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. References 1. Kurz LT, Garfin SR, Booth RE Jr: Harvesting autogenous iliac bone grafts: A review of complications and techniques. Spine 1989;14:1324-1331. 2. Rupp RE, Podeszwa D, Ebraheim NA: Danger zones associated with fibular osteotomy. J Orthop Trauma 1994;8:54-58. 3. Ebraheim NA, Yang H, Lu J, Biyani A, Yeasting RA: Anterior iliac crest bone graft: Anatomic considerations. Spine 1997;22:847-849. 4. Rupp RE, Ebraheim NA, Jackson WT: Anatomic and radiographic considera- tions in the placement of anterior pel- vic external fixator pins. Clin Orthop 1994;302:213-218. 5. Lu J, Ebraheim NA, Huntoon M, Heck BE, Yeasting RA: Anatomic considera- tions of superior cluneal nerve at pos- terior iliac crest region. Clin Orthop 1998;347:224-228. Bone-Graft Harvesting Journal of the American Academy of Orthopaedic Surgeons 218 6. Xu R, Ebraheim NA, Yeasting RA, Jackson WT: Anatomic considerations for posterior iliac bone harvesting. Spine 1996;21:1017-1020. 7. Stitgen SH, Cairns ER, Ebraheim NA, Niemann JM, Jackson WT: Anatomic considerations of pin placement in the proximal tibia and its relationship to the peroneal nerve. Clin Orthop 1992; 278:134-137. 8. Scott W, Petersen RC, Grant S: A method of procuring iliac bone by trephine curettage. J Bone Joint Surg Am 1949;31:860. 9. Wolfe SA, Kawamoto HK: Taking the iliac-bone graft: A new technique. J Bone Joint Surg Am 1978;60:411. 10. 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J Oral Surg 1981;39:676-677. 28. Coventry MB, Tapper EM: Pelvic instability: A consequence of remov- ing iliac bone for grafting. J Bone Joint Surg Am 1972;54:83-101. 29. Goulet JA, Senunas LE, DeSilva GL, Greenfield MLVH: Autogenous iliac crest bone graft: Complications and functional assessment. Clin Orthop 1997;339:76-81. 30. Bosworth DM: Repair of herniae through iliac-crest defects. J Bone Joint Surg Am 1955;37:1069-1073. 31. Gore DR, Gardner GM, Sepic SB, Mollinger LA, Murray MP: Function following partial fibulectomy. Clin Orthop 1987;220:206-210. . Trauma 1994; 8:5 4-58. 3. Ebraheim NA, Yang H, Lu J, Biyani A, Yeasting RA: Anterior iliac crest bone graft: Anatomic considerations. Spine 1997;2 2:8 47-849. 4. Rupp RE, Ebraheim NA, Jackson WT: Anatomic. 1992; 27 8:1 34-137. 8. Scott W, Petersen RC, Grant S: A method of procuring iliac bone by trephine curettage. J Bone Joint Surg Am 1949;3 1:8 60. 9. Wolfe SA, Kawamoto HK: Taking the iliac-bone graft:. Joint Surg Am 1978;6 0:4 11. 10. Jones AA, Dougherty PJ, Sharkey NA, Benson DR: Iliac crest bone graft: Os- teotome versus saw. Spine 1993;1 8: 2048-2052. 11. Vail TP, Urbaniak JR: Donor-site mor- bidity