Elsevier

The Spine Journal

Volume 9, Issue 11, November 2009, Pages 893-898
The Spine Journal

Clinical Study
Donor-site complications of autogenous nonvascularized fibula strut graft harvest for anterior cervical corpectomy and fusion surgery: experience with 163 consecutive cases

https://doi.org/10.1016/j.spinee.2009.04.020Get rights and content

Abstract

Background context

The fibula is a source of bone graft for reconstruction of the appendicular and axial skeleton.

Purpose

The aim of this study is to determine donor-site complications and morbidity in a large series of patients who underwent autogenous fibula harvesting for anterior cervical corpectomy and fusion (ACCF) surgery.

Study design/setting

Retrospective review (Level III).

Patient sample

One hundred sixty-three patients over an eight-year period who underwent ACCF with autogenous fibula.

Outcome measures

Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records.

Methods

Retrospective study of patients who underwent ACCF with autogenous nonvascularized fibula strut graft over an eight-year period (from 1995 to 2002) was conducted. Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records.

Results

One hundred sixty-three patients underwent ACCF with autogenous fibula graft during the study period. The most common short-term complication (lasting <3 months) was incisional pain, present in 86 of 163 patients (53%). Incisional pain lasted longer than 3 months in 25 of 163 patients (15%) but resolved in all but two patients by 24 months. Two patients (1.2%) developed superficial peroneal neuromas. Five patients (3%) developed tibial stress fractures. Two patients (1.2%) developed ankle instability. Fifteen (9%) patients developed cellulitis that resolved in all patients after a short course of oral antibiotics, with one additional patient developing a deep infection requiring surgical debridement and intravenous antibiotics.

Conclusions

Although autogenous fibula is an excellent graft for multilevel ACCF reconstruction, surgeons should carefully consider the associated morbidity of fibular harvest before surgery. In this series, most complications were of short duration. However, nine patients with long-term complications required five additional surgical procedures. Therefore, patients who are scheduled to undergo autogenous fibula harvest should be advised about these potential complications.

Introduction

Evidence & Methods

Fibular struts are an excellent source of structural autograft used in spinal surgery.

In this single-surgeon case series, the authors report the rates of complications. Although most complications were short-term and resolved without treatment, chronic incisional pain, superficial neuromas, tibial stress fractures, and 3% reoperations were reported. These were concerning enough to the authors to inspire a change in their practice.

While single-surgeon series may lack the ability to be generalized, these findings clearly suggest strategies to limit these complications or develop alternative spinal reconstruction materials.

The Editors

The fibula can be a source of bone graft for reconstruction of the appendicular and axial skeleton [1], [2], [3]. However, harvesting autogenous fibula may lead to donor-site complications, such as pain, injury to the superficial peroneal nerve, infection, tibial stress fractures, and ankle instability [4], [5], [6], [7]. The incidence of such complications has been reported in the literature to range from 40% to 57.7% [8], [9]. However, most such reports have a small cohort size, ranging from 10 to 104 patients [8], [9]. Therefore, there is a need for studies with larger numbers of subjects so that the incidence and scope of these complications can be more fully understood and appreciated.

Most of the reports on this subject have focused on vascularized fibula harvest for the treatment of avascular necrosis of the femoral head [10], [11]. The literature on complications from fibular strut grafting for anterior spinal reconstruction has concentrated more on complications at the recipient site than the donor site [12], [13], [14]. However, to our knowledge there is no study in the literature that has exclusively studied the incidence and types of complications at the donor site when nonvascularized fibula (used simply as a strut graft) is harvested for anterior cervical spine reconstruction. The aim of this study is to report on the donor-site complications and morbidity in a large series of patients who underwent autogenous fibula harvesting for anterior cervical corpectomy and fusion (ACCF) surgery.

Section snippets

Methods

This was a retrospective study of patients who underwent ACCF with autogenous nonvascularized fibula strut graft by the senior surgeon (JDK) over an eight-year period (1995–2002). Patients who had incomplete records or those who had a history of trauma to the lower extremities were excluded. Most of the patients presented with cervical myelopathy with compression of the spinal cord spanning two or more vertebral bodies. Autologous fibula was used as a strut graft if the patient required two or

Results

A total of 163 patients underwent ACCF with autogenous fibula graft during the study period. Average patient age was 54.9±11.8 years old (range, 31–84). Most of these patients had either two- or three-level corpectomies, with an average of 2.4±0.5 levels (range, 2–4). Donor-site morbidity was further classified into either short-term (<3 months postoperatively) or long-term (>3 months postoperatively; Table 2).

Discussion

Reconstruction of the anterior cervical spine after discectomy or corpectomy can be performed with either an allograft or autograft [16]. Experience with both types of bone graft in the literature suggests that autograft may be associated with higher rates of union as compared with allograft [17], [18]. For single-level anterior cervical decompression and arthrodesis, autogenous iliac crest bone graft is considered by many to be the gold standard [16]. For multilevel anterior vertebrectomy and

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    FDA device/drug status: not applicable.

    Author disclosures: JDK (research support, Medtronic, J&J); JYL (research support, Stryker, Medtronic).

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