Autologous Bone Graft Harvesting Research Articles

Retrograde Versus Antegrade Femoral Bone Graft Harvesting Using the Reamer–Irrigator–Aspirator

To compare retrograde versus antegrade femoral bone graft harvesting using the reamer-irrigator-aspirator system to determine whether there was any difference in intraoperative, postoperative, or patient outcome variables. Retrospective cohort study. Urban Level I Trauma Center. Ninety-four (62 antegrade and 32 retrograde procedures) consecutive adult patients who underwent femoral autologous bone graft harvesting using the Synthes reamer-irrigator-aspirator system between April 2008 and March 2013. Amount of bone graft, perioperative fractures or other complications, and postoperative hip and/or knee pain. There was no significant difference between demographic or medical comorbidities between the groups. There was no significant difference in the side of the graft harvest, graft volume, hospital length of stay, or the ability to ambulate on postoperative day 1. There was a significantly increased incidence of iatrogenic fracture or prophylactic nailing with antegrade reaming (4 vs. 0, P = 0.01). Average length of follow-up was 500 (range, 20-1477) days for the antegrade group and 378 (range, 19-706) days for the retrograde group. The antegrade group had a nonsignificant increased incidence of hip pain (8.1% vs. 3.1%, P = 0.66), and the retrograde group had a significantly higher incidence of knee pain (15.6% vs. 1.6%, P = 0.02) at 6-month follow-up. Neither hip nor knee complaints were present at final follow-up. No cases of delayed femur fracture, infection, or abductor and/or antalgic gait involving the donor extremity were seen at final follow-up. This study provides support to the safety of femoral bone graft harvesting using both antegrade and retrograde techniques. Both techniques provide reliable, high-volume, nonstructural autologous bone graft with minimal associated morbidity. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reamer Irrigator Aspirator bone graft harvesting: Complications and outcomes in an Asian population

IntroductionAutologous bone grafting has been accepted as the gold standard in the treatment of non-unions and in definitive filling of segmental bone defects. However, there have been well-recognised complications associated with their harvest. The Reamer Irrigator Aspirator (RIA) system is an alternative technique of autologous bone graft harvesting. Studies have been published in the Western population showing the efficacy and outcome of this technique. No prior studies were done in the Asian population, who has smaller average canals, different femoral geometry as compared to Caucasians and weaker bone density in both genders.We aim to present the findings and discuss its suitability in the Asian population when dealing with segmental bone loss and non-unions requiring reconstruction. MethodsWe conducted a retrospective analysis of all trauma patients with segmental bone loss and non-unions treated with RIA bone grafting over a 4.5 year period.A total of 57 cases of RIA bone grafting were conducted on 53 patients. The amount of bone graft harvested, blood loss and post-operative pain were measured. Patients were followed up for union rate as well as complications of the procedure. ResultsUnion was achieved in 86.8% of patients. The mean time to union was 17.64 weeks. Seven patients did not achieve union after the first RIA surgery, in which six of seven were open fractures initially and six were smokers.One major intra-operative complication was recorded, that being a fractured femoral shaft due to thinning of the cortex by the RIA harvester. There were two patients who developed donor site superficial soft tissue infection that resolved after a course of antibiotics. There were no long-term complications seen in all patients. ConclusionsThe safety and efficacy of RIA bone graft harvesting for the management of non-union in the Asian population is promising, with adequate graft quantities, high success and low complication rates that are comparable to the Caucasian population. The diameter of the medullary canal in our population is suitable for this procedure. We believe that RIA bone graft harvesting provides a reliable and safe alternative source of autologous bone grafts for bone grafting of non-union sites.

Autologous bone graft harvesting: a review of grafts and surgical techniques.

Spinal fusion with or without instrumentation often requires the use of bone graft. Bone graft may be autogenous or exogenous. There are various forms of bone graft which may be acquired from numerous sites. Knowledge of fusion biology is imperative for understanding the benefits and limitations of these grafts. Equally as important is the knowledge of outcome measures, management of donor-site morbidity, and potential reconstruction. This review details the methods of obtaining bone graft and details the properties of each, as well as discusses observed outcomes, donor-site morbidities, and reconstruction techniques.

Proximal Tibia Bone Graft: An alternative Donor Source especially for Foot and Ankle Procedures.

Bone graft is essential in various orthopaedic procedures. Among the many donor sites for harvesting autologous bone graft, the iliac crest has been the most commonly used. However, for foot and ankle procedures the proximal tibia has gained popularity as an alternative donor site due to its anatomic proximity to the primary surgical site. In this article we evaluated the possible complications associated with harvesting proximal tibia bone graft. Our study showed the low incidence of morbidity in harvesting proximal tibia bone graft, thereby providing a good alternative donor for foot and ankle procedures.

Complications with the use of bone morphogenetic protein 2 (BMP-2) in spine surgery

Background contextRecombinant human bone morphogenetic protein 2 (rhBMP-2) is a very potent osteogenic growth factor that has been used successfully in various spine fusions, obviating the need for autologous iliac crest bone graft harvest and therefore avoiding the associated morbidities. PurposeIn the past few years, a tremendous increase in rhBMP-2 usage was noted, and concerns regarding costs, benefits, and safety issues were raised by many. The goal of this work was to provide a comprehensive review of the adverse events and complications associated with use of rhBMP-2. Study designLiterature review. MethodsThis is a review of the current literature on the reported adverse events, complications, and concerns associated with rhBMP-2 use. ResultsThis article discusses the wide spectrum of adverse outcomes related to rhBMP-2 use in the lumbar and the cervical spine; retrograde ejaculation, antibodies formation, postoperative radiculitis, postoperative nerve root injury, ectopic bone formation, vertebral osteolysis/edema, dysphagia and neck swelling, hematoma formation, interbody graft lucency, and wound healing complications are reviewed. Cost-related concerns, dosage considerations, carrier types, and theoretical carcinogenesis concerns were also presented. ConclusionsDespite the excellent spinal fusion rates promoted by this powerful molecule, the increasingly reported adverse outcomes associated with bone morphogenetic protein usage have created real concerns. This article will provide the reader with a good understanding of the reported complications associated with rhBMP-2 use and ultimately help recognize its safety spectrum and limits for better clinical application.

Is bone transplantation the gold standard for repair of alveolar bone defects?

New strategies to fulfill craniofacial bone defects have gained attention in recent years due to the morbidity of autologous bone graft harvesting. We aimed to evaluate the in vivo efficacy of bone tissue engineering strategy using mesenchymal stem cells associated with two matrices (bovine bone mineral and α-tricalcium phosphate), compared to an autologous bone transfer. A total of 28 adult, male, non-immunosuppressed Wistar rats underwent a critical-sized osseous defect of 5 mm diameter in the alveolar region. Animals were divided into five groups. Group 1 (n = 7) defects were repaired with autogenous bone grafts; Group 2 (n = 5) defects were repaired with bovine bone mineral free of cells; Group 3 (n = 5) defects were repaired with bovine bone mineral loaded with mesenchymal stem cells; Group 4 (n = 5) defects were repaired with α-tricalcium phosphate free of cells; and Group 5 (n = 6) defects were repaired with α-tricalcium phosphate loaded with mesenchymal stem cells. Groups 2–5 were compared to Group 1, the reference group. Healing response was evaluated by histomorphometry and computerized tomography. Histomorphometrically, Group 1 showed 60.27% ± 16.13% of bone in the defect. Groups 2 and 3 showed 23.02% ± 8.6% (p = 0.01) and 38.35% ± 19.59% (p = 0.06) of bone in the defect, respectively. Groups 4 and 5 showed 51.48% ± 11.7% (p = 0.30) and 61.80% ± 2.14% (p = 0.88) of bone in the defect, respectively. Animals whose bone defects were repaired with α-tricalcium phosphate and mesenchymal stem cells presented the highest bone volume filling the defects; both were not statistically different from autogenous bone.

Site Selection and Pain Outcome After Autologous Bone Graft Harvest

In foot and ankle surgery, there are multiple sites used for autologous bone graft, including the proximal (PT) or distal tibia (DT), calcaneus (C), and iliac crest (ICBG). There has been no comparison between these anatomic areas and the potential for acute or persistent pain at 1 year. The purpose of this study was to prospectively compare patient-reported outcomes of acute and persistent pain at 1 year after surgery to determine if harvest site selection made a difference. As part of a clinical trial examining ankle and hindfoot fusion rates with autograft compared with synthetic graft, the autologous bone graft harvest sites were assessed with visual analog pain outcome scores at 3, 24, 36, and 52 weeks after surgery. Patients with a score of 20+ defined clinically significant pain. Four harvest sites were compared: ICBG, PT, DT, and C. Fisher exact test was used to compare the graft site pain between locations. Twelve percent of subjects reported clinically significant pain at 24 weeks and 8.5% at 52 weeks postoperatively. Each lower extremity harvest site (C, DT, PT) showed higher rates of clinically significant graft harvest site pain than the ICBG at 52 weeks. Autologous bone graft harvest carried a risk of persistent pain at up to 1 year (weeks 24-52) in 18% of patients. Lower-extremity bone graft sites had the greatest risk for persistent pain at 1 year. Level II, prospective comparative study.

Initial Experience with BoneBac Press<sup>TM</sup>: A Novel Autologous Bone Graft Harvesting and Collecting Device

Object: The objective of this study is to analyze the utility of a novel autologous bone graft harvesting and collecting device in spinal fusion surgeries. Methods: 35 patients underwent fusion procedures in the cervical or lumbar spine using the BoneBac PressTM. Procedures included anterior cervical discectomy with fusion (ACDF), lumbar laminectomy and posterolateral arthrodesis, and transforaminal lumbar interbody fusion (TLIF). The amount of bone graft collected from each level was determined as well as the need for additional bone graft extenders. Fusion rates were determined based on an independent radiographic evaluation performed 5 to 12 months postoperatively. Results: 54 total levels were operated upon, collecting a total of 176.0 cc of autograft. The average amount of bone collected was 3.26 cc/level. In the cervical and lumbar spine the average amount of bone collected per level was 2.30 cc and 6.77 cc respectively. The fusion rate was 94.3% at 10 months postoperatively. In most cases no additional bone graft extender was needed. Autologous bone collected had excellent handling characteristics and was easily packed into cages or placed posterolaterally. Conclusions: The use of autograft bone material collected using the BoneBac PressTM is costeffective, significantly reduces bone graft cost, and eliminates donor graft site morbidity while promoting successful fusion.

Use of bone graft substitutes in the management of tibial plateau fractures

The current available evidence for the use of bone graft substitutes in the management of subchondral bone defects associated with tibial plateau fractures as to their efficiency and safety has been collected following a literature review of the Ovid MEDLINE (1948–Present) and EMBASE (1980–Present).Nineteen studies were analysed reporting on 672 patients (674 fractures), with a mean age of 50.35 years (range 15–89), and a gender ratio of 3/2 males/females. The graft substitutes evaluated in the included studies were calcium phosphate cement, hydroxyapatite granules, calcium sulphate, bioactive glass, tricalcium phosphate, demineralised bone matrix, allografts, and xenograft.Fracture healing was uneventful in over 90% of the cases over a variant period of time. Besides two studies reporting on injectable calcium phosphate cement excellent incorporation was reported within 6 to 36 months post-surgery. No correlation was made by any of the authors between poor incorporation/resorption and adverse functional or radiological outcome. Secondary collapse of the knee joint surface ≥2 mm was reported in 8.6% in the biological substitutes (allograft, DBM, and xenograft), 5.4% in the hydroxyapatite, 3.7% in the calcium phosphate cement, and 11.1% in the calcium sulphate cases. The recorded incidence of primary surgical site and donor site infection (3.6%) was not statistically significant different, however donor site-related pain was reported up to 12 months following autologous iliac bone graft (AIBG) harvest. Shorter total operative time, greater tolerance of early weight bearing, improved early functional outcomes within the first year post-surgery was also recorded in the studies reporting on the use of injectable calcium phosphate cement (Norian SRS).Despite a lack of good quality randomised control trials, there is arguably sufficient evidence supporting the use of bone graft substitutes at the clinical setting of depressed plateau fractures.

Qualitative and Quantitative Differences Between Bone Graft Obtained from the Medullary Canal (with a Reamer/Irrigator/Aspirator) and the Iliac Crest of the Same Patient

Donor site morbidity and limited volume remain primary drawbacks of using bone graft from the iliac crest and an impetus for finding other sources of autologous bone-graft material. The Synthes Reamer/Irrigator/Aspirator (RIA) has been found to have value as an autologous bone-graft harvesting device. The purpose of this study was to compare the cellular and biochemical characteristics of bone grafts obtained with use of the RIA and from the iliac crest of the same patient. A prospective study was performed on a consecutive series of ten skeletally mature patients presenting for repair of nonunited tibial or femoral fractures. Graft material was harvested from both the iliac crest (in the standard fashion) and the medullary canal of the femur or tibia (with use of the RIA) of each patient. Portions of each autologous graft sample were assessed histologically and by genomewide transcriptional profiling for biochemical markers known to be expressed during fracture-healing. Principal-component analysis comparing the messenger RNA expression profiles in the RIA and iliac crest samples showed that the expression profile at each harvest site was unique and independent of patient, age, sex, or any identified comorbidity. Transcriptional analysis showed that the RIA samples had greater levels of expression of genes associated with vascular, skeletal, and hematopoietic tissues. Additionally, stem cell markers and growth factors that act early in the osteogenic cascade were more abundant in the RIA samples compared with the iliac crest samples. This is the first study to directly compare the histological and molecular profiles of bone grafts from reaming debris and the iliac crest of the same patient. The debris generated during intramedullary reaming, harvested with use of the RIA technique, and the bone graft harvested from the iliac crest possessed a similar transcriptional profile for genes known to act in the early stages of bone repair and formation. This suggests that reaming debris may be a viable alternative to iliac crest bone graft when autologous cancellous graft is needed.

Current and Emerging Basic Science Concepts in Bone Biology

Ongoing research in bone biology has brought cutting-edge technologies into everyday use in craniofacial surgery. Nonetheless, when osseous defects of the craniomaxillofacial skeleton are encountered, autogenous bone grafting remains the criterion standard for reconstruction. Accordingly, the core principles of bone graft physiology continue to be of paramount importance. Bone grafts, however, are not a panacea; donor site morbidity and operative risk are among the limitations of autologous bone graft harvest. Bone graft survival is impaired when irradiation, contamination, and impaired vascularity are encountered. Although the dura can induce calvarial ossification in children younger than 2 years, the repair of critical-size defects in the pediatric population may be hindered by inadequate bone graft donor volume. The novel and emerging field of bone tissue engineering holds great promise as a limitless source of autogenous bone. Three core constituents of bone tissue engineering have been established: scaffolds, signals, and cells. Blood supply is the sine qua non of these components, which are used both individually and concertedly in regenerative craniofacial surgery. The discerning craniofacial surgeon must determine the proper use for these bone graft alternatives, while understanding their concomitant risks. This article presents a review of contemporary and emerging concepts in bone biology and their implications in craniofacial surgery. Current practices, areas of controversy, and near-term future applications are emphasized.

Restoration of iliac crest defects following autologous tricortical bone graft harvesting using tutobone

Restoration of iliac crest defects following autologous tricortical bone graft harvesting using tutobone

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: A systematic review

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the ‘gold standard’ and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Prospective, Randomized, Multi-Center Feasibility Trial of rhPDGF-BB versus Autologous Bone Graft in a Foot and Ankle Fusion Model

The increased morbidity and surgical time associated with harvesting autologous bone graft (ABG) have encouraged surgeons to develop synthetic orthobiologic alternatives. The recombinant form of platelet-derived growth factor (rhPDGF-BB), an angiogenic, mitogenic, and chemotactic cytokine, has been shown to significantly enhance bone formation in human periodontal osseous defects when combined with a tricalcium phosphate carrier (β-TCP). The purpose of this prospective, controlled, randomized, multi-center feasibility clinical trial was to compare the safety and efficacy of this biosynthetic bone graft substitute (Augment™ Bone Graft) to ABG during ankle and hindfoot fusion. Twenty adult subjects requiring ankle or hindfoot fusion from three U.S. centers were enrolled and randomized in a 2:1 ratio to receive Augment™ or ABG, respectively. Surgical approach and fixation techniques were standardized, and minimum followup was 9 months. The primary endpoint was radiographic osseous union, evaluated by a blinded independent radiologist. Secondary endpoints included assessment of clinical success, union rate by serial computed tomography (CT) examination, time to full weightbearing, AOFAS Ankle-Hindfoot Score (AOFAS), Foot Function Index (FFI), Short Form-12 (SF-12), and Visual Analog pain assessment Scale (Pain VAS). At 36 weeks, 77% (10/13) of the Augment™ and 50% (3/6) of the ABG patients were fused based on radiographic criteria. There were two nonunions in the Augment™ group (9%, 2/14). Healing rates based on 12 week CT scanning (50% osseous bridging) were 69% (9/13) in the Augment™ and 60% (3/5) in the ABG groups, respectively. All functional outcome measures (FFI, AOFAS, SF-12), as well as the VAS pain scores, improved in both groups over time. Surgical procedure times lasted an average 26 minutes longer for the ABG as compared to the Augment™ populations. There were no device related serious adverse events in this study. Based on the available data, the rate of radiographic union, time to full weightbearing, and outcomes scores between the Augment™ and ABG subjects appear comparable. Augment™ may represent a safe and efficacious treatment alternative to ABG during foot and ankle arthrodesis.

Femoral Fracture After Harvesting of Autologous Bone Graft Using a Reamer/Irrigator/Aspirator

A case of postoperative fracture in the donor femur after obtaining autologous bone graft with a reamer/irrigator/aspirator is presented. This procedure was successful in healing a difficult femoral nonunion, but the patient sustained a fracture of the contralateral (bone graft donor) femur 20 days after surgery. A mechanical analysis is conducted of this case and recommendations are made. Unrestricted weightbearing on a limb that has undergone reamer/irrigator/aspirator bone graft harvesting, particularly in a noncompliant patient, is probably inadvisable. If possible, one should obtain bone graft from the same limb as the fracture being treated because this will leave the patient with one unaltered limb for mobilization.

Prospective study of iliac crest bone graft harvest site pain and morbidity

Background context Morbidity associated with autologous bone graft harvest is an important factor in determining the utility of expensive alternatives such as recombinant bone morphogenic protein. The most frequently reported complication associated with graft harvest is chronic pain. Purpose To prospectively determine the degree of pain and morbidity associated with autologous iliac crest bone graft harvest and its effect on activities of daily living. Study design Prospective observational cohort study. Patient sample One hundred ten adult patients undergoing elective posterior lumbar spinal fusion surgery involving autologous iliac crest bone graft harvest. Outcome measures Patient self-reported Visual Analog Scale (VAS) scores for pain and a study-specific questionnaire regarding activities of daily living. Methods One hundred ten patients were prospectively enrolled. Postoperative VAS scores (0–100) for harvest site pain were obtained at 6-week, 6- and 12-month follow-up. Patients completed a 12-month questionnaire regarding the persistence of specific symptoms and resulting limitation of specific activities. Results One hundred four patients were available for 1-year follow-up. Mean VAS pain scores (scale 0–100) at 6 weeks, 6 and 12 months were 22.7 (standard deviation [SD], 25.9), 15.9 (SD, 21.5), and 16.1 (SD, 24.6), respectively. At 12 months, 16.5% reported more severe pain from the harvest site than the primary surgical site, 29.1% reported numbness, and 11.3% found the degree of numbness bothersome, whereas 3.9% were bothered by scar appearance. With respect to activity limitations resulting from harvest site pain at 1 year, 15.1% reported some difficulty walking, 5.2% with employment, 12.9% with recreation, 14.1% with household chores, 7.6% with sexual activity, and 5.9% irritation from clothing. Conclusions There is a significant rate of persistent pain and morbidity from iliac crest bone graft harvest when associated with elective spine surgery. Mean pain scores progressively decline over the first postoperative year. Nevertheless, harvest site pain remains functionally limiting in a significant percentage of patients 1 year after surgery. Rates of functional limitation are higher than previously reported and may be because of increased sensitivity of the prospective study design and targeted investigation of these specific symptoms. Validity of these findings is necessarily limited by patient ability to discriminate harvest site pain from alternative sources of back and buttock pain.

Prospective evaluation of chronic pain associated with posterior autologous iliac crest bone graft harvest and its effect on postoperative outcome

BackgroundAutogenous Iliac Crest Bone Graft (ICBG) has been the "gold standard" for spinal fusion. However, bone graft harvest may lead to complications, such as chronic pain, numbness, and poor cosmesis. The long-term impact of these complications on patient function and well-being has not been established but is critical in determining the value of expensive bone graft substitutes such as recombinant bone morphogenic protein. We thus aimed to investigate the long-term complications of ICBG. Our second aim was to evaluate the psychometric properties of a new measure of ICBG morbidity that would be useful for appropriately gauging spinal surgery outcomes.MethodsProspective study of patients undergoing spinal fusion surgery with autologous ICBG. The SF-36v2, Oswestry Disability Index, and a new 14-item follow-up questionnaire addressing persistent pain, functional limitation, and cosmesis were administered with an 83% response rate. Multiple regression analyses examined the independent effect of ICBG complications on physical and mental health and disability.ResultsThe study population included 170 patients with a mean age of 51.1 years (SD = 12.2) and balanced gender (48% male). Lumbar fusion patients predominated (lumbar = 148; cervical n = 22). At 3.5 years mean follow-up, 5% of patients reported being bothered by harvest site scar appearance, 24% reported harvest site numbness, and 13% reported the numbness as bothersome. Harvest site pain resulted in difficulty with household chores (19%), recreational activity (18%), walking (16%), sexual activity (16%), work activity (10%), and irritation from clothing (9%). Multivariate regression analyses revealed that persistent ICBG complications 3.5 years post-surgery were associated with significantly worse disability and showed a trend association with worse physical health, after adjusting for age, workers' compensation status, surgical site pain, and arm or leg pain. There was no association between ICBG complications and mental health in the multivariate model.ConclusionChronic ICBG harvest site pain and discomfort is reported by a significant percentage of patients undergoing this procedure more than three years following surgery, and these complications are associated with worse patient-reported disability. Future studies should consider employing a control group that does not include autologous bone graft harvest, e.g., a group utilizing rhBMP, to determine whether eliminating harvest-site morbidity does indeed lead to observable improvement in clinical outcome sufficient to justify the increased cost of bone graft substitutes.

Composite Ceramic Bone Graft Substitute in the Treatment of Locally Aggressive Benign Bone Tumours

To report the use of a composite ceramic bone graft substitute containing calcium sulphate and hydroxyapatite (HA) in the treatment of large expansive osteolytic benign bone tumours. 4 women and 9 men aged 8 to 49 (mean, 22) years with aneurysmal bone cysts (n=6) or giant cell tumours (n=7) in the epi- or meta-physeal areas of the lower limbs underwent curettage, phenolisation, and filling with bone graft substitute containing calcium sulphate and HA. The mean tumour size was 38.5 (range, 18-65) ml. The patients were followed up for a mean of 41 (range, 33-52) months. Range of movement, Musculoskeletal Tumor Society Rating Score (MTSRS), and haematological and blood biochemical parameters were measured. Two patients had recurrence at 7 and 9 months, both progressed to grade-III giant cell tumours. One underwent revision with an iliac crest autograft, whereas the other underwent en bloc excision and prosthetic replacement. The 11 other lesions displayed clinical and radiological consolidation at a mean of 4.6 (range, 3-7) months. No restriction of range of movement was observed, except in the patient undergoing prosthetic replacement. The mean MTSRS was 96% (range, 83-100%) of that expected for normal function. During the follow-up period, haematological and blood biochemical parameters stayed within normal limits. Composite bioceramic osteoconductive grafts, which combine porous HA with calcium sulphate, provide a framework for human osteogenesis and avoid donor-site morbidity (autologous bone graft harvesting). Tumour recurrence remains a major concern especially in young patients, as revision invariably requires removal of additional bone, potentially compromising joint integrity.

The safety and utility of bone morphogenetic protein in anterior and posterior cervical-spine fusions

Purpose of review: Interest in using recombinant human bone morphogenetic proteins in the cervical spine has been motivated by the desire to avoid the complications associated with autologous bone-graft harvest or bone-graft alternatives as well as to ensure successful fusion. Well-performed, prospective clinical studies have demonstrated the efficacy of recombinant human bone morphogenetic proteins to promote bony union in the long bones and in the lumbar spine. It is appealing to consider applying these highly osteoinductive molecules to cervical fusions, and this article summarizes the recent reports of such applications. Recent findings: Several cohort studies have reported on recombinant human bone morphogenetic proteins being used with primary anterior cervical-spine surgery. In general, these studies indicate high fusion rates but also increase local complications such as soft-tissue edema. Although local swelling may be dose-dependent, this has not been studied as an independent variable. No posterior cervical-spine fusion series have been reported with recombinant human bone morphogenetic proteins at this point. Summary: In considering recombinant human bone morphogenetic proteins for cervical-spine surgery, the appropriate dose, carrier, and surgical technique will need further defining and optimization. Additionally, implant costs and risks must be balanced against potential benefits.

Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) for Cervical Fusion: Is There a Role in Cervical Trauma?

Objective: To identify a high quality bone source for cervical fusion especially in the setting of trauma, while avoiding the morbidity of iliac crest grafting and the issues of nonhealing or resorbtion with homologous or allo or xenografts. Method: Using poly-ether-ether-ketone (PEEK) cages as containers, rhBMP-2 was placed in an absorbable collagen sponge as the sole bone source in 3 patients who underwent a 2 level anterior cervical fusion and rigid plating. Results: Cervical fusion at both levels of the cervical spine was obtained in the 3 patients starting at 8 weeks postoperatively and was solid at 4-6 months after surgery without any complications. Conclusion: rhBMP-2 contained in an absorbable collagen sponge is an excellent osteoinductor for cervical fusion, free of adverse effects, avoiding the need for autologous bone grafts. Additional evaluations are necessary to determine the long-term efficacy of rhBMP-2. The use of rhBMP-2 within a synthetic or allograft bone source may obviate the need for autologous bone graft harvesting in the setting of cervical trauma.