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Iliac crest donor site morbidity following open and closed methods of bone harvest for alveolar cleft osteoplasty
Journal of Cranio-Maxillofacial Surgery (2000) 28, 31±38 # 2000 European Association for Cranio-Maxillofacial Surgery doi:10.1054/jcms.1999.0105, available online at http://www.idealibrary.com on
Iliac crest donor site morbidity following open and closed methods of bone harvest for alveolar cleft osteoplasty Harald Eu®nger, Heikki LeppaÈnen Department of Oral & Maxillofacial Surgery, Facial Plastic Surgery, Ruhr-University, Bochum, Germany SUMMARY. Donor site morbidity after bone harvesting still remains a crucial problem in alveolar cleft osteoplasty. This study focuses on ilium donor site morbidity comparing two dierent techniques. A series of 52 consecutive patients was divided in half. All had anterior iliac crest bone grafts. In the study group the harvesting was performed with a closed osteotomy using a cylindrical Shepard osteotome. The control group underwent the traditional open osteotomy. In the open osteotomy group the short-term morbidity at the donor site was slightly greater than in the closed harvesting group. The low short-term morbidity in the closed harvesting group was re¯ected in the analgesic consumption which was three times higher in the open osteotomy group ( p50.008). The most striking dierence occurred in the appearance of the mature scar: a length of 24.2 mm (mean) in the closed harvesting group against 60.3 mm in the open osteotomy group ( p50.0001), and a width of 4.9 mm (mean) versus 7.7 mm, respectively ( p50.003). The long-term morbidity was negligible in both groups. Based on these ®ndings we suggest that bone harvesting from the anterior iliac crest remains the preferred method, provided that closed harvesting is undertaken. # 2000 European Association for Cranio-Maxillofacial Surgery
INTRODUCTION
Kortebein et al., 1991; Sadove et al., 1990; SindetPedersen and Enemark, 1990; Thaller et al., 1991; Wolfe and Berkowitz, 1983). Hence the mandibular symphysis or the calvarial sites have been advocated recently because of morbidity at these donor sites should be considerably less than at the iliac crest (Baehr and Coulon, 1996; Borstlap et al., 1990; Harsha et al., 1986; Koole et al., 1989; Kortebein et al., 1991; Sadove et al., 1990; Sindet-Pedersen and Enemark, 1990; Wolfe and Berkowitz, 1983). However, among others, Canady et al. (1993) concluded that the iliac crest is a suitable site to harvest cancellous bone for alveolar defect grafting and should not be rejected solely because of concerns regarding excessive morbidity. In 1984 Scott et al. presented a closed method of procuring cancellous bone from the iliac crest with a medium-sized curette via a 2.5 cm incision. The authors had performed this procedure in 150 cases without complications. Early ambulation was possible as muscle stripping was entirely eliminated. In 1985 Caddy and Reid described a similar technique for secondary alveolar reconstruction. They used a bone biopsy set to trephine cores of autogenous cancellous bone from the ilium. The method was tested ®rst in a cadaver and then applied in 10 clinical cases. The authors found the aesthetic and functional results at the donor site to be superior to the conventional open osteotomy. Thaller et al. (1991) also used a bone biopsy trephine. Relating their experience from 24 patients they recommended this technique when signi®cant reduction of donor site morbidity is required. Furthermore it was to be
Autogenous bone grafting of the alveolar cleft is well established. The prevailing consensus states that the best results in alveolar bone grafting are achieved when the procedure is performed prior to the eruption of the permanent canine (Boyne and Sands, 1972; Kortebein et al., 1991). In Europe the procedure is called `secondary alveolar osteoplasty' when it is performed in the mixed dentition phase. Various donor sites for alveolar cleft grafting have been described and the preferred site has been a matter for debate for many years. At present the main sources for autogenous bone are iliac crest, calvarium and mandibular symphysis. Numerous reports suggest that autogenous bone graft harvesting of the ilium is the gold standard with which all other types of alveolar grafts should be compared (Canady et al., 1993; van Damme and Merkx, 1996; Jackson et al., 1986; Kalk et al, 1996; Kline and Wolfe, 1995; Stoelinga et al., 1990). However, some authors have suggested that the iliac crest donor site produces an unacceptably high degree of postoperative morbidity, such as persistent pain, prolonged recovery time, haemorrhage, limping, visible scarring, bone contour deformities, lesions of the lateral femoral cutaneous nerve, meralgia paraesthetica, pelvic fracture and peritonitis (Beirne et al., 1996; Borstlap et al., 1990; Caddy and Reid, 1985; Dawson et al., 1996; Harsha et al., 1986; Ilankovan et al., 1998; Koole et al., 1989; This paper is dedicated to our teacher Prof. Dr Dr Egbert Machtens on the occasion of his 65th birthday. 31
32 Journal of Cranio-Maxillofacial Surgery
performed as an outpatient procedure, and is particularly suitable in Third World countries. In 1987 Shepard and Dierberg developed a special cylindrical osteotome for this purpose. Their aim was to perform bone harvesting from the iliac crest with minimum invasiveness using local anaesthesia. They noted the disadvantage in the trephine devices of that time, namely, that the bone graft was often left attached as the instrument was withdrawn. To solve this problem a cylindrical osteotome with luminal tines was developed in order to separate the graft at the tip of the osteotome when it is rotated. The instrument set comprises four main parts: the ®rst is a surface cutter designed to cut through the outer cortical bone, the other three components are the actual osteotomes with dierent diameters. The instruments are able to remove bone cylinders of up to 5 cm in length. Operative technique consists of making a 2.5 cm incision over the iliac crest. The authors used local anaesthesia in their series taking care to inject beneath the periosteum. The incision was made sharply down to the periosteum, and retractors were used to expose the bone. The mallet was then used to tap the cortex cutter about 0.5 cm into the bone to remove a small cortical disk of it. The cylindrical osteotome of appropriate diameter was then driven into the cancellous bone with a mallet. A 908 twist of the instrument separated the rod of bone when the appropriate depth was achieved. The cancellous bone cylinder was then extracted. Several bone grafts may be harvested through the initial plug hole by varying the direction of the cylindrical osteotome (Fig. 1). After sucient bone had been harvested, the cortical bone disk was replaced and a standard wound closure was performed (Shepard and Dierberg, 1987). In 1995 this closed harvesting technique with the instruments recommended by Shepard and Dierberg
(1987) was adopted in our department and has been successfully used since then. The aim of this study was to evaluate two dierent techniques of harvesting anterior iliac crest bone, namely the traditional open osteotomy and the closed technique. Finally, a modi®cation of the instruments used in our closed bone harvesting procedure is described. MATERIAL AND METHODS During the period 1993±98, 52 patients with a unilateral or bilateral cleft lip alveolus and palate were operated on for reconstruction of the alveolar process. Preoperative orthodontic transverse maxillary expansion and alignment of teeth was completed. All 52 consecutive patients received alveolar bone grafts from the anterior iliac crest. In bilateral cases both sides were reconstructed simultaneously. The prevalent open osteotomies of the hip gradually decreased in our clinic as the closed bone harvesting technique was newly adopted in the summer 1995. Half of these patients had their iliac bone harvesting performed with the open osteotomy, the remaining 26 patients underwent the closed harvesting method using the Shepard osteotome (Shepard and Dierberg, 1987). With our main interest being the donor site morbidity, this study did not record the graft success rate, graft resorption, or tooth eruption at the recipient site. Instead, operating time and technique, postoperative pain medication, subjective pain sensation, complications, length and width of the mature scar, bone contour de®cits and nerve paraesthesia were recorded allowing short- and long-term morbidity to be compared in both patient groups. In the traditional open osteotomy technique group the male-female ratio was 15 : 11 and the mean age at operation was 9.6 years (range 7±20 years). Nineteen
Fig. 1 ± Amount of bone that can be obtained from a child with the use of the 6 mm osteotome via a single incision. The closed harvesting technique allows directional variation of the cylindrical osteotome between the cortical iliac plates from one crestal access site, producing a further cancellous cylinder with each new insertion.
Donor site morbidity 33
patients had a unilateral and seven a bilateral cleft. The bone harvesting was performed under general anaesthesia. The donor site was located on the anterior crest, well behind the anterior superior iliac spine. An incision was made, in most cases lateral to the crest with minimal undermining. The bone harvesting was carried out using an osteotome or an oscillating saw after the cartilage cap (pedicled) had been re¯ected medially or laterally. Often a sharp spongiosa curettage would complete the procedure. The sharp bony edges were smoothed and the crest cap was sutured back into position. Finally haemostasis was achieved using bone wax or collagen material. The soft tissues were closed in layers and the skin with continuous sutures. A pressure dressing with elastic tape was left in place, usually for 24 h. Drains were often used in this group and in most cases they were removed on the ®rst or second postoperative day. The second group comprised 26 patients whose bone was harvested with a cylindrical trephine, developed and described by Shepard and Dierberg (1987). The male±female ratio was 17 : 9 the mean age at operation 12.2 years (range 8±31 years). A unilateral cleft was treated in 21 cases and a bilateral one in ®ve cases. In the closed harvesting procedure the instrument was tapped into the bone through a sucient opening in the soft tissue. When more bone was required, the spongiosa cylinders were detached in an arc like fashion. After harvesting, a layered soft tissue closure was performed and a pressure dressing was left in place for 24 h. In this group drains were hardly ever used, a few had mini-vac wound drains which were removed on the ®rst postoperative day. In both groups the patients received prophylactic perioperative penicillin (or clindamycin in case of penicillin allergy). The postoperative care was similar and consisted of daily hip wound cleansing and removal of the skin sutures after approximately one week. All patients were mobilized early, mostly on the ®rst postoperative day, and discharged after 8±12 days. Supporting physiotherapy was oered when needed. Patients received all necessary pain relief on demand, which consisted of paracetamol 250 or 500 mg suppositories or pills. The 52 patients were invited for an interview and examination after a follow-up period varying between 1 and 6 years. Donor site morbidity was evaluated using three methods: 1. A 3-page questionnaire with a patient interview, which in its ®rst part dealt with immediate postoperative donor site morbidity. The experienced morbidity was estimated using a graduated scale from 1±6, similar to the one used at German schools, mark 1 being painfree and mark 6 meaning extremely painful. The present hip morbidity was evaluated to obtain information about long-term morbidity and was again scored on the scale 1 to 6 with 1 meaning very good, or normal compared with the non-operated side, whilst 6 meant the worst
possible. The appearance of the hip wound was also questioned using the same scale. 2. The mature scar length, width, unevenness, colour, bone contour and skin sensibility changes were recorded. Conspicuous and/or palpable bone de®cits were noted. 3. A survey of the patient ®les yielded details of diagnosis, operation date and time, the manner by which the bone was obtained, intraoperative problems, blood loss, wound closure, use of drains, early postoperative measures, need for pain relief, and supporting therapies. Any complications were listed. Statistical analysis of the numerical parameters obtained was performed using the unpaired (two-tailed) Student's t-test. Our adaptation of the closed harvesting method include minor modi®cations: in contrast to the original description of Shepard and Dierberg (1987) we do not use retractors to expose the bone in order to keep the incision even smaller. In addition, we ®nd the 8 mm cortex cutter and the corresponding osteotome too big to be used between the cortical plates of children's ilia and instead we use the 6 mm osteotome for both purposes, cortex cutting and graft harvesting. However, in spite of the soft, mostly cartilagenous bone cap in this age group, it was feared that the osteotome might be damaged. Therefore a 6 mm osteotome was fabricated deliberately for this indication and introduced in our set of instruments. Other centres have successfully introduced dierent modi®cations for the same purpose (Hemprich, 1998). Finally, we prefer not to replace the bone cap as we use it for grafting, especially to support the nasal alar base. RESULTS The short-term hip morbidity in the open osteotomy group yielded an average value of 2.5, estimated on a scale of 1±6 (Table 1). The best value was 1 and the worst 5. The female patients estimated their shortterm postoperative hip pain at 2.6 (mean), which did not dier signi®cantly from the male patients. Fourteen patients in this group found the alveolar wound more painful than the hip donor site, 10 patients stated the opposite, and 2 felt there was no dierence. Fifteen patients needed postoperative pain relief which in most cases consisted of paracetamol 250 mg suppositories. Some patients required 500 mg paracetamol suppositories which involved taking 250 mg dose as a calculating unit (CU) allowing comparison of the absolute received dose between both groups. Thus, in this group the overall analgesic consumption was 40 CUs, i.e. 1.5 CUs as an average dose per person. Fifteen patients needed postoperative physiotherapeutic support or crutches to mobilize. The average operation time was 2 h 50 min. The present hip morbidity was estimated at 1.3 mean, ranging from 1 to 3. One patient, (score 3), remarked
34 Journal of Cranio-Maxillofacial Surgery Table 1 ± Summary of the important parameters and statistics for short-term and long-term morbidity in both patient groups Short-term morbidity Group
Open osteotomy
Closed harvesting
n Hip pain rating Physiotherapyy Wound infection Analgesics Dose in CU t-test for the CU-dierence: p50.008, considered very signi®cant
26 patients 2.5 15 patients 0 15 patients 40 CU
26 patients 2.1 (scale 1±6) 5 patients 1 5 patients 9 CU Long-term morbidity
Group
Open osteotomy
Closed harvesting
Scar length (mean) Min Max t-test for the scar length dierence: p50.0001, considered very signi®cant
60 mm 32 mm 100 mm
24 mm 10 mm 80 mm
Scar width (mean) Min Max t-test for the scar width dierence: p50.003, considered very signi®cant Present hip `feel' Present hip looks Iliac crest de®cit Sensory alteration
that the hip wound site still hurts, and another patient expressed a feeling of constant itching. A pulling sensation and a clicking sound were occasionally reported by two other patients. The appearance of the hip donor site was assessed as 1.9 on average, suggesting patient satisfaction. The average mature scar length measured 60.3 mm with a minimum of 32 mm and a maximum of 100 mm. Average scar width was 7.7 mm. Half of the patients in this group had an unsightly hip scar with visible bony contour ¯attening or concavity, which was also readily palpable. In the closed bone harvesting patient group the average short-term hip morbidity was assessed at 2.1, with a range from 1 to 4 (Table 1). The female patients estimated their postoperative hip pain at 2.0 which conforms with the overall result of this group. Sixteen patients found that intraoral recipient site more painful than the hip donor site, and 10 patients the opposite. Only ®ve out of 26 patients needed postoperative analgesics. The dosage paracetamol in this group equals nine CUs with a calculated average of 0.4 CUs per person. Crutches or supporting physiotherapy were requested in ®ve cases. The average operation time was 2 h. The present ®ndings of the operated hip were rated at 1.1 (mean). Two patients complained of occasional itching at the hip donor site. One wound healing complication occurred consisting of a local infection and seroma at the donor site, which resolved during the ®rst postoperative week without further sequelae. The appearance of the hip donor site was rated at 1.5. Physical examination revealed an average mature scar length of 24.3 mm, (range 10±80 mm), and a width of 4.9 mm (Fig. 2). No conspicuous bone contour
7.7 mm 2.0 mm 15 mm 1.3 1.9 0 0
4.9 mm 2.0 mm 11 mm 1.1 (scale 1±6) 1.5 (scale 1±6) 0 0
de®cits were observed. Approximately half of the patients in this group had an invisible bony impression in the iliac crest corresponding with the puncture site. This palpable bony dimple was no more than a few millimetres in any case. In both groups answers on short-term hip morbidity yielded surprisingly similar ratings, the average estimate being 2.5 in the open osteotomy group, and 2.1 in the closed harvesting group, re¯ecting low short-term hip morbidity. Gender seemed to make no dierence. Nevertheless, patients who underwent the open osteotomy procedure found the short-term morbidity of the donor site slightly greater than those who had a closed harvesting. This dierence was considered not statistically signi®cant ( p50.31). Operation time was on average 50 minutes shorter in the closed bone harvesting group. This cannot be explained solely by the higher number of bilateral osteoplasties in the open osteotomy group. The retrospective comparison between the postoperative donor site pain and the recipient site pain was also very similar in both patient groups; 10 patients in both groups found the short-term postoperative pain worse in the hip than in the upper jaw. Marked dierences appear when considering the amount of analgesics consumed. In the open osteotomy group 15 out of 26 patients had postoperative pain relief, whereas only 5 out of 26 patients in the closed group requested analgesics. Expressed in comparable units the dierence becomes even more remarkable; 40 CUs in the open osteotomy group versus 9 CUs in the closed group which is considered a very signi®cant dierence (p=0.008). Notable dierence also occurred in the support requested during postoperative mobilization, 15 patients in the open
Donor site morbidity 35
Fig. 2 ± A mature hip scar of a patient who underwent closed bone harvesting representing the common appearance.
osteotomy group needed physiotherapy, crutches or even a wheel chair, whereas only 5 patients in the closed group requested these. Regardless of the harvesting technique used the patients' ®ndings about the hip donor site were consistent. In the open osteotomy group the average estimate concerning the present feeling of the operated hip was valued at 1.3 and respectively 1.1 in the closed group. Little divergence in ®ndings about the hip donor site appearance occurred either; the open osteotomy group gave the donor site looks 1.9 and the closed bone harvesting group 1.5. These dierences were not statistically signi®cant. Physical examination showed mean mature scar length of 60.3 mm in the open osteotomy group and of 24.2 mm in the closed harvesting group with a mean dierence of 36.1 mm (p50.001). The average scar width in the open osteotomy group was 7.7 mm and 4.9 mm in the closed group. Here the p value of 0.003 was very signi®cant. Table 1 summarizes the signi®cant numerical parameters and statistics. DISCUSSION Donor site morbidity characterizes the use of autogenous tissues. A review of the literature reporting complications following bone harvesting from the anterior iliac crest reveals persistent pain, nerve injury, haemorrhage, limping, persistent gait abnormalities, conspicuous scarring, bone contour de®cit, infection, fracture, meralgia paraesthetica, peritonitis and herniation. The amount of bone harvested, the age of the patient, and the surgical technique used are considered to have an impact on the complications (Canady et al., 1993). Harsha et al. (1986) suggested that the morbidity associated with removal of bone from the traditional autogenous donor sites, such as ilium, rib and tibia, is often greater than that associated with the facial surgery per se. Partly based
on this assumption the harvesting of cranial or mandibular bone grafts has gained importance recently in many centres, and was encouraged by the possibly higher osteoinductive property of a membraneous cranial bone graft versus a bone graft from endochondral sites such as ilium (Koole et al., 1989; Ilankovan et al., 1998). In contrast, Sadove et al. (1990) suggested that even if the concept of a similar embryological origin intuitively favours a cranial donor site, it is unlikely that the facial skeletal recipient site holds the embryology of the donor site in any regard. Instead, the composition of the graft, including the cell numbers, particulate size, and biochemical elements directly determines its fate rather than its prior developmental origin. Also their is concern over the relative risks involved in harvesting from the cranium versus the ilium or ribs. Sadove et al. (1990) evaluated 30 patients receiving either cranial or iliac bone for alveolar reconstruction and emphasized the technique of harvest more than the donor site. It was noticed that cranial bone has a higher cortical to marrow ratio than that of ilium (cranial chips have a high cortical component and less cellularity). Cortical elements may be more favourable to initial osteoclastic rather than osteoblastic induction and, in conjunction with the known delayed revascularization, account for the slower and often incomplete healing when compared with cancellous grafts. Witsenburg and Remmelink (1993) postulated that meticulous operative technique at the recipient site is of much more importance to the eventual outcome of the bony reconstruction than the donor site. After evaluating 307 cranial bone grafts for facial reconstruction Jackson et al. (1986) concluded that in contradistinction to Wolfe and Berkowitz (1983) and Harsha et al. (1986) they would no longer use cranial bone grafts in secondary reconstruction of alveolar clefts, mostly due to the unfavourably high proportion of cortical elements. On the other hand, iliac crest cancellous bone can be
36 Journal of Cranio-Maxillofacial Surgery
packed ®rmly into the defect to give an ideal alveolar reconstruction (Hall and Posnick, 1983). Sadove et al. (1990) suggested in addition to this that more preserved Haversian systems and intact osteocytes in the bone graft favour the better prognosis at the recipient site, and that the thermal trauma from power instruments may easily reduce these desirable qualities. This does not occur in closed bone harvesting, where no power instruments are used, and could partly explain the reduction of the harvest site morbidity as the local thermal trauma is negligible. Numerous authors have discussed the allegedly reduced donor site morbidity when using cranial grafts, including minimal postoperative pain and the fact that the incision and subsequent scar are hidden in a hair-bearing area (Harsha et al., 1986, Jackson et al., 1986; Kline and Wolfe, 1995; Koole et al., 1989; Kortebein et al., 1991, Sadove et al., 1990, SindetPedersen and Enemark, 1990; Witsenburg and Remmelink, 1993, Wolfe and Berkowitz, 1983). In the large meta-analysis of Kline and Wolfe (1995) the overall complication rate of calvarial bone harvesting was 0.18%. Exposure of dura, that was not counted as a complication, was estimated to occur in 11% of cases. Complications included wound infections, lacerations of dura, blood vessels or cerebral cortex, subdural haemorrhage, 9 month postoperative coma, permanent hemiplegia and aphasia. The degree of bony depression at the donor site seemed to depend on the amount and type of bone removed. The authors expressed concern about decreased skull strength at the donor site following split calvarial bone harvesting. Especially in children, weakening of skull could be a major concern and a primary reason for replacing all outer-table fragments after collecting diploic bone. It was also recommended considering an alternative donor site if the adult patient might be anticipated as receiving multiple blows to the head, e.g. sportsmen. The authors found that patients were generally quite tolerant of relative depressions under hair-bearing areas, as long as no sharp edges could be felt (Kline and Wolfe, 1995). An issue the authors did not discuss was how to manage the visible scarring and bony depression in elderly balding males. Also utilization of coronal ¯aps may cause an annoying hairless scar zone visible in balding individuals. Kortebein et al. (1991) compared 108 patients having iliac crest bone grafts with 27 patients, who had calvarial bone as the graft material. In both groups, morbidity was reported to be very low. In 1990 Sindet-Pedersen and Enemark compared alveolar grafting results in 60 patients who received bone grafts from the mandibular symphysis and iliac crest. They showed that all iliac bone harvest patients complained of pain from the donor site and gained normal mobility within a few weeks of surgery. Patients undergoing mandibular symphyseal bone grafts did not complain speci®cally of pain from the donor site. They emphasized the advantages of mandibular symphyseal grafting as being reduced operating time, morbidity and hospitalization, and the avoidance of a cutaneous scar. Borstlap et al.
(1990) compared the outcome of alveolar cleft grafting between bone grafts harvested from rib and mandibular symphysis. Both groups had only minor complaints about the donor site. Using quantitative CT-assisted measurements Baehr and Coulon (1996) determined the average bone volume obtainable from the mandibular symphysis at 1.0 cm3, so that for cleft volumes larger than 1.5 cm3 this donor site is not suitable. Potential risks of this donor site include damage to tooth roots and the mental nerves, and growth disturbances (Baehr and Coulon, 1996). In taking rib grafts Laurie et al. (1984) commented on pleural laceration requiring chest drainage occurring in 9% of cases. The literature reveals pneumothorax as a complication in 5±30% and long-term pleuritic pain in up to 7% of patients undergoing rib grafting (Kline and Wolfe, 1995, Laurie et al., 1984). Kline and Wolfe (1995) documented an interference with chest-wall or breast development after rib graft harvesting in children as another problem. In addition, an intractable unsightly scar may result (Laurie et al., 1984). The tibial plateau has seldom been recommended as a harvest site despite its relatively good accessibility and availability of spongiosa. Kline and Wolfe (1995) reported only three cases (0.3%) of tibial harvesting in their review of 1000 bone grafting procedures from various donor sites, The complication rate of tibial grafting is reported to range up to 3.8% (van Damme and Merkx, 1996). Van Damme and Merkx (1996) suggested a modi®cation of tibial harvesting using a cylindrical instrument. They reported no complications in any of their nine patients, morbidity was low and the scars were unremarkable even in females. The graft-take at the recipient site was good in all cases. On the other hand, the authors mentioned as a disadvantage the poor mechanical strength of the grafts, which is due to the fatty bone-marrow containing large open areas. The nine patients ranged in age from 22 to 67 years which re¯ects the concern regarding growth disturbances when tibial bone harvesting is performed in young patients. The authors concluded that the use of tibia as donor site is contraindicated in children and adolescents. In a recent study Ilankovan et al. (1998) compared the morbidity of 30 patients who underwent trephine bone harvesting either from the iliac crest or the tibial shaft. The results showed no signi®cant dierence in morbidity between the two groups, whereas the tibial trephine procedure was easier, quicker and there was less blood loss. Pain and gait disturbances were noticeably reduced in the tibial versus the iliac harvesting group. The authors did not comment on any possible growth disturbance that might be caused when the epiphyseal line is manipulated in a child's tibia, nor did they advise caution about the patient's age. Considering the iliac crest donor site Rudman (1997) stated that harvesting cancellous bone did not result in delayed ambulation or prolonged hospitalisation. Dawson et al. (1996) recorded similar ®ndings suggesting that there was no long-term
Donor site morbidity 37
donor site morbidity at the iliac crest, and that shortterm morbidity was frequently overstated and in itself not a valid reason to change to calvarial or mandibular donor sites. Stoelinga et al. (1990) observed that the anterior iliac crest, provided the cartilage cap was preserved and repositioned after harvesting the graft, appeared to be a safe and reliable source from which the associated morbidity was minor. Laurie et al. (1984) compared harvesting of rib and iliac bone with the traditional open osteotomy techniques and reported a low rate of long-term complications in the iliac group. However, the short-term morbidity was observed to be high. Nevertheless, the authors stated that the ilium provides abundant cancellous bone that is particularly useful for closure of alveolar clefts, and that the ilium is likely to remain a common donor site. Interestingly, several of the patients who had experienced both donor sites, rib and ilium, were in no doubt of their preference for the iliac site in the long term. In our opinion the known disadvantages of the hip, namely donor site morbidity and scarring, represent only relative contraindications even when open harvesting techniques are used. Both issues can be eectively reduced by closed bone harvesting. The diering views of preferred donor sites by various authors have lead to numerous studies verifying, more or less signi®cantly, the superiority of their chosen donor site and harvesting method. When the donor sites other than ilium were introduced, discussion always focused on hip morbidity as an important disadvantage to the iliac crest donor site. We agree that in some respects hip morbidity after traditional open osteotomy harvesting can be high, signi®cant improvements can be made by adapting to the newer closed technique. Among advantages are shorter bone harvesting time and the fact that the operating room nurses also found the closed harvesting technique to be a welcome alternative as the instruments required for the closed harvesting number only a fraction of the open osteotomy instrument set. Comparing the questionnaire results with the data from patients' ®les concerning the short-term morbidity enhanced and con®rmed the validity of the recorded information. In the assessment of the subjective morbidity by the patient questionnaire, a visual analogue scale might have been more precise than the imaginary scale from 1 to 6. Yet the latter was familiar to all patients because of its similarity to the rating system used in German schools. Based on these results we conclude that bone harvesting from the anterior iliac crest still remains the gold standard method, provided that the procedure is performed with minor invasive techniques, such as cylinder trephine harvesting. Sucient cancellous bone can always be obtained and simultaneously with the recipient site preparation, with only minimum short-term morbidity and without long-term morbidity. Remarkably low morbidity at the donor site after a small hip incision
with minimum scarring and bone contour de®cit can be achieved. Thus morbidity at the iliac donor site is in itself not a valid reason to change to other donor sites. Acknowledgements The authors would like to thank Mr Peter Ward Booth for his convincing clinical demonstration of closed bone harvesting in East Grinstead in spring 1995. Furthermore we express our thanks to Medicon e.G., Tuttlingen, Germany, for providing us with the 6 mm cortex cutter.
References Baehr W, Coulon JP: Limits of the mandibular symphysis as a donor site for bone grafts in early secondary cleft palate osteoplasty. Int J Oral Maxillofac Surg 25: 389±393, 1996 Beirne JC, Barry HJ, Brady FA, Morris VB: Donor site morbidity of the anterior iliac crest following cancellous bone harvest. Int J Oral Maxillofac Surg 25: 268±271, 1996 Borstlap WA, Heidbuchel KL, Freihofer HP, Kuijpers-Jagtman AM: Early secondary bone grafting of alveolar cleft defects, a comparison between chin and rib grafts. J Cranio Maxillofac Surg 18: 201±208, 1990 Boyne PJ, Sands NR: Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 30: 87±93, 1972 Caddy CM, Reid CD: An atraumatic technique for harvesting cancellous bone for secondary alveolar bone grafting in cleft palate. Br J Plast Surg 38: 540±543, 1985 Canady JW, Zeitler D, Thompson S, Nicholas C: Suitability of the iliac crest as a site for harvest of autogenous bone grafts. Cleft Palate Craniofac J 30: 579±581, 1993 Damme PA van, Merkx MAW: A modi®cation of the tibial bonegraft-harvesting technique. Int J Oral Maxillofac Surg 25: 346±348, 1996 Dawson KH, Egbert MA, Myall RWT: Pain following iliac crest bone grafting of alveolar clefts. J CranioMaxillofac Surg 24: 151±154, 1996 Hall HD, Posnick JC: Early results of secondary bone grafts in 106 alveolar clefts. J Oral Maxillofac Surg 41: 289±294, 1983 Harsha BC, Turvey TA, Powers SK: Use of autogenous cranial bone grafts in maxillofacial surgery: a preliminary report. J Oral Maxillofac Surg 44: 11±15, 1986 Hemprich A: Personal communication, 1998 Ilankovan V, Stronczek M, Telfer M, Peterson LJ, Stassen LFA, Ward-Booth P: A prospective study of trephined bone grafts of the tibial shaft and iliac crest. Br J Oral Maxillofac Surg 36: 434±439, 1998 Jackson IT, Helden G, Marx R: Skull bone grafts in maxillofacial and craniofacial surgery. J Oral Maxillofac Surg 44: 949±955, 1986 Kalk WW, Raghoebar GM, Jansma J, Boering G: Morbidity from iliac crest bone harvesting. J Oral Maxillofac Surg 54: 1424±1429, 1996 Kline RM, Wolfe SA: Complications associated with the harvesting of cranial bone grafts. Plast Reconstr Surg 95: 5±13, 1995 Koole R, Bosker H, Norman van der Dussen F: Late secondary autogenous bone grafting in cleft patients comparing mandibular and iliac crest grafts. J Cranio-Maxillofac Surg 17: 28±30, 1989 Kortebein MJ, Nelson CL, Sadove AM: Retrospective analysis of 135 secondary alveolar cleft grafts using iliac or calvarial bone. J Oral Maxillofac Surg 49: 493±498, 1991 Laurie SWS, Kaban B, Mulliken JB, Murray JE: Donor-site morbidity after harvesting rib and iliac bone. Plast Reconstr Surg 73: 933±938, 1984 Rudman RA: Prospective evaluation of morbidity associated with iliac crest harvest for alveolar cleft grafting. J Oral Maxillofac Surg 55: 219±223, 1997
38 Journal of Cranio-Maxillofacial Surgery Sadove AM, Nelson CL, Eppley BL, Nguyen B: An evaluation of calvarial and iliac donor sites in alveolar cleft grafting. Cleft Palate J 27: 225±228, 1990 Scott W, Petersen RC, Grant S: A method of producing iliac bone by trephine curettage. J Bone Joint Surg 860: 14±21, 1984 Shepard GH, Dierberg WJ: Use of the cylinder osteotome for cancellous bone grafting. Plast Reconstr Surg 76: 37±42, 1987 Sindet-Pedersen S, Enemark H: Reconstruction of alveolar clefts with mandibular or iliac crest bone grafts: a comparative study. J Oral Maxillofac Surg 48: 554±558, 1990 Stoelinga PJ, Haers PE, Leenen RJ, Soubry RJ, Blijdorp PA, Schoenaers HA: Late management of secondarily grafted clefts. Int J Oral Maxillofac Surg 19: 97±102, 1990 Thaller SR, Patel M, Zimmerman T, Feldman M: Percutaneous iliac bone grafting of secondary alveolar clefts. J Craniofac Surg 2: 135±139, 1991 Witsenburg B, Remmelink HJ: Reconstruction of residual alveolopalatal bone defects in cleft patients, a retrospective study. J Cranio-Maxillofac Surg 21: 239±244, 1993
Wolfe SA, Berkowitz S: The use of cranial bone grafts in the closure of alveolar and anterior palatal clefts. Plast Reconstr Surg 72: 444±451, 1983
Priv.-Doz. Dr Dr H. Eu®nger Department of Oral & Maxillofacial Surgery Facial Plastic Surgery In der Schornau 23-25 44892 Bochum Tel: +49 234 299 3501 Fax: +49 234 299 3509 Paper received 15 July 1999 Accepted 1 February 2000
Iliac crest donor site morbidity following open and closed methods of bone harvest for alveolar cleft osteoplasty Harald Eu®nger, Heikki LeppaÈnen Department of Oral & Maxillofacial Surgery, Facial Plastic Surgery, Ruhr-University, Bochum, Germany SUMMARY. Donor site morbidity after bone harvesting still remains a crucial problem in alveolar cleft osteoplasty. This study focuses on ilium donor site morbidity comparing two dierent techniques. A series of 52 consecutive patients was divided in half. All had anterior iliac crest bone grafts. In the study group the harvesting was performed with a closed osteotomy using a cylindrical Shepard osteotome. The control group underwent the traditional open osteotomy. In the open osteotomy group the short-term morbidity at the donor site was slightly greater than in the closed harvesting group. The low short-term morbidity in the closed harvesting group was re¯ected in the analgesic consumption which was three times higher in the open osteotomy group ( p50.008). The most striking dierence occurred in the appearance of the mature scar: a length of 24.2 mm (mean) in the closed harvesting group against 60.3 mm in the open osteotomy group ( p50.0001), and a width of 4.9 mm (mean) versus 7.7 mm, respectively ( p50.003). The long-term morbidity was negligible in both groups. Based on these ®ndings we suggest that bone harvesting from the anterior iliac crest remains the preferred method, provided that closed harvesting is undertaken. # 2000 European Association for Cranio-Maxillofacial Surgery
INTRODUCTION
Kortebein et al., 1991; Sadove et al., 1990; SindetPedersen and Enemark, 1990; Thaller et al., 1991; Wolfe and Berkowitz, 1983). Hence the mandibular symphysis or the calvarial sites have been advocated recently because of morbidity at these donor sites should be considerably less than at the iliac crest (Baehr and Coulon, 1996; Borstlap et al., 1990; Harsha et al., 1986; Koole et al., 1989; Kortebein et al., 1991; Sadove et al., 1990; Sindet-Pedersen and Enemark, 1990; Wolfe and Berkowitz, 1983). However, among others, Canady et al. (1993) concluded that the iliac crest is a suitable site to harvest cancellous bone for alveolar defect grafting and should not be rejected solely because of concerns regarding excessive morbidity. In 1984 Scott et al. presented a closed method of procuring cancellous bone from the iliac crest with a medium-sized curette via a 2.5 cm incision. The authors had performed this procedure in 150 cases without complications. Early ambulation was possible as muscle stripping was entirely eliminated. In 1985 Caddy and Reid described a similar technique for secondary alveolar reconstruction. They used a bone biopsy set to trephine cores of autogenous cancellous bone from the ilium. The method was tested ®rst in a cadaver and then applied in 10 clinical cases. The authors found the aesthetic and functional results at the donor site to be superior to the conventional open osteotomy. Thaller et al. (1991) also used a bone biopsy trephine. Relating their experience from 24 patients they recommended this technique when signi®cant reduction of donor site morbidity is required. Furthermore it was to be
Autogenous bone grafting of the alveolar cleft is well established. The prevailing consensus states that the best results in alveolar bone grafting are achieved when the procedure is performed prior to the eruption of the permanent canine (Boyne and Sands, 1972; Kortebein et al., 1991). In Europe the procedure is called `secondary alveolar osteoplasty' when it is performed in the mixed dentition phase. Various donor sites for alveolar cleft grafting have been described and the preferred site has been a matter for debate for many years. At present the main sources for autogenous bone are iliac crest, calvarium and mandibular symphysis. Numerous reports suggest that autogenous bone graft harvesting of the ilium is the gold standard with which all other types of alveolar grafts should be compared (Canady et al., 1993; van Damme and Merkx, 1996; Jackson et al., 1986; Kalk et al, 1996; Kline and Wolfe, 1995; Stoelinga et al., 1990). However, some authors have suggested that the iliac crest donor site produces an unacceptably high degree of postoperative morbidity, such as persistent pain, prolonged recovery time, haemorrhage, limping, visible scarring, bone contour deformities, lesions of the lateral femoral cutaneous nerve, meralgia paraesthetica, pelvic fracture and peritonitis (Beirne et al., 1996; Borstlap et al., 1990; Caddy and Reid, 1985; Dawson et al., 1996; Harsha et al., 1986; Ilankovan et al., 1998; Koole et al., 1989; This paper is dedicated to our teacher Prof. Dr Dr Egbert Machtens on the occasion of his 65th birthday. 31
32 Journal of Cranio-Maxillofacial Surgery
performed as an outpatient procedure, and is particularly suitable in Third World countries. In 1987 Shepard and Dierberg developed a special cylindrical osteotome for this purpose. Their aim was to perform bone harvesting from the iliac crest with minimum invasiveness using local anaesthesia. They noted the disadvantage in the trephine devices of that time, namely, that the bone graft was often left attached as the instrument was withdrawn. To solve this problem a cylindrical osteotome with luminal tines was developed in order to separate the graft at the tip of the osteotome when it is rotated. The instrument set comprises four main parts: the ®rst is a surface cutter designed to cut through the outer cortical bone, the other three components are the actual osteotomes with dierent diameters. The instruments are able to remove bone cylinders of up to 5 cm in length. Operative technique consists of making a 2.5 cm incision over the iliac crest. The authors used local anaesthesia in their series taking care to inject beneath the periosteum. The incision was made sharply down to the periosteum, and retractors were used to expose the bone. The mallet was then used to tap the cortex cutter about 0.5 cm into the bone to remove a small cortical disk of it. The cylindrical osteotome of appropriate diameter was then driven into the cancellous bone with a mallet. A 908 twist of the instrument separated the rod of bone when the appropriate depth was achieved. The cancellous bone cylinder was then extracted. Several bone grafts may be harvested through the initial plug hole by varying the direction of the cylindrical osteotome (Fig. 1). After sucient bone had been harvested, the cortical bone disk was replaced and a standard wound closure was performed (Shepard and Dierberg, 1987). In 1995 this closed harvesting technique with the instruments recommended by Shepard and Dierberg
(1987) was adopted in our department and has been successfully used since then. The aim of this study was to evaluate two dierent techniques of harvesting anterior iliac crest bone, namely the traditional open osteotomy and the closed technique. Finally, a modi®cation of the instruments used in our closed bone harvesting procedure is described. MATERIAL AND METHODS During the period 1993±98, 52 patients with a unilateral or bilateral cleft lip alveolus and palate were operated on for reconstruction of the alveolar process. Preoperative orthodontic transverse maxillary expansion and alignment of teeth was completed. All 52 consecutive patients received alveolar bone grafts from the anterior iliac crest. In bilateral cases both sides were reconstructed simultaneously. The prevalent open osteotomies of the hip gradually decreased in our clinic as the closed bone harvesting technique was newly adopted in the summer 1995. Half of these patients had their iliac bone harvesting performed with the open osteotomy, the remaining 26 patients underwent the closed harvesting method using the Shepard osteotome (Shepard and Dierberg, 1987). With our main interest being the donor site morbidity, this study did not record the graft success rate, graft resorption, or tooth eruption at the recipient site. Instead, operating time and technique, postoperative pain medication, subjective pain sensation, complications, length and width of the mature scar, bone contour de®cits and nerve paraesthesia were recorded allowing short- and long-term morbidity to be compared in both patient groups. In the traditional open osteotomy technique group the male-female ratio was 15 : 11 and the mean age at operation was 9.6 years (range 7±20 years). Nineteen
Fig. 1 ± Amount of bone that can be obtained from a child with the use of the 6 mm osteotome via a single incision. The closed harvesting technique allows directional variation of the cylindrical osteotome between the cortical iliac plates from one crestal access site, producing a further cancellous cylinder with each new insertion.
Donor site morbidity 33
patients had a unilateral and seven a bilateral cleft. The bone harvesting was performed under general anaesthesia. The donor site was located on the anterior crest, well behind the anterior superior iliac spine. An incision was made, in most cases lateral to the crest with minimal undermining. The bone harvesting was carried out using an osteotome or an oscillating saw after the cartilage cap (pedicled) had been re¯ected medially or laterally. Often a sharp spongiosa curettage would complete the procedure. The sharp bony edges were smoothed and the crest cap was sutured back into position. Finally haemostasis was achieved using bone wax or collagen material. The soft tissues were closed in layers and the skin with continuous sutures. A pressure dressing with elastic tape was left in place, usually for 24 h. Drains were often used in this group and in most cases they were removed on the ®rst or second postoperative day. The second group comprised 26 patients whose bone was harvested with a cylindrical trephine, developed and described by Shepard and Dierberg (1987). The male±female ratio was 17 : 9 the mean age at operation 12.2 years (range 8±31 years). A unilateral cleft was treated in 21 cases and a bilateral one in ®ve cases. In the closed harvesting procedure the instrument was tapped into the bone through a sucient opening in the soft tissue. When more bone was required, the spongiosa cylinders were detached in an arc like fashion. After harvesting, a layered soft tissue closure was performed and a pressure dressing was left in place for 24 h. In this group drains were hardly ever used, a few had mini-vac wound drains which were removed on the ®rst postoperative day. In both groups the patients received prophylactic perioperative penicillin (or clindamycin in case of penicillin allergy). The postoperative care was similar and consisted of daily hip wound cleansing and removal of the skin sutures after approximately one week. All patients were mobilized early, mostly on the ®rst postoperative day, and discharged after 8±12 days. Supporting physiotherapy was oered when needed. Patients received all necessary pain relief on demand, which consisted of paracetamol 250 or 500 mg suppositories or pills. The 52 patients were invited for an interview and examination after a follow-up period varying between 1 and 6 years. Donor site morbidity was evaluated using three methods: 1. A 3-page questionnaire with a patient interview, which in its ®rst part dealt with immediate postoperative donor site morbidity. The experienced morbidity was estimated using a graduated scale from 1±6, similar to the one used at German schools, mark 1 being painfree and mark 6 meaning extremely painful. The present hip morbidity was evaluated to obtain information about long-term morbidity and was again scored on the scale 1 to 6 with 1 meaning very good, or normal compared with the non-operated side, whilst 6 meant the worst
possible. The appearance of the hip wound was also questioned using the same scale. 2. The mature scar length, width, unevenness, colour, bone contour and skin sensibility changes were recorded. Conspicuous and/or palpable bone de®cits were noted. 3. A survey of the patient ®les yielded details of diagnosis, operation date and time, the manner by which the bone was obtained, intraoperative problems, blood loss, wound closure, use of drains, early postoperative measures, need for pain relief, and supporting therapies. Any complications were listed. Statistical analysis of the numerical parameters obtained was performed using the unpaired (two-tailed) Student's t-test. Our adaptation of the closed harvesting method include minor modi®cations: in contrast to the original description of Shepard and Dierberg (1987) we do not use retractors to expose the bone in order to keep the incision even smaller. In addition, we ®nd the 8 mm cortex cutter and the corresponding osteotome too big to be used between the cortical plates of children's ilia and instead we use the 6 mm osteotome for both purposes, cortex cutting and graft harvesting. However, in spite of the soft, mostly cartilagenous bone cap in this age group, it was feared that the osteotome might be damaged. Therefore a 6 mm osteotome was fabricated deliberately for this indication and introduced in our set of instruments. Other centres have successfully introduced dierent modi®cations for the same purpose (Hemprich, 1998). Finally, we prefer not to replace the bone cap as we use it for grafting, especially to support the nasal alar base. RESULTS The short-term hip morbidity in the open osteotomy group yielded an average value of 2.5, estimated on a scale of 1±6 (Table 1). The best value was 1 and the worst 5. The female patients estimated their shortterm postoperative hip pain at 2.6 (mean), which did not dier signi®cantly from the male patients. Fourteen patients in this group found the alveolar wound more painful than the hip donor site, 10 patients stated the opposite, and 2 felt there was no dierence. Fifteen patients needed postoperative pain relief which in most cases consisted of paracetamol 250 mg suppositories. Some patients required 500 mg paracetamol suppositories which involved taking 250 mg dose as a calculating unit (CU) allowing comparison of the absolute received dose between both groups. Thus, in this group the overall analgesic consumption was 40 CUs, i.e. 1.5 CUs as an average dose per person. Fifteen patients needed postoperative physiotherapeutic support or crutches to mobilize. The average operation time was 2 h 50 min. The present hip morbidity was estimated at 1.3 mean, ranging from 1 to 3. One patient, (score 3), remarked
34 Journal of Cranio-Maxillofacial Surgery Table 1 ± Summary of the important parameters and statistics for short-term and long-term morbidity in both patient groups Short-term morbidity Group
Open osteotomy
Closed harvesting
n Hip pain rating Physiotherapyy Wound infection Analgesics Dose in CU t-test for the CU-dierence: p50.008, considered very signi®cant
26 patients 2.5 15 patients 0 15 patients 40 CU
26 patients 2.1 (scale 1±6) 5 patients 1 5 patients 9 CU Long-term morbidity
Group
Open osteotomy
Closed harvesting
Scar length (mean) Min Max t-test for the scar length dierence: p50.0001, considered very signi®cant
60 mm 32 mm 100 mm
24 mm 10 mm 80 mm
Scar width (mean) Min Max t-test for the scar width dierence: p50.003, considered very signi®cant Present hip `feel' Present hip looks Iliac crest de®cit Sensory alteration
that the hip wound site still hurts, and another patient expressed a feeling of constant itching. A pulling sensation and a clicking sound were occasionally reported by two other patients. The appearance of the hip donor site was assessed as 1.9 on average, suggesting patient satisfaction. The average mature scar length measured 60.3 mm with a minimum of 32 mm and a maximum of 100 mm. Average scar width was 7.7 mm. Half of the patients in this group had an unsightly hip scar with visible bony contour ¯attening or concavity, which was also readily palpable. In the closed bone harvesting patient group the average short-term hip morbidity was assessed at 2.1, with a range from 1 to 4 (Table 1). The female patients estimated their postoperative hip pain at 2.0 which conforms with the overall result of this group. Sixteen patients found that intraoral recipient site more painful than the hip donor site, and 10 patients the opposite. Only ®ve out of 26 patients needed postoperative analgesics. The dosage paracetamol in this group equals nine CUs with a calculated average of 0.4 CUs per person. Crutches or supporting physiotherapy were requested in ®ve cases. The average operation time was 2 h. The present ®ndings of the operated hip were rated at 1.1 (mean). Two patients complained of occasional itching at the hip donor site. One wound healing complication occurred consisting of a local infection and seroma at the donor site, which resolved during the ®rst postoperative week without further sequelae. The appearance of the hip donor site was rated at 1.5. Physical examination revealed an average mature scar length of 24.3 mm, (range 10±80 mm), and a width of 4.9 mm (Fig. 2). No conspicuous bone contour
7.7 mm 2.0 mm 15 mm 1.3 1.9 0 0
4.9 mm 2.0 mm 11 mm 1.1 (scale 1±6) 1.5 (scale 1±6) 0 0
de®cits were observed. Approximately half of the patients in this group had an invisible bony impression in the iliac crest corresponding with the puncture site. This palpable bony dimple was no more than a few millimetres in any case. In both groups answers on short-term hip morbidity yielded surprisingly similar ratings, the average estimate being 2.5 in the open osteotomy group, and 2.1 in the closed harvesting group, re¯ecting low short-term hip morbidity. Gender seemed to make no dierence. Nevertheless, patients who underwent the open osteotomy procedure found the short-term morbidity of the donor site slightly greater than those who had a closed harvesting. This dierence was considered not statistically signi®cant ( p50.31). Operation time was on average 50 minutes shorter in the closed bone harvesting group. This cannot be explained solely by the higher number of bilateral osteoplasties in the open osteotomy group. The retrospective comparison between the postoperative donor site pain and the recipient site pain was also very similar in both patient groups; 10 patients in both groups found the short-term postoperative pain worse in the hip than in the upper jaw. Marked dierences appear when considering the amount of analgesics consumed. In the open osteotomy group 15 out of 26 patients had postoperative pain relief, whereas only 5 out of 26 patients in the closed group requested analgesics. Expressed in comparable units the dierence becomes even more remarkable; 40 CUs in the open osteotomy group versus 9 CUs in the closed group which is considered a very signi®cant dierence (p=0.008). Notable dierence also occurred in the support requested during postoperative mobilization, 15 patients in the open
Donor site morbidity 35
Fig. 2 ± A mature hip scar of a patient who underwent closed bone harvesting representing the common appearance.
osteotomy group needed physiotherapy, crutches or even a wheel chair, whereas only 5 patients in the closed group requested these. Regardless of the harvesting technique used the patients' ®ndings about the hip donor site were consistent. In the open osteotomy group the average estimate concerning the present feeling of the operated hip was valued at 1.3 and respectively 1.1 in the closed group. Little divergence in ®ndings about the hip donor site appearance occurred either; the open osteotomy group gave the donor site looks 1.9 and the closed bone harvesting group 1.5. These dierences were not statistically signi®cant. Physical examination showed mean mature scar length of 60.3 mm in the open osteotomy group and of 24.2 mm in the closed harvesting group with a mean dierence of 36.1 mm (p50.001). The average scar width in the open osteotomy group was 7.7 mm and 4.9 mm in the closed group. Here the p value of 0.003 was very signi®cant. Table 1 summarizes the signi®cant numerical parameters and statistics. DISCUSSION Donor site morbidity characterizes the use of autogenous tissues. A review of the literature reporting complications following bone harvesting from the anterior iliac crest reveals persistent pain, nerve injury, haemorrhage, limping, persistent gait abnormalities, conspicuous scarring, bone contour de®cit, infection, fracture, meralgia paraesthetica, peritonitis and herniation. The amount of bone harvested, the age of the patient, and the surgical technique used are considered to have an impact on the complications (Canady et al., 1993). Harsha et al. (1986) suggested that the morbidity associated with removal of bone from the traditional autogenous donor sites, such as ilium, rib and tibia, is often greater than that associated with the facial surgery per se. Partly based
on this assumption the harvesting of cranial or mandibular bone grafts has gained importance recently in many centres, and was encouraged by the possibly higher osteoinductive property of a membraneous cranial bone graft versus a bone graft from endochondral sites such as ilium (Koole et al., 1989; Ilankovan et al., 1998). In contrast, Sadove et al. (1990) suggested that even if the concept of a similar embryological origin intuitively favours a cranial donor site, it is unlikely that the facial skeletal recipient site holds the embryology of the donor site in any regard. Instead, the composition of the graft, including the cell numbers, particulate size, and biochemical elements directly determines its fate rather than its prior developmental origin. Also their is concern over the relative risks involved in harvesting from the cranium versus the ilium or ribs. Sadove et al. (1990) evaluated 30 patients receiving either cranial or iliac bone for alveolar reconstruction and emphasized the technique of harvest more than the donor site. It was noticed that cranial bone has a higher cortical to marrow ratio than that of ilium (cranial chips have a high cortical component and less cellularity). Cortical elements may be more favourable to initial osteoclastic rather than osteoblastic induction and, in conjunction with the known delayed revascularization, account for the slower and often incomplete healing when compared with cancellous grafts. Witsenburg and Remmelink (1993) postulated that meticulous operative technique at the recipient site is of much more importance to the eventual outcome of the bony reconstruction than the donor site. After evaluating 307 cranial bone grafts for facial reconstruction Jackson et al. (1986) concluded that in contradistinction to Wolfe and Berkowitz (1983) and Harsha et al. (1986) they would no longer use cranial bone grafts in secondary reconstruction of alveolar clefts, mostly due to the unfavourably high proportion of cortical elements. On the other hand, iliac crest cancellous bone can be
36 Journal of Cranio-Maxillofacial Surgery
packed ®rmly into the defect to give an ideal alveolar reconstruction (Hall and Posnick, 1983). Sadove et al. (1990) suggested in addition to this that more preserved Haversian systems and intact osteocytes in the bone graft favour the better prognosis at the recipient site, and that the thermal trauma from power instruments may easily reduce these desirable qualities. This does not occur in closed bone harvesting, where no power instruments are used, and could partly explain the reduction of the harvest site morbidity as the local thermal trauma is negligible. Numerous authors have discussed the allegedly reduced donor site morbidity when using cranial grafts, including minimal postoperative pain and the fact that the incision and subsequent scar are hidden in a hair-bearing area (Harsha et al., 1986, Jackson et al., 1986; Kline and Wolfe, 1995; Koole et al., 1989; Kortebein et al., 1991, Sadove et al., 1990, SindetPedersen and Enemark, 1990; Witsenburg and Remmelink, 1993, Wolfe and Berkowitz, 1983). In the large meta-analysis of Kline and Wolfe (1995) the overall complication rate of calvarial bone harvesting was 0.18%. Exposure of dura, that was not counted as a complication, was estimated to occur in 11% of cases. Complications included wound infections, lacerations of dura, blood vessels or cerebral cortex, subdural haemorrhage, 9 month postoperative coma, permanent hemiplegia and aphasia. The degree of bony depression at the donor site seemed to depend on the amount and type of bone removed. The authors expressed concern about decreased skull strength at the donor site following split calvarial bone harvesting. Especially in children, weakening of skull could be a major concern and a primary reason for replacing all outer-table fragments after collecting diploic bone. It was also recommended considering an alternative donor site if the adult patient might be anticipated as receiving multiple blows to the head, e.g. sportsmen. The authors found that patients were generally quite tolerant of relative depressions under hair-bearing areas, as long as no sharp edges could be felt (Kline and Wolfe, 1995). An issue the authors did not discuss was how to manage the visible scarring and bony depression in elderly balding males. Also utilization of coronal ¯aps may cause an annoying hairless scar zone visible in balding individuals. Kortebein et al. (1991) compared 108 patients having iliac crest bone grafts with 27 patients, who had calvarial bone as the graft material. In both groups, morbidity was reported to be very low. In 1990 Sindet-Pedersen and Enemark compared alveolar grafting results in 60 patients who received bone grafts from the mandibular symphysis and iliac crest. They showed that all iliac bone harvest patients complained of pain from the donor site and gained normal mobility within a few weeks of surgery. Patients undergoing mandibular symphyseal bone grafts did not complain speci®cally of pain from the donor site. They emphasized the advantages of mandibular symphyseal grafting as being reduced operating time, morbidity and hospitalization, and the avoidance of a cutaneous scar. Borstlap et al.
(1990) compared the outcome of alveolar cleft grafting between bone grafts harvested from rib and mandibular symphysis. Both groups had only minor complaints about the donor site. Using quantitative CT-assisted measurements Baehr and Coulon (1996) determined the average bone volume obtainable from the mandibular symphysis at 1.0 cm3, so that for cleft volumes larger than 1.5 cm3 this donor site is not suitable. Potential risks of this donor site include damage to tooth roots and the mental nerves, and growth disturbances (Baehr and Coulon, 1996). In taking rib grafts Laurie et al. (1984) commented on pleural laceration requiring chest drainage occurring in 9% of cases. The literature reveals pneumothorax as a complication in 5±30% and long-term pleuritic pain in up to 7% of patients undergoing rib grafting (Kline and Wolfe, 1995, Laurie et al., 1984). Kline and Wolfe (1995) documented an interference with chest-wall or breast development after rib graft harvesting in children as another problem. In addition, an intractable unsightly scar may result (Laurie et al., 1984). The tibial plateau has seldom been recommended as a harvest site despite its relatively good accessibility and availability of spongiosa. Kline and Wolfe (1995) reported only three cases (0.3%) of tibial harvesting in their review of 1000 bone grafting procedures from various donor sites, The complication rate of tibial grafting is reported to range up to 3.8% (van Damme and Merkx, 1996). Van Damme and Merkx (1996) suggested a modi®cation of tibial harvesting using a cylindrical instrument. They reported no complications in any of their nine patients, morbidity was low and the scars were unremarkable even in females. The graft-take at the recipient site was good in all cases. On the other hand, the authors mentioned as a disadvantage the poor mechanical strength of the grafts, which is due to the fatty bone-marrow containing large open areas. The nine patients ranged in age from 22 to 67 years which re¯ects the concern regarding growth disturbances when tibial bone harvesting is performed in young patients. The authors concluded that the use of tibia as donor site is contraindicated in children and adolescents. In a recent study Ilankovan et al. (1998) compared the morbidity of 30 patients who underwent trephine bone harvesting either from the iliac crest or the tibial shaft. The results showed no signi®cant dierence in morbidity between the two groups, whereas the tibial trephine procedure was easier, quicker and there was less blood loss. Pain and gait disturbances were noticeably reduced in the tibial versus the iliac harvesting group. The authors did not comment on any possible growth disturbance that might be caused when the epiphyseal line is manipulated in a child's tibia, nor did they advise caution about the patient's age. Considering the iliac crest donor site Rudman (1997) stated that harvesting cancellous bone did not result in delayed ambulation or prolonged hospitalisation. Dawson et al. (1996) recorded similar ®ndings suggesting that there was no long-term
Donor site morbidity 37
donor site morbidity at the iliac crest, and that shortterm morbidity was frequently overstated and in itself not a valid reason to change to calvarial or mandibular donor sites. Stoelinga et al. (1990) observed that the anterior iliac crest, provided the cartilage cap was preserved and repositioned after harvesting the graft, appeared to be a safe and reliable source from which the associated morbidity was minor. Laurie et al. (1984) compared harvesting of rib and iliac bone with the traditional open osteotomy techniques and reported a low rate of long-term complications in the iliac group. However, the short-term morbidity was observed to be high. Nevertheless, the authors stated that the ilium provides abundant cancellous bone that is particularly useful for closure of alveolar clefts, and that the ilium is likely to remain a common donor site. Interestingly, several of the patients who had experienced both donor sites, rib and ilium, were in no doubt of their preference for the iliac site in the long term. In our opinion the known disadvantages of the hip, namely donor site morbidity and scarring, represent only relative contraindications even when open harvesting techniques are used. Both issues can be eectively reduced by closed bone harvesting. The diering views of preferred donor sites by various authors have lead to numerous studies verifying, more or less signi®cantly, the superiority of their chosen donor site and harvesting method. When the donor sites other than ilium were introduced, discussion always focused on hip morbidity as an important disadvantage to the iliac crest donor site. We agree that in some respects hip morbidity after traditional open osteotomy harvesting can be high, signi®cant improvements can be made by adapting to the newer closed technique. Among advantages are shorter bone harvesting time and the fact that the operating room nurses also found the closed harvesting technique to be a welcome alternative as the instruments required for the closed harvesting number only a fraction of the open osteotomy instrument set. Comparing the questionnaire results with the data from patients' ®les concerning the short-term morbidity enhanced and con®rmed the validity of the recorded information. In the assessment of the subjective morbidity by the patient questionnaire, a visual analogue scale might have been more precise than the imaginary scale from 1 to 6. Yet the latter was familiar to all patients because of its similarity to the rating system used in German schools. Based on these results we conclude that bone harvesting from the anterior iliac crest still remains the gold standard method, provided that the procedure is performed with minor invasive techniques, such as cylinder trephine harvesting. Sucient cancellous bone can always be obtained and simultaneously with the recipient site preparation, with only minimum short-term morbidity and without long-term morbidity. Remarkably low morbidity at the donor site after a small hip incision
with minimum scarring and bone contour de®cit can be achieved. Thus morbidity at the iliac donor site is in itself not a valid reason to change to other donor sites. Acknowledgements The authors would like to thank Mr Peter Ward Booth for his convincing clinical demonstration of closed bone harvesting in East Grinstead in spring 1995. Furthermore we express our thanks to Medicon e.G., Tuttlingen, Germany, for providing us with the 6 mm cortex cutter.
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Priv.-Doz. Dr Dr H. Eu®nger Department of Oral & Maxillofacial Surgery Facial Plastic Surgery In der Schornau 23-25 44892 Bochum Tel: +49 234 299 3501 Fax: +49 234 299 3509 Paper received 15 July 1999 Accepted 1 February 2000