Reconstruction

Question 1

How much bone can be obtained from an anterior iliac crest?

Answer 1

50 mL of corticocancellous bone (restore 5 cm defect)

Question 2

What nerves are adjacent to the anterior iliac crest?

Answer 2

-Lateral cutaneous branch of iliohypogastric nerve (most common)
-Lateral cutaneous branch of subcostal nerve
-Lateral femoral cutaneous nerve (2.5% courses 1cm of the anterior superior spin) causing meralgia paresthetica

Question 3

What is your technique for anterior iliac crest harvest?

Answer 3

-Hip roll placed
-Landmarks (AIS, crest)
-Incision 3 cm lateral and 1 cm posterior to AIS, 5 cm in length
-Skin and subcutaneous tissue down to tensor fascia lata
-Dissection between muscle groups (tensor fascia lata/gluteus medius lateral, external abdominal oblique/iliacus medially)
-Dissection of iliacus medially to expose medial crest
-Osteotomy and harvest corticocancellous block
-Harvest cancellous bone (don’t undermine AIS due to fx by satorius muscle)
-Hemostasis
-Closure

Question 4

How much bone can you get from a posterior iliac crest?

Answer 4

100 mL of corticocancellous bone

Question 5

What are the disadvantages to the posterior iliac crest?

Answer 5

-Flipping patient, only 1 team, pt prone

Question 6

What nerves are important in the posterior iliac crest?

Answer 6

Middle cluneal nerve: S1, S2, S3
Superior cluneal nerve: L1, L2, L3

Question 7

What is your technique for a posterior iliac crest bone graft?

Answer 7

-10 cm curvilinear incision marked 3 cm from midline
-Dissection through skin and subcutaneous tissue, palpate iliac spine and crest
-Incise through lumbodorsal fascia to bony crest
-Osteotomy
-Harvest corticocancellous block/cancellous bone
-Hemostasis/closure

Question 8

What complications are associated with a posterior iliac crest bone graft?

Answer 8

-Gait disturbance (more common anterior due to stripping tensor fascia lata)
-Retroperitoneal hemorrhage
-Hematoma
-Adynamic ileus
-Fracture
-Sensory issues

Question 9

How much bone can be harvested from a fibula?

Answer 9

25 cm of vascularized bone

-15 mm diameter (good for implants)

Question 10

How much bone must be left?

Answer 10

-6 cm bone proximal and distal for joint stability

Question 11

What is the skin paddle with a fibula?

Answer 11

-Soleus muscle for soft tissue (including muscle increases skin paddle survival due to more musculocutaneous perforators)

Question 12

What nerve grafts can be completed with a fibula harvest?

Answer 12

-Lateral cutaneous or sural communicating nerve

Question 13

What is the blood supply relevant to the fibula?

Answer 13

Peroneal artery is blood supply

-Popliteal artery divides above knee into anterior and posterior tibial arteries

-Distal to knee the posterior tibial has collateral to the peroneal artery

-Two Venae comitantes (2 veins) run parallel to peroneal artery and provide venous outflow

-Need MRA for vessel eval (preferred over Doppler or angiography)

Question 14

What are complications from a fibula graft?

Answer 14

-Flap loss
-Skin paddle loss
-Compartment syndrome (closure too tight, reopen area)
-Limb ischemia