How can we optimize anterior iliac crest bone harvesting? An anatomical and radiological study

Caecum Rupture Secondary to Iliac Crest Bone Graft: A Case Report

Autogenous bone grafting is a common surgical method in orthopaedics. The anterior iliac crest is a common site for harvesting autologous bone grafts. There are many complications after iliac bone harvesting, and pain and discomfort at the donor site are the most common sequelae. However, intestinal rupture after iliac bone harvesting has not been reported. We report a case of caecum rupture in a 58-year-old male after harvesting bone from his iliac crest. After proper surgical repair, the patient was discharged from the ICU and his bowel function recovered. This serious complication of bone harvesting from the iliac crest prompted investigation of the technique of iliac crest harvesting and donor site reconstruction.

Comparison of the inner side and two-sided approaches for iliac crest bone graft harvesting for pediatric pelvic osteotomy

Background

The iliac crest is one of the most used bone graft sources. In this study, we aimed to identify the effects of inner side and two-sided approaches for iliac crest bone harvesting on post-surgery ilium growth in children.

Materials and methods

We retrospectively analyzed 47 patients who underwent pelvic osteotomy and iliac crest bone graft (ICBG) procedures from January 2015 to September 2018. The patients were divided into an inner table ilium exposure group (group A) and the inner-outer table ilium exposure group (group B) and were followed up with radiography in postoperative months 1, 3, 6, and 12, and the growth areas were measured using PACS software. Complications such as damage to the arteries or nerves, ureteral injury, gastrointestinal hernia, ileus, abnormal cosmetic appearance, sensory disturbances, and functional limitations were recorded based on clinical records.

Results

There were 22 patients aged 5.3±1.5 years in group A and 25 patients aged 5.9±1.8 years in group B. There were no significant differences in demographics between the two groups, or in growth in the first month. However, bone graft growth at months 3, 6, and 12 was significantly better in group A than in group B. There was no significant difference in complications between the two groups.

Conclusion

Exposure of only the inner table of the ilium resulted in faster recovery of the bone defect than two-sided exposure in pelvic osteotomy. Therefore, we suggest protecting the outer side of the ilium during surgery.

Level of evidence

Level III

Postmortem evaluation of neuromuscular damages more extensive than the surgical intervention area after iliac crest bone graft

Several complications may occur following iliac bone grafting, one of the common sites for autologous bone harvesting. Of these, it is difficult to localize the damage in neurological complications due to the presence of several nerves in a similar distribution area with variations among individuals. To minimize these complications, conventional clinical anatomical studies using normal human cadavers have estimated the theoretical neurological damage area corresponding to the surgical intervention area. We report a case of neuromuscular damage in a 93-year-old woman who had an iliac crest defect after a bone graft, based on the virtual and physical dissections with histological confirmations.In this study, the patient was confirmed to have severe neuromuscular complications with major complications including a hernia protruding through the iliac defect. One of the two ilioinguinal nerves was extracted with the hernia sac through the iliac defect, and its distal part was completely damaged. The iliohypogastric nerve, which was far from the defect foramen, also showed remarkable fibrosis and demyelination, affected by the degeneration of the transversus abdominis muscles.The present anatomical findings show that the area of eventual neuromuscular damage should be estimated to larger than the conventionally predicted area of direct nerve damage, which is usually concomitant with the surgical intervention area.

Sternal Tumor Resection and Reconstruction Using Iliac Crest Autograft

Primary malignant tumors of the sternum are rare among bone tumors. Even with radical resection, the survival rate for sternal tumors remains low. Resection often results in significant bone defects in the chest wall, and reconstruction must provide adequate protection for pulmonary and respiratory structures. Flexible materials have historically been used for sternal reconstructions following failed sternotomies in cardiac surgery. Although these have had some success, they fail to provide adequate support for patients undergoing reconstruction secondary to tumor resection, who are otherwise healthy and active. Although rigid materials offer greater protection, they frequently cause chronic pain and respiratory complications. More recently, bone grafts have been used to reconstruct sternal defects, and the limited published reports are promising.

Donor site morbidity of vascularized bone grafts from the medial femoral condyle for osseous revascularization

BACKGROUND

Vascularized bone grafts from the medial femoral condyle (MFC) are used to gain surgical revascularization of osseous defects. To date objective data regarding the donor site morbidity are limited. This study aims to evaluate the donor site associated outcome after MFC flap harvest.

PATIENTS AND METHODS

From 2008 to 2016, 22 patients who underwent MFC bone flap harvest for osseous revascularization of 9 talus, 8 scaphoids, 2 metacarpals, 1 phalanx, 1 pilon tibiale, and 1 distal femur were included. Outcome analysis was performed for the whole cohort as well as for two subgroups (recipient site upper [group A] and lower extremity [group B]) by the lower extremity functional scale (LEFS), the OAK-score of the Swiss Orthopedic Society and the visual analog scale (VAS). Additionally, a 3D gait analysis was performed for four patients.

RESULTS

The mean flap size was 1 × 1 × 3 cm. No flap loss was observed. One minor surgical revision was performed due to donor site hematoma. Mean follow-up was 35.8 (12-98) months. Mean LEFS-score was 74.9 ± 9.5 (A: 74.3 ± 7.9; B: 75.6 ± 11.2, p > .05) and OAK-score was 92.8 ± 9.4 (A: 93.2 ± 5.8; B: 92.4 ± 12.3, p > .05). At follow-up examination, pain at rest was stated with 0.1 ± 0.2 (A: 0.1 ± 0.3; B 0 ± 0, p > .05) and with activity 0.6 ± 1.4 (A: 1.2 ± 1.8; B: 0 ± 0, p > .05) on VAS. The 3-D gait analysis showed normative walking patterns.

CONCLUSION

After MFC flap harvest knee function and gait pattern were almost unimpaired. Donor site morbidity can be considered as being of minor concern in the decision-making for this microvascular procedure.

A review of main anatomical and sonographic features of subcutaneous nerve injuries related to orthopedic surgery

Lesion to subcutaneous nerves is a well-known risk of orthopedic surgery and a significant cause of postoperative pain and dissatisfaction in patients. High-resolution ultrasound can be used to visualize the vast majority of small subcutaneous nerves of the upper and lower limbs. Ultrasound detects nerve abnormalities such as focal hypoechoic thickening, stump neuroma, and scar encasement, and provides information not only about the peripheral nerve itself but also about its relationship to adjacent anatomical structures. The purpose of this review is to provide an overview of the anatomy of the main subcutaneous nerves damaged during orthopedic surgery, recall at-risk procedures, and offer useful anatomic landmarks to help the sonographer identify and follow the nerves when an iatrogenic lesion is suspected.

Comprehensive analysis of the volume of bone for grafting that can be harvested from iliac crest donor sites

Our aim was to calculate the volumes of cancellous, cortical, and corticocancellous bone that can be harvested as a graft from the anterior and posterior iliac crests using 3-dimensional computed tomography (CT) and software in a living adult population. We selected random CT scans of the pelvis from 31 men and 29 women from the Department of Radiology imaging database. CT data in DICOM file format were imported into Mimics software. The anterior iliac crest and posterior iliac crest bone graft-harvested boundaries were measured. The volume of the 3-dimensional cortical and cancellous bone grafts was measured using the Mimics software. There were significant differences in all comparisons between the anterior and posterior iliac crest, except for volumes of cortical bone. More cancellous and total corticocancellous bone can be harvested from the posterior than the anterior iliac crest, together with similar or smaller volumes of cortical bone. Sex, but not age, is an important factor in terms of the amount of bone that can be harvested, with a wide range of volumes individually from both iliac crests.

Anatomic feasibility of a new endopelvic approach for iliac crest bone harvesting

PURPOSE

For the past few years, anterior exposure for surgery of the lumbar spine has gained popularity for the treatment of disk disease or spondylosis. Cancellous bone remains the gold standard for fusion. Iliac crest bone harvesting is safe but there are donor site complications. Bone substitutes exist, like recombinant human bone morphogenic protein-2 rhBMP-2. This alternative offers a high rate of fusion but with local and general complications. The aim of our study is to show the feasibility of an endopelvic approach for iliac bone crest harvesting to avoid donor site complication.

METHOD

Twenty anterior retroperitoneal lumbar spine approaches have been realized in the anatomy department of the University of Bordeaux. The volumes of cancellous bone have been measured and procedure complications have been reported.

RESULTS

The mean volume of cancellous bone was 5.9 cc, the maximum volume was 8.2 cc and the minimum volume was 4.5 cc. No complications have been reported during the approach or the bone harvesting.

CONCLUSIONS

Anterior retroperitoneal approach for iliac bone crest harvesting is a safe way to obtain sufficient volume of cancellous bone for a single lumbar spinal fusion. This exposure avoids the risks of an iliac crest donor site complications or rhBMP-2 complications.

Results of 10-year follow-up of the iliac donor site of graft patients

OBJECTIVES

To measure levels of pain and iliac regeneration at the iliac crest donor site during a 10-year follow-up of graft patients.

METHODS

This prospective study used a visual analogue scale (VAS) to assess pain at the donor site at 1 month and 1, 3, 5 and 10 years postoperatively. Iliac regeneration status was recorded at 1, 3, 5, 7 and 10 years postoperatively by comparing plain radiographs.

RESULTS

A total of 32 patients participated in the study. Mean VAS scores at 1 month, 1 year, 3, 5, and 10 years were 3.22, 3.39, 3.45, 2.02 and 1.38, respectively. There was no statistically significant difference between pain scores at 1 month and 1 year, but pairwise comparisons revealed significant differences between the other timepoints. The mean iliac regeneration rank scores at 1, 3, 5, 7 and 10 years were 1.36, 2.22, 2.97, 3.75 and 4.70, respectively; all pairwise comparisons were statistically significant.

CONCLUSION

The iliac donor site showed a declining trend in pain, which appeared to have started 3 years postoperatively. Long-term follow-up showed that the ilium is readily able to repair itself.