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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
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
vascularized
Non- Vascularised bone graft
canals
Microanatomy & Physiology
Bone is a complex tissue containing four
cell types
the osteoprogenitor (osteogenic) cell
the osteoblast
the osteocyte
the osteoclast
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-)
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
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
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,
Autografts
Cancellous
+++ +++ ++ -
Cortical ++ ++ ++ ++
Allografts
Cancellous - +++ ++ -
Cortical
- ++ ++ ++
Demineralized
- + +++ -
Synthetics
BMPs
- - ++++ -
Ca. sulfate - ++ - +
Factors affect successful
implantation of allograft