Bone grafting: Difference between revisions
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All bone requires a blood supply in the transplanted site. Depending on where the transplant site is and the size of the graft, an additional blood supply may be required. For these types of grafts, extraction of the part of the [[periosteum]] and accompanying blood vesels along with donor bone is required. This kind of graft is known as a [[vital bone graft]]. |
All bone requires a blood supply in the transplanted site. Depending on where the transplant site is and the size of the graft, an additional blood supply may be required. For these types of grafts, extraction of the part of the [[periosteum]] and accompanying blood vesels along with donor bone is required. This kind of graft is known as a [[vital bone graft]]. |
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An autograft may also be performed without a solid bony structure, for example using bone reamed from the [[anterior superior iliac spine]]. In this case there is an osteoinductive and osteogenic action, however there is no osteoconductive action, as there is no solid bony structure. |
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[[File:RightFemurV.JPG|thumb|280px|A bone allograft.]] |
[[File:RightFemurV.JPG|thumb|280px|A bone allograft.]] |
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Revision as of 00:26, 3 September 2010
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Bone grafting is a surgical procedure that replaces missing bone with material from the patient's own body, an artificial, synthetic, or natural substitute. Bone grafting is used to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly.
Biological mechanism
| Osteoconductive | Osteoinductive | Osteogenic | |
|---|---|---|---|
| Alloplast | + | – | – |
| Xenograph | + | – | – |
| Allograph | + | +/– | – |
| Autograph | + | + | + |
Bone grafting is possible because bone tissue, unlike most other tissues, has the ability to regenerate completely if provided the space into which to grow. As native bone grows, it will generally replace the graft material completely, resulting in a fully integrated region of new bone. The biologic mechanisms that provide a rationale for bone grafting are osteoconduction, osteoinduction and osteogenesis.[1]
Osteoconduction
Osteoconduction occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone. Osteoblasts from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone.[1] In the very least, a bone graft material should be osteoconductive.
Osteoinduction
Osteoinduction involves the stimulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators are bone morphogenetic proteins (BMPs).[1] A bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger the formation of new osteoblasts, theoretically promoting faster integration of the graft.
Osteopromotion
Osteopromotion involves the enhancement of osteoinduction without the possession of osteoinductive properties. For example, enamel matrix derivative has been shown to enhance the osteoinductive effect of demineralized freeze dried bone allograft (DFDBA), but will not stimulate de novo bone growth alone.[2]
Osteogenesis
Osteogenesis occurs when vital osteoblasts originating from the bone graft material contribute to new bone growth along with bone growth generated via the other two mechanisms.[1]
Types and Tissue Sources
Autograft
Autologous (or autogenous) bone grafting involves utilizing bone obtained from the same individual receiving the graft. Bone can be harvested from non-essential bones, such as from the iliac crest, or more commonly in oral and maxillofacial surgery, from the mandibular symphysis (chin area) or anterior mandibular ramus (the coronoid process); this is particularly true for block grafts, in which a small block of bone is placed whole in the area being grafted. When a block graft will be performed, autogenous bone is the most preferred because there is less risk of the graft rejection because the graft originated from the patient's own body.[3] As indicated in the chart above, such a graft would be osteoinductive and osteogenic, as well as osteoconductive. A negative aspect of autologous grafts is that an additional surgical site is required, in effect adding another potential location for post-operative pain and complications.[4]
Autologous bone is typically harvested from intra-oral sources as the chin or extra-oral sources as the iliac crest, the fibula, the ribs, the mandible and even parts of the skull.
All bone requires a blood supply in the transplanted site. Depending on where the transplant site is and the size of the graft, an additional blood supply may be required. For these types of grafts, extraction of the part of the periosteum and accompanying blood vesels along with donor bone is required. This kind of graft is known as a vital bone graft.
An autograft may also be performed without a solid bony structure, for example using bone reamed from the anterior superior iliac spine. In this case there is an osteoinductive and osteogenic action, however there is no osteoconductive action, as there is no solid bony structure.
Allografts
Allograft bone, like autogenous bone, is derived from humans; the difference is that allograft is harvested from an individual other than the one receiving the graft. Allograft bone is taken from cadavers that have donated their bone so that it can be used for living people who are in need of it; it is typically sourced from a bone bank.
There are three types of bone allograft available:[5]
- Fresh or fresh-frozen bone
- Freeze-dried bone allograft (FDBA)
- Demineralized freeze-dried bone allograft (DFDBA)
Synthetic variants
Artificial bone can be created from ceramics such as calcium phosphates (e.g. hydroxyapatite and tricalcium phosphate), Bioglass and calcium sulphate; all of which are biologically active to different degrees depending on solubility in the physiological environment.[6] These materials can be doped with growth factors, ions such as strontium or mixed with bone marrow aspirate to increase biological activity. Some authors believe this method is inferior to autogenous bone grafting [3] however infection and rejection of the graft is much less of a risk, the mechanical properties such as Young's modulus are comparable to bone. The presence of elements such as strontium can result in higher bone mineral density and enhanced osteoblast proliferation in vivo.
Xenografts
Xenograft bone substitute has its origin from a species other than human, such as bovine. Xenografts are usually only distributed as a calcified matrix. In January 2010 Italian scientists announced a breakthrough in the use of wood as a bone substitute, though this technique is not expected to be used for humans until at the earliest 2015.[7]
Alloplastic grafts
Alloplastic grafts may be made from hydroxylapatite, a naturally occurring mineral that is also the main mineral component of bone. They may be made from bioactive glass. Hydroxylapetite is a Synthetic Bone Graft, which is the most used now among other synthetic due to its osteoconduction, hardness and acceptability by bone. Some synthetic bone grafts are made of calcium carbonate, which start to decrease in usage because it is completely resorbable in short time which make the bone easy to break again. Finally used is the tricalcium phosphate which now used in combination with hydroxylapatite thus give both effect osteoconduction and resorbability.
Growth Factors
Growth Factor enhanced grafts are produced using recombinant DNA technology. They consist of either Human Growth Factors or Morphogens (Bone Morphogenic Proteins in conjunction with a carrier medium, such as collagen).
Uses
The most common use of bone grafting is in the application of dental implants, in order to restore the edentulous area of a missing tooth. Dental implants require bones underneath them for support and to have the implant integrate properly into the mouth. People who have been edentulous (without teeth) for a prolonged period may not have enough bone left in the necessary locations. In this case, bone can be taken from the chin or from the pilot holes for the implants or even from the iliac crest of the pelvis and inserted into the mouth underneath the new implant.
In general, bone grafts are either used en block (such as from the chin or the ascending ramus area of the lower jaw) or particulated, in order to be able to adapt it better to a defect.
Another common bone graft, which is more substantial than those used for dental implants, is of the fibular shaft. After the segment of the fibular shaft has been removed normal activities such as running and jumping are permitted on the leg with the bone deficit. The grafted, vascularized fibulas have been used to restore skeletal integrity to long bones of limbs in which congenital bone defects exist and to replace segments of bone after trauma or malignant tumor invasion. The periosteum and nutrient artery are generally removed with the piece of bone so that the graft will remain alive and grow when transplanted into the new host site. Once the transplanted bone is secured into its new location it generally restores blood supply to the bone in which it has been attached.
Besides the main use of bone grafting – dental implants – this procedure is used to fuse joints to prevent movement, repair broken bones that have bone loss, and repair broken bone that has not yet healed.[8]
Bone grafts are used in hopes that the defective bone will be healed or will regrow with little to no graft rejection.[8]
Procedure
Depending on where the bone graft is needed, a different doctor may be requested to do the surgery. Doctors that do bone graft procedures are commonly orthopedic surgeons, otolaryngology head and neck surgeons, neurosurgeons, craniofacial surgeons, oral and maxillofacial surgeons, and periodontists.[9]
Risks
As with any procedure, there are risks involved; among these include reactions to medicine and problems breathing, bleeding, and infection.[8] Infection is reported to occur in less than 1% of cases and is curable with antibiotics. Overall, patients with a preexisting illness are at a higher risk of getting an infection as opposed to those who are overall healthy.[10]
Risks for grafts from the iliac crest
Some of the potential risks and complications of bone grafts employing the iliac crest as a donor site include:[10][11][12]
- acquired bowel herniation (this becomes a risk for larger donor sites (>4 cm)).[10] About 20 cases have been reported in the literature from 1945 till 1989[13] and only a few hundred cases have been reported worldwide[14]
- meralgia paresthetica (injury to the lateral femoral cutaneous nerve also called Bernhardt-Roth's syndrome)
- pelvic instability
- fracture (extremely rare and usually with other factors[15][16])
- injury to the clunial nerves (this will cause posterior pelvic pain which is worsened by sitting)
- injury to the ilioinguinal nerve
- infection
- minor hematoma (a common occurrence)
- deep hematoma requiring surgical intervention
- seroma
- ureteral injury
- pseudoaneurysm of iliac artery (rare)[17]
- tumor transplantation
- cosmetic defects (chiefly caused by not preserving the superior pelvic brim)
- chronic pain
Bone grafts harvested from the posterior iliac crest in general have less morbidity, but depending on the type of surgery, may require a flip while the patient is under general anesthesia.[18][19]
Recovery and Aftercare
The amount of time it takes for an individual to recovery depends on the severity of the injury being treated and lasts anywhere from 2 weeks to 2 months with a possibility of vigorous exercise being barred for up to 6 months.[8]
Costs
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Bone graft procedures consist of more than just the surgery. The average cost of bone graft procedures ranges from approximately $33,860 to $37,227.[20] Besides the cost of the bone graft itself (ranging from $250 to $900) other expenses for the procedure include: surgeon's fees (these vary), anesthesiologist fees (approximately $350 to $400 per hour), hospital charges (these vary; averaging about $1,500 to $1,800 a day), medication charges ($200 to $400), and additional fees for services such as medical supplies, diagnostic procedures, equipment use fees, etc.[21]
References
- ^ a b c d e Klokkevold, PR, Jovanovic, SA: Advanced Implant Surgery and Bone Grafting Techniques. In Newman, Takei, Carranza, editors: Carranza's Clinical Periodontology, 9th Edition. Philadelphia: W.B. Saunders Co. 2002. page 907-8.
- ^ Boyan, BD, et al. Porcine fetal enamel matrix derivative enhances bone formation induced by demineralized freeze dried bone allograft in vivo. J Perio 2000;71:1278-1286
- ^ a b "Bone Grafts: No Longer Just a Chip Off the Ol' Hip".
- ^ "Bone Graft Alternatives" (PDF). Retrieved 18 January 2009.
- ^ Bone Allografts
- ^ Hench, Larry L (1991). "Bioceramics: From Concept to Clinic" (PDF). Journal of the American Ceramic Society. 74: 1487.
- ^ "Italian scientists' 'wood to bone' medical breakthrough". BBC News. 2010-01-03. Retrieved 2010-02-18.
- ^ a b c d "Bone Graft - Surgery Procedures & Risks - NY Times Health Information".
- ^ "Bone Grafting - Definition, Purpose, Demographics, Description, Diagnosis/preparation, Aftercare, Risks, Normal results, Morbidity and mortality rates, Alternatives".
- ^ a b c John Gray Seiler III, MD, Joseph Johnson, MD, Georgia Hand and Microsurgery Clinic, Atlanta, Ga. (2000). "Iliac Crest Autogenous Bone Grafting: Donor Site Complications". J South Orthop Assoc. 9 (2): 91–97. PMID 10901646.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Banwart JC, Asher MA, Hassanein RS. (1995). "Iliac crest bone graft harvest donor site morbidity. A statistical evaluation". Spine. 20 (9): 1055–60. doi:10.1097/00007632-199505000-00012. PMID 7631235.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA. (1996). "Complications of iliac crest bone graft harvesting". Clin Orthop Relat Res. (329): 300–9. PMID 8769465.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ M. M. Hamad; S. A. Majeed (1989). "Incisional hernia through iliac crest defects". Archives of Orthopaedic and Trauma Surgery. 108 (6): 383–385. doi:10.1007/BF00932452. PMID 2695010.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ Anisuddin Bhatti, Waqar Ahmed. (1999). "Herniation through ILiac Crest Bone Graft donor site". J Surg Pak. 4 (2): 37–9.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ "Pelvic fracture: The iliac crest bone grafting complication".
- ^ Matthew J Oakley,Wade R Smith, Steven J Morgan, Navid M Ziran, and Bruce H Ziran (2007). "Repetitive posterior iliac crest autograft harvest resulting in an unstable pelvic fracture and infected non-union: case report and review of the literature". Patient Saf Surg. 1 (6): 6. doi:10.1186/1754-9493-1-6. PMC 241775. PMID 18271999.
{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link) - ^ Andy Shau-Bin Chou, MD; Chein-Fu Hung, MD; Jeng-Hwei Tseng, MD; Kuang-Tse Pan, MD; Pao-Sheng Yen, MD; (2002). "Pseudoaneurysm of the Deep Circumflex Iliac Artery: A Rare Complication at an Anterior Iliac Bone Graft Donor Site Treated by Coil Embolization" (PDF). Chang Gung Med J. 25 (7).
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)[dead link] - ^ Marx RE, Morales MJ (1988). "Morbidity from bone harvest in major jaw reconstruction: a randomized trial comparing the lateral anterior and posterior approaches to the ilium". J. Oral Maxillofac. Surg. 46 (3): 196–203. doi:10.1016/0278-2391(88)90083-3. PMID 3280759.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P (2002). "Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes". J Bone Joint Surg Am. 84-A (5): 716–20. PMID 12004011.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ Glassman SD, Carreon LY, Campbell MJ, Johnson JR, Puno RM, Djurasovic M, Dimar JR (2008). "The perioperative cost of Infuse bone graft in posterolateral lumbar spine fusion". Spine J. 8 (3): 443–8. doi:10.1016/j.spinee.2007.03.004. PMID 17526436.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ "Bone grafting".