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Back to Journal »Treatment and Clinical Risk Management» Volume 16
Iliac bone harvesting technique for bone reconstruction. Comparative study of Tricortical Bone Harvelling and Trapdoor technology
Authors: Zhu Jianfeng, Xu Wenxin, Hu Qi, Wu Tianqi, Liu Hai
Published on June 23, 2020, the 2020 volume: 16 pages 559-565
DOI https://doi.org/10.2147/TCRM.S257336
Single anonymous peer review
Reviewing editor: Professor Wang Deyun
Zhu Jiafu,1 Wei Xing,1 Hu Qiang,1 Wu Tianquan,2 Liu Hong1 1Department of Orthopedics, Zhejiang Tongde Hospital, Hangzhou 310012; 2 Department of Orthopedics, Keqiao District Hospital of Traditional Chinese Medicine, Shaoxing City, Shaoxing 312030 Mailing Address: Xu Weixing, Department of Orthopedics, Zhejiang Tongde Hospital No. 234, Gucui Road, Hangzhou City, Zhejiang Province 310012 People’s Republic of China Phone +86 -13750837328 Email [email protected] Objective: To study the effect of bone harvesting based on trapdoor procedures and tricortical iliac bone harvesting on patients' pain in the donor site of iliac bone grafts Its clinical effect. Methods: A retrospective analysis of the clinical data of 65 patients with tibial plateau fractures who underwent autologous iliac support grafts in two hospitals from January 2014 to January 2019. ) Was the experimental group, and those who received tricortical iliac bone extraction (31 cases) were the control group. This study compared the differences between the two bone extraction methods in terms of incision length at the donor site of the iliac bone graft, intraoperative blood loss, bone extraction volume, operation time and postoperative complications. Subsequently, it assessed the pain experienced by the two patient groups at their iliac bone graft donor sites and their clinical effects. Results: One week after operation, there was no significant difference in the pain scores (measured by SF-MPQ-2) of the iliac bone graft donor site between the experimental group and the control group. But at 3 weeks, 5 weeks, and 3 months after surgery, the pain score of the donor site of the iliac bone graft in the experimental group was significantly lower than that in the control group. The length of incision at the iliac bone donor site and the operation time in the experimental group were not significantly different from those in the control group. However, the blood loss, bone removal and complication rate of the iliac donor site in the experimental group were significantly lower than those in the control group. Conclusion: Bone collection based on trapdoor procedure has lower donor site pain, intraoperative blood loss and postoperative complications. However, for bone transplantation in areas with severe bone loss, tricortical iliac bone extraction is still the best choice. Keywords: ilium, bone graft, pain, clinical effect
Compared with artificial bone grafts and allogeneic bone grafts, autologous iliac bone grafts have better effects in graft rejection and osteogenesis. 1 Therefore, autologous iliac bone transplantation is often used to treat diseases such as bone loss, spondylosis and joint fusion, and is regarded as the gold standard for bone transplantation. 2,3 However, some patients receiving autologous iliac bone grafts experience postoperative pain and other complications in their iliac bone graft donor sites. 4 In this study, retrospective analysis was performed using retrospective analysis. Two hospitals (Zhejiang Tongde Hospital and Shaoxing Keqiao District Hospital of Traditional Chinese Medicine) received 65 cases of tibial plateau fractures with autologous iliac bone grafting (ie, trapped bone removal or tricortical iliac bone removal) in the clinical data of 65 cases in 2014. Compare the effects of the two types of bone harvests between January and January 2019. The treatment methods and clinical effects of the pain in the donor site of the iliac bone graft of the two groups of patients. The results are as follows:
This study was reviewed and approved by the Ethics Committee of the Medical Ethics Committee of Zhejiang Tongde Hospital, and was carried out in accordance with the requirements of the regulatory authorities and the Declaration of Helsinki and Good Clinical Practice Guidelines. Informed consent is exempted considering the retrospective nature of data collection and the use of de-identified medical records. The patient's personal privacy and individual biological characteristics are strictly confidential. (Theory number 2020015). This study retrospectively analyzed the clinical data of 65 patients with tibial plateau fractures who received autologous iliac bone support grafts in two hospitals from January 2014 to January 2019. Harvesting method. Those who underwent trapdoor surgery for bone removal (34 cases) were the experimental group, and those who received tricortical iliac bone removal (31 cases) were the control group. The experimental group consisted of 24 men and 10 women, aged between 24 and 62 years (mean age: 41.6 ± 2.7 years). Among them, there were 15, 11, and 8 fractures of Schatzker II, Schatzker III, and Schatzker IV, respectively. In contrast, the control group included 21 men and 10 women, aged between 23 and 63 years (mean age: 42.2 ± 2.6 years). Among them, 13, 10 and 8 people suffered from Schatzker II, Schatzker III and Schatzker IV fractures, respectively. The bone removal surgery was performed by the author of this study. The exclusion criteria of the study were as follows: (a) patients with pelvic fracture or bone tumor before surgery; and (b) patients with pelvic pain due to spondylopathy. There were no significant differences between the two groups in terms of age, gender, and fracture type, so the data are suitable for comparison (Table 1). Table 1 General conditions of the two groups before surgery
Table 1 General conditions of the two groups before surgery
Perform general anesthesia or spinal anesthesia. Use the cushion to raise the hip (donor site), and use the top of the iliac spine 2 cm behind the anterior superior iliac spine to determine the predetermined incision length. Keep the periosteum and fascia on the top 1/3 of the ilium, and cut the 0.2-0.3cm thin plate bone horizontally at the top (the cutting length is within the predetermined bone removal length range). Lift the thin bone plate and periosteum inward. Collect the bottom bones as needed and stop on the internal bone table. After the bone is taken, the bone wound is filled with absorbable gelatin sponge wrapped in gauze. Suture in situ on the thin bone containing the periosteal pedicle. The deep fascia and the inner iliac fascia are tightly sutured to completely stop bleeding. No drainage is required (Figure 1A-F). Figure 1 (AF) depicts a 45-year-old male patient who underwent general anesthesia before undergoing open reduction, internal fixation, and bone grafting to treat a fracture of the left tibial plateau. During the operation, bone harvesting based on a trapdoor procedure was used. (A) illustrates the location of the bone removal site before surgery. (B) Show the station after the trap door is opened. (C) Depicts the position when the trapdoor is placed back into the ilium. (D) shows the postoperative image of the pelvis. (E) illustrates a significant left tibial plateau fracture and articular surface collapse. (F) illustrates the postoperative left tibial plateau.
Figure 1 (AF) depicts a 45-year-old male patient who underwent general anesthesia before undergoing open reduction, internal fixation, and bone grafting to treat a fracture of the left tibial plateau. During the operation, bone harvesting based on a trapdoor procedure was used. (A) illustrates the location of the bone removal site before surgery. (B) Show the station after the trap door is opened. (C) Depicts the position when the trapdoor is placed back into the ilium. (D) shows the postoperative image of the pelvis. (E) illustrates a significant left tibial plateau fracture and articular surface collapse. (F) illustrates the postoperative left tibial plateau.
Perform general anesthesia or spinal anesthesia. Use the cushion to raise the patient's hip (donor site), and use the top of the iliac spine (3 cm behind the anterior superior iliac spine) to determine the length of the subsequent incision. During the operation, a bone knife was used to cut off the internal and external stages of the iliac bone. The three cortical bone pieces from the inner surface, the outer surface and the iliac spine were harvested. After the bone is taken, the bone wound is filled with absorbable gelatin sponge wrapped in gauze. In the case of excessive bleeding, a thin layer of bone wax is applied to the surface of the bone to seal the gap and completely stop the bleeding. The drainage system is not used (Figure 2A-C). Figure 2 (AE) depicts a 53-year-old female patient who underwent general anesthesia before undergoing open reduction, internal fixation, and bone grafting to treat a fracture of the right tibial plateau. During the operation, tri-cortical iliac bone extraction was used. (A) illustrates the location of the bone removal site before surgery. (B) Shows the bones being collected. (C) shows the postoperative image of the pelvis. (D) There is an obvious right tibial plateau fracture and articular surface collapse. (E) is the postoperative image of tibial plateau fracture.
Figure 2 (AE) depicts a 53-year-old female patient who underwent general anesthesia before undergoing open reduction, internal fixation, and bone grafting to treat a fracture of the right tibial plateau. During the operation, tri-cortical iliac bone extraction was used. (A) illustrates the location of the bone removal site before surgery. (B) Shows the bones being collected. (C) shows the postoperative image of the pelvis. (D) There is an obvious right tibial plateau fracture and articular surface collapse. (E) is the postoperative image of tibial plateau fracture.
24-hour anti-inflammatory treatment during and after the operation, and patient-controlled analgesia (injection into the patient's vein) for 2 days. Two weeks after the operation, analgesics were used or not according to the requirements of the patient's painless ward. Anticoagulation was observed for 12 hours after operation, and a continuous passive exercise machine was used on the third day after operation to help the patient perform functional exercises of the affected limb. Two weeks after the operation, the suture was removed and the patient was discharged. All patients did not use analgesics after discharge.
The short-form McGill Pain Questionnaire 2 (SF-MPQ-2) 5 was used to compare the pain in the donor site of the iliac bone graft at 1 week, 3 weeks, 5 weeks, and 3 months after the operation of the two groups. -MPQ-2 is composed of four summary scales, which can assess persistent, intermittent, neuropathic and affective pain. It is easy to use, time-saving and reliable, and can comprehensively evaluate neuropathic and non-neuropathic pain. This study compared the differences between the two bone extraction methods in terms of incision length at the donor site of the iliac bone graft, intraoperative blood loss, bone extraction volume, operation time and postoperative complications. Subsequently, this study evaluated the pain experienced by the two patient groups at the donor site of the iliac bone graft and the clinical effects of bone extraction methods.
All data were analyzed using SPSS v19.0. At the beginning of the analysis, the data is evaluated to determine whether they have a normal distribution. The pain score of the iliac bone graft donor site (measured by SF-MPQ-2 at the same time), incision length, intraoperative blood loss, bone removal, and number of operations of the two groups of patients were all normally distributed and showed homogeneous variance (using x±s ). Then perform two independent sample t-tests. Χ2 was used to test the incidence of complications at the donor site of the iliac bone graft in the two patient groups, where p <0.05 indicates a statistically significant difference.
One week after operation, comparing the experimental group (6.48±0.62) and the control group (7.21±0.18) iliac bone graft donor site pain score (measured by SF-MPQ-2), the difference was not statistically significant (p> 0.05). However, at 3 weeks, 5 weeks, and 3 months after surgery, the pain scores of the iliac bone graft donor site in the experimental group (11.08±0.45, 1.25±0.03, and 0.05±0.01, respectively) were significantly lower than those in the control group (p<0.05) (Respectively 26.45±0.36, 14.54±0.37 and 5.64±0.87; Table 2). Table 2 Pain scores at the donor site of the iliac bone graft in the two patient groups (x ± S; measured with SF-MPQ-2)
Table 2 Pain scores at the donor site of the iliac bone graft in the two patient groups (x ± S; measured with SF-MPQ-2)
The incision length and operation time (5.18±0.12 cm and 12.65±0.84 min, respectively) of the iliac donor site in the experimental group and the control group (5.21±0.07 cm and 12.65±0.84 min) were not significantly different (p> 0.05). 11.24 ± 0.67 minutes, respectively). In contrast, the amount of blood loss and bone removal (8.39±0.62 mL and 8.35±0.72 cm3, respectively) of the iliac bone graft donor site in the experimental group and the control group were significantly different (p <0.05) (21.81 ± 0.27) mL and 13.24 ± 0.27 cm3). One patient in the experimental group was injured due to the abnormal running of the lateral femoral cutaneous nerve during bone removal, which resulted in numbness of the lateral thigh. The pain in the pelvic area of the patient still exists after the operation. Four patients in the control group experienced complications during follow-up. One patient experienced heterotopic ossification during advanced hematoma. One patient developed abdominal wall irritation due to lumbar hernia. A patient experienced an avulsion fracture of the anterior superior iliac spine (donor site) due to vigorous activity. A patient felt pain due to a sunken iliac bone while wearing a waist belt. The complication rate of the experimental group (1/34) was significantly different from that of the control group (4/31; Table 3) (p <0.05). Table 3 Differences in the length of the incision at the donor site of the iliac bone graft, the amount of blood loss during the operation, the amount of bone taken, the operation time and the incidence of complications between the two groups of patients
Table 3 Differences in the length of the incision at the donor site of the iliac bone graft, the amount of blood loss during the operation, the amount of bone taken, the operation time and the incidence of complications between the two groups of patients
Figure 1A-F depicts a 45-year-old male patient who underwent general anesthesia before undergoing open reduction, internal fixation, and bone grafting to treat a fracture of the left tibial plateau. During the operation, bone harvesting based on a trapdoor procedure was used. Figure 1A illustrates the location of the bone removal site before surgery. Figure 1B shows the station with the trap door opened. Figure 1C depicts the position when the trapdoor is placed back into the ilium. Figure 1D shows the postoperative image of the pelvis. Figure 1E shows a clear left tibial plateau fracture and articular surface collapse. Figure 1F illustrates the postoperative left tibial plateau.
Figure 2A-E depicts a 53-year-old female patient who underwent general anesthesia before undergoing open reduction, internal fixation, and bone grafting to treat a fracture of the right tibial plateau. During the operation, tri-cortical iliac bone extraction was used. Figure 2A illustrates the location of the bone removal site before surgery. Figure 2B shows the bones being collected. Figure 2C shows the postoperative image of the pelvis. Figure 2D shows a clear right tibial plateau fracture and articular surface collapse. Figure 2E is a postoperative image of tibial plateau fracture.
Autologous iliac bone extraction is a common orthopedic surgery. Autogenous iliac bone grafting can accelerate the anastomosis of blood vessels at the graft site and the bone graft, nourish the bone tissue at the graft site, induce the formation of new bone tissue, and promote bone healing. 6 Although the iliac bone donor sites are located in the shallow layer, they provide a rich supply of bone and are convenient for simple bone collection operations. However, postoperative complications at the iliac donor site have been reported. 7 Less common complications after surgery include serious events such as peritoneal perforation, urethral injury, and retroperitoneal hematoma. The more common complications after the operation include nerve injury, hematoma, hernia8 and donor site pain, the latter being the most common complications. 9 These complications place a considerable burden on the patient's personal and professional life.
At present, bone collection based on trap procedure and tricortical iliac bone collection are two common bone collection methods. Bone collection based on the trapdoor procedure preserves the shape of the iliac spine and prevents the depression of the iliac bone graft donor site. In contrast, tri-cortical iliac osteotomy can cause different degrees of iliac spine injury. The uneven bone edges in the donor site of the ilium graft can irritate the soft tissues, and the pressure generated by the frenulum can cause pain in the donor site. In addition, removing the inner and outer surfaces of the bone may cause abdominal hernia 10 and cause pain at the donor site. These results support the conclusions in the literature regarding the main complications of tricortical iliac bone collection. 8
Bone collection based on the trapdoor procedure preserves the inner surface of the bone and the shape of the iliac spine. With the support of the iliac bone and the internal table of the iliac bone, this surgical method can control bleeding at the donor site, limit hematoma, and promote self-remodeling and self-filling of bone wounds in the later stage of recovery. In contrast, the tricortical iliac bone extraction will cause a large amount of soft tissue exfoliation and cancellous bone exposure in the internal and external regions of the donor site, which may increase bleeding at the donor site. Damage to the donor site and soft tissue collapse limit the control of hematomas, which may spread to the gluteal muscles and iliac muscles and cause heterotopic ossification and pain.
Bone extraction based on the Trapdoor procedure preserves the integrity of the inner surface of the bone, enhances the stability of the inner side of the anterior superior iliac spine and the stretch resistance of the base of the anterior superior iliac spine. As the lower limb fractures healed, the iliac bone also recovered, enhancing the stretch resistance of the anterior superior iliac spine. In contrast, tricortical iliac osteotomy can lead to poor stability at the base of the anterior superior iliac spine, poor stretch resistance, and increased fracture probability. Among the patients who underwent tricortical iliac bone collection in this study, one patient had an avulsion fracture of the anterior superior iliac spine (donor site). For this patient, although the donor site is 3 cm away from the anterior superior iliac spine, a large number of bone removal and bone removal longer than 3 cm still lead to poor biomechanical stability of the patient's anterior superior iliac spine. 12,13 This indicates that bone harvesting based on the trapdoor procedure is still a safe and effective option for iliac bone grafting, although it allows for fewer bones to be harvested compared to tricortical iliac bone harvesting.
(a) Does not penetrate the endothelial layer of the trapdoor (i.e. the endothelial layer of the iliac bone), maintains the integrity of soft tissues such as the axial periosteum and fascia, and induces anchoring, maintains blood flow, and promotes bone remodeling; (b) If The amount of collected bone is very large, and multiple bone collections based on trapdoor procedures can be performed to prevent the formation of deep hematomas in the collected deep bones. It is necessary to avoid collecting near the inner surface of the bone to prevent fracture of the inner surface of the iliac bone. (c) Gauze and absorbable gelatin sponge can be used to cover the damage to the bone removal site. If there is too much bleeding, apply a thin layer of bone wax on the surface of the bone. However, this may have a negative impact on the reconstruction of the donor site in the later stages of recovery.
In short, bone collection based on trap procedures can significantly reduce pain at the donor site, intraoperative blood loss and postoperative complications. However, for bone transplantation in areas with significant bone loss, tricortical iliac bone extraction is still the best choice, although it has a higher incidence of pain at the patient’s donor site compared with bone extraction based on trapdoor procedures. More complications later. Due to the small number of patients in the study and the short follow-up time, more prospective studies must be conducted by different medical institutions in the future. In addition, it is necessary to analyze the correlation between the relevant indicators of the iliac bone graft donor site.
There is no significant difference between the operation time and the length of the incision between the bone extraction based on the trapdoor procedure and the tricortical iliac bone extraction. Bone collection based on the trap procedure can significantly reduce the pain at the donor site, intraoperative blood loss and postoperative complications. However, for bone transplantation in areas with significant bone loss, tricortical iliac bone extraction is still the best choice, although it will cause a higher incidence of patient donor site pain compared with bone extraction based on trapdoor procedures. More complications later.
SF-MPQ-2, McGill Pain Questionnaire Summary 2.
The author is happy to share the de-identified participant data. The data in this study includes graphs and tables, which can be obtained by contacting the corresponding author. The data can be used permanently after the article is published.
All authors participated in data analysis, drafting and revising the article, finally approved the version to be published, agreed to the journal the article was submitted to, and agreed to be responsible for all aspects of the work.
All authors declare that they have no conflicts of interest.
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