Bone Graft Substitutes
Allosoure Allofuse Biomet ProOsteon Biomet InterGro DBM Biomet BonePlast Exactech Opteform Exactech Optefil Exactech Optecure Exactech OpteMx Isotis AccellDBM Isotis Accell Total DBM Isotis Accell Conexus Lifenet Optimum DBM Lifenet IC Graft Lifenet Cellect DBM Lifenet OraGraft Medtronic Infuse Medtronic Granules Medtronic Matrix Medtronic Putty Medtronic Osteofil DBM Orthofix Osteomax Osteotech Grafton Stryker OP-1 implant Stryker OP-I putty Stryker Calstrux Stryker Hydroset Synthes DBX Synthes Norian Synthes Chronos Wright Osteoset Wright MIIG X3 Wright Cellplex Wright Allomatrix Wright Ignite Zimmer CopiOS
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Bone healing stages: Impact > Induction > Inflammation > Soft callus(5-21days) > Hard callus > Remodeling.
Vascular Phases of Bone repair:
- Phase I: 0-1wk: reduction in blood flow
- Phase II: 1-4 weeks increased blood flow
- Phase III: 5-8 weeks returns normal
Positive Bone Healing Factors
- High vascular fracture areas
- Increased bone surface area
- Mechanical stability
- Mechanical loading
- Bone Growth Factors (BMP 2,3,6,7,9)
Negative Bone Healing Factors
- Smoking (nicotine, and decreased oxygenation)
- Diabetes
- Radiation
- Tumors
- Mechanical instability
- Infection
- Corticosterioids
- Chemotherapy
- Malnutrition
- Metabolic bone disease
- NSAIDs
- HIV
Cancellous Chips
- 5- to 7-mm freeze-dried cancellous chips
- Limited structural support; osteoconductive and limited osteoinductive
Corticocancellous bone segments
- May be cut to shape/size/fill segmental defects
- High structural support, osteoinductive
- Disease potential; immunogenicity; slow incorporation
Autograft: see Myeroff C, Archdeacon M: Autogenous bone graft: Donor sites and techniques. J Bone Joint Surg Am 2011; 93(23):2227-2236
Distal Tibia
Iliac Crest Autograft
- Gold standard
- Osteoconductive, osteogenic. Minimal active BMPs.
- Complications: acute/chronic donor site pain, infection, fracture, hematoma (Arrington ED, CORR 1996;329:300)
- Ebraheim NA, JAAOS 2001;9:210
Proximal Tibia
Allograft
Platelet Concentrates / Autologous Growth Factor (AGF)
- Rich in platelet-derive growth factor, TGF-B,
- Has not been shown to be beneficial in spinal fusion (Weiner BK, Spine 2003;28:1968)
Growth and Differentiation Factor 5
- Synonms: MP-52, LAP-4, CDMP-1, BMP-14, Radotermin, Healos/rhGDF-5
- 100% fusion rate in rabbits (Magit DP, Spine 2006:31:2180).
- Further human research needed
Ultrasound
Calcium Phosphate
- Injectable through minimal incision
- High compressive strength
- Not osteoconductive or inductive
- Slow reabsorbtion, limited shear or tensile strength
Calcium sulfate
- Pellets, paste, putty
- Injectable through minimal incision; may be combined with antibiotics
- Minimal structural support, water-soluble, rapid resorption
Hydroxyapatite
- Slowly degradable ceramic
- Animal studies demonstrate increased fixation strength, no clear clinic advantage.
- Can be shaped to fill defect
- Slow resorption
Tricalcium Phosphate
- Synonyms: beta-tricalcium phosphate
- Osteoconductive. Osteogenic and inductive when mixed with marrow aspirate.
- Minimal to no structural support, variable rapid resorption rates
- Trade names: Vitoss, Orthovita, Malvern, PA
Demineralized Bone Matrix (DBM)
Bone Morphogenetic Proteins (BMPs)
- Low molecular weight noncollagenous glycoproteins; part of TGF-beta superfamily.
- rhBMP-2 (Infuse-Metronic) has shown clinical utility in spinal fusion (Glassman SD, Spine 2005;30:1694) and tibial fractures (Swiontkowski MF, JBJS 2006;88A:1258).
- BMP-7 (OP-1-Stryker): has shown clinical utlity in spinal fusion (Vaccaro AR, Spine 2005;30:2709) and tibial nonunions (Friedlaender AR, JBJS 2001;83A(suppl 1):s151).
- recombinant BMPs have been shown to increase new cancer risk in lumbar spinal arthrodesis patients at 40mg rhBMP-2/CRM. (Carragee EJ, JBJS 2013:95:1537-45)
Bone Marrow Aspirate
- Bone marrow is aspirated from both anterior iliac crests, concentrated on a cell separator, and then injected percutaneously.
- 88% helaing rate in atrophic tibial nonuions. (Hernigjou P, JBJS 2005;87A:1430).
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