Video Gallery

Video Gallery

To View the Video

Tips and Tricks in Harvesting of Bone from the Iliac Crest

March 15, 2015

Contributors: Cosma Calderaro, MD; Antonello Montanaro, MD; Francesco Turturro, MD; Gabriele Bolle, MD; Stefania De Sanctis, MD; Andrea Ferretti, MD; Luca Labianca, MD; Luca Labianca, MD

BACKGROUND: Autogenous bone grafting is often done in orthopaedic surgery for a variety of orthopaedic conditions, including difficult fractures, joint arthrodesis, replacement of bone defects, and repair of nonunions. Newer microsurgical operative methods have enhanced our bone grafting capabilities and now allow for transport of vascularized autogenous bone grafts to repair segmental bone defects, for the treatment of bone infection, and for the treatment of osteonecrosis. The iliac crest is currently the most common source for obtaining autogenous bone for the purpose of grafting. The ilium has been identified as an excellent source of both cortical and cancellous bone. Both the anterior and posterior portions of the iliac crest are often used for the purpose of bone grafting. Autogenous bone graft has the advantage of being accessible during the procedure and can function as an osteoinductive signal or as an osteoconductive bridge. The iliac crest grafting has some complications that should be known by the surgeon, and the surgery procedure itself has some tricks and tips that are useful to learn. It helps to avoid some risks as neurologic or splanchnic damage, bleeding, pain to the grafting site, or skin incision. For all these reasons we believe that this video has an important role in teaching a procedure very useful and frequent in orthopaedic surgery, describing how to do it and trick and tips to avoid complications.INTRODUCTION: Maybe the first thing to know about this procedure are criteria for exclusion from harvesting bone from the iliac crest. They are previous operations in this area; systemic bony or neurological diseases; long-standing treatment with steroids, immunosuppressive drugs, chemotherapy in the previous two months, or drug misuse in the previous three months. One of the most frequent complications is a lesion of the lateral femoral cutaneous nerve (LFCN). Based on a clinical investigation, it has been reported that harvesting iliac bone graft causes injury to the LFCN in about 10% of patients. For this reason it is recommended that an incision should be terminated 15 to 20 mm posterior to the anterior superior iliac spine (ASIS) in order to avoid injury to the lateral femoral cutaneous nerve (LFCN), that could cause numbness, burning, itching, and pain, known as meralgia paraesthetica. The size of the bone graft which is harvested may also influence the incidence of injuries to this nerve. In our hospital we start with antibiotic prophylaxis (penicillin 10 million units intravenously) the evening before operation and continue twice a day until the evening of the second postoperative day.

TECHNIQUE: The technical procedure is briefly described as follows. The pelvis is raised about 30 degrees by underlying towels. The skin over the iliac crest is put under stretch by placing a fist above the iliac crest and pushing the abdominal wall medially. The skin incision is about 50mm long, starts about 20 mm behind the anterior iliac spine, and runs parallel to the iliac crest . After relaxing the skin, the incision line finally lies about 20mm lateral to the iliac crest, avoiding mechanical irritation of the scar by tight clothes or a waistband. After the skin incision we make a blunt dissection of the subcutaneous tissues until the periosteum of the iliac crest is found. Bleeding is avoided by meticulous haemostasis, the periosteum of the iliac crest is incised, and the periosteal layer with the iliac muscle dissected bluntly medially. The iliac fossa is dissected to a depth of about 80mm. A 4-5 cm incision is made parallel to and just inferior to the iliac crest, starting 3 cm posterior to the ASIS to avoid injury to the lateral femoral cutaneous nerve. After subperiosteal stripping of the iliacus muscle, it was retracted to expose the ilium. Graft was obtained using an osteotome. The size (length, depth, and width) of the graft is harvested following the need for subsequent surgery. The wound is then closed in layers and a pressure bandage applied over the area of the iliac crest.

DISCUSSION: In 2011, 10 patients were recruited following the matching criteria. None of them had any lesion of the lateral femoral cutaneous nerve. In three patients, the harvested bone was used for a posttraumatic bone defect (all tibial fracture); in three cases, was used in surgery for malunion fractures; in four patients, was used as bone stock for lengthening of lateral foot column (pediatrics). No intra-operative complications such splanchnic damage or excessive blood loss. At three years of follow up, no pain is reported by any patient to the donor site.

Results for "Hip and Pelvis"

2 of 2
2 of 2

X