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Journal of Cranio-Maxillofacial Surgery (2000) 28, 3138

# 2000 European Association for Cranio-Maxillofacial Surgery


doi:10.1054/jcms.1999.0105, available online at http://www.idealibrary.com on

Iliac crest donor site morbidity following open and closed methods
of bone harvest for alveolar cleft osteoplasty
Harald Eunger, Heikki Leppanen
Department of Oral & Maxillofacial Surgery, Facial Plastic Surgery, Ruhr-University, Bochum, Germany
SUMMARY. Donor site morbidity after bone harvesting still remains a crucial problem in alveolar cleft
osteoplasty. This study focuses on ilium donor site morbidity comparing two dierent techniques. A series of 52
consecutive patients was divided in half. All had anterior iliac crest bone grafts. In the study group the harvesting
was performed with a closed osteotomy using a cylindrical Shepard osteotome. The control group underwent the
traditional open osteotomy.
In the open osteotomy group the short-term morbidity at the donor site was slightly greater than in the closed
harvesting group. The low short-term morbidity in the closed harvesting group was reected in the analgesic
consumption which was three times higher in the open osteotomy group ( p50.008). The most striking dierence
occurred in the appearance of the mature scar: a length of 24.2 mm (mean) in the closed harvesting group against
60.3 mm in the open osteotomy group ( p50.0001), and a width of 4.9 mm (mean) versus 7.7 mm, respectively
( p50.003). The long-term morbidity was negligible in both groups.
Based on these ndings we suggest that bone harvesting from the anterior iliac crest remains the preferred
method, provided that closed harvesting is undertaken. # 2000 European Association for Cranio-Maxillofacial
Surgery

INTRODUCTION

Kortebein et al., 1991; Sadove et al., 1990; SindetPedersen and Enemark, 1990; Thaller et al., 1991;
Wolfe and Berkowitz, 1983). Hence the mandibular
symphysis or the calvarial sites have been advocated
recently because of morbidity at these donor sites
should be considerably less than at the iliac crest
(Baehr and Coulon, 1996; Borstlap et al., 1990;
Harsha et al., 1986; Koole et al., 1989; Kortebein
et al., 1991; Sadove et al., 1990; Sindet-Pedersen and
Enemark, 1990; Wolfe and Berkowitz, 1983). However, among others, Canady et al. (1993) concluded
that the iliac crest is a suitable site to harvest
cancellous bone for alveolar defect grafting and
should not be rejected solely because of concerns
regarding excessive morbidity.
In 1984 Scott et al. presented a closed method of
procuring cancellous bone from the iliac crest with a
medium-sized curette via a 2.5 cm incision. The
authors had performed this procedure in 150 cases
without complications. Early ambulation was possible as muscle stripping was entirely eliminated. In
1985 Caddy and Reid described a similar technique
for secondary alveolar reconstruction. They used a
bone biopsy set to trephine cores of autogenous
cancellous bone from the ilium. The method was
tested rst in a cadaver and then applied in 10 clinical
cases. The authors found the aesthetic and functional
results at the donor site to be superior to the
conventional open osteotomy. Thaller et al. (1991)
also used a bone biopsy trephine. Relating their
experience from 24 patients they recommended this
technique when signicant reduction of donor site
morbidity is required. Furthermore it was to be

Autogenous bone grafting of the alveolar cleft is well


established. The prevailing consensus states that the
best results in alveolar bone grafting are achieved
when the procedure is performed prior to the
eruption of the permanent canine (Boyne and Sands,
1972; Kortebein et al., 1991). In Europe the procedure
is called `secondary alveolar osteoplasty' when it is
performed in the mixed dentition phase. Various
donor sites for alveolar cleft grafting have been
described and the preferred site has been a matter for
debate for many years. At present the main sources
for autogenous bone are iliac crest, calvarium and
mandibular symphysis. Numerous reports suggest
that autogenous bone graft harvesting of the ilium is
the gold standard with which all other types of
alveolar grafts should be compared (Canady et al.,
1993; van Damme and Merkx, 1996; Jackson et al.,
1986; Kalk et al, 1996; Kline and Wolfe, 1995;
Stoelinga et al., 1990). However, some authors have
suggested that the iliac crest donor site produces an
unacceptably high degree of postoperative morbidity,
such as persistent pain, prolonged recovery time,
haemorrhage, limping, visible scarring, bone contour
deformities, lesions of the lateral femoral cutaneous
nerve, meralgia paraesthetica, pelvic fracture and
peritonitis (Beirne et al., 1996; Borstlap et al., 1990;
Caddy and Reid, 1985; Dawson et al., 1996; Harsha
et al., 1986; Ilankovan et al., 1998; Koole et al., 1989;
This paper is dedicated to our teacher Prof. Dr Dr Egbert
Machtens on the occasion of his 65th birthday.
31

32 Journal of Cranio-Maxillofacial Surgery

performed as an outpatient procedure, and is


particularly suitable in Third World countries.
In 1987 Shepard and Dierberg developed a special
cylindrical osteotome for this purpose. Their aim was
to perform bone harvesting from the iliac crest with
minimum invasiveness using local anaesthesia. They
noted the disadvantage in the trephine devices of that
time, namely, that the bone graft was often left
attached as the instrument was withdrawn. To solve
this problem a cylindrical osteotome with luminal
tines was developed in order to separate the graft at
the tip of the osteotome when it is rotated. The
instrument set comprises four main parts: the rst is a
surface cutter designed to cut through the outer
cortical bone, the other three components are the
actual osteotomes with dierent diameters. The
instruments are able to remove bone cylinders of up
to 5 cm in length. Operative technique consists of
making a 2.5 cm incision over the iliac crest. The
authors used local anaesthesia in their series taking
care to inject beneath the periosteum. The incision
was made sharply down to the periosteum, and
retractors were used to expose the bone. The mallet
was then used to tap the cortex cutter about 0.5 cm
into the bone to remove a small cortical disk of it.
The cylindrical osteotome of appropriate diameter
was then driven into the cancellous bone with a
mallet. A 908 twist of the instrument separated the
rod of bone when the appropriate depth was
achieved. The cancellous bone cylinder was then
extracted. Several bone grafts may be harvested
through the initial plug hole by varying the direction
of the cylindrical osteotome (Fig. 1). After sucient
bone had been harvested, the cortical bone disk
was replaced and a standard wound closure was
performed (Shepard and Dierberg, 1987).
In 1995 this closed harvesting technique with the
instruments recommended by Shepard and Dierberg

(1987) was adopted in our department and has been


successfully used since then. The aim of this
study was to evaluate two dierent techniques
of harvesting anterior iliac crest bone, namely the
traditional open osteotomy and the closed technique.
Finally, a modication of the instruments used in our
closed bone harvesting procedure is described.
MATERIAL AND METHODS
During the period 199398, 52 patients with a
unilateral or bilateral cleft lip alveolus and palate
were operated on for reconstruction of the alveolar
process. Preoperative orthodontic transverse maxillary expansion and alignment of teeth was completed.
All 52 consecutive patients received alveolar bone
grafts from the anterior iliac crest. In bilateral cases
both sides were reconstructed simultaneously. The
prevalent open osteotomies of the hip gradually
decreased in our clinic as the closed bone harvesting
technique was newly adopted in the summer 1995.
Half of these patients had their iliac bone harvesting
performed with the open osteotomy, the remaining 26
patients underwent the closed harvesting method
using the Shepard osteotome (Shepard and Dierberg,
1987). With our main interest being the donor site
morbidity, this study did not record the graft success
rate, graft resorption, or tooth eruption at the
recipient site. Instead, operating time and technique,
postoperative pain medication, subjective pain sensation, complications, length and width of the mature
scar, bone contour decits and nerve paraesthesia
were recorded allowing short- and long-term morbidity to be compared in both patient groups.
In the traditional open osteotomy technique group
the male-female ratio was 15 : 11 and the mean age at
operation was 9.6 years (range 720 years). Nineteen

Fig. 1 Amount of bone that can be obtained from a child with the use of the 6 mm osteotome via a single incision. The closed harvesting
technique allows directional variation of the cylindrical osteotome between the cortical iliac plates from one crestal access site, producing a
further cancellous cylinder with each new insertion.

Donor site morbidity 33

patients had a unilateral and seven a bilateral cleft.


The bone harvesting was performed under general
anaesthesia. The donor site was located on the
anterior crest, well behind the anterior superior iliac
spine. An incision was made, in most cases lateral to
the crest with minimal undermining. The bone
harvesting was carried out using an osteotome or
an oscillating saw after the cartilage cap (pedicled)
had been reected medially or laterally. Often a sharp
spongiosa curettage would complete the procedure.
The sharp bony edges were smoothed and the crest
cap was sutured back into position. Finally haemostasis was achieved using bone wax or collagen
material. The soft tissues were closed in layers and
the skin with continuous sutures. A pressure dressing
with elastic tape was left in place, usually for 24 h.
Drains were often used in this group and in most
cases they were removed on the rst or second
postoperative day.
The second group comprised 26 patients whose
bone was harvested with a cylindrical trephine,
developed and described by Shepard and Dierberg
(1987). The malefemale ratio was 17 : 9 the mean
age at operation 12.2 years (range 831 years). A
unilateral cleft was treated in 21 cases and a bilateral
one in ve cases. In the closed harvesting procedure
the instrument was tapped into the bone through a
sucient opening in the soft tissue. When more bone
was required, the spongiosa cylinders were detached
in an arc like fashion. After harvesting, a layered soft
tissue closure was performed and a pressure dressing
was left in place for 24 h. In this group drains were
hardly ever used, a few had mini-vac wound drains
which were removed on the rst postoperative day.
In both groups the patients received prophylactic
perioperative penicillin (or clindamycin in case of
penicillin allergy). The postoperative care was similar
and consisted of daily hip wound cleansing and
removal of the skin sutures after approximately one
week. All patients were mobilized early, mostly on
the rst postoperative day, and discharged after
812 days. Supporting physiotherapy was oered
when needed. Patients received all necessary pain
relief on demand, which consisted of paracetamol 250
or 500 mg suppositories or pills.
The 52 patients were invited for an interview and
examination after a follow-up period varying between
1 and 6 years. Donor site morbidity was evaluated
using three methods:
1. A 3-page questionnaire with a patient interview,
which in its rst part dealt with immediate
postoperative donor site morbidity. The
experienced morbidity was estimated using a
graduated scale from 16, similar to the one
used at German schools, mark 1 being painfree
and mark 6 meaning extremely painful. The
present hip morbidity was evaluated to obtain
information about long-term morbidity and
was again scored on the scale 1 to 6 with 1
meaning very good, or normal compared with
the non-operated side, whilst 6 meant the worst

possible. The appearance of the hip wound was


also questioned using the same scale.
2. The mature scar length, width, unevenness,
colour, bone contour and skin sensibility
changes were recorded. Conspicuous and/or
palpable bone decits were noted.
3. A survey of the patient les yielded details of
diagnosis, operation date and time, the manner
by which the bone was obtained, intraoperative
problems, blood loss, wound closure, use of
drains, early postoperative measures, need for
pain relief, and supporting therapies. Any
complications were listed. Statistical analysis
of the numerical parameters obtained was
performed using the unpaired (two-tailed)
Student's t-test.
Our adaptation of the closed harvesting method
include minor modications: in contrast to the
original description of Shepard and Dierberg (1987)
we do not use retractors to expose the bone in order
to keep the incision even smaller. In addition, we nd
the 8 mm cortex cutter and the corresponding
osteotome too big to be used between the cortical
plates of children's ilia and instead we use the 6 mm
osteotome for both purposes, cortex cutting and graft
harvesting. However, in spite of the soft, mostly
cartilagenous bone cap in this age group, it was
feared that the osteotome might be damaged. Therefore a 6 mm osteotome was fabricated deliberately
for this indication and introduced in our set of
instruments. Other centres have successfully introduced dierent modications for the same purpose
(Hemprich, 1998). Finally, we prefer not to replace
the bone cap as we use it for grafting, especially to
support the nasal alar base.
RESULTS
The short-term hip morbidity in the open osteotomy
group yielded an average value of 2.5, estimated on a
scale of 16 (Table 1). The best value was 1 and the
worst 5. The female patients estimated their shortterm postoperative hip pain at 2.6 (mean), which
did not dier signicantly from the male patients.
Fourteen patients in this group found the alveolar
wound more painful than the hip donor site, 10
patients stated the opposite, and 2 felt there was no
dierence. Fifteen patients needed postoperative pain
relief which in most cases consisted of paracetamol
250 mg suppositories. Some patients required 500 mg
paracetamol suppositories which involved taking
250 mg dose as a calculating unit (CU) allowing
comparison of the absolute received dose between
both groups. Thus, in this group the overall analgesic
consumption was 40 CUs, i.e. 1.5 CUs as an average
dose per person. Fifteen patients needed postoperative physiotherapeutic support or crutches to mobilize. The average operation time was 2 h 50 min. The
present hip morbidity was estimated at 1.3 mean,
ranging from 1 to 3. One patient, (score 3), remarked

34 Journal of Cranio-Maxillofacial Surgery


Table 1 Summary of the important parameters and statistics for short-term and long-term morbidity in both patient groups
Short-term morbidity
Group

Open osteotomy

Closed harvesting

n
Hip pain rating
Physiotherapyy
Wound infection
Analgesics
Dose in CU
t-test for the CU-dierence: p50.008, considered very signicant

26 patients
2.5
15 patients
0
15 patients
40 CU

26 patients
2.1 (scale 16)
5 patients
1
5 patients
9 CU
Long-term morbidity

Group

Open osteotomy

Closed harvesting

Scar length (mean)


Min
Max
t-test for the scar length dierence: p50.0001, considered very signicant

60 mm
32 mm
100 mm

24 mm
10 mm
80 mm

Scar width (mean)


Min
Max
t-test for the scar width dierence: p50.003, considered very signicant
Present hip `feel'
Present hip looks
Iliac crest decit
Sensory alteration

that the hip wound site still hurts, and another


patient expressed a feeling of constant itching. A
pulling sensation and a clicking sound were occasionally reported by two other patients. The appearance of the hip donor site was assessed as 1.9 on
average, suggesting patient satisfaction. The average
mature scar length measured 60.3 mm with a minimum of 32 mm and a maximum of 100 mm. Average
scar width was 7.7 mm. Half of the patients in this
group had an unsightly hip scar with visible bony
contour attening or concavity, which was also
readily palpable.
In the closed bone harvesting patient group the
average short-term hip morbidity was assessed at 2.1,
with a range from 1 to 4 (Table 1). The female
patients estimated their postoperative hip pain at 2.0
which conforms with the overall result of this group.
Sixteen patients found that intraoral recipient site
more painful than the hip donor site, and 10 patients
the opposite. Only ve out of 26 patients needed
postoperative analgesics. The dosage paracetamol in
this group equals nine CUs with a calculated average
of 0.4 CUs per person. Crutches or supporting
physiotherapy were requested in ve cases. The
average operation time was 2 h. The present ndings
of the operated hip were rated at 1.1 (mean). Two
patients complained of occasional itching at the hip
donor site. One wound healing complication occurred
consisting of a local infection and seroma at the
donor site, which resolved during the rst postoperative week without further sequelae. The appearance of the hip donor site was rated at 1.5. Physical
examination revealed an average mature scar length
of 24.3 mm, (range 1080 mm), and a width of
4.9 mm (Fig. 2). No conspicuous bone contour

7.7 mm
2.0 mm
15 mm
1.3
1.9
0
0

4.9 mm
2.0 mm
11 mm
1.1 (scale 16)
1.5 (scale 16)
0
0

decits were observed. Approximately half of the


patients in this group had an invisible bony impression in the iliac crest corresponding with the puncture
site. This palpable bony dimple was no more than a
few millimetres in any case.
In both groups answers on short-term hip morbidity yielded surprisingly similar ratings, the average
estimate being 2.5 in the open osteotomy group, and
2.1 in the closed harvesting group, reecting low
short-term hip morbidity. Gender seemed to make no
dierence. Nevertheless, patients who underwent the
open osteotomy procedure found the short-term
morbidity of the donor site slightly greater than
those who had a closed harvesting. This dierence
was considered not statistically signicant ( p50.31).
Operation time was on average 50 minutes shorter in
the closed bone harvesting group. This cannot be
explained solely by the higher number of bilateral
osteoplasties in the open osteotomy group. The
retrospective comparison between the postoperative
donor site pain and the recipient site pain was also
very similar in both patient groups; 10 patients in
both groups found the short-term postoperative pain
worse in the hip than in the upper jaw. Marked
dierences appear when considering the amount of
analgesics consumed. In the open osteotomy group
15 out of 26 patients had postoperative pain relief,
whereas only 5 out of 26 patients in the closed group
requested analgesics. Expressed in comparable units
the dierence becomes even more remarkable; 40
CUs in the open osteotomy group versus 9 CUs
in the closed group which is considered a very
signicant dierence (p=0.008). Notable dierence
also occurred in the support requested during
postoperative mobilization, 15 patients in the open

Donor site morbidity 35

Fig. 2 A mature hip scar of a patient who underwent closed bone harvesting representing the common appearance.

osteotomy group needed physiotherapy, crutches or


even a wheel chair, whereas only 5 patients in the
closed group requested these. Regardless of the
harvesting technique used the patients' ndings about
the hip donor site were consistent. In the open
osteotomy group the average estimate concerning the
present feeling of the operated hip was valued at 1.3
and respectively 1.1 in the closed group. Little
divergence in ndings about the hip donor site
appearance occurred either; the open osteotomy
group gave the donor site looks 1.9 and the closed
bone harvesting group 1.5. These dierences were not
statistically signicant. Physical examination showed
mean mature scar length of 60.3 mm in the open
osteotomy group and of 24.2 mm in the closed
harvesting group with a mean dierence of 36.1 mm
(p50.001). The average scar width in the open
osteotomy group was 7.7 mm and 4.9 mm in the
closed group. Here the p value of 0.003 was very
signicant. Table 1 summarizes the signicant numerical parameters and statistics.
DISCUSSION
Donor site morbidity characterizes the use of autogenous tissues. A review of the literature reporting
complications following bone harvesting from the
anterior iliac crest reveals persistent pain, nerve
injury, haemorrhage, limping, persistent gait abnormalities, conspicuous scarring, bone contour decit,
infection, fracture, meralgia paraesthetica, peritonitis
and herniation. The amount of bone harvested, the
age of the patient, and the surgical technique used are
considered to have an impact on the complications
(Canady et al., 1993). Harsha et al. (1986) suggested
that the morbidity associated with removal of bone
from the traditional autogenous donor sites, such as
ilium, rib and tibia, is often greater than that
associated with the facial surgery per se. Partly based

on this assumption the harvesting of cranial or


mandibular bone grafts has gained importance
recently in many centres, and was encouraged by
the possibly higher osteoinductive property of a
membraneous cranial bone graft versus a bone graft
from endochondral sites such as ilium (Koole et al.,
1989; Ilankovan et al., 1998). In contrast, Sadove et al.
(1990) suggested that even if the concept of a similar
embryological origin intuitively favours a cranial
donor site, it is unlikely that the facial skeletal
recipient site holds the embryology of the donor site
in any regard. Instead, the composition of the graft,
including the cell numbers, particulate size, and
biochemical elements directly determines its fate
rather than its prior developmental origin. Also their
is concern over the relative risks involved in harvesting from the cranium versus the ilium or ribs. Sadove
et al. (1990) evaluated 30 patients receiving either
cranial or iliac bone for alveolar reconstruction and
emphasized the technique of harvest more than the
donor site. It was noticed that cranial bone has a
higher cortical to marrow ratio than that of ilium
(cranial chips have a high cortical component and less
cellularity). Cortical elements may be more favourable to initial osteoclastic rather than osteoblastic
induction and, in conjunction with the known
delayed revascularization, account for the slower
and often incomplete healing when compared with
cancellous grafts. Witsenburg and Remmelink (1993)
postulated that meticulous operative technique at the
recipient site is of much more importance to the
eventual outcome of the bony reconstruction than the
donor site. After evaluating 307 cranial bone grafts
for facial reconstruction Jackson et al. (1986)
concluded that in contradistinction to Wolfe and
Berkowitz (1983) and Harsha et al. (1986) they would
no longer use cranial bone grafts in secondary
reconstruction of alveolar clefts, mostly due to the
unfavourably high proportion of cortical elements.
On the other hand, iliac crest cancellous bone can be

36 Journal of Cranio-Maxillofacial Surgery

packed rmly into the defect to give an ideal alveolar


reconstruction (Hall and Posnick, 1983). Sadove et al.
(1990) suggested in addition to this that more
preserved Haversian systems and intact osteocytes
in the bone graft favour the better prognosis at the
recipient site, and that the thermal trauma from
power instruments may easily reduce these desirable
qualities. This does not occur in closed bone harvesting, where no power instruments are used, and could
partly explain the reduction of the harvest site
morbidity as the local thermal trauma is negligible.
Numerous authors have discussed the allegedly
reduced donor site morbidity when using cranial
grafts, including minimal postoperative pain and the
fact that the incision and subsequent scar are hidden
in a hair-bearing area (Harsha et al., 1986, Jackson
et al., 1986; Kline and Wolfe, 1995; Koole et al., 1989;
Kortebein et al., 1991, Sadove et al., 1990, SindetPedersen and Enemark, 1990; Witsenburg and
Remmelink, 1993, Wolfe and Berkowitz, 1983). In
the large meta-analysis of Kline and Wolfe (1995) the
overall complication rate of calvarial bone harvesting
was 0.18%. Exposure of dura, that was not counted
as a complication, was estimated to occur in 11% of
cases. Complications included wound infections,
lacerations of dura, blood vessels or cerebral cortex,
subdural haemorrhage, 9 month postoperative coma,
permanent hemiplegia and aphasia. The degree of
bony depression at the donor site seemed to depend
on the amount and type of bone removed. The
authors expressed concern about decreased skull
strength at the donor site following split calvarial
bone harvesting. Especially in children, weakening of
skull could be a major concern and a primary reason
for replacing all outer-table fragments after collecting
diploic bone. It was also recommended considering
an alternative donor site if the adult patient might be
anticipated as receiving multiple blows to the head,
e.g. sportsmen. The authors found that patients were
generally quite tolerant of relative depressions under
hair-bearing areas, as long as no sharp edges could be
felt (Kline and Wolfe, 1995). An issue the authors did
not discuss was how to manage the visible scarring
and bony depression in elderly balding males. Also
utilization of coronal aps may cause an annoying
hairless scar zone visible in balding individuals.
Kortebein et al. (1991) compared 108 patients having
iliac crest bone grafts with 27 patients, who had
calvarial bone as the graft material. In both groups,
morbidity was reported to be very low.
In 1990 Sindet-Pedersen and Enemark compared
alveolar grafting results in 60 patients who received
bone grafts from the mandibular symphysis and iliac
crest. They showed that all iliac bone harvest patients
complained of pain from the donor site and gained
normal mobility within a few weeks of surgery.
Patients undergoing mandibular symphyseal bone
grafts did not complain specically of pain from the
donor site. They emphasized the advantages of
mandibular symphyseal grafting as being reduced
operating time, morbidity and hospitalization, and
the avoidance of a cutaneous scar. Borstlap et al.

(1990) compared the outcome of alveolar cleft


grafting between bone grafts harvested from rib and
mandibular symphysis. Both groups had only minor
complaints about the donor site. Using quantitative
CT-assisted measurements Baehr and Coulon (1996)
determined the average bone volume obtainable from
the mandibular symphysis at 1.0 cm3, so that for cleft
volumes larger than 1.5 cm3 this donor site is not
suitable. Potential risks of this donor site include
damage to tooth roots and the mental nerves, and
growth disturbances (Baehr and Coulon, 1996).
In taking rib grafts Laurie et al. (1984) commented
on pleural laceration requiring chest drainage occurring in 9% of cases. The literature reveals pneumothorax as a complication in 530% and long-term
pleuritic pain in up to 7% of patients undergoing rib
grafting (Kline and Wolfe, 1995, Laurie et al., 1984).
Kline and Wolfe (1995) documented an interference
with chest-wall or breast development after rib graft
harvesting in children as another problem. In
addition, an intractable unsightly scar may result
(Laurie et al., 1984).
The tibial plateau has seldom been recommended
as a harvest site despite its relatively good accessibility and availability of spongiosa. Kline and Wolfe
(1995) reported only three cases (0.3%) of tibial
harvesting in their review of 1000 bone grafting
procedures from various donor sites, The complication rate of tibial grafting is reported to range up to
3.8% (van Damme and Merkx, 1996). Van Damme
and Merkx (1996) suggested a modication of tibial
harvesting using a cylindrical instrument. They
reported no complications in any of their nine
patients, morbidity was low and the scars were
unremarkable even in females. The graft-take at the
recipient site was good in all cases. On the other
hand, the authors mentioned as a disadvantage the
poor mechanical strength of the grafts, which is due
to the fatty bone-marrow containing large open
areas. The nine patients ranged in age from 22 to
67 years which reects the concern regarding growth
disturbances when tibial bone harvesting is performed in young patients. The authors concluded
that the use of tibia as donor site is contraindicated in
children and adolescents. In a recent study Ilankovan
et al. (1998) compared the morbidity of 30 patients
who underwent trephine bone harvesting either from
the iliac crest or the tibial shaft. The results showed
no signicant dierence in morbidity between the two
groups, whereas the tibial trephine procedure was
easier, quicker and there was less blood loss. Pain and
gait disturbances were noticeably reduced in the tibial
versus the iliac harvesting group. The authors did not
comment on any possible growth disturbance that
might be caused when the epiphyseal line is manipulated in a child's tibia, nor did they advise caution
about the patient's age.
Considering the iliac crest donor site Rudman
(1997) stated that harvesting cancellous bone did
not result in delayed ambulation or prolonged
hospitalisation. Dawson et al. (1996) recorded similar
ndings suggesting that there was no long-term

Donor site morbidity 37

donor site morbidity at the iliac crest, and that shortterm morbidity was frequently overstated and in itself
not a valid reason to change to calvarial or
mandibular donor sites. Stoelinga et al. (1990)
observed that the anterior iliac crest, provided the
cartilage cap was preserved and repositioned after
harvesting the graft, appeared to be a safe and
reliable source from which the associated morbidity
was minor. Laurie et al. (1984) compared harvesting
of rib and iliac bone with the traditional open
osteotomy techniques and reported a low rate of
long-term complications in the iliac group. However,
the short-term morbidity was observed to be high.
Nevertheless, the authors stated that the ilium
provides abundant cancellous bone that is particularly useful for closure of alveolar clefts, and that the
ilium is likely to remain a common donor site.
Interestingly, several of the patients who had
experienced both donor sites, rib and ilium, were in
no doubt of their preference for the iliac site in the
long term.
In our opinion the known disadvantages of the hip,
namely donor site morbidity and scarring, represent
only relative contraindications even when open
harvesting techniques are used. Both issues can be
eectively reduced by closed bone harvesting. The
diering views of preferred donor sites by various
authors have lead to numerous studies verifying,
more or less signicantly, the superiority of their
chosen donor site and harvesting method. When the
donor sites other than ilium were introduced,
discussion always focused on hip morbidity as an
important disadvantage to the iliac crest donor site.
We agree that in some respects hip morbidity after
traditional open osteotomy harvesting can be high,
signicant improvements can be made by adapting to
the newer closed technique. Among advantages are
shorter bone harvesting time and the fact that the
operating room nurses also found the closed harvesting technique to be a welcome alternative as the
instruments required for the closed harvesting number only a fraction of the open osteotomy instrument set.
Comparing the questionnaire results with the data
from patients' les concerning the short-term morbidity enhanced and conrmed the validity of the
recorded information. In the assessment of the
subjective morbidity by the patient questionnaire, a
visual analogue scale might have been more precise
than the imaginary scale from 1 to 6. Yet the latter
was familiar to all patients because of its similarity to
the rating system used in German schools.
Based on these results we conclude that bone
harvesting from the anterior iliac crest still
remains the gold standard method, provided that
the procedure is performed with minor invasive
techniques, such as cylinder trephine harvesting.
Sucient cancellous bone can always be obtained
and simultaneously with the recipient site preparation, with only minimum short-term morbidity and
without long-term morbidity. Remarkably low
morbidity at the donor site after a small hip incision

with minimum scarring and bone contour decit


can be achieved. Thus morbidity at the iliac donor
site is in itself not a valid reason to change to other
donor sites.
Acknowledgements
The authors would like to thank Mr Peter Ward Booth for his
convincing clinical demonstration of closed bone harvesting in East
Grinstead in spring 1995. Furthermore we express our thanks to
Medicon e.G., Tuttlingen, Germany, for providing us with the
6 mm cortex cutter.

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Priv.-Doz. Dr Dr H. Eunger
Department of Oral & Maxillofacial Surgery
Facial Plastic Surgery
In der Schornau 23-25
44892 Bochum
Tel: +49 234 299 3501
Fax: +49 234 299 3509
Paper received 15 July 1999
Accepted 1 February 2000