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Bone Grafting and Bone Graft Substitutes PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Bone Grafting and Bone Graft Substitutes” by David Hak, MD.

This medical PowerPoint presentation is about bone grafting, a surgical procedure that involves transplanting bone tissue from one area of the body to another to stimulate bone growth and healing. Bone grafting is commonly used to treat bone fractures, spinal fusion, dental implants, and other bone-related injuries and conditions.

However, not everyone is a candidate for bone grafting or may not have enough bone tissue available for transplantation. In such cases, bone graft substitutes may be used as an alternative. Bone graft substitutes are synthetic or biological materials that are used to promote bone growth and regeneration.

There are several types of bone graft substitutes, including:

Synthetic bone grafts: These are man-made materials such as calcium phosphates, hydroxyapatite, and tricalcium phosphate. These materials are designed to mimic the structure and composition of natural bone tissue.
Allografts: These are bone tissues obtained from a human donor. The bone tissue is screened and processed to remove any potential disease-causing agents before being used in surgery.
Xenografts: These are bone tissues obtained from animals, usually cows or pigs. Like allografts, the bone tissue is processed to remove any potential disease-causing agents.
Growth factors: These are naturally occurring proteins that stimulate bone growth and regeneration. Growth factors can be isolated and used to promote bone healing and growth.

The choice of bone graft or graft substitute depends on several factors, including the size and location of the bone defect, the patients age and overall health, and the surgeons preference and experience. Your doctor will work with you to determine the best treatment option for your specific condition.

Tags : bone grafting, transplanting bone tissue, bone fractures, spinal fusion, dental implants, bone-related injuries, Synthetic bone grafts, Allografts, Xenografts, Orthopaedic Surgery, Orthopaedic Surgery PowerPoint presentation

Published on : Jun 23, 2023 | Views : 2693 | Downloads : 6

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Slide 1-

Bone Grafting and Bone Graft Substitutes Original Author: James Krieg, MD Revision Author: David Hak, MD
Slide 2-

Bone Graft Function Structural support of articular fracture Tibial plateau fracture Prevent post-op collapse Void filler to prevent fracture Cyst excision Improved healing of fracture and nonunions Speed healing Fewer nonunions
Slide 3-

Mechanisms of Bone Growth Osteoconduction Provides matrix for bone growth Osteoinduction Growth factors encourage mesenchymal cells to differentiate into osteoblastic lineages Osteogenesis Transplanted osteoblasts and periosteal cells directly produce bone
Slide 4-

Types of Bone Grafts Autograft Allograft Bone graft substitutes Most have osteoconductive properties Osteoinductive agents rhBMP-2 (Infuse) and rhBMP-7 (OP-1)
Slide 5-

Autogenous Bone Graft “Gold standard” Standard by which other materials are judged May provide osteoconduction, osteoinduction and osteogenesis Drawbacks Limited supply Donor site morbidity
Slide 6-

Autogenous Bone Grafts Cancellous Cortical Free vascular transfers Bone marrow aspirate
Slide 7-

Cancellous Bone Grafts Three dimensional scaffold (osteoconductive) Osteocytes and stem cells (osteogenic) A small quantity of growth factors (osteoinductive) Little initial structural support Can gain support quickly as bone is formed
Slide 8-

Cortical Bone Grafts Less biologically active than cancellous bone Less porous, less surface area, less cellular matrix Prologed time to revascularizarion Provides more structural support Can be used to span defects Vascularized cortical grafts Better structural support due to earlier incorporation Also osteogenic, osteoinductive Transported periosteum
Slide 9-

Bone Marrow Aspirate Osteogenic Mesenchymal stem cells (osteoprogenitor cells) exist in a 1:50,000 ratio to nucleated cells in marrow aspirate Numbers decrease with advancing age Can be used in combination with an osteoconductive matrix
Slide 10-

Autograft Harvest Cancellous Iliac crest (most common) Anterior- taken from gluteus medius pillar Posterior- taken from posterior ilium near SI joint Metaphyseal bone May offer local source for graft harvest Greater trochanter, distal femur, proximal or distal tibia, calcaneus, olecranon, distal radius, proximal humerus
Slide 11-

Autograft Harvest Cancellous harvest technique Cortical window made with osteotomes Cancellous bone harvested with gouge or currette Can be done with trephine instrument Circular drills for dowel harvest Commercially available trephines or “harvesters” Can be a percutaneus procedure
Slide 12-

Autograft Harvest Cortical Fibula common donor Avoid distal fibula to protect ankle function Preserve head to keep LCL, hamstrings intact Iliac crest Cortical or tricortical pieces can be harvested in shape to fill defect
Slide 13-

Bone Allografts Cancellous or cortical Plentiful supply Limited infection risk (varies based on processing method) Provide osteoconductive scaffold May provide structural support
Slide 14-

Bone Allografts Available in various forms Processing methods may vary between companies / agencies Fresh Fresh Frozen Freeze Dried
Slide 15-

Bone Allografts Fresh Highly antigenic Limited time to test for immunogenicity or diseases Use limited to joint replacement using shape matched osteochondral allografts
Slide 16-

Bone Allografts Fresh frozen Less antigenic Time to test for diseases Strictly regulated by FDA Preserves biomechanical properties Good for structural grafts
Slide 17-

Bone Allografts Freeze-dried Even less antigenic Time to test for diseases Strictly regulated by FDA Can be stored at room temperature up to 5 years Mechanical properties degrade
Slide 18-

Graft Incorporation Hematoma formation Release of cytokines and growth factors
Slide 19-

Graft Incorporation Hematoma formation Release of cytokines and growth factors Inflammation Development of fibrovascular tissue
Slide 20-

Graft Incorporation Hematoma formation Release of cytokines and growth factors Inflammation Development of fibrovascular tissue Vascular ingrowth Often extending Haversian canals
Slide 21-

Graft Incorporation Hematoma formation Release of cytokines and growth factors Inflammation Development of fibrovascular tissue Vascular ingrowth Often extending Haversian canals Focal osteoclastic resorption of graft
Slide 22-

Graft Incorporation Hematoma formation Release of cytokines and growth factors Inflammation Development of fibrovascular tissue Vascular ingrowth Often extending Haversian canals Focal osteoclastic resorption of graft Intramembranous and/or endochondral bone formation on graft surfaces
Slide 23-

Graft Incorporation Cancellous bone interface between graft and host bone
Slide 24-

Graft Incorporation Cortical allograft strut graft placed next to cortex of host After 4 years of incorporation
Slide 25-

Partial incorporation of hydroxyapatite bone graft substitute\ Biopsy of material obtained 1 year post-op Bone Graft Substitute Incorporation
Slide 26-

Bone Graft Substitutes Need for bone graft alternatives has lead to development of numerous bone graft substitutes Avoid morbidity of autogenous bone graft harvest Mechanical properties vary Most offer osteoconductive properties Some provide osteoinductive properties
Slide 27-

Bone Graft SubstitutesPotential Roles Extender for autogenous bone graft Large defects Multiple level spinal fusion Enhancer To improve success of autogenous bone graft Substitute To replace autogenous bone graft
Slide 28-

Bone Graft Substitutes Calcium phosphate Calcium sulfate Collagen based matrices Demineralized bone matrix Hydroxyapatite Tricalcium phosphate Osteoinductive proteins
Slide 29-

Bone Graft Substitutes Resorption rates vary widely Dependant on composition Calcium sulfate - very rapid Hydroxyapatite (HA) – very, very slow Some products may be combined to optimize resorption rate Also dependant on porosity, geometry
Slide 30-

Bone Graft Substitutes Mechanical properties vary widely Dependant on composition Calcium phosphate cement has highest compressive strength Cancellous bone compressive strength is relatively low Many substitutes have compressive strengths similar to cancellous bone All designed to be used with internal fixation
Slide 31-

Calcium Phosphate Injectable pastes of calcium and phospate Norian SRS (Synthes/Stratec) Alpha BSM (Etex/Depuy) Callos Bone Void Filler (Skeletal Kinetics)
Slide 32-

Calcium Phosphate Injectable Very high compressive strength once hardens Some studies of its use have allowed earlier weightbearing and range of motion
Slide 33-

Osteoconductive void filler Low compressive strength – no structural support Rapidly resorbs May be used as a autogenous graft extender Available from numerous companies Osteoset, Calceon 6, Bone Blast, etc. Calcium Sulfate
Slide 34-

Pellets Pellet injectors Bead kits Allows addition of antibiotics Injectable May be used to augment screw purchase Calcium Sulfate
Slide 35-

Collagen Based Matrices Highly purified Type 1 bovine dermal fibrillar collagen Bone marrow is added to provide bone forming cells Collagraft (Zimmer) Collagen / HA / Tricalcium phosphate Healos (Depuy) Collagen / HA
Slide 36-

Demineralized Bone Matrix Prepared from cadaveric human bone Acid extraction of bone leaving Collagen Noncollagenous proteins Bone growth factors BMP quantity extremely low and variable Sterilized which may decrease the availability of BMP
Slide 37-

Available from multiple vendors in multiple preparations Gel Putty Strip Combination products with cancellous bone and other bone graft substitute products Demineralized Bone Matrix
Slide 38-

Growth factor activity varies between tissue banks and between batches While they may offer some osteoinductive potential because of available growth factors, they mainly act as an osteoconductive agents Han B et al. J Orthop Res. 21(4):648-54, 2003. Blum B, et al. Orthopedics. 27 (1 Suppl): S161 – S165, 2004. Demineralized Bone Matrix
Slide 39-

Hydroxyapatite Produced from marine coral exoskeletons that are hydrothermically converted to hydroxyapatite, the natural mineral composition of bone Interconnected porous structure closely resembles the porosity of human cancellous bone Coralline hydroxyapatite Cancellous Bone
Slide 40-

Hydroxyapatite Marketed as ProOsteon by Interpore Cross Available in various size blocks & granules ProOsteon 500 Very slow resorption ProOsteon 500 R Only a thin layer of HA Faster resorption
Slide 41-

Tricalcium Phosphate Wet compressive strength slightly less than cancellous bone Available as blocks, wedges, and granules Numerous tradenames Vitoss (Orthovita) ChronOS (Synthes) Conduit (DePuy) Cellplex TCP (Wright Medical) Various Theri__ names (Therics)
Slide 42-

Bone Morphogenetic Proteins Produced by recombinant technology Two most extensively studied and commercially available BMP-2 (Infuse) Medtronics BMP-7 (OP-1) Stryker Biotech
Slide 43-

BMP-2 for Open Tibial Fractures Prospective, randomized study 450 patients BESTT Study Group, et al. J Bone Joint Surg 84A: 2123, 2002. All received IM nail (vast majority with UNREAMED technique) and appropriate soft tissue management Randomized to 3 treatments at time of definitive wound closure Placebo 0.75 mg/ml BMP-2/ACS 1.50 mg/ml BMP-2/ACS
Slide 44-

44% reduction in risk of nonunion/delayed union with high dose BMP-2 Significantly faster fracture healing Significantly fewer invasive interventions hardware failures infections Results BESTT Study Group, et al. J Bone Joint Surg 84A: 2123, 2002.
Slide 45-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction 27 y.o male with lateral split/depression tibial plateau fracture. Note posterolateral depression.
Slide 46-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction ORIF with allograft cancellous bone chips to fill defect and support depressed area Alternatively could use any osteoconductive substitute with similar compressive strength
Slide 47-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction 4 months s/p surgery and the graft is well incorporated.
Slide 48-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect 29 y.o male with defect s/p IMN Type IIIB open tibia fracture. Gentamicin PMMA beads were used as spacers and removed.
Slide 49-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect s/p bone grafting with iliac crest autograft.
Slide 50-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect 14 months after injury, the fracture is healed and the nail removed.
Slide 51-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect Stimulate healing Atrophic and Oligotrophic Nonunions 26 y.o. woman with established atrophic nonunion of the clavicle.
Slide 52-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect Stimulate healing Atrophic and Oligotrophic Nonunions Plating with cancellous iliac crest autograft.
Slide 53-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect Stimulate healing Atrophic and Oligotrophic Nonunions 6 months after surgery, she is healed and asymptomatic.
Slide 54-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect Stimulate healing Nonunions Arthrodesis Failed subtalar arthrodesis
Slide 55-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect Stimulate healing Nonunions Arthrodesis Repeat fusion with autogenous iliac crest.
Slide 56-

Indications for Bone Graft Provide mechanical support Metaphyseal impaction Replace bone Cortical or segmental defect Stimulate healing Nonunions Arthrodesis 6 months after surgery, fused successfully
Slide 57-

Thank You Return to General/Principles Index If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@ota.org