Long Term Autograft Harvest Site Pain after Ankle and Hindfoot Arthrodesis

Abstract

Category: Ankle; Hindfoot; Other Introduction/Purpose: Autologous bone has traditionally been the gold standard for grafting material during foot or ankle arthrodesis. While autograft use has been effective, its harvest does present certain distinctive risks to the patient including persistent harvest site pain. Previous studies have examined harvest site pain, but most have focused on the iliac crest and none provide longer term follow-up. The purpose of this study was to examine long-term (7-10 year) donor site pain from four lower extremity harvest site locations in subjects undergoing autograft harvest for hindfoot or ankle arthrodesis. Methods: All subjects in the control arm of a previously conducted Level 1 clinical trial comparing autologous bone with a synthetic bone graft substitute for hindfoot or ankle arthrodesis were invited back for a single visit at a minimum of 5 years following their initial surgery. Autograft was harvested from either the proximal tibia (51.7%), iliac crest (17.2%), calcaneus (15.5%), distal tibia (6.8%), or other location (8.6%). Harvest site pain, fusion site pain, and weight-bearing pain were evaluated using a 100-point visual analog scale (VAS), with clinically significant pain considered as any score greater than 20 (Todd et al., 1996). Results: Of the 130 subjects receiving autograft in the original trial, 58 returned for assessment at a mean follow-up of 9.0 years (Table 1). The mean harvest site VAS at final follow-up was 4.4 (range, 0.0-97.0) with 37.9% of subjects reporting some level of pain. The percentage of subjects who reported clinically significant pain was 35.7%, 21.4%, 18.2%, 10.5%, 8.9%, and 5.2% at 2, 6, 12, 24, 52 weeks, and final follow-up, respectively. Of those subjects reporting clinically significant pain at final follow-up, two had undergone harvest from the proximal tibial and one from the iliac crest. A significant correlation was found between harvest site pain and both weight-bearing and fusion site pain, but not between harvest site pain and the volume of graft harvested. Conclusion: This study is the first to examine persistence of long-term harvest site pain following autologous bone graft harvest during hindfoot or ankle arthrodesis. Over one-third of patients still reported persistent pain at an average follow-up of 9 years, with 5% experiencing clinically significant pain. The proximal tibia harvest site had the greatest incidence of reported pain. These data suggest that harvesting autologous bone does carry inherent risk of persistent, long-term pain. This factor should be considered when informing patients of procedural risks and when choosing between autograft or graft substitute during arthrodesis surgery.