Anterior iliac crest bone graft harvesting results in minimal morbidity

Issue: December 2010

When performing an iliac crest bone graft for orthopedic trauma reconstruction, an anterior harvesting technique resulted in minimal pain, according to a retrospective study.

“Usually with a spine procedure, the iliac crest bone graft is harvested posteriorly, so the surgeon does not need to reposition the patient for the posterior fusion procedure,” said co-author Sangmin Ryan Shin, MD, a third year resident in orthopedic surgery at Boston University Medical Center. “But all of our patients had grafting with an anterior harvesting technique. By harvesting anteriorly, there is less morbidity. Patients do not complain of pain nearly as much.”

Long-lasting pain

The study’s inspiration was the experience of the other co-author, Paul Tornetta III, MD, a professor of orthopedic surgery and the residency program director in orthopedics at Boston Medical Center. Tornetta had been performing orthopedic trauma reconstructive procedures for patients requiring a bone graft via an anterior harvesting method.

“The problem with bone grafting, especially the iliac crest, is that the pain lasts a long time and is prevalent. This has been documented in numerous studies, in particular with spine procedures,” Shin told Orthopedics Today. “But we felt that patients treated by Dr. Tornetta were not experiencing the duration of pain indicated in the literature and that the incidence of pain was lower.”

The two authors sought to determine the incidence and duration of pain from the graft site and the severity of their pain.

Retrospective review

The medical records of 46 consecutive patients treated by Tornetta who had undergone iliac crest bone graft with anterior harvesting during a 7-year period were reviewed. “All grafts were taken by removing the inner table of the ilium from 2 cm posterior to the anterior superior iliac spine, for a 6- to 8-cm distance after releasing the abdominal musculature,” said Shin, noting that the average bone harvested was 40 cc.

A total of 30 study patients, 20 men and 10 women at an average age of 46 years, were interviewed at a mean follow-up of 4.5 years after undergoing harvesting for the treatment of nonunion (n=24) or post-traumatic arthrosis (n=6).

All thirty patients had a Visual Analog Score (VAS) of 0 for pain at final follow-up. “Only four of these patients experienced pain that lasted more than 2 weeks, and no pain lasted more than 6 months,” said Shin, who presented study results at the 2010 Annual Meeting of the Orthopaedic Trauma Association in Baltimore. “The literature indicates pain can last up to 2 years with iliac crest bone graft harvesting.”

Three of the four patients who endured pain for more than 2 weeks after graft harvest said they would not elect to have another graft, but would seek alternative graft sources. However, the remaining 27 patients interviewed said they would consent to a future bone graft, if recommended.

To potentially reduce postoperative pain, the authors recommend avoiding the abductor insertion and not touching the outer cortex of the ilium during harvesting.

Three of the 30 patients required ambulatory assistance, for less than 6 months.

There were no postoperative wound complications. Three patients, though, complained of permanent numbness on top of the scar, but none mentioned thigh numbness indicating involvement of the lateral femoral cutaneous nerve. In addition, 28 of 30 patients were satisfied with the cosmetic results and no patient was limited in activity associated with the harvest site. – by Bob Kronemyer

Reference:

Shin SR, Tornetta P III. Does long-term donor site morbidity after anterior iliac crest bone graft harvesting exist? Paper #20. Presented at the 2010 Annual Meeting of the Orthopaedic Trauma Association. Oct. 13-16, 2010. Baltimore.

Sangmin Ryan Shin, MD,can be reached at Boston University Medical Center, Dept. of Orthopedic Surgery, 850 Harrison Ave., D2 North, Boston, MA 02118; 617-414-4865; e-mail: ryan.shin@bmc.org. He has no direct financial interest in any products or companies mentioned in this article.

In this study, the investigators have addressed an important question; does bone graft harvesting from the iliac crest lead to long-term pain? Many orthopedic trauma surgeons with considerable experience in harvesting bone from the iliac crest don't put much credence in past articles that report a nearly 50% complication rate with iliac crest bone graft (ICBG) harvesting. This investigation, by a senior surgeon known for his meticulous surgical technique and data reporting, seems to confirm what many of us feel; past reports of postoperative pain and morbidity from ICBG procedures have been exaggerated and may not be relevant to our patient population. However, before all of us can be truly comfortable that we are not harming our patients by performing such techniques, a well-designed prospective study is needed. Although the current study is consistent with many of our experiences, the retrospective nature of it, with some patients being queried about their pain seven years postoperatively, prevents us from fully understanding the natural history of our patient's discomfort after undergoing ICBG harvest.

– Joseph Borrelli, Jr., MD
UT Southwestern Medical Center