Bone Healing and Grafting

Mike Conzemius, DVM, PhD

Diplomate ACVS

Type of Fracture Healing

Direct Healing
Primary Osteonal Reconstruction
Contact healing
Gap healing

Secondary Osteonal Reconstruction

Indirect Healing
Distraction Osteogenesis

Primary Osteonal Reconstruction

Not required for good outcome
goal for articular fractures

Not faster; slower early mechanical strength

Requires absolute stability
Interfragmentary strain <2%

Occurs with anatomic alignment of fracture

ends
Contact healing
Gap healing (gaps < 1 mm)

Interfragmentary Strain Theory

Strain: = L/L
Different tissues have different strain tolerances
before they yield and fail
Bone = 2%
Cartilage = 10%
Granulation Tissue = 100%

Interfragmentary Strain Theory

Theory
pluripotential cells are responsive to the local
deformation within the fracture gap
bone can form only if the interfragmentary
strain is less than the yield tolerance
= L/L
if L = 1 mm and desired is < 2% than L at
fracture gap must be < 0.02 mm

Contact Healing
Cutting cones are formed at ends of osteons
nearest the fracture
Osteoclasts line the spearhead of the cutting cone
for bone resorption
Osteoblasts line the rear of the cutting cone for
bone formation
Resorption and formation occur simultaneously at
50-80 um/day
Osteonal remodeling across location of cortical
contact of fracture pieces

Gap Healing
Gap is filled by blood vessels and loose
connective tissue
After ~2 weeks vascular supply is established;
osteoblasts deposit lamellar bone in gap
perpendicular to fragment ends
Cutting cones cross area formed by new osteons
within the gap and those at fracture ends
Cutting cone cross fracture ends and new bone is
remodeled along lines of load (Wolffs Law)

Secondary Osteonal Reconstruction

Interfragmentary strain is >2% within gap
Bone cannot form directly within gap
Bone resorption occurs at fracture end, increasing
size of gap and decreasing strain
External bony callus stabilizes fragment ends
decreasing strain
If gap or strain are too large indirect healing
occurs

Indirect Bone Healing

Inflammation
Soft Callus
Hard Callus
Remodelling

Inflammation
Hemorrhage and hematoma formation
White cells clean dead bone, debris,
bacteria
Release of growth factors and other proteins
for angiogenesis and cell differentiation
Granulation tissue forms

Soft Callus
Fibrous tissue forms at periphery where blood
supply is abundant
Fibrocartilage forms at center where blood supply
is limited
Increased instability results in increased callus size
Tissues bridge fracture and decrease
interfragmentary strain

Hard Callus
Intramembranous ossification
bone from fibrous tissue

Endochondral ossification
bone from cartilage

Remodeling
Wolffs law
bone formed in response to mechanical load
dynamization/staged destabilization-increased load
can lead to increased bone formation

lamellar bone and marrow cavity form

Will reduce callus size

size and location can impede function

Requires months to years

Distraction Osteogenesis
Bone forms under the law of tension stress
Wolffs Law occurs even with tension

Typically intramembranous ossification

Bone Grafting
A bone graft is a transfer a living tissue
An implant is nonviable material placed
into the body

Why do we graft?
Osteogenesis
viable cells contribute to new bone formation

Osteoinduction
proteins, factors, hormones are transferred that
modulate host cells

Osteoconduction
matrix upon which new bone can be formed
implants can be osteoconductive

What do we graft?
Cancellous bone
metaphyseal regions, surface area, 80% porosity

Cortical bone
mechanical strength, 10% porosity
frequently corticocancellous

Osteochondral
cartilage attached to parent bone

Composite
fresh graft added to preserved allograft

What do we graft?
Implants
allograft
bone morphogenic proteins
recombinant materials

Where do we get graft?

Autograft
same individual, allows for osteogenesis,
osteoinduction and osteoconduction
Free (10%) or Vascularized (90%)

Isograft
same family

Allograft
same species

Xenograft
different species

How do I collect free grafts?

Free cancellous and corticocancellous autografts
metaphyseal regions
proximal humerus, shaft of ilium, ribs, proximal tibia

aseptic collection
can regraft in 8 weeks
avoid oscillating equipment
place directly onto host bone-air kills cells
place into blood soaked sponge-saline kills cells
be generous
must be in stable, sterile environment

How do I collect Vascularized grafts?

Vascularized corticocancellous grafts
medial aspect of tibial diaphysis (mandible defects)
distal ulna (humeral, femoral defects)
fibular strut (femoral head osteonecrosis in man)

Increased cell survival

Increased patient morbidity
Generally for large bony defects
Must be in stable environment

Allograft Bone Banks

Any bone, any size

Cancellous bone chips are popular and effective
Aseptic collection, storage, administration
Freeze @ -70C
Cost effectiveness vs. autograft morbidity

How do Autografts Heal?

Inflammation
Revascularization
2x time for cortical grafts b/c of porosity

Osteoinduction
decreased with cortical grafts

Osteoconduction
decreased with cortical grafts

Remodeling
initiated with osteoclasts (vs. osteoblasts) with cortical grafts

How do Allografts heal?

Creeping substitution
Basic bone remodeling at graft-host interface
bone resorption is followed by bone production

May take years

When should we graft?

Nonunion fractures
Highly comminuted fractures
Fractures with bone loss
When expecting a delayed union
Arthrodesis
Limb salvage
When in doubt?

Biomaterials as Implants
Plasma sprayed
hydroxyapatite, AlO, TiO

Bioglass, Coral
Tantalum trabecular metal (Hedrocel)