Iliac crest bone graft harvesting techniques: a comparison

Iliac Crest Bone Graft Harvest for Alveolar Cleft Repair: A Systematic Review Comparing Minimally Invasive Trephine and Conventional Open Techniques

Background: In the course of developing a standardized pathway for alveolar cleft repair, we conducted a systematic review comparing minimally invasive trephine with conventional open technique for iliac crest bone graft harvest in a pediatric population. Methods: A systematic review was conducted of studies comparing open with minimally invasive trephine techniques in pediatric populations undergoing alveolar cleft repair. Exclusion criteria included reviews, case series, editorials, abstracts, and those with adult-only populations. Data were compiled with outcome variables selected a priori. Results: Of 422 manuscripts screened, five met criteria. These comprised 257 patients (116 open, 141 trephine). Average age was 11 years. Patients undergoing trephine harvest had reduced length of stay (1.0-5.0 days trephine vs 1.25-5.4 days open), time to unassisted ambulation (16-46 hours vs 20-67 hours open), and less postoperative narcotic use (0.31 mg/kg vs 1.64 mg/kg IV morphine). Volume of cancellous bone was reported as 2.53 mL for open versus 1.22 mL for trephine in one study, and trephine graft was supplemented with demineralized bone in 54% of cases in another study. The use of anesthetic adjuncts was inconsistent but had a significant effect on postoperative pain and ambulation. Conclusions: Compared to open techniques, the minimally invasive trephine bone graft harvest is associated with a shorter time to discharge, slightly lower infection rates, and reduced opioid use. The possible benefits of trephine harvest must however be balanced against the risk of insufficient graft harvest. Finally, the choice of perioperative analgesic adjuncts significantly impacts patient outcomes regardless of the technique employed.

Comparison of two preserved cartilage iliac crest cortical-cancellous bone blocks graft harvesting techniques in children: A prospective, double-blind, randomized clinical trial

PURPOSE

To compare donor-site morbidity for alveolar bone grafting results following cartilage-preserving outer and inner cortico-cancellous iliac crest (OCIC and ICIC) bone block grafting in children.

MATERIALS AND METHODS

Patients were randomly divided into two groups and prospectively reviewed. In the OCIC and ICIC groups, cortico-cancellous bone blocks were harvested at outer and inner iliac crest respectively. Patient characteristics and surgical parameters were compared; pain intensity and duration, lateral femoral cutaneous nerve (LFCN) injury, gait disturbance, scar and contour satisfaction were analysed postoperatively.

RESULTS

Forty-nine consecutive patients (OCIC, 24; ICIC, 25) were included. There were no significant differences in patient characteristics or donor-site surgical parameters. The mean pain score on the first post-operative day was significantly lower in the OCIC group (3.75±1.70) than in the ICIC group (5.20±2.08) (p=0.012). The pain duration was similar in the two groups (median: 5 days). Temporary LFCN injury only occurred in 3 patients in the ICIC group. Postoperatively, the duck and circle gaits were observed in the OCIC and ICIC groups, respectively. There were no significant differences in the claudication duration, scar and contour satisfaction between the groups.

CONCLUSION

OCIC bone graft harvesting is marginally advantageous in children due to less early postoperative donor-site pain and a lower risk of nerve damage.

Secondary Alveolar Bone Grafting in Patients with Cleft Lip and Palate: A Step-by-Step Video Series

SUMMARY

Secondary alveolar bone grafting is one of the key surgical procedures performed to restore dental arch continuity and facilitate tooth eruption in patients with cleft lip and palate. Harvest of cancellous bone graft from the iliac crest has become the gold standard; however. there is no consensus regarding the ideal technique. An optimal bone harvest technique must be aimed at producing minimal donor-site morbidity and patient discomfort. The success of the bone grafting procedure depends largely on the surgical technique. To restore cleft alveolar defects, one must be able to conceptualize the different underlying aspects of the problem to perform an effective surgical repair. It is important for surgeons-in-service to adopt newer techniques that significantly enhance the overall outcome. This article describes two techniques of iliac bone harvest and the principles involved in execution of the alveolar bone grafting procedure. The accompanying four-part video series depicts the bone harvest, flap design, dissection of the recipient cleft alveolus, and bone grafting in a step-by-step manner.

Outcomes and complications of the reamer irrigator aspirator versus traditional iliac crest bone graft harvesting: a systematic review and meta-analysis

BACKGROUND

The reamer irrigator aspirator (RIA) is a relatively recent device that is placed in the medullary canal of long bones to harvest a large volume of bone marrow, which is collected in a filtered canister. This study compares outcomes and complications of the RIA versus a traditional iliac crest bone graft (ICBG) for the treatment of bone defects.

METHODS

This meta-analysis was conducted according to the PRISMA guidelines. The Embase, Google Scholar, PubMed, and Scopus databases were accessed in June 2021. All clinical trials comparing the RIA and ICBG with a minimum of 6 months follow-up were included.

RESULTS

Data from 4819 patients were collected. The RIA group demonstrated lower site pain (P < 0.0001), fewer infections (P = 0.001), and a lower rate of adverse events (P < 0.0001). The ICBG group demonstrated a greater rate of bone union (P < 0.0001). There was no difference between groups in VAS (P = 0.09) and mean time to union (P = 0.06).

CONCLUSION

The current evidence supports the use of the RIA, given its low morbidity and short learning curve.

Autologous Bone Grafting in Trauma and Orthopaedic Surgery: An Evidence-Based Narrative Review

Autologous bone grafting is common in trauma and orthopaedic surgery. Both the Reamer Irrigator Aspirator (RIA) and Iliac Crest Bone Graft (ICBG) aim to obtain autologous bone graft. Although the process of harvesting a bone graft is considered simple, complications may occur. This study examined morbidity and pain at the donor site, blood loss, and iatrogenic fractures, comparing RIA and ICBG. The source of the autologous bone graft, the alternative graft sites, and the storage modalities of the harvested bone marrow were also evaluated. In May 2021, PubMed, Embase, Scopus, and Google Scholar were accessed, with no time constraints. RIA may produce greater blood loss, but with less morbidity and complications, making it a potential alternative source of bone grafting.

Alveolar bone grafting and gingivoperiosteoplasty in bilateral cleft lip and palate

PURPOSE OF REVIEW

Gingivoperiosteoplasty (GPP) and alveolar bone grafting (ABG) procedures have a vast history. There have been many publications regarding ABG and secondary ABG, with and without presurgical infant orthopedics (PSIO), in bilateral cleft lip and palate patients. There is little long-term data available describing results of both techniques.

RECENT FINDINGS

The interdisciplinary approach to primary and secondary surgical procedures has proven to be beneficial for patients with bilateral cleft lip and palate. In the neonates, naso-alveolar molding (NAM) has been found to optimize the aesthetic outcome as well as re-approximating the arches to facilitate GPP. During the mixed dentition stage, arch preparation/expansion before the secondary ABG procedure improves arch morphology, restores the functional interarch relationship, and facilitates surgery.

SUMMARY

This review aims to highlight the key points of both the procedures and why combining both procedures along with PSIO procedures such as NAM might be helpful for the patients in the long term.

Open Reduction and Internal Fixation for Humeral Shaft Nonunion: Bone Grafting Is Not Routinely Required and Avoids Donor Site Morbidity

OBJECTIVES

To document union rate, complications and patient-reported outcomes after open reduction and internal fixation (ORIF), with and without bone grafting (BG), for humeral diaphyseal nonunion after failed nonoperative management.

DESIGN

Retrospective.

SETTING

University teaching hospital.

PATIENTS AND INTERVENTION

From 2008 to 2017, 86 consecutive patients [mean age 59 years (range 17-86), 71% (n = 61/86) women] underwent nonunion ORIF (plate and screws) at a mean of 7 months postinjury (range 3-21.5). Eleven (13%) underwent supplementary BG.

MAIN OUTCOME MEASUREMENTS

Union rate and complications for 83 patients (97%) at a mean of 10 months (3-61). Patient-reported outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12, satisfaction) for 53 living, cognitively-intact patients (78%) at a mean of 4.9 years (0.3-9.2).

RESULTS

Ninety-three percent (n = 77/83) achieved union after nonunion ORIF. Complications included recalcitrant nonunion (7%, n = 6/83), iatrogenic radial nerve palsy (6%, n = 5/83), infection (superficial 7%, n = 6/83; deep 2%, n = 2/83), and iliac crest donor site morbidity (38%, n = 3/8). The union rate with BG was 78% (n = 7/9) and without was 95% (n = 70/74; P = 0.125), and was not associated with the nonunion type (atrophic 91%, n = 53/58; hypertrophic 96%, n = 24/25; P = 0.663). Median QuickDASH was 22.7 (0-95), EQ-5D 0.710 (-0.181-1), EQ-visual analog scale 80 (10-100), SF-12 physical component summary 41.9 (16-60.5), and mental component summary 52.6 (18.7-67.7). Nineteen percent (n = 10/53) were dissatisfied with their outcome.

CONCLUSIONS

ORIF for humeral diaphyseal nonunion was associated with a high rate of union. Routine BG was not required and avoided the risk of donor site morbidity. One in 5 patients were dissatisfied despite the majority achieving union.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Randomized clinical trial: expanded autologous bone marrow mesenchymal cells combined with allogeneic bone tissue, compared with autologous iliac crest graft in lumbar fusion surgery

BACKGROUND CONTEXT

Although autogenous iliac crest bone graft (AICBG) is considered the gold-standard graft material for spinal fusion, new bone substitutes are being developed to avoid associated complications and disadvantages. By combining autologous bone marrow mesenchymal stromal cells (MSCs) expanded ex vivo and allogenic cancellous bone graft, we obtain a tissue-engineered product that is osteoconductive and potentially more osteogenic and osteoinductive than AICBG, owing to the higher concentration of MSCs.

PURPOSE

This study aimed to evaluate the feasibility and safety of implanting a tissue-engineered product consisting of expanded bone marrow MSCs loaded onto allograft bone (MSC+allograft) for spinal fusion in degenerative spine disease, as well as to assess its clinical and radiological efficacy.

STUDY DESIGN/SETTING

A prospective, multicenter, open-label, blinded-reader, randomized, parallel, single-dose phase I-II clinical trial.

PATIENT SAMPLE

A total of 73 adult patients from 5 hospitals, with Meyerding grade I-II L4-L5 degenerative spondylolisthesis and/or with L4-L5 degenerative disc disease who underwent spinal fusion through transforaminal lumbar interbody fusion (TLIF).

OUTCOME MEASURES

Spinal fusion was assessed by plain X-ray at 3, 6, and 12 months and by computed tomography (CT) at 6 and 12 months post-treatment. An independent radiologist performed blinded assessments of all images. Clinical outcomes were measured as change from baseline value: visual analog scale for lumbar and sciatic pain at 12 days, 3, 6, and 12 months posttreatment, and Oswestry Disability Index and Short Form-36 at 3, 6, and 12 months posttreatment.

METHODS

Patients who underwent L4-L5 TLIF were randomized for posterior graft type only, and received either MSC+allograft (the tissue-engineered product, group A) or AICBG (standard graft material, group B). Standard graft material was used for anterior fusion in all patients. Feasibility was measured primarily as the percentage of randomized patients who underwent surgery in each treatment group. Safety was assessed by analyzing treatment-emergent adverse events (AEs) for the full experimental phase and appraising their relationship to the experimental treatment. Outcome measures, both radiological and clinical, were compared between the groups.

RESULTS

Seventy-three patients were randomized in this study, 36 from the MSC+allograft group and 37 from the AICBG group, and 65 were surgically treated (31 group A, 34 group B). Demographic and comorbidity data showed no difference between groups. Most patients were diagnosed with grade I or II degenerative spondylolisthesis. MSC+allograft was successfully implanted in 86.1% of randomized group A patients. Most patients suffered treatment-emergent AEs during the study (88.2% in group A and 97.1% in group B), none related to the experimental treatment. X-ray-based rates of posterior spinal fusion were significantly higher for the experimental group at 6 months (p=.012) and 12 months (p=.0003). CT-based posterior fusion rates were significantly higher for MSC+allograft at 6 months (92.3% vs 45.7%; p=.0001) and higher, but not significantly, at 12 months (76.5% vs 65.7%; p=.073). CT-based complete response (defined as the presence of both posterior intertransverse fusion and anterior interbody fusion) was significantly higher at 6 months for MSC+allograft than for AICBG (70.6% vs 40%; p=.0038), and remained so at 12 months (70.6% vs 51.4%; p=.023). Clinical results including patient-reported outcomes improved postsurgery, although there were no differences between groups.

CONCLUSIONS

Compared with the current gold standard, our experimental treatment achieved a higher rate of posterior spinal fusion and radiographic complete response to treatment at 6 and 12 months after surgery. The treatment clearly improved patient quality of life and decreased pain and disability at rates similar to those for the control arm. The safety profile of the tissue-engineered product was also similar to that for the standard material, and no AEs were linked to the product. Procedural AEs did not increase as a result of BM aspiration. The use of expanded bone marrow MSCs combined with cancellous allograft is a feasible and effective technique for spinal fusion, with no product-related AEs found in our study.

Trephine biopsy versus conventional open surgical technique for bone graft harvesting from the olecranon: A retrospective comparison of perioperative outcomes

OBJECTIVE

This study aimed to compare the perioperative clinical outcomes of trephine biopsy (TB) with the conventional open surgical method (COSM) in bone graft harvesting from the olecranon.

METHODS

In this retrospective study, 130 patients who underwent bone graft harvesting from the olecranon using either TB or COSM were included. Patients were then divided into two groups: the COSM group (48 patients; 36 men and 12 women; mean age=32 years; age range=18-52) and the TB group (82 patients; 61 men and 21 women; mean age=34 years; age range=20-62). The mean follow-up was 30 months (range=17-57) in the COSM group and 26.8 months (range=6-48 months) in the TB groups. The two groups were compared in terms of pain intensity, operating time, complication rate, elbow range of motion, and the scar sensitivity of the graft donor site. Pain intensity was measured using the visual analogous scale (VAS) on postoperative days 1 and 15. Other outcome measures were evaluated at the final follow-up.

RESULTS

In the TB group, the mean VAS score was 4±1.62 on postoperative day 1 and 1.6±0.76 on postoperative day 15. In the COSM group, the mean VAS score was 7.2±1.38 on postoperative day 1 and 3.1±1.34 on postoperative day 15. The early VAS scores were significantly higher in the COSM group than in the TB group (p<0.05). The mean operating time was 7±1.99 minutes in the TB group and 20±4.51 minutes in the COSM group. Hematoma occurred in one patient from each group, with an incidence of 2.1% in the COSM group and 1.2% in the TB group. There was no significant difference between the two groups regarding elbow range of motion at final follow-up p>0.05). No patient in the TB group showed sensitivity of the scar region, while scar sensitivity occurred in 3 of 48 patients (0.6%) in the COSM group.

CONCLUSION

Compared with COSM, TB seems to be a safe technique with similar complication rates. TB can provide shorter operating time, less postoperative pain, and smaller and less sensitive scar compared with COSM.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

The efficacy of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis

Background

The bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis has not been explained in detail. We aimed to analyze the efficacy of bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis.

Methods

We treated 32 thoracic or thoracolumbar tuberculosis patients by one-stage posterior debridement, allograft bone graft using titanium mesh, posterior instrumentation, and fusion from May 2011 to September 2015. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were analyzed preoperatively, postoperatively, and at final follow-up. The Cobb angles were recorded to evaluate the kyphosis correction and the loss of correction. The bony fusion was evaluated by X-ray and computed tomography images, and the bony fusion classifications were recorded.

Results

All patients had pain relief. The erythrocyte sedimentation rate, C-response protein, and hepatorenal function were normal at final follow-up. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were improved in all the patients. All patients achieved bone fusion. Twenty-eight patients achieved complete fusion (Grade I), whereas only four patients achieved partial fusion (Grade II). The preoperative Cobb angle was 33.6 ± 9.3°. The Cobb angle was reduced to 10.6 ± 2.6° postoperatively and was found to be 11.4 ± 3.1° at the final follow-up. The mean angle correction was 23.0 ± 8.9°, and the correction rate was 66.2 ± 12.2%. The mean angle lost was 0.8 ± 0.9°, and the lost rate was 5.8 ± 5.4% at the final follow-up.

Conclusions

Allograft bone using titanium mesh in the posterior-only surgical treatment is effective for patients with thoracic and thoracolumbar spinal tuberculosis. It can correct kyphosis, and most patients can achieve complete bony fusion.

Complications Associated With Anterior Iliac Bone Grafting for the Reconstruction of Dentoalveolar Defects

The aim of this study is to evaluate donor- and recipient-site complications of iliac bone grafting for the reconstruction of atrophic jaws.Our study includes 86 consecutive patients with atrophic jaws who underwent iliac bone grafting surgery. At the donor site, hematoma, infection, paresthesia, chronic pain, prolonged gait disturbance, fracture of the ilium, and esthetic concerns; at the recipient site, hematoma, infection, prolonged pain, graft exposure, graft loss, and loss of the implants were evaluated.Grafting was successfully performed in all patients. The mean follow-up period was 35 months. Prolonged gait disturbance (20.9%) and paresthesia (9.3%) were the most frequently observed donor-site complications. At the recipient site, hematoma (8.1%), infection (12.8%), prolonged pain (11.6%), partial graft exposure (33.7%), total graft exposure (7%), partial graft loss (17.4%), and total graft loss (5.8%) were observed.Reconstruction of atrophic jaws can be achieved successfully with iliac bone grafting. However, there are possible donor- and recipient-site complications that have to be taken into consideration.

Secondary alveolar bone grafting in cleft lip and palate: A comparative analysis of donor site morbidity in different age groups

INTRODUCTION

There is no consensus regarding the optimal timing for secondary alveolar bone grafting for clefts defects. We aimed to investigate the potential correlation between the age of patients during surgery, donor site symptoms, surgical time and hospitalization following this procedure.

MATERIAL AND METHODS

The outcome of 195 consecutive alveolar bone grafting procedures among different age groups (mean: 7.1 years; range 1.8-40.5) was retrospectively assessed based on a chart review and purpose-prepared report forms. The association between age, gender and hospitalization following bone harvesting was tested by Spearman rank correlation, while relationships (i.e. between age and pain) were evaluated by logistic regression.

RESULTS

The most frequent donor site complaints included: pain equal to or exceeding that of the recipient site (93%) and gait disturbances (92.5%) immediately after the procedure. Chronic complaints included: iliac contour alteration (40.1%), unsightly scar (23%) and recurring discomfort (2.1%). Statistical analysis showed no correlation between donor site symptoms, their duration or hospitalization time following surgery at different ages, except a higher incidence of significant pain immediately after bone harvesting in older females (r = 0.268; p = 0.030).

CONCLUSION

Alveolar bone grafting at an earlier age does not increase donor site symptoms, surgical duration or hospitalization following surgery.

Longer Operative Time Is Associated With Increased Adverse Events After Anterior Cervical Diskectomy and Fusion: 15-Minute Intervals Matter

Little is known about the impact of operative time, as an independent and interval variable, on general health perioperative outcomes following anterior cervical diskectomy and fusion. Therefore, patients undergoing a 1-level anterior cervical diskectomy and fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program. Operative time (as an interval variable) was tested for association with perioperative outcomes using a multivariate regression that was adjusted for differences in baseline characteristics. A total of 15,241 patients were included. Increased surgical duration was consistently correlated with a rise in any adverse event postoperatively, with each additional 15 minutes of operating time raising the risk for having any adverse event by an average of 10% (99.64% confidence interval, 3%-17%, P<.001). In fact, 15-minute increases in surgical duration were associated with incremental increases in the rates of venous thromboembolism, sepsis, unplanned intubation, extended length of hospital stay, and hospital readmission. Greater operative time, despite controlling for other patient variables, increases the risk for overall postoperative adverse events and multiple individual adverse outcomes. This increased risk may be attributed to anesthetic effects, physiologic stresses, and surgical site issues. Although it is difficult to fully isolate operative time as an independent variable because it may be closely related to the complexity of the surgical pathology being addressed, the current study suggests that surgeons should maximize operative efficiency as possible (potentially using strategies that have been shown to improve operative time in the 15-minute magnitude), without compromising the technical components of the procedure. [Orthopedics. 2018; 41(4):e483-e488.].

Hybrid composites of mesenchymal stem cell sheets, hydroxyapatite, and platelet-rich fibrin granules for bone regeneration in a rabbit calvarial critical-size defect model

The reconstruction of large bone defects remains a major clinical challenge, and tissue engineering is a promising technique for resolving this problem. Many attempts have been made to optimize bone tissue engineering protocols. The aim of the present study was to develop a process incorporating mesenchymal stem cell (MSC) sheets with nanoscale hydroxyapatite (nano-HA) and autologous platelet-rich fibrin (PRF) granules for enhanced bone formation within a critical-sized rabbit cranial defect. MSC sheets and PRF were prepared prior to in vivo experiments. The osteogenic differentiation ability of MSCs and the ultrastructure of PRF were also studied. A total of 15 New Zealand white rabbits were used in the current study and critical-size defects (CSDs) were surgically introduced in the cranium (diameter, 15 mm). The surgical defects were treated with MSC/PRF composites, MSC composites or left empty. Animals were euthanized at week 8 post-surgery. Iconography, histological and histomorphometric analysis were performed to assess de novo bone formation. The percentage of new bone in the MSC/PRF group (35.7±5.1%) was significantly higher than that in the MSC (18.3±3.2%; P<0.05) and empty defect groups (4.7±1.5%; P<0.05). The results of the present study suggest that combined application of an MSC sheet with nano-HA and granular PRF enhances bone regeneration in a rabbit calvarial CSD model, and provides a novel insight into bone tissue regeneration for large bone defects.

Use of a trephine bur and curette for minimally invasive harvesting of particulate cancellous bone and marrow from the iliac crest: a case of alveolar ridge reconstruction

Iliac particulate cancellous bone and marrow (PCBM) is still the most predictable autogenous graft material for vertical ridge reconstruction because of its high cell content as well as osteoinductive and osteoconductive properties. However, postoperative meralgia paresthetica, gait disturbance, pain, and bleeding have been reported following conventional harvesting from the anterior iliac crest. We present a case of minimally invasive harvesting of iliac PCBM. A short incision was made, and the iliac crest was exposed after elevation of the periosteal membrane. Only the iliac cortical bone was removed using a trephine bur to avoid perforation. PCBM was harvested with hand curettes and grafted into the vertical ridge defect. Because of the small surgical field, gait disturbance was resolved within 1 day without other postoperative complications. This technique is potentially useful for harvesting a small amount of iliac PCBM.

Iliac Crest Donor Site for Children With Cleft Lip and Palate Undergoing Alveolar Bone Grafting: A Long-term Assessment

The authors aimed to accurately assess the donor site morbidity from iliac crest bone grafts for secondary bone grafting in patients with cleft lip and palate alveolar defects. Fifty patients between 3 months and 10 years following alveolar bone grafting for cleft lip and palate were entered into the study. Two-thirds of patients had no significant concerns about the donor site. The remaining third had some concerns about the appearance of their hips and less than 10% of patients expressing strong agreement with statements about concerns with shape, appearance, and self-consciousness about the iliac crest donor site. Examination findings showed the average length of scar being 5.4 cm and a third of patients having some minor palpable boney irregularities of the iliac crest. The authors found that the alveolar crest donor site is well tolerated by patients long term but has a measurable morbidity long term.

Morbidity associated with anterior iliac crest bone graft harvesting in children undergoing orthopaedic surgery: a prospective review

PURPOSE

Autologous iliac crest bone grafting is an integral part of many orthopaedic surgical procedures. Several studies have documented morbidity and prolonged pain following iliac crest bone graft harvesting in adults; however, in children there is a paucity of information. The purpose of the present study was to quantify the degree of pain and morbidity associated with anterior iliac crest graft harvesting in children undergoing non-spinal orthopaedic surgery.

METHODS

Patients were prospectively enrolled prior to orthopaedic surgery. A patient self-reported visual analogue score was used to record pain at specified time points following surgery. In addition, the patients were reviewed at 2 and 6 weeks, 3 months and 1 year after surgery to record any complications.

RESULTS

Data was collected on 33 patients (34 graft sites). Only one patient (2.94 %) had a complication, namely an injury to the lateral femoral cutaneous nerve. This resolved 3 months after surgery. 89 % of patients had no pain at the iliac crest graft harvest site 3 months after surgery. The three patients who had pain at 3 months had visual analogue scores of 1.0, 1.1 and 1.3, respectively.

CONCLUSION

This series reveals a very low complication rate and minimal iliac crest graft harvest site pain in children undergoing non-spinal orthopaedic surgery. In addition, the pain experienced is short-lived.

Perioperative findings and complications of non-vascularised iliac crest graft harvest: The experience of a Nigerian tertiary hospital

Background:

The reconstruction of a mandibular defect remains a significant challenge to the reconstructive surgeon. In developing countries like Nigeria, the required facilities and expertise for vascularised graft surgery are not readily available, thus mandibular defects are commonly reconstructed with non-vascularised bone grafts. The aim of this study is to describe the experience with the reconstruction of mandibular defects using non-vascularised iliac crest bone grafts (NVICBG) at a Nigerian tertiary hospital.

Patients and Methods:

This was a descriptive longitudinal study in which data was prospectively collected from patients who had mandibular reconstruction secondary to benign lesions using NVICBG at the University College Hospital, Ibadan, over a 24-month period. Information recorded included demography, cause of mandibular defect, type of mandibular resection, span of defect, peri-operative data, recipient site complications and donor site complications. Patient satisfaction with facial aesthetic outcome was assessed with the use of visual analogue scale score.

Results:

Twenty patients had mandibular resection and immediate reconstruction with NVICBG. The mean age was 31.61 (+/−11.05) years. Mean span of the defects was 10.65 (+/−2.88) cm. At the recipient site, two patients had extra-oral wound dehiscence and two patients had intra-oral wound dehiscence of which one patient had loss of the graft. Donor site complications noted were seromas and wound dehiscence. Eighteen patients had paraesthesia of the lateral femoral cutaneous nerve. All patients had temporary abnormal gait. The mean duration of abnormal gait was 2.11 weeks (SD +/−0.74). Majority of the patients were satisfied with the aesthetic outcome.

Conclusion:

NVICBG, though limited in its versatility has satisfactory aesthetic outcome with relatively few complications. It appears that this method of reconstruction can be used even for large mandibular defects contrary to perceptions of many reconstructive surgeons.

Surgical tip: a minimally invasive mini open technique for harvesting iliac crest bone graft

Level of Evidence:

Level V, expert opinion.

Bone graft substitutes currently available in orthopaedic practice: the evidence for their use

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Estudo prospectivo controlado randomizado: comparando duas formas de tratamento para o sitio doador de enxerto ósseo em cirurgia da coluna vertebral

OBJETIVO: Comparar a colocação de geléia Gelfoan® versus a colocação apenas de dreno de sucção na área doadora, avaliando a dor pós-operatória, presença de complicações e seguimento dos pacientes. MÉTODOS: Foram randomizados por programa de computador 30 pacientes, sendo que em 14 pacientes foi utilizado Gelfoan® com anestésico e em 16 pacientes utilizamos dreno de sucção. Todos os pacientes foram avaliados em cinco períodos consecutivos, sendo avaliada a dor baseada na Escala Visual Analógica (VAS) e observado a incidência de complicações. Foram incluídos pacientes com abordagem anterior ou posterior, sendo considerado como fonte doadora única a crista ilíaca. Foram incluídos pacientes com 18 a 70 anos de idade de ambos os sexos. RESULTADOS: Foi observado que a dor pós-operatória foi menor com Gelfoan® nas primeiras avaliações, mas na média o resultado foi semelhante, não apresentando diferença estatística entre ambas as técnicas. Na média das avaliações, a escala visual analógica de dor foi de dois; não se observando complicações na área da retirada do enxerto. CONCLUSÃO: A abordagem com Gelfoan® com bupivacaina melhora a dor nas primeiras 48h pós-cirurgia, quando comparada com dreno de sucção a vácuo, mas na média ambas a técnicas são seguras, com presença de dor residual nas duas intervenções, mas com baixo índice de complicações. Não observamos complicações em nosso estudo.

Morbidity associated with anterior iliac crest bone graft

OBJECTIVE

The aim of this retrospective study was to assess the morbidity of the harvest of the anterior iliac bone graft and the overall satisfaction rates in a group of patients who underwent harvesting of iliac crest bone graft.

PATIENTS AND METHODS

Patients who underwent iliac crest bone graft procedures from January 2002 to August 2009 were recalled and invited to answer a questionnaire about postoperative pain, sensory disturbance, functional limitations, and cosmetic appearance.

RESULTS

A total of 61 patients were included in this retrospective study. Seventeen patients (28%) reported postoperative pain. A patient reported an intraoperative hip fracture. Sensory disturbances were reported by 3 patients.

CONCLUSIONS

Anterior iliac crest can still be considered a favorable donor site for preprosthetic and cleft surgery. Given its relatively low morbidity rate, early ambulation, and hospital discharge, anterior iliac crest still remains the donor site of choice according to the authors.

Iliac wing fracture following graft harvesting from the anterior iliac crest: literature review based on a case report

The morbidity of bone graft harvesting from the iliac crest has been widely discussed in the literature. For some authors, it is considered to be low and for others relatively high. We report on a case of a fracture of the iliac wing after graft harvesting from the anterior iliac crest despite good surgical technique. This complication is well known and most of these fractures heal uneventfully if treated conservatively. However, if anatomical and technical considerations are respected, the patient could be spared this inconvenience. Based on a literature review, we discuss the procedure's potential complications and how to avoid them in an update.

Continuous bupivacaine infusion in iliac bone graft donor sites to minimize pain and hospitalization

PURPOSE

To assess the efficacy of continuous bupivacaine infusion at the iliac crest donor site in reducing postoperative pain and inpatient hospital stay.

METHODS

Forty consecutive cleft lip/palate patients who underwent alveolar bone grafting at a single institution between 2003 and 2008 were identified, and their charts were retrospectively reviewed. Opioid analgesic use, self-reported pain indices, and length of hospital stay were analyzed. Comparisons were made between those patients who received a bupivacaine infusion pump at the iliac crest harvest site and those who did not.

RESULTS

Twenty patients underwent iliac crest bone graft harvest followed by intraoperative placement of a continuous 0.25% bupivacaine infusion pump, and 20 were managed primarily with postoperative intravenous and parenteral analgesics. There were no statistically significant differences in demographics between the two cohorts. Those patients receiving continuous bupivacaine had a decreased length of hospital stay (mean, 2.9 versus 1.4 days; p = .0077), a statistical trend toward decreased opioid use (p = .032), and a lower average subjective pain score on the day of surgery (p = .0058).

CONCLUSION

There is a significant decrease in the length of hospitalization when using a continuous local infusion pump to deliver bupivacaine to the iliac crest following bone graft harvest. The pump is tolerated by patients and carries little morbidity. As such, the benefit of reduced cost from a reduced hospital stay is worthwhile. Continuous bupivacaine infusion is recommended for the iliac crest donor site.

Characterization of cortico-cancellous bone along the iliac crest: focus on graft harvesting

PURPOSE

The iliac crests are rich sources of cortical as well as cancellous bone. Though the proportions of cortico-cancellous tissue vary along the crest, a detailed morphometric characterization of the osseous tissue along the iliac crest is hard to come across in literature. This paucity of anatomical data on the quantity of cortical and cancellous bone along the iliac blade has prompted this study.

METHODS

Male [n = 40] and female [n = 40] pelvises were obtained from fresh cadaveric material. Two parallel strips of bones, each 15 mm high, were cut along the iliac crest. Each of these segments was divided into three (anterior, intermediate and posterior) approximately equal parts and measured for: (a) length, (b) width, (c) thickness, of the outer and inner shell of cortical bones, (d) thickness of the cancellous tissue between the outer and inner cortices, and (e) the volume of available cancellous bone in each part was calculated.

RESULTS

The upper segment was found to be wider than the lower segment. The intermediate part of the upper segment was the widest and possessed the thickest and most voluminous content of cancellous tissue. The posterior parts of both the segments were thin. Cortical bones gradually thinned out posteriorly. The outer cortices were thicker than the inner ones. Parameters in the males generally measured higher than the females; the right side had higher values than the left.

CONCLUSIONS

Strategies for graft harvesting from the iliac crests should be based upon the morphological assessment of the bone at the desired site of harvest.

Iliac crest bone graft harvesting complications: A case of liver herniation

The iliac crest is an easily accessible donor site offering a relatively large and safe supply of bone. There are however possible complications; residual pain frequently, and more rarely herniation. This latter's true incidence is unknown in a literature review, which found 15 articles. We report a case of liver herniation in a 64-year-old overweight lady after harvesting bone from her iliac crest. The clinical diagnosis was confirmed by CT scan. Despite an appropriate surgical repair, the hernia recurred. This serious complication of bone harvesting from the iliac crest, and possible other undesirable events described, prompted reconsideration of our harvesting techniques, and the use in our unit of bone substitutes or cell therapy to fill bone defects.

Prospective study of iliac crest bone graft harvest site pain and morbidity

BACKGROUND CONTEXT

Morbidity associated with autologous bone graft harvest is an important factor in determining the utility of expensive alternatives such as recombinant bone morphogenic protein. The most frequently reported complication associated with graft harvest is chronic pain.

PURPOSE

To prospectively determine the degree of pain and morbidity associated with autologous iliac crest bone graft harvest and its effect on activities of daily living.

STUDY DESIGN

Prospective observational cohort study.

PATIENT SAMPLE

One hundred ten adult patients undergoing elective posterior lumbar spinal fusion surgery involving autologous iliac crest bone graft harvest.

OUTCOME MEASURES

Patient self-reported Visual Analog Scale (VAS) scores for pain and a study-specific questionnaire regarding activities of daily living.

METHODS

One hundred ten patients were prospectively enrolled. Postoperative VAS scores (0-100) for harvest site pain were obtained at 6-week, 6- and 12-month follow-up. Patients completed a 12-month questionnaire regarding the persistence of specific symptoms and resulting limitation of specific activities.

RESULTS

One hundred four patients were available for 1-year follow-up. Mean VAS pain scores (scale 0-100) at 6 weeks, 6 and 12 months were 22.7 (standard deviation [SD], 25.9), 15.9 (SD, 21.5), and 16.1 (SD, 24.6), respectively. At 12 months, 16.5% reported more severe pain from the harvest site than the primary surgical site, 29.1% reported numbness, and 11.3% found the degree of numbness bothersome, whereas 3.9% were bothered by scar appearance. With respect to activity limitations resulting from harvest site pain at 1 year, 15.1% reported some difficulty walking, 5.2% with employment, 12.9% with recreation, 14.1% with household chores, 7.6% with sexual activity, and 5.9% irritation from clothing.

CONCLUSIONS

There is a significant rate of persistent pain and morbidity from iliac crest bone graft harvest when associated with elective spine surgery. Mean pain scores progressively decline over the first postoperative year. Nevertheless, harvest site pain remains functionally limiting in a significant percentage of patients 1 year after surgery. Rates of functional limitation are higher than previously reported and may be because of increased sensitivity of the prospective study design and targeted investigation of these specific symptoms. Validity of these findings is necessarily limited by patient ability to discriminate harvest site pain from alternative sources of back and buttock pain.

A Comparison of Shepard's Osteotome versus Trapdoor Flap Technique to Harvest Iliac Crest Bone for Secondary Alveolar Bone Grafting

Objective:

To compare the postoperative donor site morbidity and alveolar bone graft results following two different techniques for iliac crest bone graft harvest: a closed (Shepard's osteotome) and an open (trapdoor flap) technique.

Design:

A retrospective review of two cohorts of alveolar bone grafts performed from 1998 to 2004 in Birmingham Children's Hospital by two surgeons using different harvest techniques. Medical and nursing anesthetic notes and medication charts were reviewed. Alveolar bone graft results were assessed using preoperative and postoperative radiographic studies.

Patients:

A total of 137 patients underwent an operation. Of these, 109 patients were compatible with the inclusion criteria (data available, first operation, no multiple comorbidities). Sixty-four patients had iliac bone harvested using the open trapdoor technique, while 45 had the same procedure using the closed osteotomy technique.

Results:

Maximum bone graft volumes harvested were similar with both techniques. The mean length of hospital stay was 50.9 hours for the osteotome and 75.5 hours for the open technique group (p < .0001). The postoperative analgesia requirement was higher and the postoperative mobilization was delayed and more difficult for the open technique patients (p < .0005). Kindelan scores performed by two independent orthodontists were similar for both techniques.

Conclusion:

The findings demonstrate that harvesting bone from the iliac crest using an osteotome technique reduces time in hospital, analgesia requirements, and postoperative donor site morbidity with no detrimental outcome.

Orthogonal cutting of cancellous bone with application to the harvesting of bone autograft

Autogenous bone graft harvesting results in cell death within the graft and trauma at the donor site. The latter can be mitigated by using minimally invasive tools and techniques, while cell morbidity may be reduced by improving cutter design and cutting parameters. We have performed orthogonal cutting experiments on bovine cancellous bone samples, to gain a basic understanding of the cutting mechanism and to determine design guidelines for tooling. Measurements were performed at cutting speeds from 11.2 to 5000 mm/min, with tool rake angles of 23 degrees, 45 degrees and 60 degrees, and depths of cut in the range of 0.1-3.0 mm. Horizontal and vertical cutting forces were measured, and the chip formation process video recorded. Continuous chip formation was observed for rake angles of 45 degrees and 60 degrees , and depths of cut greater than 0.8 mm. Chip formation for depths of cut greater than 1.0 mm was accompanied by bone marrow extruding out of the free surfaces and away from the rake face. Specific cutting energies decreased with increasing rake angle, increasing depth of cut and increasing cutting speed. Our orthogonal cutting experiments showed that a rake angle of 60 degrees and a depth of cut of 1mm, will avoid excessive fragmentation, keep specific cutting energy low and promote bone marrow extrusion, which may be beneficial for cell survival. We demonstrate how drill bit clearance angle and feed rate can be calculated facilitating a 1mm depth of cut.

Donor site morbidity following iliac crest bone harvesting for cervical fusion: a comparison between minimally invasive and open techniques

We have studied the occurrence of donor site morbidity, cosmesis and overall satisfaction with graft procedure in 76 patients who had undergone iliac crest bone harvesting for anterior cervical discectomy and fusion (ACDF). Totally 24 patients underwent an open procedure and 52 a minimally invasive trephine harvesting method. Although our study demonstrated substantial donor site pain and its effect on ambulation in both groups, this was of limited duration. Two patients, one in each group, suffered long-term pain that was eventually resolved. Totally 8.3% of patients in the open group suffered minor complications and 11.5% in the trephine group. There were two cases of meralgia parasthetica. There were no major complications in either group. There was no statistically significant difference in morbidity between the open and trephine groups. There was a trend towards significance (P = 0.076) for pain at the donor site, with less pain reported by patients who underwent the trephine procedure for harvesting.

A prospective, randomized, double-blind study of the efficacy of postoperative continuous local anesthetic infusion at the iliac crest bone graft site after posterior spinal arthrodesis: a minimum of 4-year follow-up

STUDY DESIGN

Parallel design, prospective, double-blinded, randomized, controlled trial composed of 2 independent groups treated with a continuous infusion catheter (saline vs. Marcain) placed into the iliac crest bone graft site (ICBG).

OBJECTIVE

To determine the long-term effects of postoperative continuous local anesthetic agent infusion at the ICBG harvest site in reducing chronic pain, narcotic usage and improving long-term, postoperative function and satisfaction with the surgical procedure.

SUMMARY OF BACKGROUND DATA

Harvesting iliac crest bone has been shown to be a source of pain and morbidity. In our initial study, we reported that patients who received local anesthetic at the graft site noted a reduction in acute postoperative pain (VAS) and narcotic usage. METHODS.: Twenty-six patients underwent posterior iliac crest bone graft harvesting. Patients were randomly assigned to receive 96 mL (2 mL/h x 48 hours) of either 0.5% Marcain or normal saline delivered via a continuous infusion catheter placed at the ICBG harvest site. Postoperative pain scores, narcotic use/frequency, activity level, and length of stay (LOS) were recorded and reported previously. At a minimum of 4 years after surgery (mean, 4.7 years; range, 4.5-5.4 years), all patients completed a questionnaire documenting their current VAS pain score (iliac crest), frequency of pain (days per month), level of activity, chronic pain at the ICBG site, and overall satisfaction with the procedure.

RESULTS

Nine of 11 patients (82%) in the treatment group and 10 of 14 patients (71%) in the control group were available at final follow-up (1 death occurred in the control group unrelated to the study). The treatment group had a statistically significant decrease in the graft site pain VAS score (1.4 vs. 4.8) and increased satisfaction with the procedure at a minimum of 4 years postprocedure (P < 0.05). Additionally, no patient in the treatment group developed chronic iliac crest dysesthesias (0 of 9) versus 7 of 10 patients (70%) in the control group (P < 0.05).

CONCLUSION

Continuous infusion of 0.5% Marcain at the ICBG harvest site significantly reduced chronic dysesthesias. Overall satisfaction with the procedure, number of painful days per month, and VAS scores were significantly better in the treatment group at 4 years. No long-term complications were attributed to either the ICBG site or the catheter-infusion system. The use of continuous local anesthetic infusion at the iliac crest may help in alleviating graft-related pain beyond the perioperative phase.