Received: 25 January 2000

Revision requested: 22 May 2000

Revision received: 15 September 2000
Accepted: 4 January 2001
Abstract Objective. To report the
imaging findings in nine patients
who developed pelvic instability af-
ter bone graft harvest from the poste-
rior aspect of the iliac crest.
Design and patients. A retrospective
study was performed of the imaging
studies of nine patients who devel-
oped pelvic pain after autologous
bone graft was harvested from the
posterior aspect of the ilium for spi-
nal arthrodesis. Plain films, bone
scans, and CT and MR examinations
of the pelvis were reviewed. Perti-
nent aspects of the clinical history of
these patients were noted, including
age, gender and clinical symptoms.
Results. The age of the patients
ranged from 52 to 77 years (average
69 years) and all were women. The
bone graft had been derived from the
posterior aspect of the iliac crest
about the sacroiliac joint. All pa-
tients subsequently developed sub-
luxation of the pubic symphysis.
Eight patients had additional insuffi-
ciency fractures of the iliac crest ad-
jacent to the bone graft donor site,
and five patients also revealed sub-
luxation of the sacroiliac joint. Two
had insufficiency fractures of the
sacrum and one had an additional
fracture of the pubic ramus.
Conclusions. Pelvic instability is a
potential complication of bone graft
harvesting from the posterior aspect
of the iliac crest. The pelvic instabil-
ity is manifested by insufficiency
fractures of the ilium and sublux-
ation of the sacroiliac joints and pu-
bic symphysis.
Keywords Pelvis Lumbar spine
Fusion Insufficiency Fracture
Skeletal Radiol (2001) 30:278281
Int Skeletal Soc (ISS) 2001 ARTI CLE
Karence Chan
Donald Resnick
Mini Pathria
Jon Jacobson
Pelvic instability after bone graft harvesting
from posterior iliac crest:
report of nine patients
Introduction
The posterior portion of the ilium is a common harvest
site for autologous bone graft used for various surgical
applications such as spinal arthrodesis and reconstructive
surgery [1]. This site is popular because of its large quan-
tity of cancellous or corticocancellous bone [2]. However,
there are a few complications that have been associated
with such harvesting, including infection, hematoma,
neurologic and vascular injury, acute fracture at the har-
vest site, and muscle or bowel herniation through this site
[3]. Some of these complications are readily recognized
and are treated accordingly, but others are overlooked [4].
In 1972, Coventry and Tapper reported six cases of pel-
vic instability after bone graft had been harvested from the
iliac bone [5]. Since then, this complication of harvesting
has not been addressed and is unknown to many physicians.
When this instability develops, patients symptoms very of-
ten are nonspecific and can be indistinguishable from those
of many spinal disorders [5]. Therefore, vague lower back
pain, resulting from pelvic instability, is often attributed to a
pre-existing back problem, and is not recognized or treated.
In this study, we report nine patients with such a com-
plication, i.e., pelvic instability after harvesting of bone
from the posterior aspect of the iliac crest, causing per-
sistent disability after lumbar or lumbosacral fusion.
Supported by VA Grant number SA-360
K. Chan M. Pathria J. Jacobson
Department of Radiology,
School of Medicine, University of California,
San Diego Medical Center, San Diego,
CA 92103-1990, USA
D. Resnick (

)
Department of Radiology (114),
Veterans Affairs Medical Center,
San Diego, CA 92161, USA
Present addresses:
K. Chan, Department of Radiology,
One Hoag Drive, Newport Beach,
CA 92663, USA
J. Jacobson, Department of Radiology,
University of Michigan Medical Center,
Taubman Center 9210 G,
1500 East Medical Center Drive,
Ann Arbor, Michigan 48109-0326, USA
279
Materials and methods
We retrospectively reviewed the imaging studies in nine patients
seen during a 2-year period who developed pelvic pain after autol-
ogous bone graft had been harvested from the posterior aspect of
the ilium for spinal fusion. Conventional radiographs of the pelvis
were evaluated. Patients with subluxation of the pubic symphysis
or sacroiliac joints, or both, and/or sclerosis of the ilium were se-
lected. Pertinent clinical histories, information regarding the type
of surgery that had been performed, the site of bone graft, and the
interval from the times of surgery to the first radiographic exami-
nation demonstrating pelvic instability were studied. Available
bone scans and CT and MR imaging studies were also reviewed.
MR imaging was obtained on Signa 1.5-T superconducting
unit magnet (General Electric Medical Systems, Milwaukee,
Wis.). The following pulse sequences were used: sagittal T1-
weighted (TR/TE, 550/160) and T2-weighted (TR/TE, 3900/96)
with field of view 2727, slice thickness 4 mm and 4 NEX; and
axial proton density (TR/TE, 3150/17) and T2-weighted (TR/TE,
3150/102) with field of view 2020, slice thickness 6 mm and 2
NEX. T1-weighted (TR/TE, 550/16) images obtained with fat sat-
uration following intravenous administration of a gadolinium-con-
taining compound were also available in one patient; the matrix
was 256192. CT scanning (General Electric, High Speed Advan-
tage, Milwaukee, Wis.) was performed with contiguous axial sec-
tion of 5 mm thickness through the pelvis.
Results
All patients were women. Their age range was 52 to 77
years (average 69 years). None of the patients had bone
densitometry performed prior to the surgery and none of
the patients had metabolic or metastatic bone disorder.
All had bone graft removed from the ilium for lumbar
spine fusion, a procedure that was performed by several
different spine surgeons. Five patients had graft taken
from the posterior aspect of the right ilium, three from
the left, and one from both sites. Three patients under-
went repeated bone graft harvesting from the same site.
After surgery, all developed vague pelvic pain, which
was different from the type of back pain they had experi-
enced prior to surgery. Six patients developed pain with-
in months of the surgery. Information regarding the tem-
poral relationship of the pain and the time of surgery was
incomplete in the other three patients (Table 1).
Soon after the onset of pelvic pain, conventional ra-
diographs were obtained as summarized in Table 1. All
patients developed incongruity at the pubic symphysis
(Fig. 1). Eight patients also had an additional fracture of
the ilium at the site of harvesting (Fig. 2), and two had a
positive bone scan (Fig. 3) at these sites as well as ab-
normal radionuclide accumulation in the sacroiliac joints
and pubic symphysis. Five patients had subluxation of
one or both sacroiliac joints. One patient had sclerosis of
both iliac crests but no further study was obtained.
Moreover, two patients had additional fractures of the
sacrum, and one had a fracture of the pubic rami.
One patient had additional CT and MR studies (Fig.
4). Both studies demonstrated a fracture of the ilium at
the harvest site. Both sacroiliac joints were widened and
subluxed. Fracture fragments were noted around the sac-
roiliac joints. MR images showed edema in the sacrum
and ilium and about the sacroiliac joints.
Discussion
The most common site used for bone graft harvesting is
the posterior aspect of the ilium, just posterior to the sac-
roiliac joint and extending to the posterior rim of the ili-
ac crest. Occasionally, the harvest site also is extended to
the sacroiliac joint when large amounts of cancellous
bone are needed for surgery, but the harvesting proce-
dure should not violate the sacroiliac joint itself [2]. Al-
though violation of the pelvic ring is known to cause pel-
vic instability, this is not reported as a complication of
this type of surgery, probably because proper respect is
given to the important posterior stabilizing structures of
the pelvis at the time of surgery. However, in our pa-
tients, pelvic instability developed within a few months
after the harvesting procedure, suggesting that the insta-
bility was a complication of the procedure itself. By the
surgical removal of a significant amount of bone, the
strength of the posterior pelvic ring clearly weakens. The
distribution of mechanical forces applied to the pelvic
frame changes, and the risk of deformation of the pelvic
bones increases substantially [6]. Three of nine patients
Table 1 Patient analysis
(+, positive; , negative)
Patient no. Interval from time Symphysis pubis Harvest site Sacroiliac
of surgery to positive subluxation/ fracture joint
imaging findings dislocation subluxation
1 3 months + +
2 3 months + + +
3 2 months + +
4 Unknown + + +
5 7 months + + +
6 ? 7 years +
7 Unknown + +
8 1 month + + +
9 4 months + + +
280
Fig. 1 A 52-year-old woman had bone graft harvested from the
right iliac crest. Two months later, she developed pelvic pain. Pel-
vic film shows subluxation and bone sclerosis at the pubic sym-
physis (arrow)
Fig. 2 A 72-year-old woman with bone graft removed from right
iliac crest. Three months later, her pelvic film shows subluxation
at the pubic symphysis and fracture (arrow) of right iliac bone, at
the graft harvest site
Fig. 3AC A 68-year-old woman with pelvic insufficiency frac-
ture. A Initial radiograph of the pelvis reveals the bone graft har-
vesting from the left iliac crest. The pubic symphysis is normal.
B Bone scan obtained 2 years later shows intense uptake in poste-
rior portion of both ilii, sacrum, about both sacroiliac joints, and
pubic symphysis. C Pelvic radiograph obtained 7 months later re-
veals dislocation of the pubic symphysis (arrows) with the pubic
bones overlapping on top of each other. Both iliac crests showed
increased sclerosis, consistent with insufficiency fractures
281
in our study underwent repetitive bone graft harvesting,
with material derived from the same site, further sup-
porting the hypothesis that excessive and aggressive re-
moval of bone from the posterior aspect of the pelvis in-
creases the risk of pelvic fracture. Lichtblau [7] and
Coventry and Tapper [5] emphasized that the major liga-
mentous support of the sacroiliac joint is posterosuperior
in location. Removal of bone graft from the posterior as-
pect of the ilium potentially can destroy some of the lig-
aments, leading to pelvic instability as well.
Although none of the patients had bone density evalu-
ation prior to the bone graft harvesting, the fact that all
the patients were women and elderly suggests pre-exist-
ing osteopenia or osteoporosis may also predispose such
patients to insufficiency fractures when the distribution of
force around the pelvis has been altered and the posterior
supporting ligaments have been weakened. Perioperative
immobilization causes further disuse osteopenia, also pre-
disposing to pelvic instability. Perhaps, in elderly women,
evaluation of bone density should be performed before
considering autologous bone graft harvesting. If a patient
has pre-existing osteopenia, alternative sources for graft
material, such as cadaveric bone, should be considered.
In our series, the most common initial imaging mani-
festation of pelvic instability was subluxation or disloca-
tion of the pubic symphysis. All patients had such
changes. The second most common radiographic mani-
festation in our patients was diffuse sclerosis just inferior
to the harvest site. A fracture line also may be apparent.
Diastasis of the sacroiliac joint adjacent to the harvest
site also was a common finding in our series. Insufficien-
cy fractures also involved the sacrum. Therefore, when
evaluating a radiograph of the pelvis following such har-
vesting procedure, the symphysis pubis, sacroiliac joint,
sacrum, and harvest site should be assessed.
There are a number of limitations to our study. First, as
we did not review all patients undergoing such harvesting
procedures, we do no know the frequency of this complica-
tion. Second, as we also did not review all such postopera-
tive patients with persistent or new back pain, we do not
know the frequency of this complication in symptomatic
patients. Third, although several different surgeons had
performed the procedures in our patients, it is not clear
whether some specific aspect of the surgery was instru-
mental with regard to subsequent pelvic instability. All
were experienced spine surgeons, however. Fourth, the
number of patients reported here is small and our observa-
tions are restricted to those undergoing lumbar arthrodesis.
It is possible that fusion of the lumbar spine, as compared
with the thoracic or cervical spine, alters the distribution of
forces applied to the pelvis. Obviously, analysis of a larger
series of patients undergoing various surgical procedures
of the spine requiring harvesting of bone from the pelvis
needs to be accomplished. Finally, our purpose was to re-
port this complication and to review the associated imag-
ing findings; we are unable to document the diagnostic ad-
vantages of one imaging method compared with the others.
In conclusion, pelvic instability is a potential compli-
cation of harvesting of bone from the posterior aspect of
the iliac crest. Such instability is manifested by insuffi-
ciency fractures of the ilium or sacrum, or both, sublux-
ation of the sacroiliac joint, and fracture or dislocation of
or about the pubic symphysis.
Fig. 4 A 52-year-old woman had multiple spinal fusions. Bone
graft was repeatedly obtained from both iliac crests. One month af-
ter the final bone graft harvesting, she developed severe lower back
pain. CT scan of the sacrum shows fractures of both iliac crests and
sacrum with subluxation of both sacroiliac joints (arrows)
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