Ambulatory in-office anterior iliac crest bone harvesting.

OBJECTIVE: A prospective study was performed to evaluate the harvesting of autologous bone within the private practice environment, using either a power-driven trephine or corticocancellous block harvesting, and to assess the clinical safety, postoperative morbidity, and patient satisfaction associated with this application. STUDY DESIGN: Thirty-nine patients requiring 40 bone harvests from the anterior iliac crest for maxillofacial reconstruction were included for study. The ages ranged from 16 to 73 years (mean 48.4 years). All surgeries were performed by a single surgeon. Patients were recovered and discharged home directly from the office. RESULTS: Forty iliac crest harvests were performed in the private practice venue from 2001 to 2004, 23 by motorized trephine and 17 by open corticocancellous block harvest. No peri-operative complications were encountered. Postoperative questionnaires were returned by 32 patients. Thirty patients reported that they would undergo hip surgery in an ambulatory environment again if required. CONCLUSION: Harvesting of bone from the anterior iliac crest is a safe and predictable surgical procedure for the private oral and maxillofacial surgical practice setting in selected cases, resulting in a low complication rate. Patient acceptance of this surgery in the private practice venue is high.     

Heterotopic bone formation causing recurrent donor site pain following iliac crest bone harvesting

An unusual case of recurrent iliac crest donor site pain secondary to heterotopic bone formation is described. The literature is reviewed with a special emphasis on the aetiology and treatment of this entity.     

超声引导下腹横筋膜平面阻滞用于髂嵴前部取骨移植术的效果

目的 探讨超声引导下腹横筋膜平面(TFP)阻滞在髂嵴前部取骨移植术的应用效果。
方法 选择行髂嵴前部取骨移植术患者59例,男32例,女27例,年龄18～64岁,BMI 18～24 kg/m²,ASA Ⅰ或Ⅱ级。将患者随机分为两组：超声引导下TFP阻滞联合全麻组（T组,n=30）和常规全麻组（G组,n=29）。T组行超声引导下术侧TFP阻滞,G组不进行TFP阻滞。记录麻醉诱导前1 min、手术开始后1、10、30、60 min和手术结束时的HR、MAP和呼出气七氟醚浓度（C_ETSev）、术中芬太尼、瑞芬太尼和丙泊酚用量、拔管时间、PACU停留时间。记录术后4、8、12、24、48 h髂骨供区的静息和活动时VAS疼痛评分。记录PCIA总按压次数、有效按压次数、曲马多补救镇痛用量、补救镇痛和患者对髂骨供区镇痛的满意情况。
结果 与G组比较,手术开始后1、10、30 min T组HR明显减慢、MAP明显降低（P＜0.05）,手术开始后1 min至手术结束时T组C_ETSev明显降低（P＜0.05）;T组术中芬太尼、瑞芬太尼和丙泊酚用量明显减少（P＜0.05）,拔管时间和PACU停留时间明显缩短（P＜0.05）;T组术后4、8、12 h的静息和活动时VAS疼痛评分、术后PCIA总按压次数、有效按压次数、曲马多补救镇痛用量明显减少（P＜0.05）、补救镇痛率明显降低（P＜0.05）,患者对髂骨供区镇痛满意率明显升高（P＜0.05）。
结论 超声引导下TFP阻滞用于髂嵴前部取骨移植术麻醉和镇痛效果较好,有利于减少围术期麻醉镇痛药用量,血流动力学平稳,恢复快速,安全性高,患者满意度高。     

Complications following iliac crest bone grafting

Avulsion of the anterior superior iliac spine occurred after procurement of bicortical bone grafts from the anterior superior iliac crest area in two patients. The defect in the anterior ilium with a weak spike of bone created a significant stress riser and led to avulsion of the anterior superior iliac spine by the action of the sartorius and tensor fascia lata. Bicortical grafts should be taken from areas as much as 5 cm posterior to the anterior superior iliac spine to avoid this complication.     

髂骨移植并发症的相关研究

[目的]探讨髂骨移植的并发症的原因及预防措施.[方法]回顾研究1990年～2005年10月828例髂骨移植患者,对出现的并发症进行统计分析.[结果]浅感染45例;深部感染10例;局部血肿60例;深部血肿4例;神经损伤30例;血管损伤3例,均发生在髂骨后部取骨时,为臀上动脉断裂;髂骨骨折2例,腹壁疝1例.[结论]取骨位置及操作不当是引起并发症的主要原因,了解髂骨解剖特点,正确选择取骨位置、微创操作是预防并发症的主要措施.     

A modified technique for harvesting full-thickness iliac crest bone graft

STUDY DESIGN: A prospective follow-up study of patients undergoing anterior spinal decompression and bone graft with cortical iliac crest bone. OBJECTIVE: To describe a modified technique for harvesting cortical bone graft from the anterior iliac crest. SUMMARY OF BACKGROUND DATA: Cortical bone graft from the iliac crest frequently is used in various orthopedic and spinal procedures. The resulting defect in the iliac crest has been associated with many complications. METHODS: Twenty patients were included in this study. All had burst vertebral fracture requiring anterior spinal decompression and cortical bone grafting. The modified technique was used for harvesting the iliac crest bone graft in all patients. RESULTS: All patients were satisfied with the appearance of the iliac crest. None reported chronic pain at the graft site. None had fracture of the iliac wing, and none had symptoms related to the lateral femoral cutaneous nerve or herniation of pelvic contents through the bony defect in the iliac wing. CONCLUSION: This modified technique is technically straightforward and cost-effective. It preserves the contour and shape of the iliac crest and avoids cosmetic deformities and chronic pain at the graft site. It creates a window in the iliac wing rather than disrupting the continuity of the iliac crest, which leaves the iliac wing structurally stronger than with currently used techniques.     

Ultrasound-guided lateral-medial transmuscular quadratus lumborum block for analgesia following anterior iliac crest bone graft harvesting: a clinical and anatomical study

Background

The anterior iliac crest (AIC) is one of the most common sites for harvesting autologous bone, but the associated postoperative pain can result in significant morbidity. Recently, the transmuscular quadratus lumborum block (TQL) has been described to anesthetize the thoraco-lumbar nerves. This study utilizes a combination of cadaveric models and clinical case studies to evaluate the dermatomal coverage and analgesic utility of TQL for AIC bone graft donor site analgesia.

Methods

Ten ultrasound-guided TQL injections were performed in five cadaver specimens using a lateral-to-medial transmuscular approach. Twenty mL of 0.5% methylcellulose was injected on each side after ultrasound confirmation of the needle tip ventral to the quadratus lumborum muscle (QLM). Cranio-caudal and medial-lateral extent of the dye spread in relation to musculoskeletal anatomy and direct staining of the thoraco-lumbar nerves were recorded. Following the anatomical findings, continuous catheter TQL blocks were performed in four patients undergoing ankle surgery with autologous AIC bone graft. The dermatomal anesthesia and postoperative analgesic consumption were recorded.

Results

In the anatomical component of the study, 9/10 specimens showed a lateral spread anterior to the transversalis fascia and medially between the QLM and psoas major muscle. Direct staining of the branches of the T12, L1, and L2 nerves was noted ventral to the QLM, while variable staining of the T9-T11 nerves was seen laterally in the transversus abdominis plane and the transversalis fascia. The vertical spread of injectate anterior to the QLM was T12 to the iliac crest (n = 5/10) and L1 to the iliac crest (n = 4/10). In the four patients who received TQL, the T9-L2 dermatomal anesthesia correlated with the injectate spread seen in the cadavers and provided effective analgesia at the bone graft donor site.

Conclusion

Ultrasound-guided TQL injections consistently cover the thoraco-lumbar innervation relevant to the AIC graft donor site. The injectate spread seen in anatomical dissections correlated with the dermatomal anesthesia clinically. The TQL has the potential to provide reliable analgesia for patients undergoing AIC bone graft harvesting.

     

Bone harvesting from the iliac crest

BACKGROUND: Autogenous bone grafts from the iliac crest are frequently harvested for autologous bone transplantation. Although an autologous bone transplant does improve the local bone healing potency, significant donor site morbidity must be considered. METHODS: In this study we elucidate special bone harvesting techniques from the iliac crest and review the literature related to clinical significance of donor site morbidity. Furthermore, our own experiences are compared and discussed critically with relevant data of other investigators. RESULTS: The increasing number of scientific publications which focus on bone harvesting techniques and related complications in recent years indicate the high interest and relevance of this issue. There is a tendency to alternatives such as biomaterials as bone substitutes, whereas the role of growth factors and cell therapeutics in the treatment of bony defects are still being evaluated in clinical studies. CONCLUSION: Although autologous, heterotopic bone transplantation is still the gold standard in the treatment of bony defects, there is a tendency towards the application of biomaterials, stem cells, and growth factors. Conscientious observation of relevant anatomic considerations during bone harvesting procedures may help to avoid complications.     

Anterior iliac crest bone graft harvesting using the corticocancellous reamer system

OBJECTIVE: To evaluate the anterior iliac crest bone graft harvesting procedure using a corticocancellous acetabular reamer system. DESIGN: A total of 390 bone grafting procedures were reviewed using retrospective chart review. Two hundred twenty procedures were performed using the reamer system, and 170 were performed using traditional techniques (cortical strip, tricortical wedge, and cancellous trap door grafts). SETTING: The Hospital for Special Surgery, New York, New York. PARTICIPANTS: Operative cases involving an anterior iliac crest bone graft procedure between January 1, 1991 and February 28, 1998. MAIN OUTCOME MEASUREMENTS: Complications were organized by the categories major, intermediate, and minor. Statistical analysis included assessment of comorbidity to determine risk factors that may be associated with a propensity for complications. RESULTS: Of the 390 patients reviewed, 13.1 percent (51 of 390) developed a total of seventy-one complications. Of the seventy-one complications, forty were reamer-associated and thirty-one were traditional method-associated complications. As compared with the traditional group, major morbidity was lower in the reamer group (0.9 percent [2 of 220] as compared with 1.8 percent [3 of 170] [ p = 0.4]). Intermediate and minor morbidity were slightly higher in the reamer group than in the traditional group (5.9 percent [13 of 220] as compared with 5.3 percent [9 of 170] [ p = 0.7] and 9.5 percent [21 of 220] as compared with 7.1 percent [12 of 170] [ p = 0.4], respectively). Of the forty reamer-associated complications, 90 percent (36 of 40) resolved within ninety days (average 36.6 days). Of the thirty-one traditional method-associated complications, 74.2 percent (23 of 31) were resolved by 90 days (average 50.6 days). Using logistical regression analysis obesity (body mass index) ( p = 0.03) and smoking ( p = 0.03) were correlated with development of a complication. Furthermore, if a patient was obese and a smoker, the analysis predicted an 83 percent chance of developing a complication. CONCLUSIONS: The reamer technique was found to be safe and efficacious while producing a large amount of autogenous corticocancellous bone graft. Overall complication rates for the reamer and the traditional groups were comparable. The corticocancellous reamer system represents an effective option for bone graft harvesting.     

Morbidity of iliac crest bone graft harvesting in adolescent deformity surgery

The iliac crest as a source of bone graft has remained popular and continues to be the standard source of bone graft material in spinal arthrodesis surgery. The purpose of the present study was to quantify the frequency and severity of posterior iliac crest bone graft harvest site pain associated with adolescent spinal deformity correction procedures. Patients were evaluated prospectively at a minimum of 1 year after a spinal fusion procedure for idiopathic scoliosis or kyphosis. Patients were asked to quantify the pain level at their harvest site over the previous month based on a 0-to-10 numeric rating scale. Data were collected on 71 patients: 60 with adolescent idiopathic scoliosis and 11 with Scheuermann's kyphosis. There was no gender difference noted, with 1 of the 10 boys (10%) and 6 of the 61 girls (10%) reporting postoperative pain. Seven of 60 patients with scoliosis reported pain (12%), whereas none of the patients with Scheuermann's kyphosis reported pain. None reported a pain level greater than 3 of 10 or any effect on activity level. This series shows that iliac crest bone graft harvest site pain is absent in most patients (90%) and of limited severity in those who reported pain (score 相似文献   

Morbidity associated with anterior iliac crest bone graft harvesting in children undergoing orthopaedic surgery: a prospective review

Purpose

Autologous iliac crest bone grafting is an integral part of many orthopaedic surgical procedures. Several studies have documented morbidity and prolonged pain following iliac crest bone graft harvesting in adults; however, in children there is a paucity of information. The purpose of the present study was to quantify the degree of pain and morbidity associated with anterior iliac crest graft harvesting in children undergoing non-spinal orthopaedic surgery.

Methods

Patients were prospectively enrolled prior to orthopaedic surgery. A patient self-reported visual analogue score was used to record pain at specified time points following surgery. In addition, the patients were reviewed at 2 and 6 weeks, 3 months and 1 year after surgery to record any complications.

Results

Data was collected on 33 patients (34 graft sites). Only one patient (2.94 %) had a complication, namely an injury to the lateral femoral cutaneous nerve. This resolved 3 months after surgery. 89 % of patients had no pain at the iliac crest graft harvest site 3 months after surgery. The three patients who had pain at 3 months had visual analogue scores of 1.0, 1.1 and 1.3, respectively.

Conclusion

This series reveals a very low complication rate and minimal iliac crest graft harvest site pain in children undergoing non-spinal orthopaedic surgery. In addition, the pain experienced is short-lived.     

Polylactic acid mesh reconstruction of the anterior iliac crest after bone harvesting reduces early postoperative pain after anterior cervical fusion surgery

OBJECTIVE: Autologous iliac crest bone enhances the rate of spinal arthrodesis. However, graft site complications are common, with donor site pain being particularly troublesome. Reconstruction of the hip defect with an absorbable polylactic acid mesh to restore the bony cortical contour has been proposed to reduce hip pain. METHODS: Thirty-nine consecutive patients treated by a single senior surgeon (BAG) during a 14-month period were studied. All patients had cervical spondylosis treated through an anterior approach supplemented with an autologous hip graft. Patients with preexisting hip pain were excluded. Pain was rated on a scale of 1 to 10 at 1 week and 3 months after surgery via a questionnaire. Postoperative pain medication regimens were standardized. RESULTS: Thirty patients were available for follow-up, 15 with mesh implantation and 15 without. Hip pain in the mesh-treated group averaged 4.7 and 1.6 at 1 week and 3 months, respectively. Hip pain in the standard-treatment group averaged 6.9 and 2.5 at 1 week and 3 months, respectively. These differences were statistically significant (P = 0.004 at 1 wk and 0.055 at 3 mo). Hospital length of stay was shorter in the mesh-treated group (2.1 versus 3.2 d, respectively), but this difference was not statistically significant. Two patients without mesh treatment complained of the cosmetic defect resulting from absent bone, and three had temporary difficulty with hip eversion or flexion. Two patients in the mesh-treated group developed seromas, which were treated conservatively. CONCLUSION: Reconstruction of the iliac crest reduces early postoperative pain. Other potential benefits may include shorter hospitalizations and a reduced incidence of hip weakness; however, careful attention to wound closure is necessary to prevent seroma formation.     

Cancellous bone in the anterior part of the iliac crest

Summary Calcified tissue in the iliac crest and the adjoining ala of the ilium was investigated by scanning electron micrographs of thick, polished sections from which the marrow had been removed. Some quantitative properties of the trabeculae and of the marrow spaces were obtained from measurements on the images of the polished surfaces. Most of the cortex of the crest was porous, about 25% void, of varying thickness, intruding into the cancellous space in some regions. A structure containing about 35% by volume of bone was found at and near the anterior superior spine. Compact bone of normal appearance began as thin medial and proximal sheets below the crest, and thickened until at 20–30 mm it was substantial. The cancellous bone contained by these structures was varied. Two main zones were distinguished, whose junction ran from just below the anterior superior spine to the lower portion of the iliac fossa. In the lateral zone, adjacent to the crest, there were arch-like structures, commencing from the medial and proximal walls, and meeting, or even crossing, near the centre. The medial zone was distinguished by large marrow cavities and strongly orientated trabeculae. The relative volume of bone was similar in the two zones, falling from a maximum of 15–20% to about 5% in the regions of the anterior inferior spine and the iliac fossa. The average width of the trabeculae was significantly greater in the medial than in the lateral zone (W _b (m)0.16 mm, W_b(l)0.12 mm). Inclusions of very heavily constructed trabeculae, having average widths of about 0.35 mm, were found in both zones.     

脊柱前路手术髂前嵴取骨并发症相关分析

目的:探讨脊柱前路手术髂前嵴取骨的并发症发生情况。方法:回顾性分析2001年1月-2005年9月取髂骨行脊柱植骨融合术的154例患者,取骨部位均为髂前嵴,统计供骨区并发症,分析其相关因素。结果:术后随访时间均超过1年。28例(18.2%)患者发生不同程度的并发症,其中14例(9.1%)出现轻度并发症,12例(7.8%)出现中度并发症,2例(1.3%)出现重度并发症。127例(82.5%)患者接受了问卷调查,其中17例(13.4%)患者诉取骨处疼痛,疼痛自我感觉评分为1-6分(平均2分),其中3例(2.4%)患者需服用非甾体类抗炎药以减轻疼痛;7例(5.5%)患者诉取骨处有麻木感;无患者诉取骨处的疼痛及麻木感影响其日常活动;122例(96.1%)患者对供骨区切口外观满意。结论:髂前嵴取骨并发症中供骨区疼痛及麻木发生率较高,尤其是疼痛,应引起足够的重视。     

Postoperative pain following posterior iliac crest bone graft harvesting in spine surgery: a prospective,randomized trial

Background Context

Postoperative pain at the site of bone graft harvest for posterior spine fusion is reported to occur in 6%–39% of cases. However, the area around the posterior, superior iliac spine is a frequent site of referred pain for many structures. Therefore, many postoperative spine patients may have pain in the vicinity of the posterior iliac crest that may not in fact be caused by bone graft harvesting. The literature may then overestimate the true incidence of postoperative iliac crest pain.

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.     

RIA versus iliac crest bone graft harvesting: A meta-analysis and systematic review

BackgroundReamer-Irrigator-Aspirator (RIA) of long bones is increasingly being used as an alternative to iliac crest harvesting for bone-grafts. This meta-analysis compares both harvesting techniques with regard to donor site morbidity, healing potency and implantation site morbidity.MethodsPubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR) with corresponding 95% confidence interval (95%CI).ResultsA total of 5 studies were included. RIA carries a lower risk for chronic pain (0% versus 14.2%, OR 0.08, 95% CI 0.02 – 0.35) and infection (1% versus 5.9%, OR 0.29, 95% CI 0.09- 0.9) at the donor site compared to iliac crest harvesting. Iliac crest bone-harvesting has an inherent additional risk of neuropraxia of the lateral femoral cutaneous nerve and numbness of the scar which is not encountered in RIA harvesting. Risk for other reported complications such as hematoma and iatrogenic fractures appear equal in both groups. The clinical healing potential of both bone grafts, in terms of union rate (OR 1.53, 95%CI 0.62 – 3.75) at the implantation site and time-to-union (MD 0.44 months, 95%CI -1.72 – 0.83), seems equal.ConclusionThe main difference between RIA and iliac crest bone graft harvesting is the considerable higher risk of chronic pain of the pelvic procedure. Although risk for infection was also higher for the iliac crest group, the absolute difference is relatively small. Evidence suggests an equal healing potential of the grafts themselves irrespective of harvesting method.