Generally speaking, at this stage we believe that the iliac crest is best suited for the reconstruction of a curved bone and the fibula for the repair of a long bone. Our most gratifying results have been in jaw reconstructions, and it is notable that, in one patient, virtually the entire mandible was reconstructed with bone from one hip. Several alternative designs are available for this purpose,2,6 and it is possible to achieve an exact replica of the lower jaw by careful bone sculpture and osteotomies where appropriate, at the same time retaining an intact blood supply. Although other techniques are available for smaller defects of bone and soft tissue, we believe this graft is unsurpassed for the large composite defect of the jaw.

Similar results have been achieved with reconstruction of the pelvis and the medial arch of the foot, where the iliac crest contour provides a favorable match. Most difficulties have been experienced with reconstruction of the long bones of the extremities, and here the graft is still being refined.

In the upper extremity, the fibula is unparalleled for the long bones. The iliac graft is generally too bulky, except perhaps in the region of the large joints. So far, we have used this graft to fuse the wrist in a patient in whom there was a large defect involving the radius, the carpus, and the first metacarpal bone, and in another to reconstruct the distal humerus and elbow joint.

In the lower extremity, this graft has proven highly successful for one-stage repair of the soft tissues and of bone defects as large as 8 cm. A relatively straight length of the iliac crest can be harvested for this purpose between the anterior superior iliac spine and the tuberosity of the iliac crest. In three cases, however, this graft was used to repair tibial defects of 11, 12, and 13 cm. In each patient the curved graft united at each end, but in two patients late fracture was seen in the center of the graft at 1 year. Both united spontaneously within 4 to 6 weeks, but one required an osteotomy of the graft because of malunion. In the third patient, the bone in the line of weight-bearing stress remodeled, but that portion of the crest outside the line of the tibia did not. An osteotomy of this portion of the bone was necessary 3 years after the transfer because of the unacceptable leg contour.

To overcome this problem, we have devised a step osteotomy of the graft, done at the time of transfer, to straighten the bone curvature. To date, this has been performed successfully in one patient to repair a 14 cm defect of the tibia combined with what has been our largest skin flap thus far.2

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