Reconstruction of large iliac crest defects after graft harvest using autogenous rib graft: a prospective controlled study

Safety and performance of a novel synthetic biomimetic scaffold for iliac crest defect reconstruction during surgical treatment of pelvic girdle pain: a first-in-human trial

INTRODUCTION

Surgical treatment of pelvic girdle pain (PGP) involves arthrodesis of sacroiliac (SI) and pubic symphysis joints. Fusion of pubic symphysis involves the implantation of an autologous iliac crest tricortical graft harvested from the iliac crest. The objective was to assess the safety of a novel synthetic graft substitute (b.Bone) for iliac crest reconstruction and to evaluate the results of PGP surgical treatment.

SOURCES OF DATA

Consecutive participants undergoing pelvic fusion and requiring iliac crest reconstruction were enrolled and followed-up for 12 months in a prospective first-in-human clinical investigation. Adverse events were documented, and health-related quality of life was evaluated using EuroQol-5D-5L questionnaire. Iliac crest defect healing was evaluated by the Modified Lane and Sandhu radiological scoring system. In addition, relevant published peer-reviewed scientific articles identified from PubMed.

AREAS OF AGREEMENT

The EQ-5D-5L scores improved steadily reaching the highest point at 365 days. By 365 days complete healing of the bone defect was observed.

AREAS OF CONTROVERSY

The management of PGP remains challenging with mixed results reported in the literature.

GROWING POINTS

While there is lack of consensus on how to manage PGP, the present study shows improved outcomes at one year following surgery. The synthetic b.Bone scaffold is a safe option with good healing outcomes for iliac crest defect reconstruction.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although b.Bone synthetic scaffold found to be safe, further studies reporting on surgical treatment of PGP are required to confirm the findings in comparative trials.

Bone and parietal anterior iliac crest reconstruction for trans-iliac hernia after tricortical graft harvesting: An original technique

Tricortical cortico-cancellous bone allografts from the anterior iliac crest are routinely used in revision arthroplasty and to treat non-union. Trans-iliac herniation (TIH) has been reported as an exceptional complication after extensive graft harvesting. The various reconstruction techniques include isolated parietal reconstruction and combined parietal and bone reconstruction using allografts or a spacer to reconstruct the bone defect. No previous study has evaluated a combined reconstruction technique involving both bone reconstruction with a titanium plate and abdominal wall reconstruction with a parietal reinforcement prosthesis. This technical note describes the evaluation of an original combined reconstruction technique used after failure of isolated parietal reconstruction to treat TIH. Through a direct approach to the anterior iliac crest, the bone defect was repaired using a flexible titanium cranio-facial reconstruction plate and the abdominal wall defect using a polypropylene/poliglecaprone parietal reinforcement prosthesis. This original technique was demonstrated to be effective for treating TIH, with no recurrence after 2.5 years of follow-up. In addition, this technique involves no added morbidity related, for instance, to allograft using or spacer migration.

Reconstruction of iliac crest defect after autogenous harvest with bone cement and screws reduces donor site pain

Background

The iliac crest is the most common autogenous bone graft donor site, although associated with postoperative pain, functional disability, cosmesis, morphology and surgical satisfaction. We assessed each aspect above by comparing iliac crest reconstruction with bone cement and screws following harvest with no reconstruction.

Methods

We evaluated patients who underwent large iliac crest harvesting, including ten patients who underwent iliac crest defect reconstruction with bone cement and cancellous screws (R group) and ten randomly matched patients without reconstruction (NR group) were evaluated prospectively in the same period. Local pain, cosmesis and other complications were assessed postoperatively at 1 week, 6 weeks, 3 months and 6 months.

Results

Pain, cosmesis and satisfaction of patients significantly differed between the two groups. The R group exhibited less complications and lower pain visual analogue scores at postoperative 1 week (p < 0.001), 6 weeks (p < 0.001) and 3 months (p < 0.01) but not at 6 months, at which time patients reported almost no pain. One patient reported pain for more than 1 year in the NR group. The R group exhibited better cosmesis, morphology and satisfaction than the NR group. In the NR group, one patient suffered pain when sitting up and another when wearing a belt.

Conclusion

Postoperative pain can be reduced and cosmesis can be improved through reconstructing the iliac crest defects after autogenous harvesting with bone cement and cancellous screws. The technique is simple, safe and easy to implement.

Kirschner Wire and Bone Cement is a Viable Alternative to Reconstruction of Large Iliac Bone Defects After Strut Bone Graft Harvesting

STUDY DESIGN

A retrospective study.

OBJECTIVE

To assess the safety and efficacy of iliac crest defect reconstruction using Kirschner wire (K-wire)/polymethylmethacrylate (PMMA) versus traditional autologous rib graft reconstruction.

SUMMARY OF BACKGROUND DATA

The iliac crest has been the preferred donor site for strut bone graft for various spinal fusion surgeries.

METHODS

Seventy-three patients (44 males and 29 females; average age: 57.2 y) were divided into 2 groups: the rib group (35 patients) and the K-wire/PMMA group (38 patients). All operations involved anterior spinal interbody fusion. Patients were followed-up, on average, for 34.2 months using plain radiographs and both pain and cosmesis visual analog scales (VAS) to assess the clinical results after surgery.

RESULTS

Almost all patients had pain VAS scores of ≤1 and grade 1 cosmesis VAS scores with no significant difference between the 2 groups in terms of either pain or cosmesis (P=1.00 and 0.505, respectively). In addition, few complications were noted in both groups. Radiographic complications in the rib group and the K-wire group numbered 4 (11%) and 2 (5%), respectively; however, did not significantly differ between the 2 groups (P=0.418). One case required intraoperative revision of the length of the K-wire and 1 case needed reoperation for iliac ring fracture and K-wire migration. An additional case required revision due to a bad fall.

CONCLUSIONS

K-wire and bone cement reconstruction is an effective and safe alternative method for large iliac bone defect repair when autologous rib graft is not available.

Comparison of rabbit rib defect regeneration with and without graft

Rib segment, as one of the most widely used autologous boneresources for bone repair, is commonly isolated with an empty left in the defect. Although defective rib repair is thought to be unnecessary traditionally, it's of vital importance actually to promote rib regeneration for patients with better postoperative recovery and higher life quality. Comparative investigations on rabbit rib bone regeneration with and without graft were reported in this article. A segmental defect was performed on the 8th rib of 4-month-old male New Zealand rabbits. The mineralized collagen bone graft (MC) was implanted into the defect and evaluated for up to 12 weeks. The rib bone repair was investigated by using X-ray at 4, 8 and 12 weeks and histological examinations at 12 weeks after surgery, which showed a higher bone remodeling activity in the groups with MC implantation in comparison with blank control group, especially at the early stage of remodeling.

Autogenous rib grafts for reconstruction of the manubrium after resection: technical refinements and outcomes

OBJECTIVE

Sternal reconstruction after resection is essential for restoring the rigidity of the chest cavity. However, no consensus has been reached regarding the most physiologic or efficacious material for this procedure. We present our clinical experience with autogenous rib grafts for reconstruction of the manubrium after resection and discuss the refinements in this procedure.

METHODS

Twelve consecutive patients with a confirmed diagnosis of a primary neoplasm in the manubrium between March 2003 and August 2013 were analyzed retrospectively. All patients underwent manubrium resection and immediate reconstruction with autogenous rib grafts.

RESULTS

No cases of perioperative mortality were noted. The median operation time was 129 minutes. One patient experienced mild paradoxical movement; the other patients recovered well without any complications. The median follow-up period after surgery was 69 months. Two patients died. One patient with chondrosarcoma died as a result of cardiac disease 26 months after surgery and another patient with non-Hodgkin lymphoma died as a result of local recurrence 6 months after surgery. Computed tomographic scans for the other 10 patients have shown neither dislocation nor abnormality of the transplanted ribs; moreover, no absorption of the grafts or recurrence was noted. None of the patients required prescription analgesics for the pain at the donor site at the 3-month follow-up visit.

CONCLUSIONS

This case series demonstrates the successful use of autogenous rib grafts in the reconstruction of the manubrium after resection. We consider that the reconstruction technique is a safe and effective alternative to a complex problem.

A retrospective study of iliac crest bone grafting techniques with allograft reconstruction: do patients even know which iliac crest was harvested? Clinical article

OBJECT

Considerable biological research has been performed to aid bone healing in conjunction with lumbar fusion surgery. Iliac crest autograft is often considered the gold standard because it has the vital properties of being osteoconductive, osteoinductive, and osteogenic. However, graft site pain has been widely reported as the most common donor site morbidity. Autograft site pain has led many companies to develop an abundance of bone graft extenders, which have limited proof of efficacy. During the surgical consent process, many patients ask surgeons to avoid harvesting autograft because of the reported pain complications. The authors sought to study postoperative graft site pain by simply asking patients whether they knew which iliac crest was grafted when a single skin incision was made for the fusion operation.

METHODS

Twenty-five patients underwent iliac crest autografting with allograft reconstruction during instrumented lumbar fusion surgery. In all patients the autograft was harvested through the same skin incision but with a separate fascial incision. At various points postoperatively, the patients were asked if they could tell which iliac crest had been harvested, and if so, how much pain did it cause (10-point Numeric Rating Scale).

RESULTS

Most patients (64%) could not correctly determine which iliac crest had been harvested. Of the 9 patients who correctly identified the side of the autograft, 7 were only able to guess. The 2 patients who confidently identified the side of grafting had no pain at rest and mild pain with activity. One patient who incorrectly guessed the side of autografting did have significant sacroiliac joint degenerative pain bilaterally.

CONCLUSIONS

Results of this study indicate the inability of patients to clearly define their graft site after iliac crest autograft harvest with allograft reconstruction of the bony defect unless they have a separate skin incision. This simple, easily reproducible pilot study can be expanded into a larger, multiinstitutional investigation to provide more definitive answers regarding the ideal, safe, and cost-effective bone graft material to be used in spinal fusions.

Tissue engineering rib with the incorporation of biodegradable polymer cage and BMSCs/decalcified bone: an experimental study in a canine model

Background

The reconstruction of large bone defects, including rib defects, remains a challenge for surgeons. In this study, we used biodegradable polydioxanone (PDO) cages to tissue engineer ribs for the reconstruction of 4cm-long costal defects.

Methods

PDO sutures were used to weave 6cm long and 1cm diameter cages. Demineralized bone matrix (DBM) which is a xenograft was molded into cuboids and seeded with second passage bone marrow mesenchymal stem cells (BMSCs) that had been osteogenically induced. Two DBM cuboids seeded with BMSCs were put into the PDO cage and used to reconstruct the costal defects. Radiographic examination including 3D reconstruction, histologic examination and mechanical test was performed after 24 postoperative weeks.

Results

All the experimental subjects survived. In all groups, the PDO cage had completely degraded after 24 weeks and been replaced by fibrous tissue. Better shape and radian were achieved in PDO cages filled with DBM and BMSCs than in the other two groups (cages alone, or cages filled with acellular DBM cuboids). When the repaired ribs were subjected to an outer force, the ribs in the PDO cage/DBMs/BMSCs group kept their original shape while ribs in the other two groups deformed. In the PDO cage/DBMs/BMSCs groups, we also observed bony union at all the construct interfaces while there was no bony union observed in the other two groups. This result was also confirmed by radiographic and histologic examination.

Conclusions

This study demonstrates that biodegradable PDO cage in combination with two short BMSCs/DBM cuboids can repair large rib defects. The satisfactory repair rate suggests that this might be a feasible approach for large bone repair.

Reconstruction of iliac crest with bovine cancellous allograft after bone graft harvest for symphysis pubis arthrodesis

PURPOSE

The aim of this study was to evaluate the safety and efficiency, as well as the incorporation characteristics of a specific type of xenograft used for iliac crest defects post-harvesting tri-cortical iliac crest bone graft.

METHODS

Sixteen patients diagnosed with chronic anterior pelvic pain were operated for pubic symphysis fusion. The tri-cortical graft harvested from the iliac crest was inserted into the pubic symphysis and compressed with a reconstruction plate. The defect in the iliac crest was filled with a block of cancellous bovine substitute (Tutobone®). The length of iliac crest defect, time to fusion of pubic symphysis, time to incorporation of the graft and complications were recorded. The postoperative pain and patients' satisfaction were evaluated.

RESULTS

The median age of patients was 36.5 years (range 27-75). Fusion was obtained in 15 patients (94 %). The median time to fusion was four months (range three to seven). The length of the iliac crest bone defect ranged from 40 to 70 mm. Integration of the bovine substitute was achieved in 15 patients (94 %) over a median period of three months (range two to six). The postoperative median pain score was 2 (range 1-5). Twelve patients (75 %) reported good satisfaction. No major complications or allergic reactions were observed.

CONCLUSIONS

The xenograft used in this study provided a safe and effective method of reconstruction of iliac crest donor site defects. It has satisfactory incorporation, high biocompatibility and no signs of inflammatory reactions. This new technique is simple and easily reproducible in routine clinical practice.

Reconstruction versus no reconstruction of iliac crest defects following harvest for spinal fusion: a systematic review: A review

OBJECT

Autologous bone from the iliac crest is commonly used for spinal fusion. However, its use is associated with significant donor site morbidity, especially pain. Reconstructive procedures of the iatrogenic defect have been investigated as a technique to alleviate these symptoms. The goal of this study was to assess the effects of reconstruction versus no reconstruction following iliac crest harvest in adults undergoing spine surgery.

METHODS

The authors searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4); MEDLINE (1948-Oct 2011); EMBASE (1947-Oct 2011); and the reference lists of articles. Randomized controlled trials (RCTs) or nonrandomized controlled trials (NRCTs) were included in the study. Two independent reviewers selected the studies, extracted data using a standardized collection form, and assessed for risk of bias.

RESULTS

Three RCTs (96 patients) and 2 NRCTs (82 patients) were included. These had a moderate to high risk of bias. The results suggest that iliac crest reconstruction may be useful in reducing postoperative pain, minimizing functional disability, and improving cosmesis. No pattern of other clinical, radiological, or resource outcomes was identified.

CONCLUSIONS

Although the available evidence is suboptimal, this systematic review supports the notion that iliac crest reconstruction following harvest for spinal fusion may reduce postoperative pain, minimize functional disability, and improve cosmesis.

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Use of occipital bone graft in pediatric posterior cervical fusion: an alternative paramedian technique and review of the literature

An alternative method of bone grafting for pediatric posterior cervical and occipitocervical fixation is presented in detail. Full-thickness autografts from small craniectomies of the occipital bone are used to augment posterior segmental fusion in pediatric patients. Twelve patients have been treated successfully without bone graft donor site complications. The technical differences from previously reported uses of calvarial autograft in spine fusion are reviewed.

Bone graft harvesting using the RIA (reaming irrigation aspirator) system - a quantitative assessment

INTRODUCTION

Autologous bone graft is still considered to be the gold standard for treating non-unions in trauma and orthopedic surgery. Intramedullary bone graft harvest appears to be an alternative to other bone graft options such as iliac crest bone graft and synthetic bone substitutes. A one-step reamer-irrigator-aspirator (RIA) system has been developed to reduce the intramedullary pressure and, as a consequence, minimize the risk of fat embolization. The purpose of this study was to determine whether the quantity of harvested intramedullary bone graft is comparable to the quantity of graft that was harvested from the iliac crest in other studies. The aim of the present study was to quantify harvested bone marrow and to compare our results to already published data.

METHODS

Eight human cadavers (7 males, 1 female, and 16 limbs) with an average age of 68 years (range, 49-79 years) were obtained for this study. Intramedullary reaming was performed in the tibiae and femora of each cadaver. Two different sizes (12- and 14-mm diameter) of the RIA system were used. After a medial parapatellar incision was made at the knee, antegrade and retrograde reaming were performed in the tibiae and femur to harvest bone graft.

RESULTS

A significantly greater quantity of bone graft was harvested from the femora (27 ± 12 g) than the tibiae (17 ± 9 g) (p = 0.007).

CONCLUSIONS

On the basis of our present results, harvesting intramedullary bone graft with the RIA system appears to be an innovative technique for bone grafting in limb reconstruction. A significantly greater quantity of bone graft was harvested from the femora than the tibiae (p = 0.007). No significant differences among age, sex, body weight, bone length, or BMI were observed. Our results showed that a sufficient quantity in weight of autogenous bone graft could be obtained using the RIA system.

Bone grafting options for lumbar spine surgery: a review examining clinical efficacy and complications

Background

Iliac crest harvest has been considered the “gold standard” at producing successful arthrodesis of the lumbar spine but is also associated with many donor-site morbidities. Many alternatives have been used to avoid iliac crest harvest, including autologous bone from other donor sites, allogeneic bone, ceramics, and recombinant human bone morphogenetic proteins (rhBMPs). This review will highlight the properties and preparations of these graft types and their potential complications and reported clinical efficacy.

Methods

A Medline search was conducted via PubMed by use of the following terms in various combinations: lumbar fusion, freeze-dried allograft, fresh-frozen allograft, autograft, iliac crest, demineralized bone matrix, rhBMP-2, rhBMP-7, scoliosis, bone marrow aspirate, HEALOS, coralline hydroxyapatite, beta tricalcium phosphate, synthetic, ceramics, spinal fusion, PLF, PLIF, ALIF, and TLIF. Only articles written in English were assessed for appropriate material. Related articles were also assessed depending on the content of articles found in the original literature search.

Conclusions

Although iliac crest remains the gold standard, reported success with alternative approaches, especially in combination, has shown promise. Stronger evidence with limited sources of potential bias is necessary to provide a clear picture of their clinical efficacy.

Cord blood--an alternative source for bone regeneration

Bone regeneration is one of the best investigated pathways in mesenchymal stromal cell (MSC) biology. Therefore strong efforts have been made to introduce tissue engineering and cell therapeutics as an alternative treatment option for patients with bone defects. This review of the literature gives an overview of MSC biology aiming for clinical application including advantages but also specific challenges and problems which are associated with cord blood derived stromal cell (CB-MSC) as a source for bone regeneration. The use of postnatal CB-MSC is ethically uncomplicated and requires no invasive harvesting procedure. Moreover, most data document a high osteogenic potential of CB-MCS and also low immunoreactivity compared with other MSC types. The expression profile of CB-MSC during osteogenic differentiation shows similarities to that of other MSC types. Within the umbilical cord different MSC types have been characterized which are potent to differentiate into osteoblasts. In contrast to a large number of in vitro investigations there are only few in vivo studies available so far.