BONE GRAFT

Pawan Marasini JR 1
Department of Orthopaedics
Kathmandu Medical College Teaching hospital
Sinamangal Kathmandu
Overview
• Definition
• History
• Basic mechanism
• Bio mechanism
• Indication of bone graft
• Types of bone graft
• Graft incorporation
Definition
• Bone graft
• Bone fragment transplanted, whole or in pieces, from one site to
another.

• Bone grafting
• Bone grafting is the name of the surgical procedure, by which bone
graft, or a bone graft substitute, is placed into fractures or bone
defects, to aid in healing or to improve strength.

• By Alasandro Zori from his book bone grafting 2012

Bone grafting by St Cosmas and St Damian

From- Bone Graft implanting by John Older (ED) 1992

History
• Georg Axhausen (1877-1960) and Erich Lexer (1867-
1937), German surgeons, and the North American
surgeon Dallas B. Phemister (1882-1951)

• Léopold Ollier (1830-1900)

• In 1881, MacEwen

• In 1668, Job van Meekeren

Basic mechanism
Phemister suggested creeping substitution
Transplanted bone

Invade the vasculature

old bone is resolved by new bone

• Abbot and associates added surface cells in bone graft survive and participate in bone formation
• Ray and Sabet also confirmed the fact that superficial cells survive
Cancellous bone

Necrotic tissue in the marrow space and Haversian system

are removed by macrophage

Granulation tissue preceeded by advancement of

capillaries invade the area of resorption

Pleuripotent mesenchymal cell differentiate into osteoblast

and lay down bone and osteoclast resolve the necrotic
tissue eventually new bone is formed
Corticle bone
Process is much slower
There must be invasion of bone through the haversian
system of the transplant

Osteoclast create a large space in which the granulation

tissue penetrates the center of the corticle and new bone is
laid out through out the length of the haversian system
Bio mechanism
• Osteoinduction
• Osteoconduction
• Osteogenesis
• Osteopromotion
Osteoinduction(Urist’s experiment )
• BMP

At the time of injury, adequate cells for

bone repair are both undifferentiated
and differentiated bone cells. The
majority of newly formed bone depends Osteoinductive action of BMP7 after
on the undifferentiated cells that are 19 days of incorporation
induced to become preosteoblasts
Bone healing by osteoinduction
Osteoinduction with implant
Osteoconduction
• 3 Dimentional scffholding ECM
• Growth factors (IGF I, II), (FGF), TGF-β,(PDGF)

Micropore Microfiber Nanofiber

Osteogenesis

• Transplanted osteoblasts and periosteal cells

directly produce bone
Bone Graft Indications
The indications for bone grafting are to:
• Fill cavities or defects resulting from cysts,
tumors,
• Bridge joints and provide arthrodesis
• Bridge major defects or establish the continuity of
a long bone
• Provide bone blocks to limit joint motion
(arthroereisis)
• Establish union in a pseudarthrosis
• Promote union or fill defects in delayed union,
malunion,fresh fractures, or osteotomies
Types of Bone Grafts
• Autograft (autogenous)
• Allograft (allogenous)
Autogenous Bone Graft
• “Gold standard”
• Standard by which other materials are judged
• Provides osteoconduction, osteoinduction
and osteogenesis
• Drawbacks
• Limited supply
• Donor site morbidity
Autogenous Bone Grafts

• Cancellous (osteogenesis)
• Cortical (Structural support )
• Bone marrow aspirate
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
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
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
Autograft Harvest
• Cancellous
• Iliac crest (most common)
• Anterior- anterior superior illiac crest
• Posterior- the posterior iliac crest

• Metaphyseal bone
• May offer local source for graft harvest
• Greater trochanter, distal femur, proximal or distal tibia,
calcaneus, olecranon, distal radius, proximal humerus
Autograft Harvest
• Cancellous harvest technique
• Cortical window made with osteotomes
• Cancellous bone harvested with gouge or currette
• Can be done with trephine instrument
• Commercially available trephines or “harvesters”
• Can be a percutaneus procedure
Autograft Harvest
• Cortical
• Fibula common donor
• distal fibula to protect to be protected for ankle
function
• Head preserved to keep Lateral collateral ligament ,
hamstrings intact
• Iliac crest
• Cortical or tri cortical pieces can be harvested in
shape to fill defect
Bone Allografts
• Cancellous or cortical
• Plentiful supply
• Limited infection risk (varies based on
processing method)
• Provide osteoconductive scaffold
• May provide structural support
Bone Allografts
• Fresh
• Fresh Frozen
• Freeze Dried
Graft Incorporation
• Biologic activity of a bone graft
• The condition of the perigraft environment
• The mechanical environment
Bone garft in chid with extensive bone
loss

An example of a structural autograft: after

extensive bone loss caused by a high
energy trauma, non-vascularized fibular
diaphises was transferred to the tibia
(“Tibialization of the Fibula”) and fixed with
plate and screws
Autologus grafts in pseudoarthrosis

Pseudarthrosis treated in child of

7 years
Autografts in non union fractures

Bone graft done in our hospital

in 74 years old female
Autografts in malunited fracture

Malunited DCP with Bone graft

Autografts In ABC

Autograft fibula transferred for

pathological fracture of femur
Autografts in Giant cell tumors

GCT in 7 year old boy who was diagnosed as giant cell tumor
Allograft in Ewing’s sarcoma

X ray of bone graft done in patient with

Ewing’s sarcoma
Allograft for spine
New trends in the bone graft
• Concept of bone bank in western countries
Thank You