Morbidity of iliac crest

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Oral Maxillofac Surg9:48-53, 2011

Morbidity After Iliac Crest Bone GraftHarvesting Over an Anterior Versus

Posterior ApproachStephan T. Becker, MD, DMD,* Patrick H. Warnke, PhD,†

Eleonore Behrens, DMD,‡ and Jörg Wiltfang, PhD§

Purpose: For larger augmentations before implant insertions, as well as spinal arthrodesis surgery, theiliac crest is the standard source of bone grafting. This study assesses iliac morbidity after bone graftharvesting from the anterior and posterior ilium.

Materials and Methods: A total of 97 patients who underwent corticocancellous iliac crest boneharvesting for augmentations of the jaws from 2004 to 2007 at the Department of Oral and MaxillofacialSurgery, University Hospital Kiel, Kiel, Germany, were included. Their morbidity was assessed withspecially designed questionnaires.

Results: Pain levels were rated nearly equally on a visual analog scale (1, no pain; 10, strongest pain)by the anterior and posterior groups. At 1 week after bone harvesting, pain was rated 4.9 for the anteriorapproach and 4.8 for posterior (P � .89). The corresponding values after 6 months were 1.4 and 1.6,respectively (P � .64). Subjective evaluation of the scars showed scores of 2.7 and 3.0, respectively(P � .76). Of the patients, 81% and 88%, respectively, would opt to undergo the operation again.

Conclusions: Patients reported a noticeable reduction in quality of life after elective bone graftharvesting. Nevertheless, nearly all patients would undergo the same procedure again. Both approacheswere rated similarly, so for smaller amounts of bone graft needed, the anterior and posterior approachescan be recommended, whereas the posterior approach is suitable for larger amounts.© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:48-53, 2011
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hoosing the optimal approach for iliac bone harvest-ng is a challenge for surgeons in implantology andrthopedics. With this study, we will try to provide aasis for decision making by evaluating morbidityepending on different surgical approaches for iliacone harvesting.

*Department of Oral and Maxillofacial Surgery, Christian-Albre-

hts University, Kiel, Germany.

†Department of Oral and Maxillofacial Surgery, Christian-Albre-

hts University, Kiel, Germany, and Faculty of Health Sciences and

edicine, Bond University, Gold Coast, Queensland, Australia.

‡Department of Oral and Maxillofacial Surgery, Christian-Albre-


§Department of Oral and Maxillofacial Surgery, Christian-Albre-


Address correspondence and reprint requests to Dr Becker:

epartment of Oral and Maxillofacial Surgery, Christian-Albrechts-

niversity, Arnold-Heller-Strasse 3, Haus 26, 24105 Kiel, Germany;

-mail: [email protected]

2011 American Association of Oral and Maxillofacial Surgeons

278-2391/11/6901-0008$36.00/0

aoi:10.1016/j.joms.2010.05.061

48

In maxillofacial and orthopedic surgery, bone aug-entations are done routinely. It is essential to have a

table and sufficient amount of bone to enable im-lant loading even in cases of alveolar atrophy. Inpinal fusion surgery the goal is to achieve solid fu-ion, to maximize clinical outcomes. This goal hasenerated enormous interest in developing bone graftlternatives or extenders that enhance or replace au-ologous bone grafts.1 Nevertheless, allogeneic or xe-ogeneic bone and bone substitutes are of inferioruality to date, for example, because they lack osteo-ompetent cells.2 Autogenous bone grafts from theliac crest are still the gold standard as graft materialor spinal fusion because they have all propertiesssential for adequate fusion.1

Several factors must be taken into considerationhen choosing the donor site, including the locationf the recipient bed, the quality and quantity of boneequired, and potential complications.3 The iliac crestepresents the most commonly used4 extraoral donorite for nonvascularized bone because of the largeuantity of cortical and cancellous bone,3 availability,
nd easy access.5
mailto:[email protected]

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BECKER ET AL 49

For iliac crest harvesting, several complicationsave been described: chronic pain, sensory loss,ound breakdown, contour defect, hernia through

he donor site, instability of the sacroiliac joint, gaitisturbance, pathologic fracture, adynamic ileus, ure-hral injury, seroma, hematoma, and hemorrhage.6

Different trials with varying results have been car-ied out to compare anterior and posterior ap-roaches for iliac bone grafting.6-8 A low incidence ofonor-site morbidity is reported for anterior cancel-

ous iliac crest bone in secondary bone grafting of theleft alveolus.9 Studies have reported that the anteriorpproach to the ilium causes considerably more prob-ems than the posterior approach.10 On the otherand, the potential morbidity of bone harvest fromhe posterior ilium is said to be greater than thatrom the anterior iliac crest, because of the proximityo the sacroiliac joint and the sciatic nerve. In reality,amage to these areas is rare.6 Because these opera-ions are elective, how the patient rates them is mostmportant.

The purpose of this study was to quantify the se-erity of morbidity by subjective evaluation of pain byatients after iliac crest harvest associated with jawugmentation procedures by evaluation with ques-ionnaires and to compare these data depending onhe surgical approach.

aterials and Methods

PATIENTS

This study included 97 consecutive patients (48emale patients and 49 male patients) aged 17 to 89ears who received combined cortical and cancellousone grafting of the ilium at the Department of Oralnd Maxillofacial Surgery, University of Kiel, Kiel,ermany, from 2004 to 2007. Patients who only re-eived cancellous bone harvesting (eg, for cleft sur-ery) were excluded. Additional inclusion criteriaere the absence of pain before surgery and no pre-

ious surgery or injury to the ilium. All patients gavenformed consent for participation. The protocol waspproved by the Institutional Ethics Committee (A40/08) and adhered to the tenets of the Declarationf Helsinki.The patient groups (anterior harvest and posterior

arvest) were homogeneous to a great extent. Thege distribution of the groups is presented in Table 1.ean values (about 55 years) as well as quartiles and

xtremes were similar. The patients were operated ono harvest bone for dental implant insertion. Thereas no randomization. Diseases leading to the need

or augmentation are presented in Figure 1. The ma-ority of patients had severe atrophy of the jaws oreconstruction after neoplasm including benign tu-
ors. m
All surgery was performed with the patient undereneral anesthesia. Bone from the anterior approachas harvested following the technique of Kalk et al,11

hereas posterior harvesting was done as describedy Bloomquist and Feldman.12 Harvesting startedith a saw, and then a chisel and mallet were used.fter harvesting of the cortical segments, cancellousone was collected with curettes. The amount ofone was determined by putting the bone into aeasuring cylinder partially filled with saline solution.he operations were performed by different sur-eons.To reduce postoperative pain, for the first 5 days,

buprofen (600 mg 3 times daily) was prescribed. Inddition, the patients received Sultamicillin (375 mgy mouth 3 times daily) for 5 days or, in the case ofenicillin allergy, clindamycin (300 mg by mouth 3imes daily).

QUESTIONNAIRE

A questionnaire was sent to the participants 1 to 4ears after surgery. Those who did not respond to theuestionnaire within 6 weeks were called and askedgain to participate.

The questionnaires were specially designed toather information about typical problems with iliacrest bone harvesting. Besides personal information,e recorded data about the prosthetic reconstruc-

ion. Patients were also asked how long the pain athe donor site had lasted and how strong they per-eived the pain to be, as rated on a 10-point visualnalog scale (VAS) (1, no pain; 10, strongest pain) inhe first week, in the first month, after 6 months, andfter 1 year postoperatively. In addition, gait distur-ances as well as the use of crutches were queried. Allatients were asked whether they would undergo theame operation again, whether they would recom-end this operation to friends or relatives with the

ame problem, and how they rated the remaining scarn a VAS (1, modest; 10, ugly). Problems after 1

Table 1. AGE DISTRIBUTION OF GROUP

Age Anterior Posterior

aximum (yr) 82 895% quartile (yr) 64 67edian (yr) 57 60

5% quartile (yr) 38 46inimum (yr) 18 17ean (yr) 52 56

E of mean (yr) 2 2o. of patients 50 47

OTE. The patient groups were similar to a great extent.

ecker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oralaxillofac Surg 2011.

onth and 1 year at work, during leisure tasks, and in

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50 MORBIDITY AFTER ILIAC CREST BONE GRAFT HARVEST

veryday life were also recorded. Only problems withhe iliac crest were questioned, not oral pain.

STATISTICAL EVALUATION

Distributions of age, duration of pain, bone volumearvested, type of dentures, gait disturbances, andeed for crutches, as well as the willingness of theatient to repeat the operation if needed or to recom-end it to others, were calculated. In addition, we

valuated problems at work, during leisure tasks, and

IGURE 1. Diseases leading to need for augmentation by group:A) anterior and (B) posterior. In the majority of cases these wereevere atrophy of the jaws or reconstruction after neoplasm includ-ng benign tumors.


n everyday life after 1 and 12 months.BM

The following parameters were analyzed with vari-nce analyses for the factor harvest from the anteriorpproach versus the posterior approach: pain after 1eek, 1 month, 6 months, and 1 year and scar forma-

ion at the point of evaluation. Least squares meansnd 95% confidence intervals are presented in textnd figures.

esults

Of the patients, 60% (58 of 97) answered the ques-ionnaire. Pain levels for both groups started atround 5 at 1 week (P � .89) (Fig 2) after surgery onVAS ranging from 1 (no pain) to 10 (maximal pain).fter 1 month (P � .37), the pain levels averagedetween 2 and 3, whereas after 6 months (P � .64)nd 12 months (P � .37), they were close to 1 in bothroups. The course of pain levels over time was fairlyarallel for the anterior and posterior approachesith overlapping confidence intervals. The median

ength of pain duration (14 days in the anterior groups. 21 days in the posterior group) as well as quartilesre presented in Table 2, together with the amountsf bone volume harvested. The mean volume reached2 cm3 for the anterior approach and 18 cm3 for theosterior approach.The assessment of the scar at the point of evalua-

ion was nearly identical for both groups (2.7 fornterior approach vs. 3.0 for posterior approach, P �76) (Fig 3).

The dentures integrated afterward were fixed inbout half of the patients (Fig 4). Gait disturbancesccurred in 12 of 26 patients in the anterior groupnd 11 of 31 in the posterior group. In addition, 17 of6 patients needed crutches in the anterior group andof 32 in the posterior group. A total of 21 of 24

atients of the anterior group would undergo the

IGURE 2. Pain levels over time after surgery on VAS ranging from(no pain) to 10 (maximal pain) by group. The parallel course of

he anterior and posterior harvest groups, with widely overlappingonfidence intervals, should be noted.


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BECKER ET AL 51

ame operation again. In the posterior group the cor-esponding value was 28 of 32.

Some patients had problems in different situationsfter 1 month and even after 12 months (Fig 5).

During surgery, in 9 cases bone was harvestedccidentally bicortically, mostly because of a very thinancellous layer, and 1 patient had a fracture of thelium that occurred when entering an elevator. Theracture could be treated conservatively without caus-ng further problems.

iscussion

Pain is the most frequently cited complication ofarvesting iliac crest bone grafts. Pain levels in thistudy peaked at around 5 at 1 week after surgery on a

Table 2. MEDIAN PAIN DURATION AFTER SURGERYAS WELL AS QUARTILES AND AMOUNT OF BONEVOLUME HARVESTED BY GROUP

Anterior Posterior

ain duration75% quartile (d) 30 61Median (d) 14 2125% quartile (d) 6 7No. of patients 24 29

one volume harvestedMean (cm3) 12 18SE of mean (cm3) 1 1No. of patients 42 46


IGURE 3. Assessment of scar 1 to 4 years after surgery on VASanging from 1 (modest) to 10 (ugly). Nearly identical values wereound for both groups (P � .7612).

necker et al. Morbidity After Iliac Crest Bone Graft Harvest. J Oralaxillofac Surg 2011.

AS ranging from 1 (no pain) to 10 (maximal pain).fter 1 month, they averaged between 2 and 3,hereas after 6 and 12 months, the pain levels were

lose to 1 in both groups. The course of pain levelsver time indicated no differences for the anteriorpproach and the posterior approach. The medianength of pain duration was 14 days for anterior and1 days for posterior. Some patients in our study hadroblems in different situations after 1 month andven after 12 months. This is in accordance withnother study, where 119 adult patients who under-ent iliac crest bone grafting were evaluated to assess

he effect of bone grafts.13 They stated that they hadain for approximately 6 weeks, and even 10% per-eived moderate pain for 2 years. In contrast to ouresults, in a retrospective study of treatment forhronic osteomyelitis, 58 patients completed a ques-ionnaire about pain comparing anterior and posteriorone grafting from the iliac crest.3 Postoperative paint the donor site was significantly more severe and ofreater duration after anterior harvesting. One studyeported that 74% of the patients were free of painithin 3 weeks after anterior harvesting whereas 26%ad pain for a few weeks to several months.4 Nkenket al6 stated that the morbidity resulting from bonearvest from the posterior iliac crest was lower thanhat from the anterior iliac crest in terms of postop-rative pain, gait disturbances, and sensitivity disor-ers. Among 71 adolescent patients undergoing spi-al arthrodesis surgery after harvest of posterior iliacrest bone, pain was absent in 90% of the patients and

IGURE 4. Characteristics of anterior and posterior groups: Pro-ortions of patients who would recommend operation to others orndergo it again and patients who needed crutches, had gaitisturbances, and had dentures integrated.


o higher than 3 of 10.14 Another study, by Kessler et

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52 MORBIDITY AFTER ILIAC CREST BONE GRAFT HARVEST

l,10 showed that the posterior approach causedewer postoperative problems for patients, but it haso be mentioned that they also included patients whonly had cancellous bone harvests. Significantly loweralues for subjective pain (2.2 on average on a VAS)ave been described by other investigators retrospec-ively for bone harvest from the anterior iliac crest.11

egarding morbidity, the muscular attachments play aignificant role in terms of postoperative pain and gaitisturbance. The reflection and retraction of the ten-or fascia lata muscle seemed to be the primary rea-ons for the increased morbidity observed with thenterior approach.6

Gait disturbances in this study occurred in 46% ofhe patients in the anterior group and 35% in theosterior group. We found that 17 of 26 patientseeded crutches in the anterior group and 8 of 32 inhe posterior group. These values are higher thanhose reported in another study, where 79% of pa-ients had no gait disturbance after 3 weeks.4

Satisfaction with the operation was remarkablyigh in both groups (81% for anterior and even 88%or posterior). This is in accordance with other au-hors who reported on satisfaction values after har-est of 83% to 88% for the posterior approach and

IGURE 5. Proportions of patients with problems (A) 1 month andB) 12 months after surgery.


2% to 86% for the anterior approach.15 Of 32 pa- c

ients, 30 would undergo iliac crest harvesting fromhe anterior approach again.16

The mean volume of bone harvested in this studyas 12 cm3 for the anterior approach and 18 cm3 for

he posterior approach. Other studies reported vol-mes of 13 cm3 for anterior and 30 cm3 for posterior3

nd 15 cm3 for anterior and 25 cm3 for posterior.10

One patient had a fracture of the ilium that hap-ened 1 week after surgery when entering an eleva-or. The fracture could be treated sufficiently withouturgery. Anterior fractures—also painful—remain sta-le and heal spontaneously, whereas posterior frac-ures are said to very often require complex surgicalreatments and cause significant disability.5 Mostlyate fractures occur, which can almost always bereated conservatively.17 Only 16% of fractures re-uire further treatment.5

In a questionnaire study with 58 patients compar-ng anterior and posterior bone grafting from the iliacrest, major complications were reported in 6% fornterior and 2% for posterior, with minor complica-ions rates of 15% and 0%, respectively. Major com-lications were defined as those prolonging hospi-alization, requiring additional surgery, or causingubstantial disability.3

Several different complications after ilium bonearvesting are described, such as infection (0%-3%),3

emporary impairment (0%-20%),15 hernia,18 and neu-ologic injuries.4,19 Damage to the superior and me-ial cluneal nerves during the soft tissue approach tohe posterior ilium has been described as a complica-ion. Temporary sensory loss, which did not lastonger than 1 month, has been detected in 12% ofatients.6 The potential morbidity of bone harvest

rom the posterior ilium is said to be greater than thatrom the anterior iliac crest, because of the proximityf the sacroiliac joint and the sciatic nerve. Neverthe-

ess, damage to these areas is rare.6 In our patientroups no obvious differences in complication ratesould be observed.Similar to our response rate of 60%, a previous

tudy reported that 73% of patients could be con-acted and overall only 51% answered questionnairesbout autogenous iliac crest bone graft.13

The iliac crest offers many advantages as a donorite, including easy accessibility and the possibility toarvest large amounts of bone and to close the woundrimarily,8 whereas the posterior approach leads to

ncreased operation time because of the need to ro-ate the patient during surgery.

It has to be mentioned that the results of our ret-ospective study may be different from those of pro-pective studies.

Patients reported a noticeable reduction in qualityf life after elective bone graft harvesting. In a few
ases (3 of 97), pain lasted for 1 year. Nevertheless,

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BECKER ET AL 53

early all patients would undergo the same proce-ure. There were no obvious differences between theapproaches for iliac bone harvesting. Even the scar

ssessment was nearly identical, so when smallermounts of bone graft are needed, both the anteriorpproach and the posterior approach can be recom-ended, whereas only the posterior approach is suit-

ble for larger amounts.

eferences1. Brandoff JF, Silber JS, Vaccaro AR: Contemporary alternatives

to synthetic bone grafts for spine surgery. Am J Orthop 37:410,2008

2. Landes CA, Stubinger S, Laudemann K, et al: Bone harvesting atthe anterior iliac crest using piezoosteotomy versus conven-tional open harvesting: A pilot study. Oral Surg Oral Med OralPathol Oral Radiol Endod 105:e19, 2008

3. Ahlmann E, Patzakis M, Roidis N, et al: Comparison of anteriorand posterior iliac crest bone grafts in terms of harvest-sitemorbidity and functional outcomes. J Bone Joint Surg Am84:716, 2002

4. Cricchio G, Lundgren S: Donor site morbidity in two differentapproaches to anterior iliac crest bone harvesting. Clin ImplantDent Relat Res 5:161, 2003

5. Nocini PF, Bedogni A, Valsecchi S, et al: Fractures of the iliaccrest following anterior and posterior bone graft harvesting.Review of the literature and case presentation. Minerva Stoma-tol 52:441, 2003

6. Nkenke E, Weisbach V, Winckler E, et al: Morbidity of harvest-ing of bone grafts from the iliac crest for preprosthetic aug-mentation procedures: A prospective study. Int J Oral Maxillo-fac Surg 33:157, 2004

7. Hall MB, Vallerand WP, Thompson D, et al: Comparative ana-
tomic study of anterior and posterior iliac crests as donor sites.J Oral Maxillofac Surg 49:560, 1991
8. Marx RE, Morales MJ: Morbidity from bone harvest in major jawreconstruction: A randomized trial comparing the lateral ante-rior and posterior approaches to the ilium. J Oral MaxillofacSurg 46:196, 1988

9. Beirne JC, Barry HJ, Brady FA, et al: Donor site morbidity of theanterior iliac crest following cancellous bone harvest. Int J OralMaxillofac Surg 25:268, 1996

0. Kessler P, Thorwarth M, Bloch-Birkholz A, et al: Harvesting ofbone from the iliac crest—Comparison of the anterior andposterior sites. Br J Oral Maxillofac Surg 43:51, 2005

1. Kalk WW, Raghoebar GM, Jansma J, et al: Morbidity from iliaccrest bone harvesting. J Oral Maxillofac Surg 54:1424, 1996

2. Bloomquist DS, Feldman GR: The posterior ilium as a donor sitefor maxillo-facial bone grafting. J Maxillofac Surg 8:60, 1980

3. Goulet JA, Senunas LE, DeSilva GL, et al: Autogenous iliac crestbone graft. Complications and functional assessment. Clin Or-thop Relat Res 76, 1997

4. Kager AN, Marks M, Bastrom T, et al: Morbidity of iliac crestbone graft harvesting in adolescent deformity surgery. J PediatrOrthop 26:132, 2006

5. Mischkowski RA, Selbach I, Neugebauer J, et al: Lateralfemoral cutaneous nerve and iliac crest bone grafts—Ana-tomical and clinical considerations. Int J Oral MaxillofacSurg 35:366, 2006

6. Freilich MM, Sandor GK: Ambulatory in-office anterior iliaccrest bone harvesting. Oral Surg Oral Med Oral Pathol OralRadiol Endod 101:291, 2006

7. Zijderveld SA, ten Bruggenkate CM, van Den Bergh JP, et al:Fractures of the iliac crest after split-thickness bone grafting forpreprosthetic surgery: Report of 3 cases and review of theliterature. J Oral Maxillofac Surg 62:781, 2004

8. Velchuru VR, Satish SG, Petri GJ, et al: Hernia through an iliaccrest bone graft site: Report of a case and review of theliterature. Bull Hosp Jt Dis 63:166, 2006

9. Oakley MJ, Smith WR, Morgan SJ, et al: Repetitive posterioriliac crest autograft harvest resulting in an unstable pelvicfracture and infected non-union: Case report and review of the
literature. Patient Saf Surg 1:6, 2007

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Morbidity of iliac crest