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Spontaneous posterior iliac crest regeneration enabling second bone graft harvest; a case report.

ABSTRACT: We present a case of a revision spinal fusion in which successful bone graft reharvesting was performed from the posterior iliac crest 4 years after initial intracortical harvesting. To date, only anterior iliac crest regeneration has been reported in orthopedic trauma patients. A 70-year-old man with a history of two prior instrumented lumbar fusion operations developed thoracolumbar kyphosis junctional to the lumbosacral fusion mass. His first operation was an instrumented posterolateral lumbar fusion L1 to L5, where bone graft was harvested from the right iliac crest using the intracortical harvesting technique. The second procedure was performed 18 months later and consisted of an extension of the fusion to the sacrum due to L5-S1 level derived symptoms. The bone graft for this procedure was taken with the same technique from the left iliac crest. The development of thoracolumbar junctional kyphosis necessitated the third operation, which consisted of a same-day anterior-posterior extension of the fusion to T10. Prior to this third procedure, a spinal computer tomography was performed that documented regeneration of the cancellous bone in the right iliac crest. This permitted reharvesting of almost 40 ml of cancellous bone using the intracortical bone harvesting technique from the right iliac crest. Histological analysis showed mature bone. Cancellous bone regeneration and restoration of the local anatomy of the ilium are possible after intracortical bone harvesting. This regeneration can provide autologous bone graft to assist fusion in subsequent operations.

SUBMITTER: Papadopoulos EC

PROVIDER: S-EPMC2744760 | biostudies-other | 2009 Sep

REPOSITORIES: biostudies-other

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Project description:BackgroundAutogenous Iliac Crest Bone Graft (ICBG) has been the "gold standard" for spinal fusion. However, bone graft harvest may lead to complications, such as chronic pain, numbness, and poor cosmesis. The long-term impact of these complications on patient function and well-being has not been established but is critical in determining the value of expensive bone graft substitutes such as recombinant bone morphogenic protein. We thus aimed to investigate the long-term complications of ICBG. Our second aim was to evaluate the psychometric properties of a new measure of ICBG morbidity that would be useful for appropriately gauging spinal surgery outcomes.MethodsProspective study of patients undergoing spinal fusion surgery with autologous ICBG. The SF-36v2, Oswestry Disability Index, and a new 14-item follow-up questionnaire addressing persistent pain, functional limitation, and cosmesis were administered with an 83% response rate. Multiple regression analyses examined the independent effect of ICBG complications on physical and mental health and disability.ResultsThe study population included 170 patients with a mean age of 51.1 years (SD = 12.2) and balanced gender (48% male). Lumbar fusion patients predominated (lumbar = 148; cervical n = 22). At 3.5 years mean follow-up, 5% of patients reported being bothered by harvest site scar appearance, 24% reported harvest site numbness, and 13% reported the numbness as bothersome. Harvest site pain resulted in difficulty with household chores (19%), recreational activity (18%), walking (16%), sexual activity (16%), work activity (10%), and irritation from clothing (9%). Multivariate regression analyses revealed that persistent ICBG complications 3.5 years post-surgery were associated with significantly worse disability and showed a trend association with worse physical health, after adjusting for age, workers' compensation status, surgical site pain, and arm or leg pain. There was no association between ICBG complications and mental health in the multivariate model.ConclusionChronic ICBG harvest site pain and discomfort is reported by a significant percentage of patients undergoing this procedure more than three years following surgery, and these complications are associated with worse patient-reported disability. Future studies should consider employing a control group that does not include autologous bone graft harvest, e.g., a group utilizing rhBMP, to determine whether eliminating harvest-site morbidity does indeed lead to observable improvement in clinical outcome sufficient to justify the increased cost of bone graft substitutes.

Project description:BackgroundPosterior open-wedge osteotomy and glenoid reconstruction using a J-shaped iliac crest bone graft showed promising clinical results for the treatment of posterior instability with excessive glenoid retroversion and posteroinferior glenoid deficiency.PurposeTo evaluate the biomechanical performance of the posterior J-shaped graft to restore glenoid retroversion and posteroinferior deficiency in a cadaveric shoulder instability model.Study designControlled laboratory study.MethodsA posterior glenoid open-wedge osteotomy was performed in 6 fresh-frozen shoulders, allowing the glenoid retroversion to be set at 0°, 10°, and 20°. At each of these 3 preset angles of glenoid retroversion, the following conditions were simulated: (1) intact joint, (2) posterior Bankart lesion, (3) 20% posteroinferior glenoid deficiency, and (4) posterior J-shaped graft (at 0° of retroversion). With the humerus in the Jerk position (60° of glenohumeral anteflexion, 60° of internal rotation), stability was evaluated by measuring posterior humeral head (HH) translation (in mm) and peak translational force (in N) to translate the HH over 25% of the glenoid width. Glenohumeral contact patterns were measured using pressure-sensitive sensors. Fixation of the posterior J-graft was analyzed by recording graft micromovements during 3000 cycles of 5-mm anteroposterior HH translations.ResultsReconstructing the glenoid with a posterior J-graft to 0° of retroversion significantly increased stability compared with a posterior Bankart lesion and posteroinferior glenoid deficiency in all 3 preset degrees of retroversion (P < .05). There was no significant difference in joint stability comparing the posterior J-graft with an intact joint at 0° of retroversion. The posterior J-graft restored mean contact area and contact pressure comparable with that of the intact condition with 0° of retroversion (222 vs 223 mm2, P = .980; and 0.450 vs 0.550 MPa, P = .203). The mean total graft displacement after 3000 cycles of loading was 43 ± 84 µm, and the mean maximal mediolateral graft bending was 508 ± 488 µm.ConclusionBiomechanical analysis of the posterior J-graft demonstrated reliable restoration of initial glenohumeral joint stability, normalization of contact patterns comparable with that of an intact shoulder joint with neutral retroversion, and secure initial graft fixation in the cadaveric model.Clinical relevanceThis study confirms that the posterior J-graft can restore stability and glenohumeral loading conditions comparable with those of an intact shoulder.

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Spontaneous posterior iliac crest regeneration enabling second bone graft harvest; a case report.

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