TECHNICAL NOTE
J Oral Maxillofac Surg
Posterior Iliac Crest Bone Harvest:
Review of Technique, Complications, and
Use of an Epidural Catheter for
Postoperative Pain Control
James B. Mazock, MS, DDS,* Sterling R. Schow, DMD,†
and R. Gilbert Triplett, DDS, PhD‡
The iliac crest is a common source for autogenous
grafting in oral and maxillofacial surgery. Numerous
articles1-5 in our literature have discussed indications,
techniques, and complications from anterior iliac
crest bone graft harvests. In larger reconstruction
cases, the volume of bone available from the posterior
iliac crest makes it attractive as the donor site. Unfor-
tunately, a relative paucity of literature focuses spe-
cifically on the surgical approach to the posterior
ilium.6 The purpose of this paper is to detail the
patient positioning, physiologic changes involved in
the prone position, the surgical anatomy, and a de-
scription of the technique. The incidence and man-
agement of complications using this technique were
investigated from a 4-year, retrospective chart review.
Patient Positioning
One of the most important technical considerations
in posterior iliac crest (PIC) bone harvesting is proper
patient positioning. Although most commonly used
for anorectal or gluteal surgery, the position for PIC
bone harvest is a low prone jackknife position, also
Received from Oral and Maxillofacial Surgery, Baylor College of
Dentistry, The Texas A&M University System Health Science Cen-
ter, Dallas, TX.
*Resident.
†Professor and Director of Residency.
‡Regents Chair and Professor.
Address correspondence and reprint requests to Dr Schow:
Professor and Director of Residency Oral and Maxillofacial Surgery,
Baylor College of Dentistry, The Texas A&M University System
Health Science Center, 3302 Gaston Ave, Dallas, TX 75246; e-mail:
srschow@tambcd.edu
© 2003 American Association of Oral and Maxillofacial Surgeons
0278-2391/03/6112-0020$30.00/0
doi:10.1016/j.joms.2003.03.001
1497
61:1497-1503, 2003
termed the modified prone, ventral deceits, or ventral
recumbent position.7
Before anesthetic induction, appropriate padding
of the operating room table is completed (Fig 1).
Anesthetic induction and intubation usually are ac-
complished on the patient’s hospital bed. Transfer to
the operating table dictates a team approach. Sur-
geons and staff are in parallel to the patient while the
anesthesiologist secures the endotracheal tube. The
patient is smoothly rolled on to the operating table,
taking care not to displace the endotracheal tube or
any intravascular lines. The patient’s head is placed
on its side with the endotracheal tube positioned
laterally. As in the supine position, the endotracheal
tube must be secured without excessive pressure on
the nose or other facial structures to avoid pressure
necrosis. The arms are positioned superiorly with the
shoulders abducted no greater than 90°. Extreme lat-
eral hyperabduction must be avoided to decrease
pressure on the capsule of the shoulder joint. Ample
padding must also be used for the elbows to protect
the ulnar nerve. Bilateral shoulder girdle rolls are
placed along the anterior and lateral thorax. A large
pelvic roll or sandbag is placed under the anterior
iliac crest to support the pelvis. When properly
placed, the thorax and pelvic rolls also aid in reducing
the intrathoracic and intra-abdominal pressures. A
midtable break, or reverse flex of approximately 210°,
allows the surgical site to be in the most superior
portion of the operating field, thereby decreasing
dependent venous oozing and blood loss. All other
pressure points, such as the patient’s knees and feet,
must also be carefully padded (Fig 2).
Physiologic Concerns
Several studies in the anesthesia literature have
investigated the hemodynamic changes associated
with prone positioning during general anesthesia.
1498
FIGURE 1. Operating table prepared with appropriate padding for
posterior iliac crest bone harvest. Head is to left. Note shoulder,
pelvic, and lower leg padding.
Early reports8 focused on decreased central venous
pressure associated with the use of the prone posi-
tion. More recently, attention has focused on other
hemodynamic variables to better evaluate risk factors
in using the prone position.
Backofen and Schauble9 found marked decreases in
stroke volume and cardiac output associated with
turning the patient into the prone position while
under general anesthesia. Using a convex frame to
elevate the pelvis and thorax above the head and
extremities, Yokayama et al10 found significant de-
creases in the stroke volume index and cardiac index
but essentially no change in other hemodynamic vari-
ables. However, using transesophageal echocardiog-
raphy, Toyota and Amaki11 did not find changes in the
stroke volume index or cardiac index but rather
found a reduction in left ventricular volume and com-
pliance, likely due to increased intrathoracic pressure
in the prone position.
In summary, the literature suggests that patients
with evidence of poor cardiac reserve such as con-
gestive heart failure or hypoperfusion may not toler-
ate the hemodynamic changes associated with the
prone position. On the other hand, the average
healthy patient can tolerate the prone position with-
out any identifiable hemodynamic alterations.
An additional cardiovascular concern is that of
proper placement of the pelvic roll directly over the
bony pelvis. It is important to remember that a pelvic
roll incorrectly placed too far superiorly can com-
press the inferior vena cava. In addition to reducing
venous return to the heart, increased intracaval pres-
sures can cause engorgement of the vertebral venous
plexuses, potentially increasing blood loss at the sur-
gical site.
The prone position also presents a number of phys-
iologic changes in the respiratory system. The patient
must raise the entire thoracic weight off the sternum
to effectively expand the chest. In addition, the ab-
POSTERIOR ILIAC CREST BONE HARVEST
dominal viscera and the diaphragm are forced ceph-
alad in the low prone jackknife position, further in-
creasing the work of breathing.7 Therefore, proper
placement of shoulder girdle and pelvic rolls is crucial
to free up the abdominal contents and allow easier
ventilation, especially in the obese patient. Similar to
the pelvic roll, shoulder rolls placed too far inferiorly
can impede the excursions of the bony thorax, thus
increasing inspiratory pressures and necessitating
larger tidal volumes. This may cause pulmonary baro-
traumas and potentially even a pneumothorax.
Other potential complications associated with the
prone position include injuries to the head and neck
region, particularly to the ocular region. Corneal abra-
sion, conjunctival and periorbital edema, and blind-
ness have been reported in prone patients.12 Typi-
cally, the cases of blindness occurred after prolonged
multilevel lumbar laminectomies on patients with
multiple arteriosclerotic risk factors. Retinal ischemia
from prolonged inadvertent pressure on the globe by
the head support is thought to be the likely etiology in
such cases. Other reported injuries include damage to
various cranial nerves, cervical spine injuries, and
various cutaneous nerve injuries.7
After the harvest of the posterior ilium, the operat-
ing table is leveled and all padding and rolls are
removed. The patient is then harmoniously rolled to
the supine position with support under the pelvis and
lower extremities with the anesthesiologist managing
the endotracheal tube. Emphasis is also placed on
protecting intravascular lines, catheters, and monitors
and preventing orthopedic injuries to the patient and
turning personnel. Using this routine, we have had no
untoward events related to patient positioning and
surgery.
FIGURE 2. Arm, head, thorax, pelvis, knee, and lower leg pads are
properly positioned and the operating table reverse flexed to place the
posterior iliac crest at the most superior height of the field.
MAZOCK, SCHOW, AND TRIPLETT
FIGURE 3. A, Diagrammatic representation of the sensory distribution and incision line for the right posterior iliac crest harvest. B, Anatomy traced
on the operative site just before incision.
Surgical Anatomy and Technique
The use of an oblique incision in harvesting the
posterior ilium offers excellent access to the iliac
crest. When appropriately positioned, the ilium is at
the highest point in the field and palpation of the
crest is enhanced. A surgical marking pen is used to
trace the spinal midline, the posterior superior iliac
spine, and the PIC (Figs 3A, B). After sterile prepara-
tion of the field, sounding of the iliac crest with a
25-gauge needle and infiltration of 0.5% bupivacaine
with 1:200,000 epinephrine are accomplished to de-
termine crestal position and provide local anesthetic
benefits. This is potentially helpful if the iliac crest
cannot be easily palpated with digital pressure. In
obese individuals, a 22-gauge spinal needle can help
locate the position of the iliac crest in relation to the
overlying skin and local anesthesia can be delivered
through this method.
The incision through skin and subcutaneous tissue
is started 1 cm from the posterior superior iliac spine
and extends approximately 5 to 6 cm along the crest
superolaterally (Figs 3A, B). This incision is designed
to avoid injury to the superior and medial cluneal
nerves. The superior cluneal nerves arise from the
dorsal rami of L1, L2, and L3 and emerge from the
lumbodorsal fascia and course caudally over the pos-
terior iliac crest to innervate the skin over the supe-
rior two thirds of the buttocks.13 The distance of the
superior cluneal nerves from the posterior superior
iliac spine and the midline has typically been de-
scribed as 8 cm.14 However, recent anatomic studies
1499
in the orthopedic literature15,16 have shown the loca-
tion of the medial branch of the superior cluneal
nerves to be approximately 6.5 cm from the posterior
superior iliac spine and 8 cm from the midline. The
middle cluneal nerves arise from the lateral branches
of the dorsal rami of S1, S2, and S3 and emerge
through the gluteus maximus and fascia to send cuta-
neous branches to the skin inferolaterally over the
inferior third of the buttocks.
Blunt dissection is used until fascial attachments of
the internal oblique and gluteus maximus muscles are
visible directly over the crest. Sharp dissection with
electrocautery is used midcrestally to avoid incising
the muscle bellies, which would contribute to greater
postoperative morbidity.2 The oblique incision allows
subperiosteal access to the greatest quantity of bone
with the least morbidity. Some authors describe an
oblique incision through the belly of the gluteus maxi-
mus in an attempt to decrease cluneal nerve injuries;
we do not advocate this because of the markedly
increased morbidity, pain, and bleeding.6,17 The peri-
osteum is often quite tenacious, and it is important to
carefully elevate the margins of the periosteum to
reduce tearing and enhance closure. The medial peri-
osteal release must allow for visualization of the entire
width of the iliac crest. Even though the greatest
reservoir of cancellous bone is in the region of the
posterior superior iliac spine, great care must be
taken in this area. Periosteal reflection should not
extend closer than 1 cm to the posterior superior iliac
spine to avoid damage to the adjacent sacroiliac liga-
1500
FIGURE 4. Initial osteotomies are completed with a reciprocating
saw and osteotomes through the cortical bone at the iliac crest and the
lateral cortical plate.
ments. Numerous reports ranging from mild pelvic
instability to frank dislocation have been described
from excessive ligamentous disruption.18-21 Subluxa-
tion and dislocation with or without disruption of the
pelvic ring have occurred primarily after removal of
full-thickness grafts. Herniation of abdominal contents
has been reported after harvest of full-thickness
grafts.5,22,23
Once the gluteal attachments are released, a Cobb
periosteal elevator is used to further extend the peri-
osteal-muscle retraction inferiorly and laterally, expos-
ing the lateral surface of the ilium to a depth of
approximately 5 cm. This depth of dissection does
not expose the sciatic notch. The Taylor retractor is
placed at a depth of approximately 5 cm and stabi-
lized. Care is taken not to change the position of the
Taylor retractor to prevent its dislodgement into the
sciatic notch. The superior gluteal artery and nerve
course together in the most superior aspect of the
sciatic notch and have been injured by trauma from
the Taylor or other retractor.24 If injured, the superior
gluteal artery may retract proximally into the pelvis,
making hemostasis very difficult to achieve.14,25 The
ureter and the iliac vessels are also closely related to
the sciatic notch and have been traumatically injured
in several reports.5,25-27
Depending on the size and shape of the osseous
defect to be reconstructed, a reciprocating saw is
positioned approximately 4 to 5 cm inferior to the
iliac crest and 1 cm anterior to the posterior superior
iliac spine and the graft outlined. Under copious irri-
gation, the saw is used to score the cortical bone
perpendicular to the crest. A 1-cm-wide straight os-
teotome is used to score the cortical bone perpendic-
ular to the crest. A 1-cm paralleling cut, at the same
depth, is also completed to the crest (Fig 4). This
reduces the stresses placed on the posterior iliac
POSTERIOR ILIAC CREST BONE HARVEST
spine and sacroiliac joint and reduces the potential for
stress fractures of the iliac bone. A curved osteotome
joins the inferior aspect of the osteotomies. A 1-cm-
wide straight osteotome is used to score the crest
toward the inner table and redefines the paralleling
cuts. A curved osteotome is then used to complete
the cortical bone cuts.
The cortices of the posterior ilium converge
slightly at the depth of the harvest site, although
much less than the anterior ilium. Therefore, care
must be taken not to perforate the inner table and risk
injuring structures previously described. The os-
teotome should be allowed to “track along” the inner
table inferiorly until the corticocancellous block is
delivered (Fig 5). Additional corticocancellous blocks
are harvested in the same manner. Being able to
visualize the curved osteotome edge in the initial
block removal site lets the surgeon maximize the
block thickness while lowering the risk of perforating
the medial cortex. Once adequate blocks have been
harvested, cancellous bone is retrieved from the mar-
gins and the inner table with gouges and curettes (Fig
6). The bony margins are smoothed with a bone rasp,
and the wound is copiously irrigated with a saline
solution. Microfibrillar collagen is fluffed into the
wound and carefully packed into the bleeding cancel-
lous margins for hemostasis. Recently, in cases where
platelet-rich plasma is used to supplement the bone
graft, platelet-poor plasma is added to the donor site
defect for hemostasis.
Interrupted 2-0 polylactic acid sutures are placed to
reapproximate the periosteal layer. Before completely
closing the periosteum, a 20-gauge catheter is in-
serted percutaneously near the superior aspect of the
incision and directed toward the osseous defect. The
introducing needle is removed, and a radiopaque
FIGURE 5. The initial “strip” of corticocancellous bone is delivered.
Subsequent strips may be harvested visualizing the lateral surface of
the medial cortical plate of the iliac wing.
MAZOCK, SCHOW, AND TRIPLETT 1501

be delivered for a duration of 2 to 7 days without

refill.
Intermittent delivery of anesthetic can be per-
formed by the patient through the catheter after they
have been instructed on the appropriate amount (3
mL) and technique for delivery. This option has been
well tolerated by patients and relieves them of the
burden of carrying the infusion pump. Our results
with both intermittent and continuous infusion have
been excellent. Many orthopedic surgeons are cur-
rently using similar anesthetic infusion techniques
following joint operations on shoulders and knees.29

FIGURE 6. After harvest of several corticocancellous blocks, addi- Record Review

tional cancellous bone may be harvested with curettes and gauges. Up
to 150 cc3 of bone may be harvested from a single posterior iliac Thirty-four cases of PIC bone harvest were reviewed
donor site. for incidence and types of complications. The bone
procurements were performed from 1998 to 2002 un-
der the supervision of the same surgeons using the
polyamide epidural catheter (Braun Medical Inc, previously described technique. Thirty-three patients
Bethlehem, PA) is inserted through the introducing underwent unilateral PIC harvest and 1 was bilateral, for
catheter into the depth of the wound. The catheter is a total of 35 operated sites. The ages ranged from 20 to
removed, and a bacteriostatic 0.22-␮m Millipore filter 79 years with a mean age of 50 years. Three minor
(Millipore, Carrigtwohill, Ireland), which contains a complications (8.57%) and 1 major complication
Luer-Loc (Becton, Dickinson & Co, Franklin Lakes, (2.85%) were encountered. The sole major complication
NJ), is affixed to the distal end of the epidural cathe- was a patient with a neurosensory deficit in the distri-
ter. The catheter is shortened for convenience, and bution of the superior cluneal nerve. The sensory dis-
the bacteriostatic filter is capped off. Approximately 3 turbance developed immediately postoperatively and
mL of 0.5% bupivacaine is given as an initial bolus resolved by 6 months postoperatively.
dose. The periosteum is subsequently closed com-
pletely, leaving the catheter in a subperiosteal loca-
tion. A 3-0 nonresorbable suture is used to secure the
catheter to the skin to prevent accidental displace-
ment throughout the remainder of the case (Fig 7).
The remainder of the incision is closed in layers to
eliminate dead space and further reduce the risk of
seroma and hematoma formation. Placement of a
drain is not routine, unless dictated by heavy oozing.
A clear, semipermeable adhesive covering and a pres-
sure dressing are then placed over the surgical site.
Postoperatively, local anesthetic can be infused
into the donor site through the catheter intermittently
or with a continuous infusion pump, depending on
the surgeon’s preference. Bupivacaine has been
shown to provide adequate relief of postoperative
pain.28 Compliance and education of the patient and
family in addition to ready availability of sterile anes-
thetic syringes, needles, and desired local anesthetic
must be considered in advance.
Continuous infusion pumps are commercially avail-
able as self-contained, portable appliances that are
transported by the patient via a shoulder strap attach-
ment. The continuous infusion pumps tend to be FIGURE 7. An epidural catheter capped with a 0.22-␮m Millipore
filter with a Luer-Loc injection port is placed to the depth of the wound.
more cumbersome for the patient. The continuous The catheter is used for intermittent injection of 0.5% bupivacaine for
infusion pumps can carry an anesthetic dose that may postoperative analgesia.
1502
The 3 minor complications included the postopera-
tive formation of seromas. Once a seroma is suspected,
it should be aspirated and adequate pressure dressing
applied to reduce dead space and enhance attachment
of the 2 surfaces. If multiple aspirations are required, a
polyethylene catheter may be placed and attached to
negative suction. Prompt treatment is indicated because
the presence of a seroma increases the incidence of
subcutaneous infection. The same situation applies to
subcutaneous hematomas, and drainage is required, be-
cause the blood affords an excellent culture medium
and prevents apposition between the 2 surfaces.30
These were all managed conservatively and subse-
quently resolved spontaneously. No reoperations were
required.
Discussion
Our results compare well with the incidence of
other posterior and anterior hip complications re-
ported in our literature and very well to the incidence
of major and minor complications cited in the ortho-
pedic literature.23,31 Prevention of complications is
achieved by focusing on the techniques we have
described with attention paid to good layered closure
and the application of an adequate pressure dressing
for the prevention of seroma formation.
The iliac crest is a common source for autologous
bone grafts in oral and maxillofacial surgery. Approx-
imately 50 cm3 of corticocancellous bone may be
obtained from the anterior ilium. The risk of local
morbidity to vascular supply, musculature, and ner-
vous system significantly increases when attempts to
harvest a greater amount of bone from the anterior
ilium are performed. When the demand for cancel-
lous bone exceeds 50 cm3, the posterior ilium offers
the greatest single reservoir.
It has been shown that approximately 100 to 150
cm3 of corticocancellous bone can be safely har-
vested from the posterior ilium.1 This is because of
the uniform thickness of the PIC and the uniformity of
its width to the depth of the harvest site inferiorly.
Extending the dissection for harvesting of additional
bone does not increase the risk for blood loss, gait
disturbances, pain, or overall morbidity.2,23
The advantages of the posterior ilium harvest out-
weigh the disadvantages, when a greater amount of
bone is needed. The advantages can be summarized as
an increase in harvest volume, minimal postoperative
pain, early ambulation, and low incidence of overall
complications. The disadvantages include increased
surgical time due to patient positioning and the in-
ability to perform simultaneous procedures compared
with anterior ilium harvest. The convenience of per-
forming the anterior ilium harvest in conjunction with
POSTERIOR ILIAC CREST BONE HARVEST
an additional team preparing the recipient site signif-
icantly decreases surgical time. In respect to the ad-
ditional time needed to turn the patient, performing
the posterior ilium harvest can add as much as 60 to 90
minutes to the procedure. Using sound surgical tech-
nique, a generous amount of autogenous bone can be
harvested from the PIC with minimal morbidity.
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