Xương chậu : kỹ thuật và biến chứng pps

Journal of the American Academy of Orthopaedic Surgeons
210
Autogenous bone graft has been
used frequently to augment bone
healing for delayed union or non-
union of the long bones and for
spinal fusion, as well as to fill in bone
defects after fractures, after curettage
or resection of tumors, and during
revision arthroplasty. The most
commonly used site for harvesting is
the posterior iliac crest, because it
can provide a large quantity of both
cancellous and corticocancellous
bone. The anterior ilium is the sec-
ond most common site.
The fibula is a less common site
for bone harvesting. Fibular bone
graft can be used for anterior inter-
body fusion in the spine and for
reconstruction of defects in the long
bones. The vascularized fibular graft
also may be used in major recon-
struction of the limbs and in the
treatment of congenital pseudarthro-
sis of the tibia, infected nonunions of
long bones, nonunions of the femoral
neck, and femoral head osteonecrosis.
Although bone-graft harvesting
is not a complicated procedure, it is
not without morbidity. The compli-

cations associated with bone har-
vesting vary from donor-site pain to
neurovascular injury.
1,2
An under-
standing of the anatomy of the do-
nor sites, the surgical techniques,
and the potential complications of
harvesting bone grafts from the
ilium and fibula is important to
minimize morbidity.
Surgical Anatomy
Ilium
The ilium is the largest part of
the innominate bone and has three
surfaces. The inner surface is com-
posed of the rough sacroiliac surface
posteroinferiorly and the smooth,
concave surface superoanteriorly.
The sacroiliac surface is divided into
the articular surface inferoanteriorly
and the nonarticular surface pos-
terosuperiorly. Immediately anterior
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
Dr. Ebraheim is Professor and Chairman,
Department of Orthopaedic Surgery, Medical
College of Ohio, Toledo. Dr. Elgafy is Fellow in

Orthopaedic Surgery, Medical College of Ohio.
Dr. Xu is Professor of Orthopaedic Surgery,
Jiaxing Second Hospital, Jiaxing, China.
Reprint requests: Dr. Ebraheim, Department
of Orthopaedic Surgery, Medical College of
Ohio, 3000 Arlington Avenue, Toledo, OH
43699.
Copyright 2001 by the American Academy of
Orthopaedic Surgeons.
Abstract
The ilium and the fibula are the most common sites for bone-graft harvesting.
The different methods for harvesting iliac bone graft include curettage, trapdoor
or splitting techniques for cancellous bone, and the subcrestal-window tech-
nique for bicortical graft. A tricortical graft from the anterior ilium should be
taken at least 3 cm posterior to the anterior superior iliac spine (ASIS). Iliac
donor-site complications include pain, neurovascular injury, avulsion fractures
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-
ing include the lateral femoral cutaneous, iliohypogastric, and ilioinguinal
nerves anteriorly and the superior cluneal nerves and superior gluteal neuro-
vascular bundle posteriorly. Violation of the sacroiliac joint can be avoided by
limiting the harvested area to 4 cm from the posterior superior iliac spine
(PSIS) and by not penetrating the inner cortex. The caudal limit for bone har-
vesting should be the inferior margin of the roughened area anterior to the PSIS
on the outer table to keep from injuring the superior gluteal artery. Potential
complications of fibular graft harvesting include neurovascular injury, com-
partment syndrome, extensor hallucis longus weakness, and ankle instability.
The neurovascular structures at risk for injury during fibular bone-graft har-
vesting include the peroneal nerves and their muscular branches in the proxi-

mal third of the fibular shaft and the peroneal vessels in the middle third.
J Am Acad Orthop Surg 2001;9:210-218
Bone-Graft Harvesting From Iliac and Fibular
Donor Sites: Techniques and Complications
Nabil A. Ebraheim, MD, Hossein Elgafy, MD, and Rongming Xu, MD
Nabil A. Ebraheim, MD, et al
Vol 9, No 3, May/June 2001
211
anteriorly and concave posteriorly.
The gluteus minimus, medius, and
maximus muscles are attached to the
outer surface of the ilium. The iliac
crest has inner and outer lips.
The bone stock of the ilium is
thickest in two regions. The first is
the area extending from 2 to 3 cm
posterior to the anterior superior
iliac spine (ASIS) to a point 6 to 8
cm posteriorly along the iliac crest.
The second is the posteroinferior
portion (sacroiliac surface area) of
the ilium.
3,4
The neurovascular structures
adjacent to the ilium include the
lateral femoral cutaneous, iliohy-
pogastric, and ilioinguinal nerves
anteriorly (Fig. 1, A) and the supe-
rior cluneal nerves and superior
gluteal neurovascular bundle pos-

teriorly (Fig. 1, B). These structures
are vulnerable to injury during
bone-graft harvesting.
The iliohypogastric nerve arises
from the ventral ramus of L1 and
emerges from the lateral border of
the psoas major. It perforates the
transverse abdominal muscle above
the pelvis and supplies the trans-
verse and internal oblique abdomi-
nal muscles. Its lateral cutaneous
branch supplies the skin of the pos-
terior part of the gluteal region.
The ilioinguinal nerve also comes
from the ventral ramus of L1 and
runs just medial to the iliohypogas-
tric nerve proximally. Distally, it
crosses in front of the upper part of
the iliacus muscle and passes into
the inguinal canal to supply the skin
of the groin area.
The lateral femoral cutaneous
nerve is the sensory branch from the
L2 and L3 ventral rami. In the ante-
rior iliac region, it exits the iliac fossa
from beneath the inguinal ligament
just inferior to the ASIS and becomes
extrafascial almost immediately over
the anterior lateral thigh. However,
in some patients, it exits the iliac

fossa over the anterior iliac crest,
which places the nerve at high risk
for injury during an approach to the
anterior iliac region.
The superior cluneal nerves orig-
inate from the dorsal rami of L1, L2,
and L3. They emerge from the lum-
bodorsal fascia and cross the iliac
crest approximately 6 to 8 cm lateral
to the posterior superior iliac spine
(PSIS).
5
These nerves provide sen-
sation to the region of the posterior
iliac crest and the cephalad portion
of the buttock.
The superior gluteal artery is a
main branch of the internal iliac ar-
tery. It leaves the pelvis through the
most proximal portion of the greater
sciatic notch, staying against the
bony notch and supplying the glu-
teal muscles.
Safety Zone for Posterior Iliac
Graft Harvesting
The posterior iliac region (extra-
articular) is divided into three zones
(Fig. 2). Zone 1 is the portion of the
ilium situated superior to a line
extending from the PSIS to the apex

of the sacroiliac joint anteriorly. The
anterior margin of zone 1 is the
superior extension of the posterior
border of the superior edge of the
articular surface. The inferior mar-
gin is a line extending anteriorly
from the PSIS to the apex of the
sacroiliac joint, oriented perpendicu-
lar to the posterior margin of the
superior edge. During posterior iliac
bone-graft harvesting, zone 1 can be
defined as the portion of the ilium
situated superior to a line extending
anteriorly from the PSIS and oriented
perpendicular to the plane of the op-
erating table, with an anteroposterior
width of 3 to 4 cm.
Zones 2 and 3 are the anterior
and inferior extensions, respectively,
of zone 1. The ideal area for poste-
rior iliac bone-graft harvesting is
zone 1, as there is no risk of violation
of the sacroiliac joint. Zone 2 or zone
3 may be considered if a greater
quantity of cancellous bone graft is
required; however, the surgeon must
be aware of the risk of violation of
the sacroiliac joint.
6
Fibula

The fibula consists of a proximal
head, a slender shaft, and a distal
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-
or iliac spine (PSIS).
Superior cluneal nerves
Oblique
incision
Iliohypogastric
nerve
Ilioinguinal
nerve
Iliacus
muscle
Psoas
muscle
Lateral
femoral
cutaneous
nerve
Anomalous course of
lateral femoral nerve
Quadratus lumborum muscle
Vertical
incision
Superior gluteal
neurovascular
bundle
6 cm
PSIS

6 cm
}
A B
Bone-Graft Harvesting
Journal of the American Academy of Orthopaedic Surgeons
212
lateral malleolus. The fibular head
articulates with the lateral tibial
condyle, which is palpable and is
located approximately 2 cm distal to
the knee joint. The fibular shaft has
three crests: anterior, posterior, and
interosseous. The interosseous mem-
brane is attached to the interosseous
border. There are also three surfaces
divided by the crests: lateral, pos-
teromedial, and anteromedial. The
lateral surface is associated with the
peroneal muscles; the posteromedial
surface, with the flexor muscles; and
the anteromedial surface, with the
extensor muscles. The lateral malle-
olus is connected to the distal tibia at
the syndesmosis proximally and ar-
ticulates with the talus distally.
The neurovascular structures sur-
rounding the fibula include the pero-
neal nerves and the anterior tibial
and peroneal vessels. The common
peroneal nerve in the region of the

knee courses obliquely from poste-
rior to anterior over the fibular neck
and divides into superficial, deep,
and recurrent branches. In addition,
its fibers fan broadly; the peroneus
longus and extensor digitorum lon-
gus receive most of their nerve fibers
from this generalized fanning. The
extensor hallucis longus is often sup-
plied by only one branch from the
deep peroneal nerve, leaving this
muscle susceptible to denervation.
7
In the middle third of the fibula, the
peroneal artery and vein lie just
medial to the fibular shaft, and the
superficial peroneal nerve lies lateral
to the fibula within the peroneus
longus muscle. The deep peroneal
nerve and anterior tibial artery and
vein are anteromedial to the fibula
on the interosseous membrane.
Harvesting From the Ilium
There are several surgical techniques
for harvesting of bone grafts from the
ilium. These include trephine curet-
tage, the trapdoor technique, Wolfe’s
technique, and the subcrestal-window
method.
1,8,9

Cancellous Bone Grafts
Cancellous bone grafts can be har-
vested from the ASIS, iliac tubercle,
or PSIS by using trephine curettage
(Fig. 3).
8
With this technique, a small
incision is made over the iliac spine
or tubercle, and a hole is made in the
cortex. A medium-size curette is then
used, and cancellous bone grafts are
taken from a 45-degree arc in each
direction. The cavity created in the
ilium is packed with absorbable gela-
tin sponge to prevent hematoma for-
mation.
With the trapdoor technique,
which may be the best method, can-
cellous bone is harvested from the
iliac tubercle, which lies 3 cm poste-
rior to the ASIS.
1
The attachments of
the fascia and the abdominal mus-
cles to the iliac crest are kept intact.
A horizontal cut extending from 3
cm posterior to the ASIS to a point 6
to 8 cm posteriorly is made through
the iliac crest, allowing the crest to
be reflected medially. Cancellous

bone is harvested from between the
inner and outer cortices of the ilium.
The reflected iliac crest is then hinged
back and secured by wires or sutures.
Cancellous bone can also be har-
vested with the splitting technique
reported by Wolfe and Kawamoto
9
(Fig. 4). After two coronal cuts have
been made through the ilium, two
oblique cuts are made, starting at the
middle of the iliac crest, to reflect the
medial and lateral cortices of the
ilium. After harvesting of the cancel-
lous bone, the inner and outer cor-
tices of the iliac crest are fixed to-
gether with wires or sutures.
Corticocancellous Bone Grafts
Harvesting of corticocancellous
bone grafts is a common procedure
for posterior spine fusion. Unicorti-
cal and cancellous bone grafts can be
harvested from the outer table of the
posterior ilium. Several longitudinal
parallel cuts through the outer table
of the ilium are first made with a
straight osteotome. The number of
cuts depends on the amount of bone
graft required (Fig. 5, A). A horizon-
tal cut along the inferior edges of the

previously made cuts is then per-
Figure 2 The three zones in the posterior
iliac region. Zone 1 is the portion of the
ilium situated superior to a line extending
from the PSIS to the apex of the sacroiliac
joint anteriorly. Zones 2 and 3 are the ante-
rior and inferior extensions, respectively, of
zone 1. Zone 1 is the ideal area for posteri-
or iliac bone-graft harvesting, with no risk
of violation of the sacroiliac joint. (Adapted
with permission from Ebraheim N, Xu R,
Yeasting R, Jackson WT: Anatomic consid-
erations for posterior iliac bone harvesting.
Spine 1996;21:1017-1020.)
Zone 1
Zone 3
PSIS
Sacroiliac joint
Zone 2
Figure 3 Curettage technique for harvest-
ing of cancellous bone grafts.
ASIS
Iliac tubercle
PSIS
Nabil A. Ebraheim, MD, et al
Vol 9, No 3, May/June 2001
213
formed to fracture the outer table
and isolate the bone strips. The corti-
cocancellous bone strips are removed

by a midline cut along the iliac crest.
Additional cancellous bone from be-
neath the iliac crest and the inner
table of the ilium can be harvested
with a curette or gouge. To avoid
violation of the sacroiliac joint dur-
ing harvesting of posterior iliac bone
graft, the harvesting area should be
limited to 4 cm from the PSIS (i.e.,
within zone 1). The inner cortex
should not be penetrated.
6
The inner table of the anterior
ilium is another site for harvesting
corticocancellous bone graft. This
site is particularly useful when the
abductor mechanism must be re-
tained, such as in professional foot-
ball players. To approach the harvest
site, the iliacus muscle is dissected
from the inner table of the ilium
(Fig. 5, B).
Tricortical and Bicortical
Bone Grafts
Tricortical or bicortical bone graft
is frequently used for anterior inter-
body fusion in the cervical and lum-
bar spines. Tricortical bone graft is
harvested from the anterior ilium 3
cm posterior to the ASIS by two par-

allel cuts through both the inner and
outer tables utilizing a double-bladed
oscillating saw or straight osteot-
omes (Fig. 6, A). Bicortical bone
graft may be harvested from below
the iliac crest by use of the subcrestal-
window technique (Fig. 6, B).
1
It is preferable to use an oscillat-
ing saw rather than an osteotome
for iliac bone-graft harvesting. Bio-
mechanical study has shown that
the osteotome has a weakening ef-
fect on graft strength.
10
Further-
more, the use of an oscillating saw
likely will minimize the incidence
of fractures of the ilium as a com-
plication of bone-graft harvesting.
A double-bladed oscillating saw
allows precise control of thickness,
depth, and parallel orientation of
the cuts.
Harvesting From
the Fibula
The fibula is approached through a
straight lateral incision, with the
dissection carried deep between the
posterior and lateral compartments

of the leg. The ideal area for har-
vesting of a fibular graft is the mid-
dle third of the fibular shaft. The
proximal and distal 10 cm should be
avoided to reduce the risks of pero-
neal nerve damage and ankle in-
stability, respectively. If extensive
reconstruction is required, the prox-
imal four fifths of the fibula can be
used, leaving the distal 6 to 8 cm of
the fibula to support the lateral mal-
leolus. A Gigli saw is usually used
to harvest the graft.
To harvest a vascularized fibular
graft, the peroneal vascular pedicle
is dissected proximally to its bifur-
cation from the tibial vessels. One
peroneal vein is ligated and divided.
The tourniquet is then deflated. Af-
ter blood flow to the fibula has been
confirmed, the peroneal artery and
the peroneal vein are clipped and
divided, leaving as long a pedicle
on the fibula as possible.
11
Technical
Recommendations
Anterior Iliac Crest
The anterior ilium is approached
by a skin incision made parallel and

just above or below the iliac crest,
beginning at least 3 cm posterior to
the ASIS to avoid injury to the lateral
femoral cutaneous nerve. A direct
8 cm
3 cm
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.
Bone-Graft Harvesting
Journal of the American Academy of Orthopaedic Surgeons
214
skin incision over the iliac crest
should be avoided, as it may result
in a painful scar postoperatively.
The length of the skin incision de-
pends on the size of the bone graft
to be taken.
After retraction of the skin and
identification of the superior border
of the iliac crest, a cut directly down
to the bone on the middle of the
superior border of the iliac crest is
carried out with an electrocautery
device. A subperiosteal dissection
over the medial and lateral edges of

the iliac crest and down to the inner
and outer tables of the ilium avoids
injury to the ilioinguinal and ilio-
hypogastric nerves. To avoid avul-
sion of the ASIS, bicortical or tricor-
tical grafts should be taken from an
area at least 3 cm posterior to the
ASIS. After harvesting of the bone
graft, the medial periosteum, along
with the fascia of the abdominal
muscles, and the lateral periosteum,
along with the gluteal fascia, are re-
paired over the defect in the iliac
crest.
Posterior Iliac Crest
The posterior ilium can be ap-
proached by a vertical incision paral-
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
should be avoided because this will
injure the superior cluneal nerves.
After retraction of the skin and sub-
cutaneous fat, the iliac crest proximal
to the PSIS is identified. Dissection

directly down to the bone at the
middle of the superior border of the
iliac crest is then made with an elec-
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
bone graft. Violation of the sacroiliac
joint can be avoided by limiting the
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
artery.
12
With the patient lying
prone on the operating table, the
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
has been harvested, the reflected
gluteal fascia is securely sutured to
the periosteum and the dorsolumbar
fascia.
When performing a lower lum-
bar fusion, posterior iliac graft can
be harvested either by making an-
other separate incision or by using
the same incision and dissecting in
the fascial plane. Some studies
have shown no difference in mor-
bidity between one incision and
two incisions; other studies have
shown that the rate of complica-
tions is related to the use of sepa-
rate incisions. A potential disad-
A B
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).
ASIS
PSIS
ASIS
PSIS
Iliac
muscle
Nabil A. Ebraheim, MD, et al
Vol 9, No 3, May/June 2001
215
vantage of harvesting the graft from

the same incision is that, if the ex-
posure is limited, less graft material
may be harvested.
As there is no difference in the
quality or quantity of the bone
between the right and left sides, the
decision about the side from which
the graft is to be harvested should
be based on whether the patient
has a symptomatic sacroiliac joint.
If so, it is logical to harvest the graft
from the symptomatic side, to avoid
morbidity on the asymptomatic
side.
Regardless of the type of bone
graft harvested, the exposed cancel-
lous bone surface should be carefully
filled with bone wax or absorbable
gelatin sponge after irrigation. He-
mostasis is important to avoid hema-
toma and infection at the donor site.
Sasso et al
13
conducted a prospective
randomized study to assess the
effectiveness of postoperative suc-
tion drainage at the iliac donor site.
Their findings suggested that rou-
tine use of suction drainage is not
necessary.

Iliac Donor-Site
Complications
The reported iliac donor-site compli-
cations after bone-graft harvesting
include pain,
1,14-16
neurovascular
injury,
12,17-22
avulsion fractures of the
ASIS,
23,24
hematoma,
14,15
infection,
1
herniation of abdominal contents,
25,26
gait disturbance,
1,27
cosmetic defor-
mity,
1
instability of the sacroiliac
joint,
28
and ureteral injury.
21
Donor-Site Pain
Donor-site pain is the most com-

mon complaint after surgery and
often interferes with early mobi-
lization. The reported incidence of
donor-site pain, defined as persis-
tent pain at least 3 months after
surgery, varies greatly, ranging from
2.8% to 17% in recent series.
14,15
The
precise cause of donor-site pain re-
mains unclear. It may be muscular
or periosteal secondary to the strip-
ping of the abductors from the ilium,
or it may be related to injury of the
superior cluneal nerves.
1,16
Goulet
et al
29
found that the incidence of
donor-site pain was higher for pa-
tients who underwent graft harvest-
ing for spine surgery than for those
in whom the graft was harvested for
surgery not involving the spine.
Summers and Eisenstein
16
found
that an unsatisfactory outcome from
spine fusion was associated with a

significantly higher (P<0.001) preva-
lence of donor-site pain. The associ-
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,
numbness, and dysesthesias in the
distribution of the affected nerve.
Damage to the nerves adjacent to the
ilium most likely results from direct
transection or excessive traction.
The lateral femoral cutaneous nerve
is at risk for injury during harvest-
ing of anterior iliac bone.
17,18
The
superior cluneal nerves are more
vulnerable to injury during harvest-
ing of posterior iliac bone.
5,6
The
ilioinguinal, iliohypogastric, superior
gluteal, sciatic, and femoral nerves
are also potentially at risk. Sensory
nerve injuries that result in neuroma

formation can be treated by either
injection or resection.
Vascular Injury
Vascular injury is a rare but seri-
ous complication. Kahn
12
first re-
ported two cases of superior gluteal
artery laceration secondary to poste-
rior iliac bone harvesting. Another
three cases have subsequently been
reported.
19,22
False aneurysm and
arteriovenous fistula of the superior
gluteal vessels after removal of bone
grafts have also been reported.
20,21
Harvesting iliac bone too close to
the greater sciatic notch and im-
proper placement of the Taylor re-
tractor in the greater sciatic notch
are the main reasons for injury to the
A B
Figure 6 A, Harvesting of a tricortical bone graft. B, Subcrestal-window technique.
ASIS
PSIS
Subcrestal
window
3 cm

Bone-Graft Harvesting
Journal of the American Academy of Orthopaedic Surgeons
216
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
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
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
has been reported.
23,24
A stress riser
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.
To avoid this complication, bicorti-
cal or tricortical grafts should be

taken from an area no closer to the
ASIS than 3 cm. Older female pa-
tients with osteopenic bone are more
likely to have iliac graft-site fracture;
therefore, particular care should be
taken with this population.
Violation of the Sacroiliac Joint
Involvement of the sacroiliac joint
secondary to posterior iliac bone-
graft harvesting may occur because
of the complicated anatomy of the
area, the large amount of bone graft
needed for spine surgery, thin cor-
tices, and limited visualization due
to the bleeding from exposed cancel-
lous bone. Although violation of the
sacroiliac joint is not uncommon, it
may be occult, necessitating com-
puted tomography (CT) for diagnosis.
Coventry and Tapper
28
reported six
cases of an unstable sacroiliac joint
after removal of bone grafts from the
posterior iliac crest. This complica-
tion results from damage to the pos-
terior sacroiliac ligaments. Violation
may involve the ligamentous or sy-
novial parts of the joint, resulting in
arthritic changes and subsequent per-

sistent sacroiliac joint pain (Fig. 7).
The diagnosis of sacroiliac joint pain
after violation requires an index of
suspicion, as the symptoms may be
vague and indistinguishable from
those of the primary spinal disorder.
Injection of local anesthetic into the
sacroiliac joint may be helpful in
confirming the site of pain. Fusion
of the sacroiliac joint may be neces-
sary if the pain is persistent.
Hernia
Herniation of abdominal contents
through an iliac bone-graft donor
site may occur if the defect is large
and the adjacent muscles are not
carefully repaired.
25,26
Symptoms
include abdominal pain and a mass
with bowel sounds. The diagnosis
may be confirmed with a CT scan.
Treatment follows the principles
of surgery for hernias—reduction
of the hernia contents and oblitera-
tion of the defect. Three operations
have been described. The first is a
soft-tissue repair that includes
advancement of the muscles and
fascia, imbrication, and fascial

flaps. The second supplements
these with a mesh. The third, origi-
nally described by Bosworth,
30
changes the profile of the involved
iliac crest so as to recontour the
bone defect created by the graft
harvesting. Initially, the iliac crest
is straightened by removing the
remaining parts on both sides of
the defect. This is followed by mo-
bilization of the fascial insertion
of the transverse and the external
and internal oblique muscles so
that they can be attached directly to
the ilium along the new crest. The
ASIS must also be transported dis-
tally and posteriorly, which draws
the muscular, ligamentous, and fas-
cial structures tightly across the
defect.
26,30
Hematoma
Hematoma has been cited as a
complication of iliac bone-graft har-
vesting, which may result in infec-
tion. The reported incidence of he-
matoma formation is very low in
recent series.
14,15

Bleeding from the
exposed cancellous bone or injury to
the vessels adjacent to the anterior
ilium, such as the deep circumflex
iliac, iliolumbar, and fourth lumbar
vessels, may result in hematoma for-
mation. Measures that help decrease
this risk include restricting the expo-
sure to a strictly subperiosteal loca-
tion, obtaining hemostasis before clo-
sure, and using a suction drain.
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
during posterior iliac bone-graft harvesting.
Nabil A. Ebraheim, MD, et al
Vol 9, No 3, May/June 2001
217
Gait Disturbance
Gait disturbance manifested as a
limp or abductor lurch is a potential
problem secondary to harvesting of
the bone graft from the posterior
iliac region.
1,27
This problem results
from weakness of the hip abductors
(mainly the gluteus medius muscle)
caused by excessive stripping dur-
ing the exposure. This complication
can be prevented by securely reap-

proximating the gluteal fascia to the
periosteum of the iliac crest.
Infection
Infection at the donor site occurs
in approximately 1% of patients (i.e.,
about the same rate as in other clean
orthopaedic cases).
1
Treatment of in-
fection includes irrigation, debride-
ment, and antibiotic therapy. Mea-
sures that can be taken to reduce the
risk of infection include periopera-
tive antibiotic administration, use of
separate instruments to avoid conta-
mination from other potentially in-
fected sites, meticulous hemostasis,
and use of newer techniques utiliz-
ing trephines to avoid muscle strip-
ping and thereby reduce soft-tissue
morbidity.
Other Complications
Other complications associated
with iliac bone-graft harvesting are
cosmetic deformity and ureteral in-
jury. The defect that results from
harvesting a large tricortical bone
graft may cause cosmetic deformity.
1
A variety of techniques have been

utilized in an attempt to eliminate
the defect, among them the use of
ceramic spacers, calcium sulfate, and
bone morphogenetic protein. Injury
to the ureter during harvesting of a
posterior iliac bone graft is extreme-
ly rare; only one such case has been
reported in the literature. This in-
jury is caused by extensive electro-
cauterization in the greater sciatic
notch with the intent of controlling
massive bleeding from the superior
gluteal vessels.
21
Fibular Donor-Site
Complications
Potential complications of fibular
graft harvesting include neurovas-
cular injury, compartment syn-
drome, weakness of the extensor
hallucis longus, and ankle instabil-
ity.
2,11
In the proximal third of the
fibula, the peroneal nerves and their
muscular branches are at primary
risk. The extensor hallucis longus is
susceptible to denervation because it
is generally supplied by only one
branch from the deep peroneal

nerve.
2
In the middle third of the
fibula, the peroneal vessels are the
major structures at risk. Harvesting
the distal 10 cm of the fibula should
be avoided, as it will result in ankle
instability.
Vail and Urbaniak
11
studied
donor-site morbidity after harvest-
ing of vascularized fibular grafts.
Muscle weakness was noted in 25
(10%) of the 247 limbs at 3 months
after graft harvesting and in 2 (3%)
of the 74 limbs that were evaluated
at 5 years or more. The incidence of
pain at the ankle joint was 1.6% at 3
months but increased to 11.5% at 5
years. The prevalence of subjective
sensory abnormalities increased
from 4.9% at 3 months postopera-
tively to 11.8% at 5 years.
Gore et al
31
studied 41 patients
who underwent fibular bone-graft
harvesting. At an average follow-
up interval of 27 months (range, 19

to 35 months), 24 patients (58%)
were pain-free, 11 (27%) had mild
pain, and 6 (15%) had moderate or
severe pain. There were no differ-
ences in the range of motion of the
ankle and subtalar joints between
the operated and nonoperated sides.
The average muscle strength was
lower on the operated side, but this
difference was statistically signifi-
cant (P<0.01) only for ankle ever-
tors in men.
Summary
Knowledge of the surgical anatomy
of the ilium and fibula, the harvest-
ing techniques, and the potential
complications of obtaining bone
graft can decrease the morbidity of
the procedure. Harvesting of bone
graft is an apparently simple proce-
dure, but may result in numerous
complications. Selection of the graft
site, approach, and technique should
be tailored to the type and quantity
of the graft desired. The choice be-
tween autologous graft and other
materials can best be made with an
understanding of the risks and bene-
fits of each technique.
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