BONE GRAFTING

Mimbo H.W
Adult and Reconstruction Section
Department of Orthopaedic and Traumatology
Hasan Sadikin General Hospital
Medical School of Padjadjaran University
2005
Introduction

Definition :
Bone grafting is surgery to place new
bone into spaces around a broken bone or
in between holes & defects in bone which
held in place with pins, plates, or screws

Bone grafts are bone that is transplanted

from one area of the skeleton to another to
aid in healing and strengthening
Introduction

Sources
Bone or bone-like materials used in bone
grafts may come from :
the patient's own healthy bone
(an autograft)
frozen or donated bone fro the same species
(an human allograft)
frozen or donated bone fro the different species
(a xenograft)
a man-made source
(substitutes allograft)
History
Hippocrates & Egyptians
The transplantation of animal tissues into
humans
Joob van Meekren (1600)
Attempted to fill a defect in soldiers
cranium w/ the dogs skull
Deutcland Surgeon (1821)
1st experimental autogenous bone grafting
created in animal skulls
History
Sir William Mc Ewen (1879)
Introduced allografting by replacing the prox. two-
third of a humerus in 4 yo boy w/ bone
procedured from other psnt
Past 2 decades
Evolved significantly w/ the fundamental
understanding of osseous healing, cellular &
molecular biology
In 1998 Of the 300.000 procedures performed
9 of 10 involved the use of autograft or allograft
tissue
Fractures need bone grafts
Indication
Bone grafts are used to:
Repair broken bones (bone loss to fill cavities
or defect in bone)
Repair injured bone thats not healed (non union,
malunion, delayed union)
For bridging gaps in the shafts of bones (trauma,
infection or tumour)
In the surgical fusion to bridge joints & provide
arthrodesis
To provide bone blocks to limit joint motion
Establishing union in pseudoarthrosis
Function :
mechanical
biologycal
Mechanical Function
a large amount of bone or disc material that
is removed caused of # or during surgery
defending that span in spinal procedures
many levels of vertebrae during spinal fusion

Biologycal Function
situations where healing may be difficult
nicotine, alcohol habitual
the presence of diseases such as :
diabetes mellitus
autoimmune deficiencies
Standard Procedure
The grafted bone acts as a scaffold around which
new bone tissue is laid by :
creeping substitution by vascular invasion from the
surrounding tissues
stimulates new bone formation by the principle of
induction
The current standard an autograft usually from
the iliac crest, the distal femur or the proximal tibia
It possesses all of the characteristics necessary for
new bone growth : osteoconductivity
osteogenicity osteoinductivity
 Osteogenicity
the graft that is transplanted to aid in healing
Osteoconductivity
the graft supports the attachment of new
osteoblasts and osteoprogenitor cells
It provides an interconnected structure
through which new cells can migrate and new
vessels can form
Osteoinductivity
the ability of a graft to induce non-
differentiated stem cells or osteoprogenitor
cells to differentiate into osteoblasts
Vascularised bone graft

Marx 1983
Transferred complete w/ its blood supply
which is anastomosed to vessel at recipient
site
by removing the graft with a vascular
pedicle
requires the anastamosis of the vessels
by microsurgical methods
eq: illiac crest circumflex arteries

proximal tibia branch peroneal artery

 Free-vascularized

vascularized
Non- Vascularised bone graft

Brunelli in Italy (1979)

Transferred without its blood supply which
is anastomosed to vessel at recipient site
depend on integration of the bone graft
with the vascularized condition in recipient
site :
peripheral resorption

vascular infiltration of the Haversian

canals
Microanatomy & Physiology
Bone is a complex tissue containing four
cell types
the osteoprogenitor (osteogenic) cell
the osteoblast

the osteocyte

the osteoclast

Osteoprogenitor cells consist of

determined osteoprogenitor cells (DOC)
DOC located on or near all free surfaces of
bone including :
the cambium layer of the periosteum
the endosteum
the Haversian canals
bone marrow
DOC involved in normal bone growth &
become activated in bone healing,
healing inducible
osteoprogenitor cells (which concentrated in
muscle and connective tissue)
 Osteoblasts
uninucleate cells which contribute to bone
formation by secreting :
the collagenous bone matrix
osteoid cells

Osteocytes
osteoblasts that have become surrounded
by bone matrix
Osteoclasts
multinucleate cells formed from the fusion
of circulating monocytes
responsible for bone resorption effected
through the release of collagenase & other
proteolytic enzymes
The morphologic forms of
bone
Woven bone
an immature form characterized by random
organization of its fibrous elements & usually
found in early fracture repair
Lamellar bone
a mature bone composed of successive layers
w/ a highly organized infrastructure
solid mass of compact bone (cortical) or
spongy-trabecular mass (cancellous bone)
where the spaces contain bone marrow
Biology activity of bone
grafting
to activate surrounding host tissues & support the
ingrowth of host osteogenic tissue
the graft site goes through several concurrent phases :
platelet aggregation & degranulation release of
cytokines & growth factors inflammation processed
neutrophils, macrophages & fibroblasts are recruited
via chemical messengers :
Kinins
Complement
Histamine
Serotonin
Prostaglandins
leukotrienes
Biology activity of bone
grafting
macrophages & giant cells debride
the wound of devitalized protein
osteocytes release of lysosomal
enzymes osteoid destruction the
inflammatory phase (one week in cancellous
autografts)
mesenchymal cells proliferate by day 3
differentiate into chondroblasts by day 5 &
osteoblasts by day 10
Biology activity of bone
grafting
the osteoinduction of inducible pluripotent
stem cells by BMP &TGF- (first 1 to 2
weeks)
Vascular ingrowth osteoclastic activity
initiating graft resorption
Osteoclasts resorb the dead bone
osteoblasts deposit an osteoid
mineralized into new host bone graft
trabeculae are gradually replaced by new
host bone
Biology activity of bone
grafting
Osteoconduction lasts several months in
cancellous grafts and may take years in cortical
bone
Motion at the graft/host bone or soft tissue
interface will impede or prevent revascularization
Bone graft success depends on :
the host recipient site
local growth factors of the host
bone graft viability
the volume of bone grafted
the structural & function of the bone graft
Biology activity of bone
grafting
Growth factors polypeptides that bind to
specific cell membrane receptors & stimulate
or inhibit certain cell functions
Five important growth factors :
platelet-derived growth factor (PDGF)
transforming growth factor-beta (TGF-)

insulin-like growth factor

basic fibroblastic growth factor

epidermal growt factor

Biology activity of bone
grafting
The grafted cells can be damage w/ :
air
saline
solution
antibiotics
the cancellous graft diffusion of nutrients
& limited capillary microanastomosis
autogenous cancellous and vascularized
corticocancellous bone grafts have a greater
chance of survival & an immune response
Biology activity of bone
grafting
Cancellous graft vascularity
advances at a rate of 0.2-1.0 mm/day &
may be completed within 1-3 wks
Cortical grafts revascularized 4-8
wks for fresh autogenous grafts & >4
mth for frozen grafts or allografts with a
histocompatibility antigen difference
Glossary of Key Terms
Osteoconduction The process whereby a microscopic and
macroscopic scaffolding is provided for inward
migration of cellular elements involved in bone
formation (mesenchymal cells, osteoclasts,
osteoblasts, and vasculature) for bone
ingrowth

Osteogenesis Primary bone formation by transplanted living

cells

Osteoinduction
The process whereby bone formation is stimulated by
an implant or transplant. The process is preceded by
resorption of mineral by osteoclasts or by deminerali-
zation with acids and proceeds by induction of
differentiation of host mesenchymal cells into
chondroblasts

Alloimplant The transfer of nonviable materials from a

donor of the same species.

Most allografts are actually alloimplants

Osteoinductive polypeptide able to induce de
Bone Morphogenetic novo bone formation. Found in bone (e.g.,

Protein demineralized bone powder.)

 Classification (Laurencin et al)

Type Description Caracteristic

Autograft Biology Transplantation Osteogenic

1. Autogenous taken from one Osteoinductive

Bone Marrow anatomic site to Osteoconductive

another site in the produce more
2. Autogenous
Cancelous same individual
satisfactory
Bone results
faster formation
of new bone and
blood vessel
 Classification (Laurencin et al)

Type Description Caracteristic

Allograft Biology Transplantation Depending on
1. Allograft taken from one the disparity in
Cortical Bone anatomic site of histocompatibility
2. Allograft
the others between donor
individuals (tissue and host
Cancelous
Bone bank) of the same as a spacer tend
species to be less
satisfactory
 Classification (Laurencin et al)

Type Description Caracteristic

Massive Epiphyseal Comprising :
Osteochondral cancelous bone & Diaphyseal
marrow grafts cortical bone
Allografts washed in Metaphyseal
antibiotics-free cancelous bone
tissue culture Articular cartilage
medium & cleaned Used in :
of excessive soft Joint reconstruct.
tissue attachment after limb
salvage
 Classification (Laurencin et al)

Type Description Caracteristic

Allogenic Bone grafts in the form of :
substitutes which a powder
Demineralized mild acid extraction crushed granule
Matrix Bone Graft of bone leaves
putty
behind growth
factors, collagen & chips
non-collagen protein gel
that proceded that can be injected
processed allograft through a syringe
Classification (AATB)

Autografts transplanted directly from one

area of skeleton into his or her own s
Allografts (Homogenous) taken from
donors or cadavers treated by tissue freezing,
freeze-drying, gamma irradiation, electron
beam radiation, & ethylene oxide
Xenografts (Heterogenous) the material
transplanted is derived from a member of a
different species
Classification (AATB)

Cancellous bone grafts

a graft composed of cancellous bone to
promote osteogenesis
Cancelous Bone Chips used as supplements
to a cortical grafts or a metallic plates
Cancelous Graft used as autogenous grafts

to filling up bone cavities

Corticocancelous bone grafts
a graft composed of bone cortex in
grafting, to provide structural stability
Cancellous Bone Grafts
a 3-dimensional coarse trabecular lattice
intercommunicating spaces occupied by BM
in the epiphysis & metaphysis of long bones
fresh cancellous autografts optimal graft
obtained from :
Sternum
tuber coxae
proximal tibia
proximal humerus
ribs
porosity of cancellous bone 30 to 90% live
 Vascularization peripheral resorption & vascular
infiltration of the Haversian canals
Osteoclasts resorb bone at a relatively high rate
(50/day) significant weakening at 2-6 weeks
Used for :
filling cavities in highly comminuted fractures
a part of fusion operation of the spine
augmenting the compression site being fixed internaly
filling the space after the crushing of metaphysis
atrophic non-union fractures
occupying the spaces left revising of loose prothesis
augmenting acetabular deficient during hip surgery
Corticocancellous Bone
Grafts
Source in the metaphysis of long bones
Needed where bone has been lost
a result of trauma
removed caused its contain of neoplasm

reinforced by metallic implants

 Comparisson
Cancellous graft
Better survival of osteogenic
cells cause the structure
allows diffusion & early
microvascular
Large endosteal surface
supplies osteoprogenitor
Abundant red marrow supplies
many osteoprogenitor cells
Corticocancelous
graft
Dense bone is a barrier to
diffusion
Small endosteal surface
supplies osteoprogenitor
Abundant red marrow supplies
fewer osteopregenitor cells
 Comparisson
Cancellous graft
Healing by creeping
substitution new bone is
deposited on dead trabeculae
followed by removal
Relatively weak
Corticocancelous
graft
Removal of necrotic matrix
from around the central canals
of bones occurs first followed
by new
Relatively strong
Classification (AATB)
Onlay bone grafts
consisting of cortical bone placed across a
bone defect & fastened by screws to
immobilize the fragments
promotes osteogenesis
Inlay bone grafts
Placed into slots created in cortical bone at
the recipient site & sometimes used in joint
arthrodeses
a cancellous or corticocancellous bone block
is used to distract & fuse the involved
vertebral bodies
Classification (AATB)

H Shaft grafts
a type of bone grafts in which the tissue is
shaped like the letter H, which allows to be
wedged between spinous processes or stabilized
lumbosaccral junction
Stent grafts
corticocancellous bone allografts placed within
the medullary cavity of the recipient bone & are
occasionally used as part of arthrodesis
Incorporation of corticocancelous grafts can be
very slow to accelerate incorporation
Classification (AATB)

Strut grafts
employed to provide stability and
stimulate osteogenesis
an entire vertebral body is removed &
a strut from another bone most often
in the spine
notched into the two neighboring
vertebral bodies
Classification (AATB)
Peg Grafts
Considered an innocuous means of internal
fixation rather than a means of osteogenesis
Limited used small bones of the hand, foot
& medial maleolus
Medullary Grafts
Interferes w/ endosteal circulation, fixation
was insecure & healing was satisfactory
Rarely used except in the MT,MC, distal radius
Classification (AATB)

Osteoperiosteal Grafts
the same but less osteogenic than multiple
corticocancellous grafts
Hemicylindrical Grafts
The affected bone is placed across the defect
& suplemented by another grafting
Suitable for obliterating large defect

Bone Transplanted
Fibular grafts
n lay strips of cancelous graft a. Chip Graft
b. Onlay-strips graft
c. Onlay-cortical graft
d. Inlay-cortical graft
e. Latch graft
f. Block graft
g. Sliding graft
h. Osteocartilagenous graft
Open Bone Grafting
(Papineau Technique)
Principles :
Granulation tissue markedly resists infection
Autogenous cancelous grafts are rapidly
vascularization & resistant to infection
The infected area is completely excised

Adequate drainage is provided

Adequate immobilization is provided

Systemic antibiotics are used for prolonged

periode
Open Bone Grafting
(Papineau Technique)

Used for Chronic Osteomyelitis

Stages :
Debridement excission of infected tissue w/
or without stabilization using External Fixation
or Intramedulary Rod
Cancelous auto bone grafting

Skin closure
Classification (AATB)
Substitutes Bone Graft
Allograft Based Bone Graft Substitutes
requires the sterilization & deactivation of
proteins normally found in healthy bone
extracellular matrix bone growth factors,

proteins & other bioactive materials for

osteoinduction & bone healing
the desired factors and proteins are

removed using a demineralizing agent (HCl)

Demineralized Bone Matrix
 Factor-based bone graft substitutes
natural
and recombinant growth factors
used alone or in combination with other
materials
transforming growth factor-beta [TGF-]
platelet-derived growth factor (PDGF)

fibroblast growth factor (FGF)

bone morphogenetic protein (BMP)

 Cell-based bone graft substitutes
use cells to generate new tissue alone or seeded
onto a support matrix (mesenchymal stem cells)

Ceramic-based bone graft substitutes

Ca.Phosphat, Ca. Sulfate & Bioglass
(OsteoGraf, Norian SRS, ProOsteon, Osteoset)
Polymer-based bone graft substitutes
degradable & nondegradable polymers
(Cortoss, open porosity polylactic acid polymer
[OPLA], Immix)
Allograft

Frozen cancellous allograft

Cancellous allograft blocks
Segmental cortical allografts
Allogenic cortical bone grafts
Demineralized Bone Matrix
Fresh frozen cortical allografts (Lyophilized)
Unicortical allografts
Bone Substitutes (Synthetic implants)
Types of Processed Bone
Allograft
Fresh
Fresh Frozen
Cryopreserved
Freeze-dried (lyophilized)
Demineralized
Types of Procurement
Allograft
Clean
Aseptic
Sterilization :
Gamma Irradiation
Ethylene Oxide
Physical Forms :
Powder
Particulate
Chips
Struts
Blocks and Wedges
Cortical Section
 Graft Materials and Functional Properties

Osteogenic Osteoconductive Osteoinductive Mechanical

Autografts

Cancellous
+++ +++ ++ -
Cortical ++ ++ ++ ++
Allografts

Cancellous - +++ ++ -
Cortical
- ++ ++ ++
Demineralized
- + +++ -
Synthetics

BMPs
- - ++++ -
Ca. sulfate - ++ - +
Factors affect successful
implantation of allograft

Correct sizing of allograft

Resolve or control infection prior to
surgery
Provide good graft-host contact and
stability
Provide rigid internal fixation
Use of cancellous bone autograft
Complications
Recipient-graft non-unions
Graft fractures
Graft infection