Scott Bartlett, Michael Ehrenfeld, Gerson Mast, Adrian Sugar
Edward Ellis III
Incision should be placed in the "bikini line" lateral to the anterior iliac crest.
The direction of the approach should then be changed to allow direct access to the iliac crest. Minimal tissue dissection is carried out to avoid opening up tissue spaces.
An incision is made lateral to the anterior crest in the avascular plane superior to the upper lateral thigh muscles down to cartilage or bone.
A transverse incision is made across the iliac crest approximately 1 cm behind the anterior superior iliac spine (to avoid damage to the lateral cutaneous nerve of the thigh).
Orthopedic osteotomes are then used to perform transverse...
...and sagittal osteotomies to raise the crest pedicled medially on the muscles of the abdominal wall and exposing the cancellous bone.
Note: In children with a cartilaginous iliac cap the crest can simply be raised by raising the cartilage from the bone with a knife (without the use of osteotomes).
A narrow orthopedic gouge is then used to harvest cancellous bone.
When sufficient bone has been obtained the defect in the ilium is packed with a hemostatic agent.
The lid is replaced and fixed with strong resorbable sutures.
Pearl: For good postoperative pain control, an epidural cannula may be inserted into the wound and secured to skin with adhesive tape.
The wound is then closed in layers with resorbable sutures.
Particular attention is paid to the use of a buried subcuticular suture for the final skin closure with the knot on each end also buried.
Ideally, the use of a subcuticular closure with a resorbable suture will obviate the need of suture removal.
The wound closure can also be reinforced by adhesive tape and a dressing
The wound is then filled with long acting local anaesthetic through the epidural cannula.