International Orthopaedics (SICOT) (2014) 38:1753 DOI 10.1007/s00264-014-2404-0
LETTER TO THE EDITOR
Iliac crest bone grafting: raising awareness of a common pitfall Denosshan Sri & Jonathan Compson
Received: 27 May 2014 / Accepted: 30 May 2014 / Published online: 24 June 2014 # SICOT aisbl 2014
Dear Sir, In International Orthopaedics, Hernigou et al. [1] showed a tenfold reduction in complications with the use of percutaneous aspiration of bone marrow stem cells from the iliac crest over classical iliac crest bone graft (ICBG) harvesting in reconstructive orthopaedic surgery. The iliac crest is the ‘gold standard’ source of bone graft and is considered a routine procedure in orthopaedic practice. Despite this familiarity, there is a high degree of morbidity associated with the procedure, with postoperative pain affecting 16.5–40 % of patients and major complications such as vascular injury, nerve injury, fracture and hernias reported in 2.4–8.6 % of cases [2, 3]. It is therefore vital that patients are appropriately counselled and consented for this potentially risky procedure. An audit carried out at our tertiary referral centre looked at the consenting of patients who underwent ICBG harvesting and the documentation of the procedure in the operative records. Having looked at 50 patients over a six month period, it was found that although the procedure itself was present in the consent form of all patients, only 4 % went into the particular complications of the procedure itself. Moreover, 8 % failed to identify the side of the procedure. The adequacy of the operative notes was based on criteria which included the mention of ICBG in the operative title and notes, identification of side, approach, procedure, complications and closure. Only 20 % of records were acceptable, with 34 % neglecting to mention the side from which the graft was taken. We have since implemented ICBG operative templates in a computerised system that can be easily incorporated into a patient’s electronic operative notes and amended according to the specifics of the patient’s procedure. D. Sri Kings College Hospital, Denmark Hill, London SE5 9RS, UK D. Sri (*) : J. Compson 6 Kingsbridge Road, London SM4 4PS, UK e-mail: [email protected]
The complications of ICBG harvesting have been shown to cause significant limitations to patient activity, with one study showing that 12–14 % struggle with household and recreational activities and 5.2 % struggle with employment at one year follow-up [3]. Surgical trainees are often involved in consenting patients and documenting operative notes, and they need to regard the ICBG harvest as a separate procedure in its own right; indeed trainee operative logbooks reflect this by listing ICBG as a stand-alone procedure. Trainees need to recognise the significant morbidity associated with this procedure and ensure that not only are patients counselled appropriately, but also that the documentation reflects this. This can be formally achieved locally through departmental teaching and training or even during trainee induction. Conflict of interest The authors declare that they have no conflict of interest.
References 1. Hernigou P, Desroches A, Queinnec S, Flouzat Lachaniette CH, Poignard A, Allain J, Chevallier N, Rouard H (2014) Morbidity of graft harvesting versus bone marrow aspiration in cell regenerative therapy. Int Orthop. doi:10.1007/s00264-014-2318-x [Epub ahead of print] 2. Sen MK, Miclau T (2007) Autologous iliac crest bone graft: should it still be the gold standard for treating nonunions? Injury 38(Suppl 1): S75–S80. doi:10.1016/j.injury.2007.02.012 3. Kim DH, Rhim R, Li L, Martha J, Swaim BH, Banco RJ, Jenis LG, Tromanhauser SG (2009) Prospective study of iliac crest bone graft harvest site pain and morbidity. Spine J 9(11):886–892. doi:10.1016/j. spinee.2009.05.006
LETTER TO THE EDITOR
Iliac crest bone grafting: raising awareness of a common pitfall Denosshan Sri & Jonathan Compson
Received: 27 May 2014 / Accepted: 30 May 2014 / Published online: 24 June 2014 # SICOT aisbl 2014
Dear Sir, In International Orthopaedics, Hernigou et al. [1] showed a tenfold reduction in complications with the use of percutaneous aspiration of bone marrow stem cells from the iliac crest over classical iliac crest bone graft (ICBG) harvesting in reconstructive orthopaedic surgery. The iliac crest is the ‘gold standard’ source of bone graft and is considered a routine procedure in orthopaedic practice. Despite this familiarity, there is a high degree of morbidity associated with the procedure, with postoperative pain affecting 16.5–40 % of patients and major complications such as vascular injury, nerve injury, fracture and hernias reported in 2.4–8.6 % of cases [2, 3]. It is therefore vital that patients are appropriately counselled and consented for this potentially risky procedure. An audit carried out at our tertiary referral centre looked at the consenting of patients who underwent ICBG harvesting and the documentation of the procedure in the operative records. Having looked at 50 patients over a six month period, it was found that although the procedure itself was present in the consent form of all patients, only 4 % went into the particular complications of the procedure itself. Moreover, 8 % failed to identify the side of the procedure. The adequacy of the operative notes was based on criteria which included the mention of ICBG in the operative title and notes, identification of side, approach, procedure, complications and closure. Only 20 % of records were acceptable, with 34 % neglecting to mention the side from which the graft was taken. We have since implemented ICBG operative templates in a computerised system that can be easily incorporated into a patient’s electronic operative notes and amended according to the specifics of the patient’s procedure. D. Sri Kings College Hospital, Denmark Hill, London SE5 9RS, UK D. Sri (*) : J. Compson 6 Kingsbridge Road, London SM4 4PS, UK e-mail: [email protected]
The complications of ICBG harvesting have been shown to cause significant limitations to patient activity, with one study showing that 12–14 % struggle with household and recreational activities and 5.2 % struggle with employment at one year follow-up [3]. Surgical trainees are often involved in consenting patients and documenting operative notes, and they need to regard the ICBG harvest as a separate procedure in its own right; indeed trainee operative logbooks reflect this by listing ICBG as a stand-alone procedure. Trainees need to recognise the significant morbidity associated with this procedure and ensure that not only are patients counselled appropriately, but also that the documentation reflects this. This can be formally achieved locally through departmental teaching and training or even during trainee induction. Conflict of interest The authors declare that they have no conflict of interest.
References 1. Hernigou P, Desroches A, Queinnec S, Flouzat Lachaniette CH, Poignard A, Allain J, Chevallier N, Rouard H (2014) Morbidity of graft harvesting versus bone marrow aspiration in cell regenerative therapy. Int Orthop. doi:10.1007/s00264-014-2318-x [Epub ahead of print] 2. Sen MK, Miclau T (2007) Autologous iliac crest bone graft: should it still be the gold standard for treating nonunions? Injury 38(Suppl 1): S75–S80. doi:10.1016/j.injury.2007.02.012 3. Kim DH, Rhim R, Li L, Martha J, Swaim BH, Banco RJ, Jenis LG, Tromanhauser SG (2009) Prospective study of iliac crest bone graft harvest site pain and morbidity. Spine J 9(11):886–892. doi:10.1016/j. spinee.2009.05.006
