Armamentarium

History of the Procedure

The first documented use of the posterior ilium as a site for bone graft harvest was in 1946 in the orthopedic surgery literature. In 1950, Dingman advocated using the posterior ilium for craniomaxillofacial defects. Since the 1980s, oral and maxillofacial surgeons have used the posterior ilium as a source of corticocancellous bone.

History of the Procedure

The first documented use of the posterior ilium as a site for bone graft harvest was in 1946 in the orthopedic surgery literature. In 1950, Dingman advocated using the posterior ilium for craniomaxillofacial defects. Since the 1980s, oral and maxillofacial surgeons have used the posterior ilium as a source of corticocancellous bone.

Indications for the Use of the Procedure

The posterior iliac crest bone graft (PICBG) is indicated for maxillofacial reconstruction of skeletal defects requiring a significant volume of cortical, cancellous, or corticocancellous bone. Typically, defects requiring more than 40 mL of cancellous bone marrow or defects requiring large corticocancellous blocks are appropriate for PICBG. The PICBG can provide greater than 100 mL of cancellous bone marrow or maximum 5 × 5 cm cortical block.

Limitations and Contraindications

The most significant limitation of the PICBG harvest is the prone positioning required. Placing the patient prone and then switching to the supine position following harvest can add 1 to 2 hours of surgical time. In addition, unlike the anterior iliac crest bone harvest, only one surgical team is able to operate during PICBG harvest, adding further operating time and, in turn, increased anesthesia time and hospital cost. Absolute contraindications are few but include previous fracture, radiation to site, infection at site, and any type of systemic metabolic bone disease such as osteoporosis. In addition, because this harvest is completed under general anesthesia, any contraindication to general anesthesia is a contraindication to the PICBG harvest. Relative contraindications include current use of oral or intravenous bisphosphonates or chronic steroid use.

Technique: Posterior Iliac Crest Bone Graft Harvest

Prior to any surgery, a review of pertinent surgical anatomy is critical. The largest amount of bone reservoir in the ilium is in the area of the posterior tubercle, or the area that the ilium posteriorly articulates with the sacrum. The PICBG provides up to 100 cc of uncompressed bone. Muscular attachments in this area include the gluteus maximus muscle and the gluteus minimus muscle. Most of the bone is located beneath the insertion of the gluteus maximus and is defined by the presence of a well-defined palpable triangular fossa. The gluteus medius attaches to the posterior ilium inferior to the gluteus maximus insertion. Superiorly, the thoracodorsal fascia of the latissimus dorsi attaches to the posterior ilium. Blood supply to this area is via the deep circumflex iliac artery. Pertinent neural anatomy includes the superior and medial cluneal nerves. The superior cluneal nerves are dorsal rami from L1, L2, and L3, which pierce the lumbodorsal fascia superior to the posterior iliac crest and innervate the skin over the posterior medial buttocks. While the medial cluneal nerves arise from S1, S2, and S3 and arise from the sacral foramina and course laterally to innervate the medial buttocks, the insertion of the gluteus maximus is between the superior and medial cluneal nerves. The sciatic notch and nerve, which supply the motor innervation to the lower extremity, are 6 to 8 cm inferior to the posterior iliac crest and should not be encountered during routine dissection. An incision placed between these nerves will prevent sensory loss postoperatively ( Figure 122-1, A ).