Autologous Bone Graft Harvesting Research Articles

Treatment of Humeral Nonunions with Allograft, Demineralized Bone Matrix, and Plate Fixation

Objective: Due to the risks inherent in autologous iliac crest bone graft harvest, the results of patients with humeral nonunions who were treated with allograft, demineralized bone matrix, and plate fixation were evaluated. Design: Retrospective review of patients who underwent operative treatment of humeral nonunions with allograft, demineralized bone matrix, and plate fixation. Setting: University medical center. Patients: Ten patients with nonunions of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 2 years follow-up were included. The mean duration of the nonunion preoperatively was 24 months (range, 4-120 months). The patients had undergone an average of one (range, 0-3) previous surgery on the humerus. Intervention: Open reduction and internal fixation with plate and screw fixation and bone graft. All ten patients had bone grafting with cancellous allograft and demineralized bone matrix, while four of the ten also had intramedullary fibular allograft supplementing the fixation in cases of osteopenia or bone loss. Main Outcome Measures: Clinical and radiographic evidence of bone union. Medical records, operative reports, physical examination, and preoperative, postoperative, and follow-up radiographs were reviewed. Outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) to evaluate subjective outcome. Results: At a mean follow-up of 33 months (range, 25-42 months; minimum, 2 years) 9 of the 10 nonunions (90 %) had healed. One patient required a second operation to gain union. The nonunion that failed to heal, in a patient with severe coronary artery disease and congestive heart failure, initially healed at 3 months but at 40 months postoperatively had refractured through the old nonunion site with loss of internal fixation after a fall at home. Patient outcomes evaluated with the DASH questionnaire demonstrated 3 excellent, 4 good, 2 fair, and 1 poor result at follow-up. All patients with healed fractures at follow-up had functional shoulder and elbow range of motion. Conclusions: These results show that allograft and demineralized bone matrix can be a useful adjunct to plate fixation in the treatment of humeral nonunions, even in patients who have had previous surgery.

Experimental Anterior Lumbar Interbody Fusion With an Osteoinductive Bovine Bone Collagen Extract

A randomized experimental porcine anterior lumbar interbody fusion. To determine the osteoinductive potential of a bovine bone derived collagen lyophilisate for anterior interbody spinal fusion in an animal model. Complications associated with autologous bone graft harvesting are still major concerns when performing spinal fusion surgery. A new formulation of bovine bone collagen-protein extracts (Colloss) has been shown to be effective in animal studies as a bone graft enhancer. The present study further tested its osteogenic potential in the anterior spinal fusion cage in a controlled animal study. Twelve normal Danish landrace pigs of 50 kg each were chosen as experimental animals. Lumbar spine interbody fusion of L3-L4, L4-L5 using titanium alloy cages was performed on each pig with pedicle screws instrumentation. Cages packed with either autograft or Colloss were randomly assigned to the two levels. Pigs were followed up to 3 months. After termination, the spine segments were evaluated by radiograph, micro-CT, and histomorphometry Ten pigs completed the study. Implant breakage, loosening, or spinal deformity was not observed after 12 weeks on radiograph examination. Micro-CT evaluations demonstrated that cages with Colloss had the same fusion rate (9 of 10) as those with autograft, further evaluation of bone volume (BV/TV), and trabecular thickness (Tb Th) also showed no different between them. Histologically, both autograft and Colloss levels had 80% (8 of 10) fusion rate. Histomorphometric results revealed that the only difference was the Colloss-filled cages had a higher cartilage tissue volume (P < 0.04). Colloss was effective as a bone graft substitute. It achieved the same fusion rate and the samepercentage of new bone formation as that of autologous iliac bone graft in this demanding porcine anterior spinal fusion model after 12 weeks.

Vulnerability of the subcostal nerve to injury during bone graft harvesting from the iliac crest.

Autologous bone graft harvesting from the iliac crest remains the gold standard for fusion surgery. One disadvantage of autologous bone harvesting is the patient's enduring postoperative pain at the donor site. Nerve injury is one of the postulated mechanisms that may account for this pain. The object of this study was to determine whether the lateral cutaneous branch of the subcostal nerve is vulnerable to injury in the process of obtaining grafts from the anterior iliac crest. Anatomical dissections were performed on 10 cadaveric specimens to ascertain the size of the T-12 subcostal nerve and its position in relation to the iliac crest. The lateral cutaneous branch of the subcostal nerve may lie as close as 6 cm from the anterior superior iliac spine. This nerve is very vulnerable to injury when harvesting bone from the anterior iliac crest. Knowledge of the anatomy may decrease the risk of injury to this nerve.

Anterior cervical discectomy and fusion: role of anterior plate fixation in degenerative cervical disorders

Anterior surgical approaches to the cervical spine have steadily gained in popularity since originally proposed in the 1950’s. 1 Along with the expanded use of the anterior approach, since the original description of the anterior cervical discectomy, there has been an overwhelming trend to combine this with an intervertebral fusion. Between 1985 and 1996, there has been a 300% increase in cervical spine fusion procedures. 2 Ninety percent of these fusions have been in the treatment of degenerative cervical spine disorders. The literature supports this trend as the long-term outcome of patients appears to be favorably impacted by the addition of the fusion. 3,4 Despite the fact that the original techniques pioneered by Smith and Robinson, Cloward, and Bailey and Badgley have been refined only relatively modestly over the past several decades, a failure of the reconstruction continues to be one of the most common causes of an unsatisfactory clinical outcome. 1,5,6 This is in addition to the morbidity that may be associated with a bone graft harvest if autograft is utilized for the fusion. Several reports in the literature have documented a roughly 20% rate of complications, either major or minor, from the site of an autologous bone graft harvest. 7-9

Porous tricalcium phosphate and transforming growth factor used for anterior spine surgery.

Harvesting autologous bone graft from the iliac crest is associated with considerable secondary morbidity. Bone graft substitutes such as porous ceramics are increasingly used for spinal surgery. This paper presents the results of an animal study in which beta-tricalcium phosphate (beta-TCP) bone substitutes were used for anterior spinal surgery in sheep and baboons. The presented baboon study also investigated the effect of impregnating the ceramic material with transforming growth factor (TGF). In the first study, using the sheep model, a stand-alone instrumented anterior fusion was performed. The animals were randomized into three treatment groups: autologous bone, beta-TCP granules, and sham group. The results were analyzed biomechanically and histologically at three survival intervals: 8, 16 and 32 weeks. An additional animal group was added later, with ceramic pre-filled implants. In the second study, a baboon model was used to assess the osteointegration of a 15-mm-diameter porous beta-TCP block into the vertebral body. The experiment was partially motivated by a new surgical procedure proposed for local bone graft harvest. Three treatment groups were used: beta-TCP plug, beta-TCP plug impregnated with TGF-beta3, and a sham group with empty defect. The evaluation for all animals included computer tomograms at 3 and 6 months, as well as histology at 6 months. In the sheep model, the mechanical evaluation failed to demonstrate differences between treatment groups. This was because massive anterior bone bridges formed in almost all the animals, masking the effects of individual treatments. Histologically, beta-TCP was shown to be a good osteoconductor. While multiple signs of implant micromotion were documented, pre-filling the cages markedly improved the histological fusion outcomes. In the baboon study, the beta-TCP plugs were completely osteointegrated at 6 months. For the group that used ceramic plugs impregnated with TGF-beta3, no incremental advantage was seen as a result of this particular application. However, TGF-beta3 is a potent growth factor at a very low dose. Not only does it speed up the ceramic material resorption, but it is also responsible for massive regional new bone formation. More experiments are required to better understand the biological effects of this growth factor in relation to bone formation, and to be able to take clinical advantage of them.

Natural history of posterior iliac crest bone graft donation for spinal surgery: a prospective analysis of morbidity.

A prospective study was conducted to examine bone graft donor site morbidity in 106 consecutive patients undergoing posterior spinal fusion. To perform a prospective analysis of donor site morbidity, to document the incidence of major complications, and to collect information on the impact of autologous bone graft harvesting from the posterior iliac crest on the overall outcome of spinal surgery. Bone graft harvesting from the posterior iliac crest for spinal fusion is a source of significant morbidity. Previous retrospective case studies indicate that minor complications are common, but they do not define the natural history and complications of posterior iliac crest bone graft harvesting. A standardized harvesting technique was used. At 3, 6, and 12 months after surgery, the patients completed a proforma questionnaire rating symptoms on a visual analog scale and underwent a postoperative examination by the surgeon. Finally, overall surgical outcome was assessed at 12 months. The major component of morbidity is donor site pain. Mean pain scores were 1.640 at 3 months, 1.812 at 6 months, and 1.207 at 12 months. The pain at 12 months was significantly less than at 3 and 6 months (P = 0.005), with a trend toward the highest scores at 6 months. A pain score of 0 was reported by 55% of the patients. Local sensory loss was found in 10% of the patients. Outcome assessment showed significant differences in morbidity for surgery performed at different spinal levels (P = 0.001), with lumbosacral surgery resulting in worse outcomes than either cervical (P < 0.05) or thoracolumbar (P < 0.05) surgery. Significantly higher visual analog scores were observed at 6 months in patients with poorer overall outcomes. According to this study, it is reasonable to reassure patients that a good result from spinal surgery will not be compromised by severe symptoms or major morbidity secondary to posterior iliac crest bone graft donation. Before surgery, patients may be advised concerning the risks of donor site pain, which improves significantly by 12 months, local tenderness, and uncommonly localized sensory loss.

Outcome in Cloward anterior fusion for degenerative cervical spinal disease.

The Cloward ventral interbody fusion is often employed for treatment of cervical degenerative disease. The present study was aimed at evaluating results and complications in this classical type of autologous bone graft procedure in a cohort of patients with radiculopathy (RP) or myeloradiculopathy (MRP). Indications for and limitations of the technique were investigated by retrospective data analysis in a series of 106 patients (30 females and 76 males). These underwent single or multiple level Cloward fusion in a total of 145 levels. Neuroradiological investigations included lateral and antero-posterior cervical spine X-rays, axial CT scans, and MRI. The presence of postoperative ossification and stable bony fusion in the fused segments was confirmed by X-rays and, when necessary, by CT. The median postoperative follow-up period was 6.5 years (range 4-10.5 years). Short term outcome in RP patients was good in 26 cases (92.9%) and fair in 2 cases (7.1%). A good short term outcome was seen in 55 MRP patients (70.5%), a fair outcome in 20 patients (25.6%), and a poor outcome in 3 patients (3.8%). Patients having myelopathy signs for less than 1 year had a significantly better outcome than those with clinical signs for more than 1 year (p < 0.05). MRP patients below the age of 40 years had a significantly better outcome than those above the age of 40 (p < 0.05). In the long term, radiculopathy was cured or significantly improved in 92.8% of cases, and myeloradiculopathy in 64%. One year after surgery, there were 139 stably fused segments (96%) and 6 segments showing osseous non-union (4%). Plain lateral radiographs demonstrated, besides the bony fusion in the respective segment, relatively frequent graft collapse with slight to severe correction losses and kyphotic deformity of the cervical spine. However, these findings did not necessarily correlate with the clinical outcome. Autologous bone graft harvesting caused a rather high short-term morbidity with donor site pain and/or wound haematoma in 33% of the cases. These surgery-related complications, however, were of a temporary nature, as long-term complications (cutaneous hypaesthesiae) were found in 2 patients (1.8%) only. In conclusion, Cloward anterior cervical fusion for degenerative spinal disease is a relatively simple and safe surgical procedure with favourable short and long term results. In our hands, graft donor site complications dominate the side effects of surgery, and the percentage of non-unions is rather low. Because of the relatively frequent bone graft collapse and the late loss of postural correction of the spine, we cannot recommend the Cloward type fusion for multisegmental procedures. In such cases, an instrumented plate fusion should be carried out in order to prevent graft collapse and non-union, and to allow for a shorter convalescence period.

Posterolateral and anterior interbody spinal fusion models in the sheep.

Posterolateral and anterior interbody spinal arthrodesis is a frequent procedure, but high nonunion rates are reported and harvesting autologous bone graft from the iliac crest significantly increases morbidity. Bone graft substitutes are an alternative, but to date clinical results are not conclusive. Bone substitutes can be organic or inorganic, biologic or synthetic. They can have osteoconductive properties, inductive properties or both. Animal experiments are essential to investigating bone substitutes using biomechanical and histologic methods not available in clinical studies. Few authors reported on instrumented anterior fusion models, but none used the sheep model. In the current study posterolateral and anterior interbody fusion models in sheep are described. Both models used instrumented fusions, applying porous mineral scaffolds, alone or mixed with bone. The surgical techniques are described step-by-step and potential difficulties are highlighted. Preliminary results are reported for the posterolateral fusion model using coralline graft substitutes. The coral granules mixed with locally harvested bone had fusion outcomes similar to pure autologous bone. The graft substitute showed marked resorption between 12 and 20 weeks. All fusions had bone cortex and good trabecular connectivity. Histologic evaluation suggests after 20 weeks nearly the entire surface of the substitute is covered with new bone. Porous mineral bone substitutes mixed with locally harvested autologous bone are thought to be a valid alternative for posterolateral fusions.

BONE GRAFTING FOR SPINAL FUSION

At least 250,000 spinal fusions are performed in the United States each year, nearly all requiring implantation of bone graft material. The preferred technique for most of these operations is the transplantation of structured or morcellized autologous corticocancellous bone from the iliac crest. Further, because of the increasing frequency of spinal fusion surgery during the 1990s, arthrodesis of the spine has become the most common reason for autologous bone graft harvest. This article reviews the current clinical status of autogenous bone grafts and alternative materials in spinal fusion surgery.

Analysis of harvest morbidity and radiographic outcome using autograft for anterior cervical fusion.

Retrospective study of 184 autologous iliac crest bone grafts used for anterior cervical fusion in 144 procedures. To evaluate the effect of autologous iliac crest bone graft harvest site on operation and recovery and to identify patients at risk for harvest morbidity. Although autologous iliac crest bone graft is considered the most successful grafting material, concerns about harvest morbidity provide a rationale for considering allograft. Data about the use of autograft therefore would assist spinal surgeons in selecting the appropriate substrates for fusion after anterior cervical decompression. Statistical analysis based on patient gender, smoking history, obesity, and medical or pharmacologic risk factors for wound healing was used to evaluate morbidity after patient interviews and examinations. Limited assessment of radiographic outcome also was performed. A second operation because of donor site morbidity was performed in four patients (2.8%), but only one (0.7%) with meralgia paresthetica had permanent sequelae. Superficial wound infection or dehiscence occurred in 5.6% of patients, with a disproportionate number of women, obese patients, and those with medical risk represented. Protracted wound symptoms of pain and poor cosmesis were reported in 2.8% and 3.5% of patients, respectively, and also were found in a significant number of female and obese patients. Evidence of fusion was present in 97% of cases. Autologous iliac crest bone graft harvest results in minimal major morbidity when regional anatomy is respected and careful technique is observed. The identification of patients at risk for minor complications suggests that allograft may be appropriate in these patients; however, prospective comparison is required to identify whether graft material or technical factors determine fusion success and relative benefit.

Donor site morbidity at the iliac crest: comparison of percutaneous and open methods

The Journal of Bone and Joint Surgery. British volumeVol. 76-B, No. 5 ArticlesFree AccessDonor site morbidity at the iliac crest: comparison of percutaneous and open methodsDN Kreibich, IR Scott, JM Wells, M SalehDN KreibichSearch for more papers by this author, IR ScottSearch for more papers by this author, JM WellsSearch for more papers by this author, M SalehSearch for more papers by this authorPublished Online:1 Sep 1994https://doi.org/10.1302/0301-620X.76B5.8083285AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited ByCross-sectional analysis of spatial distribution and total amount of harvestable calvarian split boneAnnals of Anatomy - Anatomischer Anzeiger, Vol. 234Trephine Technique for Iliac Crest Bone Graft Harvest16 September 2020 | Spine, Vol. 46, No. 1Treatment of distal clavicle nonunion with and without bone graftingInjury, Vol. 49Application of vascularized fibular graft for reconstruction and stabilization of multilevel cervical tuberculosisMedicine, Vol. 97, No. 3Vascularized Bone Grafts in Spine SurgeryBone Autografting, Allografting and Banking22 April 2014Revisionsendoprothetik20 October 2011Complications following autologous bone graft harvesting from the iliac crest and using the RIA: A systematic reviewInjury, Vol. 42Characterization of cortico-cancellous bone along the iliac crest: focus on graft harvesting4 December 2010 | Surgical and Radiologic Anatomy, Vol. 33, No. 5Complications Related to GraftProspective study of iliac crest bone graft harvest site pain and morbidityThe Spine Journal, Vol. 9, No. 11Percutaneous Bone Grafting from the Distal FemurThe Annals of The Royal College of Surgeons of England, Vol. 90, No. 1The use of irradiated allograft in a paediatric population: an Indian experience28 June 2006 | Cell and Tissue Banking, Vol. 8, No. 1Tissue banking in MexicoCell and Tissue Banking, Vol. 7, No. 3Ambulatory in-office anterior iliac crest bone harvestingOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Vol. 101, No. 3Autogenous bone grafting from proximal tibia in elective foot and ankle surgeryFuß & Sprunggelenk, Vol. 4, No. 1The Syringe Technique for Minimally Invasive Bone GraftingJournal of Orthopaedic Trauma, Vol. 19, No. 9Reconstruction of mandibular defects following tumor ablation by vertical distraction osteogenesis using intraosseous distraction devices8 September 2004 | Clinical Oral Implants Research, Vol. 16, No. 1Vascularized Bone Grafts in Spine SurgeryReview Management of nonunion in trauma2 September 2016 | Trauma, Vol. 6, No. 3Two-Year Fusion Rate Equivalency Between Grafton® DBM Gel and Autograft in Posterolateral Spine FusionSpine, Vol. 29, No. 6Long-term complications of distal radius bone graftsThe Journal of Hand Surgery, Vol. 28, No. 5Preservation of ridge dimensions following grafting with coral granules of 48 post-traumatic and post-extraction dento-alveolar defectsDental Traumatology, Vol. 19, No. 4Comparison of conventional surgery with motorized trephine in bone harvest from the anterior iliac crestOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Vol. 95, No. 2Clinical success in harvesting autogenous bone using a minimally invasive trephineJournal of Oral and Maxillofacial Surgery, Vol. 61, No. 2Management of non-unions with mono-lateral external fixationInjury, Vol. 32Surgical harvesting of bone graft from the ilium: point of viewMedical Hypotheses, Vol. 55, No. 6The Management of Acute Bone Loss Following TraumaBifocal Techniques for Non-Union and DeformityExternal Fixation Techniques for Arthrodesis of the Knee and AnkleQuantification of bone harvested from the iliac crest using a power-driven trephineJournal of Oral and Maxillofacial Surgery, Vol. 57, No. 7An open fracture of the ulna with bone loss, treated by bone transportInjury, Vol. 30, No. 5Osteogenic effect of a gastric pentadecapeptide, BPC-157, on the healing of segmental bone defect in rabbits: a comparison with bone marrow and autologous cortical bone implantationBone, Vol. 24, No. 3Fracture of the tibial diaphysis treated by external fixation and the axial alignment grid: a single surgeon's experienceInjury, Vol. 28, No. 7Biocompatible Osteoconductive Polymer Versus Iliac GraftSpine, Vol. 21, No. 18External fixation of the wristInjury, Vol. 27, No. 1Bone Allograft Safety and Performance Vol. 76-B, No. 5 Metrics Downloaded 103 times History Published online 1 September 1994 Published in print 1 September 1994 InformationCopyright © 1994, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

Pathologic fracture of the proximal ulna through a bone graft donor site

Complications of harvesting autologous bone graft from the iliac crest and tibia are well known; exclusive use of upper extremity donor sites in hand surgery has therefore been advocated. Six weeks of postoperative elbow splinting has been recommended after harvest of large proximal ulnar grafts. We report two cases of pathologic fracture of the proximal ulna complicating local bone grafting and question whether the risk of fracture and the attendant patient inconvenience and potential joint stiffness incurred by postoperative immobilization are exceeded by the morbidity of carefully done iliac crest grafting.