Prospective evaluation of morbidity associated with iliac crest harvest for alveolar cleft grafting

J Oral Maxillofac Surg 55:219-223, 1997

Prospective Evaluation of Morbidity Associated With Iliac Crest Harvest for Alveolar Cleft Grafting ROBERT

A. RUDMAN,

DDS, MS*

Purpose: This study prospectively evaluated the morbidity associated with iliac crest bone harvest when performed for alveolar cleft grafting. Patients and Methods: Twenty-two consecutive patients who underwent an alveolar cleft graft with iliac crest bone harvest were evaluated. The estimated blood loss, length of hip incision, and volume of bone that was harvested were recorded. The duration of time until postoperative ambulation and the length of hospitalization were measured. Results: All patients tolerated the iliac harvest without major complication, and the volume of bone was sufficient in all but one case. Postoperatively, ambulation occurred at an average of 3 hours 18 minutes. Twenty-one patients were discharged the day after surgery; one patient had the surgery performed as an outpatient. Conclusions: Harvesting cancellous bone from the iliac crest does not result in delayed ambulation or prolonged hospitalization. The morbidity that has been reported to occur with iliac crest bone harvest was not consistent with the results of this study.

Osseous reconstruction of the alveolar cleft is an accepted practice in the overall management of the cleft patient, with recognized benefits being 1) obliteration of the oronasal fistula, 2) cross-arch stability, 3) periodontal support for the teeth adjacent to the cleft, 4) allowance for orthodontic alignment of the teeth, and 5) improved alar base supp~rt.‘-~ Although a few clinicians still advocate primary alveolar cleft grafting,4,5 the more accepted practice would be traditional secondary grafting’,2,6.7 or early secondary grafting.’ The anterior iliac crest is considered to be.the “gold standard” of donor sites for alveolar cleft grafting.’ However, the main disadvantage with iliac crest harvest is reported to be the discomfort that results in delayed ambulation and prolonged hospitalization. lo This postoperative morbidity has led surgeons to use

cranial bone,9,11,12 the mandibular symphysis,‘3-‘6allogeneic bone,17-19 and alloplastic materials20~2’ to lessen the morbidity associated with graft harvest. The purpose of this study was to prospectively evaluate the morbidity associated with iliac crest bone harvesting for alveolar cleft grafting. Materials

Twenty-two consecutive patients who underwent an alveolar cleft graft between June 1993 and December 1994 were included in this investigation. Fourteen patients were male and eight were female, with an average age of 12 years 8 months (range, 5 years 4 months to 17 years 2 months). Sixteen patients had a unilateral cleft defect, and six had a bilateral alveolar cleft (Table 1).

* Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Florida, Gainesville, FL. Address correspondence and reprint requests to Dr Rudman: Department of Oral and Maxillofacial Surgery, University of Florida, JHMHC 1001416, Gainesville, FL 32610. 0 1997 American

Association

of Oral and Maxillofacial

and Methods

SURGICAL TECHNIQUE

All patients underwent harvest from the left anterior iliac crest. Bupivicaine 0.5% with 1:200,000 epinephrine (Abbott Laboratories, North Chicago, IL) was in-

Surgeons

0278-2391/97/5503-0003$3,00/O

219

220

MORBIDITY

Table

1.

Patient

Sex

1 2 3 4 5 6 I 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

M F M F M F M F F F F M M M M M F M M M M M

’

Abbreviations:

Age 9 yr 5 yr llyr 10yr 7 yr 13yr 14 yr 17yr llyr 12yr 10 yr 10yr 10yr 13 yr 8 yr 14yr 8 yr 9 yr 9 yr 8 yr 9 yr 8 yr LAC,

ILIAC

HARVEST

FOR

CLEFT

GRAFTING

Data Cleft

Patient No.

OF

Length

Type

11 mo 4mo 5mo 9mo 2 mo 3mo 4 mo 2mo 9mo 8mo 11 mo 6mo 6mo 10 mo 7 mo 7mo 11 mo 2 mo 4 mo 0 mo 4 mo 11 mo

RAC RAC LAC LAC LAC LAC RAC LAC LAC RAC LAC LAC RAC LAC BAC RAC LAC BAC BAC BAC BAC BAC

left alveolar

cleft;

of Incision (mm)

Estimated

right

alveolar

Loss

Condensed WI

50 160 15 100 30 100 175 75 250 140 48 165 200 150 75 500 70 40 150 200 100 160

30 21 35 30 32 30 28 27 30 35 31 25 33 28 31 30 27 32 29 28 31 28 RAC,

Blood WA

cleft;

filtrated into the subcutaneoustissuesto aid in hemostasis. An incision was made approximately 1 cm lateral to the iliac crest through skin and subcutaneous tissues.Dissection was continued through Scarpa’s fascia directly over the iliac crest. A longitudinal incision was made through the cartilaginous cap, taking care to avoid the origin of the external oblique muscle. Slight undermining of the cartilage was performed to facilitate closure. An osteotome was used to bisect the crest into medial and lateral halves. Osteotomies were then created through the crest and medial cortex both at the anterior and posterior extent of the longitudinal osteotomy (Fig 1). The medial half of the crest was outfractured, and cancellous bone was removed with sharp curettes and stored in saline (Fig 2). Powdered Avitene (MedChem Products, Inc, Woburn, MA) was placed into the resultant cavity, and the medial cortex was repositioned and securedwith 2-O Vicryl sutures (Ethicon, Somerville, NJ) placed through the previously undermined cartilage. Scarpa’s fascia was reapproximated with 4-O Vicryl suture (Ethicon). Approximately 4.0 mL bupivicaine 0.5% with 1:200,000 epinephrine was infiltrated beneath Scarpa’s fascia to provide postoperative analgesia. Closure was completed in a layered fashion. The site was dressed with Adaptic (Johnson and Johnson, Medical Inc, Arlington, TX), and a pressure dressing was applied. The length of the cutaneousincision, volume of bone harvested after condensation, and estimated blood loss

BAC,

bilateral

Bone

3.4 3.0 4.2 3.4 2.1 2.4 3.0 3.2 3.8 3.6 3.4 3.6 3.6 4.4 4.6 5.8 3.0 4.4 6.2 9.2 3.6 5.4 alveolar

Time

Until

Ambulation

2 hr 33 min 5hr 4min 2 hr 10 min 2 hr 39 min 1 hr 55 min 3 hr 20 min 3 hr 32 min 5 hr 46 min 4 hr 11 min 3 hr 27 min 2 hr 35 min 2 hr 43 min 2 hr 47 min 1 hr 45 min 3 hr 5 min 1 hr 57 min 2 hr 28 min 4 hr 49 min 4 hr 2 min 5 hr 3 min 2hr57min 3hr 5min

cleft.

from the hip harvest were measuredand recorded. The anesthesiologist calculated the blood loss by subtracting the amount of irrigation used from the total volume in the suction canister and by accounting for blood on the spongesand drapes. Postoperative orders instructed the nursing staff to “ambulate the patient on return to the room when stable,” and record the time. The time from patient’s entrance into the recov-

FIGURE 1. The vertical osteotomies of the crest and medial cortex.

that section

the medial

half

ROBERT

221

A. RUDMAN

Discussion

FIGURE 2. medial cortex

The outfractured and the harvesting

medial half of the iliac crest and of cancellous bone with a curette.

ery room until ambulation and days until discharge were recorded. Results All patients tolerated the operative procedure without major complication. Blood loss from the iliac crest harvest averaged 137 mL (range, 40 to 500 mL). The average length of the cutaneous incision was 29 mm (range, 21 to 35 mm). The harvested bone was condensedin a syringe to increase density, and the average volume measured was 4.1 mL (range, 2.1 to 9.2 mL) (Table 1). The volume of bone harvested was more than sufficient in all cases, with the exception of one patient (patient 6). In this case, approximately 0.5 cc particulate BioOss (Osteohealth Co, Shirley, NY) was mixed with the autogenous cancellous bone to provide sufficient volume. Postoperatively, ambulation occurred at an average of 3 hours 18 minutes (range, 1 hour 45 minutes to 6 hours 3 minutes). All patients reported cutaneous anesthesiain the region of the surgical site and experienced only mild discomfort on ambulation. Twentyone patients were discharged the day after surgery. One patient (patient 14) had the surgery performed on an outpatient basis and was discharged from the recovery room. During the postoperative course, no complications such as hematoma, seroma, paresthesia, or infection were experienced in the donor site. Although the patients favored the operated side during ambulation for the first postoperative week, none showed a gait disturbance at the 2-week follow-up visit.

Osseousreconstruction of the alveolus for the management of a cleft defect has been performed since the early 1900~.~*~~~ Primary grafting was the standard of care during the 1960~,*~,*~and, although some practitioners still advocate the procedure, the concept has fallen into disfavor. A split rib was the most commonly used graft material for primary grafting. Currently, the accepted standard is secondary grafting, which is performed before the eruption of the canine tooth.6 The iliac crest has been used as a donor site since the inception of secondary cleft grafting. Many advantages exist to the use of the iliac crest, such as abundant volume, ease of harvest, favorable quality of bone, and ability to harvest the graft simultaneously with the oral procedure and thus reduce operating time. The choice of donor site is determined by several factors, including surgeon’s preference, volume of bone required and available, embryologic origin of the bone, and morbidity associated with the harvest. The major criticism of the use of the iliac crest for alveolar cleft grafting is postoperative discomfort that limits ambulation and results in prolonged hospitalization and extended recovery time. This has prompted surgeons to investigate other donor sites for autogenous bone, and even to explore allogeneic sourcesand alloplastic materials. Donor sites that have been used for alveolar cleft grafting include rib, tibia, calvarium, and the mandibular symphysis. In recent years, cranial bone has been advocated as a donor site preferable to the iliac crest. Several advantageshave been noted and include 1) a nonvisible scar; 2) no secondary deformity at the donor site; 3) abundance of bone in children; 4) little postoperative pain, resulting in shorter hospitalization; 5) donor site in the sameoperative field; and 6) greater graft volume survival with membranousbone.g,11,26 Successrates for alveolar clefts grafted with calvarial bone are varied, with Wolfe and Berkowitz” reporting 89.1%, Kortebein et al” reporting 63%, and Sadove et al9 reporting 66.6%. Other investigators have abandoned the use of calvarial bone because of dissatisfaction with the ossification of the grafted clefts and periodontal defects along adjacent teeth.26 The mandibular symphysis also develops embryologically in a membranous fashion.13,16Since 1980, symphyseal bone has been used as a donor site, especially in European centers.27Morbidity associatedwith bone harvest from the symphysis has been reported as minimal, and the successrate of the grafted clefts was satisfactory. The main detriment with symphyseal bone is the available volume. The site should be reserved for small defects, or in patients in whom transverse

222

MORBIDITY

expansion is not complete, to minimize the cleft dimension.16 Early independent clinical observations have suggested that bone obtained from a membranous source would survive grafting procedures more successfully than bone from an endochondral source.” Animal studies showed that when corticocancellous blocks were grafted to the facial skeleton in an onlay fashion, bone of membranous origin maintained its volume significantly better than endochondral bone.29,30Earlier revascularization of membranous bone was thought to contribute to maintenance of the graft volume.31 Both the mandibular symphysis and calvarium differentiate in a membranous fashion. Proponents of calvarial and mandibular bone attribute their membranous origin and early revascularization as justification for use. However, there are two main contentions that challenge the rationale for the use of membranous bone in alveolar cleft grafting. First, the osseous deformity is a continuity defect of the alveolar process and pyriform rim. To reconstruct the alveolar cleft, the bone is inlayed between the osseous segments rather than onlayed on the maxilla. Second, cancellous bone and not a corticocancellous block is used for alveolar grafting. Based on these two contentions, one cannot logically apply the conclusions from membranous bone research to the specialized situation of the alveolar cleft defect. The concept of membranous grafts having a biologic superiority over the iliac crest remains theoretical and unsubstantiated.’ The l-day hospitalization that was seen in this study is significantly shorter than that reported by other investigators who harvested bone from the iliac crest. Troxell et al’ reported an average hospitalization period of 3.6 days. Hall and Posnick7 reported an average hospitalization of 3.8 days’ for patients with a unilateral cleft graft and 4.1 days for patients who underwent a bilateral grafting procedure. These reports may not have a direct correlation to the results from this study because they were published in the early 1980s during a period of more lenient hospital stays and less insurance restrictions. More recently Canady et a13’ reported a mean hospitalization of 2.5 days. Although advocates of cranial bone claim a shorter postoperative course, no studies are available that report on the duration of hospitalization. Wolfe and Berkowitz” mention a hospitalization of “1 to 2 days” but provide no actual data on their patient population. With only minor modification, the method of iliac crest harvest presented in this article is consistent with that previously reported by Canady et a1.32During dissection, special care is taken to avoid the gluteus medius muscle laterally and the abdominal muscles medially. The medial periosteal attachments are not elevated because the medial cortex is outfractured and

pedicled to the iliacus muscle. This method almost totally eliminates muscle dissection and periosteal elevation, two factors that have long been identified as major contributors to postoperative discomfort with iliac crest harvest.33-35 The administration of bupivacaine locally provided for profound analgesia of approximately 6 hours. When questioned during the postoperative period, many patients were unable to determine which hip had been operated on. In one patient (patient 6), the volume of bone was found to be insufficient for the complete osseous reconstruction of the defect. This finding was surprising because the patient was 13 years 3 months of age, weighed 36.8 kg, and the volume of condensed bone required measured only 2.9 mL. Rather than harvest the opposite iliac crest, 0.5 mL BioOss (Osteohealth Co), an anorganic natural bovine bone matrix, was combined with the 2.4 mL autogenous bone to provide adequate volume. The graft was judged to be successful based on subsequent clinical and radiographic examination.

OF ILIAC

HARVEST

FOR

CLEFT

GRAFTING

Conclusions

The iliac crest has been, and most likely, will continue to be, a favorable donor site for maxillofacial reconstruction procedures. The morbidity associated with the iliac crest harvest has often exceeded the discomfort experienced by the alveolar cleft grafting procedure itself. The surgical technique used limits muscle dissection and periosteal elevation and provides acceptable access for cancellous bone harvest. The local administration of bupivacaine provides for anesthesia of the iliac crest region and results in decreased postoperative discomfort. The early ambulation and decreased length of hospitalization reported in this study contrast with the findings of other investigators. Since the inception of secondary cleft grafting, the iliac crest has proved to be the standard with which other donor sites are compared. With conservative surgical technique and controlled regional analgesia, the iliac crest should continue to be the “gold standard.” References 1. Troxell JB, Fonseca RJ, Osbon DB: A retrospective study of alveolar cleft grafting. J Oral Maxillofac Surg 40:721, 1982 2. Turvey TA, Vig K, Moriarty J, et al: Delayed bone grafting in the cleft maxilla and palate: A retrospective analysis. Am J Orthod 86:244, 1984 3. Helfrick JF: Principles of Oral and Maxillofacial Surgery. Philadelphia, PA, Lippincott, 1992, p 1575 4. Rosenstein SW, Monroe CW, Kemahan DA, et al: The case for early bone grafting in cleft lip and palate. Plast Reconstr Surg 70x297. 1982

RAYMOND

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J. FONSECA

5. Nelson CL: Primary alveolar cleft bone grafting. Oral Maxillofat Surg Clin North Am 3:599, 1991 6. Boyne PJ, Sands NR: Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 30:87, 1972 7. Hall HD, Posnick JC: Early results of secondary bone grafts in 106 alveolar clefts. J Oral Maxillofac Surg 41:289, 1983 8. Boyne PJ: Bone grafting in the osseous reconstruction of alveolar and palatal clefts. Oral Maxillofac Surg Clin North Am 3:589, 1991 9. Sadove AM, Nelson CL, Eppley BL, et al: An evaluation of calvarial and iliac donor sites in alveolar cleft grafting. Cleft Palate J 27:225, 1990 10. Harsha BC, Turvey TA, Powers SK: Use of autogenous cranial bone grafts in maxillofacial surgery: A preliminary report. J Oral Maxillofac Surg 44: 1I, 1986 11. Wolfe SA, Berkowitz S: The use of cranial bone grafts in the closure of alveolar and anterior palatal clefts. Plast Reconstr Surg 72:659, 1983 12. 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, 1991 13. Sindet-Pedersen S, Enemark H: Mandibular bone grafts for reconstruction of alveolar clefts. J Oral Maxillofac Surg 46:533, 1988 14. Koole R, Bosker H, van der Dussen FN: Late secondary autogenous bone grafting in cleft patients comparing mandibular (ectomesenchymal) and iliac crest (mesenchymal) grafts. J Craniomaxillofac Surg 17:28, 1989 15. Borstlap WA, Heidbuchel KLWM, Freihofer PM, et al: Early secondary bone grafting of alveolar cleft defects: A comparison between chin and rib grafts. J Craniomaxillofac Surg 18:201, 1990 16. 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, 1990 17. Marx RE, Miller RI, Ehler WJ, et al: A comparison of particulate allogeneic and particulate autogenous bone grafts into maxillary alveolar clefts in dogs. J Oral Maxillofac Surg 42:3, 1984 18. Kraut RA: The use of allogeneic bone for alveolar cleft grafting. Oral Surg Oral Med Oral Path01 64:278, 1987 19. Nique T, Fonseca RJ, Upton LG, et al: Particulate allogeneic

20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

bone grafts into maxillary alveolar clefts in humans: A preliminary report. J Oral Maxillofac Surg 45:386, 1987 Cullum PE, Frost DE, Newland TB, et al: Evaluation of hydroxylapatite particles in repair of alveolar clefts in dogs. J Oral Maxillofac Surg 46:290, 1988 Horswell BB, El Deeb M: Nonporous hydroxylapatite in the repair of alveolar clefts in a primate model: Clinical and histologic findings. J Oral Maxillofac Surg 47:946, 1989 von Eiselsberr FW: Zur technik der uranoolastik. Arch Klin Chir 64:509, 1901 Lexer E: Die verwendung der freien knochenplastik nebst versuchon iiber gelenkuersteifung und gelenktranplantation. Arch Klin Chir 86:939, 1908 Blckdabl M, Nordin KE: Replacement of the maxillary bone defect in cleft palate. Acta Chir Stand 122:131, 1961 Brauer RO, Cronin TD: Maxillary orthopedics and anterior palate repair with bone grafting. Cleft Palate J 1:31, 1964 Jackson IT, Helden G, Marx R: Skull bone grafts in maxillofacial and craniofacial surgery. J Oral Maxillofac Surg 44:949, 1986 Bosker H, Van Dijk L: Het bottansplantaat uit de mandibula voor herstel van de gnatho-palatoscbisis. Ned Tijdscbr Tandheelkd 87:383, 1980 Peer LA: The fate of autogenous human bone grafts. Br J Plast Surg 3:233, 1951 Smith JD, Abramson M: Membranous vs endochondral bone autografts. Arch Otolaryngol 99:203, 1974 Zins JE, Whitaker LA: Membranous versus endochondral bone: Implications for craniofacial reconstruction. Plast Reconstr Surg 72:778, 1983 Kusiak JF, Zins JE, Whitaker LA: The early revascularization of membranous bone. Plast Reconstr Surg 76:510, 1985 Canady JW, Zeitler DP, Thompson SA, et al: Suitability of the iliac crest as a site for harvest of autogenous bone grafts. Cleft Palate Craniofac J 30:579, 1993 Scott W, Petersen RC, Grant S: A method of procuring iliac bone by trephine curettage. J Bone Joint Surg Am 31:860, 1949 Flint M: Chip bone grafting of the mandible. Br J Plast Surg 17: 1964. Bloomquist DS, Feldman GR: The posterior ilium as a donor site for maxillo-facial bone grafting. J Maxillofac Surg 8:60, 1980

J Oral Maxillofac Surg 55:223-224, 1997

Discussion Prospective Evaluation of Morbidity Associated With Iliac Crest Harvest for Alveolar Cleft Grafting Raymond J. Fonseca, DMD University

of Pennsylvania,

Philadelphia,

Pennsylvania

The question of the preferred donor site for alveolar cleft grafting has been debated for many years. All three sources of autologous bone (iliac crest, calvarium, and mandibular symphysis) have their advantages and disadvantages. Additionally, the use of bone substitutes such as hydroxylapatite has also been advocated. However, this material has limited use in alveolar cleft grafting, especially when an unempted tooth is present adjacent to the cleft site. On the other hand,

allogeneic bone grafts have been used to fill the defect in a residual alveolar cleft with excellent results. The author embarked on this study to prospectively evaluate the morbidity associated with iliac crest bone harvest when performed for alveolar cleft grafting. He points out the advantages of an iliac crest donor site, such as abundant volume, the ease of harvest, the favorable quality of the bone, and the ability to harvest a graft simultaneously with the oral procedure and thus reduce operating time. He also points out the differences between the results of this study and others, including a length of hospitalization that was significantly shorter than that reported by other investigators who harvested the bone from the iliac crest. Additionally, the author states that no comparison should be made between this study and the previous studies relative to the length of hospitalization because other variables such as insurance