Dr. Atul Prakash
Orthopedician and Traumatology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
How effective is a bone graft from the person's pelvic area for a non-union from a bunionectomy? This is regarding the first metatarsal of my left foot. I had two previous bone grafts for non-union after bunionectomy. The bone was not taken from my body. I have had bunionectomy in both feet. The right foot was successful. The left foot still has the nonunion. I went to an orthopedic surgeon who said that a bone graft from my pelvic area would work.
Hello,
Welcome to icliniq.com.
Autologous bone grafts which are procured from one's own bone are the best option wherever a graft is needed. Amongst the autologous bone grafts, the iliac (pelvic bone) grafts are the workhorse of all grafting procedures. These autologous grafts provide all the required ingredients for healing.
Patient's Query
Thank you doctor,
I am very glad to read your answer. Is it 99 % effective? In what circumstance, if any, would this type of procedure not work? I only ask because I had two prior bone grafts that were unsuccessful. I am assuming that the iliac graft is much more powerful than the bone grafts that come from somewhere other than your own body. Am I correct?
Hello,
Welcome back to icliniq.com.
Fracture healing is affected by multiple factors:
Iliac bone grafts work the best, but they too can fail if more than one of the above factors come to play a role. Most commonly, it is a combination of smoking and local infection and an instability at the graft site that cause the failure. Nobody will give you a 99 % guarantee, but if all the above factors are taken into consideration and actively corrected, then you have a situation where the graft will work.
Patient's Query
Hi doctor,
This is very helpful. How are these factors assessed? I will be seeing an orthopedic surgeon who will go over the results of a CT scan and MRI. He has reviewed all of my medical records from previous surgeries (performed by other doctors). This surgeon came highly recommended to me by another doctor. Therefore, is it likely that he has assessed the factors you mentioned? Would it make sense to ask him about all the factors you mentioned?
Hello,
Welcome back to icliniq.com.
Definitely, you should discuss these points with him tactfully. You may already know about the patient factors like smoking, hypothyroidism, diabetes, steroids intake, NSAIDs, etc. So, I request you tell him every detail. The surgeon and surgical factors depend on his expertise and I am sure he is very proficient at his job. The local factors are scarring, blood supply, infection and again you will have some idea about this too, as you would know if an infection has occurred in the past or not. If the scar tissue is abundant, it needs to be removed, and bone ends freshened to a bleeding bone such that the bone can heal from both ends. The site needs to be compressed and stabilized again. You can discuss the implant he plans to put. You should go ahead with the surgery only if you feel he has answered all your questions to your satisfaction.
Patient's Query
Hi doctor,
I have a few more questions. By pelvic area, does he mean the bone graft is likely to be from my hip? I have had six surgeries in total. Is this likely to affect the success of this next pelvic bone graft? The initial surgery was the bunionectomy which became a non-union. Two were bone grafts that failed. Why does that happen? Is it because it is not from the body? The other two to three surgeries (lost count) were to put plates and screws along with a bone stimulator. One of the surgeries included the use of bone stimulator after as well. So my question is, are these previous surgeries going to affect the outcome of the graft surgery? Regarding medications, I take Paxil, Strattera, Lithium, Synthroid (thyroid was completely removed due to earliest stage cancer). What is the likelihood of these medications affecting the bone graft success? Otherwise, I think my blood is healthy except that the joint in the first metatarsal kind of collapsed after the non-union staying for a long period of time. So should I double check with my doctor if my blood is healthy for the surgery? Also, my big toe is about an inch shorter than normal from all the surgeries and it points upward while I am in a sitting position. If the scar tissue is removed (hoping), will the big toe likely stop pointing up while I am sitting? Also, the doctor said he will lengthen the toe some. Will this make my push off when I am walking more effective, more like my other big toe in the right foot which is at normal length? Would a good question for my surgeon be to ask him what effect will the operative factors you mentioned have on the success of the pelvic bone graft? How likely is it that the pelvic bone graft causes some permanent damage or pain ? Do you think my balance on one foot could be a little off because of the scarring which might be the cause of my toe pulling upward in a sitting position? Or is the shortened big toe possibly contributing to the balance issue?
Hello,
Welcome back to icliniq.com.
Can I request for an X-ray and a clinical picture of both your feet to make some more sense of what you have written? The Iliac crest is the site of the graft and not the hip bone. Earlier, grafts were artificial or freeze-dried bone. Yes, Paxil (Paroxetine) is known to affect bone healing. Repeated surgery is the reason for poor blood supply as each surgery leads to more scarring. Lengthening of the bone carries an additional risk of delayed healing and nonunion. As your toe is short, to restore length, an intercalary graft will be used which will have two ends that need to heal and the central portion is prone to fracture and needs to be protected. Yes, you should ask your doctor all the questions raised.
Thank you.
Patient's Query
Hi doctor,
I do not have the X-ray handy as I am not home. So, can a doctor remove the scarring and create a good blood supply? Is it possible that the Paxil issue can be overcome by taking the bone graft from my body as it is more powerful than the grafts outside my body? I do not know if they were artificial or freeze-dried bone. My doctor knows that I take Paxil and did not say anything. Regarding the intercalary graft, my doctor only mentioned the pelvic graft. I thought the pelvic graft would fix the non-union and lengthen at the same time. Are these two separate issues? Regarding the lengthening and delayed healing, if the doctor has a lot of experience and knows how to protect the intercalary graft from a fracture (I think I will be wearing a cast), then are my chances of success high? Are the issues that I am addressing in this text the ones I need to ask the doctor to feel confident in going forward with this surgery? Should I also ask my doctor: What effect will the operative factors (amount of gap, compression and bone ends) have on the success of pelvic bone graft? Or is this where it would not be tactful? How safe is the pelvic graft in being likely to not cause permanent effects? If the scar tissue is removed, will the big toe likely stop pointing up while I am sitting? Will this make my push off when I am walking more effective? To what degree can he correct any alignment and balance issues? Is the scarring, shortened toe or both the cause of the balance issue? Will he remove the scarring on the inside and outside of the foot? I am trying to figure out all the questions for my surgeon. This is my hope for these last two texts to you. I want to be as clear as possible. If you feel there are questions that are not tactful I am open to any suggestionsyou have on how to phrase them to sound tactful. Or if they are not necessary to ask. Again, I greatly appreciate all of your help. Thank you.
Hello,
Welcome back to icliniq.com.
The sclerotic bone needs to be trimmed to the bleeding bone. It adds to the shortening. Paxil is an SSRI (selective serotonin reuptake inhibitor) and by its nature inhibits osseointegration. But, quantification of this effect is not possible. An intercalary graft is a way of putting the graft. Usually, it is applied on top of a nonunion but in your case, it will be applied in the bone gap hence intercalary. Yes, the graft will need to be protected by a plate, and cast for six weeks or more. With regards to the questions, you should say that you are concerned and have done some reading and want him to assure you that these factors have been taken into consideration. A pelvic graft is safe, it will, however, leave a scar along the groin crease. It will be painful for some time. After the toe is straightened and the fracture healed, your push-off strength will improve. The bottom line is, feel confident, have trust, do not doubt but at the same time ask politely and have him answer. Do not get stuck with one aspect, trust his judgment. As doctors, we cannot play God but we can reassure patients that we have done our best and have had all the bases covered.
Patient's Query
Hi doctor,
Great answers. Regarding the weakening effect of Paxil in this procedure, is it the key most likely in using the pelvic bone graft instead of the bone grafts used on me previously that were not part of my own body?
Hello,
Welcome back to icliniq.com.
The weakening effect of Paxil cannot be quantified. It is not like smoking where studies have shown a marked negative effect on healing bone. Paxil has shown some effect but cannot be quantified. Using the iliac graft is your best option.
Patient's Query
Thank you doctor,
Are the pelvic bone graft, the iliac crest, and groin crease all the same location? I looked at some pictures and if I am correct it is the top part of the pelvis. Also, am I correct to say the iliac crest is the pelvic area that joins with the hip or where the hip muscle starts?
Hello,
Welcome back to icliniq.com.
At the top of the groin crease, you will feel a bone come up as you run your fingers from the midline to the side. This is the beginning of the iliac crest and the bone grafts will be taken just beyond the tip of the iliac bone. This is a part of the pelvic bone. Groin crease is just a way to describe what and where to look.
Patient's Query
Hi doctor,
Is it close to where the left hip bone merges? Some pictures show the iliac crest and hip bone merging. Also, when you said groin crease earlier you did not mean that crease at the top of my leg by the pelvis area, did you?
Hello,
Welcome back to icliniq.com.
Search online for 'iliac crest' and the picture you see will be the pelvis, and the fan-like bone you see is the iliac bone with the top three crest. The groin crease is the crease that you see at the top of the thigh when you sit.
Patient's Query
Hi doctor,
I watched a video where they described the two hip bones as part of the pelvis and showed the iliac crest. It showed that bone marrow is taken from the iliac crest for the graft. They pointed to the iliac crest as the thin part at the top of the hip. Is this the bone graft procedure you are talking about? I also saw a picture where they pointed to the groin area as the incision location where the crease connects the top of your thigh to the body. Is this the point of incision for the pelvic bone graft? Does the surgeon cut there and then makes his way to the iliac crest to extract the bone marrow for the graft?
Hello,
Welcome back to icliniq.com.
Yes, you got it exactly right. That is what it is all about.
Patient's Query
Hi doctor,
Thank you.
Hello,
Welcome back to icliniq.com.
You are most welcome. All the best.
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Orthopedician and Traumatology
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