Bone Graft Harvest: Tibia, Fibula, Iliac Crest

Removal of a Tibial Graft

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To avoid excessive loss of blood, use a tourniquet (preferably pneumatic) when the tibial graft is removed. After removal of the graft, the tourniquet can be released without disturbing the sterile drapes.
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Make a slightly curved longitudinal incision over the anteromedial surface of the tibia, placing it so as to prevent a painful scar over the crest.
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Without reflecting the skin, incise the periosteum to the bone.
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With a periosteal elevator, reflect the periosteum medially and laterally exposing the entire surface of the tibia between the crest and the medial border. For better exposure at each end of the longitudinal incision, incise the periosteum transversely. The incision through the periosteum is I shaped.
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Because of the shape of the tibia, the graft is usually wider at the proximal end than at the distal end. This equalizes the strength of the graft because the cortex is thinner proximally than distally. Before cutting the graft, drill a hole at each corner of the anticipated area ( Figure 1-1 ).

Figure 1-1
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With a single-blade saw, remove the graft by cutting through the cortex at an oblique angle, preserving the anterior and medial borders of the tibia. Do not cut beyond the holes, especially when cutting across at the ends because overcutting here weakens the donor bone and may serve as the initiation point of a future fracture. This is particularly true at the distal end of the graft.
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As the graft is pried from its bed have an assistant grasp it firmly to prevent it from dropping to the floor.
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Before closing the wound, remove additional cancellous bone from the proximal end of the tibia with a curet. Take care to avoid the articular surface of the tibia or in the case of a child, the physis.
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The periosteum over the tibia is relatively thick in children and can usually be sutured as a separate layer. In adults it is often thin, and closure may be unsatisfactory. Suturing the periosteum and the deep portion of the subcutaneous tissues as a single layer is recommended.
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If the graft has been properly cut, little shaping is necessary. Our practice is to remove the endosteal side of the graft because (1) the thin endosteal portion provides a graft to be placed across from the cortical graft; and (2) the endosteal surface, being rough and irregular, should be removed to ensure good contact of the graft with the host bone.

Removal of Fibular Grafts

Three points should be considered during the removal of a fibular graft: (1) the peroneal nerve must not be damaged; (2) the distal fourth of the bone must be left to maintain a stable ankle; and (3) the peroneal muscles should not be cut ( Figure 1-2 ).