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Bone grafts and bone grafts substitutes
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Bone grafting

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presentation on various bone grafts, graft substitutes and techniques

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Bone grafting

  2. 2.  What is graft ?  What is grafting?  What are bone grafts ?  History of bone grafting  Objectives and rationale of bone grafting  Biological concept of using bone grafts  techniques
  3. 3.  A viable tissue that after removal from a donor site is implanted with in a reciepient tissue is then restored repaired and regenerated. what is grafting ?  Grafting is a procedure used to replace/ restore missing tissue.
  4. 4. what are bone grafts ?  bone grafts are the materials used for replacement or augmentation of bone.
  5. 5.  The principles, indication and techniques of bone grafting were established before the metalurgic age of orthopedic surgery  The first recorded bone implant was performed in 1668  Lane and sandhu introduced internal fixation  Albee,henderson,campbell intoduce the principle of osteogenesis in bone grafting
  6. 6.  osteoinduction – induce differentiation of stem cell into osteogenic cells  Osteoconduction- provide passive porous scaffold upon which new bone can form  osteogenesis- provide stem cell with osteogenic potential ,which directly lays down new bone
  7. 7.  Increase in clinical bone defect fill.  To preserve and augment bone for future bone grafting when required.
  8. 8.  Fill cavities or defects resulting from cysts or tumors  Bridge joint and provide arthrodesis  Bridge major defects or establish continuity of long bone
  9. 9.  Provide bone block to limit joint motion(arthroereisis)  Establish union in a pseudarthrosis  Promote union or fill defects in delayed union , malunion , fresh fracture or osteotomies
  10. 10.  Bone is transferred from one site to other in the same individual  Ideal as bone graft posses all characteristic necessary for new bone growth i.e osteoconductivity, osteoinductivity osteogenicity  includes- cortical bone grafts cancellous vascularised bone grafts autologus bone marrow grafts
  11. 11.  ADVANTAGE no immune reaction all three properties present
  12. 12.  DISADVANTAGE  additional surgery  donor site morbidity -inflamation ,infection, chronic pain and cosmetic  limited quantities of bone graft
  13. 13.  Obtained from  tibia  fibula  iliac crest  Used primarily for structural support
  14. 14.  Obtained from  thicker portion of ilium  greater trochanter  proximal metaphysis of the tibia  lower radius  olecranon  from an excised femoral head  More rapidly incoporated into host bone than cortical autografts
  15. 15. Uses of cancellous bone graft - excellent choice for non unions with <5 to 6 cm of bone loss and that do not required structural integrity - used to fill bone cyst or bone voids after reduction of depressed articular surface such as in tibial plateu fracture Stable internal or external fixation is required for graft consolidation and fracture healing
  16. 16. PRIMARY PHASE - haemorrhage - inflamation - accumulation of haematopoietis cells including neutrophills, macrophages, and osteoclasts - removal of necrotic tissue
  17. 17. - osteoconductive factors released from graft during resorption and cytokines released during inflamation - recruitment and stimulation of mesenchymal stem cells to osteogenic cells - active bone formation
  18. 18. - Osteoblasts lines dead trabecule lay down osteoid - haemopoitic marrow cells forms new bone in transplanted bone - remodeling i.e woven bone slowly being transformed into lameler bone by cordinated activities of osteoblasts and osteoclasts - incorporation of graft
  19. 19. - In cortical bone graft first osteoclastic resorption than osteoblastic activity - In cancellous bone graft bone formation and resorption occurs simultaneously called creeping substitution -Therefore cancellous bone graft incorporate quickly -But doesnot provide immediate structural support
  20. 20.  Bone is transferred with its blood supply which is anastomosed to vessel at recipient site  Available donor sites  iliac crest(with one circumflex artery)  fibula(with the peroneal artery)  radial shaft
  21. 21.  Vascularised grafts remain completely viable and incoporated like that of fracture healing
  22. 22.  Graft is obtained from an individual other than the patient  used in small children where sufficient graft is not available from donor site  in adults where large defects have to be filled like-  periprosthetic long bone fracture  revision total joint surgery  reconstruction after tumor excision
  23. 23. ADVANTAGE  no donor site morbidity  large amount can be used DISADVANTAGE  immune reaction  risk of infection  disease transmission  reduced osteoinductivity and osteogenicity
  24. 24.  Graft must be harvested under sterile condition and doner must be cleared for malignancy , syphilis, cmv and hiv  Antigenicity can be reduced by freezing (at 70 deg c) , freeze drying or by ionizing radiation  Demineralization also reduces antigenicity and enhances osteoconductive property
  26. 26.  Donor must be screened for bacterial ,viral(HIV,hepatitis) and fungal infection , malignancy , collagen vascular disease , metabolic bone disease , and presence of toxins.
  27. 27.  bone is harvested in a clean , nonsterile environment   sterilized by irradiation , strong acid or ethylene oxide  Freeze dried for storage
  28. 28.  Bone substitutes are natural , synthetic or composit materials used to fill bone defects and promote bone healing
  29. 29. PROPERTY CLASSES OSTEOCONDUCTION Calcium sulfate, ceramics, calcium phosphate cements, collagen, bioactive glass, synthetic polymers OSTEOINDUCTION Demineralised bone matrix, bone morphogenic proteins growth factors, gene therapy OSTEOGENESIS Bone marrow aspirate COMBINED composites
  30. 30. GRAFT CATEGORY MECHANISM OF ACTION AVAILABLE FORMS Demineralised bone matrix Osteoconductive and osteoinductive Putty , injectable gels, Injectable paste, Flexible sheets, Formable discs, Moldable putty, Preformed strips, Fibres mixed with cancellous chips Calcium sulphate osteoconductive Moldable hardening paste, Pellets and beads injectable cement
  31. 31. Tricalcium phosphate osteoinductive Granules, strips, putty, Extrudable forms, Preformed blocks Coralline hydroxyapetite osteoconductive Small granules, blocks Calcium phosphate cement osteoconductive Injectable cement, Packable cement Collagen combination product osteoconductive Hydroxyapetite and collagen in strips, Preformed collagen blocks with embedded tricalcium phosphate granules, Malleable collagen putty with embedded tricalcium phosphate
  32. 32. Synthetic resorbable osteoconductive Granules, Plugs, Blocks, wedges Recombinant BMP 2 osteoinductive Poweder carried on a collagen sponge Recombinant BMP 7 osteoinductive Lyophilised powder reconstitutted to form wet sand material, Lyophilised powder reconstituted to form putty
  33. 33.  Primarily as osteoconductive agent  Delivery medium for antibiotic  To fill small defects after bone resection in chronic osteomylitis
  34. 34.  Contains stem cells and osteoprogenitor cells , which are able to transform into osteoblasts  Multiple small volume aspirate is obtained from iliac crest(four 1ml aspirates from separate site puncture)  Centrifugation of aspirate in order to concentrate the cellular contents has provided encouraging results in animal experiment
  35. 35.  BMPs are osteoconductive  BMP-2 and BMP-7 are manufactured using recombinant technique  Used in treatment of non-union and open tibial fracture  Used with a carrier which may be allograft, DMB, collagen or bioactive bone cement
  36. 36. ONLAY CORTICAL GRAFT  graft is placed subperiosteally across the fragments without mobilizing the fragments .  Cortical graft was suplemented with cancellous bone for osteogenesis.  Advantages- - simple to do - blood suply of the fragments and the normal impacting forces of fracture is not disturbed
  37. 37.  Uses- - malunited , nonunited fracture of shaft of long bone - bridging joints to produce arthrodesis  Fixation is achived by internal or external metalic device
  38. 38. DUAL ONLAY GRAFT  Two cortical onlay grafts are placed opposite each other on the host bone across the nonunion and are fixed with the same set of screws  They grip the fragments like a vise  Uses- to fix nonunited short osteoporotic fracture near a joint
  40. 40. ADVANTAGE  Mechanichal fixation is better than fixation by a single onlay bone graft  two grafts add strength and stability  Grafts form a trough into which cancellous bone may be packed  during healing the dual graft prevent contracting fibrous tissue from compromising transplanted cancellous bone
  41. 41. DISADVANTAGE -same as single cortical grafts  not as strong as metalic fixator devices  Extremity usualy must serve as a donor site if autogenous graft are used  Not as osteogenic as autogenous iliac grafts  The surgery necessary to obtain them has more risk
  42. 42.  A slot or rectangular defect is created in the cortex of host bone then a graft of the same size or slighty smaller is fitted in to the defect  Ocaisonaly used in arthrodesis, particularly at the ankle
  43. 43.  Usefull for- filling defects or cavities resulting from cysts, tumor for establishing bone blocks and for wedging in osteotomies  Cancellous grafts are usefull for arthrodesis of spine because osteogenesis is prime concern
  44. 44.  Harvested from - anterior iliac crest using an acetabula reamer, - femoral canal using a reamer-irrigator- aspirator(large volume cancellous bone graft can be harvested)
  45. 45.  A massive hemicylindrical cortical graft from the affected bone is placed across the defect and supplemented by cancellous iliac bone  Suitable for obliterating large defects of the tibia and femur  Applicable for resection of bone tumor when amputation is to be avoided
  46. 46.  Fibula graft is most commonly used.  Usefull for filling large defects in the diaphsial portion of bones of upper extremity  In children ,the fibula can be used to span a long gap in the tibia
  47. 47. FACTOR POSITIVE NEGATIVE local Good vascular supply at the graft site, Large surface area, Mechanical stability, Mechanical loading, Growth factors, Electrical stimulation radiation, Tumor, mechanical instability, Local bone disease, Denervation, infection systemic Growth hormone Thyroid hormone Somatomedins Vitamins A and D Insulin Parathyroid hormone Corticosteroids NSAID drugs Chemotherapy Smoking Sepsis Diabetes Malnutrition Metabolic bone disease
  48. 48.  tourniquet aplied to avoid excessive blood loss  Make a slightly curved longitudinal incision over the anteromedial surface of the tibia.
  49. 49.  Because of the shape of the tibia, the graft is usually wider at the proximal end than at the distal end.  periosteum over the tibia is relatively thick in children and is sutured as a separate layer  in adults periosteum is thin and is sutured along with the subcutaneous tissue
  50. 50. PRECAUTION  the peroneal nerve must not be damaged  the distal fourth of the bone must be left to maintain a stable ankle  the peroneal muscles should not be cut  Disect along the anterior surface of the septum between the peroneus longus and soleus muscle.
  51. 51.  Protect the peroneal nerve by tracing it from the posteromedial aspect of of the distal end of biceps femoris tendon.
  52. 52.  Protect the anterior tibial vessel that pass between the neck of fibula and the tibia by subperiosteal dissection  After the resection is complete, suture the biceps tendon and the fibular collateral ligament to the adjacent soft tissues
  53. 53. iliac crest is an ideal source of bone graft because –  it is relatively subcutaneous  has ample cancellous bone  has cortical bone of varying thickness  Removal of the bone carries minimal risk  usually there is no significant residual disability
  54. 54.  Large cancellous and corticocancellous grafts may be obtained from the anterosuperior iliac crest and the posterior iliac crest.  In children the physis of the iliac crest is preserved together with the attached muscle
  55. 55.  Generaly only one cortex and the cancellous bone are removed for grafts  the fractured crest along with the apophysis is replaced in contact with the remnanat of the ilium by nonabsorbable suture.
  56. 56.  INCISION along the subcutaneous border of the iliac crest at the point of contact of the periosteum with the origins of the gluteal and trunk muscles  When the crest of the ilium is not required as part of the graft, split off the lateral side or both sides of the crest in continuity with the periosteum
  57. 57. ◦ Hernia devlops if full thickness massive grafts were taken. ◦ The superior cluneal nerves are at risk if dissection is carried farther than 8 cm lateral to the posterior superior iliac spine
  58. 58.  superior gluteal vessels can be damaged by retraction against the roof of the sciatic notch  Removal of large full-thickness grafts from the anterior ilium can result in significant cosmetic deformity  Arteriovenous fistula,  pseudoaneurysm,  ureteral injury,  anterior superior iliac spine avulsion,  and pelvic instability
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presentation on various bone grafts, graft substitutes and techniques


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