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Current Concepts Review

Bone Grafts and Bone Graft Substitutes
in Orthopaedic Trauma Surgery
A Critical Analysis
By William G. De Long Jr., MD, Thomas A. Einhorn, MD, Kenneth Koval, MD,
Michael McKee, MD, Wade Smith, MD, Roy Sanders, MD, and Tracy Watson, MD
Investigation performed at Temple University School of Medicine, Marlton, New Jersey

➤ Osteoinduction is a process that supports the mitogenesis of undifferentiated mesenchymal cells, leading to
the formation of osteoprogenitor cells that form new bone.

➤ The human skeleton has the ability to regenerate itself as part of the repair process.

➤ Recombinant bone morphogenetic protein has osteoinductive properties, the effectiveness of which is sup-
ported by Level-I evidence from current literature sources.

➤ Osteoconduction is a property of a matrix that supports the attachment of bone-forming cells for subsequent
bone formation.

➤ Osteogenic property is a relatively new term that can be defined as the generation of bone from bone-
forming cells.

Orthopaedic trauma surgery requires the regular use of bone
grafts to help provide timely healing of musculoskeletal injuries.
The iliac crest autologous graft remains the gold standard. The
morbidity associated with the harvest of bone graft has caused
practitioners to seek methods of enhancing healing with bone
graft substitutes. The term bone graft substitute describes a spec-
trum of products that have various effects on bone-healing. Un-
fortunately, there is little information in the literature about
when and where to use these devices. In general, we categorize
the properties of bone graft substitutes as osteoinductive, osteo-
conductive, or osteogenic. Going through the operating room
storage areas in our institutions, we find many of these products
available, with various trade names that can be misleading and
confusing. The purpose of this review is to give the practicing
surgeon a basic fund of knowledge on the topic of bone graft
substitutes as well as an opinion on the levels of evidence in the
current literature supporting the use of the various materials.
The answers to the most difficult questions regarding bone graft
substitutes require multicenter prospective randomized stud-
ies. These are extremely difficult to design and execute, with the
cost being the most onerous obstacle. Industrial funding has
been one of the ways to get this type of work completed. The
full details of all of the requirements for making a project of this
magnitude successful is beyond the scope of this project. The
authors are all members of the Orthopaedic Trauma Associa-
tion Orthobiologics Committee. Because of their expertise, they
were charged by the President of the organization to provide
this brief summary for use by the orthopaedic community. The
opinions stated here are based on the literature, and the recom-
mendations are based on the levels of evidence supporting
claims from this body of information.
Osteoinductive Bone Substitutes
One of the unique aspects of the human skeleton is its ability
to regenerate itself as part of a repair process. Skeletal repair
involves a series of events that parallel embryological develop-

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or
grants in excess of $10,000 from Stryker Biotech. In addition, one or more of the authors or a member of his or her immediate family received, in
any one year, payments or other benefits or a commitment or agreement to provide such benefits from commercial entities (DePuy and Osteotech
[less than $10,000] and Stryker Biotech [in excess of $10,000]). Also, a commercial entity (Stryker Biotech and Osteotech) paid or directed in any
one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other chari-
table or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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ment. As all skeletal tissues evolve from mesenchyme, undif-
ferentiated mesenchymal cells make a genetic commitment to
a particular cellular lineage early in the developmental or re-
pair process. In the case of repair, some stimulus must signal
the undifferentiated mesenchymal cells to differentiate along a
chondro-osteogenic pathway. This phenomenon, known as
osteoinduction, is defined as “a process that supports the mito-
genesis of undifferentiated mesenchymal cells leading to the
formation of osteoprogenitor cells with the capacity to form
new bone.”1 Thus, any material that induces this process could
be considered to be osteoinductive.
The concept of osteoinduction was introduced by Mar-
shall R. Urist at the time of his discovery of the so-called bone
induction principle in the 1960s2. The initial understanding
was that bone matrix—demineralized bone matrix in particu-
lar—contains some property that can induce new bone for-
mation when implanted into an extraskeletal site. Urist and
his colleagues soon identified a protein that they named bone
morphogenetic protein (BMP); this led to a program of investi-
gation to identify and characterize an entire family of osteoin-
ductive molecules3. By the mid-1990s, it had become clear that
this family included at least fifteen BMPs and was part of the
larger transforming growth factor-β (TGF-β) superfamily of
molecules. Today, orthopaedic surgeons seek guidance on the
use of materials that may possess some of these properties and
could be therapeutically useful in the management of skeletal
injuries such as fractures or nonunions. In particular, the role
of osteoinductive factors synthesized by recombinant gene
technology or derived from autologous bone, allogeneic bone,
or demineralized bone matrix requires clarification.
Use of Levels of Evidence in the
Assessment of Scientific Information
In order to assess the quality of evidence supporting scientific
knowledge regarding a therapeutic intervention, a hierarchical
rating system was established to place a published report into
proper context for the reader. Recently introduced into this
journal, this rating system requires authors to classify their
study as therapeutic, prognostic, diagnostic, or economic/deci-
sion analysis and to provide a level-of-evidence rating4. Studies
with higher levels of evidence are more valuable to surgeons
attempting to resolve clinical dilemmas. For example, a well-
conducted, randomized controlled trial (Level I) provides ex-
cellent information to help a clinician evaluate a treatment,
whereas a review article, while helpful, is essentially based on an
expert’s personal opinion (Level V). While the answer to a clini-
cal question must be based on a composite assessment of all
evidence of all types and no one study should be considered de-
finitive, reports with higher levels of evidence are generally con-
sidered more appropriate for clinical decision-making.
Level-of-evidence ratings for multiple studies address-
ing a clinical care recommendation can be summarized with
use of a grades-of-recommendation table. This requires that
authors not only rate the quality of the evidence reported but
also provide the quality of a clinical care recommendation
based on the evidence to support it.
BONE GRAFTS AND BONE GRAFT SUBSTITUTES
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Grades of Recommendation
A. Good evidence (Level-I studies with consistent findings)
for or against recommending intervention.
B. Fair evidence (Level-II or III studies with consistent find-
ings) for or against recommending intervention.
C. Poor-quality evidence (Level-IV or V studies with consis-
tent findings) for or against recommending intervention.
I. There is insufficient or conflicting evidence not allowing a
recommendation for or against intervention.
Use of Demineralized Bone Matrix
To our knowledge, there have been no studies in which the in-
vestigators carefully evaluated the osteoinductive properties of
allograft bone per se. However, there have been studies on
demineralized bone matrix as a source of osteoinductive pro-
teins and, while most of the structural aspects of an allograft
are eliminated by an extensive demineralization process, dem-
ineralized bone matrix is, strictly speaking, allogeneic bone
tissue. Since the true test of osteoinductivity is whether a ma-
terial that has been implanted in a nonosseous site forms
bone, the inability of allograft bone to do this in patients ar-
gues against its having substantial osteoinductive activity.
Demineralized bone matrix has been shown to produce this
effect in animal studies, but it too has never demonstrated this
effect in patients. In addition, different demineralized bone
matrix products have been found to vary with regard to their
osteogenic response in animal models.
Demineralized bone matrix is produced by acid extrac-
tion of allograft. It contains type-1 collagen, non-collagenous
proteins, and osteoinductive growth factors5. As noted above,
the TGF-β superfamily includes a number of factors in addition
to the BMPs. The factors that are known to be osteoinductive
are the BMPs, GDFs (growth differentiation factors), and possi-
bly TGF-β 1, 2, and 3. Thus, when demineralized bone matrix is
implanted in an animal, all of these factors potentially work in
combination to produce the observed osteogenic response.
However, while studies of animals have documented the os-
teoinductive effects of demineralized bone matrix6,7, there is a
paucity of clinical studies with similar findings. Isolated case
reports and uncontrolled retrospective reviews (Level-IV
evidence) have suggested potential therapeutic effects of dem-
ineralized bone matrix in the treatment of phalangeal cysts8 and
maxillocraniofacial deformities9. Tiedeman et al.10 reported on
an uncontrolled case series of forty-eight patients in whom
demineralized bone matrix had been used in conjunction with
bone marrow for the treatment of skeletal injuries. Thirty-nine
patients were available for follow-up, and thirty of them showed
healing. The most common diagnosis for the patients who did
not have healing was recalcitrant nonunion. However, since
there was no control group, the role of demineralized bone ma-
trix in the thirty patients who had healing remains unknown.
There are numerous demineralized bone matrix formu-
lations based on refinements of the manufacturing process.
They are available as freeze-dried powder, granules, gel, putty,
or strips. They have also been developed as combination prod-
ucts with other materials such as allogeneic bone chips and
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calcium sulfate granules. All have been shown to have osteoin-
ductive effects in animals, but we are not aware of any Level-I
studies of the use of demineralized bone matrix alone in hu-
mans. One prospective controlled study showed equivalent
rates of spinal fusion between sides in patients who had been
treated with autograft on one side and a 2:1-ratio composite
of Grafton DBM (gel) and autograft on the other, suggesting a
potential use of Grafton DBM as a bone-graft extender11. Only
anecdotal information is available regarding similar applica-
tions in patients with long-bone fractures and nonunions.
There is now evidence of differential potencies of dem-
ineralized bone matrix preparations based on the manufac-
turer and manufacturing process12. Because these materials
were originally developed as reprocessed human tissues, clear-
ance for marketing was achieved without the need for ran-
domized controlled trials comparing their efficacy with that of
autologous bone. However, as currently marketed formula-
tions of these products include carrier substances such as glyc-
erol, starch, and hyaluronic acid, the United States Food and
Drug Administration (FDA) now plans to regulate demineral-
ized bone matrix products as Class-II medical devices. Cur-
rently marketed demineralized bone matrix products will
most likely be reclassified with use of the 510K pathway, which
requires demonstration of substantial equivalence to a predi-
cate device but still not does not require demonstration of ef-
ficacy comparable with that of autologous bone graft.
Use of Bone Morphogenetic Proteins
To our knowledge, the first reports on the use of BMP to treat
clinical conditions came from the Department of Orthopaedic
Surgery at the University of California at Los Angeles. Urist pu-
rified the protein in his laboratory, and Johnson and colleagues
used the protein in clinical settings13. These uncontrolled retro-
spective series (Level-IV evidence) had encouraging results and
stimulated further investigation in this area. Because extraction
of purified human BMP from cadaver bone provided small
yields, the ability to produce it in large quantities was limited.
Therefore, companies turned to the use of recombinant gene
technology to develop individual BMPs and to focus on those
that have the greatest potential for bone induction in patients.
Because the use of this technology is viewed by the FDA as being
associated with risk, recombinant BMPs are classified as Class-
III devices.
At the present time, two recombinant BMPs, rhBMP-2
and rhBMP-7 (also known as osteogenic protein-1 [OP-1])
are available for clinical use. Each has been evaluated in ran-
domized controlled trials involving trauma patients, and those
studies provided data that qualify as Level-I evidence. In a
large prospective, randomized, controlled, partially blinded,
multicenter study, Friedlaender et al.14 assessed the efficacy of
the OP-1 Device (3.5 mg of rhBMP-7 in a bovine bone-
derived type-1 collagen-particle delivery vehicle; Stryker Bio-
tech, Hopkinton, Massachusetts) in comparison with that of
autografting in the treatment of 122 patients with a total of
124 tibial nonunions. All of the nonunions were at least nine
months old and had shown no progress toward healing for the
BONE GRAFTS AND BONE GRAFT SUBSTITUTES
INO R T H O P A E D I C TR A U M A S U R G E R Y
three months prior to the patient’s enrollment in the study. All
patients were treated with reamed intramedullary nailing of
the nonunion and were then randomized to have either au-
tograft bone or OP-1 implanted at the nonunion site. Despite
randomization, there were more smokers in the OP-1 group.
Nine months after the surgery, 81% of the sixty-three non-
unions treated with OP-1 and 85% of the sixty-one treated
with autograft had clinical evidence of union. Radiographic
assessments suggested healing of 75% and 84% of these non-
unions, respectively. As statistical analysis of these results
showed equivalent efficacy between OP-1 and autograft, the
authors concluded that OP-1 was a safe and effective alterna-
tive to bone graft in the treatment of tibial nonunions. A limi-
tation of the study was that the investigators could not control
for the potential healing effects produced by reamed in-
tramedullary nailing of tibial nonunions. It is noteworthy that
half of the nonunions treated in this study were of fractures
that had failed to heal following reamed nailing as primary
treatment. Another positive effect of the use of OP-1 was that
there was a reduction in the rate of infections compared with
that in the control group.
More recently, the BMP-2 Evaluation in Surgery for Tibial
Trauma (BESTT) Study Group reported the results of a large
multinational, prospective, randomized, controlled study of the
effects of INFUSE (rhBMP-2 on an absorbable type-1 collagen
sponge; Medtronic Sofamor Danek, Memphis, Tennessee) in
the treatment of open tibial fractures15. Four hundred and fifty
patients with such an injury were initially managed with irriga-
tion, débridement, and intramedullary nail fixation. At the time
of definitive wound closure, the patients were randomized to
one of three groups: standard closure, standard closure and the
addition of 6 mg of rhBMP-2 to the fracture site, or standard
closure and the addition of 12 mg of rhBMP-2 to the fracture
site. The primary outcome measure in this study was the rate of
secondary interventions (returns to the operating rooms for ad-
ditional treatment). The group treated with the higher dose of
rhBMP-2 (1.5 mg/kg) had fewer secondary interventions. Inter-
estingly, although not used as primary outcome measures, an
accelerated time to union, improved wound-healing, and a re-
duced infection rate were also found in the patients treated with
the high dose of rhBMP-2.
In a similar study, McKee et al.16 investigated the use of
OP-1 in the treatment of open tibial fractures. The fracture
was treated initially with irrigation, débridement, and locked
intramedullary nailing and, at the time of definitive wound
closure, the patient was randomized to be managed with ei-
ther standard closure or standard closure and the addition of
3.4 mg of OP-1 to the fracture site. One hundred and twenty-
two patients with a total of 124 tibial fractures were enrolled in
the study. There was a significant decrease in the rate of sec-
ondary interventions for delayed unions and nonunions (the
primary outcome measure) in the OP-1-treated group (p =
0.02). There was a corresponding improvement in patient
function, with 80% of the OP-1 group having no or mild pain
with activity at twelve months postinjury compared with 65%
of the control group (p = 0.04).
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Osteoconductive Bone Graft Substitutes
Allograft
Approximately one-third of the bone grafts used in North
America are allografts17. Allograft bone is an attractive alterna-
tive to autogenous bone as it avoids donor site morbidity, is rel-
atively abundant, and can be used off the shelf. Fresh allograft
bone is less frequently used than processed allograft because of
an inadequate time for disease screening. Disease transmis-
sion is the major risk and disadvantage of the use of allograft
materials, and the risk is increased when fresh allografts are
used. However, one must keep in mind that, although there is a
risk of bacterial and viral infection transmission, there have
been relatively few reported cases considering the large number
of allograft procedures done each year.
Frozen allografts are stored at temperatures below −60°C,
which decreases enzyme degradation and host immune re-
sponse. Freeze-drying involves removal of water from the tissue
with subsequent vacuum packing and storage at room tempera-
ture. This destroys all osteogenic cells and leaves only limited
osteoinductive capability. The host immune response is less ro-
bust than the response to fresh or fresh-frozen allograft. Al-
lografts can be processed as a powder, cancellous or cortical
chips, wedges, pegs, dowels, or struts. In addition, they can be
machined into shapes, such as screws, for specific situations.
Sterility is a major concern with the use of allografts,
highlighting the need for aseptic tissue retrieval and adequate
donor screening. However, even those safeguards do not elim-
inate the risk of infection. Therefore, serological testing must
be performed. The FDA requires testing for HIV-1 (human
immunodeficiency-1), HIV-2, and HCV (hepatitis-C virus)
antibody. Many states also require testing for hepatitis-B core
antibody. The AATB (American Association of Tissue Banks)
requires additional testing for HTLV-I (human T-cell lympho-
tropic virus-I) and HTLV-II antibodies. Additional testing for
HIV with use of polymerase chain reaction and for hepatitis
with use of nucleic acid amplification as well as testing for cy-
tomegalovirus and syphilis antibodies is frequently done.
Grafts may be processed or terminally sterilized. Terminal
sterilization involves the treatment of the tissue with a single
modality at the completion of the harvest and processing to
provide sterility. This is commonly done with techniques such
as gamma irradiation or ethylene oxide sterilization. Ethylene
oxide sterilization is more cost-efficient, but it may negatively
affect the mechanical strength or biologic activity of the graft.
Terminal sterilization with gamma radiation has been found to
have greater effects on the mechanical properties of allografts,
whereas ethylene oxide affects the osteoinductive properties.
The risk of disease transmission with fresh allografts and
the difficulty with storage and distribution of these grafts have
led to the predominant use of fresh-frozen and freeze-dried al-
lografts. These allografts are primarily osteoconductive, but
they retain a variable number of osteoinductive proteins. The
osteoinductive properties vary according to the type of allograft
and the processing methods used to prepare, sterilize, and store
the allograft material prior to implantation. Incorporation of
allograft bone begins with passive osteoconduction. Bone for-
BONE GRAFTS AND BONE GRAFT SUBSTITUTES
INO R T H O P A E D I C TR A U M A S U R G E R Y
mation is then further stimulated through osteoinduction.
Incorporation of allograft bone differs according to the type of
graft that is used. Cortical strut grafts are incorporated by
creeping substitution through the process of intramembranous
bone formation at the cortical junctions18,19. Cortical graft ends
with an exposed medullary canal are incorporated by enchon-
dral ossification. This process involves weakening of the initial
structural strength of the cortical graft as it is resorbed. Strength
is recovered as new bone formation occurs20. In contrast, cancel-
lous allograft chips or powders are incorporated solely by en-
chondral bone formation along the osteoconductive framework
of the graft, which strengthens the construct over time20.
The use of allograft has become widespread. Potential ap-
plications in the trauma setting include reconstruction of skele-
tal defects, augmentation of fracture repair, and treatment of
nonunion. The primary application of allografts in trauma sur-
gery consists of use of cancellous or corticocancellous chips as
an osteoconductive filler for metaphyseal defects such as occur
with tibial plateau fractures. Assessment of their efficacy in this
application is extremely difficult. Van Houwelingen and McKee
reported on a case series of six humeral nonunions treated with
a combination of compression plate fixation and cortical onlay
allografts21. All six nonunions had united at a mean of 3.4
months. Hornicek et al. reported on a series of nine humeral
nonunions treated in a similar fashion; union was achieved in
all patients at an average of 2.9 months22.
Haddad et al. reported on a retrospective case series of
forty patients in whom a femoral fracture around a well-fixed
prosthetic femoral stem was treated with cortical onlay strut
allografts, with or without plate fixation and without revision
of the femoral component23. Thirty-nine of the forty fractures
united. Wang and Weng reported the results of a retrospective
study of nine patients in whom a distal femoral shaft non-
union had been treated with internal fixation combined with
cortical allograft strut grafts24. All fractures united at an aver-
age of five months.
Herrera et al. reported the results of a retrospective study
of unstable distal radial fractures treated with cancellous al-
lograft augmentation of both internal and external fixation25.
None of seventeen patients evaluated after treatment with this
protocol had a poor result. The authors concluded that cancel-
lous allograft was a useful adjunct for treatment of unstable dis-
tal radial fractures with metaphyseal comminution.
There is Level-IV evidence supporting the use of cortical
and cancellous allografts in reconstructive trauma surgery21,24,25.
Additional research is needed to determine the ideal material
for encouraging bone formation with these applications.
Calcium Phosphate Synthetic Substitutes
Calcium phosphate synthetic substitutes (Table I) are consid-
ered to be medical devices by the FDA. To market a medical
device, a Premarket Notification must be submitted to show
that the device is essentially equivalent to a legally marketed
device26. Calcium phosphate substitutes are osteoconductive,
but they are not osteoinductive unless growth factors, BMPs,
or other osteoinductive substances are added to create a com-
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TABLE I Commercially Available Calcium Phosphate Products
Calcium Phosphate Product Company
Cements
SRS (Skeletal Repair System) Synthes/Norian
BoneSource Howmedica
Alpha-BSM DePuy
Biobon Biomet/Merck
Ceramics
Mimix Biomet
Cerasorb Curasan, CryoLife
ChronOS Synthes
Vitoss Orthovita
Pro Osteon Interpore Cross
Endobon Biomet/Merck
Composite grafts
Collagraft Zimmer
Healos Orquest
posite graft. They do not provide a high level of structural
support because they are brittle and have little tensile
strength27. They increase bone formation by providing an os-
teoconductive matrix for host osteogenic cells to create bone
under the influence of host osteoinductive factors27.
Calcium phosphate is available in a variety of forms and
products, including ceramics, powders, and cements. Ceram-
ics are highly crystalline structures created by heating non-
metallic mineral salts at temperatures greater than 1000°C, a
process known as sintering. These phosphate materials have
variable rates of osteointegration based on their crystalline
size and stoichiometry. They have the advantage of incorpo-
rating at a slower rate than calcium sulfate materials.
One of the commonly available resorbable ceramics is
tricalcium phosphate. These ceramics can be obtained in
block, granular, powder, or putty form. Coralline ceramics are
formed by thermochemically treating coral with ammonium
phosphate, leaving tricalcium phosphate with a structure and
porosity that are similar to those of cancellous bone. Pore size
and porosity are important characteristics of bone graft sub-
stitutes. No osseous ingrowth occurs with pore sizes of 15 to
40 µm. Osteoid formation requires minimum pore sizes of
100 µm, with pore sizes of 300 to 500 µm reported to be ideal
for osseous ingrowth28. Some authors, however, have reported
that pore size may be less critical than the presence of inter-
connecting pores for osseous ingrowth. Interconnecting pores
prevent the formation of blind alleys, which are associated
with low oxygen tension; low oxygen tension prevents os-
teoprogenitor cells from differentiating into osteoblasts29.
Synthetic hydroxyapatite is a crystalline calcium phos-
phate osteoconductive bone substitute that is also manufac-
tured as a ceramic through a sintering process. Animal studies
have suggested that hydroxyapatite may have some osteoinduc-
tive properties in addition to its osteoconductive capabilities30,31.
However, because of slow in vivo resorption and a high brittle-
BONE GRAFTS AND BONE GRAFT SUBSTITUTES
INO R T H O P A E D I C TR A U M A S U R G E R Y
Type
Calcium phosphate injectable cement
Calcium phosphate cement
Calcium phosphate cement
Calcium phosphate putty
Synthetic tricalcium phosphate
Beta-tricalcium phosphate
Beta-tricalcium phosphate
Beta-tricalcium phosphate
Coralline hydroxyapatite
Cancellous hydroxyapatite
Bovine collagen, hydroxyapatite, and tricalcium phosphate
Hydroxyapatite-coated bovine collagen
ness, which have caused clinicians to be concerned about slow
bone formation, hydroxyapatite is not commonly used alone as
an osteoconductive bone substitute. Tricalcium phosphate is
less brittle and has a faster resorption rate than hydroxyapatite.
Animal studies have demonstrated that 95% of calcium phos-
phate is resorbed in twenty-six to eighty-six weeks32,33. Trical-
cium phosphate and hydroxyapatite have been combined into a
biphasic calcium phosphate composite that has a faster resorp-
tion rate than pure hydroxyapatite.
Calcium phosphate can also be manufactured as a ce-
ment, by adding an aqueous solution to dissolve the calcium,
which is followed by a precipitation reaction in which the cal-
cium phosphate crystals grow and the cement hardens. The
primary advantage of cements over blocks, granules, or pow-
ders is the ability to custom-fill defects and increased com-
pressive strength. However, cement can be extruded beyond
the boundaries of the fracture, potentially damaging the sur-
rounding tissue. This presents a potential disadvantage of
these phosphate materials, as they will not dissolve if they
happen to migrate into the joint.
The ability of calcium phosphate bone substitutes to act
as a bone-void filler has been documented in animal studies and
human case series34-36. Cameron evaluated the incorporation
time of tricalcium phosphate by placing an 8.5 by 3-mm disk of
the material into the cut surface of tibiae in a series of twenty
patients undergoing total knee replacement37. The disks of tri-
calcium phosphate could not be detected radiographically at six
months, and the authors concluded that tricalcium phosphate
was a useful resorbable bone-filler material. In a retrospective
case series, forty-three patients with traumatic bone defects or
nonunion of the femur, tibia, calcaneus, humerus, ulna, or ra-
dius had treatment augmented with tricalcium phosphate38.
Ninety percent of the fractures and 85% of the nonunions had
united at the time of follow-up, at an average of twelve months
(minimum duration, six months). The authors concluded that
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tricalcium phosphate was a useful substitute for cancellous
bone. In a prospective randomized study of forty closed tibial
plateau fractures with metaphyseal defects conducted by Bu-
cholz et al.39, patients were randomized to have the defect filled
with either autogenous bone or porous hydroxyapatite. At an
average of 15.4 months postoperatively, no significant radio-
graphic or clinical differences were appreciated between the
two groups.
The more recent availability of calcium phosphate as a
cement has increased the applications of this osteoconductive
material because of its increased compression strength and
improved custom-filling of bone defects. Investigators have
evaluated the use of calcium phosphate cement products for
augmentation of the repair of fractures of the distal radial
metaphysis, tibial plateau, calcaneus, hip, and spine. Several
randomized studies40, including one multicenter randomized
controlled trial involving forty patients with a distal radial
fracture41, have shown that patients treated with cement aug-
mentation and immobilization had a faster regain of grip
strength and range of motion than did patients treated with
external fixation. Zimmermann et al. performed a prospective
study of fifty-two postmenopausal, osteoporotic women in
whom a distal radial fracture had been treated with either
percutaneous pinning alone or percutaneous pinning supple-
mented by injection of calcium phosphate cement42. The patie-
nts treated with cement augmentation had superior functional
outcomes at two years after the surgery. In a randomized study
of 323 distal radial fractures treated with closed reduction and a
cast or with percutaneous pinning, augmentation with calcium
phosphate cement was compared with treatment without such
augmentation43. At the time of early follow-up, the patients with
cement augmentation were found to have improved grip
strength, range of motion, and social functioning and decreased
swelling. However, by one year, no clinical differences between
the groups were detected.
In a prospective study of twenty-six patients in whom a
tibial plateau fracture had been treated with open reduction
and internal fixation with injection of calcium phosphate ce-
ment into the residual bone defect, only two patients had ra-
diographic evidence of loss of reduction at a mean of 19.7
months44. In another series, of fourteen patients in whom a
lateral tibial plateau fracture with a metaphyseal defect had
been treated with open reduction and internal fixation and
filling of the defect with calcium phosphate cement, only one
patient had had an altered fracture reduction at an average of
thirty months45.
Schildhauer et al. reported on a series of thirty-six joint-
depression-type calcaneal fractures that had been treated with
internal fixation augmented by calcium phosphate cement46.
They found that patients who had been allowed to bear weight
as early as three weeks after the surgery had no radiographic ev-
idence of loss of reduction, and there was no significant differ-
ence in functional outcome scores between patients who had
been allowed to begin bearing weight before six weeks and those
who began it after six weeks. However, the authors did note an
11% infection rate. Seventy-five percent of the infections devel-
BONE GRAFTS AND BONE GRAFT SUBSTITUTES
INO R T H O P A E D I C TR A U M A S U R G E R Y
oped in smokers, and histological evaluation of tissue from those
patients demonstrated no giant cells or eosinophils to suggest a
foreign body or allergic reaction. Although this infection rate is
an important outcome to consider, the authors concluded that
cement augmentation of internal fixation of joint-depression-
type calcaneal fractures allowed earlier weight-bearing with no
change in postoperative outcomes.
Early results have demonstrated that augmentation of
femoral neck and intertrochanteric hip fractures with calcium
phosphate cement is feasible, with no substantial increase in
complications47. A randomized prospective study showed that
femoral neck fractures treated with cannulated screws aug-
mented with calcium phosphate cement had less postopera-
tive displacement than those treated with cannulated screws
alone48. The magnitude of this difference in displacement was
decreased at six weeks after the surgery compared with the av-
erage difference at one week after the surgery.
No authors of human studies have been able to clearly
demonstrate the resorption rate of calcium phosphate cement.
Animal studies have shown that up to 80% of the cement is re-
sorbed at ten weeks, with resorption and replacement with
bone continuing for as long as thirty weeks49,50. This process
occurs by dissolution as well as by osteoclast resorption.
The lack of osteoprogenitor cells and osteoinductive po-
tential of calcium-based bone substitutes has led to the develop-
ment of composite grafts in an attempt to accelerate bone
formation. A composite graft is created by adding an osteoin-
ductive factor to an osteoconductive calcium phosphate matrix
to theoretically increase bone formation. A prospective, ran-
domized, multicenter trial of 249 long-bone fractures in pa-
tients followed for a minimum of two years was conducted to
compare autogenous bone graft with a composite graft consist-
ing of biphasic calcium phosphate ceramic mixed with bovine
collagen and autogenous bone marrow51. No significant differ-
ences in union rates, functional outcomes, or complications
were found between the two groups. The authors concluded
that a calcium phosphate composite graft was as effective as an
autogenous iliac crest bone graft for the treatment of long-bone
fractures requiring bone graft augmentation (Level-I evidence).
Table I lists some of the commercially available osteo-
conductive products that are commonly used.
Materials with Osteogenic Properties
Humans require three elements for bone-healing: extracellular
matrix, growth factors, and cells. The results of healing are
usually quite remarkable, but when it fails the biology must be
reestablished to reflect the injury condition or embryological
development such that healing may once again begin. There is
no formal definition of materials with osteogenic properties.
The term has evolved as the entire field of tissue engineering
has expanded into the musculoskeletal system52. For the pur-
pose of this paper, the working definition of osteogenesis is the
generation of bone from bone-forming cells. Thus, the pres-
ence of adult mesenchymal stem cells in an autograft helps to
prepare a bone to respond to injury. Orthopaedic surgeons
have employed this approach for decades through the use of
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autologous bone and bone marrow grafts. The critical compo-
nent necessary to all bone formation is the ability to provide
viable osteoprogenitor cells.
Bone Morphogenesis Cascade
Osteogenesis begins with a stem cell that gives rise to progeni-
tor cells. These progenitors then advance to preosteoblasts and
then to osteoblasts. These cells have a more limited life span,
of about forty days. Eventually the osteoblast provides matrix
for new bone tissue as well as bone-lining cells and osteocytes.
An osteocyte’s life expectancy may be as long as twenty years.
Bone marrow is a plentiful source of musculoskeletal stem
cells, but the cells can also be found in periosteum, cartilage,
muscle, fat, and vascular pericytes53. Connective tissue progen-
itors describe the population of stem cells and progenitors
that are actively engaging in proliferation and differentiation
into connective tissue. A bone marrow aspirate has a high
concentration of connective tissue progenitors. One milliliter
of iliac aspirate contains approximately 40 million nucleated
cells, 1500 of which are connective tissue progenitors54.
Historic Perspective
The first attempt at tissue engineering took place in 1668 by
the Dutch surgeon Job van Meek’ren55. This was the first docu-
mented bone-grafting procedure in the literature. In 1980,
Lindholm and Urist56 were the first to try adding bone marrow
to bone matrix to enhance healing in a study that quantified
new bone formation. Connolly and Shindell reported the suc-
cessful clinical use of percutaneous bone marrow injection for
treatment of a nonunion of the tibia in 198657. This was fol-
lowed in 1991 with the successful treatment of eighteen of
twenty tibial nonunions with injections combined with either
the use of a cast (ten patients) or a Lottes nail (ten patients)58.
The two failures were in the cast treatment group.
Bone marrow aspirate often is diluted twenty to forty-
fold with blood elements. The aspiration technique is very
specific in order to maximize the number of effective progeni-
tor cells per unit volume. Muschler et al.54 studied this issue
and reported that no more than 2 mL of blood should be aspi-
rated from any given area in the iliac crest to avoid dilution
with peripheral blood. On the basis of these data, a selective
retention system was developed that has the ability to concen-
trate progenitor cells three to four times and load them onto
an allograft substrate for delivery.
Substantiation by In Vitro and Animal Models
Many reports of enhanced bone-healing through the use of
cell-based strategies are based on in vitro and animal studies.
Connolly et al.59 investigated the effects of concentrating mar-
row by centrifugation in a rabbit nonunion model. The results
with centrifugation were superior to those with unprocessed
marrow. In a similar study, performed with use of a canine
tibial nonunion model, distraction gaps held with external fix-
ation were filled with bone marrow aspirate, demineralized
bone matrix, or a composite graft of both materials60. A con-
trol group was treated with autograft. Use of the combination
BONE GRAFTS AND BONE GRAFT SUBSTITUTES
INO R T H O P A E D I C TR A U M A S U R G E R Y
of demineralized bone matrix and marrow (the composite
graft) yielded results that were superior to those in the single-
agent groups and similar to those in the autograft group.
Bruder et al.61 evaluated bone marrow combined with a po-
rous tricalcium phosphate cylinder in a canine nonunion
model stabilized with plates. Use of the composite graft pro-
vided results that were superior to those of treatment with the
ceramic cylinders alone, which resulted in only modest bone
formation. Lane et al.62 investigated the potential of combining
bone marrow cells with rhBMP-2 in a rat femoral defect
model. This combination was superior to either rhBMP-2 or
marrow cells by themselves as well as to treatment with synge-
neic bone-grafting. The authors believed that this represented
a synergistic effect of the two materials and emphasized the
importance of growth factors being present.
A sheep tibial defect model was used to evaluate hy-
droxyapatite combined with either rhBMP-7 or bone mar-
row63. Treatment with the composite grafts yielded results that
were as good as those in an autograft control group and were
superior to those in either a void group or a group treated
with hydroxyapatite alone. Muschler et al.64 reported on the
use of a selective cell-retention method of enriching allograft
(Cellect) in a canine spine fusion model. The selective cell
process allows the concentration of connective tissue progeni-
tors to be increased three to fourfold. A union score, quantita-
tive computed tomography, and mechanical testing were used
to measure the results, and all three showed the use of the
selective-retention-enriched bone matrix and bone-marrow
clot to be superior to the use of bone matrix alone or non-
enriched bone matrix and bone-marrow clot.
The results from animal studies provide a compelling
sense that application of bone marrow is effective for the pro-
motion of bone-healing. The combination of cells with a ce-
ramic substance seems to work very well. When bone marrow
is mixed with matrix and BMP there seems to be a strong syn-
ergistic effect, as one would expect because all three elements
necessary for bone-healing are plentiful. Despite these find-
ings, history has shown that positive results in animals do not
guarantee the same in humans.
Clinical Application of Autologous Bone Marrow
Historically, autograft has been the material of choice used
by orthopaedic surgeons to enhance and supplement bone-
healing. Autograft is considered osteogenic because it con-
tains connective tissue progenitors. The matrix and growth
factors contained therein provide osteoconductive and osteoin-
ductive properties, respectively. The concentration of connec-
tive tissue progenitors is affected by the volume of cancellous
bone harvested. There is also a morbidity associated with
this procedure65 (reported to range from 25% to 30% when
pain and wound drainage are included), which caused many
surgeons to seek alternatives to autograft for bone growth
enhancement.
Using a bone marrow aspirate is another way to apply
connective tissue progenitors to enhance bone growth and re-
pair. This is done intraoperatively with ease and is associated
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with a low morbidity rate. To our knowledge, Connolly et al. tribute to the early stages of bone repair and thus initiate the en-
were the first surgeons to report on the use of bone marrow tire fracture-healing cascade. Several strategies for platelet
aspirate as a clinical alternative to autograft57,66. However, their concentration and delivery have been developed on the basis of
work represents Level-IV evidence at best. this assumption, but we are not aware of any published pro-
Garg et al.67 reported good results in their series of twenty spective comparative studies of these strategies. Current indica-
patients in whom a nonunion had been treated with bone mar- tions are based only on multiple case reports, longitudinal
row injection. This was a single-surgeon experience with no his- series, and abstracts documenting the effectiveness of platelet
toric or case-matched controls (Level IV). Similarly, Healey et gels and concentrates74. This material appears to function best as
al.68 successfully treated nonunions in a group of children with a physiologic carrier for other autogenous, allogeneic, or allo-
cancer by simply injecting a bone marrow aspirate. Wientroub plastic graft materials.
et al.69 also reported on the use of autologous marrow to im-
prove the effectiveness of allografts in children. Goel et al.70 re- Overview
ported that they employed bone marrow injections, with use of The use of autologous bone, the so-called gold standard for
local anesthesia, for patients who were on waiting lists for open augmentation of bone-healing, is actually supported by very
repair of a nonunion. They used the procedure in an attempt to little direct clinical evidence. We are not aware of any studies
provide a low-cost alternative treatment, and they claimed suc- in the literature in which the effectiveness of autograft was
cess in fifteen of twenty patients; however, no control group was compared with that of no graft. That is not to say that au-
evaluated. In summary, to our knowledge, there currently is no tograft is not an efficacious material. Indeed, surgeons have
Level-I evidence documenting the effectiveness of bone marrow used it for over a century with great success. As such, it re-
for the enhancement of bone-healing. mains the standard against which all bone substitutes are mea-
Recently, Hernigou et al. reported on sixty patients with sured. Clinical evidence for the use of currently available bone
a noninfected nonunion who had undergone bone marrow graft substitutes ranges from Level I to Level IV. The Ortho-
aspiration from both iliac crests followed by injection into the paedic Trauma Association Orthobiologics Committee pro-
nonunion site71. Each nonunion site received a relatively con- vided a summary of the levels of recommendation regarding
stant volume of 20 mL of concentrated bone marrow. The various bone graft substitutes, which can be found in Table II.
number of progenitor cells that was transplanted was esti- The osteoinductive effects of rhBMP-2 and 7 are well docu-
mated by counting the fibroblast colony-forming units. The mented, and Level-I evidence supports their clinical use.
volume of mineralized bone formation was determined by There is less documentation for many of the osteoconductive
comparing preoperative computerized tomography scans with bone substitutes. Some are supported by Level-I evidence,
scans made four months following the injection. The results whereas others made their way into the marketplace simply by
showed union in fifty-three of the sixty patients, with positive showing equivalent efficacy to a predicate medical device and
correlations between the volume of mineralized callus at four have not been subjected to clinical analysis. At least one such
months and the number and concentration of colony-forming
units. The seven patients in whom the fracture did not unite TABLE II Bone Graft Substitutes
had lower numbers and concentrations of colony-forming
units. This study provided Level-III evidence for the use of au- Grade of
tologous bone marrow, which seems to be the best evidence Bone Graft Substitute Recommendation
thus far for the potential efficacy of this osteogenic material. Osteoinductive
Allograft bone I
Use of Platelet-Rich Plasma and Demineralized bone matrix C
Related Peripheral Blood Concentrates Purified human BMP C
Following an acute fracture or an operative intervention, (not commercially available)
platelets are activated by thrombin and subendothelial col- OP-1 device A
lagen with the subsequent release of their granules into the INFUSE A
wound environment. This fracture or wound hematoma con- Osteoconductive
tains a pool of platelet-derived factors released from the plate- CaPO4 B
lets, which can stimulate the formation of blood vessels; the A
invasion of pluripotential mesenchymal stem cells, mono- CaSO4 B
cytes, and macrophages; and the further aggregation of plate- C
lets. As a result, these molecules do not directly stimulate bone Allograft C
formation, but they have been referred to as osteopromotive Hydroxyapatite A
factors72,73. They act as signaling agents to these cells and affect Osteogenic and osteopromotive
critical repair functions such as cell migration, proliferation, Selective cellular retention (Cellect) I
differentiation, and angiogenesis. Bone marrow aspirate injection/implantation B
It would seem intuitive that, in orthopaedic surgery, the
Platelet-rich plasma and blood concentrates I
ability to deliver a concentrated amount of platelets would con-
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osteoconductive material, when used as a composite with au-
tologous bone, has shown efficacy equivalent to that of au-
tograft. Data regarding the use of autologous bone marrow are
inconsistent. Recent information suggests that methods to in-
crease the number and concentration of osteoprogenitor cells
may lead to an effective bone marrow graft material. Informa-
tion regarding the clinical efficacy of autologous blood con-
centrates such as platelet gels is still lacking. Similarly, there
are few studies in the literature in which one type of bone graft
substitute was measured against another substitute for a spe-
cific indication. There remains a great need for controlled,
prospective, randomized studies to provide reliable informa-
tion regarding the use of these materials.
William G. De Long Jr., MD
Department of Orthopaedic Surgery, Temple University, One
Greentree Centre, Suite 104, Marlton, NJ 08053. E-mail address:
william.delong@tuhs.temple.edu
Thomas A. Einhorn, MD
Department of Orthopaedics, Boston University Medical Center,
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BONE GRAFTS AND BONE GRAFT SUBSTITUTES
INO R T H O P A E D I C TR A U M A S U R G E R Y
720 Harrison Avenue, Suite 808, Boston, MA 02118
Kenneth Koval, MD
Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon,
NH 03756
Michael McKee, MD
St. Michael’s Hospital, 55 Queen Street East, Suite 800, Toronto, ON
M5C 1R6, Canada
Wade Smith, MD
Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204
Roy Sanders, MD
Florida Orthopaedic Institute, 4 Columbia Drive, Suite 710, Tampa,
FL 33606-3568
Tracy Watson, MD
Department of Orthopaedic Surgery, St. Louis University
Health Science Center, 3635 Vista Avenue, 7th Floor, St. Louis,
MO 63110-0250
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