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Hernia through an Iliac Bone Graft Donor Site CASE REPORT

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Hernia through an Iliac Bone-Graft Donor Site: A CASE REPORT
ROBERT L. REID
J Bone Joint Surg Am. 1968;50:757-760.



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Publisher Information          The Journal of Bone and Joint Surgery
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             Hernia                            through                                 an Iliac                              Bone-Graft                                         Donor                          Site
                                                                                             A      CASE                REPORT


             BY        LIEUTENANT                            COLONEL                      ROBERT                L.       REID,                1Iolieal            (‘oips,         ( psite(l          Statcs       Army

Front         the Department                        of Orthopaedic                       Surgery,         Letterman                   General              Hospital,             San        Francisco,                California

             Massive                      full-tlsiektsess                        iliac-botte                  grafts                are          cotsstssotsly                   used            its     orthopaedic
surgery,                but          hertiiae                through                   the        donor               site      are            rare.            During                the      last           fifty       years,
otsly         sevets           cases                Isave          beets            reported                   ins the               Etiglish                   literature,                  but         the          trite        in-
cidence                of this              complieatiots                         is utsktsow-ti.




                                                                                   Preoperat             iVe     left        ihiao         (lefect.


             The           nsatsagensetit                          of       the            repot’ted                  hertsiae                 has          varied.                   Oldfield                swung            tlse
apotseurosis                    of          f-he      gluteus                   nsedirts           nsuscle               superiorly                        as     a      flap         eoveritig                the       defect
atsd         imbricated                       the        inferolateral                          edge           of the            al)otseltrosis                          of the exterisal      oblique
muscle              over            it.      A       graft          of          fascia           lata          over          f-lie itssbricatiots                          completed      isis repair.
Lewits             and         Bradley                   repaired                    the defect     usitsg                             the iliopsoas                          frons  within                           and the
low-er            border         of the                 external                   oblique   externally.                                 Bosworth’s                         case itsvolved                            a defect
much              closer            to       the        iliac           crest            thats          its t.lse case                       to       be        described.                   He         believed               the
development                          of       the        hertiia                depetided                 on          the       fornsatiots                    of a rigid    ritig,    atsd                               in his
repair            he     obliterated                         the        ritsg          by        removitig                   bone              on        either    side, t.ratssplatsting                                    the
anterior                portion                    itseluding                   f-he        atiterior-superior                                 spine              atid          its      attachments                          sub-
PeriosteallY    to ats itsferior                                           positiots.    Pyrtek   atsd Kelly                                                     advocated                    the        same            repair
a.s did Lewiti    and Bradley                                              but otslv for small        hertiiae.                                                 For larger                  otses,        they           added
a tatit-alum   prosthesis     atsd                                         a graft    of fascia lata.
         *   J, ster          Arns -           IlOsl)ital,              F Irt       llincker,           Alahansa               3(1360.

vol.     so-. ,        NO.     4.     JUNE            5968                                                                                                                                                                      757
755                                                                                    H. L. HEll)




                            FIG.       2                                                     Fn;.          3                                                                 Fsu.      4
     Fig.     2: Ilernsia     bulging   thtoughs        iliac defect.       A six-inich     inscisioni      ins the a1 nselsnosis            (If t lie ext ernial
oblique          nsttscle   1)arallel atsd lateral           to the left nectits        abdominsis.          Two       fmtrthen    iiiCiSiOiis       (reate    the
fa.scial      flap.
     Fig.     3: Hernia       sac removed        : peritonseism        aiid internal        oblique        stit-itsed.
      Fig.    4: Lateral-ba.--oed      exterisal        oblique     fascial     flap rotated           aisd leading           eolge sutured            inside   me-
mnaininig         iliuns  to) iliacus  fascia.



                                                                                                                                                                     -1




                                                                                                                                                       I.




                                                                                              FIG.          5

      Imisnsediate                postoperat         ive        roenstgeiso)granl.          It      shows           the     enslan-ged              iliao          olefect          :015(1 gs-otsisol      boise
fragnients                 near       suture     line      at     the    superior     edge          of reniainsinsg               iliuns.


             Its f-he l)resetlt                  case,           a differetit         techtsique                    of repair                was            use(I            its which             a lates’al
flap         of f-he apotseUl’osis    of the extertsal                                           oblique                n uscle             was        i’otated                 over         the        defect
atid         attached    to the iliaeus    fascia.

                                                                                     Case            Report
            The      pat      ienst     BIts   a fifty-isiisc-yeai-old               B-bite          B(Ifl511i5         B-ho) was           seens      at          Let termisans           Gensen-al       I Ills-

                                                                                                                  THE     JOURNAL.                OF        BONE         ANI)         Jo)mxT       SURGERY
                                                                          IIE1SNIA                           TlIt(OUGH                             AN               ILIAC                  BONE-GRAFT                                          DONOR                       SITE                                                                       759




                                                                                                                                                                        FIG.               6

    11 (Ui SI go.m 51 gi:tmss I If I)elVis     nisa Ic Ii se yean-  aft en lien-i sin lepain                                                                                                                                         sho lBs              I lie        en slangeol                        lefeo-l                anul                cois-
sIllillISt11115 (If the gillImiRl         l)IIise Iii thie slit StiC site.



pit       :tl        ii    s .\.I)iil                  1 )65                  s-it h a lien-nt in t hromighi                                                 a sllngicIsl                         (lefeot.                in         t lie       left.          ilim inn.           ‘Else               lien-is a                B:t5                Ii rst
isotioe(l ins 1961 , :Ll)l)nIlxifliatel\                                                                                  t hnee             mislInit his                   aftei              a 1)olstenioi lliflil)(IsIIcittlflisillis                                                                  ill      whsichs a left
biollit ioal alstogensllus iliac-hone                                                                                                                       the henisia cattse(l no sVnsptomiis,
                                                                                                                         gnaft haol beens uscol. Insitiall -,                                                                                                                                                                                        hint,
aft en :11)1)11 sxiniiat                                          clv           Ii5#{128}       year,               t   hie 1)i1t iens t first                               heard              bowel                 sominsols                 ins t he mass.                              For           appil                 Iximat                 ely
eight            cci S till list                       hs 1)efl                lie         hen-         hllspit                alizat            11 115, t          lien-c           BIOS         inscn-ea-.insg                        local            i aiis            aft     ci st aisdinsg,                               B-alkinsg,
I Ii      lhnivinsg                     nit        fllstI             Iii1lI1)ile.                    kt       i 5(1 I         imsie B-en-c t hen-c                                       mv          gast         iIliistcst                 usa! svml)t                         1)1155.

                 Fhse               1)at ienst                     BIts              a slightly                          obese             Bliitc                   wllnsaii,                   BhIIse                   general                  1)liysical                     exansinsat                       illU           BItS                isor-

misah.            A. Bell                        hiealed                            1st     em         Ii    nsiol-hinse                     lunibar                        115(1510           (hal         50ai               Bas            1)reseist..                  Ins t lie regil                        lit     (If          t lie          left
(      1st      eniI)n               i liac              (nest            ,     It         t ensolen                nnass               nicaslnrinsg                           t hree                 b-          five          censt imsseten-s                           BSLS           1)Isll)al)le                          Buds                   t hse
1)atienst Ba5                                 eneot                   ansol              BIlS   stnaiisinsg (Ii cl)ughsinsg.    \.us(lsltatillns revealed                                                                                                         boBel               511015015                     fl          the           niiass.
\Vhseis I hie                           1)11t ieist                      as               nelaxed    or slipinse,    I he miiass B_as easily neoliscible,                                                                                                         :115(1 (lefect ins t lie
                                                                                                                                                                                                                                                                       a                                                                      ilimins,
:tl)l)ioXiniiatelV                                          flllin            l)\          sevens             oeist inieters,                                BIt5            1)alPable.
                 B          1(9     st ge-n s gnanss                                 I If t      lie 1)elvis                       shsl Iweol                 a (lefect                     ins I lie left                       ilisinsi          ( Fig.              I   ).     Thie            (It     lien           labl           hat           (Ii

examisinsat                        ilIils              vene              nsllnmnal.                     The              stosli          guaiac                      t est           Bas          isegat              ive        (Iii         t hiee            olocasilliss.
                ( )ns .\.pril                      2 1 , 1 1)6.5, t lie lien,                                       s ia vas               nel)Isineol.                       Thsn          high             a 01 invc(l                      ins cision s f Illol%%-insg t hse ci-est                                                        ( If    t he
ililsns                   tisll exteisdiisg                                     distally                     as           ins the                iiiStCi1II1                    ihiofensllnal                         appi-oaoh,                           the          rcmainsinsg                             ihimsmss ai5(1                              its
at t tOhiell                       glut           ei         sene              idenst            ified.                 i he       samssage-shsapeol                                       Iserisial                sac          B ILs          B it      hiiis an iliac                       olefect                    mea.usn-insg
flllir           h            seveis censtinieters.                                                   Tnaotillns                       was          a )plieo1                    to        the         hienisial                     use with                   (Iansl)s                  Bhiile                Use             iliumu                mis-
niseoliat                  clv         aOlj a(eis                       t t I I t he                  (lefeot                  v:is       fneeol              I If t         he ext erisal                          gllstei               ansol us I dual                             iliad              is.      The                 sac            was
Ilpeiseol                     tisll          exoised,                         and               the         penmtllnseltmsi                         BIt5             olllsed                lssinsg               a nltnsisinsg                   00 (hsnI)nuo                              catgut                      slstllie.                    Fhse
    e
:tist nilIi-slIl)(9ilIi                                            iliflOsl)iise Bas                                      (let :sohsed                   B-it Is ans ostellt                                Ilmise,            leaving                   all      sl)ft-t issue                          at t :uhsniso-nst                            s ins

Place.                    .1t.iS Ssnsslsooessfl                                     1 at t en)j)t                                  nsa(le            t   II    flil)V                  t his          pmeoe              (If     hI lise           l)llstenmorly                      ansd     dist ally                                      a       dc-
scnibell                     l)\            lI    15BI            lit     Ii              Ihie         1)l    lie          1)1st        CiIl)i           l(I(Itt              1015        of       t lie          olefect               iii      t Isis oase                      vas    I lie ieasllis                                 fun           I-lie
f:sihsie                    (If      t hsis            miianlelsven.                             ,-\.ftem                I isis        failed,                t he            ext enisal                    III)hmolltc                 fasoia                 aisol        aponsettiosis                                weic                     fred!
fl-I I            Soaipas                              fasoia                  I sy hI mm5 t olisseot                                  11lit , 1)iI Iced                       liisg           ansI        cr11     sily,            aiflil       1st          t I I I hse liisea                       all):!.           .\.      six-in                   (hi
liScisillis                   (Fig. 2)                           :ss theis niiatle us the extciisal                                                                     IIh)liOflnc al)llileliiIIsis                                                          lateial III ihit laieial
                                                                                                                                                                                                                                               1)m1itll( 1-sisd
hI hold                     I If      t he             left             i-cot        (iS        aboll         Iniiiisis                iiiliscle.                   _ \.t       t lie          l)IoXiniial                      :515(1 olistal                    ensds              of       t his             miscisil               lii,          t.B()

1)itiitll( l              Beidii SOisiI            1155                                  miitsole at. an s aisgle      t o it , cleat ing a millsscsslofasomal             flap based slil)eiiI                                                                                                                                   Ii      t I I I hse
Ilefect    aisol j list mne(lial                                                         I I I it , Ilt tachseol I 01 the slsbst    :515cc (If I lie extenisal       I Ibhm(1lse  mismiscie. The                                                                                                                                  flap                 as
I hseis II Itmit dli laterall                                                            mtisol insfeiionlv, aisd t lie leaoling            edge     vas     stst lsieol     Bit h 00 ohinllnsic                                                                                                                                    sut              lti(15

iisside                   I lie       ilitins                t   II     I lie            ihia(lis            fascia                   ( Figs.            3          tis(l       4    ).     The             boise              I hat           hind            beens             remss(Ive(1                    1 II wioleis                          I hse
Ilefe(t                    %\-:Is           gilllsiso!                   us          a      boise            null and                        plaoe(1 iseam thse fasoial ststuie line at                                                                                          the          lIlBem                    edge              (If         the
lldfdot               .      Fhse i(miitiiS(ldiof the                                                       \VI)ltilOl BIts                       (1(lse(lus layeis, :115(1ais al)oll)niimnsalbinsolen                                                                                             :o.- :spplieol.                                    Fhie

Vo)L.            50-A.                NO)              4.        JiNi                    5965
760                                                                      R.   L. REID


estimated         blood           cubic centimeters.
                                loss was        500     After   six weeks    of complete bed rest, progressive
walking         was     begun         There was no recurrence
                                    as tolerated.                   of the hernia in the follow-up     of twenty
months.    No defect has appeared      in the anterior    abdominal      wall where the external     oblique ap-
oneurosis flap originated. The patient has resumed          her former level of activity without symptoms.
A roentgenogram     made immediately      after surgery (Fig. 5) showed the enlargement       of the iliac defect
and     the    ground       bone         near   the   superior   edge     of remaining         ilium.   At    one    year    after   surgery,       a roent-
genogram          of the        pelvisshowed consolidation                    of the ground         bone     (Fig.   6).    Subsequemst         roemstgeno-
grams         showed      essentially    no further change.

                                                                        References
1.    BOSWORTH,      D. M. : Repair       of Herniae      through     Iliac-Crest     Defects.       J. Bone and Joint- Surg.,
   37-A : 1069-1073,           Oct. 1955.
2. LEWIN,      M. L., and BRADLEY,            E. T. : Traumatic       Iliac Hernia with Extensive               Soft Tissise Loss.
   Surgery,      26 : 601-607,      1949.
3. OLDFIELD,       M. C.: Iliac Hernia          after Bone-Grafting.        Lancet-,   1 : 810-812,       1945.
4. PYRTEK,       L. J., and KELLY,        C.: Management           of Herniation     through        Large Iliac Bone Defects.
   Ann.     Surg., 152 : 998-1003,        1960.




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