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Morbidity from iliac crest bone harvesting
DISCUSSION
1430
J Oral Maxillofac 54:1430, 1996
Surg
Discussion Morbidity
From
Iliac Crest
Bone
Harvesting
Matthew B. Hall, DMD, MD Winter
Park,
Florida
This is an excellent study of patients’ reactions to, and problems associated with, use of the anterior iliac crest as a donor site for autogenous bone. The iliac crest has been a popular source of bone for several decades, both for large and small grafts. For spinal surgery, the posterior iliac crest is convenient, just as the anterior iliac crest is convenient for maxillofacial reconstruction because of not having to alter the patient’s position during surgery. In my experience, the procedure described in this study is the most conservative and least complicated surgical approach for obtaining bone from the anterior ilium when partial-thickness corticocancellous blocks and a good quantity of cancellous bone are required. An oscillating saw can be used instead of osteotomes for removing the corticocancellous block. This study is especially intriguing because all of the patients evaluated were having very elective procedures, that is, preprosthetic augmentation and repair of alveolar cleft defects, as opposed to bone grafts for reconstruction after severe facial trauma or ablative cancer surgery. One could speculate that patients electing to have preprosthetic bone augmentation would be more sensitive to donor site recovery and postoperative problems than patients undergoing more dramatic facial reconstruction. The 2.2 pain severity average, the 8.4 subjective acceptability score, and the 98% satisfaction with the resultant scar appear to indicate an overall favorable response by this group of patients. It is also very interesting to note that there were no statistically significant differences between group A and group B, except for the use of crutches, despite the mean age difference of 34 years. In my experience, children seem to return to normal pain-
less ambulation faster than adults and have less than to no subjective complaints about the iliac donor site weeks to months later. It is nice to see this study actually illustrate this clinical impression by showing the marked difference in the use of crutches, and chronic pain complaints, including meteorotropism. The question of whether placement of a drain reduces postoperative problems is frequently discussed by clinicians. It is thus very interesting to note that the authors found no difference in hematoma or seroma formation between those patients with drains and those without drains. The authors’ discussion of sensory innervation and potential nerve injury is excellent. In several hundred iliac grafts, I have seen only two patients mention numbness, and this was in the area of the anterolateral thigh. In one of these cases the problem resolved completely in 3 to 4 months and in the other it had not completely resolved at 1 year postoperatively. Neither patient complained of this as a problem. I have never known a patient to develop dysesthesia of the skin or complain of numbness, as is the finding in this study. This, of course, does not mean dysesthesia cannot occur. The authors’ technique calls for 24 hours of bed rest followed by use of crutches for up to 4 weeks. In addition, the average hospital stay for the patients in this study was 4 to 5 days. Typically, for my patients having similar procedures, the hospitalization ranges from a 23-hour overnight observation to a 2-day hospital stay. I have also treated several patients in the office under sedation and local anesthesia, as well as in an outpatient surgicenter, with no change in surgical technique, and sent the patients home the day of surgery. None of these patients developed any problems. I also do not prescribe the use of crutches and allow patients to have cautious progressive ambulation, as tolerated, starting the second day. Occasionally, however, some of my adult patients have elected to use crutches for 1 to 2 weeks.
1430
J Oral Maxillofac 54:1430, 1996
Surg
Discussion Morbidity
From
Iliac Crest
Bone
Harvesting
Matthew B. Hall, DMD, MD Winter
Park,
Florida
This is an excellent study of patients’ reactions to, and problems associated with, use of the anterior iliac crest as a donor site for autogenous bone. The iliac crest has been a popular source of bone for several decades, both for large and small grafts. For spinal surgery, the posterior iliac crest is convenient, just as the anterior iliac crest is convenient for maxillofacial reconstruction because of not having to alter the patient’s position during surgery. In my experience, the procedure described in this study is the most conservative and least complicated surgical approach for obtaining bone from the anterior ilium when partial-thickness corticocancellous blocks and a good quantity of cancellous bone are required. An oscillating saw can be used instead of osteotomes for removing the corticocancellous block. This study is especially intriguing because all of the patients evaluated were having very elective procedures, that is, preprosthetic augmentation and repair of alveolar cleft defects, as opposed to bone grafts for reconstruction after severe facial trauma or ablative cancer surgery. One could speculate that patients electing to have preprosthetic bone augmentation would be more sensitive to donor site recovery and postoperative problems than patients undergoing more dramatic facial reconstruction. The 2.2 pain severity average, the 8.4 subjective acceptability score, and the 98% satisfaction with the resultant scar appear to indicate an overall favorable response by this group of patients. It is also very interesting to note that there were no statistically significant differences between group A and group B, except for the use of crutches, despite the mean age difference of 34 years. In my experience, children seem to return to normal pain-
less ambulation faster than adults and have less than to no subjective complaints about the iliac donor site weeks to months later. It is nice to see this study actually illustrate this clinical impression by showing the marked difference in the use of crutches, and chronic pain complaints, including meteorotropism. The question of whether placement of a drain reduces postoperative problems is frequently discussed by clinicians. It is thus very interesting to note that the authors found no difference in hematoma or seroma formation between those patients with drains and those without drains. The authors’ discussion of sensory innervation and potential nerve injury is excellent. In several hundred iliac grafts, I have seen only two patients mention numbness, and this was in the area of the anterolateral thigh. In one of these cases the problem resolved completely in 3 to 4 months and in the other it had not completely resolved at 1 year postoperatively. Neither patient complained of this as a problem. I have never known a patient to develop dysesthesia of the skin or complain of numbness, as is the finding in this study. This, of course, does not mean dysesthesia cannot occur. The authors’ technique calls for 24 hours of bed rest followed by use of crutches for up to 4 weeks. In addition, the average hospital stay for the patients in this study was 4 to 5 days. Typically, for my patients having similar procedures, the hospitalization ranges from a 23-hour overnight observation to a 2-day hospital stay. I have also treated several patients in the office under sedation and local anesthesia, as well as in an outpatient surgicenter, with no change in surgical technique, and sent the patients home the day of surgery. None of these patients developed any problems. I also do not prescribe the use of crutches and allow patients to have cautious progressive ambulation, as tolerated, starting the second day. Occasionally, however, some of my adult patients have elected to use crutches for 1 to 2 weeks.