Page 253 - Advances in Biomechanics and Tissue Regeneration

REFERENCES 249

greater compressive stresses upon maximum bone extraction in the anterior calcaneus that corresponded to the neutral
triangle. Thus the qualitative load redistribution is clinically significant even when stress values are equivalent to the
intact foot in models that have experienced bone harvest.
Our study provides important results to guide the clinical management of a postoperative patient after they
have received a calcaneal bone harvest. After simulated increasing bone removal, tensile stress also dramatically
increased when Achilles tendon tension was included in the simulation. Furthermore, forces surrounding the
donor site were redistributed. These findings support the notion of an increased risk of calcaneal fracture when
including traction exerted by the Achilles tendon after graft harvest. Feeney et al. [4] described the utilization of a
below-the-knee cast worn for 4–10weeks when autologous calcaneal bone was harvested for use in foot surgery.
This was followed by partial weight bearing for 2–4weeks while wearing a lace up training style shoe. Feeney et al.
[4] reported one of the cases of calcaneal fracture in their investigation was sustained at the 8-week mark when first
weight bearing without a cast. The authors of that study suggested that to avoid future fractures, a longer period
of weight bearing may be helpful. However, we advocate that ankle stabilization, such as in a cast or posterior
splint positioned in some degree of plantarflexion would be useful to minimize the Achilles tendon traction
and the fracture risk.

12.5 CONCLUSION

Using the calcaneus for autologous bone harvest in surgical procedures involving the foot is associated with many
advantages and few adverse outcomes. One of the more serious comorbidities of this procedure is fracture of the cal-
caneus. Traditionally, the size of harvested bone is determined at the discretion of the physician performing the sur-
gery. Results from our study provide important guidelines for optimal maximum bone extraction for this type of
procedure and effective immobilization positioning in postoperative management.

Acknowledgments
The authors gratefully acknowledge the support of the Ministry of Economy and Competitiveness of the government of Spain through the project
DPI2016-77016-R.

References

[1] S.A. Alter, L. Licovski, Bone grafting for reconstructive osteotomies of the foot, J. Foot Ankle Surg. 35 (1996) 418–427.
[2] K.T. Mahan, H.J. Hillstrom, Bone grafting in foot and ankle surgery. A review of 300 cases, J. Am. Podiatr. Med. Assoc. 88 (1998) 109–118,
https://doi.org/10.7547/87507315-88-3-109.
[3] S.M. Raikin, K. Brislin, Local bone graft harvested from the distal tibia or calcaneus for surgery of the foot and ankle, Foot Ankle Int. 26 (2005)
449–453.
[4] S. Feeney, S. Rees, M. Tagoe, Tricortical calcaneal bone graft and management of the donor site, J. Foot Ankle Surg. 46 (2007) 80–85.
[5] S.D. Schulhofer, L.M. Oloff, Iliac crest donor site morbidity in foot and ankle surgery, J. Foot Ankle Surg. 36 (1997) 155–158. discussion 161.
[6] E.M. Younger, M.W. Chapman, Morbidity at bone graft donor sites, J. Orthop. Trauma 3 (1989) 192–195.
[7] K.R. Biddinger, G.A. Komenda, L.C. Schon, M.S. Myerson, A new modified technique for harvest of calcaneal bone grafts in surgery on the foot
and ankle, Foot Ankle Int. 19 (1998) 322–326.
[8] J.K. DeOrio, D.C. Farber, Morbidity associated with anterior iliac crest bone grafting in foot and ankle surgery, Foot Ankle Int. 26 (2005) 147–151.
[9] C. Hierholzer, D. Sama, J.B. Toro, M. Peterson, D.L. Helfet, Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on
healing, J. Bone Joint Surg. Am. 88 (2006) 1442–1447.
[10] M.H. Hofbauer, R.J. Delmonte, M.L. Scripps, Autogenous bone grafting, J. Foot Ankle Surg. 35 (1996) 386–390.
[11] K.T. Mahan, Calcaneal donor bone grafts, J. Am. Podiatr. Med. Assoc. 84 (1994) 1–9, https://doi.org/10.7547/87507315-84-1-1.
[12] R.W. Mendicino, E. Leonheart, P. Shromoff, Techniques for harvesting autogenous bone graft of the lower extremity, J. Foot Ankle Surg.
35 (1996) 428–435.
[13] N. Nigro, D. Grace, Radiographic evaluation of bone grafts, J. Foot Ankle Surg. 35 (1996) 378–385.
[14] B.N. Summers, S.M. Eisenstein, Donor site pain from the ilium. A complication of lumbar spine fusion, J. Bone Joint Surg Br. 71 (1989) 677–680.
[15] J.M. Garcia-Aznar, J. Bayod, A. Rosas, R. Larrainzar, R. Garcia-Bogalo, M. Doblare, L.F. Llanos, Load transfer mechanism for different meta-
tarsal geometries: a finite element study, J. Biomech. Eng. 131 (2009), 021011. https://doi.org/10.1115/1.3005174.
[16] G.N. Duda, F. Mandruzzato, M. Heller, J. Goldhahn, R. Moser, M. Hehli, L. Claes, N.P. Haas, Mechanical boundary conditions of fracture heal-
ing: borderline indications in the treatment of unreamed tibial nailing, J. Biomech. 34 (2001) 639–650.
[17] M.J. Gomez-Benito, P. Fornells, J.M. Garcia-Aznar, B. Seral, F. Seral-Innigo, M. Doblare, Computational comparison of reamed versus unreamed
intramedullary tibial nails, J. Orthop. Res. 25 (2007) 191–200, https://doi.org/10.1002/jor.20308.
[18] A. Gefen, Stress analysis of the standing foot following surgical plantar fascia release, J. Biomech. 35 (2002) 629–637.

I. BIOMECHANICS