Bone-Graft Harvesting From Iliac and Fibular

Donor Sites: Techniques and Complications

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Nabil A. Ebraheim, MD, Hossein Elgafy, MD, and Rongming Xu, MD

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Abstract

The ilium and the fibula are the most common sites for bone-graft harvesting. standing of the anatomy of the do-
The different methods for harvesting iliac bone graft include curettage, trapdoor nor sites, the surgical techniques,
or splitting techniques for cancellous bone, and the subcrestal-window tech- and the potential complications of
nique for bicortical graft. A tricortical graft from the anterior ilium should be harvesting bone grafts from the
taken at least 3 cm posterior to the anterior superior iliac spine (ASIS). Iliac ilium and fibula is important to
donor-site complications include pain, neurovascular injury, avulsion fractures minimize morbidity.
of the ASIS, hematoma, infection, herniation of abdominal contents, gait distur-
bance, cosmetic deformity, violation of the sacroiliac joint, and ureteral injury.
The neurovascular structures at risk for injury during iliac bone-graft harvest- Surgical Anatomy
ing include the lateral femoral cutaneous, iliohypogastric, and ilioinguinal
nerves anteriorly and the superior cluneal nerves and superior gluteal neuro- Ilium
vascular bundle posteriorly. Violation of the sacroiliac joint can be avoided by The ilium is the largest part of
limiting the harvested area to 4 cm from the posterior superior iliac spine the innominate bone and has three
(PSIS) and by not penetrating the inner cortex. The caudal limit for bone har- surfaces. The inner surface is com-
vesting should be the inferior margin of the roughened area anterior to the PSIS posed of the rough sacroiliac surface
on the outer table to keep from injuring the superior gluteal artery. Potential posteroinferiorly and the smooth,
complications of fibular graft harvesting include neurovascular injury, com- concave surface superoanteriorly.
partment syndrome, extensor hallucis longus weakness, and ankle instability. The sacroiliac surface is divided into
The neurovascular structures at risk for injury during fibular bone-graft har- the articular surface inferoanteriorly
vesting include the peroneal nerves and their muscular branches in the proxi- and the nonarticular surface pos-
mal third of the fibular shaft and the peroneal vessels in the middle third. terosuperiorly. Immediately anterior
J Am Acad Orthop Surg 2001;9:210-218 to the sacroiliac surface is the iliac
fossa, which is the site for attach-
ment of the iliacus muscle. The
outer surface of the ilium is convex
Autogenous bone graft has been graft can be used for anterior inter-
used frequently to augment bone body fusion in the spine and for
healing for delayed union or non- reconstruction of defects in the long
union of the long bones and for bones. The vascularized fibular graft Dr. Ebraheim is Professor and Chairman,
spinal fusion, as well as to fill in bone also may be used in major recon- Department of Orthopaedic Surgery, Medical
College of Ohio, Toledo. Dr. Elgafy is Fellow in
defects after fractures, after curettage struction of the limbs and in the Orthopaedic Surgery, Medical College of Ohio.
or resection of tumors, and during treatment of congenital pseudarthro- Dr. Xu is Professor of Orthopaedic Surgery,
revision arthroplasty. The most sis of the tibia, infected nonunions of Jiaxing Second Hospital, Jiaxing, China.
commonly used site for harvesting is long bones, nonunions of the femoral
the posterior iliac crest, because it neck, and femoral head osteonecrosis. Reprint requests: Dr. Ebraheim, Department
can provide a large quantity of both Although bone-graft harvesting of Orthopaedic Surgery, Medical College of
Ohio, 3000 Arlington Avenue, Toledo, OH
cancellous and corticocancellous is not a complicated procedure, it is 43699.
bone. The anterior ilium is the sec- not without morbidity. The compli-
ond most common site. cations associated with bone har- Copyright 2001 by the American Academy of
The fibula is a less common site vesting vary from donor-site pain to Orthopaedic Surgeons.
for bone harvesting. Fibular bone neurovascular injury.1,2 An under-

210 Journal of the American Academy of Orthopaedic Surgeons

 Nabil A. Ebraheim, MD, et al

anteriorly and concave posteriorly. the pelvis and supplies the trans- bodorsal fascia and cross the iliac
The gluteus minimus, medius, and verse and internal oblique abdomi- crest approximately 6 to 8 cm lateral
maximus muscles are attached to the nal muscles. Its lateral cutaneous to the posterior superior iliac spine
outer surface of the ilium. The iliac branch supplies the skin of the pos- (PSIS).5 These nerves provide sen-
crest has inner and outer lips. terior part of the gluteal region. sation to the region of the posterior
The bone stock of the ilium is The ilioinguinal nerve also comes iliac crest and the cephalad portion
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thickest in two regions. The first is from the ventral ramus of L1 and of the buttock.
the area extending from 2 to 3 cm runs just medial to the iliohypogas- The superior gluteal artery is a
posterior to the anterior superior tric nerve proximally. Distally, it main branch of the internal iliac ar-
iliac spine (ASIS) to a point 6 to 8 crosses in front of the upper part of tery. It leaves the pelvis through the
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cm posteriorly along the iliac crest. the iliacus muscle and passes into most proximal portion of the greater
The second is the posteroinferior the inguinal canal to supply the skin sciatic notch, staying against the
portion (sacroiliac surface area) of of the groin area. bony notch and supplying the glu-
the ilium.3,4 The lateral femoral cutaneous teal muscles.
The neurovascular structures nerve is the sensory branch from the
adjacent to the ilium include the L2 and L3 ventral rami. In the ante- Safety Zone for Posterior Iliac
lateral femoral cutaneous, iliohy- rior iliac region, it exits the iliac fossa Graft Harvesting
pogastric, and ilioinguinal nerves from beneath the inguinal ligament The posterior iliac region (extra-
anteriorly (Fig. 1, A) and the supe- just inferior to the ASIS and becomes articular) is divided into three zones
rior cluneal nerves and superior extrafascial almost immediately over (Fig. 2). Zone 1 is the portion of the
gluteal neurovascular bundle pos- the anterior lateral thigh. However, ilium situated superior to a line
teriorly (Fig. 1, B). These structures in some patients, it exits the iliac extending from the PSIS to the apex
are vulnerable to injury during fossa over the anterior iliac crest, of the sacroiliac joint anteriorly. The
bone-graft harvesting. which places the nerve at high risk anterior margin of zone 1 is the
The iliohypogastric nerve arises for injury during an approach to the superior extension of the posterior
from the ventral ramus of L1 and anterior iliac region. border of the superior edge of the
emerges from the lateral border of The superior cluneal nerves orig- articular surface. The inferior mar-
the psoas major. It perforates the inate from the dorsal rami of L1, L2, gin is a line extending anteriorly
transverse abdominal muscle above and L3. They emerge from the lum- from the PSIS to the apex of the
sacroiliac joint, oriented perpendicu-
lar to the posterior margin of the
Quadratus lumborum muscle Superior cluneal nerves
superior edge. During posterior iliac
Oblique
incision
bone-graft harvesting, zone 1 can be
Iliohypogastric 6 cm defined as the portion of the ilium
nerve
PSIS
situated superior to a line extending
anteriorly from the PSIS and oriented
Ilioinguinal perpendicular to the plane of the op-
nerve
erating table, with an anteroposterior
width of 3 to 4 cm.
Lateral
femoral 6 cm Zones 2 and 3 are the anterior
cutaneous and inferior extensions, respectively,
nerve of zone 1. The ideal area for poste-
}

Vertical
rior iliac bone-graft harvesting is
Iliacus zone 1, as there is no risk of violation
incision
muscle
of the sacroiliac joint. Zone 2 or zone
3 may be considered if a greater
Psoas
muscle
Superior gluteal quantity of cancellous bone graft is
neurovascular required; however, the surgeon must
bundle
Anomalous course of
be aware of the risk of violation of
A lateral femoral nerve B the sacroiliac joint.6
Figure 1 A, Location of nerves in relation to the anterior ilium. B, Location of the superior
cluneal nerves and superior gluteal neurovascular bundle in relation to the posterior superi- Fibula
or iliac spine (PSIS). The fibula consists of a proximal
head, a slender shaft, and a distal

Vol 9, No 3, May/June 2001 211

 Bone-Graft Harvesting

rior to anterior over the fibular neck to 8 cm posteriorly is made through

Zone 2
and divides into superficial, deep, the iliac crest, allowing the crest to
Zone 1
and recurrent branches. In addition, be reflected medially. Cancellous
its fibers fan broadly; the peroneus bone is harvested from between the
longus and extensor digitorum lon- inner and outer cortices of the ilium.
gus receive most of their nerve fibers The reflected iliac crest is then hinged
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from this generalized fanning. The back and secured by wires or sutures.
extensor hallucis longus is often sup- Cancellous bone can also be har-
plied by only one branch from the vested with the splitting technique
PSIS deep peroneal nerve, leaving this reported by Wolfe and Kawamoto9
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muscle susceptible to denervation.7 (Fig. 4). After two coronal cuts have
Zone 3 In the middle third of the fibula, the been made through the ilium, two
peroneal artery and vein lie just oblique cuts are made, starting at the
Sacroiliac joint medial to the fibular shaft, and the middle of the iliac crest, to reflect the
superficial peroneal nerve lies lateral medial and lateral cortices of the
to the fibula within the peroneus ilium. After harvesting of the cancel-
Figure 2 The three zones in the posterior longus muscle. The deep peroneal lous bone, the inner and outer cor-
iliac region. Zone 1 is the portion of the nerve and anterior tibial artery and tices of the iliac crest are fixed to-
ilium situated superior to a line extending vein are anteromedial to the fibula gether with wires or sutures.
from the PSIS to the apex of the sacroiliac
joint anteriorly. Zones 2 and 3 are the ante- on the interosseous membrane.
rior and inferior extensions, respectively, of Corticocancellous Bone Grafts
zone 1. Zone 1 is the ideal area for posteri- Harvesting of corticocancellous
or iliac bone-graft harvesting, with no risk
of violation of the sacroiliac joint. (Adapted Harvesting From the Ilium bone grafts is a common procedure
with permission from Ebraheim N, Xu R, for posterior spine fusion. Unicorti-
Yeasting R, Jackson WT: Anatomic consid- There are several surgical techniques cal and cancellous bone grafts can be
erations for posterior iliac bone harvesting.
Spine 1996;21:1017-1020.) for harvesting of bone grafts from the harvested from the outer table of the
ilium. These include trephine curet- posterior ilium. Several longitudinal
tage, the trapdoor technique, Wolfe’s parallel cuts through the outer table
technique, and the subcrestal-window of the ilium are first made with a
lateral malleolus. The fibular head method.1,8,9 straight osteotome. The number of
articulates with the lateral tibial cuts depends on the amount of bone
condyle, which is palpable and is Cancellous Bone Grafts graft required (Fig. 5, A). A horizon-
located approximately 2 cm distal to Cancellous bone grafts can be har- tal cut along the inferior edges of the
the knee joint. The fibular shaft has vested from the ASIS, iliac tubercle, previously made cuts is then per-
three crests: anterior, posterior, and or PSIS by using trephine curettage
interosseous. The interosseous mem- (Fig. 3).8 With this technique, a small
brane is attached to the interosseous incision is made over the iliac spine
border. There are also three surfaces or tubercle, and a hole is made in the
divided by the crests: lateral, pos- cortex. A medium-size curette is then Iliac tubercle
teromedial, and anteromedial. The used, and cancellous bone grafts are ASIS
lateral surface is associated with the taken from a 45-degree arc in each
peroneal muscles; the posteromedial direction. The cavity created in the
surface, with the flexor muscles; and ilium is packed with absorbable gela-
the anteromedial surface, with the tin sponge to prevent hematoma for-
extensor muscles. The lateral malle- mation.
olus is connected to the distal tibia at With the trapdoor technique, PSIS
the syndesmosis proximally and ar- which may be the best method, can-
ticulates with the talus distally. cellous bone is harvested from the
The neurovascular structures sur- iliac tubercle, which lies 3 cm poste-
rounding the fibula include the pero- rior to the ASIS.1 The attachments of
neal nerves and the anterior tibial the fascia and the abdominal mus-
and peroneal vessels. The common cles to the iliac crest are kept intact. Figure 3 Curettage technique for harvest-
peroneal nerve in the region of the A horizontal cut extending from 3 ing of cancellous bone grafts.
knee courses obliquely from poste- cm posterior to the ASIS to a point 6

212 Journal of the American Academy of Orthopaedic Surgeons

 Nabil A. Ebraheim, MD, et al

cm
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38
cm
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ASIS

A B C D

Figure 4 Wolfe technique for harvesting of cancellous bone grafts.9 A, Two coronal cuts are made through the ilium. B, Two oblique
cuts are made, starting at the middle of the iliac crest. C, Harvesting of the cancellous bone. D, The inner and outer cortices of the iliac
crest are fixed together with wires or sutures.

formed to fracture the outer table allel cuts through both the inner and proximal and distal 10 cm should be
and isolate the bone strips. The corti- outer tables utilizing a double-bladed avoided to reduce the risks of pero-
cocancellous bone strips are removed oscillating saw or straight osteot- neal nerve damage and ankle in-
by a midline cut along the iliac crest. omes (Fig. 6, A). Bicortical bone stability, respectively. If extensive
Additional cancellous bone from be- graft may be harvested from below reconstruction is required, the prox-
neath the iliac crest and the inner the iliac crest by use of the subcrestal- imal four fifths of the fibula can be
table of the ilium can be harvested window technique (Fig. 6, B).1 used, leaving the distal 6 to 8 cm of
with a curette or gouge. To avoid It is preferable to use an oscillat- the fibula to support the lateral mal-
violation of the sacroiliac joint dur- ing saw rather than an osteotome leolus. A Gigli saw is usually used
ing harvesting of posterior iliac bone for iliac bone-graft harvesting. Bio- to harvest the graft.
graft, the harvesting area should be mechanical study has shown that To harvest a vascularized fibular
limited to 4 cm from the PSIS (i.e., the osteotome has a weakening ef- graft, the peroneal vascular pedicle
within zone 1). The inner cortex fect on graft strength. 10 Further- is dissected proximally to its bifur-
should not be penetrated.6 more, the use of an oscillating saw cation from the tibial vessels. One
The inner table of the anterior likely will minimize the incidence peroneal vein is ligated and divided.
ilium is another site for harvesting of fractures of the ilium as a com- The tourniquet is then deflated. Af-
corticocancellous bone graft. This plication of bone-graft harvesting. ter blood flow to the fibula has been
site is particularly useful when the A double-bladed oscillating saw confirmed, the peroneal artery and
abductor mechanism must be re- allows precise control of thickness, the peroneal vein are clipped and
tained, such as in professional foot- depth, and parallel orientation of divided, leaving as long a pedicle
ball players. To approach the harvest the cuts. on the fibula as possible.11
site, the iliacus muscle is dissected
from the inner table of the ilium
(Fig. 5, B). Harvesting From Technical
the Fibula Recommendations
Tricortical and Bicortical
Bone Grafts The fibula is approached through a Anterior Iliac Crest
Tricortical or bicortical bone graft straight lateral incision, with the The anterior ilium is approached
is frequently used for anterior inter- dissection carried deep between the by a skin incision made parallel and
body fusion in the cervical and lum- posterior and lateral compartments just above or below the iliac crest,
bar spines. Tricortical bone graft is of the leg. The ideal area for har- beginning at least 3 cm posterior to
harvested from the anterior ilium 3 vesting of a fibular graft is the mid- the ASIS to avoid injury to the lateral
cm posterior to the ASIS by two par- dle third of the fibular shaft. The femoral cutaneous nerve. A direct

Vol 9, No 3, May/June 2001 213

 Bone-Graft Harvesting

lel to the midline or a lateral oblique

incision within a 6-cm distance from
the PSIS to avoid the superior clu-
neal nerves (Fig. 1, B).5 A curved or
transverse incision along the iliac
crest in the posterior iliac region
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should be avoided because this will

PSIS injure the superior cluneal nerves.
ASIS After retraction of the skin and sub-
cutaneous fat, the iliac crest proximal
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to the PSIS is identified. Dissection

directly down to the bone at the
middle of the superior border of the
Iliac iliac crest is then made with an elec-
muscle trocautery device. The periosteum
and the dorsolumbar fascia on the
medial edge of the iliac crest should
be kept intact. The dissection contin-
ues subperiosteally over the lateral
edges of the iliac crest and down to
the outer table of the ilium.
It is important to identify the
working area before harvesting the
PSIS bone graft. Violation of the sacroiliac
joint can be avoided by limiting the
ASIS
harvested area to 4 cm from the PSIS
(i.e., in zone 1). The inner cortex
should not be penetrated.6 The cau-
dal limit should be the inferior mar-
gin of the roughened area anterior to
the PSIS on the outer table to keep
from injuring the superior gluteal
A B artery. 12 With the patient lying
prone on the operating table, the
Figure 5 Techniques for harvesting of corticocancellous bone grafts from the outer table
of the posterior ilium (A) and from the inner table of the anterior ilium (B).
gouge or osteotome should be di-
rected perpendicular to the operat-
ing table so as to avoid the greater
sciatic notch. When the bone graft
skin incision over the iliac crest injury to the ilioinguinal and ilio- has been harvested, the reflected
should be avoided, as it may result hypogastric nerves. To avoid avul- gluteal fascia is securely sutured to
in a painful scar postoperatively. sion of the ASIS, bicortical or tricor- the periosteum and the dorsolumbar
The length of the skin incision de- tical grafts should be taken from an fascia.
pends on the size of the bone graft area at least 3 cm posterior to the When performing a lower lum-
to be taken. ASIS. After harvesting of the bone bar fusion, posterior iliac graft can
After retraction of the skin and graft, the medial periosteum, along be harvested either by making an-
identification of the superior border with the fascia of the abdominal other separate incision or by using
of the iliac crest, a cut directly down muscles, and the lateral periosteum, the same incision and dissecting in
to the bone on the middle of the along with the gluteal fascia, are re- the fascial plane. Some studies
superior border of the iliac crest is paired over the defect in the iliac have shown no difference in mor-
carried out with an electrocautery crest. bidity between one incision and
device. A subperiosteal dissection two incisions; other studies have
over the medial and lateral edges of Posterior Iliac Crest shown that the rate of complica-
the iliac crest and down to the inner The posterior ilium can be ap- tions is related to the use of sepa-
and outer tables of the ilium avoids proached by a vertical incision paral- rate incisions. A potential disad-

214 Journal of the American Academy of Orthopaedic Surgeons

 Nabil A. Ebraheim, MD, et al

donor-site pain was higher for pa-

Subcrestal tients who underwent graft harvest-
window ing for spine surgery than for those
in whom the graft was harvested for
surgery not involving the spine.
cm

Summers and Eisenstein 16 found

3
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PSIS that an unsatisfactory outcome from

spine fusion was associated with a
significantly higher (P<0.001) preva-
lence of donor-site pain. The associ-
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ASIS
ation between workmen’s compen-
sation status and donor-site pain has
also been reported in the literature.

Nerve Injury
Nerve injury is a common com-
plication associated with iliac bone
harvesting. Since the nerves at risk
are sensory, the characteristic symp-
toms include pain, paresthesias,
A B numbness, and dysesthesias in the
distribution of the affected nerve.
Figure 6 A, Harvesting of a tricortical bone graft. B, Subcrestal-window technique.
Damage to the nerves adjacent to the
ilium most likely results from direct
transection or excessive traction.
vantage of harvesting the graft from Iliac Donor-Site The lateral femoral cutaneous nerve
the same incision is that, if the ex- Complications is at risk for injury during harvest-
posure is limited, less graft material ing of anterior iliac bone.17,18 The
may be harvested. The reported iliac donor-site compli- superior cluneal nerves are more
As there is no difference in the cations after bone-graft harvesting vulnerable to injury during harvest-
quality or quantity of the bone include pain, 1,14-16 neurovascular ing of posterior iliac bone.5,6 The
between the right and left sides, the injury,12,17-22 avulsion fractures of the ilioinguinal, iliohypogastric, superior
decision about the side from which ASIS,23,24 hematoma,14,15 infection,1 gluteal, sciatic, and femoral nerves
the graft is to be harvested should herniation of abdominal contents,25,26 are also potentially at risk. Sensory
be based on whether the patient gait disturbance,1,27 cosmetic defor- nerve injuries that result in neuroma
has a symptomatic sacroiliac joint. mity,1 instability of the sacroiliac formation can be treated by either
If so, it is logical to harvest the graft joint,28 and ureteral injury.21 injection or resection.
from the symptomatic side, to avoid
morbidity on the asymptomatic Donor-Site Pain Vascular Injury
side. Donor-site pain is the most com- Vascular injury is a rare but seri-
Regardless of the type of bone mon complaint after surgery and ous complication. Kahn12 first re-
graft harvested, the exposed cancel- often interferes with early mobi- ported two cases of superior gluteal
lous bone surface should be carefully lization. The reported incidence of artery laceration secondary to poste-
filled with bone wax or absorbable donor-site pain, defined as persis- rior iliac bone harvesting. Another
gelatin sponge after irrigation. He- tent pain at least 3 months after three cases have subsequently been
mostasis is important to avoid hema- surgery, varies greatly, ranging from reported.19,22 False aneurysm and
toma and infection at the donor site. 2.8% to 17% in recent series.14,15 The arteriovenous fistula of the superior
Sasso et al13 conducted a prospective precise cause of donor-site pain re- gluteal vessels after removal of bone
randomized study to assess the mains unclear. It may be muscular grafts have also been reported.20,21
effectiveness of postoperative suc- or periosteal secondary to the strip- Harvesting iliac bone too close to
tion drainage at the iliac donor site. ping of the abductors from the ilium, the greater sciatic notch and im-
Their findings suggested that rou- or it may be related to injury of the proper placement of the Taylor re-
tine use of suction drainage is not superior cluneal nerves.1,16 Goulet tractor in the greater sciatic notch
necessary. et al29 found that the incidence of are the main reasons for injury to the

Vol 9, No 3, May/June 2001 215

 Bone-Graft Harvesting

superior gluteal artery. Exploration

and ligation or embolization can be
used to control the bleeding from a
lacerated artery.12,22 The artery may
retract; therefore, one should not
blindly use a hemostat or clip for
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fear of sciatic or superior gluteal

nerve injury. In such cases, exposure
of the artery can be improved by par-
tial ostectomy of the ilium, use of a
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transabdominal approach, or embo-

lization.

Fractures of the Ilium

Avulsion fracture of the ASIS as
a complication of bicortical or tricor-
tical anterior iliac bone harvesting Figure 7 Axial CT scan of the sacroiliac joints shows large anterior bridging osteophytes
on the right, as well as iliac and sacral subchondral sclerosis due to violation of the joint
has been reported.23,24 A stress riser during posterior iliac bone-graft harvesting.
can be created when a graft is taken
too close to the ASIS, and avulsion
results from the action of the sarto-
rius and tensor fascia lata muscles. The diagnosis of sacroiliac joint pain bone defect created by the graft
To avoid this complication, bicorti- after violation requires an index of harvesting. Initially, the iliac crest
cal or tricortical grafts should be suspicion, as the symptoms may be is straightened by removing the
taken from an area no closer to the vague and indistinguishable from remaining parts on both sides of
ASIS than 3 cm. Older female pa- those of the primary spinal disorder. the defect. This is followed by mo-
tients with osteopenic bone are more Injection of local anesthetic into the bilization of the fascial insertion
likely to have iliac graft-site fracture; sacroiliac joint may be helpful in of the transverse and the external
therefore, particular care should be confirming the site of pain. Fusion and internal oblique muscles so
taken with this population. of the sacroiliac joint may be neces- that they can be attached directly to
sary if the pain is persistent. the ilium along the new crest. The
Violation of the Sacroiliac Joint ASIS must also be transported dis-
Involvement of the sacroiliac joint Hernia tally and posteriorly, which draws
secondary to posterior iliac bone- Herniation of abdominal contents the muscular, ligamentous, and fas-
graft harvesting may occur because through an iliac bone-graft donor cial structures tightly across the
of the complicated anatomy of the site may occur if the defect is large defect.26,30
area, the large amount of bone graft and the adjacent muscles are not
needed for spine surgery, thin cor- carefully repaired.25,26 Symptoms Hematoma
tices, and limited visualization due include abdominal pain and a mass Hematoma has been cited as a
to the bleeding from exposed cancel- with bowel sounds. The diagnosis complication of iliac bone-graft har-
lous bone. Although violation of the may be confirmed with a CT scan. vesting, which may result in infec-
sacroiliac joint is not uncommon, it Treatment follows the principles tion. The reported incidence of he-
may be occult, necessitating com- of surgery for hernias—reduction matoma formation is very low in
puted tomography (CT) for diagnosis. of the hernia contents and oblitera- recent series.14,15 Bleeding from the
Coventry and Tapper28 reported six tion of the defect. Three operations exposed cancellous bone or injury to
cases of an unstable sacroiliac joint have been described. The first is a the vessels adjacent to the anterior
after removal of bone grafts from the soft-tissue repair that includes ilium, such as the deep circumflex
posterior iliac crest. This complica- advancement of the muscles and iliac, iliolumbar, and fourth lumbar
tion results from damage to the pos- fascia, imbrication, and fascial vessels, may result in hematoma for-
terior sacroiliac ligaments. Violation flaps. The second supplements mation. Measures that help decrease
may involve the ligamentous or sy- these with a mesh. The third, origi- this risk include restricting the expo-
novial parts of the joint, resulting in nally described by Bosworth, 30 sure to a strictly subperiosteal loca-
arthritic changes and subsequent per- changes the profile of the involved tion, obtaining hemostasis before clo-
sistent sacroiliac joint pain (Fig. 7). iliac crest so as to recontour the sure, and using a suction drain.

216 Journal of the American Academy of Orthopaedic Surgeons

 Nabil A. Ebraheim, MD, et al

Gait Disturbance ceramic spacers, calcium sulfate, and pain at the ankle joint was 1.6% at 3
Gait disturbance manifested as a bone morphogenetic protein. Injury months but increased to 11.5% at 5
limp or abductor lurch is a potential to the ureter during harvesting of a years. The prevalence of subjective
problem secondary to harvesting of posterior iliac bone graft is extreme- sensory abnormalities increased
the bone graft from the posterior ly rare; only one such case has been from 4.9% at 3 months postopera-
iliac region.1,27 This problem results reported in the literature. This in- tively to 11.8% at 5 years.
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from weakness of the hip abductors jury is caused by extensive electro- Gore et al31 studied 41 patients
(mainly the gluteus medius muscle) cauterization in the greater sciatic who underwent fibular bone-graft
caused by excessive stripping dur- notch with the intent of controlling harvesting. At an average follow-
ing the exposure. This complication massive bleeding from the superior up interval of 27 months (range, 19
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/23/2024

can be prevented by securely reap- gluteal vessels.21 to 35 months), 24 patients (58%)

proximating the gluteal fascia to the were pain-free, 11 (27%) had mild
periosteum of the iliac crest. pain, and 6 (15%) had moderate or
Fibular Donor-Site severe pain. There were no differ-
Infection Complications ences in the range of motion of the
Infection at the donor site occurs ankle and subtalar joints between
in approximately 1% of patients (i.e., Potential complications of fibular the operated and nonoperated sides.
about the same rate as in other clean graft harvesting include neurovas- The average muscle strength was
orthopaedic cases).1 Treatment of in- cular injury, compartment syn- lower on the operated side, but this
fection includes irrigation, debride- drome, weakness of the extensor difference was statistically signifi-
ment, and antibiotic therapy. Mea- hallucis longus, and ankle instabil- cant (P<0.01) only for ankle ever-
sures that can be taken to reduce the ity.2,11 In the proximal third of the tors in men.
risk of infection include periopera- fibula, the peroneal nerves and their
tive antibiotic administration, use of muscular branches are at primary
separate instruments to avoid conta- risk. The extensor hallucis longus is Summary
mination from other potentially in- susceptible to denervation because it
fected sites, meticulous hemostasis, is generally supplied by only one Knowledge of the surgical anatomy
and use of newer techniques utiliz- branch from the deep peroneal of the ilium and fibula, the harvest-
ing trephines to avoid muscle strip- nerve.2 In the middle third of the ing techniques, and the potential
ping and thereby reduce soft-tissue fibula, the peroneal vessels are the complications of obtaining bone
morbidity. major structures at risk. Harvesting graft can decrease the morbidity of
the distal 10 cm of the fibula should the procedure. Harvesting of bone
Other Complications be avoided, as it will result in ankle graft is an apparently simple proce-
Other complications associated instability. dure, but may result in numerous
with iliac bone-graft harvesting are Vail and Urbaniak 11 studied complications. Selection of the graft
cosmetic deformity and ureteral in- donor-site morbidity after harvest- site, approach, and technique should
jury. The defect that results from ing of vascularized fibular grafts. be tailored to the type and quantity
harvesting a large tricortical bone Muscle weakness was noted in 25 of the graft desired. The choice be-
graft may cause cosmetic deformity.1 (10%) of the 247 limbs at 3 months tween autologous graft and other
A variety of techniques have been after graft harvesting and in 2 (3%) materials can best be made with an
utilized in an attempt to eliminate of the 74 limbs that were evaluated understanding of the risks and bene-
the defect, among them the use of at 5 years or more. The incidence of fits of each technique.

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Vol 9, No 3, May/June 2001 217

 Bone-Graft Harvesting

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218 Journal of the American Academy of Orthopaedic Surgeons