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Learn the Bone graft harvest: Iliac crest surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Bone graft harvest: Iliac crest surgical procedure.
There are many options available for filling bone defects operatively, and the first question to be asked is whether the primary stability given by structural graft is needed or whether simply “space-filling” morcellised graft will do.
If primary stability is required the next question is whether the situation will be manageable with iliac crest autograft. Where smaller defects need to be reconstructed with an element of structural stability, then the iliac crest is the main “go to” option, for example:
Hallux Rigidus: Revision of failed replacement with bone block MTP fusion (Wright Ortholoc plate)
Hallux Rigidus: First MTP Fusion, revision of failed Kellers using DocPrice plate and vascularised allograft.
Iliac crest autograft also has an excellent track-record in stabilising the shoulder, as detailed in our instructional techniques:
Arthroscopic Endobutton bone block stabilisation of shoulder with iliac crest graft (Smith and Nephew)
Anterior shoulder stabilisation using arthroscopically introduced bone block and Arthrex TightRopes-RT
If larger amounts of structural autograft bone are required then this will likely need to be with a vascularised allograft, often harvested from the fibula:
Intercalary humeral excision and allograft reconstruction with vascularised fibula (the Capanna technique)
Another option for large defects where structural stability is required is the use of massive allograft, from cadaveric donors:
Distal femoral Shark bite resection of an osteosarcoma and allograft reconstruction using Patient Specific Instrumentation (PSI, Ossis Orthopaedics)
Bone transport techniques are also useful in post-traumatic situations, both using frames and over intra-medullary nails, where stability is required and bone defects are large:
Femoral shaft fracture: Open femoral fracture bone defect treated with the Precice Bone Transport Nail (Nuvasive)
Alternatively, if immediate stability is required then in certain anatomical locations a metallic cage that osseo-integrates and can be filled with morcellised graft may suffice:
Tibio-talo-calcaneal(double) fusion using 4WEB custom talar replacement and Oxbridge nail (OrthoSolutions)
Anterior Cervical Discectomy and Fusion using the DePuy Zero-P VA cage
Transforaminal Interbody Lumbar Fusion (TILF) for impending cauda equina syndrome: Navigated Medtronic Solera Pedicle Screws Insertion and Globus ALTERA Interbody cage
Increasingly, though for in the main non-structural defects, engineered bone substitutes also have a role to play. They are used for smaller joints where structural correction is required, or just as space filling substances that encourage osseoconduction.
Pes Planus correction: Lateral column lengthening and medial column fusion ( over-corrected club foot deformity)
Allograft can be structural, as detailed above with massive allografts. More commonly it is taken from femoral heads, a bi-product of total hip replacement, and can yield smaller structural elements or just large bone chips to fill defects that are stabilised by additional means:
Supra-malleolar distal tibial osteotomy: Medial opening wedge with Arthrex plate.
Total Hip replacement (revision): Direct exchange to Rimfit socket (Stryker) with X-change Rim-Mesh (Stryker) and impaction bone grafting
There are a number of other areas where autograft can straightforwardly be harvested from including the proximal and distal tibial metaphysis, calcaneous, distal radius and the proximal femur. The iliac crest is however one of the most utilitarian sites and its harvesting should be second nature to all orthopaedic surgeons. There are some straightforward steps to adhere to, to make this a rapid, reproducible and safe procedure, as detailed in this technique.
Author: Mark Herron FRCS
Institution:
Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.
In the USA contact: fda.gov
In the UK contact: gov.uk
In the EU contact: ema.europa.eu
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