingrowth, which is
known as osteoconductionknown as osteoconduction

4.  we have a wide choice of autogenouswe have a wide choice of autogenous
bone donor sites, including jaws, iliacbone donor sites, including jaws, iliac
crest, calvarium, rib and tibia. Bycrest, calvarium, rib and tibia. By
expanding the donor sites to the free flapexpanding the donor sites to the free flap
arena, surgeons can expand the donorarena, surgeons can expand the donor
sites to include the scapula, radius, andsites to include the scapula, radius, and
fibula.fibula.

5. GENERAL PRINCIPLESGENERAL PRINCIPLES
 All non-vital grafts harvested without a bloodAll non-vital grafts harvested without a blood
supply must gain this from recipient bed in ordersupply must gain this from recipient bed in order
to maintain their viability.to maintain their viability.
 The larger the volume of grafted tissue, the moreThe larger the volume of grafted tissue, the more
difficult it is for ingrowth of capillaries in sufficientdifficult it is for ingrowth of capillaries in sufficient
time to prevent necrosis.time to prevent necrosis.
 Any fluid collections at the recipient site, such asAny fluid collections at the recipient site, such as
seroma or haematoma, will prevent directseroma or haematoma, will prevent direct
contact between the recipient bed and the graft,contact between the recipient bed and the graft,
with likely graft failure.with likely graft failure.

6.  The graft must be held rigidly at the recipient site,The graft must be held rigidly at the recipient site,
otherwise capillary ingrowth will be prejudicedotherwise capillary ingrowth will be prejudiced
and graft failure will ensue.and graft failure will ensue.
 The most appropriate donor site material shouldThe most appropriate donor site material should
be chosen. Harvested bone may be solid orbe chosen. Harvested bone may be solid or
particulate or combined with cartilage. Solid boneparticulate or combined with cartilage. Solid bone
may be cortical alone or cortical and cancellousmay be cortical alone or cortical and cancellous
in combination.in combination.
 In younger patients it is prudent to avoid donorIn younger patients it is prudent to avoid donor
sites where interference in growth may producesites where interference in growth may produce
either a cosmetic or functional disability.either a cosmetic or functional disability.

7. How to minimize donor siteHow to minimize donor site
morbidity……morbidity……
 Incisions should be sited so that they are barelyIncisions should be sited so that they are barely
visible.visible.
 Motor and sensory nerves in the area must beMotor and sensory nerves in the area must be
preserved.preserved.
 Musculoskeletal complexes in the area shouldMusculoskeletal complexes in the area should
be kept intact; for example, the anterosuperiorbe kept intact; for example, the anterosuperior
iliac spine and iliac crest should be preserved ifiliac spine and iliac crest should be preserved if
at all possible.at all possible.

8. COSTOCHONDRAL RIBCOSTOCHONDRAL RIB
HARVESTINGHARVESTING

9. Principles and indicationsPrinciples and indications
 There are 12 ribs on each side of the thorax.There are 12 ribs on each side of the thorax.
 The rib have a pronounced curve from posteriorThe rib have a pronounced curve from posterior
to anterior, changing direction through 180°.to anterior, changing direction through 180°.
They are also angled downwards from back toThey are also angled downwards from back to
front except fifth rib.front except fifth rib.
 The rib cage protects the intrathoracic contentsThe rib cage protects the intrathoracic contents
including the lungs and heart. Theincluding the lungs and heart. The
neurovascular intercostal bundles run in aneurovascular intercostal bundles run in a
groove along the lower surface of the rib.groove along the lower surface of the rib.
 When more than one rib is harvested, alternateWhen more than one rib is harvested, alternate
ribs are removed rather than adjacent ribs, toribs are removed rather than adjacent ribs, to
prevent cosmetic and functional chest-wallprevent cosmetic and functional chest-wall
problems.problems.

10.  A sub­periosteal approach is used for non-A sub­periosteal approach is used for non-
vital rib harvest.vital rib harvest.
 With the periosteum remainingWith the periosteum remaining in situin situ in thein the
chest wall, new bone will form in thechest wall, new bone will form in the
subperiosteal pocket. This new bone cansubperiosteal pocket. This new bone can
sometimes be harvested in future if it is ofsometimes be harvested in future if it is of
sufficient bulk.sufficient bulk.

11.  Rib can provide cartilage alone, bone alone or aRib can provide cartilage alone, bone alone or a
combination of both cartilage and bone on thecombination of both cartilage and bone on the
same strut.same strut.
 Cartilage is a relatively inert tissue and thereforeCartilage is a relatively inert tissue and therefore
resorbs slowly. It does not integrate readily withresorbs slowly. It does not integrate readily with
adjacent bone at the recipient site which can beadjacent bone at the recipient site which can be
used to advantage in temporomandibular jointused to advantage in temporomandibular joint
ankylosis.ankylosis.
 It also retains its growth potential and canIt also retains its growth potential and can
therefore be used to replace the secondarytherefore be used to replace the secondary
growth centre of the mandibular condyle ingrowth centre of the mandibular condyle in
children.children.

12.  Cartilage has inherent stresses which are notCartilage has inherent stresses which are not
manifest immediately but take from 30 minutesmanifest immediately but take from 30 minutes
to one hour to develop.to one hour to develop.
 When cartilage is used as a subcutaneous strutWhen cartilage is used as a subcutaneous strut
(e.g. along the nasal bridge) this property may(e.g. along the nasal bridge) this property may
cause deformation of an initially satisfactorycause deformation of an initially satisfactory
reconstruction with time.reconstruction with time.
 The cartilage should be carved then left out ofThe cartilage should be carved then left out of
the body for 30 minutes to deform, prior to finalthe body for 30 minutes to deform, prior to final
carving and placement in its recipient site.carving and placement in its recipient site.

13.  The natural curve of the rib lends itself readily toThe natural curve of the rib lends itself readily to
combined orbital floor and medial orbital wall, orcombined orbital floor and medial orbital wall, or
zygomatic arch and body reconstruction.zygomatic arch and body reconstruction.
 Rib bone or cartilage is used to reconstruct theRib bone or cartilage is used to reconstruct the
nasal bridge.nasal bridge.
 Segments of rib may also be used asSegments of rib may also be used as
interpositional grafts in mandibular or maxillaryinterpositional grafts in mandibular or maxillary
Le Fort 1, 11 and III osteotomies.Le Fort 1, 11 and III osteotomies.
 The combination of bone with a small amount ofThe combination of bone with a small amount of
chondral cartilage is an ideal reconstruction forchondral cartilage is an ideal reconstruction for
the mandibular condyle after freeingthe mandibular condyle after freeing
temporomandibular ankylosis.temporomandibular ankylosis.

14.  Split rib is used for brain coverage andSplit rib is used for brain coverage and
protection when part of the cranium hasprotection when part of the cranium has
been lost.been lost.
 The rib can also be used as an onlay graftThe rib can also be used as an onlay graft
in the malar prominence, superior andin the malar prominence, superior and
inferior orbital rims, chin and the bridge ofinferior orbital rims, chin and the bridge of
the nose.the nose.
 A combination of costal cartilages can beA combination of costal cartilages can be
carved to reconstruct the whole auricle.carved to reconstruct the whole auricle.

15. Preoperative preparationPreoperative preparation
 When one or two ribs are to be harvested, anWhen one or two ribs are to be harvested, an
incision is made in the submammary crease.incision is made in the submammary crease.
 This should be marked when the patient isThis should be marked when the patient is
awake and erect as the submammary crease isawake and erect as the submammary crease is
no longer readily visible when the patient isno longer readily visible when the patient is
supine and asleep on the operating table.supine and asleep on the operating table.
 A preoperative chest X-ray is mandatory toA preoperative chest X-ray is mandatory to
exclude intrathoracic abnormalities and anyexclude intrathoracic abnormalities and any
unusual rib pattern.unusual rib pattern.
 The patient is warned about the siting of the scarThe patient is warned about the siting of the scar
and immediate postoperative problems ofand immediate postoperative problems of
discomfort and pneumothorax.discomfort and pneumothorax.

16. Incision and procedureIncision and procedure
 A 5 cm long incision is madeA 5 cm long incision is made
in the submammary crease,in the submammary crease,
starting approximately 4 cmstarting approximately 4 cm
from the midline. The incisionfrom the midline. The incision
is carried through skin andis carried through skin and
subcutaneous fat to thesubcutaneous fat to the
muscles of the anterior chestmuscles of the anterior chest
wall.wall.
 The muscle encountered firstThe muscle encountered first
is the lower edge ofis the lower edge of
pectoralis major.pectoralis major.
 In the lateral part of theIn the lateral part of the
wound, slips of serratuswound, slips of serratus
anterior can be seenanterior can be seen
inserting onto the rib.inserting onto the rib.

17.  Following wide undermining in the planeFollowing wide undermining in the plane
superficial to the muscle, the rib to besuperficial to the muscle, the rib to be
harvested is palpated.harvested is palpated.
 If two ribs are required the rib in the centreIf two ribs are required the rib in the centre
of the operative field is not used and theof the operative field is not used and the
ribs above and below this rib are chosen.ribs above and below this rib are chosen.
 An incision with cut diathermy is madeAn incision with cut diathermy is made
through the muscle onto and through thethrough the muscle onto and through the
periosteum of the rib to be harvested.periosteum of the rib to be harvested.

18. The periosteum is elevated from the anteriorThe periosteum is elevated from the anterior
and superior aspects of the rib using Howarthand superior aspects of the rib using Howarth
elevator.elevator.

19.  No attempt is made at this juncture to pushNo attempt is made at this juncture to push
posteriorly as the elevator may perforate theposteriorly as the elevator may perforate the
pleural cavity.pleural cavity.
 Instead the periosteal elevator is run along theInstead the periosteal elevator is run along the
superior surface of the rib from medial to lateralsuperior surface of the rib from medial to lateral
and the periosteum then falls away from the riband the periosteum then falls away from the rib
at its posterosuperior aspect.at its posterosuperior aspect.
 The same procedure is followed with theThe same procedure is followed with the
anteroinferior periosteum until the lower borderanteroinferior periosteum until the lower border
of the rib is reached.of the rib is reached.
 Care is taken here because the intercostalCare is taken here because the intercostal
neurovascular bundle runs in a groove on theneurovascular bundle runs in a groove on the
under surface of the rib.under surface of the rib.

20.  Once theOnce the
subperiosteal plane onsubperiosteal plane on
the posterior surfacethe posterior surface
of the rib has beenof the rib has been
started, it is thenstarted, it is then
relatively easy to freerelatively easy to free
a small strip ofa small strip of
periosteum fromperiosteum from
superior to inferior withsuperior to inferior with
the use of the Howarththe use of the Howarth
raspatory, on theraspatory, on the
posterior surface ofposterior surface of
the rib.the rib.

21.  The curved Doyen's ribThe curved Doyen's rib
raspatory is thenraspatory is then
inserted into thisinserted into this
channel and the sharpchannel and the sharp
edge of the resparatoryedge of the resparatory
is used to strip off theis used to strip off the
posterior periosteumposterior periosteum
from this point laterallyfrom this point laterally
and medially.and medially.

22.  Once sufficient bone has been cleared the TudorOnce sufficient bone has been cleared the Tudor
Edward's rib shears are introduced to make theEdward's rib shears are introduced to make the
lateral cut first. Then the rib shears are used tolateral cut first. Then the rib shears are used to
make the anterior cut.make the anterior cut.
 A examination is made of the deep periostealA examination is made of the deep periosteal
surface to see whether there are any pleuralsurface to see whether there are any pleural
tears. Water is then placed in the wound and thetears. Water is then placed in the wound and the
anaesthetist asked to exert positive pressureanaesthetist asked to exert positive pressure
ventilation to see whether there is any bubbling inventilation to see whether there is any bubbling in
the wound which indicates a pleural tear.the wound which indicates a pleural tear.
 If there is an air leak it is wise to use a temporaryIf there is an air leak it is wise to use a temporary
chest drain inserted low in the anterior axillarychest drain inserted low in the anterior axillary
line through a separate stab incision in the skin.line through a separate stab incision in the skin.

23. • When cartilage is harvested
in continuity with rib then a
diamond of periosteum and
perichondrium is left attached
to the anterior surface of the
adjacent rib and costal
cartilage to prevent
disarticulation of the bone
and cartilage
• The lateral cut is made firstThe lateral cut is made first
and the rib elevated with theand the rib elevated with the
left hand whilst the requisiteleft hand whilst the requisite
amount of cartilage is cut withamount of cartilage is cut with
a no. 15 bladea no. 15 blade

24.  Bupivacaine 0.5% is injected proximally intoBupivacaine 0.5% is injected proximally into
intercostal bundles of the harvested rib and theintercostal bundles of the harvested rib and the
ribrib above and below this.above and below this.
 AnAn epidural cannula and suction drain areepidural cannula and suction drain are
inserted through two separate puncture wounds.inserted through two separate puncture wounds.
 The periosteum and theThe periosteum and the musclemuscle surfaces aresurfaces are
closed with a continuous 2/0 chromic suture. Theclosed with a continuous 2/0 chromic suture. The
subcutaneous fat is closed as a separate layersubcutaneous fat is closed as a separate layer
with resorbable sutures and the skin is closed witwith resorbable sutures and the skin is closed wit
subcuticular 3/0 Prolene suture.subcuticular 3/0 Prolene suture.

25. ComplicationsComplications
 Wound infectionWound infection
 Loss of fixationLoss of fixation
 Exposure or fracture of the graftExposure or fracture of the graft
 Chest wall instabilityChest wall instability
 Pleural laceration and pneumothoraxPleural laceration and pneumothorax

26. SKULL BONESKULL BONE
HARVESTINGHARVESTING

27. Principles and indicationPrinciples and indication
 The skull bone vary in thickness at different sites,The skull bone vary in thickness at different sites,
at different ages in the same individual andat different ages in the same individual and
between individuals.between individuals.
 However, posterior part of the skull,However, posterior part of the skull,
in the region of the parietal and occipital bone isin the region of the parietal and occipital bone is
relatively thick.relatively thick.
 The outer and inner table of skull boneThe outer and inner table of skull bone
is separated by the vascular diploe.is separated by the vascular diploe.
 In young children and the elderly the diploe mayIn young children and the elderly the diploe may
be non-existent so that it proves impossible tobe non-existent so that it proves impossible to
separateseparate inner and outer tables of skull bone.inner and outer tables of skull bone.
 The skull bone is curved in two dimensions andThe skull bone is curved in two dimensions and
therefore fits neatly into defects such as thetherefore fits neatly into defects such as the
orbital floor and zygomatic prominence.orbital floor and zygomatic prominence.

28. Preoperative preparationPreoperative preparation
 On the evening prior to operation, the patient'sOn the evening prior to operation, the patient's
scalp should be shampooed with an antisepticscalp should be shampooed with an antiseptic
shampoo containing povidone-iodine 4%.shampoo containing povidone-iodine 4%.
 Only sufficient hair to gain access to the incisionOnly sufficient hair to gain access to the incision
line and for later suturing is shaved from theline and for later suturing is shaved from the
affected scalp.affected scalp.
 The patient is warned about possible dural tears,The patient is warned about possible dural tears,
venous haemorrhage and cerebrovascularvenous haemorrhage and cerebrovascular
accidents.accidents.
 CT scans of the skull at 5-7 mm intervals will helpCT scans of the skull at 5-7 mm intervals will help
in deciding on the thickest areas of bone for donorin deciding on the thickest areas of bone for donor
site material.site material.

29. Incision and ProcedureIncision and Procedure
 If a bicoronal flap is used for the recipientIf a bicoronal flap is used for the recipient
site then the posterior flap is elevated in thesite then the posterior flap is elevated in the
subgaleal plane until the area of bonesubgaleal plane until the area of bone
chosen for harvest is encounteredchosen for harvest is encountered

30.  The scalp flap is turned back with rakeThe scalp flap is turned back with rake
retractors and the periosteum is incised.retractors and the periosteum is incised.
 The periosteum is retracted and if theThe periosteum is retracted and if the
bone is thick enough a burr is used to cutbone is thick enough a burr is used to cut
through the outer table of the skull aroundthrough the outer table of the skull around
the proposed donor site.the proposed donor site.
 A curved osteotome is inserted into theA curved osteotome is inserted into the
diploe and gently tapped to free the outerdiploe and gently tapped to free the outer
table from the inner table.table from the inner table.

31.  With largerWith larger
segments of bone asegments of bone a
formal craniotomyformal craniotomy
is carried outis carried out

32.  Once the burr hole has been made aOnce the burr hole has been made a
periosteal elevator is used to separateperiosteal elevator is used to separate
dura from the overlying cranial bonedura from the overlying cranial bone

33.  This bone is taken to a side table and split intoThis bone is taken to a side table and split into
inner and outer table using power saws. Oneinner and outer table using power saws. One
bone surface can be used to cover the exposedbone surface can be used to cover the exposed
brain using wires or plates and the other is usedbrain using wires or plates and the other is used
as donor material.as donor material.
 All dural tears are repaired with a continuousAll dural tears are repaired with a continuous
suture technique.suture technique.
 If a significant section of dura has been thenIf a significant section of dura has been then
fascia lata is harvested to cover this area and afascia lata is harvested to cover this area and a
combination of human fibrin glue and continuouscombination of human fibrin glue and continuous
suture should seal any potential defects in thesuture should seal any potential defects in the
dural layer.dural layer.

34. ComplicationsComplications
 Intracranial complications- extraduralIntracranial complications- extradural
haematoma, direct intracerebral trauma orhaematoma, direct intracerebral trauma or
counter-coup injuries.counter-coup injuries.
 Cranial bone that is completely removedCranial bone that is completely removed
and replaced may develop osteomyelitis.and replaced may develop osteomyelitis.

35. ILLIAC CRESTILLIAC CREST
HARVESTINGHARVESTING

36. ANATOMY OF REGIONANATOMY OF REGION

37. Principles and indicationsPrinciples and indications
 The ilium is curved anteroposteriorly andThe ilium is curved anteroposteriorly and
superoinferiorly. This is advantageous forsuperoinferiorly. This is advantageous for
reconstruction of curved mandibular defects.reconstruction of curved mandibular defects.
 The ilium provides excellent corticocancellousThe ilium provides excellent corticocancellous
struts which may be used as solid interpositionalstruts which may be used as solid interpositional
grafts to replace continuity defects in thegrafts to replace continuity defects in the
mandible.mandible.
 It also be used to replace orbital floor and wallIt also be used to replace orbital floor and wall
defects.defects.
 Iliac bone is currently in use with osseointegratedIliac bone is currently in use with osseointegrated
implants in the maxilla (sinus lifts).implants in the maxilla (sinus lifts).

38.  In maxillofacial surgery, the patient willIn maxillofacial surgery, the patient will
usually be lying supine on the operatingusually be lying supine on the operating
table and so the common site of harvest istable and so the common site of harvest is
from the anterior part of the illium.from the anterior part of the illium.
 Three approaches to harvest bone-Three approaches to harvest bone-
 a lateral approach stripping tensora lateral approach stripping tensor
fascia lata and gluteus muscle.fascia lata and gluteus muscle.
 a medial approach stripping iliacusa medial approach stripping iliacus
 a crestal approach splitting a portion ofa crestal approach splitting a portion of
iliac crest.iliac crest.

39. IncisionIncision
 The incision must not be sited over the crest asThe incision must not be sited over the crest as
this will result in widening of the scar and tetheringthis will result in widening of the scar and tethering
to the crest.to the crest.
 The maximum width of the bone to be harvestedThe maximum width of the bone to be harvested
should be used as a guide to the length of theshould be used as a guide to the length of the
incision (e.g. if the bone to be harvested measuresincision (e.g. if the bone to be harvested measures
8 X 5 cm, then the skin incision need only be 5 cm8 X 5 cm, then the skin incision need only be 5 cm
long). Where the harvest is only of particulatelong). Where the harvest is only of particulate
cancellous bone, the incision need only be 2-3 cmcancellous bone, the incision need only be 2-3 cm
long.long.
 All incisions should lie in skin crease lines.All incisions should lie in skin crease lines.
 The lateral scar should therefore lie parallel to theThe lateral scar should therefore lie parallel to the
crest whilst the medial scar lies at an angle ofcrest whilst the medial scar lies at an angle of
approximately 30-45° to the crest.approximately 30-45° to the crest.

40.  The incision is carried down through skin,The incision is carried down through skin,
subcutaneous fat, Scarpa's fascia to thesubcutaneous fat, Scarpa's fascia to the
muscular aponeurosis.muscular aponeurosis.
 The incision is carried obliquely throughThe incision is carried obliquely through
internal oblique and tranversus abdominisinternal oblique and tranversus abdominis
muscles to strike the ilium approximately 1 cmmuscles to strike the ilium approximately 1 cm
below the crest in young patients and 5 mmbelow the crest in young patients and 5 mm
below the crest in adults.below the crest in adults.

41. ProcedureProcedure
 Osteotome cuts are made across the iliacOsteotome cuts are made across the iliac
crest andcrest and these are angled to create athese are angled to create a
dovetail joint hinged laterally. The anteriordovetail joint hinged laterally. The anterior
osteotome cut must be at least 1 cmosteotome cut must be at least 1 cm
posterior to the anterosuperior iliac spine.posterior to the anterosuperior iliac spine.

42.  The periosteum on theThe periosteum on the
medial aspect of the ilium ismedial aspect of the ilium is
elevated inferiorly from theelevated inferiorly from the
point of incision on the crestpoint of incision on the crest
using Farabeuf rougine.using Farabeuf rougine.
Profuse bleeding may beProfuse bleeding may be
encountered at this stageencountered at this stage
when the deep circumflexwhen the deep circumflex
iliac artery and vein areiliac artery and vein are
divided. this can be dealt withdivided. this can be dealt with
diathermy.diathermy.
 A curved osteotome is thenA curved osteotome is then
inserted and crest is theninserted and crest is then
fractured out.fractured out.

43.  The proposedThe proposed
corticocancellous graftcorticocancellous graft
is then marked out.is then marked out.
 Once medial cut isOnce medial cut is
outlined, a broadoutlined, a broad
osteotome is insertedosteotome is inserted
in the cancellous bonein the cancellous bone
just medial to thejust medial to the
lateral cortical platelateral cortical plate
and intended volumeand intended volume
of bone is harvested.of bone is harvested.

44.  The iliac crest is sutured back in position usingThe iliac crest is sutured back in position using
an absorbable suture such as Vicryl or 1/0an absorbable suture such as Vicryl or 1/0
chromic catgut through the periosteum orchromic catgut through the periosteum or
cartilage. The dovetail joint will aid this.cartilage. The dovetail joint will aid this.
 The anterior abdominal wall muscles are closedThe anterior abdominal wall muscles are closed
in layers.in layers.
 The subcutaneous tissuesThe subcutaneous tissues and Scarpa's fasciaand Scarpa's fascia
areare closed with interrupted absorbable suturesclosed with interrupted absorbable sutures
and the skin is closed with a subcuticular 2/0 orand the skin is closed with a subcuticular 2/0 or
3/0 Prolene suture.3/0 Prolene suture.

45. Postoperative carePostoperative care
 The Redivac drain should be leftThe Redivac drain should be left in situin situ
until drainage is minimal - usually 48until drainage is minimal - usually 48
hours.hours.
 Antibiotics and analgesics cover.Antibiotics and analgesics cover.
 0.25% bupivacaine should be0.25% bupivacaine should be
administered through the epidural cannulaadministered through the epidural cannula
on a regular basis every 8 hours.on a regular basis every 8 hours.
 The patient should be encouraged to walkThe patient should be encouraged to walk
as soon as possible (ideally from 24 hoursas soon as possible (ideally from 24 hours
after the operation).after the operation).

46. ComplicationsComplications
 Anesthesia or paresthesia of upper lateralAnesthesia or paresthesia of upper lateral
thigh, if lateral cutaneous nerve isthigh, if lateral cutaneous nerve is
damaged.damaged.
 Postoperative illeus.Postoperative illeus.
 Perforation of abdominal viscus.Perforation of abdominal viscus.
 Herniation of intra-abdominal contents.Herniation of intra-abdominal contents.

47. HARVESTING OFHARVESTING OF
FIBULA GRAFTFIBULA GRAFT

48. Principles and indicationsPrinciples and indications
 The fibula lies on theThe fibula lies on the
lateral surface of the tolateral surface of the to
limb below the kneelimb below the knee
and articulates with theand articulates with the
superiorly andsuperiorly and
inferiorly. It isinferiorly. It is
connected to the tibiaconnected to the tibia
along its length by thealong its length by the
interosseousinterosseous
membrane and ismembrane and is
covered laterally bycovered laterally by
peroneal muscles.peroneal muscles.

49.  The common peroneal nerve, which can oftenThe common peroneal nerve, which can often
be palpated and which runs anteroinferiorlybe palpated and which runs anteroinferiorly
around the neck of the fibula to course under thearound the neck of the fibula to course under the
peroneal muscles, must always be protectedperoneal muscles, must always be protected
when harvesting this bone.when harvesting this bone.
 The ankle joint and lower quarter of the fibulaThe ankle joint and lower quarter of the fibula
must not be disturbed.must not be disturbed.
 It is therefore advisable to harvest the middleIt is therefore advisable to harvest the middle
third or the middle half of the fibula leaving thethird or the middle half of the fibula leaving the
upper and lower quarters intact.upper and lower quarters intact.

50. Incision and ProcedureIncision and Procedure
 A vertical incision is made along the lateralA vertical incision is made along the lateral
edge of the lower leg overlying the fibula.edge of the lower leg overlying the fibula.
The incision is carried through skin andThe incision is carried through skin and
subcutaneous tissue until the fasciasubcutaneous tissue until the fascia
overlying the leg muscles is encountered.overlying the leg muscles is encountered.
 The plane between the peroneal muscleThe plane between the peroneal muscle
and the soleus muscle is identified and theand the soleus muscle is identified and the
peroneal muscles are retracted anteriorlyperoneal muscles are retracted anteriorly
and soleus is retracted posteriorly.and soleus is retracted posteriorly.

52.  A totally subperiostealA totally subperiosteal
approach is usedapproach is used
around the requiredaround the required
segment of fibula.segment of fibula.
CareCare is takenis taken
superiorly to remain insuperiorly to remain in
the subperiostealthe subperiosteal
plane so that noplane so that no
damage occurs to thedamage occurs to the
anterior tibial vesselsanterior tibial vessels
which lie between thewhich lie between the
neck of the fibula andneck of the fibula and
tibiatibia

53.  After the medial aspect of the fibula has been protectedAfter the medial aspect of the fibula has been protected
with malleable retractors, saw cuts are made through thewith malleable retractors, saw cuts are made through the
segment of fibula required and any remaining medialsegment of fibula required and any remaining medial
attachment of the interosseous membrane is thenattachment of the interosseous membrane is then
divided to free the fibula graft.divided to free the fibula graft.
 Suction drainage is used and the wound is closed inSuction drainage is used and the wound is closed in
layers with a continuous resorbable suture looselylayers with a continuous resorbable suture loosely
reapposing the peroneus and soleus muscles.reapposing the peroneus and soleus muscles.
 The subcutaneous tissues are closed with a resorbableThe subcutaneous tissues are closed with a resorbable
suture and the skin is closed with a subcuticularsuture and the skin is closed with a subcuticular 2/0 or2/0 or
3/0 Prolene.3/0 Prolene.
 The patient is rested with the leg elevated for the first 24The patient is rested with the leg elevated for the first 24
hours postoperatively but after that is rapidly mobilized.hours postoperatively but after that is rapidly mobilized.

54. Postoperative complicationsPostoperative complications
 Damage to the ankle joint will cause severeDamage to the ankle joint will cause severe
disability requiring extensive reconstructivedisability requiring extensive reconstructive
surgery.surgery.
 Damage to the common peroneal nerve willDamage to the common peroneal nerve will
result in foot drop, loss of arches of the foot andresult in foot drop, loss of arches of the foot and
a flaccid foot with loss of control.a flaccid foot with loss of control.
 In older patients with peripheral vascularIn older patients with peripheral vascular
disease the incision line may heal slowly ordisease the incision line may heal slowly or
break down.break down.

55. TIBIA BONE GRAFTTIBIA BONE GRAFT
HARVESTHARVEST

56. Principles and indicationsPrinciples and indications
 The tibia graft is performed on skeletally matureThe tibia graft is performed on skeletally mature
patients who want the benefit of autogenouspatients who want the benefit of autogenous
bone grafting without the risk and painbone grafting without the risk and pain
associated with other favorite donor sites, suchassociated with other favorite donor sites, such
as the iliac crest or calvarium.as the iliac crest or calvarium.
 The surgeon easily can obtain 25 cc ofThe surgeon easily can obtain 25 cc of
cancellous bone, which is more than adequatecancellous bone, which is more than adequate
for procedures such as bilateral sinus lifts andfor procedures such as bilateral sinus lifts and
grafting fracture nonunions.grafting fracture nonunions.

57. Review of anatomyReview of anatomy
 The primary bony landmark in the proximal tibia isThe primary bony landmark in the proximal tibia is
Gerdy's tubercle. Gerdy’s tubercle is a bonyGerdy's tubercle. Gerdy’s tubercle is a bony
protuberance between the patellar ligament (midline)protuberance between the patellar ligament (midline)
and the head of the fibula. which is palpable 90° laterally.and the head of the fibula. which is palpable 90° laterally.
There is thin skin over this area and no vital anatomicThere is thin skin over this area and no vital anatomic
structures located over Gerdy's tubercle.structures located over Gerdy's tubercle.
 The area over Gerdy's tubercle is devoid of any majorThe area over Gerdy's tubercle is devoid of any major
anatomic structure, which is a key feature in theanatomic structure, which is a key feature in the
simplicity of the surgery and the low complication rate.simplicity of the surgery and the low complication rate.
 The only anatomic structure one encounters during theThe only anatomic structure one encounters during the
dissection is the iliotibial tract, a dense fascial band thatdissection is the iliotibial tract, a dense fascial band that
runs from the anterior iliac crest to the lateral surface ofruns from the anterior iliac crest to the lateral surface of
the tibia.the tibia.

58. Surgical techniqueSurgical technique
 Gerdy's tubercle is palpatedGerdy's tubercle is palpated
and diagrammed with aand diagrammed with a
surgical marking pen.surgical marking pen.
 A 3 to 4 cm incision is madeA 3 to 4 cm incision is made
directly over Gerdy's tubercle.directly over Gerdy's tubercle.
The incision is carried sharplyThe incision is carried sharply
through the skin,through the skin,
subcutaneous tissuessubcutaneous tissues
(including the iliotibial tract),(including the iliotibial tract),
and periosteum. Theand periosteum. The
periosteum is elevated inperiosteum is elevated in
preparation for making apreparation for making a
cortical window through thecortical window through the
cortical bony plate at Gerdy'scortical bony plate at Gerdy's
tubercle.tubercle.

59.  A cortical window isA cortical window is
made with surgical burmade with surgical bur
and is removed.and is removed.
 The cancellous bone isThe cancellous bone is
harvested withharvested with
orthopedic curettes byorthopedic curettes by
going across the tibiagoing across the tibia
plateau and down theplateau and down the
shaft of the tibiashaft of the tibia

60.  Once the bone harvest is completed,Once the bone harvest is completed,
hemostasis is checked.hemostasis is checked.
 The wound is closed in layers, with theThe wound is closed in layers, with the
iliotibial tract being reapproximated with 2-iliotibial tract being reapproximated with 2-
0 or 3-0 vicryl sutures and 4-0 nylon0 or 3-0 vicryl sutures and 4-0 nylon
suture for skin closure.suture for skin closure.
 Only major complication seen with tibiaOnly major complication seen with tibia
harvest is fracture of tibia plateau.harvest is fracture of tibia plateau.

61. ReferencesReferences
1.1. Iain Hutchinson. Reconstructive surgery- bone andIain Hutchinson. Reconstructive surgery- bone and
cartilage grafts. Operative maxillofacial surgery; 93-cartilage grafts. Operative maxillofacial surgery; 93-
114.114.
2.2. G.M Kushner. Tibia bone graft harvest technique. AtlasG.M Kushner. Tibia bone graft harvest technique. Atlas
oral and maxillofacial surg clin N Am 13 (2005); 119-oral and maxillofacial surg clin N Am 13 (2005); 119-
126.126.
3.3. Ruiz, Timothy et al. Cranial bone grafts:Ruiz, Timothy et al. Cranial bone grafts:
Craniomaxillofacial applications and harvestingCraniomaxillofacial applications and harvesting
techniques. Atlas oral and maxillofacial surg clin N Amtechniques. Atlas oral and maxillofacial surg clin N Am
13 (2005); 127-137.13 (2005); 127-137.
4.4. Randall Wilk. Bony reconstruction of the jaws.Randall Wilk. Bony reconstruction of the jaws.
Principles of oral and maxillofacial surgery, Peterson,Principles of oral and maxillofacial surgery, Peterson,
39; 784-798.39; 784-798.
5.5. John, Bernard et al. Costocondral Rib Grafting. AtlasJohn, Bernard et al. Costocondral Rib Grafting. Atlas
oral and maxillofacial surg clin N Am 13 (2005); 139-oral and maxillofacial surg clin N Am 13 (2005); 139-
149.149.
6.6. Mehrara et al. Repair and grafting of bone. MathesMehrara et al. Repair and grafting of bone. Mathes
Plastic Surgery; 639-718.Plastic Surgery; 639-718.