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BONE GRAFTS

:Historical background
Surgeons have gained their experience in

reconstruction from the numerous wars

It started in WW I and concentrated around reconstruction

of the mandible but without antibiotic support


In WW II distant bone blocks were transplanted from the
ilium, rib and tibia with routine use of antibiotic
No cancellous cellular marrow

Mowlem in 1944, introduced the concept of Iliac

cancellous bone chips beginning the evolution of


predictable bony reconstruction of the jaw bone
Boyne brought about the use of particulate bone and
cancellous marrow with metallic trays splinted to large
acellular cortical bone

Unlike other tissues, the bone can regenerate


and repair itself: in many instances, bone
injuries and fractures heal without scar
formation .
Nevertheless, in pathological fractures or large
and massive bone defects, bone healing and
repair fail. Insufficient blood supply, infection
of the bone or the surrounding tissues, and
systemic diseases can negatively influence
bone healing, resulting in delayed unions or
non-unions .
Bone is the second most commonly
transplanted tissue after blood.

Bone grafts
autografts
allografts
demineralized bone matrix (DBM)

synthetics
bone morphogenetic protein (BMP)
stem cells

Epidemiology
incidence

almost 1 million bone grafting procedures performed


in US each year, with a growth of almost 13% per
year

Indications
assist inhealing of fractures, delayed unions, or

nonunions
assist inarthrodeses and spinal fusions
replace bone defects from trauma or tumor

Properties
Bone graft has aspects of one or more of these

three properties
osteoconductive

material acts as a structural framework for bone growth


demineralized

bone matrices (DBMs)

osteoinductive

material contains factors that stimulate bone growth and


induction of stem cells down a bone-forming lineage
bone

morphogenetic protein (BMP)is most common from


the transforming growth factor beta (TGF-B) superfamily

osteogenic

material directly provides cells that will produce bone


including primitivemesenchymal stem cells,
osteoblasts, and osteocytes
mesenchymal

stem cells can potentially differentiate


down any cell line
osteoprogenitor cells differentiate to osteoblasts and
then osteocytes

cancellous bone has a greater ability than cortical bone


to form new bone due to its larger surface area
autologous bone graft (fresh autograft and bone
marrow aspirate) is the only bone graft material that
contains live mensenchymal precursor cells

Autograft

Bone graft transferred from one body site to another in the


same patient
Indications
gold standard
Properties
osteogenic, osteoinductive, and osteoconductive
least immunogenic
cortical, cancellous, or corticocancellous
vascular or nonvascular
Fresh autografts contain surviving cells and osteoinductive
proteins such as BMP-2, BMP-7, FGF, IGF, and PDGF

Donor sites
iliac crestis the most common site for autograft

provides both cancellous and cortical graft


2% to 36% complication rate
blood loss and hematoma
injury to lateral femoral cutaneous or cluneal nerves
hernia formation
infection
fracture
cosmetic defect
chronic pain

fibulaandribsare most common sources of vascularized

autografts
tibial metaphysis

Allograft
Bone graft obtainedfrom a cadaverand

inserted after processing


Most commonly used bone substitute
Properties
osteoconductive onlydue to lack of viable cells
the degree of osteoconduction available depends on
the processing method (fresh, frozen, or freezedried) and type of graft (cortical or cancellous)
cortical, cancellous, corticocancellous,

Processing methods
debridement of soft tissue, wash with ethanol (remove live cells), gamma
irradiation (sterilization)

dose-dependent higher doses of irradiation kills bacteria and viruses but may
impair biomechanical properties

fresh

allograft

cleansing and processing removes cells and decreases the immune response
improving incorporation
indications
rarely used due to disease transmission and immune response of recipient

frozen

or freeze-dried

reduces immunogenicity while maintaining osteoconductive properties


reduces osteoinductive capabilities
shelf life
one year for fresh frozen stored at -20 degrees C
five years for fresh frozen stored at -70 degrees C
indefinite for freeze-dried

Demineralized bone matrix


(DBM)
Acidic extraction of bone matrixfrom

allograft
removes the minerals and leaves the

collagenous and noncollagenous structure and


proteins

Properties
osteoconductivewithout structural support
minimally osteoinductive despite preservation
of osteoinductive molecules
interproduct and interlot variability is common

Synthetics
Alternative to autografts and allografts
Various compositions available
Made in powder, pellet, or putty form
Properties
osteoconductive only

Outcomes
Level I evidence shows that calcium-phosphate

bone substitutes allow for bone defect filling, early


rehabilitation, and prevention of articular
subsidence in distal radius and tibial plateau
fractures

Bone morphogenetic proteins


(BMP)
Osteoinductiveproperties
stimulates undifferentiated perivascular

mesenchymal cells to differentiate into osteoblasts


throughserine-threonine kinase receptors

rhBMP-2 and rhBMP-7are FDA-approved for

application in long bones and spine


Complications
under or overproduction of bone
inflammatory responses
early bone resorption