Autogenous Cancellous Bone Graft Research Articles

Bone Graft Harvest from the Proximal Tibia in Foot and Ankle Arthrodesis Surgery

Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognized minor and major complications. The proximal tibia is one such potential site and is particularly suited to foot and ankle surgery, because it is within the operative field and under tourniquet control. A retrospective review was performed of 148 procedures using bone graft from the proximal tibia performed over a period of 5 years. Minimum followup was 3 months. Data were obtained from operative notes and patient interviews to establish pain, morbidity, and overall satisfaction. Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately after surgery. At followup, 96% had no pain and 4% had very mild pain with certain activities such as kneeling. There were no major complications. Four patients (2.7%) had persisting areas of paresthesia at followup, but none were troubled by it. One patient had a superficial wound infection that resolved. The period of nonweightbearing, usually 2 to 3 weeks, was dictated by the primary procedure. There were no complications related to early weightbearing The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restrictions in weightbearing after this procedure.

Surgical Treatment of Tarsal Navicular Stress Fractures

The tarsal navicular is part of the medial column of the foot. It articulates with the talus as well as the cuneiforms. The navicular can be injured with repetitive loading, such as in an athlete, resulting in a stress fracture. Patients complain of pain over the medial midfoot, especially with axial load. Plain radiographs may be normal, and MRI, CT or bone scan may be necessary to confirm the diagnosis. Nonoperative management can be successful with cast immobilization. For competitive athletes with delayed union or nonunion, surgical repair may be indicated. This is accomplished with interfragmentary screws and autogenous cancellous bone graft. Cast immobilization is important to prevent motion at the fracture site during the postoperative healing period. Nonweightbearing restrictions are used for eight to twelve weeks, or until radiographic bony union is verified. Using a comprehensive rehabilitative program, full motion and strength can be expected with eventual return to full athletic activity.

Influence of Platelet-Rich Plasma on Osteogenic Differentiation of Mesenchymal Stem Cells and Ectopic Bone Formation in Calcium Phosphate Ceramics

Platelet-rich plasma (PRP) contains a mixture of growth factors that play an important role in wound and fracture healing. While PRP enhanced bone formation by autogenous cancellous bone grafts, its influence in combination with different bone substitutes remained unknown. This study evaluated the effect of PRP on osteogenic differentiation and ectopic bone formation of human mesenchymal stem cells (MSC) in distinct resorbable calcium phosphate ceramics. Calcium-deficient hydroxyapatite (CDHA) blocks with a large specific surface area (48 m²/g) and β-tricalcium phosphate (β-TCP) with a low specific surface area (<0.5 m²/g) were loaded with 2 × 10⁵ bone marrow-derived MSC. Half of the specimens were treated with 5-fold concentrated PRP. Biocomposites were implanted subcutaneously into SCID mice or kept under osteogenic culture conditions for 2 weeks before implantation. The addition of PRP increased the specific alkaline phosphatase (ALP) activity (p = 0.012) in undifferentiated MSC/CDHA composites but not in MSC/β-TCP composites. Osteogenic preinduction was ineffective for CDHA and reduced ALP activity of β-TCP composites significantly at explantation. Ectopic bone formation was stronger in MSC/CDHA (7/32) compared to MSC/β-TCP (2/30) composites, but no influence of PRP was evident. In conclusion, the effect of PRP depended on the type of ceramic and the differentiation status of the MSC, and enhanced ALP activity of MSC on the high surface scaffold CDHA only, but PRP did not improve osteogenesis in our setting.

Treatment of nonunion of humeral shaft fracture with plate fixation and bone graft

目的 评价钢板内固定结合自体松质骨植骨治疗肱骨干骨折术后骨不愈合的疗效.方法2002年2月～2004年12月对41例肱骨干骨折术后骨不愈合患者均采用钢板内固定结合自体松质骨植骨治疗.其中男32例,女9例;平均年龄37.5岁(17～67岁).骨不愈合类型:肥大型16例,萎缩型25例.结果所有患者获平均22.6个月(8～42个月)随访.40例(97.6%)患者骨折愈合,骨折愈合时间平均为5.8个月(3～12个月).并发症:桡神经损伤3例,伤口感染1例,骨折不愈合1例.最终随访时,肩关节和肘关节功能恢复满意.结论对于肱骨干骨折术后骨不愈合的患者,采用钢板内固定加自体松质骨植骨治疗是有效的方法。

Klinische Erfahrungen mit Bone Morphogenetic Protein 7 (BMP 7) bei Pseudarthrosen langer Röhrenknochen

Nonunions of long bone fractures are considerable therapeutic and economic problems with increasing tendency. Basic surgical options are autogenous cancellous bone grafting, rod dynamization, reamed nailing, plate fixation with compression, and bone transport techniques. If these methods fail to work, alternative treatment options are needed. Since May 2001 treatment with recombinant human (rh) bone morphogenic protein 7 [BMP-7 or osteogenic protein 1 (OP-1)] in combination with a type one collagen carrier has gained interest. BMP 7 induces the formation of new bone by differentiation of stem cells, thereby initiating the reaction cascade of osteogenesis. Nonunions over 9 months and unsuccessful bone grafting delineate the indication. We report our experience with 21 patients and nonunion of long bone fractures. Between July 2002 and June 2004, 23 units of BMP 7 were implanted. The implantation sites were 7 femora, 12 tibias, 2 humeri, and 2 forearms. In ten cases BMP 7 was combined with a new osteosynthesis and bone grafting and in five patients with bone grafting alone. In contrast in eight patients BMP 7 was applied as a single procedure without any bone grafting or any change of the osteosynthesis. There were no peri- or postoperative complications. Follow-up was obtained for a minimum of 6 months. Of 23 implantations, 22 were successful with bony healing revealed by clinical and radiological evaluation. In one patient no bony consolidation of the nonunion has been seen so far. In summary, based on our results we propose BMP 7 as an additional innovative therapy of long bone nonunions.

Operative Treatment of Osteochondral Nonunion of the Distal Humerus

Three patients with ununited osteochondral fracture fragments of the distal humerus (2 anterior capitellum and trochlea; 1 posterior trochlea) who had debridement and realignment of the nonunion, autogenous cancellous bone graft, and internal fixation an average of 6 (range, 5-8) months after injury were studied. The preoperative arc of elbow flexion was 80 degrees, 35 degrees, and 25 degrees. All 3 fractures healed without implant related complications or osteonecrosis. At 28, 27, and 46 months after the index procedure for nonunion, the patients had 95 degrees, 90 degrees, and 115 degrees arcs of elbow flexion. The scores on the Mayo Elbow Performance Index were 80, 80, and 95 (2 good, 1 excellent). Based on this limited experience, it seems that operative treatment of ununited osteochondral fracture fragments can achieve union without osteonecrosis. Attempts to improve the function of the native elbow rather than salvage the situation with interpositional or prosthetic arthroplasty are worthwhile.

Quantitative scanning acoustic microscopy compared to microradiography for assessment of new bone formation

Recently, it has been shown that quantitative scanning acoustic microscopy (SAM) is a powerful tool to image the acoustic impedance of even inhomogeneous materials like bone. Therefore, the aim of our study was to compare SAM to conventional microradiography with respect to histomorphometrical assessment of undecalcified sections of newly formed bone. Forty specimens were harvested 12 weeks after implantation of either autogenous cancellous bone graft or 5.0 mg of Osteogenic Protein-1 (BMP-7) in a critical-sized defect model in sheep. Undecalcified transverse bone sections of 500 μm thickness were investigated with conventional microradiography and SAM. Linear regression analysis was carried out to compare the measurements of the area of new bone formation within the defect sites. Both methods allowed for good discrimination between newly formed bone and cortical bone at the edges of the former defect. Images obtained with SAM revealed a better resolution and sharpness compared to that of microradiographs since SAM imaging unlike microradiography does not depend on the thickness of bone sections. The results of quantitative histomorphometric analysis obtained by both methods showed no significant differences, and it was possible to predict 90% of the variability of each method (coefficient of determination r 2 = 0.90; P < 0.0001). In conclusion, SAM offers comparable quantitative histomorphometric information with a better spatial resolution than conventional microradiography. Thus, SAM is a promising new micro-visualizing technique for basic bone research.

Emprego de fixador externo circular no tratamento de complicações de fraturas do rádio e ulna em cães de raças pequenas

O objetivo deste estudo foi avaliar o método de Ilizarov no tratamento de complicações de fraturas do rádio e ulna em cães de raças pequenas. Um fixador de Ilizarov miniatura composto por anéis de alumínio e hastes de aço foi usado em três cães da raça poodle miniatura (casos 1, 2 e 3) e em um pinscher (caso 4). Os cães 1 e 4 apresentavam consolidação atrasada das porções médio-distal e distal, respectivamente, devido a prévio tratamento com tala externa. Foi aplicada uma montagem constituída por dois anéis proximais e um distal. Ambas as fraturas consolidaram, sendo que a do poodle apresentou leve desvio cranial das extremidades fraturadas. Os outros dois casos (2 e 3) consistiam de fraturas previamente tratadas por procedimento cirúrgico. O caso 2 apresentava rotação lateral do membro torácico e não-união do aspecto distal da diáfise radial com presença de pino intramedular e dois fios de cerclagem. O pino intramedular e um dos fios de cerclagem foram removidos e realizou-se a derrotação do foco da fratura. O aparelho foi montado como nos casos 1 e 4. A consolidação da fratura foi obtida com moderado desvio caudal do eixo ósseo. No caso 3, havia reabsorção óssea na diáfise do rádio e ulna devido ao emprego inadequado de fixador externo resina-pino. Empregou-se o transporte ósseo com o fixador de Ilizarov para induzir a regeneração óssea. Entretanto, este foi interrompido por falta de resposta. Manteve-se o fixador e o defeito ósseo foi tratado com enxerto esponjoso autólogo e biomateriais. A ulna ocupou parte do defeito segmentar do rádio. Foi possível concluir que o método de Ilizarov pode ser usado no tratamento de consolidação atrasada e não-união, mas o fixador externo circular é de difícil aplicação em cães de raças pequenas.

Coralline hydroxyapatite and laminectomy-derived bone as adjuvant graft material for lumbar posterolateral fusion

The purpose of this study was to evaluate the effectiveness of coralline hydroxyapatite (CHA) and laminectomy-derived bone as an adjuvant graft material when combined with autogenous iliac bone graft (AIBG) in posterolateral fusion (PLF). This prospective, case-control study involved 58 patients who underwent lumbar instrumentation-augmented PLF for degenerative spinal stenosis-induced segmental instability between July 2000 and June 2001. The patients were divided into three groups. Laminectomy bone and AIBG were placed in the right intertransverse process space in Group 1 (20 patients), CHA and AIBG were placed in Group 2 (19 patients), and laminectomy bone and CHA were placed in Group 3 (19 patients). Pure autogenous iliac cancellous bone graft was placed in the left intertransverse process space in all three groups of patients. Successful fusion was determined by two spine surgeons after examining the plain, anteroposterior, bilateral oblique, and lateral flexion-extension radiographs. If the examiners did not agree on fusion status, fine-cut computerized tomography scans of the fusion mass were used to make the final decision. The chi-square test was used to compare the fusion rate at different time intervals among the three groups. Pure AIBG placed in left intertransverse process space was associated with the best fusion rate. After 6 months, CHA produced a comparable result to laminectomy-derived bone when combined with AIBG. When laminectomy bone was mixed with CHA, the combination failed to yield a satisfactory fusion rate (57.9%) even 1 year after surgery if no AIBG was added.

ASEPTIC NECROSIS OF THE HAMATE: A CASE REPORT

The case of a 25-year-old man with osteonecrosis of the hamate is reported. He had pain and swelling in his right wrist. The diagnosis was accomplished with plain radiographs as well as with MRI. The case was treated surgically that included resection of the necrotic bone. The occured cavity was filled with autogenous cancellous bone graft. In addition, capito-hamate arthrodesis was performed. Histopathological examination following the operation demonstrated avascular necrosis of the hamate. The arthrodesis was obtained four months after the operation.

Evaluation of healing in feline femoral defects filled with cancellous autograft, cancellous allograft or Bioglass

Cancellous bone grafting is a widely accepted technique in human and veterinary orthopaedic surgery. However, the use of autogenous bone graft is limited by the additional surgical time required to harvest the graft, the morbidity associated with the donor site, and the limited availability of cancellous bone, especially in feline patients. Various allografts and bone graft substitutes are available commercially but have not been fully evaluated for efficacy in the cat. The purpose of this study was to compare the incorporation of autogenous and allogenous cancellous bone graft and Bioglass, a synthetic bone graft substitute, in femoral defects in cats. Four (4.0 mm diameter) defects were created in the lateral diaphyseal cortex of the left femur with an orthopaedic drill. In each femur, one of the cortical defects was filled with autogenous cancellous graft (harvested from the tibia), one was filled with allogenic cancellous graft, and one was filled with Bioglass. The fourth defect remained unfilled. Graft incorporation within the femoral defects was evaluated by radiographic evaluation every two weeks. Six weeks after the grafting procedure, the cats were euthanatized and high detailed radiography, dual energy X-ray absorptiometry (DEXA), histopathology and histomorphometry of the defects were performed. Satisfactory bone healing was observed within all of the defects.

Maxillary bone transportation in alveolar cleft—transport distraction osteogenesis for treatment of alveolar cleft repair

Secondary autogenous cancellous bone grafting is a widely used method for the treatment of alveolar clefts and oronasal fistulae. However, failure of iliac bone grafting sometimes occurs due to inadequate covering with the surrounding soft tissue and marked scar formation, inappropriate patient age, or large clefts. For alveolar clefts, we developed a method consisting of alveolar bone transportation, closure of the alveolar cleft, and/or grafting of new bone. Transport distraction osteogenesis along the curve of the dental arch is ideal. Alveolar bone was transported in the planned direction using a ready-made bone-borne distractor in combination with an orthodontic arch wire for transport guidance. This method allows simultaneous correction of nasal septal deviation and also correction of maxillary arch deformities and malocclusion since, the dental arch is expanded without donor sacrifice. This method can be regarded as tissue engineering to expand bone tissue. This method can be safely performed not only in patients undergoing initial treatment for alveolar clefts but also in patients in whom bone grafting has failed. Since 1997, we have performed this method in 22 patients and obtained good results.

The Biology of Bone Grafting

Many approaches are used to repair skeletal defects in reconstructive orthopaedic surgery, and bone grafting is involved in virtually every procedure. The type of bone graft used depends on the clinical scenario and the anticipated final outcome. Autogenous cancellous bone graft, with its osteogenic, osteoinductive, and osteoconductive properties, remains the standard for grafting. However, the high incidence of morbidity during autogenous graft harvest may make the acquisition of grafts from other sources desirable. The clinical applications for each type of bone graft are dictated by the structure and biochemical properties of the graft. An elegant cellular and molecular cascade follows bone transplantation. Bone graft incorporation within the host, whether autogenous or allogeneic, depends on many factors: type of graft (autogenous versus allogeneic, vascular versus nonvascular), site of transplant, quality of transplanted bone and host bone, host bed preparation, preservation techniques, systemic and local disease, and mechanical properties of the graft.

The use of hydroxyapatite and autogenous cancellous bone grafts to repair bone defects in rats

Bone grafts are frequently used in the treatment of bone defects. Bone harvesting can cause postoperative complications and sometimes does not provide a sufficient quantity of bone. Therefore, synthetic biomaterials have been investigated as an alternative to autogenous bone grafts. The objective of this study was to evaluate the repair of bone defects by autogenous cancellous bone grafts or porous bioceramic discs of hydroxyapatite/phosphate cement mixture. Two 5-mm diameter defects were made in the skulls of rats and filled with the bioceramic material or cancellous bone. The rats were sacrificed 2, 4, 8 and 24 weeks after surgery and tissue samples were analyzed by radiography and histology. By the 24th week, the defects filled with autogenous cancellous bone grafts or bioceramic material showed similar volumes of bone tissue within the defect. However, defects treated with bioceramic material were almost completely closed as a result of the joining of ceramic fragments and the neoformed bone tissue, while those filled with autogenous grafts showed several areas filled with connective tissue. These results indicated that the osteointegration of bioceramic fragments allowed the reconstruction of parietal bone defects without the need for a bone graft.

Ununited Diaphyseal Forearm Fractures with Segmental Defects: Plate Fixation and Autogenous Cancellous Bone-Grafting

With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts. Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients. The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121 degrees in the forearm, 131 degrees at the elbow, and 137 degrees at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion). When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna.

Transpedicular Hook Screw Fixation in the Treatment of Lumbar Spondylolysis in Young Patients

Objectives: In spondylolysis, there is a defect in the pars interarticularis. Most patients with spondylolysis, and even some with spondylolisthesis are asymptomatic, and they grow up not even aware of their condition. However, back pain is the most common symptom. Most patients with lumbar spondylolysis and low-grade spondylolisthesis can be treated conservatively. Surgical treatment is indicated when any type of spondylolisthesis is accompanied by a neurological deficit. Materials and Methods: We reviewed records obtained in patients treated surgically between 2000 and 2004 at Cathay Medical Center. We found a total of eight patients with a diagnosis of lumbar spondylolysis (pars fracture). In these patients-six men and two women, with ages ranging from 17 to 37 years. The diagnosis was made according to plain radiography, CT scan and MRI imaging. For patients with spinal instability, instrumentation included the trans-pedicular screws to secure the hook. Sufficient amounts of onlay autogenous cancellous bone graft across the spondylolytic defect were performed in all our patients. The final outcome was assessed by the following criteria:(1) whether instruments remained intact;(2)whether the postoperative fracture reduction was maintained;(3)whether the functional outcome was satisfactory; and(4)preoperative and postoperative plain radiographs. Results: We found a total of eight patients with a diagnosis of lumbar spondylolysis (pars fracture). Instrumentation included the trans-pedicular screws to secure the hook. Sufficient amounts of onlay autogenous cancellous bone graft across the spondylolytic defect were performed in all our patients. Follow-up plain radiography was done every 3 months after the operation. All our patients experienced significant pain relief from low back pain and radiculopathy. No screw pullout or loosening of the instrument was observed. No pseudoarthrosis was noted and all our patients had a bilateral union. In this article, we examine the effectiveness and advantages of transpedicular hook screws in the treatment of lumbar spondylolysis. Conclusions: Direct repair of spondylolysis with transpedicular hook screws can be recommended for patients with young age, a slight slip, an instability, or failure of conservative treatment.

Posterior Stabilization of the Cervical and Upper Thoracic Spine with the CerviFix�

Posterior stabilization of the occipitocervical junction, the upper and lower cervical spine (C-spine), and the upper thoracic spine (T-spine) using the Cervi-Fix® rod system, a modular tension band system made of titanium. Various connectors are attached to the pliable rod. 3.5-mm screws are inserted through the connectors into the occiput and into each motion segment of C- and T-spine in an optimal position. Occipitocervical and upper C-spine instabilities (malformations, tumors, infections, aseptic inflammatory lesions, posttraumatic conditions). Instabilities of the lower C-spine on the condition that the anterior column is intact (iatrogenic, posttraumatic instabilities caused by degenerative or inflammatory processes, tumors). Degenerative or posttraumatic painful conditions of the lower C-spine. Additional posterior stabilization after anterior spondylodesis of the C-spine or upper T-spine. Absent stability of the anterior column due to vertebral body destruction caused by trauma, infection, or tumors. Insertion of screws into the occiput and/or into the lateral masses or pedicles of the C-spine or upper T-spine depending on the level to be fused. Adaptation of rods and their attachments to the screws with the help of connectors. Addition of autogenous cancellous bone grafts. The CerviFix® system was used for various pathologic conditions in 54 patients (26 women, 19 men, average age 59 years). Average duration of follow-up of 47 patients was 20 months. Bony fusion was obtained in all. We did not see any implant-associated complications.

Treatment of severe peri-implant bone loss using autogenous bone and a bioabsorbable polymer that delivered doxycycline (Atridox™)

With an increase of the number of implants being inserted, it is inevitable that the number of cases of peri-implantitis with loss of bone will rise. We report a case in which an autogenous cancellous bone graft was placed into the peri-implant bone defect and given protection with a bioabsorbable polymer barrier (Atridox) that released doxycycline slowly.

Clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery.

The harvesting of autogenous cancellous bone graft has many uses in foot and ankle surgery. The most common referenced donor sites are the iliac crest, distal tibia, and calcaneus. These all have demonstrated limitations, the high morbidity rate associated with the iliac crest and the poor quantity of graft from distal sources. Between April 1995 and February 2000, 155 patients were retrospectively identified who had undergone a foot or ankle procedure utilizing the ipsilateral, proximal tibia as the donor site for autogenous cancellous graft. The patients were 18 years or older with no history of previous bony surgery to the tibia used and no history of previous injury or pain in the knee. The group included patients with isolated reconstructions as well as multiextremity trauma patients. All were kept nonweightbearing on the involved extremity for a minimum of 6 weeks postoperatively. There were 90 male and 65 female patients. The average age was 41 years and 5 months. There were 51 smokers averaging 17.6 pack years (range, 1-50 pack years). Twenty-six patients were admitted alcoholics, and 12 admitted to prior intravenous drug use. Cancellous graft was utilized in both traumatic and reconstructive settings. Eighty-nine fractures in 86 patients received grafting. Sixty-nine reconstructions or fusions of the hindfoot or midfoot were done using this technique. There were no reported major complications due to this procedure. No fractures, infections, or wound breakdowns occurred during this study. There were no reported long-term problems with knee pain or function. There was one postoperative hematoma that resolved over time. There were three incidents of sensory changes at the incision site. The use of the ipsilateral proximal tibia as a source for autogenous cancellous bone graft is a procedure with low added morbidity and a source of adequate graft material.

A histomorphological study of tendon reconstruction to a hydroxyapatite-coated implant: regeneration of a neo-enthesis in vivo

The attachment of tendons and ligaments to massive endoprostheses remains a clinical challenge due to the difficulty in achieving a soft tissue implant interface with a mechanical strength sufficient to transmit the forces necessary for locomotion. We have used an in vivo animal model to study patellar tendon attachment to an implant surface. The interface generated when the patellar tendon was attached to a hydroxyapatite (HA) coated implant was examined using light microscopy and a quantitative histomorphological analysis was performed. In the Autograft Group, the interface was augmented with autogenous cancellous bone and marrow graft, and at six weeks an indirect-like insertion was observed. At twelve weeks, the interface was observed to be a layered neo-enthesis, whose morphology was similar to a normal direct tendon insertion. In the HA Group, the tendon–implant interface was not augmented, and the implant was enveloped by a dense collagenous fibrous tissue. This study shows that a tendon–implant neo-enthesis can develop in situ by employing a suitable implant surface in association with biological augmentation.