Elsevier

Injury

Volume 42, Supplement 2, September 2011, Pages S3-S15
Injury

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: A systematic review

https://doi.org/10.1016/j.injury.2011.06.015Get rights and content

Abstract

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the ‘gold standard’ and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p = 0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p = 0.016), haematoma formation (p = 0.002), fracture (p = 0.017), and hyperthrophic scar (p = 0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p = 0.004) and sensory disturbances (p = 0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Introduction

Autologous bone is considered to be the “gold standard” bone grafting material as it combines all properties required in a bone graft material: osteoinduction (BMPs and other growth factors), osteogenesis (osteoprogenitor cells) and osteoconduction (scaffold).1 It is widely used in a number of orthopaedic and oral and maxillofacial procedures for augmentation and acceleration of bone regeneration (fusion, non-union, fracture and osteotomy healing) or restoration of bony defects (traumatic, congenital, following tumour or infection). Harvested from the patient itself, autologous bone is histocompatible and nonimmunogenic, thus reducing to the minimum immunoreactions and transmission of infections.

Iliac crest bone graft (ICBG) is by far the most commonly used autologous bone graft compared to other alternative donor sites, such as the proximal tibia, distal femur, fibula, ribs and distal radius. It can be harvested from the anterior or the posterior iliac crest. Its main advantages include the availability of a fair bone quantity of bone graft (cancellous, cortico-cancellous or vascularised) with progenitor cells and growth factors, and structural support when tricortical graft is used.1, 2 Although iliac crest bone harvesting is a frequently performed surgical procedure with relatively easy access, its complications have been well documented in the literature with a wide range of morbidity rate and a number of various complications, including infection, haematoma/seroma, fracture, nerve and vascular injuries, chronic donor site pain, hernias, unsightly scars and poor cosmetic outcome.3, 4The intramedullary canal of long bones represents another potential donor site for autologous bone graft and a rich source of cells and growth factors.2, 5, 6 A relatively new device, the Reamer/Irrigator/Aspirator system (RIA) (Synthes Inc., West Chester, PA) although initially developed to simultaneous ream and aspirate the reaming debris to reduce the intramedullary pressure, heat generation and systemic effects seen during the traditional reaming process,7, 8, 9 it has been recently used to harvest bone graft from the intramedullary canal of the femur or the tibia. It provides larger volumes of autologous graft (25–90 cm3) compared to anterior ICBG (5–72 cm3); at least similar volumes when compared to posterior ICBG (25–88 cm3) and in younger individuals it may provide even larger volumes than posterior ICBG. It has been reported to have minimal complications, less pain post-harvesting and possibly a shorter harvest time compared to anterior and posterior ICBG harvesting.10 However, complications following RIA intramedullary harvesting such as cortical perforation and fracture have also been reported within the few articles published regarding this technique.10, 11, 12, 13, 14

The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) as well as from the intramedullary canal using the RIA device, in an effort to evaluate their overall reported complication rates and assess whether there is a difference in their morbidity as bone harvesting methods. By over viewing the recent literature, recommendations are made aiming to reduce morbidity from these harvesting procedures. An effort to assess the impact of ICBG harvesting in length of hospital stay (LOS) in non-orthopaedic procedures was also undertaken.

Section snippets

Literature search

We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles reporting on the clinical use of the RIA device and on the use of iliac crest (anterior and posterior) as a harvesting site for autologous bone graft for a number of orthopaedic, oral and maxillofacial procedures. The bibliographies of identified articles were manually searched, as well as the “related articles” options in PubMed Medline. The search was restricted to

Literature search

After the initial electronic search, 157 articles were yielded as potentially eligible, based on the title and the abstract. After obtaining the full text, a total of 92 articles were found to fulfil the inclusion criteria.3, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79

Discussion

Autologous bone grafting is a well established worth full tool in the armamentarium of various surgical specialties to fill skeletal defects secondary to tumours, infections, trauma, or congenital malformations; and to promote joint and spine fusion or union at the site of delayed unions, non-unions, fractures, or osteotomies; since Albee's published report for intra-articular arthrodesis of the hip for painful arthritis back in 1908.102 It is a commonly performed surgical procedure, especially

Conclusion

The number of bone regeneration procedures will continue to increase worldwide.126, 127, 128, 129 For biological enhancement of impaired fracture healing or restoration of bone defects, autologous bone graft harvesting from the iliac crest remains the ‘gold standard’.

This systematic review analysed a large cohort of patients from different studies and presented an overview of complications following ICBG harvesting. Moreover, various issues regarding the harvesting methods and how to minimise

Conflict of interest

All authors of the submitted manuscript entitled: “Complications following autologous bone grafting from the iliac crest and RIA: a systematic review” declare that they have no conflicts of interest.

References (129)

  • Z.H. Baqain et al.

    Morbidity from anterior iliac crest bone harvesting for secondary alveolar bone grafting: an outcome assessment study

    J Oral Maxillofac Surg

    (2009)
  • C. Ulucay et al.

    Surgical treatment for calcaneal intraosseous lipomas

    Foot

    (2009)
  • D.H. Kim et al.

    Prospective study of iliac crest bone graft harvest site pain and morbidity

    Spine J

    (2009)
  • M.A. Rawashdeh

    Morbidity of iliac crest donor site following open bone harvesting in cleft lip and palate patients

    Int J Oral Maxillofac Surg

    (2008)
  • G.R. Buttermann

    Prospective nonrandomized comparison of an allograft with bone morphogenic protein versus an iliac-crest autograft in anterior cervical discectomy and fusion

    Spine J

    (2008)
  • R.J. Mobbs et al.

    Anterior cervical discectomy and fusion: analysis of surgical outcome with and without plating

    Clin Neurosci

    (2007)
  • R.A. Rogachefsky et al.

    The use of tricorticocancellous bone graft in severely comminuted intra-articular fractures of the distal radius

    J Hand Surg

    (2006)
  • M.M. Freilich et al.

    Ambulatory in-office anterior iliac crest bone harvesting

    Oral Surg Oral Med Oral Pathol Oral Radiol Endod

    (2006)
  • M.C. Swan et al.

    Morbidity at the iliac crest donor site following bone grafting of the cleft alveolus

    Br J Oral Maxillofac Surg

    (2006)
  • P. Kessler et al.

    Harvesting of bone from the iliac crest – comparison of the anterior and posterior sites

    Br J Oral Maxillofac Surg

    (2005)
  • H. Eufinger et al.

    Iliac crest donor site morbidity following open and closed methods of bone harvest for alveolar cleft osteoplasty

    J Craniomaxillofac Surg

    (2000)
  • S.D. Schulhofer et al.

    Iliac crest donor site morbidity in foot and ankle surgery

    J Foot Ankle Surg

    (1997)
  • J.C. Beirne et al.

    Donor site morbidity of the anterior iliac crest following cancellous bone harvest

    Int J Oral Maxillofac Surg

    (1996)
  • K.H. Dawson et al.

    Pain following iliac crest bone grafting of alveolar clefts

    J Craniomaxillofac Surg

    (1996)
  • W.W. Kalk et al.

    Morbidity from iliac crest bone harvesting

    J Oral Maxillofac Surg

    (1996)
  • T.W. Bauer et al.

    Bone graft materials. An overview of the basic science

    Clin Orthop Relat Res

    (2000)
  • E. Ahlmann et al.

    Comparison of anterior and posterior iliac crest bone graft in terms of harvest-site morbidity and functional outcomes

    J Bone Joint Surg Am

    (2002)
  • E.M. Younger et al.

    Morbidity at bone graft donor sites

    J Orthop Trauma

    (1989)
  • F. Hoegel et al.

    Bone debris: dead matter or vital osteoblasts

    J Trauma

    (2004)
  • P.R. Stafford et al.

    Reamer–irrigator–aspirator as a bone graft harvester

    Tech Foot Ankle Surg

    (2007)
  • T.F. Higgins et al.

    Cortical heat generation using an irrigating/aspirating single-pass reaming vs conventional stepwise reaming

    J Orthop Trauma

    (2007)
  • H.C. Pape et al.

    Reamed femoral nailing in sheep: does irrigation and aspiration of intramedullary contents alter the systemic response?

    J Bone Joint Surg Am

    (2005)
  • J.A. Lowe et al.

    Complications associated with negative pressure reaming for harvesting autologous bone graft: a case series

    J Orthop Trauma

    (2010)
  • M.A. Miller et al.

    Autologous bone grafting on steroids: preliminary clinical results. A novel treatment for nonunions and segmental bone defects

    Int Orthop

    (2010)
  • A.J. Quintero et al.

    Technical tricks when using the reamer–irrigator–aspirator technique for autologous bone graft harvesting

    J Orthop Trauma

    (2010)
  • M.V. Belthur et al.

    Bone graft harvest using a new intramedullary system

    Clin Orthop Relat Res

    (2008)
  • J.T. Newman et al.

    A new minimally invasive technique for large volume bone graft harvest for treatment of fracture nonunions

    Orthopedics

    (2008)
  • T.A. Nichols et al.

    An alternative source of autograft bone for spinal fusion: the femur: technical case report

    Neurosurgery

    (2008)
  • C.G. Zalavras et al.

    Novel technique for medullary canal débridement in tibia and femur osteomyelitis

    Clin Orthop Relat Res

    (2007)
  • J. Bellapianta et al.

    Use of the reamer irrigator aspirator for the treatment of a 20-year recurrent osteomyelitis of a healed femur fracture

    J Orthop Trauma

    (2007)
  • Z. Ito et al.

    Bone union rate with autologous iliac bone versus local bone graft in posterior lumbar interbody fusion

    Spine

    (2010)
  • P. Kloen et al.

    Treatment of diaphyseal non-unions of the ulna and radius

    Arch Orthop Trauma Surg

    (2010)
  • C. Schizas et al.

    Impact of iliac crest bone graft harvesting on fusion rates and postoperative pain during instrumented posterolateral lumbar fusion

    Int Orthop

    (2009)
  • C.E. Schwartz et al.

    Prospective evaluation of chronic pain associated with posterior autologous iliac crest bone graft harvest and its effect on postoperative outcome

    Health Qual Life Outcomes

    (2009)
  • T. Lerner et al.

    A level-1 pilot study to evaluate of ultraporous beta-tricalcium phosphate as a graft extender in the posterior correction of adolescent idiopathic scoliosis

    Eur Spine J

    (2009)
  • J. Borrelli et al.

    Tricortical bone grafts for treatment of malaligned tibias and fibulas

    Clin Orthop Relat Res

    (2009)
  • H.M. Heneghan et al.

    Use of autologous bone graft in anterior cervical decompression: morbidity & quality of life analysis

    BMC Musculoskelet Disord

    (2009)
  • O. Pieske et al.

    Autologous bone graft versus demineralized bone matrix in internal fixation of ununited long bones

    J Trauma Manag Outcomes

    (2009)
  • J.R. Singh et al.

    Long-term functional outcome and donor-site morbidity associated with autogenous iliac crest bone grafts utilizing a modified anterior approach

    Bull NYU Hosp Jt Dis

    (2009)
  • M. Putzier et al.

    Allogenic versus autologous cancellous bone in lumbar segmental spondylodesis: a randomized prospective study

    Eur Spine J

    (2009)
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