Bone grafting

Classification by origin
1. Autograft – vascularized or nonvascularized
2. Allograft
3. Xenograft

Classification by structure
1. Cortical
2. Cancellous

Classification by function
1. Osteoconductive
2. Osteoinductive
3. Osteogenic
4. Structural

Cortical bone is preferred for structural indications. Vascularized bone is capable of hypertrophy
when loaded, and does not sustain any loss in strength. Unvascularized cortical bone has good
initial strength but over the first six weeks loses strength. By 12 months the strengths of
unvascularized and vascularized cortical grafts are similar.

Cancellous bone is preferred for filling defects and for promoting union. It is more osteogenic
than cortical bone but has less strength – only 4% of cortical bone, because cancellous bone is 80%
void. Cancellous bone is incorporated faster than cortical bone.

Ideal bone graft

Provides scaffold for guidance of ingrowth of new bone (osteoconductive). Has growth factors
to stimulate new bone formation (osteoinductive). Has bone cells to produce new bone
(osteogenic).

For any bone graft to be successful skeletal stability is imperative.

Integration of bone graft

Union occurs at the graft host junction through enchondral ossification. Internal repair occurs by
a process of creeping substitution.

Bone formation from autograft occurs from the cells of the autograft for the first 4 weeks and then
from the host. Only the cells within 0.3mm of the surface of the graft survive by diffusion; the
rest necrose.

For cortical bone to become revascularized there must be peripheral resorption by osteoclasts, a
process that takes months and leads to significant weakening.

Indications
1. Fill osseous defects – prefer cancellous grafts
2. Promote union in fresh fractures
3. Treat delayed or non union

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4. Provide bone blocks to prevent movement
5. To augment arthrodeses and arthroplasties

Complications and limitations of grafting

1. Limited supply
2. Donor site morbidity
3. Infection
4. Fracture
5. Nonunion
6. Graft resorption

Donor site morbidity can be significant. In a 1994 study Rawlinson found that 31% of his patients
said they would have been able to go home quicker without the pain from their iliac crest wound.
Donor site complications such as haematoma or infection are seen in around 15-20%.

Bone marrow
Osteoblastic stem cells from the bone marrow are a source of osteogenic material.

Bone marrow can be aspirated from the posterior iliac crest (100-150mL), centrifuged to
concentrate the cells and injected into a fracture or nonunion site to stimulate healing.

Bone marrow material can be combined with a carrier such as demineralized bone matrix to
prevent it from washing away. DBM is an excellent carrier material because it has
osteoconductive and osteoinductive qualities. The bone marrow supplies the osteogenic cells.

Autograft
Autograft is obtained from the patient. Cortical bone can be obtained from the tibia and
vascularized cortical bone can be obtained from the iliac crest, the ribs or the fibular. Cancellous
bone can be obtained from the iliac crest, Gerdy’s tubercle of the tibia, the radius and distal tibia.
Rib struts can be used during thoracotomies.

Fresh autograft has the highest osteoinductive and osteoconductive properties of the three types
of graft. It is revascularized the fastest and has a higher rate of union than allograft bone. The
risk of infection is minimized and there is no risk of immunogenicity.

The main problem with autograft is the donor site morbidity and the time taken for harvesting of
the graft.

Allograft
Modern bone graft processing involves:
1. Low dose irradiation to kill nonpathogenic surface bacteria. Unfortunately virucidal
doses of 30cGy will affect the mechanical properties of the graft.
2. Surgical debridement of all unwanted tissue
3. Pulsatile irrigation to remove cells and blood
4. Ethanol to denature proteins and kill viruses and bacteria
5. Antibiotic soaks to kill remaining bacteria.

Allogeneic bone is typically stored at –20 to –147 degrees celcius.

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The benefits are:
1. Theoretically unlimited supply
2. No donor site morbidity hence shorter hospital stay

The downsides are:

1. Cost
2. Risk of infection. The risk of viral transmission is approximately 1 in 600 000.
3. Risk of immune reaction
a. Note that bone and cartilage are only weakly immunogenic. Despite this, transplant
of a fresh graft is associated with a strong immune reaction. This can be decreased
by debulking as much of the cancellous bone as possible, leaving a shell graft.
b. Freezing or deep drying of allografts reduces immunogenicity. Deep frozen
allografts retain their material properties and can be used for structural support.
Freeze dried allografts are friable and weak in torsion and bending.
c. If cartilage is to be frozen, the surface is sprayed with glycerol, which helps preserve
some viable chondrocytes.
4. Less complete and rapid revascularization
5. Need to create and run a bone bank with attendant technical and legal implications

Demineralized bone matrix

Obtained by grinding up allograft bone, demineralizing it with HCl and sterilizing it with
irradiation or ethylene oxide. This leaves collagen, non collagenous proteins and growth factors.

Acts as an osteoinductive and osteoconductive matrix. It doesn’t offer structural support but is
well suited to filling cavities and defects, especially when used with autologous bone marrow.

It has the potential to transmit disease, but the decalcification process appears to inactivate and
eliminate HIV. JBJSA 2002 CCR says that there has been no documented disease transmission in
1.5 million transplants using this material.

Xenografts
Benefits: similar to allograft

Downsides: similar to allograft

Incorporation of the graft is inferior to both autograft and allograft. A zone of fibrous tissue often
surrounds the xenograft

Ceramic bone substitutes

Calcium phosphate ceramics may be used as bone conductive substances. Ceramics are brittle
and have poor tensile strength but excellent compressive strength. They should therefore be used
mainly in filling contained defects.

Calcium phosphate ceramics do not elicit an inflammatory reaction.

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Coralline hydroxyapatite e.g. Interpore
Coral calcium phosphate is converted to crystalline hydroxyapatite with a pore size of 200-500
microns and a structure very similar to human bone. It is around three times as strong as
cancellous autograft.

Should be used to fill contained defects

Calcium sulphate e.g. Osteoset

Note that Plaster of Paris is largely calcium sulphate.

Beads of crystallized calcium sulphate are osteoconductive and can be used as void filler. The
pellets dissolve over around 2-3 months and antibiotics can be added to the pellets.

A severe inflammatory response has been noted in several patients.

Injectable calcium phosphate

Skeletal repair system (Norian) consists of an injectable past of inorganic calcium and phosphate
that hardens within minutes and ultimately forms dahlite, a crystalline structure with a strength
of 55Mpa and the ability to be slowly reabsorbed.

It may be used in extra-articular distal radius fractures with a tendency to dorsal collapse, where
it may obviate the need to use percutaneous wires.

Collagraft
This is a composite of suspended bovine collagen, porous calcium phosphate ceramic and
autogenous bone marrow.

Bone Mineral Protein

Part of the TGF-β superfamily. BMP acts to induce undifferentiated cells to transform into
osteoblasts.

BMP- and –7 have been used to fill critical sized defects in rabbits.

Boden has shown in experiments on rabbits and rhesus monkeys that the fusion rates are directly
proportional to the amount of BMP used.

In his experiments Boden has had a better fusion rate with BMP than autograft, but autograft is
still the treatment of choice in human fusions.

Choice of graft
Allograft may be preferred in older patients with osteoporotic, weak or fatty cancellous bone, and
in children where it may not be possible to harvest enough graft.

Autologous cancellous graft can be used for defects of up to 6cm. Cortical grafts can be used for
segmental bone defects of 6-12 cm that require immediate structural support. Beyond 12cm a
vascularized cortical graft (i.e. fibula) is preferred, or bone transport.