Bone graft harvest: Iliac crest
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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:
Iliac crest autograft also has an excellent track-record in stabilising the shoulder, as detailed in our instructional techniques:
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:
Another option for large defects where structural stability is required is the use of massive allograft, from cadaveric donors:
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:
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:
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.
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:
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
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