2. BECKER ET AL 49
For iliac crest harvesting, several complications Table 1. AGE DISTRIBUTION OF GROUP
have been described: chronic pain, sensory loss,
wound breakdown, contour defect, hernia through Age Anterior Posterior
the donor site, instability of the sacroiliac joint, gait
Maximum (yr) 82 89
disturbance, pathologic fracture, adynamic ileus, ure- 75% quartile (yr) 64 67
thral injury, seroma, hematoma, and hemorrhage.6 Median (yr) 57 60
Different trials with varying results have been car- 25% quartile (yr) 38 46
ried out to compare anterior and posterior ap- Minimum (yr) 18 17
Mean (yr) 52 56
proaches for iliac bone grafting.6-8 A low incidence of
SE of mean (yr) 2 2
donor-site morbidity is reported for anterior cancel- No. of patients 50 47
lous iliac crest bone in secondary bone grafting of the
cleft alveolus.9 Studies have reported that the anterior NOTE. The patient groups were similar to a great extent.
approach to the ilium causes considerably more prob- Becker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oral
Maxillofac Surg 2011.
lems than the posterior approach.10 On the other
hand, the potential morbidity of bone harvest from
the posterior ilium is said to be greater than that All surgery was performed with the patient under
from the anterior iliac crest, because of the proximity general anesthesia. Bone from the anterior approach
to the sacroiliac joint and the sciatic nerve. In reality, was harvested following the technique of Kalk et al,11
damage to these areas is rare.6 Because these opera- whereas posterior harvesting was done as described
tions are elective, how the patient rates them is most by Bloomquist and Feldman.12 Harvesting started
important. with a saw, and then a chisel and mallet were used.
The purpose of this study was to quantify the se- After harvesting of the cortical segments, cancellous
verity of morbidity by subjective evaluation of pain by bone was collected with curettes. The amount of
patients after iliac crest harvest associated with jaw bone was determined by putting the bone into a
augmentation procedures by evaluation with ques- measuring cylinder partially filled with saline solution.
tionnaires and to compare these data depending on The operations were performed by different sur-
the surgical approach. geons.
To reduce postoperative pain, for the first 5 days,
Materials and Methods ibuprofen (600 mg 3 times daily) was prescribed. In
addition, the patients received Sultamicillin (375 mg
PATIENTS by mouth 3 times daily) for 5 days or, in the case of
This study included 97 consecutive patients (48 penicillin allergy, clindamycin (300 mg by mouth 3
female patients and 49 male patients) aged 17 to 89 times daily).
years who received combined cortical and cancellous
bone grafting of the ilium at the Department of Oral QUESTIONNAIRE
and Maxillofacial Surgery, University of Kiel, Kiel, A questionnaire was sent to the participants 1 to 4
Germany, from 2004 to 2007. Patients who only re- years after surgery. Those who did not respond to the
ceived cancellous bone harvesting (eg, for cleft sur- questionnaire within 6 weeks were called and asked
gery) were excluded. Additional inclusion criteria again to participate.
were the absence of pain before surgery and no pre- The questionnaires were specially designed to
vious surgery or injury to the ilium. All patients gave gather information about typical problems with iliac
informed consent for participation. The protocol was crest bone harvesting. Besides personal information,
approved by the Institutional Ethics Committee (A we recorded data about the prosthetic reconstruc-
140/08) and adhered to the tenets of the Declaration tion. Patients were also asked how long the pain at
of Helsinki. the donor site had lasted and how strong they per-
The patient groups (anterior harvest and posterior ceived the pain to be, as rated on a 10-point visual
harvest) were homogeneous to a great extent. The analog scale (VAS) (1, no pain; 10, strongest pain) in
age distribution of the groups is presented in Table 1. the first week, in the first month, after 6 months, and
Mean values (about 55 years) as well as quartiles and after 1 year postoperatively. In addition, gait distur-
extremes were similar. The patients were operated on bances as well as the use of crutches were queried. All
to harvest bone for dental implant insertion. There patients were asked whether they would undergo the
was no randomization. Diseases leading to the need same operation again, whether they would recom-
for augmentation are presented in Figure 1. The ma- mend this operation to friends or relatives with the
jority of patients had severe atrophy of the jaws or same problem, and how they rated the remaining scar
reconstruction after neoplasm including benign tu- on a VAS (1, modest; 10, ugly). Problems after 1
mors. month and 1 year at work, during leisure tasks, and in
3. 50 MORBIDITY AFTER ILIAC CREST BONE GRAFT HARVEST
The following parameters were analyzed with vari-
ance analyses for the factor harvest from the anterior
approach versus the posterior approach: pain after 1
week, 1 month, 6 months, and 1 year and scar forma-
tion at the point of evaluation. Least squares means
and 95% confidence intervals are presented in text
and figures.
Results
Of the patients, 60% (58 of 97) answered the ques-
tionnaire. Pain levels for both groups started at
around 5 at 1 week (P .89) (Fig 2) after surgery on
a VAS ranging from 1 (no pain) to 10 (maximal pain).
After 1 month (P .37), the pain levels averaged
between 2 and 3, whereas after 6 months (P .64)
and 12 months (P .37), they were close to 1 in both
groups. The course of pain levels over time was fairly
parallel for the anterior and posterior approaches
with overlapping confidence intervals. The median
length of pain duration (14 days in the anterior group
vs. 21 days in the posterior group) as well as quartiles
are presented in Table 2, together with the amounts
of bone volume harvested. The mean volume reached
12 cm3 for the anterior approach and 18 cm3 for the
posterior approach.
The assessment of the scar at the point of evalua-
tion was nearly identical for both groups (2.7 for
anterior approach vs. 3.0 for posterior approach, P
.76) (Fig 3).
The dentures integrated afterward were fixed in
about half of the patients (Fig 4). Gait disturbances
occurred in 12 of 26 patients in the anterior group
and 11 of 31 in the posterior group. In addition, 17 of
26 patients needed crutches in the anterior group and
8 of 32 in the posterior group. A total of 21 of 24
patients of the anterior group would undergo the
FIGURE 1. Diseases leading to need for augmentation by group:
(A) anterior and (B) posterior. In the majority of cases these were
severe atrophy of the jaws or reconstruction after neoplasm includ-
ing benign tumors.
Becker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oral
Maxillofac Surg 2011.
everyday life were also recorded. Only problems with
the iliac crest were questioned, not oral pain.
STATISTICAL EVALUATION
Distributions of age, duration of pain, bone volume
harvested, type of dentures, gait disturbances, and
need for crutches, as well as the willingness of the FIGURE 2. Pain levels over time after surgery on VAS ranging from
1 (no pain) to 10 (maximal pain) by group. The parallel course of
patient to repeat the operation if needed or to recom- the anterior and posterior harvest groups, with widely overlapping
mend it to others, were calculated. In addition, we confidence intervals, should be noted.
evaluated problems at work, during leisure tasks, and Becker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oral
in everyday life after 1 and 12 months. Maxillofac Surg 2011.
4. BECKER ET AL 51
Table 2. MEDIAN PAIN DURATION AFTER SURGERY
AS WELL AS QUARTILES AND AMOUNT OF BONE
VOLUME HARVESTED BY GROUP
Anterior Posterior
Pain duration
75% quartile (d) 30 61
Median (d) 14 21
25% quartile (d) 6 7
No. of patients 24 29
Bone volume harvested
Mean (cm3) 12 18
SE of mean (cm3) 1 1
No. of patients 42 46
Becker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oral
Maxillofac Surg 2011.
same operation again. In the posterior group the cor-
responding value was 28 of 32. FIGURE 4. Characteristics of anterior and posterior groups: Pro-
portions of patients who would recommend operation to others or
Some patients had problems in different situations undergo it again and patients who needed crutches, had gait
after 1 month and even after 12 months (Fig 5). disturbances, and had dentures integrated.
During surgery, in 9 cases bone was harvested Becker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oral
accidentally bicortically, mostly because of a very thin Maxillofac Surg 2011.
cancellous layer, and 1 patient had a fracture of the
ilium that occurred when entering an elevator. The
fracture could be treated conservatively without caus- VAS ranging from 1 (no pain) to 10 (maximal pain).
ing further problems. After 1 month, they averaged between 2 and 3,
whereas after 6 and 12 months, the pain levels were
close to 1 in both groups. The course of pain levels
Discussion over time indicated no differences for the anterior
Pain is the most frequently cited complication of approach and the posterior approach. The median
harvesting iliac crest bone grafts. Pain levels in this length of pain duration was 14 days for anterior and
study peaked at around 5 at 1 week after surgery on a 21 days for posterior. Some patients in our study had
problems in different situations after 1 month and
even after 12 months. This is in accordance with
another study, where 119 adult patients who under-
went iliac crest bone grafting were evaluated to assess
the effect of bone grafts.13 They stated that they had
pain for approximately 6 weeks, and even 10% per-
ceived moderate pain for 2 years. In contrast to our
results, in a retrospective study of treatment for
chronic osteomyelitis, 58 patients completed a ques-
tionnaire about pain comparing anterior and posterior
bone grafting from the iliac crest.3 Postoperative pain
at the donor site was significantly more severe and of
greater duration after anterior harvesting. One study
reported that 74% of the patients were free of pain
within 3 weeks after anterior harvesting whereas 26%
had pain for a few weeks to several months.4 Nkenke
et al6 stated that the morbidity resulting from bone
harvest from the posterior iliac crest was lower than
that from the anterior iliac crest in terms of postop-
erative pain, gait disturbances, and sensitivity disor-
FIGURE 3. Assessment of scar 1 to 4 years after surgery on VAS
ranging from 1 (modest) to 10 (ugly). Nearly identical values were
ders. Among 71 adolescent patients undergoing spi-
found for both groups (P .7612). nal arthrodesis surgery after harvest of posterior iliac
Becker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oral crest bone, pain was absent in 90% of the patients and
Maxillofac Surg 2011. no higher than 3 of 10.14 Another study, by Kessler et
5. 52 MORBIDITY AFTER ILIAC CREST BONE GRAFT HARVEST
tients, 30 would undergo iliac crest harvesting from
the anterior approach again.16
The mean volume of bone harvested in this study
was 12 cm3 for the anterior approach and 18 cm3 for
the posterior approach. Other studies reported vol-
umes of 13 cm3 for anterior and 30 cm3 for posterior3
and 15 cm3 for anterior and 25 cm3 for posterior.10
One patient had a fracture of the ilium that hap-
pened 1 week after surgery when entering an eleva-
tor. The fracture could be treated sufficiently without
surgery. Anterior fractures—also painful—remain sta-
ble and heal spontaneously, whereas posterior frac-
tures are said to very often require complex surgical
treatments and cause significant disability.5 Mostly
late fractures occur, which can almost always be
treated conservatively.17 Only 16% of fractures re-
quire further treatment.5
In a questionnaire study with 58 patients compar-
ing anterior and posterior bone grafting from the iliac
crest, major complications were reported in 6% for
anterior and 2% for posterior, with minor complica-
tions rates of 15% and 0%, respectively. Major com-
plications were defined as those prolonging hospi-
talization, requiring additional surgery, or causing
substantial disability.3
FIGURE 5. Proportions of patients with problems (A) 1 month and Several different complications after ilium bone
(B) 12 months after surgery. harvesting are described, such as infection (0%-3%),3
Becker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oral temporary impairment (0%-20%),15 hernia,18 and neu-
Maxillofac Surg 2011.
rologic injuries.4,19 Damage to the superior and me-
dial cluneal nerves during the soft tissue approach to
al,10 showed that the posterior approach caused the posterior ilium has been described as a complica-
fewer postoperative problems for patients, but it has tion. Temporary sensory loss, which did not last
to be mentioned that they also included patients who longer than 1 month, has been detected in 12% of
only had cancellous bone harvests. Significantly lower patients.6 The potential morbidity of bone harvest
values for subjective pain (2.2 on average on a VAS) from the posterior ilium is said to be greater than that
have been described by other investigators retrospec- from the anterior iliac crest, because of the proximity
tively for bone harvest from the anterior iliac crest.11 of the sacroiliac joint and the sciatic nerve. Neverthe-
Regarding morbidity, the muscular attachments play a less, damage to these areas is rare.6 In our patient
significant role in terms of postoperative pain and gait groups no obvious differences in complication rates
disturbance. The reflection and retraction of the ten- could be observed.
sor fascia lata muscle seemed to be the primary rea- Similar to our response rate of 60%, a previous
sons for the increased morbidity observed with the study reported that 73% of patients could be con-
anterior approach.6 tacted and overall only 51% answered questionnaires
Gait disturbances in this study occurred in 46% of about autogenous iliac crest bone graft.13
the patients in the anterior group and 35% in the The iliac crest offers many advantages as a donor
posterior group. We found that 17 of 26 patients site, including easy accessibility and the possibility to
needed crutches in the anterior group and 8 of 32 in harvest large amounts of bone and to close the wound
the posterior group. These values are higher than primarily,8 whereas the posterior approach leads to
those reported in another study, where 79% of pa- increased operation time because of the need to ro-
tients had no gait disturbance after 3 weeks.4 tate the patient during surgery.
Satisfaction with the operation was remarkably It has to be mentioned that the results of our ret-
high in both groups (81% for anterior and even 88% rospective study may be different from those of pro-
for posterior). This is in accordance with other au- spective studies.
thors who reported on satisfaction values after har- Patients reported a noticeable reduction in quality
vest of 83% to 88% for the posterior approach and of life after elective bone graft harvesting. In a few
82% to 86% for the anterior approach.15 Of 32 pa- cases (3 of 97), pain lasted for 1 year. Nevertheless,
6. BECKER ET AL 53
nearly all patients would undergo the same proce- 8. Marx RE, Morales MJ: Morbidity from bone harvest in major jaw
reconstruction: A randomized trial comparing the lateral ante-
dure. There were no obvious differences between the
rior and posterior approaches to the ilium. J Oral Maxillofac
2 approaches for iliac bone harvesting. Even the scar Surg 46:196, 1988
assessment was nearly identical, so when smaller 9. Beirne JC, Barry HJ, Brady FA, et al: Donor site morbidity of the
amounts of bone graft are needed, both the anterior anterior iliac crest following cancellous bone harvest. Int J Oral
Maxillofac Surg 25:268, 1996
approach and the posterior approach can be recom- 10. Kessler P, Thorwarth M, Bloch-Birkholz A, et al: Harvesting of
mended, whereas only the posterior approach is suit- bone from the iliac crest—Comparison of the anterior and
able for larger amounts. posterior sites. Br J Oral Maxillofac Surg 43:51, 2005
11. Kalk WW, Raghoebar GM, Jansma J, et al: Morbidity from iliac
crest bone harvesting. J Oral Maxillofac Surg 54:1424, 1996
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