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SEMINAR ONSEMINAR ON

BONE TRANSPLANTATIONBONE TRANSPLANTATION

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INTRODUCTIONINTRODUCTION

A bone graft is defined as any implanted material that promotesA bone graft is defined as any implanted material that promotes

a bone healing response by providing osteogenic ,osteoinductive anda bone healing response by providing osteogenic ,osteoinductive and

osteoconductive activity to local site.osteoconductive activity to local site.

The principles, indications, and techniques of boneThe principles, indications, and techniques of bone

grafting procedures were well established before "thegrafting procedures were well established before "the

metallurgic age" of orthopaedic surgery .metallurgic age" of orthopaedic surgery .

The bone is more commonly transplanted in the bodyThe bone is more commonly transplanted in the bodythan any other tissue or organ except blood.than any other tissue or organ except blood.

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CLASSIFICATION OF BONE GRAFTSCLASSIFICATION OF BONE GRAFTS

According to source:According to source:--

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CLASSIFICATION OF BONE GRAFTS ( Contd)CLASSIFICATION OF BONE GRAFTS ( Contd)

According to bony architecture & structure:According to bony architecture & structure:--

*Cancellous*Cancellous

*Cortical*Cortical

*Corticocancellous*Corticocancellous

According to blood supply:According to blood supply:--

*Vascularised*Vascularised

*Nonvascularised*Nonvascularised

According to method of preservation:According to method of preservation:--

*Fresh*Fresh*Frozen*Frozen

*Freeze dried*Freeze dried

*Demineralised*Demineralised

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HISTORYHISTORY

In 1668 the first recorded bone implant was performed.In 1668 the first recorded bone implant was performed.

In 1881 MacEwan performed human allograft operation.In 1881 MacEwan performed human allograft operation.

In 1907 Lexer was the first to perform allogeneic whole jointIn 1907 Lexer was the first to perform allogeneic whole jointtransplantation .transplantation .

In 1911 Albee established principles of cortical bone graft.In 1911 Albee established principles of cortical bone graft. In 1931 Phemister described the use of cancellous bone graft.In 1931 Phemister described the use of cancellous bone graft.

In 1942 Inclan reported the storage of autogeneic and allogeneicIn 1942 Inclan reported the storage of autogeneic and allogeneicbone .bone .

In 1951 Ray & Ward did experimental work on syntheticIn 1951 Ray & Ward did experimental work on synthetic

hydroxyapatite.hydroxyapatite. In 1976 Urist did reseach work on osteoinductive property ofIn 1976 Urist did reseach work on osteoinductive property of

bone morphogenic protein.bone morphogenic protein.

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INDICATIONINDICATION

Bone grafts may be used for the following purposes:Bone grafts may be used for the following purposes:

To fill cavities or defectsTo fill cavities or defects

To bridge joints providing arthrodesisTo bridge joints providing arthrodesis

To bridge major defects or establish the continuityTo bridge major defects or establish the continuity

To provide bone blocks to limit joint motionTo provide bone blocks to limit joint motion

(arthrorisis)(arthrorisis)

To establish union in a pseudarthrosisTo establish union in a pseudarthrosis

To promote union or fill defectsTo promote union or fill defects

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BIOLOGY OF GRAFT INCORPORATIONBIOLOGY OF GRAFT INCORPORATION

Incorporation is a process by which the graft is partiallyIncorporation is a process by which the graft is partially

or completely replaced by the host boneor completely replaced by the host bone..

Bone graft incorporation occurs in defined

Bone graft incorporation occurs in defined

stagesstages inflammation , specific immune response ,inflammation , specific immune response ,

revascularization , osteogenesis & remodelingrevascularization , osteogenesis & remodeling, which, which

occur in continuum .occur in continuum .

Specific immune response is vigorous inSpecific immune response is vigorous in

allografts but is absent in autografts.allografts but is absent in autografts.

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(Contd)(Contd)

InIn cancellous bone graftscancellous bone grafts, the necrotic tissue in marrow spaces and, the necrotic tissue in marrow spaces andhaversian canals is removed by macrophages. Granulation tissue,haversian canals is removed by macrophages. Granulation tissue,preceded by the advance of capillaries, invades the areas ofpreceded by the advance of capillaries, invades the areas ofresorption .Pluripotential mesenchymal cells differentiate intoresorption .Pluripotential mesenchymal cells differentiate intoosteoblasts, which begin to lay seams of osteoid along the deadosteoblasts, which begin to lay seams of osteoid along the dead

trabeculae of the bone graft. Osteoclasts resorb the necrotictrabeculae of the bone graft. Osteoclasts resorb the necroticbone, and eventually most of the bone graft is replaced by newbone, and eventually most of the bone graft is replaced by newhost bone.Finally, the old marrow space is filled by new marrowhost bone.Finally, the old marrow space is filled by new marrowcells.cells.

I

nI

ncortical bone graftscortical bone grafts

, the process of incorporation is, the process of incorporation issimilar butsimilar but

much slowermuch slower,, because invasion of the graft must be through the haversianbecause invasion of the graft must be through the haversiancanals of the transplantcanals of the transplant.. Osteoclasts resorb the surface of the canals,Osteoclasts resorb the surface of the canals, creatingcreatinglarger spaceslarger spacesinto which granulation tissue grows. As thisinto which granulation tissue grows. As thisgranulation tissue penetrates the center of the cortical graft, newgranulation tissue penetrates the center of the cortical graft, newbone is laid throughout the graft along enlarged haversian canals.bone is laid throughout the graft along enlarged haversian canals.

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(Contd)(Contd)

How rapidly the graft is incorporated dependsHow rapidly the graft is incorporated depends

on itson its size, structure, position, fixation, and geneticsize, structure, position, fixation, and genetic

compositioncomposition..

The role of the graft in stimulatingThe role of the graft in stimulating

incorporation may be throughincorporation may be through osteoconduction,osteoconduction,

osteoinduction, and osteogenesis.osteoinduction, and osteogenesis.

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BIOLOGY OF GRAFT INCORPORATION (Contd)BIOLOGY OF GRAFT INCORPORATION (Contd)

OsteoconductionOsteoconductionThe graft materialThe graft materialprovides a scaffold into and aroundprovides a scaffold into and aroundwhich host bone formation can occur.which host bone formation can occur.

InductionInductionoccurs when two or more tissues of different natures oroccurs when two or more tissues of different natures orproperties become intimately associated, and alterations of theproperties become intimately associated, and alterations of thedevelopmental course of the interactants results . Bone matrixdevelopmental course of the interactants results . Bone matrix

containscontainsprotein inductive factorsprotein inductive factors, such as bone morphogenetic, such as bone morphogeneticproteins (BMP)proteins (BMP) whichwhich can induce nearby mesenchymal tissues tocan induce nearby mesenchymal tissues todifferentiate into osteoblastsdifferentiate into osteoblasts..

OsteogenesisOsteogenesisin a bone graft refers toin a bone graft refers to direct formation of new bone bydirect formation of new bone byliving cells of the graftliving cells of the graft..

Thus bone grafts provide a latticework for ingrowth by host boneThus bone grafts provide a latticework for ingrowth by host boneand supply living osteogenic cells to the host bed, and growthand supply living osteogenic cells to the host bed, and growthfactors induce bone formation by the host.factors induce bone formation by the host.

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(Contd)(Contd)

Phemister introduced the termPhemister introduced the term creeping substitutioncreeping substitution.. HeHebelieved that transplanted bone was invaded by vascularbelieved that transplanted bone was invaded by vasculargranulation tissue, causing the old bone to be resorbedgranulation tissue, causing the old bone to be resorbed

and subsequently replaced by the host with new bone.and subsequently replaced by the host with new bone. Most autografts and alloimplants revascularize only by creepingMost autografts and alloimplants revascularize only by creeping

substitution.substitution. In addition to creeping substitutionIn addition to creeping substitution,, largelargeallografts also may be incorporated by a process of serial stressallografts also may be incorporated by a process of serial stressfractures that result in graft remodeling.fractures that result in graft remodeling.

Revascularization of a fresh autograft seldom occurs byRevascularization of a fresh autograft seldom occurs bymicro anastomosis with existing microvessels,micro anastomosis with existing microvessels,commonly seen in cancellous bone and is aided incommonly seen in cancellous bone and is aided incortical bone by removal of the periosteum .cortical bone by removal of the periosteum .

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SOURCESOF GRAFTSSOURCESOF GRAFTS

For most applications, autogenous bone graft isFor most applications, autogenous bone graft isindicated.indicated.

Allografts are indicated only ifAllografts are indicated only ifautogenous bone graft isautogenous bone graft isunavailableunavailableoror if it is insufficientif it is insufficient and must be augmented &and must be augmented & forfor

reconstruction ofreconstruction of massivemassive whole or partial bone defects.whole or partial bone defects. For practical reasons, isografts are almost never used in humanFor practical reasons, isografts are almost never used in human

surgerysurgery..

AlthoughAlthough xenograftsxenograftshave been tried in various forms inhave been tried in various forms in

the past, they have never met with much success,the past, they have never met with much success,because of the immunologic response of the host.because of the immunologic response of the host.

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AUTOGENOUSGRAFTAUTOGENOUSGRAFT

These grafts may beThese grafts may be cortical, cancellous, orcortical, cancellous, or

corticocancellouscorticocancellous..

They haveThey have osteogenic, osteoconductive & osteoinductiveosteogenic, osteoconductive & osteoinductiveproperty,property, faster incorporation rate and nofaster incorporation rate and no risk ofrisk of

immunological reaction or disease transfer.immunological reaction or disease transfer.

Their disadvantagesTheir disadvantages areare limited supply, have potentiallimited supply, have potential

donor site morbidity & increased convalescence period.donor site morbidity & increased convalescence period.

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TECH

NIQUES OF BONE GRAFTING

Multiple Cancellous Chips orStrips

It is used forfractures, nonunions, andfor arthrodesis

of the spine.

Cancellous bone can be taken in strips or

morcellized into fine pieces that pack readily

into small cracks or holes, orfill large, irregular voids ,resulting from cysts, tumors, or other causes, for

establishing bone blocks, and for wedging in osteotomies.

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SingleSingle--onlay Cortical Bone Graftsonlay Cortical Bone Grafts

The termThe term onlay graftonlay graftwas originated byCampbell.was originated byCampbell.

The onlay bone graft was used for nonunions of theThe onlay bone graft was used for nonunions of theshaft of any long bone, and the technique wasshaft of any long bone, and the technique wassimilar for all.similar for all.

The most common indication for this graft todayThe most common indication for this graft today isisbone grafting and stabilizing the cervical spine .A nonunionbone grafting and stabilizing the cervical spine .A nonunionor fracture siteor fracture siteiin osteoporotic bones,n osteoporotic bones, can be bridged withcan be bridged witha cortical bone graft and a plate applied to thea cortical bone graft and a plate applied to theopposite cortex, although with modern techniquesopposite cortex, although with modern techniques

it is rarely used. The onlay graft is still applicable toit is rarely used. The onlay graft is still applicable toaa limited group of fresh, malunited, and ununited fractureslimited group of fresh, malunited, and ununited fracturesand after osteotomies.and after osteotomies.

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SingleSingle--onlay Cortical Bone Grafts(Contd)onlay Cortical Bone Grafts(Contd)

PhemisterPhemisterdescribed a technique of onlay bonedescribed a technique of onlay bone

grafting for established nonunions in which thegrafting for established nonunions in which the

graft is placed subperiosteallygraft is placed subperiosteallyacross the fragmentsacross the fragments

without mobilizing the fragments.without mobilizing the fragments.

Its advantages wereIts advantages were simple to dosimple to do,, blood supply of theblood supply of the

fragments and the normal impacting forces of the fracturefragments and the normal impacting forces of the fracture

were not disturbedwere not disturbed..

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Dual-onlay Cortical Bone Graft

Boyd developed the dual-onlaycortical bone graft technique forcongenital pseudarthrosis of the tibia.They are also useful in treatingdifficult and unusual nonunited fractures

near a joint with a short, osteoporoticfragment , old nonunions of the shafts oflong bones in elderly patientsor forbridging of massive defects.

A version of this technique usingallograft is useful for revision total

joint arthroplastyto replace boneinsufficiency.

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Dual-onlay Cortical Bone Graft(contd)

The advantages of dual graftsThe advantages of dual grafts areare mechanical fixation is bettermechanical fixation is betterthanthan

fixation by a single onlay bone graft;fixation by a single onlay bone graft; the two grafts add strength andthe two grafts add strength and

stabilitystability;; the grafts form a trough into which cancellous bone may be packed;the grafts form a trough into which cancellous bone may be packed;

andand during healing , the dual grafts prevent contracting fibrous tissue fromduring healing , the dual grafts prevent contracting fibrous tissue from

compromising transplanted cancellous bone.compromising transplanted cancellous bone.

The disadvantages of dual graftsThe disadvantages of dual grafts are the same as those of singleare the same as those of single

cortical grafts:cortical grafts: they are not as strong as metallic fixation devices;they are not as strong as metallic fixation devices; anan

extremity must usually serve as a donor siteextremity must usually serve as a donor siteif autogenous grafts areif autogenous grafts are

used; andused; and they are not as osteogenic as autogenous iliac graftsthey are not as osteogenic as autogenous iliac grafts, and, and thethesurgery necessary to obtain them has more risk.surgery necessary to obtain them has more risk.

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Inlay Bone Grafts

Albee popularized the inlay bone graft for the treatment ofAlbee popularized the inlay bone graft for the treatment of

nonunions.nonunions.

Inlay grafts are created by aInlay grafts are created by a sliding technique, as a strut graft orsliding technique, as a strut graft or

graft reversal technique,graft reversal technique,

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Inlay Bone Grafts

Its used for the treatment ofIts used for the treatment ofnonunion of the tibianonunion of the tibia,,

occasionally used inoccasionally used in arthrodesis,arthrodesis, particularly at theparticularly at the

ankleankleandand epiphyseal arrest.The strut graftsepiphyseal arrest.The strut grafts

(ribs,fibula,illiac crest strips) are commonly used for(ribs,fibula,illiac crest strips) are commonly used for

anterior vertebral fusion at all levels of spine.anterior vertebral fusion at all levels of spine.

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H-Grafts

The H-graft is a

corticocancellous graft

that is usually harvested

from the ilium and isspecifically designed to

achieveposterior fusion of

the cervical spine.

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Peg andDowel GraftsPeg andDowel Grafts Dowel graftsDowel graftswere developed forwere developed for

the grafting ofthe grafting ofnonunions in anatomicnonunions in anatomicareas, such as the scaphoid and femoralareas, such as the scaphoid and femoralneck.neck. In the carpal scaphoid, theIn the carpal scaphoid, thedowel is fashioned from densedowel is fashioned from densecancellous bone.cancellous bone.

Peg graftsPeg grafts have also been used tohave also been used tobridge the tibia and fibula tobridge the tibia and fibula toproduceproduceproximal and distalproximal and distal

tibiofibular synostosis. nonunions of thetibiofibular synostosis. nonunions of themedial malleolus and some of the smallmedial malleolus and some of the smallbones of the hand, wrist, or foot.bones of the hand, wrist, or foot.Occasionally, these grafts are usedOccasionally, these grafts are usedforfor spine fusionsspine fusionsas well.as well.

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Medullary GraftsMedullary Grafts

The only possible use for aThe only possible use for a medullary graft is in themedullary graft is in the

metacarpals and the metatarsalsmetacarpals and the metatarsals, where the small size, where the small size

of the bone enhances incorporation.of the bone enhances incorporation.

Medullary grafts are not indicated for theMedullary grafts are not indicated for the

diaphysis of major long bones. Grafts in thisdiaphysis of major long bones. Grafts in this

location interfere with restoration of endosteallocation interfere with restoration of endosteal

blood supply; because they are in the central axisblood supply; because they are in the central axisof the bone, they resorb rather than incorporate.of the bone, they resorb rather than incorporate.

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Osteoperiosteal GraftsOsteoperiosteal Grafts

In osteoperiosteal grafts, the periosteum isIn osteoperiosteal grafts, the periosteum is

harvested with chips of cortical bone.They areharvested with chips of cortical bone.They arerarely used today.rarely used today.

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Hemicylindrical GraftsHemicylindrical Grafts

Hemicylindrical grafts are suitableHemicylindrical grafts are suitablefor obliteratingfor obliterating

large defectslarge defects of the tibia and femurof the tibia and femur. A massive. A massive

hemicylindrical cortical graft from the affectedhemicylindrical cortical graft from the affected

bone is placed across the defect and isbone is placed across the defect and is

supplemented by cancellous iliac bone.supplemented by cancellous iliac bone.

A procedure of this magnitude has only limitedA procedure of this magnitude has only limited

use, but it is applicableuse, but it is applicablefor resection of bone tumorsfor resection of bone tumorswhen amputation is to be avoided.when amputation is to be avoided.

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Whole Bone TransplantWhole Bone Transplant

The fibula provides the most practical graft for bridging longThe fibula provides the most practical graft for bridging longdefects in the diaphyseal portion of bones of the upper extremity (radius,defects in the diaphyseal portion of bones of the upper extremity (radius,ulna, humerus)ulna, humerus) unless the nonunion is near a joint. The shape ofunless the nonunion is near a joint. The shape ofthe proximal end of the fibula makes it a satisfactorythe proximal end of the fibula makes it a satisfactorysubstitute forsubstitute for

the distal end of the fibula or distal end of the radiusthe distal end of the fibula or distal end of the radius.. In children the fibulaIn children the fibulacan be used to span a long gap in the tibiacan be used to span a long gap in the tibia, usually by a two, usually by a two--stagestageprocedure.procedure.

A fibular graft is stronger than a fullA fibular graft is stronger than a full--thickness tibial graft, andthickness tibial graft, and

when soft tissue is scant, a wound that could not be closed overwhen soft tissue is scant, a wound that could not be closed overdual grafts may be closed over a fibular graft. Disability afterdual grafts may be closed over a fibular graft. Disability afterremoving a fibular graft is less than after removing a larger tibialremoving a fibular graft is less than after removing a larger tibialgraft.graft.

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Whole Bone TransplantWhole Bone Transplant

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Pedicle GraftsPedicle Grafts Pedicle grafts may be local or moved from a remote site usingPedicle grafts may be local or moved from a remote site using

microvascular surgical techniques .In local musclemicrovascular surgical techniques .In local muscle--pedicle bonepedicle bonegrafts, an attempt is made to preserve the viability of the graft bygrafts, an attempt is made to preserve the viability of the graft bymaintaining muscle and ligament attachments carrying bloodmaintaining muscle and ligament attachments carrying bloodsupply to the bone or, in the case of diaphyseal bone, bysupply to the bone or, in the case of diaphyseal bone, bymaintaining the nutrient artery. They are indicated inmaintaining the nutrient artery. They are indicated in reconstructivereconstructive

segmental defect in a compromised environment ,following tumour ablation,segmental defect in a compromised environment ,following tumour ablation,in biologically deficient bone (congenital pseudoarthrosis of tibia).in biologically deficient bone (congenital pseudoarthrosis of tibia).

Two examples are the transfer of the anterior iliac crest on theTwo examples are the transfer of the anterior iliac crest on themuscle attachments of the sartorius and rectus femoris for use inmuscle attachments of the sartorius and rectus femoris for use inthe Davis type of hip fusion and the transfer of the posteriorthe Davis type of hip fusion and the transfer of the posterior

portion of the greater trochanter on a quadratus muscle pedicleportion of the greater trochanter on a quadratus muscle pedicleforfor nonunions of the femoral necknonunions of the femoral neck. Free,microvascularized fibular. Free,microvascularized fibulargrafts are used tografts are used to replace major deficiencies in long bonesreplace major deficiencies in long bonesand have beenand have beeneffectively used to treateffectively used to treat avascular necrosis of the femoral head.avascular necrosis of the femoral head.

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Pedicle GraftsPedicle Grafts

Although technically moreAlthough technically more

difficult,difficult,pedicle grafts have thepedicle grafts have the

advantagesadvantagesof aof a high percentage ofhigh percentage of

cell survivalcell survival,, rapidrapid incorporationincorporation

and increased activeand increased activeparticipation of the graftedparticipation of the grafted

cells in the healing processcells in the healing process

,hence,hence mechanically andmechanically and

biologically superiorbiologically superior..

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OPERATIVE TECHNIQUES:

HARVESTING BONE GRAFTS

Ilium

The iliac crest is an ideal source of bone graft

because it is relatively subcutaneous, has natural

curvatures for fashioning grafts, has ample cancellous

bone, and has cortical bone of varying thickness.

Removal of the bone carries minimal risk and

usually there is no significant residual disability.

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Ilium

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GeneralPrinciples for harvesting illiac crest graftGeneralPrinciples for harvesting illiac crest graft

Place skin incisions slightly above or below the crestPlace skin incisions slightly above or below the crestto avoidto avoidpainful scars over bony prominences.painful scars over bony prominences.

Avoid surgical injury to the lateral femoral cutaneous nerveAvoid surgical injury to the lateral femoral cutaneous nerveanteriorly and the cluneal as well as sciatic nervesanteriorly and the cluneal as well as sciatic nerves posteriorly.posteriorly.

Dissect directly down to the boneDissect directly down to the bone, minimizing any, minimizing anyundermining of subcutaneous fat off the fascia.undermining of subcutaneous fat off the fascia.

Dissect muscle off bone subperiosteallyDissect muscle off bone subperiosteallyto avoid wanderingto avoid wanderinginto and injuring muscle.into and injuring muscle.

Close the wound in layers meticulously with

Close the wound in layers meticulously with watertightwatertightclosure of the fascia and skinclosure of the fascia and skinto minimize scar formation.to minimize scar formation.

Protect donor sites postoperatively withProtect donor sites postoperatively with limited weightlimited weightbearing.bearing.

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PosteriorIliac GraftsPosteriorIliac Grafts

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PosteriorIliac GraftsPosteriorIliac Grafts The region of the posterosuperior iliac spine is the best source of cancellous bone.The region of the posterosuperior iliac spine is the best source of cancellous bone.

To procure bone, position the patient in theTo procure bone, position the patient in theprone positionprone position.. Make aMake a straight vertical incisionstraight vertical incisiondirectly over the posterosuperior iliac spine or adirectly over the posterosuperior iliac spine or a

curvilinear incisioncurvilinear incisionthat parallels the iliac crest .that parallels the iliac crest . To prevent injury to the cluneal nerves,To prevent injury to the cluneal nerves,avoid straight transverse incisions and try not to carry incisions too far laterally.avoid straight transverse incisions and try not to carry incisions too far laterally.

Dissect sharply through the fat to the prominence of the posterior iliac crest.Dissect sharply through the fat to the prominence of the posterior iliac crest.Incise the origin of the gluteus maximus and dissect it free from the crest subperiosteally.Incise the origin of the gluteus maximus and dissect it free from the crest subperiosteally.

I

f the entire posterior iliac area is to be harvested, take down the gluteus fromI

f the entire posterior iliac area is to be harvested, take down the gluteus fromapproximately 2.5 cm superior to the posterosuperior iliac spine and inferiorapproximately 2.5 cm superior to the posterosuperior iliac spine and inferioras far as the posteroinferior spine., elevate the gluteus off the outer wall of theas far as the posteroinferior spine., elevate the gluteus off the outer wall of theilium down to the level of the sciatic notch.ilium down to the level of the sciatic notch.Avoid injury to the superior glutealAvoid injury to the superior glutealnerve and vessels.nerve and vessels.

The outer wall of the ilium is removed by firstThe outer wall of the ilium is removed by firstoutlining the area to be harvested byoutlining the area to be harvested bycutting through the outer table of the ilium with a sharp osteotome.cutting through the outer table of the ilium with a sharp osteotome.

If an onlay cancellous bone graft is to be performed, harvestIf an onlay cancellous bone graft is to be performed, harvestcorticocancellous strips with a curved gouge. Remove all underlyingcorticocancellous strips with a curved gouge. Remove all underlyingcancellous bone down to the inner table of the ilium with a curved gouge andcancellous bone down to the inner table of the ilium with a curved gouge andcurets of an appropriate size.curets of an appropriate size.

Obtain hemostasis by applying a thin layer of bone wax over bleeding pointsObtain hemostasis by applying a thin layer of bone wax over bleeding pointson the bone. Irrigate the donor site thoroughly and remove excess wax.on the bone. Irrigate the donor site thoroughly and remove excess wax.

Perform routine closure over suction drainage. Because bone graft sites tendPerform routine closure over suction drainage. Because bone graft sites tendto ooze considerabl after sur er , a l a lar e, bulk dressin .to ooze considerabl after sur er , a l a lar e, bulk dressin .

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AnteriorIliac GraftsAnteriorIliac Grafts

Large grafts of cancellous and corticocancellous bone can be harvested fromLarge grafts of cancellous and corticocancellous bone can be harvested fromthe anterior ilium.the anterior ilium.

Place the patient in aPlace the patient in a supine positionsupine position..

Make anMake an incision parallel to the crest and 1 cm proximal to itincision parallel to the crest and 1 cm proximal to it.. Do not incise anterior toDo not incise anterior tothe anterior superior iliac spine to avoid injury to the lateral femoral cutaneous nerve to thethe anterior superior iliac spine to avoid injury to the lateral femoral cutaneous nerve to thethigh.thigh.

Incise along the iliac crestIncise along the iliac crest, avoiding muscle., avoiding muscle.

Posteriorly retract the overhanging abdominal musculature proximally, toPosteriorly retract the overhanging abdominal musculature proximally, toremain on the subcutaneous border of the ileumremain on the subcutaneous border of the ileum. This approach will significantly. This approach will significantlyreduce hemorrhage and postoperative pain.reduce hemorrhage and postoperative pain.

Subperiosteally, dissect the abdominal musculatureSubperiosteally, dissect the abdominal musculatureand, subsequently, the iliacus fromand, subsequently, the iliacus fromthe inner wall of the ilium.the inner wall of the ilium.

Outline the area to be harvested with straight and curved osteotomes .Outline the area to be harvested with straight and curved osteotomes .

Cut the strips, which will be removed. Harvest the corticocancellous stripsCut the strips, which will be removed. Harvest the corticocancellous stripswith gouge.with gouge.

Do not broach the outer table ,prefer to harvest from the inner wallDo not broach the outer table ,prefer to harvest from the inner wall..

Closure and postoperative management are the same as for a posterior graft.Closure and postoperative management are the same as for a posterior graft.

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In children the physis of the iliac crest is ordinarily preservedIn children the physis of the iliac crest is ordinarily preservedtogether with the attached muscles.together with the attached muscles.

To accomplish this, a cut is made parallel to and below theTo accomplish this, a cut is made parallel to and below theapophysis, and this segment is fractured in greenstick fashion atapophysis, and this segment is fractured in greenstick fashion at

the posterior end.the posterior end. Ordinarily only one cortex and the cancellous bone are removedOrdinarily only one cortex and the cancellous bone are removed

for grafts, and the fractured crest, along with the apophysis, isfor grafts, and the fractured crest, along with the apophysis, isreplaced in contact with the remnant of the ilium and is held inreplaced in contact with the remnant of the ilium and is held inplace with heavy nonabsorbable sutures.place with heavy nonabsorbable sutures.

When fullWhen full--thickness grafts are removed from the ilium in adults,thickness grafts are removed from the ilium in adults,a similar procedure may be used, preserving the crest of the iliuma similar procedure may be used, preserving the crest of the iliumand its external contour.and its external contour.

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Wolfe and Kawamoto haveWolfe and Kawamoto havereported a method of takingreported a method of takingfullfull--thickness bone from thethickness bone from theanterior ilium; the iliac crestanterior ilium; the iliac crest

is split off obliquely bothis split off obliquely bothmedially and laterally so thatmedially and laterally so thatthe edges of the crest may bethe edges of the crest may bereapproximated after thereapproximated after thebone has been excised .bone has been excised .

The patient then cannotThe patient then cannot

readily detect the absence ofreadily detect the absence ofthe bone, and the cosmeticthe bone, and the cosmeticresult is superior. Thisresult is superior. Thismethod also is less likely tomethod also is less likely toresult in a "landslide" hernia.result in a "landslide" hernia.

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Bicortical GraftsBicortical Grafts

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OtherSources of Cancellous BoneOtherSources of Cancellous Bone

Used only ifUsed only if

aa small amount of cancelloussmall amount of cancellous

bone is needed.bone is needed.

if it is contraindicatedif it is contraindicatedoror

inconvenient to use the iliacinconvenient to use the iliac

crest.crest.

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TibiaTibia

If a large section of a cortical or cortico cancellousIf a large section of a cortical or cortico cancellousbone is needed,bone is needed, harvest it from the proximal tibiaharvest it from the proximal tibia..

Make a straight, longitudinal incision over theMake a straight, longitudinal incision over the middle ofmiddle ofthethe anteromedial surface of the tibia.anteromedial surface of the tibia. Expose theExpose theanteromedial surface of the tibia by subperiostealanteromedial surface of the tibia by subperiostealdissection.dissection.

Outline the graft to be taken and drill a 3 to 4 mm holeOutline the graft to be taken and drill a 3 to 4 mm holein the cortex. Cut through the cortex at an obliquein the cortex. Cut through the cortex at an oblique

angle to assist in removal of the graft.angle to assist in removal of the graft. Avoid the subchondral bone of the proximal tibia and, inAvoid the subchondral bone of the proximal tibia and, in

children, avoid the physeal plate.children, avoid the physeal plate.

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TibiaTibia

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GeneralPrinciplesGeneralPrinciples

Harvest from theMetaphysis of Long BonesHarvest from theMetaphysis of Long Bones

Harvest from the ipsilateral extremityHarvest from the ipsilateral extremity being operatedbeing operated ononto avoid morbidity in another extremity.to avoid morbidity in another extremity.

Keep skin incisions small and avoid harvestingKeep skin incisions small and avoid harvestingthrough sites where chronic bursitis orthrough sites where chronic bursitis ortendonitis might be a problem.tendonitis might be a problem.

Avoid harvesting excessive bone immediatelyAvoid harvesting excessive bone immediatelyadjacent to the subchondral bone of the joint.adjacent to the subchondral bone of the joint.

Avoid penetration of joints.Avoid penetration of joints.

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FibulaFibula

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FibulaFibula

Remove the shaft of the fibula throughRemove the shaft of the fibula through Henry's approach.Henry's approach. The entire proximal three quarters can be used, if necessary.The entire proximal three quarters can be used, if necessary.

Avoid in jury to the peroneal nerveAvoid in jury to the peroneal nerve..

Never remove the distal fourth of the fibulaNever remove the distal fourth of the fibula, because it is essential to the stability of, because it is essential to the stability ofthe ankle. Thethe ankle. The syndesmosis ligaments must be left intactsyndesmosis ligaments must be left intact, and a short, and a shortportion with theportion with theinterosseous membrane attached must also be retained.interosseous membrane attached must also be retained.

The entire fibula can beThe entire fibula can be removed through the interval between the peroneal muscles andremoved through the interval between the peroneal muscles andthe posterior compartment,the posterior compartment, avoiding transection of any muscles.avoiding transection of any muscles.

Remove the fibula subperiosteally from distal to proximalRemove the fibula subperiosteally from distal to proximalto avoid injury to muscles.to avoid injury to muscles.Facilitate removal by making the distal transverse cut first.Facilitate removal by making the distal transverse cut first.

Carefully dissect circumferentially around the fibulaCarefully dissect circumferentially around the fibula, avoiding injury to the peroneal, avoiding injury to the peronealvessels and dissect subperiosteally from distal to proximal until the segmentvessels and dissect subperiosteally from distal to proximal until the segment

of the fibula to be removed is exposed.of the fibula to be removed is exposed. Transect the upper end in a similar fashion. If the entire proximal fibula is toTransect the upper end in a similar fashion. If the entire proximal fibula is to

be removed, avoid injury to the peroneal nerve and the trifurcation of thebe removed, avoid injury to the peroneal nerve and the trifurcation of thepopliteal artery.popliteal artery.

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Harvest ofDiaphyseal Cortical BoneHarvest ofDiaphyseal Cortical Bone

This should be doneThis should be done only if this is the only reasonableonly if this is the only reasonablealternative.alternative.

Keep the bone graft as small as possible.Keep the bone graft as small as possible.

If possible,If possible, harvest from either the lateral or posterior surfaces ofharvest from either the lateral or posterior surfaces of

the tibiathe tibiabecause thebecause the muscle coverage lessens the risk of softmuscle coverage lessens the risk of soft--tissuetissue

complicationscomplicationsandand makes it more likely that the defect will heal tomakes it more likely that the defect will heal to

the greatest extent possible.the greatest extent possible.

Tibial diaphyseal harvest sites must be protected for a prolongedTibial diaphyseal harvest sites must be protected for a prolonged

period of time, probably for at least 6 monthsperiod of time, probably for at least 6 monthsin a wellin a well--fitted castfitted cast

brace. Decisions regarding when to cease protection andbrace. Decisions regarding when to cease protection and

allow the patient more vigorous activities are probably bestallow the patient more vigorous activities are probably bestjudged through the use ofCT scans of the donor site.judged through the use ofCT scans of the donor site.

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ALLOGRAFTSALLOGRAFTS

INTRODUCTIONINTRODUCTION

The clinical application of bone allograftingThe clinical application of bone allograftingbecame prevalent in the first two decades of thebecame prevalent in the first two decades of the20th century.20th century.

Urist recommends the term implant for nonviable boneUrist recommends the term implant for nonviable bone;;an example is frozen, freezean example is frozen, freeze--dried, sterilizeddried, sterilized

bone,bone, a derivative of whole bone that lacks viablea derivative of whole bone that lacks viablecellular components but potentially contains inductivecellular components but potentially contains inductiveprotein that can stimulate osteogenesis.protein that can stimulate osteogenesis.

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ALLOGRAFTSALLOGRAFTS

A graft may beA graft may be

orthotopicorthotopictransplanted to the same site in the recipient that ittransplanted to the same site in the recipient that it

occupied in the donoroccupied in the donor, e.g., distal femur to distal femur., e.g., distal femur to distal femur.

heterotopicheterotopictransplanted to a different site but one occupied by thetransplanted to a different site but one occupied by thesame tissue as in the donorsame tissue as in the donor, e.g., fibula to spine., e.g., fibula to spine.

ectopicectopictransplanted to a site normally occupied by a different typetransplanted to a site normally occupied by a different type

of tissueof tissue, e.g., fascia lata as a tendon graft., e.g., fascia lata as a tendon graft.

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BONE AND TISSUE BANKINGBONE AND TISSUE BANKING

Guidelines for the procurement, processing, and clinicalGuidelines for the procurement, processing, and clinical

use of bone have been established by the Americanuse of bone have been established by the American

Association of Tissue Banks. The goals of boneAssociation of Tissue Banks. The goals of bone

banking arebanking are to preserve the physical integrity of the implant andto preserve the physical integrity of the implant andits inductive proteins, reduce immunogenicity, and ensure sterilityits inductive proteins, reduce immunogenicity, and ensure sterility..

In general, a minimal interval (less than 24 hours)In general, a minimal interval (less than 24 hours)

between the death of the donor and the time ofbetween the death of the donor and the time of

procurement is desirable after following the properprocurement is desirable after following the properprocedure for consent is essentialprocedure for consent is essential

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Harvested bone isHarvested bone isfashioned into various sizes andfashioned into various sizes andshapesshapes, and, and soft tissues and cells are removedsoft tissues and cells are removedto reduceto reduceimmunogenicity.immunogenicity.

Freezing toFreezing to 7070CCin a sterile state effectivelyin a sterile state effectivelydecreases immunogenicity and maintainsdecreases immunogenicity and maintainssterility; this is generally recommended forsterility; this is generally recommended forosteoarticular allografts.osteoarticular allografts.

Ethylene oxide sterilizationEthylene oxide sterilizationalsoalso is effective,is effective,although it may destroy bonealthough it may destroy bone--inductive proteins.inductive proteins.

The bone isThe bone ispreserved by freeze dryingpreserved by freeze dryingafter removalafter removalof ethylene oxide .of ethylene oxide .

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Freezing toFreezing to 7070C and freeze drying reduce the immunogenicityC and freeze drying reduce the immunogenicity

of the implant but with some compromise to its mechanicalof the implant but with some compromise to its mechanicalstrength.strength.

Bone implants subjected to these physically damaging processing methods likeBone implants subjected to these physically damaging processing methods like(heating to more than 62(heating to more than 62C, by autoclaving, or by gammaC, by autoclaving, or by gammairradiation)irradiation)perform poorlyperform poorly incorporates more slowlyincorporates more slowly

Osteoarticular shell allografts must be stored in a fresh state forOsteoarticular shell allografts must be stored in a fresh state for24 to 72 hours until the donor has been adequately screened.24 to 72 hours until the donor has been adequately screened.The joint surfaces usually are stored in situ in the donor body atThe joint surfaces usually are stored in situ in the donor body at44C in a morgue environment.C in a morgue environment.

Quality control measures must be enforced to avoid the transfer of bacterial,Quality control measures must be enforced to avoid the transfer of bacterial,fungal, or viral pathogens to the recipientfungal, or viral pathogens to the recipient. Such measures should. Such measures should

includeincludepatients' historiespatients' histories regardingregarding malignancy,metabolic diseases,radiationmalignancy,metabolic diseases,radiationexposure,high risk behaviour and screening tests for hepatitis, acquiredexposure,high risk behaviour and screening tests for hepatitis, acquiredimmunodeficiency syndrome (AIDS), and syphilis.immunodeficiency syndrome (AIDS), and syphilis.

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SELECTION ANDPREPARATION OF THESELECTION ANDPREPARATION OF THE

GRAFTGRAFT

The ideal graft should be strong, potentially viable,The ideal graft should be strong, potentially viable,

nonreactive (nontoxic, noncarcinogenic), sterile, storable,nonreactive (nontoxic, noncarcinogenic), sterile, storable,

capable of being shaped during surgery, and affordablecapable of being shaped during surgery, and affordable..

Some autograft bone should almost always be used withSome autograft bone should almost always be used with

allograftsallograftsbecause it helps to avoid nonunion andbecause it helps to avoid nonunion and

stimulates incorporation.stimulates incorporation.

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TYPESOF ALLOGRAFTSAND THEIRTYPESOF ALLOGRAFTSAND THEIR

INDICATIONSINDICATIONS

Allografts are used whenAllografts are used when enough autograft is notenough autograft is not

available or possible (children), elderly and poor surgicalavailable or possible (children), elderly and poor surgical

risk patients.risk patients.

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TYPESOF ALLOGRAFTSAND THEIRTYPESOF ALLOGRAFTSAND THEIR

INDICATIONSINDICATIONS

Fresh allograftsFresh allograftsare used primarily toare used primarily to resurface osteochondral defectresurface osteochondral defect. They are. They are

harvested sterile and stored in antibiotic solution at 4C and implanted withinharvested sterile and stored in antibiotic solution at 4C and implanted within

33--7 days.Intense immunogenic reponse is seen, hence rarely used.7 days.Intense immunogenic reponse is seen, hence rarely used.

Frozen allograftsFrozen allograftsare harvested sterile, soft tissue and marrow elements areare harvested sterile, soft tissue and marrow elements are

removed and stored atremoved and stored at --70C.They are most commonly used70C.They are most commonly used allografts inallografts in

massive osteoarticular and segmental defectsmassive osteoarticular and segmental defects.Major disadvantage are risk of disease.Major disadvantage are risk of diseasetransmission, expensive and no secondary sterilization is possible.transmission, expensive and no secondary sterilization is possible.

Freeze dried allograftFreeze dried allograftare harvested first then secondarily sterilized. Used toare harvested first then secondarily sterilized. Used tofillfill

small defects in bone, augment other grafts.small defects in bone, augment other grafts.Advantages areAdvantages are indefinite storageindefinite storage

capacity at room temperature, easy to transport, decreased immunogenicity.capacity at room temperature, easy to transport, decreased immunogenicity.

Deminelarised allograftsDeminelarised allograftshavehavepotent osteoinductive property.potent osteoinductive property. Used in small defects ofUsed in small defects ofbone or augment other grafts.Disadvantages mechanically weak ,requiresbone or augment other grafts.Disadvantages mechanically weak ,requires

complex laboratory procedures, radiolucent.complex laboratory procedures, radiolucent.

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Bone Allografts and AlloimplantsBone Allografts and Alloimplants

Urist developed a protocol for the preparation ofUrist developed a protocol for the preparation ofchemosterilized,chemosterilized,autolyzed, antigenautolyzed, antigen--extracted allogeneic (AAA) bone that would preserve theextracted allogeneic (AAA) bone that would preserve theinductive factorsinductive factors. In this method, chloroform. In this method, chloroform--methanol is used tomethanol is used toextract lipids and cell membrane lipoproteins (4 hours); 0.6 Nextract lipids and cell membrane lipoproteins (4 hours); 0.6 Nhydrochloric acid extracts acidhydrochloric acid extracts acid--soluble proteins andsoluble proteins anddemineralizes the surface (24 hours); and neural phosphatedemineralizes the surface (24 hours); and neural phosphatebuffer in the presence of sulfhydrylbuffer in the presence of sulfhydryl--group enzyme inhibitorsgroup enzyme inhibitorsremoves endogenous intracellular and extracellularremoves endogenous intracellular and extracellulartransplantation antigens (72 hours). The bone is then frozen andtransplantation antigens (72 hours). The bone is then frozen andfreeze dried.freeze dried.

For this treatment, bone must be excised from the donor withinFor this treatment, bone must be excised from the donor within8 to 12 hours of death (minimal biodegradation time).8 to 12 hours of death (minimal biodegradation time).

TheThe principal disadvantage of AAA bone is decreased strength.principal disadvantage of AAA bone is decreased strength.Urist and Dawson have used it forUrist and Dawson have used it for spine fusions, arthrodesis of thespine fusions, arthrodesis of theknee, ankle, and wrist .knee, ankle, and wrist .

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Cartilage as AllograftCartilage as Allograft

Allogeneic cartilage, in theory, should not trigger anAllogeneic cartilage, in theory, should not trigger animmune response after transplantation because theimmune response after transplantation because the

immunogenic chondrocytes are inaccessible to theimmunogenic chondrocytes are inaccessible to thehost's immune system.host's immune system.

Late immune responses, such as lymph nodeLate immune responses, such as lymph nodehyperplasia, have been noted, however, if this immunehyperplasia, have been noted, however, if this immuneresponse is strong, it can lead to destruction of cartilageresponse is strong, it can lead to destruction of cartilageby a pannus like reaction and a joint fluid inflammatoryby a pannus like reaction and a joint fluid inflammatoryresponse.response.

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Large Composite AllograftsLarge Composite Allografts

Mankin and colleagues performed massive allograftMankin and colleagues performed massive allograft

transplantations for malignant or aggressive bonetransplantations for malignant or aggressive bone

tumors . Their improved allograft procurementtumors . Their improved allograft procurement

technique involved freezing the segments andtechnique involved freezing the segments andglycerinization of the cartilage to maintain chondrocyteglycerinization of the cartilage to maintain chondrocyte

viability during freezing and thawing. The complicationviability during freezing and thawing. The complication

rate was high, but the tumor recurrence rate was lowrate was high, but the tumor recurrence rate was low

and the outcome generally successful.and the outcome generally successful. Koskinen proposed the addition of autograft bone andKoskinen proposed the addition of autograft bone and

strong internal fixation.strong internal fixation.

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XenograftMaterialsXenograftMaterials

Bovine BoneXenograftBovine BoneXenograft

Transfer of tissues between species typicallyTransfer of tissues between species typically

elicits a severe immune response from theelicits a severe immune response from the

recipient.recipient.

Kiel bone or Surgibone is structurally strong andKiel bone or Surgibone is structurally strong and

elicits only a very weak antigenic response inelicits only a very weak antigenic response in

humans & serves only as an osteoconductivehumans & serves only as an osteoconductivescaffold.scaffold.

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TypeICollagenXenograftsTypeICollagenXenografts

Type I collagen is derived mostly from bovineType I collagen is derived mostly from bovine

skin .skin .

Collagen xenografts are most widely used inCollagen xenografts are most widely used in

dermatology and plastic surgery; as collagendermatology and plastic surgery; as collagen

sponges.sponges.

In orthopaedics, it is used as a compositeIn orthopaedics, it is used as a composite

implant.implant.

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CompositeXenograftsCompositeXenografts

Composite implants are formed from variousComposite implants are formed from various

combinations of ceramic, demineralized bonecombinations of ceramic, demineralized bone

matrix, marrow, and type I collagen.matrix, marrow, and type I collagen.

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IMMUNOLOGIC CONSIDERATIONSIMMUNOLOGIC CONSIDERATIONS

The antigenThe antigenantibody response to allografts varies considerablyantibody response to allografts varies considerably

Transplantation of allogeneic cortical and cancellous bone elicits an immuneTransplantation of allogeneic cortical and cancellous bone elicits an immuneresponse that delays healing at the osteosynthesis site and blocksresponse that delays healing at the osteosynthesis site and blocksrevascularization, resorption, and appositional new bone formation.revascularization, resorption, and appositional new bone formation.

LongLong--term studies show no difference in the morphology of eventual repairterm studies show no difference in the morphology of eventual repair

of autografts and allografts.of autografts and allografts. Diagnostic arthroscopy is the only sure way to determine the health of the graftDiagnostic arthroscopy is the only sure way to determine the health of the graft.. Ideally,Ideally, ifif

possible, evaluate the graft approximately 1 year after surgery using diagnosticpossible, evaluate the graft approximately 1 year after surgery using diagnosticarthroscopy to assess for an immune rejection phenomenon, which isarthroscopy to assess for an immune rejection phenomenon, which ischaracterized by pannus covering the graft. If this reaction occurs, thecharacterized by pannus covering the graft. If this reaction occurs, theprognosis for the graft is poorprognosis for the graft is poor..

Preoperative and postoperative serum studies can help predict an immune response.Preoperative and postoperative serum studies can help predict an immune response. ObtainObtain

serum samples be fore surgery and at 6 weeks, 12 weeks, and 1 year after theserum samples be fore surgery and at 6 weeks, 12 weeks, and 1 year after thesurgery. Test these serum samples against donor lymphocytes, if they aresurgery. Test these serum samples against donor lymphocytes, if they areobtained at the time of the graft procurement, or a panel of typedobtained at the time of the graft procurement, or a panel of typedlymphocytes in a standard lymphocyte toxicity assay.lymphocytes in a standard lymphocyte toxicity assay.

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OPERATIVE TECHNIQUESOPERATIVE TECHNIQUESAllografts forSpineSurgeryAllografts forSpineSurgery

The choice of grafting material depends on the anatomic and spatialThe choice of grafting material depends on the anatomic and spatial

constraints of the area to be stabilized and the osteogenic capacity of the hostconstraints of the area to be stabilized and the osteogenic capacity of the hostbed in orthotopic bone grafting.bed in orthotopic bone grafting.

For posterolateral grafting of the spineFor posterolateral grafting of the spine, fresh autogeneic bone, either alone, fresh autogeneic bone, either alone

or in a composite graft, is considered essentialor in a composite graft, is considered essential..

For cervical and lumbar interbody fusionsFor cervical and lumbar interbody fusions frozen or freezefrozen or freeze--drieddried

devitalized allogeneic cortical and cancellous bone may be useddevitalized allogeneic cortical and cancellous bone may be used

In degenerative processes, infection, or neoplasiaIn degenerative processes, infection, or neoplasia struts of allogeneic fibularstruts of allogeneic fibularbone can be used effectively.bone can be used effectively.

InIn operations for scoliosis performed in young childrenoperations for scoliosis performed in young children,, allograft bone (frozen, freezeallograft bone (frozen, freeze--dried,dried,or AAA bone) may be morcellized and mixed with the child's own boneor AAA bone) may be morcellized and mixed with the child's own boneto provideto provideadequate amounts of graft material. More recently, titanium cages filled withadequate amounts of graft material. More recently, titanium cages filled withvarious grafting materials have been used for interbody fusions.various grafting materials have been used for interbody fusions.

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OPERATIVE TECHNIQUESOPERATIVE TECHNIQUES

Allografts for TumorSurgeryAllografts for TumorSurgery

The needs for grafting in tumor surgery varyThe needs for grafting in tumor surgery vary

considerably, depending on whether the defectconsiderably, depending on whether the defect

is diaphyseal, ligamentous,tendinous, or cavitaryis diaphyseal, ligamentous,tendinous, or cavitary

(cysts).(cysts).

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Large Diaphyseal DefectsLarge Diaphyseal Defects

IlizarovIlizarov methodsmethods are often the bestare often the bestfor replacement.for replacement.

Other alternatives are: sliding cortical auto grafts,Other alternatives are: sliding cortical auto grafts,

large corticocancellous bone grafts from the iliaclarge corticocancellous bone grafts from the iliac

crest, vascularized fibular autografts, morcellizedcrest, vascularized fibular autografts, morcellized

autograft placed around an intramedullary rod,autograft placed around an intramedullary rod,

andand allograft bone with or without autograftallograft bone with or without autograft..

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Large CompositeDefectsLarge CompositeDefects When bone and joint lossesWhen bone and joint losses

are present, the alternativesare present, the alternatives

for replacement include thefor replacement include the

following:following: a large osteoarticulara large osteoarticular

allograftallograft,, a large diaphyseala large diaphyseal

allograft with a custom metallicallograft with a custom metallic

joint replacement threaded throughjoint replacement threaded through

the allograftthe allograft, and a, and ajoint fusionjoint fusion

using sliding autografts with orusing sliding autografts with orwithout allograft bonewithout allograft bone..

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Large CysticDefectsLarge CysticDefects Can beCan befilled with autograftsfilled with autografts

in most casesin most cases..

However, when the cystsHowever, when the cysts

are largeare large allogeneic boneallogeneic bone

(preferably AAA bone) may(preferably AAA bone) may

be morcellized andbe morcellized and

supplemented with autograftsupplemented with autograft

to fill the cyst cavity.to fill the cyst cavity.

Allografts for Joint Surface Defects (ShellAllografts for Joint Surface Defects (Shell

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Allografts for JointSurfaceDefects (ShellAllografts for JointSurfaceDefects (Shell

Allografts)Allografts)

Abrasion chondroplasty and arthroplasticAbrasion chondroplasty and arthroplasticreconstruction for joint surface defects yieldreconstruction for joint surface defects yieldpoor results , biologic resurfacing of jointpoor results , biologic resurfacing of joint

defects is being tried.defects is being tried.The shell allografts, involving theThe shell allografts, involving the

transplantation of a devascularized,transplantation of a devascularized,osteoarticular allograft with a small bonyosteoarticular allograft with a small bony

component have been tried.Early results arecomponent have been tried.Early results areinconclusive.inconclusive.

All ft f J i t S f D f t (Sh llAll ft f J i t S f D f t (Sh ll

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Allografts for JointSurfaceDefects (ShellAllografts for JointSurfaceDefects (Shell

Allografts)Allografts)

Allografts for Revision of Total Joint ArthroplastyAllografts for Revision of Total Joint Arthroplasty

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Allografts for Revision of Total Joint ArthroplastyAllografts for Revision of Total Joint Arthroplasty

Revision ArthroplastiesRevision Arthroplasties

Allografts for revision arthroplasties have beenAllografts for revision arthroplasties have been

used primarily in the hip.used primarily in the hip. Major segmental defectsMajor segmental defects

in the acetabulum as well as the proximal femurin the acetabulum as well as the proximal femur

may occur after multiple revision arthroplasties.may occur after multiple revision arthroplasties.These defects can be reconstructed withThese defects can be reconstructed with

allografts.allografts.

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Allografts for TraumaAllografts for Trauma

The following important prerequisites should beThe following important prerequisites should befollowedfollowed

1.The1.The distal anatomic parts are functionally intactdistal anatomic parts are functionally intact..

2.Good skin coverage must be present or obtainable.2.Good skin coverage must be present or obtainable.

3. I3. Infection is absentnfection is absent..

4.Circulation is adequate4.Circulation is adequate..

5.Abundant cancellous autograft is available5.Abundant cancellous autograft is available6.The6.Thegraft is protected until healinggraft is protected until healingis complete.is complete.

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Diaphyseal BoneDefectsDiaphyseal BoneDefects

The principles are :The principles are :--

morcellized bone appears tomorcellized bone appears toincorporate faster than largeincorporate faster than largesegmental allograftssegmental allografts..

when a large cortical graft iswhen a large cortical graft isneeded to bridge a gapneeded to bridge a gap it isit isrecommended that half of anrecommended that half of anallograft shaft be used withallograft shaft be used withmorcellized autogeneic bone packedmorcellized autogeneic bone packedaround itaround it..

for tibial bone loss, first obtainfor tibial bone loss, first obtainproximal & distal tibiofibularproximal & distal tibiofibularsynostosis followed by mixedsynostosis followed by mixedautograft & allograft.autograft & allograft.

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ArticularSurfaceDefectsArticularSurfaceDefects

When articular surface defects are due toWhen articular surface defects are due to

trauma, replace it with shell allograft.trauma, replace it with shell allograft.

SYNTHETIC BONE GRAFTS AND GROWTHSYNTHETIC BONE GRAFTS AND GROWTH

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SYNTHETIC BONE GRAFTSAND GROWTHSYNTHETIC BONE GRAFTSAND GROWTH

FACTORSFACTORS

SYNTHETIC BONE GRAFTS AND GROWTHSYNTHETIC BONE GRAFTS AND GROWTH

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SYNTHETIC BONE GRAFTSAND GROWTHSYNTHETIC BONE GRAFTSAND GROWTH

FACTORSFACTORS

InductionInduction Induction of bone formation occurs, as a result of nonsoluble,Induction of bone formation occurs, as a result of nonsoluble,

noncollagenous, bone morphogenetic proteins, as well as othernoncollagenous, bone morphogenetic proteins, as well as otherinductive proteins .inductive proteins .

The most intensively studied of theseThe most intensively studied of these BMPsBMPs thus far has beenthus far has been

recombinant BMP2 (rhBMPrecombinant BMP2 (rhBMP--2) and rhBMP2) and rhBMP--7, also known as osteogenic7, also known as osteogenicproteinprotein--1 (OP1 (OP--1).1).

Other growth factorsOther growth factors vizviz Platelet derived growthPlatelet derived growth factor,Transformingfactor,Transforminggrowth factorgrowth factor betabetaare under study.are under study.

Urist, showed the osteoinductive capacity ofUrist, showed the osteoinductive capacity ofDemineralised boneDemineralised bone

matrixmatrix. It is produced by the acid extraction of human cortical. It is produced by the acid extraction of human corticalbone .It includes thebone .It includes the nonnon--collagenous proteinscollagenous proteins;; bone osteoinductive growthbone osteoinductive growth

factorsfactors,( most significant beingBMP;) and,( most significant beingBMP;) and typeIcollagentypeIcollagen. DBM. DBMprovides no structural strength, and its primary use is in aprovides no structural strength, and its primary use is in astructurally stable environment.structurally stable environment.

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B MB M

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BoneMarrowBoneMarrow

Autologous red bone marrowAutologous red bone marrow, usually obtained by, usually obtained by

aspiration in adults from the axial skeleton,aspiration in adults from the axial skeleton,

contains a small but significant number of pluripotentialcontains a small but significant number of pluripotential

mesenchymal stem cells and inductive factors that havemesenchymal stem cells and inductive factors that havebeen used to treat nonunionsbeen used to treat nonunions..

Connolly et al.have demonstrated the efficacy ofConnolly et al.have demonstrated the efficacy of

repeated injection of tibial nonunions as arepeated injection of tibial nonunions as asubstitute for open operative grafting.substitute for open operative grafting.

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ConductionConduction

Bone conduction can occur through an open matrix,Bone conduction can occur through an open matrix,such as one would find in granules packed looselysuch as one would find in granules packed loosely

together, or through structural channels, such as foundtogether, or through structural channels, such as foundin some types of coral, in whichin some types of coral, in which the ideal size appears to bethe ideal size appears to besomewhere between 250 and 600 microns in diametersomewhere between 250 and 600 microns in diameter..

For orthopaedic applications, the most commonly usedFor orthopaedic applications, the most commonly usedmaterials at this time are Collagraft,Grafton, andmaterials at this time are Collagraft,Grafton, andProOsteon 500. The Norian SRS material has receivedProOsteon 500. The Norian SRS material has receivedconsiderable attention recently.considerable attention recently.

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G fG f

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GraftonGrafton

Grafton isGrafton is a form of demineralized bone matrixa form of demineralized bone matrix. It is. It is

non structural and supplied as a particulate.non structural and supplied as a particulate.

It may retain some bone induction capability.It may retain some bone induction capability.

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CollagraftCollagraft

Collagraft is aCollagraft is a nonstructural graft,a granular compositenonstructural graft,a granular composite

of hydroxyapatite and tricalcium phosphate with bovineof hydroxyapatite and tricalcium phosphate with bovine

dermal collagendermal collagen..

Collagraft has not experienced much popularity.Collagraft has not experienced much popularity.

P O tP O t

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ProOsteonProOsteon

This hydroxyapatite isThis hydroxyapatite is manufactured by the chemicalmanufactured by the chemicaltransformation of the calcium carbonate skeleton of a marinetransformation of the calcium carbonate skeleton of a marinecoral(Gonioptera).coral(Gonioptera).

It is usedIt is usedfor the filling of metaphyseal defects ,for filling thefor the filling of metaphyseal defects ,for filling the

juxtaarticular fractures,to fill defects created by the removal ofjuxtaarticular fractures,to fill defects created by the removal ofsmall benign bone tumorssmall benign bone tumors..

DisadvantageDisadvantage very brittle material so difficult to work withvery brittle material so difficult to work with..

ComplicationsComplications,, it could potentially be a problem if infectionit could potentially be a problem if infectionwere to occur & thewere to occur & the granules can occasionally get spilled.granules can occasionally get spilled.

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NorianSRSNorianSRS

It is a new unique class ofIt is a new unique class of injectableinjectable calcium phosphatescalcium phosphates.. SodiumSodiumphosphate solution is addedphosphate solution is added tto ao a mixture of three differentmixture of three differentcalcium phosphates and calcium carbonate,, resulting in a pastecalcium phosphates and calcium carbonate,, resulting in a pastethat is formable and injectable for approximately 5 minutesthat is formable and injectable for approximately 5 minutes..

Indicated in fractures in weak osteoporotic bone, otherIndicated in fractures in weak osteoporotic bone, otherjuxtaarticular fractures involving cancellous bone, in spinaljuxtaarticular fractures involving cancellous bone, in spinalreconstruction and revision acetabular arthroplastyreconstruction and revision acetabular arthroplasty..

Future TrendsFuture Trends

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Future TrendsFuture Trends

Autologous Growth FactorsAutologous Growth Factors AGFAGF (Interpore Cross(Interpore Cross

InternationalInc, Irvine, CA)InternationalInc, Irvine, CA) is an innovative concept.is an innovative concept.AGF gel is obtained from the buffy coat of the bloodAGF gel is obtained from the buffy coat of the blood

collected in the cell saver during surgery. It is rich incollected in the cell saver during surgery. It is rich in

growth factors, especially TGF and PDGF.growth factors, especially TGF and PDGF.

BovineBovine--derived bone morphoderived bone morpho--genetic protein extract (NeOsteo,genetic protein extract (NeOsteo,

Intermedics Orthopaedics, Denver, CO)Intermedics Orthopaedics, Denver, CO) is a cocktail ofis a cocktail of

growth factors and is currently being evaluated for itsgrowth factors and is currently being evaluated for its

role in human spine fusion and periodontal repair.role in human spine fusion and periodontal repair. Ossigel (Orquest, MountainView, CA)Ossigel (Orquest, MountainView, CA) is a formulation ofis a formulation of

bFGF and hyaluronic acid (Hy). A single injection ofbFGF and hyaluronic acid (Hy). A single injection of

Ossigel into the fracture site accelerates the fractureOssigel into the fracture site accelerates the fracture

healing process.healing process.

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Future TrendsFuture Trends VivescOs (IsoTis, Bilthoven, The Netherlands)VivescOs (IsoTis, Bilthoven, The Netherlands) is a tissueis a tissue--engineeredengineered

bone, developed for application in revision surgery, spinal fusion.bone, developed for application in revision surgery, spinal fusion.The bone marrow cells are harvested from the patient, thenThe bone marrow cells are harvested from the patient, thenmultiplied in culture, shaped in appropriate structure on amultiplied in culture, shaped in appropriate structure on ascaffold, and implanted into the patient.scaffold, and implanted into the patient.

The Gene therapyThe Gene therapyused for bone induction as a shortused for bone induction as a short--term, regionalterm, regional

therapy.It involves the transfer of genetic information to cellstherapy.It involves the transfer of genetic information to cellswhich synthesise the protein encoded by the gene.which synthesise the protein encoded by the gene.

The gene can be introduced directly to a specific anatomicThe gene can be introduced directly to a specific anatomicsite (site (inin--vivovivo technique)technique)

Specific cells can be harvested from the patient, expanded,Specific cells can be harvested from the patient, expanded,and genetically manipulated in tissue culture, and thenand genetically manipulated in tissue culture, and thenreimplanted (reimplanted (exex--vivovivo technique).technique).

The vehicle for gene delivery can be either viralThe vehicle for gene delivery can be either viral(adenovirus, retrovirus) or non(adenovirus, retrovirus) or non--viral (liposomes, DNAviral (liposomes, DNA--ligandligandcomplexes).complexes).

COMPLICATIONSCOMPLICATIONS

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COMPLICATIONSCOMPLICATIONS Complications in bone grafting are limited almost exclusively to the usualComplications in bone grafting are limited almost exclusively to the usual

surgicalsurgicalcomplications that can occur at the bone graft harvestcomplications that can occur at the bone graft harvestsite.site.

Complications in the use ofComplications in the use ofallograftsallograftsresult primarily from the problem ofresult primarily from the problem ofgraft rejection due to immunologic intolerancegraft rejection due to immunologic intolerance, and, and late graft failure.late graft failure.TheTheother major concern isother major concern is disease transmission, in particular the viruses ofdisease transmission, in particular the viruses ofhepatitis B, and C, and human immunodeficiency virus (HIV)hepatitis B, and C, and human immunodeficiency virus (HIV)..

The risks associated with the use ofThe risks associated with the use ofsynthetic bone graft materials andsynthetic bone graft materials andother types of processed boneother types of processed boneare quite small and related primarily toare quite small and related primarily toeithereitherpremature mechanical failure of the graftpremature mechanical failure of the graft, or, or nonunionnonuniondue to lackdue to lackof incorporation of the graft, lack of ingrowth, or inappropriateof incorporation of the graft, lack of ingrowth, or inappropriate

use of the material for the clinical situation.use of the material for the clinical situation.


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Bone GraftHarvestSitesBone GraftHarvestSites PotentialPotential early complicationsearly complications includeinclude woundwound

dehiscencedehiscence,, infectioninfection,, seromasseromasandand hematomas, pain,hematomas, pain,inadvertent injury of adjacent joints, muscleinadvertent injury of adjacent joints, muscleoror bowelbowelherniationherniation, and, and injury to important structures such asinjury to important structures such asnerves, vessels, and the ureternerves, vessels, and the ureter..

Intermediate and longIntermediate and long--term complicationsterm complications

includeinclude ugly or painful scar; bony deformity; fractureugly or painful scar; bony deformity; fracture((avulsion of the anterosuperior iliac spineavulsion of the anterosuperior iliac spine)), chronic pain;, chronic pain;

persistence of neurologic injury; and reflex sympatheticpersistence of neurologic injury; and reflex sympatheticdystropy, pseudoaneurysm as well as othersdystropy, pseudoaneurysm as well as others..

Dropp d Bon Gr ftDropp d Bon Gr ft

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Dropped Bone GraftDropped Bone Graft

Abandon the graft and harvest another one, if available.Abandon the graft and harvest another one, if available.

If the dropped graft is essential and an additionalIf the dropped graft is essential and an additionalharvest would subject the patient to additionalharvest would subject the patient to additionalmorbidity, then treat the graft as follows and use it:morbidity, then treat the graft as follows and use it:

Irrigate the graft with two or more liters of salineIrrigate the graft with two or more liters of salineusing ausing a

pulsatile irrigator depending on the size of the graft.pulsatile irrigator depending on the size of the graft.Then soak the graft in an antibiotic solution or in a very diluteThen soak the graft in an antibiotic solution or in a very dilutesolution of povidonesolution of povidone--iodineiodine for at least 10 minutesfor at least 10 minutesin a basin onin a basin onthe back table.the back table.Povidone has been shown to be cytotoxic toPovidone has been shown to be cytotoxic toosteoblasts, so the solution should be weakosteoblasts, so the solution should be weak .The graft can then.The graft can then

be inserted directly from the antibiotic solution, or, ifbe inserted directly from the antibiotic solution, or, ifpovidone solution was used, it should then again bepovidone solution was used, it should then again beirrigated to remove any residual iodophor.irrigated to remove any residual iodophor.

If the graft happens to beIf the graft happens to be cancellous bone, then adding ancancellous bone, then adding anantibiotic such as tobramycin powder to the graftantibiotic such as tobramycin powder to the graftmay be useful.may be useful.

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CONCLUSIONCONCLUSION

Bone healing is an intricate process with manyBone healing is an intricate process with manycontributing variables.Tools for understanding andcontributing variables.Tools for understanding andmanipulating the bone healing process and optimizingmanipulating the bone healing process and optimizingsuccessful bone grafting are available now.successful bone grafting are available now.

As a result,autogenous bone grafting is slowly beingAs a result,autogenous bone grafting is slowly beingreplaced as the gold standard against which all otherreplaced as the gold standard against which all otherbone graft alternatives are compared.bone graft alternatives are compared.

Although till date, no material is clinically moreAlthough till date, no material is clinically moreeffective than autografts, the search for alternativeeffective than autografts, the search for alternativematerials that can provide comparable efficacy andmaterials that can provide comparable efficacy andresults , is still going on.results , is still going on.

REFERENCEREFERENCE

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REFERENCEREFERENCE

Campbells Operative Orthopaedics 10th editionCampbells Operative Orthopaedics 10th edition

Chapmans Orthopaedic Surgery 3rd editionChapmans Orthopaedic Surgery 3rd edition

Mercers Orthopaedic Surgery 9th editionMercers Orthopaedic Surgery 9th edition

Textbook of Orthopaedics and Trauma 1st editionTextbook of Orthopaedics and Trauma 1st edition

Orthopaedics Principles & Their ApplicationOrthopaedics Principles & Their ApplicationS.L.Turek 4th editionS.L.Turek 4th edition

Orthopaedic Knowledge Update 7th and 8th editionOrthopaedic Knowledge Update 7th and 8th edition

Bone Graft substitute: past , present and future.ParikhBone Graft substitute: past , present and future.ParikhS.N J Postgrad Med vol 48 2004.S.N J Postgrad Med vol 48 2004.

www.emedicine.comwww.emedicine.com

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