|Beitragstitel||Staged Treatment for a traumatic calcaneal defect using a vascularized iliac crest graft harvested through the Pararectus Approach|
For resilient reconstruction of the weight-bearing portion in large bone defects structural grafts are needed. The iliac crest provides an autologous graft with a large amount of cancellous bone. For larger defects a vascularized (deep circumflex iliac artery; DCIA) bony graft harvested from the iliac crest has been described. However, the high morbidity of the standard surgical access for the harvest limits its usability. Recently, the Pararectus Approach has been successfully used for the treatment of various intrapelvic pathologies with only minor access morbidity. Feasibility of harvesting a DCIA iliac crest graft through a Pararectus Approach has been proven in a recent cadaver study. This is the report of the first clinical application of this technique.
A 68-year-old female sustained an open (Gustilo-Anderson type 3A) comminuted calcaneus luxation-fracture (Sanders type IIIBC) with a concomitant tibial pilon fracture (AO 43-C1) of the left lower extremity after a fall from great height. Initial treatment consisted of surgical debridement resulting in a big defect of the calcaneal body. The calcaneal tuberosity was reduced and fixated with screws. The hindfoot was spanned with an external fixator, a vacuum dressing applied and antibiotic treatment over six weeks initiated. After sterile conditions were obtained, osteosynthesis of the tibial pilon fracture was performed and soft tissue coverage was achieved with a free gracilis flap. Three months later, a vascularized (DCIA) cortical graft from the ipsilateral iliac crest was harvested using the Pararectus Approach and inserted into the bony defect.
The supplying DCIA was connected to a branch of the posterior tibial artery and the vein to a vessel on the dorsal foot draining in the great saphenous vein (both end-to-end). By the time of discharge, the patient was immobilized with a lower leg cast and total weight relief for three months.
At 12 weeks, the patient was pain free and showed no signs of infection. The hindfoot showed physiological alignment and height. Computer tomography (CT) showed proper integration of the graft. Protected full weight-bearing was initiated.
Additionally, the donor site at the iliac crest had healed well without pain or signs of herniation.
This is the first case of a bony reconstruction using a DCIA iliac crest graft harvested through the Pararectus Approach. Twelve weeks after surgery, CT scan showed partial integration of the graft. There were no donor-site complications.