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