BACKGROUND: spinal fusion is used to treat, among other pathologies, the degenerative intervertebral disc disease. Autologous iliac crest bone grafting is the golden standard treatment for increasing the rate of fusion; however, it isn\'t free of complications.
OBJECTIVE: to investigate whether patients who have posterior iliac crest graft harvesting and are blinded to the donor site, can identify from which side the graft was harvested, and whether the intensity of this pain is related to the amount of graft obtained.
METHODS: prospective, experimental, randomized and comparative, single-blind study. Adult patients who underwent primary instrumented open posterolateral lumbar fusion with autologous iliac crest bone graft between July 2019 and April 2020 were included. Patients were divided into two randomized groups. The amount of graft to be harvested was according to surgical needs. The patients were asked about pain according to the visual analogue scale in the first, third and sixth months after surgery, always requesting that the most painful side be identified.
RESULTS: a total of 44 patients (n = 23 right crest, n = 21 left crest) were analyzed. Most patients were unable to identify the side from which the bone graft was harvested, with a statistically significant difference (p-value 0.0001).
CONCLUSIONS: iliac crest bone graft harvesting is an effective and safe procedure that improves the rates of fusion without increasing the patient\'s morbidity.
UNASSIGNED: la fusión espinal es utilizada para tratar, entre otras patologías, las enfermedades degenerativas discales. El injerto óseo autólogo de cresta ilíaca es el estándar de oro para aumentar las probabilidades de fusión; sin embargo, no está exento de complicaciones.
OBJECTIVE: investigar si los pacientes a los que se les recolecta injerto de cresta ilíaca posterior y son cegados al lado del sitio donante, pueden identificar de qué lado se tomó dicho injerto y si la intensidad de este dolor está en relación con la cantidad de injerto obtenido.
UNASSIGNED: trabajo prospectivo, experimental, aleatorizado y comparativo, simple ciego. Se incluyeron pacientes adultos operados entre Julio de 2019 hasta Abril de 2020, a los cuales se les realizó una cirugía primaria de artrodesis lumbar posterolateral abierta instrumentada, con colocación de injerto óseo autólogo de cresta ilíaca. Se dividió a los pacientes en dos grupos aleatorizados. La cantidad de injerto a recolectar fue de acuerdo a las necesidades quirúrgicas. Se interrogó por el dolor según escala visual analógica al primer, tercer y sexto mes de la cirugía, siempre solicitando que se identifique el lado más doloroso.
RESULTS: se analizaron 44 pacientes (n = 23 cresta derecha, n = 21 cresta izquierda). La mayoría de los pacientes no lograron identificar el lado del cual se obtuvo el injerto óseo, con una diferencia estadística ampliamente significativa (p = 0.0001).
UNASSIGNED: la obtención de injerto óseo de cresta ilíaca es un procedimiento efectivo y seguro, que mejora las probabilidades de fusión sin aumentar la morbilidad del paciente.

In this clinical trial, patients were randomized to receive a pedicled vascularized bone graft, based on the 1,2-intercompartmental supraretinacular artery, or a non-vascularized iliac crest graft. Fixation was done with K-wires. Union and time to union were assessed using CT scans at regular intervals. Twenty-three patients received a vascularized graft, and 22 received a non-vascularized graft. Thirty-eight patients were available for union assessment and 23 for clinical measurements. There were no significant differences in union incidence, time to union, incidence of complications, patient-reported outcome scores, or wrist mobility and grip strength at final follow-up between the treatment groups. Smokers were 60% less likely to achieve union, independent of graft type. When controlling for smoking, patients receiving a vascularized graft were 72% more likely to achieve union. Given our small sample size, results should be interpreted with caution.Level of evidence: I.

To evaluate bone regeneration in alveolar defects treated with human umbilical cord-derived mesenchymal stem cells (hUCMSCs), hydroxyapatite/chitosan/gelatin (HA/CS/Gel) scaffold, and bone morphogenic protein-2 (BMP-2) in Capra hircus models.
Randomized posttest-only control group design.
Animal Hospital at Bogor Agricultural Institute.
Healthy and equally treated 24 female Capra hircus/goats.
Animals were randomly assigned to 3 experimental group design (iliac crest alveolar bone graft/ICABG [control], HA/Cs/Gel+BMP-2 [Novosys], and HA/Cs/Gel+BMP-2+UCMSCs). Graft materials were implanted in surgically made alveolar defects.
Postoperative functional score and operating time were assessed. New bone growth, bone density, inflammatory cells recruitment, and neoangiogenesis were evaluated based on radiological and histological approach at 2 time points, week 4 and 12. Statistical analysis was done between treatment groups.
Operating time was 34% faster and functional score 94.5% more superior in HA/Cs/Gel+BMP-2+hUCMSC group. Bone growth capacity in HA/Cs/Gel+BMP-2+UCMSCs mimicked ICABG, but ICABG showed possibility of bone loss between week 4 and 12. The HA/Cs/Gel+BMP-2+UCMSCs showed early bone repopulation and unseen inflammatory cells and angiogenesis on week 12.
The HA/Cs/Gel+BMP-2+hUCMSCs were superior in enhancing new bone growth without donor site morbidity compared to ICABG. The presence of hUCMSCs in tissue-engineered alveolar bone graft (ABG), supported with paracrine activity of the resident stem cells, initiated earlier new bone repopulation, and completed faster bone regeneration. The HA/Cs/Gel scaffold seeded with UCMSCs+BMP-2 is a safe substitute of ICABG to close alveolar bone defects suitable for patients with cleft lip, alveolus, and palate.

The aim of the present study was to compare the clinical outcomes of cage-shaped demineralized bone plus local bone grafts (CDBLG) with those of autogenous iliac crest bone grafts (ICBG) implanted for the treatment of single-level lumbar intervertebral disc degenerative diseases. A total of 69 cases of degenerative spinal disorder treated between January 2011 and December 2013 were retrospectively analyzed. Of these, 44 were treated with CDBLG and 25 with autogenous ICBG. All fusions were instrumented single level. Fusion was assessed after 6, 12 and 24 months by X-ray and CT scans post-operatively. Clinical outcomes were determined during follow-up and assessments included the Oswestry Disability Index, Visual Analogue Scale for back and leg pain and the Short Form-36 general health survey physical component summary. The results indicated that the overall fusion rate at 24 months post-operatively was higher in the ICBG group compared with that in the CDBLG group, although not significantly (P>0.05). All other outcome measures were significantly improved in the two groups after the surgery (P<0.05), but no significant differences were observed between the two groups (P>0.05). Blood loss and mean duration of surgery in the CDBLG group were significantly lower compared with those in the ICBG group (P<0.05). In conclusion, CDBLG achieved a similar fusion rate and clinical outcome as ICBG but was associated with significantly reduced blood loss and mean duration of surgery. In conclusion, the present study provided CDBLG bone graft as an alternative option for single-level fusion.

Postoperative pain at the site of bone graft harvest for posterior spine fusion is reported to occur in 6%-39% of cases. However, the area around the posterior, superior iliac spine is a frequent site of referred pain for many structures. Therefore, many postoperative spine patients may have pain in the vicinity of the posterior iliac crest that may not in fact be caused by bone graft harvesting. The literature may then overestimate the true incidence of postoperative iliac crest pain.
We performed a prospective study testing the hypothesis that patients will not report significantly higher visual analog scores over the graft harvest site when compared with the contralateral, non-harvested side.
This is a prospective, randomized cohort study.
Patients aged 18-75 years undergoing elective spinal fusion of one to two levels between L4 and S1 for spinal stenosis and spondylolisthesis were randomized to left-sided or right-sided iliac crest bone graft (ICBG) donor sites and blinded to the side of harvest.
Primary outcome was a 10-point visual analog scale (VAS) for pain over the left and right posterior superior iliac spine.
Bone graft was harvested via spinal access incisions without making a separate skin incision over the crest. Each patient\'s non-harvested side served as an internal control. Data points were recorded by patients on their study visit sheets preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively.
Forty patients were enrolled in the study (23 females) with an average follow-up of 8.1 months (1.5-12 months). Mean age was 51.7 years (23-77 years). Left- and right-side ICBG harvesting was performed equally between the 40 patients. The average volume of graft harvested from the left was 35.3 mL (15-70 mL) and 36.1 mL (15-60 mL) from the right. There was no statistical difference between preoperative VAS score on the harvested side compared with the non-harvested side (p=.415). Postoperatively, there were consistently higher VAS scores on the operative side; however, these differences were not statistically significant at 6 weeks (p=.111), 3 months (p=.440), 6 months (p=.887), or 12 months (p=.240). Both groups did, however, show statistically significant improvements in VAS scores over time within the operative and nonoperative sides (p<.05). Graft volume had no effect on the VAS scores (p=.382).
The current literature does not adequately illuminate the incidence of postoperative pain at the site of harvest and the relative magnitude of this pain in comparison with the patient\'s residual low back pain. This is the first study to blind the patient to the laterality of bone graft harvesting. Our randomized investigation showed that although pain on the surgical side was slightly higher, it was neither clinically nor statistically different from the nonsurgical side. Our conclusion supports surgeons\' use of autologous bone graft, which offers a cost-effective, efficacious spinal fusion supplement.

To determine the potential risk of visceral injury during Acumed drill iliac crest cancellous bone graft harvest.
Radiographic iliac crest anatomic analysis with simulated drill course to measure cancellous bone available for harvest and proximity of vulnerable pelvic structures.
Single institution, tertiary care university hospital.
One hundred pelvic computed tomography scans performed on children 8 to 12 years old without traumatic or neoplastic pathology.
Radiographic simulation of Acumed drill course within iliac bone.
(1) Potential for pelvic visceral injury. (2) Volume of cancellous bone safely available for harvest.
Superior and medial cortical thickness at the reference point remained stable across age groups; however, lateral cortical thickness increased with age (3.13 to 3.74 mm, P < .001). Cancellous bone width increased with age at all depths measured (P < .001). Through radiographic simulation, the drill could reach the bowel in 4% of cases and only through gross deviation (>30°) from the plane of the ilium. There were no cases of simulated bowel perforation within 3 cm of the reference point. The maximum cancellous volume safely harvested increased with age: 24 cc in 8-year-olds to 36 cc in 12-year-olds (P < .001).
Acumed assisted iliac crest bone graft harvest is a safe technique in which substantial amount of cancellous bone can be obtained. The low risk of bowel perforation can be further minimized by limiting the depth of drill bit penetration to less than 3 cm.

OBJECTIVE: Considerable biological research has been performed to aid bone healing in conjunction with lumbar fusion surgery. Iliac crest autograft is often considered the gold standard because it has the vital properties of being osteoconductive, osteoinductive, and osteogenic. However, graft site pain has been widely reported as the most common donor site morbidity. Autograft site pain has led many companies to develop an abundance of bone graft extenders, which have limited proof of efficacy. During the surgical consent process, many patients ask surgeons to avoid harvesting autograft because of the reported pain complications. The authors sought to study postoperative graft site pain by simply asking patients whether they knew which iliac crest was grafted when a single skin incision was made for the fusion operation.
METHODS: Twenty-five patients underwent iliac crest autografting with allograft reconstruction during instrumented lumbar fusion surgery. In all patients the autograft was harvested through the same skin incision but with a separate fascial incision. At various points postoperatively, the patients were asked if they could tell which iliac crest had been harvested, and if so, how much pain did it cause (10-point Numeric Rating Scale).
RESULTS: Most patients (64%) could not correctly determine which iliac crest had been harvested. Of the 9 patients who correctly identified the side of the autograft, 7 were only able to guess. The 2 patients who confidently identified the side of grafting had no pain at rest and mild pain with activity. One patient who incorrectly guessed the side of autografting did have significant sacroiliac joint degenerative pain bilaterally.
CONCLUSIONS: Results of this study indicate the inability of patients to clearly define their graft site after iliac crest autograft harvest with allograft reconstruction of the bony defect unless they have a separate skin incision. This simple, easily reproducible pilot study can be expanded into a larger, multiinstitutional investigation to provide more definitive answers regarding the ideal, safe, and cost-effective bone graft material to be used in spinal fusions.

BACKGROUND: Recombinant human bone morphogenetic protein (rhBMP)-2 has been used in some craniofacial centers worldwide. However, its influence on nasal morphology is unknown. Thus, the objective of this investigation was to assess the effect of maxillary alveolar reconstruction on nasal position and symmetry in unilateral complete cleft lip patients who underwent traditional iliac crest bone grafting transferring versus reconstruction using rhBMP-2.
METHODS: Nineteen unilateral complete cleft lip patients were randomly divided into two groups. In group 1, patients underwent traditional iliac crest bone grafting transferring (n = 11) and in group 2, patients underwent alveolar reconstruction using collagen matrix with lyophilized rhBMP-2 (n = 8). Computerized tomography (CT) imaging was performed preoperatively and at 6 months postoperatively using a previously standardized protocol. Linear distances using anatomic landmarks were performed using tridimensional CT data reformatted by the OsiriX(®) software. Quantitative and qualitative measurements to assess intra- and inter-group nasal position modifications were performed.
RESULTS: Intra-group pre- and postoperative comparisons showed significant differences (p < 0.05) in two linear measurements of group 1, while group 2 did not present a difference (p > 0.05). Group 2 presented significant postoperative enhancement (p < 0.05) in the quantitative nasal symmetry in one measurement. Qualitative analysis showed postoperative nasal symmetry enhancement in 75% of the measurements of group 2 and 36% of group 1. There was no statistically significant difference in the inter-group comparisons.
CONCLUSIONS: Our study demonstrated that both groups showed similar effect on nasal symmetry.

OBJECTIVE: Pain is a complex process influenced by both physiological and psychological factors. In spite of an armamentarium of analgesic drugs and techniques available to combat post-operative pain, appropriate selection, and effective management for relief of post-operative pain still poses unique challenges. The discovery of peripheral opioid receptors has led to growing interest in the use of locally applied opioids (intra-articular, intra-pleural, intra-peritoneal, and perineural) for managing acute pain. As bone graft harvesting is associated with significant post-operative pain and there is a paucity of literature on the use of peripheral opioids at the iliac crest bone harvesting site, the present study was planned to evaluate the analgesic efficacy of local administration of morphine after iliac crest bone graft harvesting.
METHODS: A total of 60 patients, 20-50 years of age scheduled to undergo elective surgery for delayed and non-union fracture both bone leg with bone grafting under general anaesthesia (GA) were randomly assigned to one of the four groups of 15 patients each: group 1: 2.5 ml normal saline (NS) +2.5 ml NS infiltrated into the harvest site at 2 sites + 1 ml NS intramuscularly (i/m); Group 2: 2.5 ml NS + 2.5 ml NS infiltrated into the harvest site at 2 sites + 5 mg morphine in 1 ml i/m.; Group 3: 2.5 mg (2.5 ml) morphine + 2.5 mg (2.5 ml) morphine infiltrated into the harvest site at 2 sites + 1 ml NS i/m; Group 4: 0.5 mg naloxone (2.5 ml) +5 mg (2.5 ml) morphine infiltrated into the harvest site at 2 sites + 1 ml NS i/m. Pain from the bone graft site and operative site was assessed for 24 h post-operatively.
RESULTS: The patients who had received morphine infiltration (Group 3) had significantly less pain scores at the graft site at 4, 6, and 10 post-operative hours. They also had significantly less morphine consumption and overall better pain relief as compared to the other groups.
CONCLUSIONS: Morphine administered peripherally provided better analgesia as compared to that given systemically and this effect was noticeable after 4 h post-operatively.

We did biomechanical loading tests to compare the quantity and quality of interfragmentary movement in fractured human cadaver mandibles that had been reconstructed with iliac crest using 3 different osteosynthesis systems. Eighteen mandibles from human cadavers with a 4.5 cm paramedian L-type defect were reconstructed with bone from the iliac crest using 3 different osteosynthesis systems and continuously loaded on the \"Mandibulator\" test bench. Six mandibles each had the bones joined together using 2 monocortical non-locking plates, 2 monocortical locking plates, or a single bicortical locking plate/fracture gap. Macroscopic deformation, failure mechanisms, and movement of the fracture gap in all 3 dimensions were assessed and quantified over increasing loading by PONTOS(®) optical measurement systems. Final mechanisms of failure were excessive deformation of the plate, fracture of the mandibular fragments, and failure of the iliac crest graft. The plate became deformed mainly in the miniplate group. The iliac crest graft failed in all the specimens in which osteosynthesis was performed by a 6-hole TriLock(®) plate. Interfragmentary movement was minimised in the miniplate group. All three osteosynthesis systems provided sufficient stability for reconstruction when mechanically loaded up to 100 N. The miniplate allowed less movement in the gap and gave better stability than the two TriLock(®) plate systems. The superiority of the miniplate was significant when compared with the 4-hole TriLock(®) plate. The transplant failed mainly in the 6-hole TriLock(®) group, which suggests that the iliac crest graft works better with the miniplate as a more malleable osteosynthesis system.