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Harvesting of bone from the iliac crest—comparison of the anterior and posterior sites
British Journal of Oral and Maxillofacial Surgery (2005) 43, 51—56
Harvesting of bone from the iliac crest—–comparison of the anterior and posterior sites P. Kessler∗, M. Thorwarth, A. Bloch-Birkholz, E. Nkenke, F.W. Neukam Department of Oral and Maxillofacial Surgery, University Hospital Erlangen-Nuremberg, Gl¨ uckstrasse 11, D-91054 Erlangen, Germany Accepted 26 August 2004
KEYWORDS Iliac crest; Augmentation; Bone transplantation
Summary In 1998 we harvested a total of 127 bone grafts from the iliac crest of 65 male and 53 female patients aged 8—80 years. We measured the quantity of bone obtained, the operating time and the donor site morbidity of the anterior approach (n = 81) compared with the posterior approach (n = 46). The mean volume of bone harvested was 15 cm3 (range: 9—25.5) of monocorticocancellous- or bicorticocancellous bone chips or those from a trephine bur. The mean operating time for the anterior approach was 35 min (range: 22—48), for the posterior approach 40 min (range: 32—55). There were 15 complications, which were limited to those in whom the volume of bone exceeded 17 cm3 . The posterior approach caused less morbidity, notably in the form of significantly less pain and irregularity of gait. The patient has, however, to be repositioned during operation, which added to its total duration. © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction For more than four decades the iliac crest has been the accepted place to get bone for augmentation in orthopaedic, neurosurgery and oral and maxillofacial surgery. In oral and maxillofacial surgery the main indications are secondary and tertiary osteoplasty in patients with cleft-lip and palate, augmen* Corresponding author. Tel.: +49 9131 8533616; fax: +49 9131 8534219. E-mail address: [email protected] (P. Kessler).
tation of bony defects after operations for tumours or large cysts, and augmentation in preprosthetic surgery for severe cases of atrophy of the alveolar crest from early loss of teeth or the aging process. Lindemann reported in 1915 the harvesting of bone from the anterior iliac crest to reconstruct mandibular bone defects after gunshot injuries.1 Dick2 reported the use of the posterior iliac crest as a donor site in orthopaedic surgery. In oral and maxillofacial surgery Dingman reported the transplantation of large segments of bone from the anterior iliac crest to reconstruct the mandible after resection of tumours. He extended the donor site from
0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2004.08.026
52 the anterior to the posterior iliac crest.3 Bloomquist and Feldman described the use of the posterior iliac crest for harvesting bone.4 The main advantages of the iliac crest is its easy accessibility, the possibility of harvesting large amounts of bone, and the ability to close the wound primarily. Previous studies, however, have shown many complications after harvesting bone from the iliac crest.13 The anterior iliac crest is more accessible than the posterior iliac crest as a donor region and bicortical grafts can be taken. Preparation of the receptor site in the head and neck and the harvesting of bone can be done simultaneously. There are, however, two disadvantages: the bicortical bone layers between the internal and external cortices below the anterior iliac crest are as thin as a blade, often making it difficult to obtain a sufficient bone volume. The other disadvantage is the risk of fracturing the anterior iliac spine, which results in a long-lasting obstacle to walking and climbing stairs.5 As the bicortical width of the bone layer beneath the posterior iliac crest does not shrink this region always offers enough cortical and cancellous bone for augmentation even in cases of extreme alveolar atrophy or for the reconstruction of large bony defects. Some authors have claimed that there is considerably less morbidity after harvesting bone from the posterior region as irregularities of gait do not occur, the patient can be mobilised earlier, and has less pain.6 The main disadvantage is the necessity to turn the patient in the course of the operation, which lengthens the operating time. The varying data about the morbidity of harvesting bone from the anterior compared with the posterior iliac crest were the reason for an evaluation of our own results. This prospective, non-randomised study was conducted in 1998 and compares the amount of bone harvested, the operating time, and the postoperative morbidity.
P. Kessler et al. terior iliac crest was chosen in all patients with cleft-lip or palate and in patients with large cystic lesions. Only cancellous bone was harvested in these two groups. The anterior iliac crest was also preferred if only one quadrant of the jaws had to be augmented by onlay grafting, and for a sinus lift operation in patients with highly atrophic alveolar processes. For defects after resection of tumours or trauma the anterior iliac site was used, if the defects could be reconstructed by a maximum of two or three corticocancellous bone strips about 40—50 mm long and 10—12 mm wide. Antibiotic prophylaxis (penicillin 10 million units intravenously) was started the evening before operation and was continued twice a day until the evening of the second postoperative day. A steroid (prednisolone) was also given (250 mg morning and evening on the day of operation, and 125 mg morning and evening on the first postoperative day). Criteria for exclusion from harvesting bone from the iliac crest were previous operations in this area; systemic bony or neurological diseases; or longstanding treatment with steroids, immunosuppressive drugs, chemotherapy in the previous 2 months, or drug misuse in the previous 3 months. All patients were operated on under general anaesthesia. For harvesting bone from the anterior iliac crest the patient lies supine. The pelvis is raised about 30◦ by underlying towels. The skin over the iliac crest is put under stretch by placing a fist above the iliac crest and pushing the abdominal wall medially. The skin incision is about 50 mm long, starts about 20 mm behind the anterior iliac spine and runs parallel to the iliac crest (Fig. 1). After relaxing the skin the incision line finally lies about 20 mm lateral to the iliac crest, avoiding mechanical irritation of the scar by tight clothes or a waistband. After the skin incision we make a
Patients and methods In 1998 we operated on 118 patients and took bone grafts from the iliac crest on 127 occasions. In 81 cases the bone was harvested from the anterior iliac crest, in 46 from the posterior. There were 65 men and 53 women. The mean age was 44 years (range: 8—80). The indications for harvesting bone and grafting were bony defects after resection of tumours (n = 40), extreme atrophy of the upper and lower alveolar crests (n = 33), cleft-lip or palatal defects (n = 25), defects after removal of large cysts (n = 17), and posttraumatic defects (n = 12). The an-
Figure 1. Anterior iliac crest. The incision line is parallel and lateral to the iliac crest (dotted line).
Harvesting of bone from the iliac crest
Figure 2. Anterior iliac crest showing exposure of the superior crest.
blunt dissection of the subcutaneous tissues until the periosteum of the iliac crest is found (Fig. 2). Bleeding is avoided by meticulous haemostasis, the periosteum of the iliac crest is incised, and the periosteal layer with the iliac muscle dissected bluntly medially. The iliac fossa is dissected to a depth of about 80 mm. After inserting a retractor an oscillating saw is used to cut parallel strips of monocortical bone from the inner table of the pelvic bone at right angles to the line of the iliac crest. These strips are about 15 mm wide (Fig. 3b). Cancellous bone is then harvested using a sharp spoon. The area of the defect is rinsed several times before a collagenous tampon (Gelita TamponTM , B. Braun Aesculap, Tuttlingen, Germany) is inserted to stop bleeding from the surrounding cancellous bone. The wound is then closed in layers and a pressure bandage applied over the area of the iliac crest. In adolescents we use only the anterior approach to the iliac crest. In these patients the cartilage covering the iliac crest is incised after the fashion of a double door. After the bone has been harvested
53 the cartilage cover is replaced and sutured with absorbable sutures. The posterior incision is made with the patient prone. The incision is about 80 mm long, follows a diagonal line from a cranial and medial position below and laterally and crosses the posterior iliac crest. This incision is a safe way to protect the gluteal branches of the posterior cutaneous nerves. After blunt dissection of the gluteal muscles the external bony wall of the posterior iliac crest is exposed. The external cortical bone is cut and harvested in the same way as we described for the anterior iliac crest and the wound is closed similarly (Fig. 3a—c). The time taken for positioning either supine or prone was recorded. Intraoperative and perioperative complications were documented and photographed. We paid special attention to those complications that are most often mentioned by other authors, including the formation of haematomas or seromas, infections, herniation, injuries to nerves, disturbances of gait and fractures. All patients required bed rest for the first 24-h, and were then mobilised on the second postoperative day. Disturbances of gait—–including limp, unsteadiness and deviation—–were documented on days 14 and 28 after operation. The assessment was made in accordance with those in the trial published by Marx and Morales.8 On the third postoperative day patients were asked to estimate pain from where bone had been harvested using to a visual analogue scale from 0 to 10 (0: no pain; 10: maximum pain).
Results A mean volume of 15 cm3 (range: 9—25.5) was harvested from the iliac crest, which included monocortical bone chips, bicortical bone chips, and bone taken with the punch needle. The mean volume har-
Figure 3. (a) Exposure of the posterior site of harvesting in the iliac crest. (b) Vertical osteotomy with the oscillating saw. (c) Exposure of cancellous bone between the inner and outer table of the posterior iliac crest.
54
Table 1
P. Kessler et al.
Complication after harvesting from the anterior and posterior iliac crest.
Complication
Anterior (n = 81)
Posterior (n = 46)
Total (n = 127)
p-value
Seroma Haematoma Infection Hyperaesthesia Total Pain
1 7 1 1 10 57
3 (6%) (4%) 0 0 5 (11%) 15 (33%)
4 9 1 1 15 72
<0.001
Irregularities of gait After 2 weeks After 4 weeks
26 (32%) 8 (10%)
(1%) (9%) (1%) (1%) (12%) (70%)
3 (6%) 1 (2%)
(3%) (7%) (1%) (1%) (12%) (57%)
29 (23%) 9 (7%)
0.002
Figures are number (%).
vested in the anterior iliac crest was 9 cm3 (range: 5—12) (n = 81) and from the posterior iliac crest 25.5 cm3 (range: 17—29) (n = 46). The mean operation time was 35 min (range: 22—48) for bone harvested from the anterior iliac crest and 40 min (range: 32—55) for the posterior iliac crest. These times do not include preparation of the area around the head and neck and for changing the position of the patient for harvesting bone from the posterior iliac crest. This manoeuvre took an additional mean time of 20 min (range: 14—27). Complications developed in 15 patients (12%) (Table 1). They developed only in those patients from whom large volumes of bone over 17 cm3 had been harvested (Fig. 4a and b). After harvesting bone from the posterior iliac crest two patients developed haematomas and three patients seromas. After harvesting bone from the anterior iliac crest seven patients developed haematomas. In one patient after harvesting from the anterior iliac crest an infection developed after the discharge of a seroma (Table 1). Another patient in this group complained of dysaesthesia in the area innervated by the lateral cutaneous nerve of the thigh. This dis-
turbance continued for 6 months, after which nerve function recovered and after 1 year there was no difference from the opposite side. Haematomas and seromas were treated by puncture and drainage. An infected seroma was widely incised and a broadspectrum antibiotic was given for 4 weeks. The wound healed and after 6 weeks the patient was free of complaints. Pain was reported by 57 (71%) of the 81 patients after harvesting from the anterior iliac crest, but by only 15 (33%) of the 46 patients after the posterior approach. Ibuprofen 600 mg or paractamol 250 or 500 mg were given three times a day to all patients for the first 3 postoperative days. The pain was then under control and decreased remarkably during the following 28 days. No patient had severe long-lasting pain. Two weeks after operation irregularities of gait were seen in 26 (32%) of the 81 patients after harvesting bone from the anterior iliac crest, but in only three patients (6%) after the posterior approach. After 4 weeks eight patients who had had the anterior operation still had problems in walking, whereas in the other group only one patient still
Figure 4. Augmentation of the maxilla. Fixation of corticocancellous bone blocks (a) laterally and (b) vertically.
Harvesting of bone from the iliac crest had problems. The complaints of the latter group referred more to getting up than walking. There were no fractures or hernias.
Discussion The use of autogenous bone from the iliac crest for augmentation and osteoplasties in the upper and lower jaw has been a well-established, reliable and uncomplicated technique in oral and maxillofacial surgery for many years.7,8 Complications at the donor site, however, are common. They include pain and bleeding, injuries to sensory nerves, and the risk of pelvic fractures.8—12 Sawin et al. and Heary et al. reported high incidences of persisting pain.11,13 Sawin et al. compared donor site morbidity after harvesting bone from ribs and iliac crest. The morbidity of the latter was significantly greater than that of the former. Chronic donor site pain was present in 25% of the patients after harvesting from the iliac crest. Heary et al. compared the surgeons’ estimation of morbidity with the true incidence after harvesting from the iliac crest. Pain at the donor site was reported in 34% of the patients interviewed and was significantly higher than anticipated by the surgeons. Nkenke et al. reported significantly more pain at the donor site after harvesting from the anterior iliac crest than after the posterior operation. After 4 weeks no major differences between the locations was found.9 Mirovsky and Neuwirth reported considerable pain in the region of the donor site as long as 2 years after harvesting from the iliac crest.10 The pelvis offers cortical, cancellous and corticocancellous bone in sufficient volume for all indications in the maxillofacial field. In our series we found the overall rate of complication was 12% and the anterior approach to the ilium caused considerably more problems than the posterior approach. Other authors have reported similar results.14—16 whereas others have reported higher rates of complications.17—19 In oral and maxillofacial surgery the anterior approach to the iliac crest is more widely used than the posterior approach.9 In our and Nkenke et al.’s studies the posterior approach caused fewer postoperative problems for patients.8 The main advantage of the posterior iliac crest region is that up to three times more cancellous bone can be obtained for transplantation. In our opinion the disadvantages of a slightly prolonged operation time, the necessity to change the position of the patient, and the restriction to harvest only monocortical bone grafts seem to be less
55 important. Even preserving the iliac cortices while taking bone grafts does not reduce the postoperative morbidity.10 In adult patients, particularly in those cases, in which large volumes of bone are required, we prefer the posterior approach to the iliac crest (Fig. 4a and b).13 The patients have significantly less pain and fewer irregularities of gait. In patients with cleft-lip or palate, however, the anterior iliac crest should be used as the amount of bone needed is usually not as great as in operations for augmentation of atrophic alveolar processes.
References ¨ ber die Beseitigung der trauma-tischen 1. Lindemann A. U Defekte der Gesichtsknochen. In: Bruhn C., editor. Die gegenw¨ artigen Behandlungswege der Kieferschußverletzungen. Bergmann: Wiesbaden; 1915. p. IV—VI. 2. Dick IL. Iliac-bone transplantation. J Bone Jt Surg 1946; 28A:1—5. 3. Dingman RO. The use of iliac bone in the repair of facial and cranial defects. Plast Reconstr Surg 1950;6:179— 83. 4. Bloomquist DS, Feldman GR. The posterior ilium as a donor site for maxillofacial bone grafting. J Maxillofac Surg 1980;8:60—4. 5. Chan K, Resnick D, Pathria M, Jacobson J. Pelvic instability after bone graft harvesting from posterior iliac crest: report of nine patients. Skelet Radiol 2001;30:278— 81. 6. Marx RE, Morales MJ. Morbidity from bone harvest in major jaw reconstruction: a randomized trial comparing the lateral anterior and posterior approaches to the ilium. J Oral Maxillofac Surg 1988;48:196—203. 7. Sandor GK, Rittenberg BN, Clokie CM, Caminiti MF. Clinical success in harvesting autogenous bone using a minimally invasive trephine. J Oral Maxillofac Surg 2003;61: 164—8. 8. Nkenke E, Weisbach V, Winckler E, Kessler P, SchultzeMosgau S, Wiltfang J, et al. Morbidity of harvesting of bone grafts from the iliac crest for preprosthetic augmentation procedures: a prospective study. Int J Oral Maxillofac Surg 2004;33:157—63. 9. Eufinger H, Leppanen H. Iliac crest donor site morbidity following open and closed methods of bone harvest for alveolar cleft osteoplasty. J Craniomaxillofac Surg 2000;28:31—8. 10. Mirovsky Y, Neuwirth MG. Comparison between the outer table and intracortical methods of obtaining autogenous bone graft from the iliac crest. Spine 2000;25:1722—5. 11. Sawin PD, Traynelis VC, Menezes AH. A comparative analysis of fusion rates and donor-site morbidity for autogeneic rib and iliac crest bone grafts in posterior cervical fusions. J Neurosurg 1998;88:255—65. 12. Heary RF, Schlenk RP, Sacchierei TA, Barone D, Brotea C. Persistent iliac crest donor site pain: independent outcome assessment. Neurosurgery 2002;50:510—6. 13. Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P. Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes. J Bone Jt Surg Am 2002;84A:716—20.
56 14. Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA. Complications of iliac crest bone harvesting. Clin Orthop 1996;329:300—9. 15. Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine 1995;20:1055—60. 16. Gerngross H, Burri C, Kinzl L, Merk J, M¨ uller GW. Komplikationen an den Entnahmestellen autologer Spongosatransplantate [Complications at removal sites of autologous cancellous bone transplants]. Aktuelle Traumatol 1982;12:146—52.
P. Kessler et al. 17. Colterjohn NR, Bednar DA. Procurement of bone graft from iliac crest. An operative approach with decreased morbidity. J Bone Jt Surg 1997;79A:756—9. 18. Goulet JA, Senunas LE, De Silva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop 1997;339:76—81. 19. Wippermann BW, Schratt HE, Steeg S, Tscherne G. Komplikationen der Spongiosaentnahme am Beckenkamm. Eine retrospektive Analyse von 1191 F¨ allen [Complications of spongiosa harvesting of the iliac crest. A retrospective analysis of 1,191 cases]. Chirurg 1997;68:1286—91.
INTERESTING CASE: Foreign body in the nose: an orbital silastic sheet had migrated into the nasal cavity
Figure 2 Silastic sheets seen from the side. with a six-month history of nasal discharge. On examination she had enophthalmos, and nasendoscopy showed opaque mucus in the right middle meatus. Coronal computed tomography (CT) showed the Silastic implant embedded in the nasal septum (Fig. 1). Endoscopic removal of the Silastic sheets (Fig. 2) and a middle meatal antrostomy led to a dramatic improvement in her symptoms at follow up after three weeks. This is a rare complication and shows the importance of radiological imaging in patients with a unilateral nasal discharge. C. Groombridge J. McGuinness
Figure 1 Coronal CT showing the Silastic implant embedded in the nasal septum together with obstruction of the right infundibulum. Blowout fractures of the orbital floor are commonly repaired with Silastic sheets.1 After such a repair, a 29-year-old woman was referred to the Royal National Throat Nose & Ear hospital
Harvesting of bone from the iliac crest—–comparison of the anterior and posterior sites P. Kessler∗, M. Thorwarth, A. Bloch-Birkholz, E. Nkenke, F.W. Neukam Department of Oral and Maxillofacial Surgery, University Hospital Erlangen-Nuremberg, Gl¨ uckstrasse 11, D-91054 Erlangen, Germany Accepted 26 August 2004
KEYWORDS Iliac crest; Augmentation; Bone transplantation
Summary In 1998 we harvested a total of 127 bone grafts from the iliac crest of 65 male and 53 female patients aged 8—80 years. We measured the quantity of bone obtained, the operating time and the donor site morbidity of the anterior approach (n = 81) compared with the posterior approach (n = 46). The mean volume of bone harvested was 15 cm3 (range: 9—25.5) of monocorticocancellous- or bicorticocancellous bone chips or those from a trephine bur. The mean operating time for the anterior approach was 35 min (range: 22—48), for the posterior approach 40 min (range: 32—55). There were 15 complications, which were limited to those in whom the volume of bone exceeded 17 cm3 . The posterior approach caused less morbidity, notably in the form of significantly less pain and irregularity of gait. The patient has, however, to be repositioned during operation, which added to its total duration. © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction For more than four decades the iliac crest has been the accepted place to get bone for augmentation in orthopaedic, neurosurgery and oral and maxillofacial surgery. In oral and maxillofacial surgery the main indications are secondary and tertiary osteoplasty in patients with cleft-lip and palate, augmen* Corresponding author. Tel.: +49 9131 8533616; fax: +49 9131 8534219. E-mail address: [email protected] (P. Kessler).
tation of bony defects after operations for tumours or large cysts, and augmentation in preprosthetic surgery for severe cases of atrophy of the alveolar crest from early loss of teeth or the aging process. Lindemann reported in 1915 the harvesting of bone from the anterior iliac crest to reconstruct mandibular bone defects after gunshot injuries.1 Dick2 reported the use of the posterior iliac crest as a donor site in orthopaedic surgery. In oral and maxillofacial surgery Dingman reported the transplantation of large segments of bone from the anterior iliac crest to reconstruct the mandible after resection of tumours. He extended the donor site from
0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2004.08.026
52 the anterior to the posterior iliac crest.3 Bloomquist and Feldman described the use of the posterior iliac crest for harvesting bone.4 The main advantages of the iliac crest is its easy accessibility, the possibility of harvesting large amounts of bone, and the ability to close the wound primarily. Previous studies, however, have shown many complications after harvesting bone from the iliac crest.13 The anterior iliac crest is more accessible than the posterior iliac crest as a donor region and bicortical grafts can be taken. Preparation of the receptor site in the head and neck and the harvesting of bone can be done simultaneously. There are, however, two disadvantages: the bicortical bone layers between the internal and external cortices below the anterior iliac crest are as thin as a blade, often making it difficult to obtain a sufficient bone volume. The other disadvantage is the risk of fracturing the anterior iliac spine, which results in a long-lasting obstacle to walking and climbing stairs.5 As the bicortical width of the bone layer beneath the posterior iliac crest does not shrink this region always offers enough cortical and cancellous bone for augmentation even in cases of extreme alveolar atrophy or for the reconstruction of large bony defects. Some authors have claimed that there is considerably less morbidity after harvesting bone from the posterior region as irregularities of gait do not occur, the patient can be mobilised earlier, and has less pain.6 The main disadvantage is the necessity to turn the patient in the course of the operation, which lengthens the operating time. The varying data about the morbidity of harvesting bone from the anterior compared with the posterior iliac crest were the reason for an evaluation of our own results. This prospective, non-randomised study was conducted in 1998 and compares the amount of bone harvested, the operating time, and the postoperative morbidity.
P. Kessler et al. terior iliac crest was chosen in all patients with cleft-lip or palate and in patients with large cystic lesions. Only cancellous bone was harvested in these two groups. The anterior iliac crest was also preferred if only one quadrant of the jaws had to be augmented by onlay grafting, and for a sinus lift operation in patients with highly atrophic alveolar processes. For defects after resection of tumours or trauma the anterior iliac site was used, if the defects could be reconstructed by a maximum of two or three corticocancellous bone strips about 40—50 mm long and 10—12 mm wide. Antibiotic prophylaxis (penicillin 10 million units intravenously) was started the evening before operation and was continued twice a day until the evening of the second postoperative day. A steroid (prednisolone) was also given (250 mg morning and evening on the day of operation, and 125 mg morning and evening on the first postoperative day). Criteria for exclusion from harvesting bone from the iliac crest were previous operations in this area; systemic bony or neurological diseases; or longstanding treatment with steroids, immunosuppressive drugs, chemotherapy in the previous 2 months, or drug misuse in the previous 3 months. All patients were operated on under general anaesthesia. For harvesting bone from the anterior iliac crest the patient lies supine. The pelvis is raised about 30◦ by underlying towels. The skin over the iliac crest is put under stretch by placing a fist above the iliac crest and pushing the abdominal wall medially. The skin incision is about 50 mm long, starts about 20 mm behind the anterior iliac spine and runs parallel to the iliac crest (Fig. 1). After relaxing the skin the incision line finally lies about 20 mm lateral to the iliac crest, avoiding mechanical irritation of the scar by tight clothes or a waistband. After the skin incision we make a
Patients and methods In 1998 we operated on 118 patients and took bone grafts from the iliac crest on 127 occasions. In 81 cases the bone was harvested from the anterior iliac crest, in 46 from the posterior. There were 65 men and 53 women. The mean age was 44 years (range: 8—80). The indications for harvesting bone and grafting were bony defects after resection of tumours (n = 40), extreme atrophy of the upper and lower alveolar crests (n = 33), cleft-lip or palatal defects (n = 25), defects after removal of large cysts (n = 17), and posttraumatic defects (n = 12). The an-
Figure 1. Anterior iliac crest. The incision line is parallel and lateral to the iliac crest (dotted line).
Harvesting of bone from the iliac crest
Figure 2. Anterior iliac crest showing exposure of the superior crest.
blunt dissection of the subcutaneous tissues until the periosteum of the iliac crest is found (Fig. 2). Bleeding is avoided by meticulous haemostasis, the periosteum of the iliac crest is incised, and the periosteal layer with the iliac muscle dissected bluntly medially. The iliac fossa is dissected to a depth of about 80 mm. After inserting a retractor an oscillating saw is used to cut parallel strips of monocortical bone from the inner table of the pelvic bone at right angles to the line of the iliac crest. These strips are about 15 mm wide (Fig. 3b). Cancellous bone is then harvested using a sharp spoon. The area of the defect is rinsed several times before a collagenous tampon (Gelita TamponTM , B. Braun Aesculap, Tuttlingen, Germany) is inserted to stop bleeding from the surrounding cancellous bone. The wound is then closed in layers and a pressure bandage applied over the area of the iliac crest. In adolescents we use only the anterior approach to the iliac crest. In these patients the cartilage covering the iliac crest is incised after the fashion of a double door. After the bone has been harvested
53 the cartilage cover is replaced and sutured with absorbable sutures. The posterior incision is made with the patient prone. The incision is about 80 mm long, follows a diagonal line from a cranial and medial position below and laterally and crosses the posterior iliac crest. This incision is a safe way to protect the gluteal branches of the posterior cutaneous nerves. After blunt dissection of the gluteal muscles the external bony wall of the posterior iliac crest is exposed. The external cortical bone is cut and harvested in the same way as we described for the anterior iliac crest and the wound is closed similarly (Fig. 3a—c). The time taken for positioning either supine or prone was recorded. Intraoperative and perioperative complications were documented and photographed. We paid special attention to those complications that are most often mentioned by other authors, including the formation of haematomas or seromas, infections, herniation, injuries to nerves, disturbances of gait and fractures. All patients required bed rest for the first 24-h, and were then mobilised on the second postoperative day. Disturbances of gait—–including limp, unsteadiness and deviation—–were documented on days 14 and 28 after operation. The assessment was made in accordance with those in the trial published by Marx and Morales.8 On the third postoperative day patients were asked to estimate pain from where bone had been harvested using to a visual analogue scale from 0 to 10 (0: no pain; 10: maximum pain).
Results A mean volume of 15 cm3 (range: 9—25.5) was harvested from the iliac crest, which included monocortical bone chips, bicortical bone chips, and bone taken with the punch needle. The mean volume har-
Figure 3. (a) Exposure of the posterior site of harvesting in the iliac crest. (b) Vertical osteotomy with the oscillating saw. (c) Exposure of cancellous bone between the inner and outer table of the posterior iliac crest.
54
Table 1
P. Kessler et al.
Complication after harvesting from the anterior and posterior iliac crest.
Complication
Anterior (n = 81)
Posterior (n = 46)
Total (n = 127)
p-value
Seroma Haematoma Infection Hyperaesthesia Total Pain
1 7 1 1 10 57
3 (6%) (4%) 0 0 5 (11%) 15 (33%)
4 9 1 1 15 72
<0.001
Irregularities of gait After 2 weeks After 4 weeks
26 (32%) 8 (10%)
(1%) (9%) (1%) (1%) (12%) (70%)
3 (6%) 1 (2%)
(3%) (7%) (1%) (1%) (12%) (57%)
29 (23%) 9 (7%)
0.002
Figures are number (%).
vested in the anterior iliac crest was 9 cm3 (range: 5—12) (n = 81) and from the posterior iliac crest 25.5 cm3 (range: 17—29) (n = 46). The mean operation time was 35 min (range: 22—48) for bone harvested from the anterior iliac crest and 40 min (range: 32—55) for the posterior iliac crest. These times do not include preparation of the area around the head and neck and for changing the position of the patient for harvesting bone from the posterior iliac crest. This manoeuvre took an additional mean time of 20 min (range: 14—27). Complications developed in 15 patients (12%) (Table 1). They developed only in those patients from whom large volumes of bone over 17 cm3 had been harvested (Fig. 4a and b). After harvesting bone from the posterior iliac crest two patients developed haematomas and three patients seromas. After harvesting bone from the anterior iliac crest seven patients developed haematomas. In one patient after harvesting from the anterior iliac crest an infection developed after the discharge of a seroma (Table 1). Another patient in this group complained of dysaesthesia in the area innervated by the lateral cutaneous nerve of the thigh. This dis-
turbance continued for 6 months, after which nerve function recovered and after 1 year there was no difference from the opposite side. Haematomas and seromas were treated by puncture and drainage. An infected seroma was widely incised and a broadspectrum antibiotic was given for 4 weeks. The wound healed and after 6 weeks the patient was free of complaints. Pain was reported by 57 (71%) of the 81 patients after harvesting from the anterior iliac crest, but by only 15 (33%) of the 46 patients after the posterior approach. Ibuprofen 600 mg or paractamol 250 or 500 mg were given three times a day to all patients for the first 3 postoperative days. The pain was then under control and decreased remarkably during the following 28 days. No patient had severe long-lasting pain. Two weeks after operation irregularities of gait were seen in 26 (32%) of the 81 patients after harvesting bone from the anterior iliac crest, but in only three patients (6%) after the posterior approach. After 4 weeks eight patients who had had the anterior operation still had problems in walking, whereas in the other group only one patient still
Figure 4. Augmentation of the maxilla. Fixation of corticocancellous bone blocks (a) laterally and (b) vertically.
Harvesting of bone from the iliac crest had problems. The complaints of the latter group referred more to getting up than walking. There were no fractures or hernias.
Discussion The use of autogenous bone from the iliac crest for augmentation and osteoplasties in the upper and lower jaw has been a well-established, reliable and uncomplicated technique in oral and maxillofacial surgery for many years.7,8 Complications at the donor site, however, are common. They include pain and bleeding, injuries to sensory nerves, and the risk of pelvic fractures.8—12 Sawin et al. and Heary et al. reported high incidences of persisting pain.11,13 Sawin et al. compared donor site morbidity after harvesting bone from ribs and iliac crest. The morbidity of the latter was significantly greater than that of the former. Chronic donor site pain was present in 25% of the patients after harvesting from the iliac crest. Heary et al. compared the surgeons’ estimation of morbidity with the true incidence after harvesting from the iliac crest. Pain at the donor site was reported in 34% of the patients interviewed and was significantly higher than anticipated by the surgeons. Nkenke et al. reported significantly more pain at the donor site after harvesting from the anterior iliac crest than after the posterior operation. After 4 weeks no major differences between the locations was found.9 Mirovsky and Neuwirth reported considerable pain in the region of the donor site as long as 2 years after harvesting from the iliac crest.10 The pelvis offers cortical, cancellous and corticocancellous bone in sufficient volume for all indications in the maxillofacial field. In our series we found the overall rate of complication was 12% and the anterior approach to the ilium caused considerably more problems than the posterior approach. Other authors have reported similar results.14—16 whereas others have reported higher rates of complications.17—19 In oral and maxillofacial surgery the anterior approach to the iliac crest is more widely used than the posterior approach.9 In our and Nkenke et al.’s studies the posterior approach caused fewer postoperative problems for patients.8 The main advantage of the posterior iliac crest region is that up to three times more cancellous bone can be obtained for transplantation. In our opinion the disadvantages of a slightly prolonged operation time, the necessity to change the position of the patient, and the restriction to harvest only monocortical bone grafts seem to be less
55 important. Even preserving the iliac cortices while taking bone grafts does not reduce the postoperative morbidity.10 In adult patients, particularly in those cases, in which large volumes of bone are required, we prefer the posterior approach to the iliac crest (Fig. 4a and b).13 The patients have significantly less pain and fewer irregularities of gait. In patients with cleft-lip or palate, however, the anterior iliac crest should be used as the amount of bone needed is usually not as great as in operations for augmentation of atrophic alveolar processes.
References ¨ ber die Beseitigung der trauma-tischen 1. Lindemann A. U Defekte der Gesichtsknochen. In: Bruhn C., editor. Die gegenw¨ artigen Behandlungswege der Kieferschußverletzungen. Bergmann: Wiesbaden; 1915. p. IV—VI. 2. Dick IL. Iliac-bone transplantation. J Bone Jt Surg 1946; 28A:1—5. 3. Dingman RO. The use of iliac bone in the repair of facial and cranial defects. Plast Reconstr Surg 1950;6:179— 83. 4. Bloomquist DS, Feldman GR. The posterior ilium as a donor site for maxillofacial bone grafting. J Maxillofac Surg 1980;8:60—4. 5. Chan K, Resnick D, Pathria M, Jacobson J. Pelvic instability after bone graft harvesting from posterior iliac crest: report of nine patients. Skelet Radiol 2001;30:278— 81. 6. Marx RE, Morales MJ. Morbidity from bone harvest in major jaw reconstruction: a randomized trial comparing the lateral anterior and posterior approaches to the ilium. J Oral Maxillofac Surg 1988;48:196—203. 7. Sandor GK, Rittenberg BN, Clokie CM, Caminiti MF. Clinical success in harvesting autogenous bone using a minimally invasive trephine. J Oral Maxillofac Surg 2003;61: 164—8. 8. Nkenke E, Weisbach V, Winckler E, Kessler P, SchultzeMosgau S, Wiltfang J, et al. Morbidity of harvesting of bone grafts from the iliac crest for preprosthetic augmentation procedures: a prospective study. Int J Oral Maxillofac Surg 2004;33:157—63. 9. Eufinger H, Leppanen H. Iliac crest donor site morbidity following open and closed methods of bone harvest for alveolar cleft osteoplasty. J Craniomaxillofac Surg 2000;28:31—8. 10. Mirovsky Y, Neuwirth MG. Comparison between the outer table and intracortical methods of obtaining autogenous bone graft from the iliac crest. Spine 2000;25:1722—5. 11. Sawin PD, Traynelis VC, Menezes AH. A comparative analysis of fusion rates and donor-site morbidity for autogeneic rib and iliac crest bone grafts in posterior cervical fusions. J Neurosurg 1998;88:255—65. 12. Heary RF, Schlenk RP, Sacchierei TA, Barone D, Brotea C. Persistent iliac crest donor site pain: independent outcome assessment. Neurosurgery 2002;50:510—6. 13. Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P. Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes. J Bone Jt Surg Am 2002;84A:716—20.
56 14. Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA. Complications of iliac crest bone harvesting. Clin Orthop 1996;329:300—9. 15. Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine 1995;20:1055—60. 16. Gerngross H, Burri C, Kinzl L, Merk J, M¨ uller GW. Komplikationen an den Entnahmestellen autologer Spongosatransplantate [Complications at removal sites of autologous cancellous bone transplants]. Aktuelle Traumatol 1982;12:146—52.
P. Kessler et al. 17. Colterjohn NR, Bednar DA. Procurement of bone graft from iliac crest. An operative approach with decreased morbidity. J Bone Jt Surg 1997;79A:756—9. 18. Goulet JA, Senunas LE, De Silva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop 1997;339:76—81. 19. Wippermann BW, Schratt HE, Steeg S, Tscherne G. Komplikationen der Spongiosaentnahme am Beckenkamm. Eine retrospektive Analyse von 1191 F¨ allen [Complications of spongiosa harvesting of the iliac crest. A retrospective analysis of 1,191 cases]. Chirurg 1997;68:1286—91.
INTERESTING CASE: Foreign body in the nose: an orbital silastic sheet had migrated into the nasal cavity
Figure 2 Silastic sheets seen from the side. with a six-month history of nasal discharge. On examination she had enophthalmos, and nasendoscopy showed opaque mucus in the right middle meatus. Coronal computed tomography (CT) showed the Silastic implant embedded in the nasal septum (Fig. 1). Endoscopic removal of the Silastic sheets (Fig. 2) and a middle meatal antrostomy led to a dramatic improvement in her symptoms at follow up after three weeks. This is a rare complication and shows the importance of radiological imaging in patients with a unilateral nasal discharge. C. Groombridge J. McGuinness
Figure 1 Coronal CT showing the Silastic implant embedded in the nasal septum together with obstruction of the right infundibulum. Blowout fractures of the orbital floor are commonly repaired with Silastic sheets.1 After such a repair, a 29-year-old woman was referred to the Royal National Throat Nose & Ear hospital