Pelvic fracture: The iliac crest bone grafting complication
The iliac crest is a common site to harvest cancellous or cortical bone graft. Described complications include: pain at the operative site, nerve and arterial injury, peritoneal perforation, sacroiliac joint instability, herniation of abdominal contents through the defect in the ilium, and false aneurysms of the superior gluteal artery (1,2). Stress fractures of the ilium have also been described. This paper describes an unusual complication in which the iliac wing fractured two weeks after graft harvesting.
An 88-year-old female fell onto her outstretched hand and sustained an intra-articular, dorsally displaced left distal radius fracture with apex volar angulation (Figure l). She underwent arthroscopic assisted reduction and internal fixation with K-wires and application of an external fixator (Figure 2). Cancellous bone graft was harvested from the left iliac crest and placed in the fracture through a limited open approach to the dorsum of the wrist.
Figure 1) Preoperative posterior-anterior (PA) (top) and lateral (bottom) radiographs show the dorsally translated, apex volar angulated, shortened, distal radial fracture
Figure 2) Postoperative PA (top) and lateral (bottom) radiographs show restoration of the tilt of the articular surface to neutral and restoration of radial length with establishment of negative ulnar variance
Two weeks postoperatively, the patient was rising from a chair at home and experienced a feeling of motion in her gluteal region and intense pain was felt over the left hemipelvis. She had difficulty ambulating and a minimally displaced left iliac wing fracture was diagnosed (Figures 3,4). This healed in six weeks and the patient continues to ambulate normally.
Figure 3) AP pelvic radiograph of patient. The fracture through the ilium is seen (small arrows). The propagation of the fracture from the posterior osteotomy site is marked with the large arrow.
Figure 4) Diagram of the radiograph in Figure 3 showing the fracture (small arrows) and the propagation from the osteotomy site (large arrow)
Our method of harvesting cancellous bone graft involves an incision made parallel to the iliac crest starting 2 cm posterior to the anterior superior iliac spine. Dissection is carried down to the periosteum. Using straight osteotomes, a cortical cap is made in the crest and retracted to expose cancellous bone (Figure 5). After harvesting the graft, the cortical cap is replaced and periosteum repaired. A drain is placed and the wound is closed. This technique is well described in the literature (3).
Figure 5) Method of harvesting iliac crest bone graft. The cortical cap is hinged on the inner table and reflected to expose the cancellous bone to be harvested
The most common reported complications of iliac crest bone grafting include: pain in up to 15% of patients, lateral femoral cutaneous nerve injury in up to 10% of patients, hematoma formation in up to 10% of patients, gluteal gait in up to 3% of patients, and infections in less than 1% (4,5). Fracture of the iliac wing has not been reported before. The mechanism of the fracture appears to be propagation from the osteotomy site (Figures 3,4). The fracture did not extend into the acetabulum. This patient did have impaired bone structure which possibly contributed to the fracture of the iliac wing.
We recommend minimizing the depth of the osteotomy cuts to decrease the stress riser produced.
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