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Understanding Bone Safety Zones During Bone Marrow Aspiration from the Iliac Crest: the Sector Rule

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Understanding Bone Safety Zones During Bone Marrow Aspiration from the Iliac Crest: the Sector Rule International Orthopaedics (SICOT) (2014) 38:2377–2384 DOI 10.1007/s00264-014-2343-9 ORIGINAL PAPER Understanding bone safety zones during bone marrow aspiration from the iliac crest: the sector rule Jacques Hernigou & Laure Picard & Alexandra Alves & Jonathan Silvera & Yasuhiro Homma & Philippe Hernigou Received: 23 March 2014 /Accepted: 25 March 2014 /Published online: 3 May 2014 # Springer-Verlag Berlin Heidelberg 2014 Abstract observed in the thinner sectors. The risk was also higher in Purpose Should the trocar suddenly lose contact with bone obese patients and the risk decreased with more experienced during bone marrow aspiration, it may result in visceral injury. surgeons. The trocar could reach the external iliac artery on The anatomy of the ilium and the structures adjacent to the pelvic CT scans in the four most anterior sectors with a higher iliac bone were studied to determine the danger of breach by a frequency in women. Posterior sectors were at risk for sciatic trocar introduced into the iliac crest. nerve and gluteal vessel damage when the trocar was pushed Methods The authors followed two series of patients, one deeper than 6 cm into the posterior iliac crest. In cadavers, the series to do measurements of distance and angles of the dissection demonstrated nine vascular or neurological lesions. structures at risk to the iliac bone and the other to evaluate Conclusions Using the sector system, trocars can be directed the risk of a trocar being directed outside the iliac wing during away from neural and vascular structures and toward zones bone marrow aspiration. The authors also examined 24 pelvices that are likely to contain larger bone marrow stock. by computed tomography (CT) scans of mature adults (48 iliac crests). Lines dividing theiliacwingintosixequalsectors Keywords Bone marrow aspiration . Complications were used to form sectors (e.g. sector 1 anterior, sector 6 Sector rule for marrow aspiration . Ilium anatomy . posterior). Vascular or neurological structures were consid- Iliac crest anatomy . Iliac artery . Neurologic complication ered at risk if they were accessible to the tip of a 10-cm trocar introduced into the iliac crest with a possible deviation of 20° from the plane of the iliac wing on the three-dimensional Introduction reconstruction. The authors tracked bone marrow aspiration of six different surgeons and calculated among 120 patients There has been growing clinical interest in the harvesting of (480 entry points) the number of times the needle lost contact autologous mesenchymal stem cells [5] through bone marrow with bone in each sector of aspiration. aspiration from the iliac crest. Autologous bone grafts [2, 6] are Results The sector system reliably predicted safe and unsafe used in orthopaedic, neurosurgical and maxillofacial surgeries, areas for trocar placement. Among the 480 entry points in the but there is a risk of pain and morbidity at the donor site. 120 patients, 94 breaches were observed and higher risks were Therapies based on autologous bone marrow cells [8–11] have been examined as a treatment for delayed union or nonunion, J. Hernigou : L. Picard : A. Alves : P. Hernigou (*) malunion, arthrodesis, limb salvage and reconstruction of bone Department of Orthopedic Surgery, Hôpital Henri Mondor, Créteil, defects [13]. Autologous cells harvested from the iliac crest France bone marrow can be used as other alternative therapies [7] e-mail: [email protected] without the complications compared to standard bone grafts. J. Silvera Little information [14] documenting the risks of bone Radiology Department, Hôpital Europeén Georges Pompidou, marrow aspiration in the iliac crest in orthopaedic surgery is Créteil, France present in the literature. Little attention has been paid to the risk to anatomical structures when the aspiration trocar (which Y. Homma Orthopaedic Surgery Department, Juntendo University, Bunkyō, is 10 cm long) penetrates the cortex of the iliac bone but fails Japan to remain within the tables of the crest. Typically, advancing 2378 International Orthopaedics (SICOT) (2014) 38:2377–2384 the trocar by hand often requires excessive downward force of the iliac bone. When the patient is thin enough for the ilium and should the needle suddenly lose contact with bone, per- to be grasped between the thumb and finger of the left hand, a foration of the abdominal cavity and potential visceral injury direct approach is possible and straightforward. When the may result as it has been reported [3, 4, 16, 18]inthe patient is heavier, it is more difficult to retract any overhang- haematological literature. Although orthopaedic surgeons are ing skin and subcutaneous fat and grasp the iliac crest between very familiar with the structures that are anterior, superior and the thumb and fingers. In this situation, the needle tip is used posterior to the iliac crest, many are not as well acquainted with to “palpate” the iliac crest and, once the centre of the crest is those that lie medial or inferior to it, and there is a need to located, the needle tip is seated into the cortical bone with one understand the risks due to bony, vascular and neurological or two brisk taps with a small, lightweight mallet. However, anatomy of the iliac crest and the pelvis. Our interest was advancing the needle by hand or with a mallet often requires piqued after performing bone marrow aspiration [12]in1,800 excessive downward force and should the needle suddenly patients treated between 1990 and 2011 at the Department of lose contact with bone, this may result in the needle perforat- Orthopedic Surgery, Henri Mondor Hospital (Paris, France) ing the abdominal cavity with the potential for visceral injury. where we observed major haematoma (four cases needing transfusion), sciatic palsy (one transient case) and three tran- Definition of the different sectors sient episodes of numbing in the area of the lateral femoral cutaneous nerve occurring after bone marrow aspiration. Al- The iliac wing sectors were formed by extending lines from the though the risk of complicationofbonemarrowaspiration[14] anterior superior and posterior superior iliac spine through the is lower than the risk of conventional harvesting of pieces of the centre of the acetabulum and the bisecting line of the angle iliac bone [15, 17], and although these patients did not need formed by the two previous lines, resulting in anterior and vascular surgery, their cases prompted us to determine the posterior halves (Fig. 1). The mean length of the iliac crest is danger of inadvertent impingement by a trocar introduced into 24 cm, and each half of the iliac wing was divided into three the iliac crest on the structures that lie adjacent to the iliac bone. sectors by drawing lines from points 4 cm apart on the iliac crest Our hypothesis was that when the trocar is introduced into to the centre of the hip. These lines were approximately perpen- some areas of the iliac crest there is a higher risk of incorrect dicular to the curve of the iliac crest. The six sectors were defined angle or excessively deep penetration, particularly in zones by these lines (Fig. 1). The corresponding sectors can be found where the iliac bone is thin. This is due to potentially thinner and marked on the patient by using the same technique (Fig. 2). bone width in some parts of the iliac bone and the need for placing the trocar in the ilium wing bone between the two tables when entering the iliac crest. Our secondary hypothesis Assessing the risk by sector for adverse placement was that there would be an increased risk of injury to vascular of the trocar structures in specific intrapelvic and extrapelvic anatomical structures during implantation of the trocar. To assess the risk by sector of a trocar being outside the iliac Therefore, we have chosen to divide the iliac crest into six crest during bone marrow aspiration, the authors examined six different zones of the iliac crest known as sectors. The sectors were imaged on a series of injected pelvic computed tomography (CT) scans that measured the thickness, maximum available bone depth for trocar purchase in these different parts of the iliac crest and the corresponding vascular structures at risk. Two series of patients were followed: (1) patients who had measurements of distance and angles of the structures at risk with the ilium and (2) patients who had bone marrow aspiration with an evaluation of the risk of a trocar being directed outside the iliac wing. Materials and methods Three different types of patient positioning and three different approaches can be used to harvest bone marrow from the iliac Fig. 1 The iliac wing (three-dimensional reconstruction) was divided by crest: patient supine and anterior crest approach, patient prone drawing lines from equidistant points spaced along the rim of the iliac and posterior iliac crest approach and patient in the left or right crest to the centre of the hip. These lines were approximately perpendic- ular to the curve of the iliac crest. Six sectors were defined by these lines. lateral position allowing medial iliac crest approach. The Sectors 1 and 2 anterior part of the iliac bone, sectors 3 and 4 centre part needle should be inserted between the outer and inner tables of the iliac bone, sectors 5 and 6 posterior part of the iliac bone International Orthopaedics (SICOT) (2014) 38:2377–2384 2379 needle losing contact with bone) of the trocar was measured and it was never found to be higher than 20°. Anatomical structures potentially at risk by sector To describe the anatomical structures that are at risk during trocar placement, we determined the relative contiguity of intrapelvic neural and vascular structures to trocars inserted into specific sectors of the iliac bone.Measurementsweredoneon injected CT scan (Fig. 3)of24anonymouspelvicangio-CT scans of mature adults. The CT scans were performed for the vascular exploration of 12 men and 12 women.
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