Terminology:

Bone is a dynamic biological tissue composed of

metabolically active cells that are integrated into a
rigid framework.

• Graft
• Vascularized bone graft
• Autograft
• Isograft
• Homograft (allograft)
• Heterograft (xenograft)
• Composite graft
• Implants
• Bone conduction, induction, integration
Types of bone:
– Histological:
• Immature (Woven, Bundle)
• Mature (compact, cancellous)
– Anatomical:
• Flat (skull, scapula, )
• Long (femur, tibia, )
• Sesamoid (patella)
– Healing:
• Membranous (enchondral)  cranial vault, facial bone,
• Endochondral  skull base, long bones, ribs
• Dual mechanism  mandible, sphenoid, occipital bones
Endochondral Ossification:
• Within cartilage. Interstitial growth. Cells
swell, burst, replace by osteocytes with
Ca+
Endochondral Ossification:
• Secondary ossification - epiphysis
• Articular cartilage and epiphysial plate -
Membranous Ossification:
• Skull, mandible, clavicle.
• Fibrous membrane, Os. center, trabeculae
Bone Structure
•65% inorganic (Ca)
•35% organic
(34% collagen, ..)
(1% cells)
Bone cells
Osteocytes
• Derived from:
– Mesenchymal precursor cells
– stem cells in bone marrow
– osteoprogenitor cells of periosteum
Osteoclasts
• Derived from:
– Hematopoetic stem cells in bone marrow (GM-CFU) that
undergo endoreduplication
– old theory = fusion of monocytes
Remodeling
• Wolff’s law
-“bone formed in response to mechanical
load”
dynamization/staged destabilization-
increased load can lead to increased
bone formation
-lamellar bone and marrow cavity form
Type of Fracture Healing
• Direct Healing
– Primary Osteonal Reconstruction
• Contact healing
• Gap healing
– Secondary Osteonal Reconstruction
• Indirect Healing
• Distraction Osteogenesis
Indirect Bone Healing
Stages:
1) the inflammatory stage (hematoma);
2) the repair stage (soft  hard callus);
3) the late remodeling stage.

Types:
- Rigid
- Semi-rigid
- Non-fusion
Indirect Bone Healing(continue)
Factors affecting healing:
I) General…
II) Local…

Complications:
• Malunion – arthritis.
• Delayed union.
• Non union.
• Joint involvement - ankylosis
• Bone necrosis – nutrient artery
• Pseudoarthrosis
Indications of bone graft

• Nonunion fractures
• Highly comminuted fractures
• Fractures with bone loss
• When expecting a delayed union
• Augmentation and normalization of facial
contour
• Creation of congenitally missing parts of
skeleton
Why we do bone graft?
• Osteognesis
– viable cells contribute to new bone formation
• Osteoinduction
– proteins, factors, hormones are transferred that
modulate host cells
• Osteoconduction
– matrix upon which new bone can be formed
– implants can be osteoconductive
Types of autogenous graft
• Cancellous bone
– metaphyseal regions, increase surface area, 80%
porosity
• Cortical bone
– Increase mechanical strength, 10% porosity
– frequently corticocancellous
• Osteochondral
– cartilage attached to parent bone
• Composite
– fresh graft added to preserved allograft
• Vascularized grafts
– Vascularized corticocancellous grafts
Sources of autogenous grafts
• Iliac creast
• Rib
• Calverial bone
• Scapula
• Radius
• Vascularized fibula
• Vascularized rib
• medial aspect of tibial diaphysis
Healing of autograft:
• Inflammation
• Revascularization
– 2x time for Cancellous grafts due to porosity
• Osteoinduction
– decreased with cortical grafts
• Osteoconduction
– decreased with cortical grafts
• Remodeling
– initiated with osteoclasts (vs. osteoblasts) with
cortical grafts
Healing of allograft:
• “Creeping substitution”
• Basic bone remodeling at graft-host
interface
– bone resorption is followed by bone
production
• May take years
Bone Graft Substitute (BMP)

Bone
Morphogenetic
Protein
Only known extracellular protein known to be
able to initiate new bone formation
BONE and CARTILAGE
• Bone (osteo) • Cartilage (chondro)
• vascular • avascular - requires diffusion
• mesodermal origin • mesodermal origin
• cells and matrix • cells and matrix
• osteoblasts • chondroblasts
• osteocytes • chondrocytes
• osteoclasts • -----
• periosteum • *perichondrium
• collagen type 1 • collagen types 1,2
• appositional growth • appositional growth
• ----- • interstitial growth
• compact, cancellous, woven • hyaline, elastic, fibrocartilage

*except articular cartilage

THANK YOU