Cancellous Graft Research Articles

Bone graft harvesting from the distal radius, olecranon, and iliac crest: a quantitative analysis.

The purpose of this study was to quantify the volume and density of cancellous bone available from 3 commonly used bone graft sites in upper extremity surgery: the distal radius, olecranon process, and anterior iliac crest. Sixteen cadavers (age range, 59-98 years) with no prior history of bone harvest or metabolic conditions affecting bone were used. Cancellous graft was obtained using standardized techniques designed to simulate the clinical setting. Packed cancellous bone volume was determined as the volume occupied by the harvested bone after compression packing with a uniform load. Defect volume was determined by measuring the volume of the site from which bone was harvested. The distal radius and olecranon provided similar volumes of packed cancellous bone (2.7 and 2.8 cc, respectively). The anterior iliac crest provided approximately twice this amount (5.3 cc). The packed cancellous bone volume/defect volume ratio was not different between the 3 sites studied. Male gender was associated with a significantly greater amount of packed cancellous bone volume for all sites. We believe the olecranon to be an alternative to the distal radius as a source of bone graft for upper extremity procedures. We suggest using the anterior iliac crest when a large volume of cancellous bone is required.

Stiffness and compactness of morselized grafts during impaction: an in vitro study with human femoral heads.

The mechanical properties of the impacted material is important when using impaction bone grafting in revision arthroplasty. We did an in vitro study to monitor the stiffness and compactness of morsellized bone grafts during impaction. Using human osteoarthrotic femoral heads as the bone source we prepared 3 types of morselized grafts with the same bone mill: (1) purely cancellous grafts, (2) cortico-cancellous grafts and (3) cortico-cancellous bone with cartilage remnants. 5 g of bone samples were progressively impacted up to 150 times in a contained cavity. All types of grafts became stiffer and stiffer during the first 30 impactions. After 30 impactions, the grafts' compactness continued to increase slowly without concomitant changes in their stiffness. Over-impaction was not useful, but did not jeopardize the implant stability. The presence of cartilage remnants considerably compromised the increase in stiffness. In contrast, the addition of cortical bone from the femoral neck did not affect the impaction and resultant stiffness.

Effect of freeze-drying and gamma irradiation on the mechanical properties of human cancellous bone.

Freeze-drying and gamma irradiation are commonly used for preservation and sterilization in bone banking. The cumulative effects of preparation and sterilization of cancellous graft material have not been adequately studied, despite the clinical importance of graft material in orthopaedic surgery. Taking benefit from the symmetry of the left and right femoral heads, the influence of lipid extraction followed by freeze-drying of a femoral head and a final 25-kGy gamma irradiation was determined, with the nonirradiated, nonprocessed counterpart as the control. Five hundred and fifty-six compression tests were performed (137 pairs for the first treatment and 141 pairs for the second). Mechanical tests were performed after 30 minutes of rehydration in saline solution. Freeze-dried femoral heads that had undergone lipid extraction experienced reductions of 18.9 and 20.2% in ultimate strength and stiffness, respectively. Unexpectedly, the work to failure did not decrease after this treatment. The addition of gamma irradiation resulted in a mean drop of 42.5% in ultimate strength. Stiffness of the processed bone was not modified by the final irradiation, with an insignificant drop of 24%, whereas work to failure was reduced by a mean of 71.8%. Freeze-dried bone was a bit less strong and stiff than its frozen control. Its work to failure was not reduced, due to more deformation in the nonlinear domain, and it was not brittle after 30 minutes of rehydration. Final irradiation of the freeze-dried bone weakened its mechanical resistance, namely by the loss of its capacity to absorb the energy (in a plastic way) and a subsequent greater brittleness.

The morselized and impacted bone graft

The results of primary hip replacements are good. However, dealing with a loose prosthesis has been problematic, especially when major bone deficiencies are encountered. These problems appear to have been solved by the introduction of the Slooff-Ling method of using morselized and impacted allograft chips. The clinical results are excellent in the hands of the innovators. However, it remains confusing that a thick layer of dead, broken, immunogenic tissue taken from another individual does not resorb and collapse during remodeling. Still harder to understand is the impression, as judged by radiography, that this thick layer seems to incorporate and remodel up to a distance of perhaps 10 mm or more from the host bone, whereas the ingrowth distance into a non-morselized graft is limited to a few mms. To clarify the biological basis of the morselized and impacted grafts better, the present study was stated. Three hypotheses were initially proposed to explain the good clinical results: 1. Morselization releases growth factors present in the graft (osteoinduction). 2. Impaction makes it easier for the ingrowing bone to climb up into the graft (osteoconduction). 3. The compliance or elasticity of the graft allows the load to produce deformations that stimulate bone formation (mechanical load). In the first studies, bone chambers were implanted in rats and the distance of new bone ingrowth into a graft in the chamber was measured. In Paper I, a morselized graft was deproteinized by slow heating under high pressure. Ingrowing bone did not reach so far into the deproteinized graft as into a non-treated one. We concluded that the proteins present in the graft partly determine how far ingrowing new bone will extend into a graft. In Paper II, a cancellous graft was impacted so that the bone volume fraction of the graft rose from 35% in the unimpacted to 65%. The impacted grafts were compared to unimpacted ones and it was shown that impaction reduced the ingrowth of new bone into a graft in the chamber at six weeks. In Paper III, this somewhat unexpected finding was further studied. Syngeneic and allogeneic grafts showed a reduced ingrowth distance at six weeks when impacted, compared to unipacted controls. However, the reduction was not found when the time for ingrowth was extended to 12 weeks, indicating a possible catch-up phenomenon. Moreover, an exogenously applied growth factor, osteogenic protein-1, was found to have increased the ingrowth distance of new bone into impacted grafts at six weeks. In Paper IV, a rabbit knee prosthesis was developed to study the effect of a mechanical load on the remodeling of a morselized and impacted graft. All rabbits had their tibial marrow cavity cleansed of cancellous bone, which was replaced by a morselized and impacted bone graft. Six rabbits received a complete tibial prosthesis with a tibial load-bearing tray and a stem transferring the load to the impacted graft with each step made by the rabbit. Another six rabbits had only the stem, without the tibial tray, inserted into the impacted graft. With this design, the load from walking was not transferred to the graft, since there was no joint surface replacement to transfer the load to the stem and the graft. Thus, the graft was loaded in rabbits receiving a full prosthesis, whereas it was unloaded in the animals receiving only the stem. New bone formation and resorption of the graft were increased in the loaded grafts, and we concluded that a load increases the rate or speed of remodeling. In Paper V, four patients were operated on for vertebral fractures. The fractures were stabilized by plates and the vertebral bodies packed with autogenous morselized graft. After 1.5 years, when the fractures were clinically and radiographically healed, a biopsy was taken. It was found, that even after such a long time, large areas remained unremodeled and sometimes even unrevascularized. In some parts, necrotic graft trabeculae were embedded in fibrous vasc

Cancellous impaction grafting in the human femur: Histological and radiographic observations in 6 autopsy femurs and 8 biopsies

6 whole postmortem femurs and 8 femoral biopsies were studied histologically, 3 months to 8 years after cancellous impaction grafting with a cemented stem for aseptic loosening. All stems were stable. Radiographs showed cortical healing in 5 cases, trabecular remodelling in 1, and trabecular incorporation in 9. There was a radiolucent line in 1 case. The histology varied. There was always a viable cortical shell around the grafted area. 1 patient showed complete bony restitution. The others still had varying amounts of remaining graft in the neo-medullary cavity, even after 8 years. The graft particles were usually embedded in dense fibrous tissue, thus forming a supporting composite tissue capable of carrying load. There was no time-dependent deterioration in the histological appearance. Radiographically, cortical healing and trabecular remodeling corresponded to viable bone. The lack of a radiolucent line said little about the viability of the tissue closest to the cement. The radiographs did not detect thin soft tissue membranes. Radiographic criteria used to assess primary total joint replacement do not necessarily apply to impaction grafting, and radiographic changes should be interpreted cautiously, especially as regards tissue viability.

Emergency management of type IIIB open tibial fractures

We present our therapeutic strategy for the treatment of type IIIB open tibial fractures. It involves emergency internal stabilisation of the bone by locked intra-medullary nailing when appropriate and skin cover using either a pedicled or free muscle flap. Where there is bone loss, a cancellous iliac graft is performed at the same time. Eighteen cases of type IIIB open tibial fractures treated between 1986 and 1995 were analysed. There were 17 men and 1 woman; the average age was 35 years. Each of the 18 patients underwent wound debridement as a primary emergency procedure with no secondary reoperation. Bone fixation was performed by locked intra-medullary nailing (AO nail, How Medica) 6–10 h after trauma. A primary cancellous iliac bone graft was performed in three cases. Cover was applied immediately after nailing (muscular pedicle flaps in 12 cases, muscular free flaps in 6 cases). Local flap cover led to two failures: both these fractures were followed by postoperative complications. The 6 free muscle flaps were successful. The average time to bone union was 6.5 months (range: 3–18.5 months) according to clinical criteria and 9 months (range: 4–27 months) according to radiological criteria. Out of the 18 fractures, 13 were primarily united (72.2% of cases); 3 involved osteitis and 2 nonunion. Sixteen patients were examined again with a mean follow-up of 4.8 years (range: 1–11 years). Six moderate malunions occurred; none needed surgical reoperation. Ankle motion was normal in 7 cases and reduced to below 50% in 9 cases when compared with the healthy ankle. Thirteen patients resumed their previous professional activities. This surgical strategy reduces bone union time, the number of operations and the time spent in hospital; it improves functional results.

Current Status of Impaction Allografting for Revision of a Femoral Component*†‡

LEOPOLD, SETH S. MAJOR§, EL PASO, TEXAS; ROSENBERG, AARON G. M.D.#, CHICAGO, ILLINOIS Author Information

Bone transport over an intramedullary nail: A case report with histologic examination of the regenerated segment

Bone transport is useful for the treatment of segmental defects, non-union and osteomyelitis. Bone transport has been compared to conventional techniques for the treatment of segmental defects and infection and found to provide better restoration of leg length, to need less cancellous grafting, to have fewer graft fractures and to require less operating time and hospital stay and to have a lower disability [ 1 Cierny G. Zorn K.E. Segmental tibial defects: comparing conventional and Ilizarov methodologies. Clin Orthop. 1994; 301: 118-123 PubMed Google Scholar , 2 Green S.A. Skeletal defects: a comparison of bone grafting and bone transport for segmental skeletal defects. Clin Orthop. 1994; 301: 111-117 PubMed Google Scholar , 3 Williams M.O. Longterm costcomparison of major limb salvage using the Ilizarov method versus amputation. Clin Orthop. 1994; 301: 156-158 PubMed Google Scholar ]. When comparing bone transport with cancellous grafting rates of union and infection have been found to be similar [ 1 Cierny G. Zorn K.E. Segmental tibial defects: comparing conventional and Ilizarov methodologies. Clin Orthop. 1994; 301: 118-123 PubMed Google Scholar , 2 Green S.A. Skeletal defects: a comparison of bone grafting and bone transport for segmental skeletal defects. Clin Orthop. 1994; 301: 111-117 PubMed Google Scholar , 3 Williams M.O. Longterm costcomparison of major limb salvage using the Ilizarov method versus amputation. Clin Orthop. 1994; 301: 156-158 PubMed Google Scholar ]. Bone transport over an intramedullary nail has been reported in animal studies [ 4 Lin V. Huang S. Lui T. Chapman M. Limb lengthening over an intramedullary nail: an animal study and clinical report. Clin Orthop. 1996; 330: 208-216 Crossref PubMed Scopus (29) Google Scholar , 5 Schemitsch E.H. Kowalski M.J. Swionkowski M.F. Harrington R.M. Comparison of the effect of reamed and unreamed locked intramedullary nailing on blood flow in the callus and strength of union following fracture of the sheep tibia. J Orthop Res. 1995; 13: 382-389 Crossref PubMed Scopus (77) Google Scholar ] and in small clinical trials [ 6 Paley D. Catagni M.A. Argnani F. Villa A. Benedetti G.B. Cattaneo R. Ilizarov treatment of tibial non-unions with bone loss. Clin Orthop. 1989; 241: 146-165 PubMed Google Scholar , 7 Prokuski L.J. Marsh J.L. Segmental bone deficiency after acute trauma: the role of bone transport. Orthop Clin North Am. 1994; 25: 753-763 PubMed Google Scholar , 8 Tornetta P. Bergman M. Watnik N. Berkowitz G. Steuer J. Treatment of grade IIIB open tibial fractures: a prospective randomized comparison of external fixation and nonreamed locked nailing. J Bone Joint Surg. 1994; 76: 13-17 Google Scholar , 9 Watson J.T. Anders M. Moed B.R. Management strategies for bone loss in tibial shaft fractures. Clin Orthop. 1995; 315: 138-152 PubMed Google Scholar ]. There are clear advantages to intramedullary fixation during bone transport, including improved rigidity of the fixation construct [ 8 Tornetta P. Bergman M. Watnik N. Berkowitz G. Steuer J. Treatment of grade IIIB open tibial fractures: a prospective randomized comparison of external fixation and nonreamed locked nailing. J Bone Joint Surg. 1994; 76: 13-17 Google Scholar , 10 Brunner U.H. Cordey J. Kessler S. Rahn B.A. Schweiberer L. Perren S.M. Bone segment transport in combination with an intramedullary nail. Injury. 1993; 24S: 29-44 Abstract Full Text PDF Scopus (12) Google Scholar ]. This has been suggested to be an important mechanical factor for optimal regeneration; other advantages include maintenance of anatomic length and alignment and early removal of the external fixation system, permitting improved patient mobilisation and muscle function [ [11] Raschke M.J. Mann J.W. Oedekoven G. Claudi B.F. Segmental transport after reamed intramedullary nailing: preliminary report of a ‘monorail’ system. Clin Orthop. 1992; 282: 233-240 PubMed Google Scholar ].

Comparison of autogenous cancellous bone grafts obtained from the sternum and proximal portion of the tibia of llamas

Objective To describe the anatomy of the sternum in llamas, define the surgical approach to the sternum for collection of cancellous bone graft tissue, and compare the histologic appearance of graft tissue obtained from the sternum with that obtained from the proximal portion of the tibia. Design Prospective study. Animals 12 llamas, 3 to 19 years old, that had been submitted for necropsy. Procedure Radiographs were taken of the sternum and left tibia of the llamas. Measurements of the sternum were determined from the radiographs and adjusted for magnification. Sternebrae volumes were estimated from these measurements. Anatomic dissections to the center of the fourth sternebra and the proximal portion of the tibia were made, and a surgical approach to the sternum was developed. Cancellous graft tissue was obtained from each site and submitted for histologic evaluation. Results Sternebrae 3, 4, and 5 were significantly larger in volume than the other sternebrae. The ventral aspect of the fourth sternebra was readily accessed for removal of graft tissue by making a 6-cm-long ventral midline incision centered 17 cm craniad to the xiphoid. Mean soft tissue thickness overlying the ventral aspect of the fourth sternebra was 3.1 cm. More tissue was obtained from the sternal (mean, 9.11 g) than from the tibial (mean, 5.16 g) sites. Sternal graft tissue consisted of trabecular bone spicules with predominantly hematopoietic marrow, whereas tibial tissue consisted of trabecular bone spicules with only fatty marrow. Conclusions and Clinical Relevance The fourth sternebra in llamas is readily accessible for obtaining autogenous cancellous bone graft tissue that consists of predominantly hematopoietic marrow. (J Am Vet Med Assoc 1999;215:362–365)

Treatment of large skeletal defects in the lower extremities using double-strut, free vascularized fibular bone grafting.

This article reports on the use of double-strut, free vascularized fibular grafts to treat six patients with infected nonunion or traumatic bone loss in the femur or tibia after prolonged treatment and multiple operations. The defects were 6-13 cm long. Five patients achieved solid union within 6 months, and one patient required additional cancellous grafting to achieve union at the distal end of the fibula. One patient experienced a stress fracture due to strenuous exercise, and union was achieved 3 months after reapplying an external fixator. Although three patients had some restricted knee motion, all patients had a satisfactory outcome in regard to walking, and no limb-length discrepancies were noted in any patient.

Porous-coated cementless acetabular cups in revision surgery: A 6- to 11-year follow-up study

Between 1986 and 1991, 65 cementless hemispherical acetabular cups were implanted in 60 patients in revision surgery. Different designs were used, including PCA (29 cups), Duraloc (14 cups), Harris-Galante (12 cups), and Omnifit (10 cups). The mean age of patients was 54.7 years. The Paprosky types of the acetabular bone defects were type 1, 2 hips; type 2, 38 hips; type 3A, 15 hips; and type 3B, 10 hips. For unrevised hips, the mean follow-up was 8.3 years (range, 6–11 years). Bone allografts were used in 56 hips: Morcellized cancellous graft was used in 42 hips, structural graft for contained defects was used in 7 hips, and structural graft for uncontained defects was used in 7 hips. There were poor clinical results in 14 hips (22%). Re-revision was necessary in 7 hips (10.8%). There was definite radiographic loosening in 18 hips and possible loosening in 4 hips. Screw failure occured in 6 hips, and a radiolucency in 1 or more DeLee-Charnley zones was apparent in 45 hips (69.2%). Moderate or severe graft resorption were found in 4 of the 42 morcellized grafts, in 6 of the 7 structural grafts for uncontained defects, and in all 7 of the 7 structural grafts for contained defects. The best results were obtained in hips with a bone defect of less than 30%. The use of a cementless acetabular cup supplemented with screws is contraindicated in hips with a bone defect greater than 50%. Hip reconstruction using structural bone—graft to stabilize the prosthesis gives the worst results.

Enhancement of fracture healing with autogenous and allogeneic bone grafts.

The factors contributing to a delayed union or nonunion are many. In general they may be divided into three major categories: deficiencies in vascularity and angiogenesis, deficiencies in the robustness of the chondroosseous response, and deficiencies in stability, strain, or physical continuity. Frequently, deficiencies in more than one category are present, thus complicating the approach to therapy. For a bone grafts to enhance fracture healing, it must provide or stimulate that which is deficient. Autogenous fresh cancellous and cortical bone most frequently are used, but other common grafts include allogeneic frozen, freeze dried, or processed allogeneic cortical, corticocancellous and cancellous grafts, and demineralized bone matrix. These grafts have varying capacities to provide active bone formation, to induce bone formation by cells of the surrounding soft tissue, and to serve as a substrate for bone formation. However, the graft cannot exert its biologic activity in isolation, dependent as it is on the surrounding environment for cells to respond to its signals and, in some cases, for blood supply. The mechanical environment of the graft site is also important. Successful graft incorporation requires that an appropriate match must be made between the biologic activity of a bone graft, the condition of the perigraft environment, and the mechanical environment. The task of the clinician who performs a bone grafting procedure for the enhancement of fracture healing is to choose the right graft or combination of grafts for the biologic and mechanical environment into which the graft will be placed.

Avascular necrosis of the metacarpal head

A case of avascular non-traumatic necrosis of the metacarpal head in a 36-year-old woman is reported. Treatment was by curettage of the necrotic bone and packing with cancellous grafts.

Platelet-rich plasma: Growth factor enhancement for bone grafts

Platelet-rich plasma is an autologous source of platelet-derived growth factor and transforming growth factor beta that is obtained by sequestering and concentrating platelets by gradient density centrifugation. This technique produced a concentration of human platelets of 338% and identified platelet-derived growth factor and transforming growth factor beta within them. Monoclonal antibody assessment of cancellous cellular marrow grafts demonstrated cells that were capable of responding to the growth factors by bearing cell membrane receptors. The additional amounts of these growth factors obtained by adding platelet-rich plasma to grafts evidenced a radiographic maturation rate 1.62 to 2.16 times that of grafts without platelet-rich plasma. As assessed by histomorphometry, there was also a greater bone density in grafts in which platelet-rich plasma was added (74.0% ± 11%) than in grafts in which platelet-rich plasma was not added (55.1% ± 8%; p = 0.005).

Acetabular reconstruction with impacted morsellised cancellous bone graft and cement

We report a long-term review of 60 acetabular components revised using impacted, morsellised bone allografts and a cemented polyethylene cup. The acetabular defects were cavitary (37) or combined (23). Follow-up was for a mean 11.8 years (10 to 15). Further revision was needed in five hips, two for septic and three for aseptic loosening. The overall survival rate at 11.8 years was 90%; excluding the septic cases it was 94%. Acetabular reconstruction with impacted morsellised cancellous grafts and cement gives satisfactory long-term results.

Acetabular reconstruction with impacted morsellised cancellous bone graft and cement: A 10- to 15-year follow-up of 60 revision arthroplasties

We report a long-term review of 60 acetabular components revised using impacted, morsellised bone allografts and a cemented polyethylene cup. The acetabular defects were cavitary (37) or combined (23). Follow-up was for a mean 11.8 years (10 to 15). Further revision was needed in five hips, two for septic and three for aseptic loosening. The overall survival rate at 11.8 years was 90%; excluding the septic cases it was 94%. Acetabular reconstruction with impacted morsellised cancellous grafts and cement gives satisfactory long-term results.

Distal tibial bone graft for foot and ankle surgery

The implanting of autologous cancellous bone graft harvested from the distal tibia is reported in a prospective study with a minimum of 6 months follow-up. From a medial incision, an average of 2.6 cc of cancellous graft from the distal tibia was used in 28 feet in 26 patients. There were no major complications, fractures, or donor site infections. Two superficial wound infections, three cases of skin irritation, and one non-union were identified at the graft site. The technique, the outcome, and a literature review are discussed. Overall, the distal tibia is a safe, effective, and practical bone graft procurement site for foot and ankle surgery.

Cancellous grafting and external fixation for unstable Colles' fractures.

We present a prospective study of the treatment of 32 unstable Colles' fractures by external fixation and cancellous grafting with minimal exposure. We inserted an external fixator between the radius and the second metacarpal, and maintained ligamentotaxis for five weeks. In 27 patients the result was good or excellent, but five fractures healed with malunion. All patients made a satisfactory functional recovery. At a mean follow-up of three years (1 to 5) after injury none had pain in the wrist and all were satisfied with the result. The average grip strength was 95% of normal. Seven patients had algodystrophy with mild impairment of finger movements in four. We conclude that the combination of cancellous grafting and external fixation is effective for the treatment of unstable Colles' fractures.

CANCELLOUS GRAFTING AND EXTERNAL FIXATION FOR UNSTABLE COLLES’ FRACTURES

We present a prospective study of the treatment of 32 unstable Colles’ fractures by external fixation and cancellous grafting with minimal exposure. We inserted an external fixator between the radius and the second metacarpal, and maintained ligamentotaxis for five weeks. In 27 patients the result was good or excellent, but five fractures healed with malunion. All patients made a satisfactory functional recovery. At a mean follow-up of three years (1 to 5) after injury none had pain in the wrist and all were satisfied with the result. The average grip strength was 95% of normal. Seven patients had algodystrophy with mild impairment of finger movements in four. We conclude that the combination of cancellous grafting and external fixation is effective for the treatment of unstable Colles’ fractures.

FEMORAL COMPONENT REVISION USING IMPACTED MORSELLISED CANCELLOUS GRAFT

We have tested the axial and torsional stability of femoral components after revision arthroplasty in a cadaver model, using impacted morsellised cancellous graft and cement. Each one of six matched pairs of fresh frozen human femora had either a primary or a revision prosthesis cemented in place. For the ‘revision’ experiments, all cancellous bone was removed from the proximal femur which was then over-reamed to create a smooth-walled cortical shell. An MTS servohydraulic test frame was used to apply axial and torsional loads to each specimen through the prosthetic femoral heads with the femur submerged in isotonic saline solution at 37°C. The mean subsidence was 0.27 ± 0.17 mm for the primary and 0.52 ± 0.30 mm for the revision groups. The difference was statistically significant (p < 0.025), but the mean subsidence was < 1 mm in both groups. The mean maximum torque before failure was 42.9 ± 26.9 N-m for the primary and 34.8± 20.7 N-m for the revision groups. This difference was not statistically significant (p > 0.015). Based on our results we suggest that revision of the femoral component using morsellised cancellous graft followed by cementing with a collarless prosthesis with a polished tapered stem restores the integrity of the proximal femur and provides immediate stability of the implant.