Successful Bone Graft Research Articles

S212: Bone Grafting for Implant Site Preparation

The survival of implants depends on the quantity and quality of bone around the implant. This lecture describes harvesting techniques and the effective use of ramus, tibia and iliac crest bones to increase the quality and quantity of bone for implant site preparation in an office setting. Case selection will be discussed to improve success rate of the grafts and minimize morbidity of the donor sites. This lecture presents four key points for more predictable and successful bone grafting. A review of bone healing physiology will enable the clinician use autogenous bone more effective and maximize the graft volume maintenance. This lecture discusses when, where and how to use cancellous, cortical and corticocancellous bones. Instruments requirement and techniques of harvesting ramus, tibia and iliac crest will be discussed in details. Technology that makes harvesting bone simpler will be discussed. Anesthetic techniques which make these procedures feasible for the office will be emphasized.

The Bone-Grafting Decision Tree: A Systematic Methodology for Achieving New Bone

Successful bone grafting requires that the clinician select the optimal bone grafting material and surgical technique from among a number of alternatives. This article reviews the biology of bone growth and repair, and presents a decision-making protocol in which the clinician first evaluates the bone quality at the surgical site to determine which graft material should be used. Bone quantity is then evaluated to determine the optimal surgical technique. Choices among graft stabilization techniques are also reviewed, and cases are presented to illustrate the use of this decision tree.

The Effect of Cigarette Smoking on Dental Implants and Related Surgery

Cigarette smoking is still considered a common habit. Of smokers, increased plaque accumulation, higher incidence of gingivitis and periodontitis, higher rate of tooth loss, and increased resorption of the alveolar ridge have been found in the oral cavity. Cigarette smoking may adversely affect wound healing, and, thus, jeopardize the success of bone grafting and dental implantation. Bone grafts and sinus lift operations are both common and well-documented procedures before dental implant placement. Heat as well as toxic by-products of cigarette smoking, such as nicotine, carbon monoxide, and hydrogen cyanide, have been implicated as risk factors for impaired healing, and, thus, may affect the success and complications of those surgical procedures. An association among dental implants, grafting procedures (i.e., bone grafts, maxillary sinuses augmentation), and history of smoking has been reported. A higher degree of complication, or implant failure rates, were found in smokers with and without bone grafts. The relationship between cigarette smoking and implant-related surgical procedures, including the incidence of complications associated with these procedures, will be described and discussed based on relevant literature and results of our recent studies.

Alveolar bone grafting: achieving the organisational standards determined by CSAG, a baseline audit at the Birmingham Children's Hospital

Birmingham Children's Hospital (BCH) is the centre for a regional comprehensive cleft service attempting to implement the national guidelines for minimum standards of care. A national audit of cleft management (CSAG) found that 58% of alveolar bone grafts were successful; published series suggest that success rates can be of the order of 95%. We present the results of an audit of alveolar bone grafting over a 33-month period, after implementation. A retrospective clinical process audit was taken from the hospital notes and an analysis of radiological outcome by Bergland score was obtained by two independent assessors. The audit highlighted the difficulties of integrating the increased clinical workload. Other difficulties included poorly standardised pre- and postoperative occlusal radiography, inconsistent orthodontic management and a lack of prospective data collection. An 81% success rate for alveolar bone grafting compares favourably to the CSAG study. Of 82 patients, 68 had sufficient data for a retrospective review; 21 were our own patients and 47 were referred into the centralised service. The success of bone grafting as defined by CSAG (including Bergland scores) is based on only two-thirds of the patients as many have their orthodontic treatment managed in more distant units and radiographs are much harder to obtain. Bone grafting later than age 11 years, was true for 28% (6/21) of our BCH patients and 46% (22/47) for those referred to our service. This audit demonstrates what has been achieved in a re-organised service in the context of Real Politik in the NHS and suggests the areas that require improvement.

Bone Grafting for Implant Site Preparation

The survival of implants depends on the quantity and quality of bone around the implant. This lecture describes harvesting techniques and the effective use of ramus, tibia and iliac crest bones to increase the quality and quantity bone for implant site preparation in an office setting. Case selection will be discussed to improve success rate of the grafts and minimize morbidity of the donor sites. This lecture presents four key points for more predictable and successful bone grafting. A review of bone healing physiology will enable the clinician use autogenous bone more effective and maximize the graft volume maintenance. This lecture discusses when, where and how to use cancellous, cortical and corticocancellous bones. Instruments requirement and techniques of harvesting ramus, tibia and iliac crest will be discussed in details. Technology that makes harvesting bone simpler will be discussed.

The influence of bone allograft processing on osteoblast attachment and function

In order to assess the influence of eight different sterilisation and disinfection methods for bone allografts on adhesion, proliferation, and differentiation of human bone marrow stromal cells (BMSC), cells were grown in culture and then plated onto pieces of human bone allografts. Following processing methods were tested: autoclavation (AUT), low-temperature-plasma sterilisation of demineralised allografts (D-LTP), ethylene oxide sterilisation (EtO), fresh frozen bone (FFB), 80 °C-thermodisinfection (80°C), γ-irradiation (Gamma), chemical solvent disinfection (CSD), and Barrycidal ®-disinfection (BAR). The seeding efficiency was determined after one hour to detect the number of attached cells before mitosis started. The cell viability was determined after 3, 7, and 21 days. Tests to confirm the osteoblastic differentiation included histochemical alkaline phosphatase staining and RT-PCR for osteocalcin. Human BMSC showed greatest attachment affinities for D-LTP-, 80°C-, and CSD-allografts, whereas less cells were found attached to AUT-, EtO-, FFB-, Gamma-, and BAR-probes. Cell viability assays at day 3 revealed highest proliferation rates within the FFB- and 80°C-groups, whereas after 21 days most viable cells were found in D-LTP-, 80°C-, CSD-, and Gamma-groups. BAR-treatment showed a considerably toxic effect and therefore was excluded from all further experiments. Highest AP-activity and gene expression of osteocalcin were detected in the D-LTP-group in comparison with all other groups. In summary, our results demonstrate that cell adhesion, final population, and function of BMSC are influenced by different disinfection and sterilisation methods. Therefore, processing-related alterations of BMSC-function may be important for the success of bone grafting. The experimental setup used in the present work may be useful for further optimisation of bone allograft processing.

A decision tree for bone graft success

Successful bone grafts to the maxillomandibular complex depend upon an understanding of basic bone biology, appropriate surgical technique, evaluation of recipient and donor sites, and knowledge of bone graft materials.This lecture presents the protocol for bone graft success and discusses the reasons that affect success and/or failure. Particular attention is directed to evaluation of the recipient site and specifically the quality and quantity of cancellous and cortical bone. This evaluation combined with an understanding of basic surgical principles aids the clinician to decide not only on appropriate surgical procedure, but upon the use of autogenous bone versus allogeneic or alloplastic grafts. This lecture guides the clinician to answer specific questions of when to use an onlay bone graft, a split cortical graft, the sandwich graft, the sinus graft, ridge preservation, socket grafts, particulate grafts with titanium or membrane stabilization.Autogenous bone has been considered the “gold standard” as the most predictable graft. However, harvesting autogenous bone requires a second surgical site, increased surgical and healing time, and increase morbidity. Is there an alternative to autogenous grafts? This lecture also discusses when autogenous grafts are absolutely indicated and when alternative graft materials are successful as well as when they fail to produce predictable success.ReferencesRoberts E, et al: Bone physiology and metabolism. Calif Dent Assoc J October:54, 1987Reddi AM, Wientroub S, Muthukumaran N: Biological principle of bone induction. Orthop Clin North Am 18:207, 1987Wittbjer J, Palmer B: Osteogenetic activity in composite grafts of demineralized compact bone and marrow. Clin Orthop 173:229, 1983 Successful bone grafts to the maxillomandibular complex depend upon an understanding of basic bone biology, appropriate surgical technique, evaluation of recipient and donor sites, and knowledge of bone graft materials. This lecture presents the protocol for bone graft success and discusses the reasons that affect success and/or failure. Particular attention is directed to evaluation of the recipient site and specifically the quality and quantity of cancellous and cortical bone. This evaluation combined with an understanding of basic surgical principles aids the clinician to decide not only on appropriate surgical procedure, but upon the use of autogenous bone versus allogeneic or alloplastic grafts. This lecture guides the clinician to answer specific questions of when to use an onlay bone graft, a split cortical graft, the sandwich graft, the sinus graft, ridge preservation, socket grafts, particulate grafts with titanium or membrane stabilization. Autogenous bone has been considered the “gold standard” as the most predictable graft. However, harvesting autogenous bone requires a second surgical site, increased surgical and healing time, and increase morbidity. Is there an alternative to autogenous grafts? This lecture also discusses when autogenous grafts are absolutely indicated and when alternative graft materials are successful as well as when they fail to produce predictable success. References Roberts E, et al: Bone physiology and metabolism. Calif Dent Assoc J October:54, 1987 Reddi AM, Wientroub S, Muthukumaran N: Biological principle of bone induction. Orthop Clin North Am 18:207, 1987 Wittbjer J, Palmer B: Osteogenetic activity in composite grafts of demineralized compact bone and marrow. Clin Orthop 173:229, 1983

Platelet-rich plasma: ready or not?

Surgeons are continually searching for ways to improve the success of bone grafting with either autogenous bone or other bone substitutes. Platelet-rich plasma (PRP) was first introduced to the oral surgery community by Whitman et al1 in their 1997 article entitled “Platelet Gel: An Autologous Alternative to Fibrin Glue With Applications in Oral and Maxillofacial Surgery.” The authors thought that “through activation of the platelets within the gel and the resultant release of. . .growth factors, enhanced wound healing should be expected.” PRP enjoyed a great increase in popularity in the oral and maxillofacial surgery community after the publication of a landmark article by Marx et al 2 in 1998. Marx et al’s study showed that combining PRP with autogenous bone in mandibular continuity defects resulted in significantly faster radiographic maturation and a histomorphometrically denser bone regenerate. It certainly seemed as though a new age in bone grafting had begun. The theory behind the use of PRP is compelling. It is now well known that platelets have many functions beyond that of simple hemostasis. Platelets contain important growth factors that, when secreted, are responsible for increasing cell mitosis, increasing collagen production, recruiting other cells to the site of injury, initiating vascular in-growth, and inducing cell differentiation. These are all crucial steps in early wound healing. Using the concept that if a few are good, then a lot may be better, increasing the concentration of platelets at a wound may promote more rapid and better healing. It seems very logical that increasing the concentration of platelets in a bone graft, and therefore increasing the concentration of growth factors, may lead to a more rapid and denser bone regenerate. The preparation of PRP is relatively simple. Blood collected from the patient undergoes a centrifugation process to concentrate the platelets. The platelets are concentrated into a small volume, which can then be added to a bone graft. When the platelet concentrate is activated, a gelatinous structure is formed and the important wound-healing growth factors are released. Platelets are known to contain a variety of growth factors, including transforming growth factor- (TGF), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF). These growth factors are released from the platelets when they are activated, secreted, or aggregated by collagen or epinephrine. 3 TGF- and PDGF improve soft tissue and bony wound healing and, when delivered exogenously, stimulate collagen production, improve wound strength, and initiate callus formation.4-6 VEGF is a powerful angiogenic growth factor with an important role in wound healing and vascularity. 7 If PRP can indeed support a faster and denser bone graft, then oral and maxillofacial reconstructive surgery would be taken to a new level. However, many aspects of this theory may or may not be true. This was eloquently articulated by Schmitz and Hollinger, in a letter to the editor, in which they questioned the actual isoforms and the biological actions of the various growth factors concentrated in PRP, and stated their opinion that “at this time, basic research does not strongly endorse the ability of PRP to promote healing.” 8

The use of OP-1 in femoral impaction grafting in a sheep model

The aim of this pilot study was to examine bone graft incorporation in femurs impacted with allograft bone alone (control group) or with allograft containing the bone morphogenetic protein OP-1 (BMP-7) (OP-1 group) in a sheep model of cemented hemiarthroplasty. Two sheep in each group were sacrificed at 6, 18 and 26 weeks. Successful bone graft incorporation was evident in both groups by six weeks but in the OP-1 group, there had been more extensive resorption of the graft. There was one case of excessive stem subsidence in the OP-1 group at six weeks. By 18 weeks, there was remodelling and trabeculation of the new bone in the OP-1 group, but this appeared less advanced in the control group. By 26 weeks, there was remodelling of bone in the graft bed. The results of this small study suggest that OP-1 promotes initial graft resorption, thus hastening bone graft incorporation and remodelling in femoral impaction grafting. The one case of stem subsidence may be associated with the early resorption seen in the OP-1 group and reinforces the need for further studies, examining dose response and using precise measures of stem movement, before this BMP is used in femoral impaction grafting at revision hip arthroplasty.

Measurement of bone morphogenetic proteins and other growth factors in demineralized bone matrix.

Osteoinductivity of demineralized bone matrix has been attributed to bone morphogenetic proteins (BMP). Other growth factors, including insulin-like growth factor-1 (IGF-1) and transforming growth factor-beta1 (TGF-beta1), have also been detected in demineralized bone matrix. Success of bone graft substitutes containing demineralized bone matrix has been assumed to be closely associated with osteoinductivity of the demineralized bone matrix. Because of differences in bone characteristics between donors and tissue banks, confirmation and measurement of osteoinductivity may play a crucial role in predicting the success of the bone graft substitute. In the current studies, BMP-2, BMP-4, TGF-beta1, and IGF-1 were measured in demineralized bone matrix. A strong association was noted between BMP-2 and TGF-beta1 levels. A strong association was also found between BMP-2 and new bone formation in an ectopic nude rat model.

Long-term complications of distal radius bone grafts

Purpose: To assess long-term results and complications of cancellous bone graft taken from the distal radius. Methods: A total of 1,670 cases of bone graft taken from the distal radius for various indications were reviewed retrospectively. The patients were evaluated for success of bone grafting and for the following complications: fracture through donor site, local infection, DeQuervain’s tenosynovitis, and neuroma of the superficial radial nerve. Results: The overall complication rate including bone graft failure within a mean follow-up period of 4.5 years was 4%. Bone graft failure required regrafting with iliac bone in 38 patients (2.3%). DeQuervain’s tenosynovitis was noted in 21 patients (1.3%), local soft-tissue infection was noted in 3 patients (0.2)%, fracture through donor site was noted in 2 patients (0.1%), and superficial radial nerve neuromas were noted in 2 patients (0.1%). There were no cases of osteomyelitis. Conclusions: Bone grafting from the distal radius is effective with minimal complications and is a practical adjunct to reconstructive hand procedures.

Bone graft alternatives in spinal fusion surgery

Autograft bone is considered the gold standard for use in spinal fusion surgery. Autograft has all three properties considered essential for successful bone grafting: osteoinduction, osteoconduction, and osteogenesis. Unfortunately, the harvest of autograft bone is associated with substantial morbidity. Bone marrow aspirate is the only other potential source of osteogenic precursor cells, but provides neither osteoconductive nor osteoinductive potential, and its current usefulness involves incorporation in a composite graft. Allograft bone is the most frequently used autograft alternative, but it suffers from significant limitations, including lack of osteogenicity and significantly decreased osteoinductance compared with autograft. The risk of infection, although small, is also a concern. Demineralized bone matrix is a popular allograft product with limited osteoinductive potential and significantly less risk of infection. However, poor regulation of this product has been a criticism, and clinical efficacy in spinal fusion requires further investigation. Ceramics are purely osteoconductive in nature and have material properties that may be too brittle for use as unprotected structural grafts. Their use as a component of composite grafts has demonstrated success in animal models and preliminary human clinical trials of spinal fusion. Recombinant growth factors, specifically the bone morphogenetic proteins 2 and 7, are currently being evaluated in clinical trials, and early results have been impressive. These products may have a role in composite grafts that may exceed the efficacy of autograft in promoting spinal fusion. Use of autologous bone grafting has long been considered the most reliable means of achieving a spinal fusion in a variety of clinical settings. Autografts provide three factors identified as important for successful graft incorporation: osteoinduction, osteoconduction, and osteogenesis. However, the supply of autograft is limited, and the process of harvesting exposes patients to added morbidity, introduces another surgical site for potential complications, and often adversely affects otherwise successful patient outcomes. The many disadvantages of autograft have led to a search for effective alternatives that match or even exceed the biologic potency of autograft while avoiding the associated morbidity. So-called “bone graft alternatives” have been one of the most popular areas of investigation during the past few years. This review presents the most recent developments, focusing primarily on the numerous osteobiologic products currently available or in the final stages of clinical testing.

Vascularized free fibular flap for mandibular reconstruction: A report of 26 cases

Purpose: Mandibular reconstruction represents a challenge to the oral and maxillofacial surgeon and has been revolutionized by the modern microvascular techniques. Rehabilitation using techniques such as reconstruction plates frequently produce a functional and cosmetic defect. The primary objective of the current study was to evaluate the usefulness of the osteomuscular free fibular flap for this purpose. Patients and Methods: The results of 26 vascularized free fibula flaps with or without a skin paddle that were used for mandibular reconstruction is presented. The “double barrel” technique was used in 6 cases. The donor site was closed directly in 2 cases and with an abdominal full-thickness skin graft in 24 cases. Results: All flaps except 1 were viable. There was partial necrosis of the skin island in 1 patient. The average length of the fibula graft was 10.96 cm, and the number of osteotomies ranged from 0 to 3. In the donor site, the most significant problem was unsatisfactory scarring related to the use of a skin graft. There were no long-term functional complications in the lower leg. Two patients have been secondarily rehabilitated with osseointegrated implants. Conclusion: The fibula flap provides a successful bone graft for mandibular restoration with an acceptably low complication rate. This method meets most of the requirements for oral and mandibular replacement. © 2001 American Association of Oral and Maxillofacial Surgeons

The effect of different membranes on onlay bone graft success in the dog mandible

Objective. The aim of this study was to compare resorbable membranes, nonresorbable membranes, and no coverage with respect to onlay bone graft healing in a dog. Experimental design. Each of four dogs had six corticocancellous blocks of ramus bone placed bilaterally as onlay grafts to the inferior lateral aspect of the mandible. On each side, one graft was left uncovered, one was covered with a collagen membrane, and one was covered with an expanded polytetrafluoroethylene membrane. Volume determinations were made at the time of graft placement and when the animals were killed. Results. There were no statistically significant differences in bone volume or histologic outcome among the three groups.

Experimental Spinal Fusion With Recombinant Human Bone Morphogenetic Protein-2

Lumbar intertransverse process arthrodesis using recombinant human bone morphogenetic protein-2 was performed in a previously established rabbit model for posterolateral spinal fusion and compared with fusions achieved using autogenous bone graft. To qualitatively compare different recombinant human bone morphogenetic protein-2 dosages and carriers and to determine the efficacy of recombinant human bone morphogenetic protein-2 as a bone graft substitute to produce lumbar intertransverse process fusion in a validated rabbit model for posterolateral spinal fusion. Autogenous bone was considered the most successful bone graft material used for spinal arthrodesis. Problems with its use may occur in 25-30% of patients and prompted the search for and investigation of bone graft substitutes and osteoinductive growth factors, such as bone morphogenetic proteins. Recombinant human bone morphogenetic protein-2 was used successfully in orthotopic sites to generate bone in animal mandibular and long bone defect models. Posterolateral intertransverse process arthrodeses were performed at L5-L6 in 56 rabbits using recombinant human bone morphogenetic protein-2 or autogenous bone graft. Rabbits were killed either 5 weeks later to qualitatively compare fusions achieved using different recombinant human bone morphogenetic protein-2 dosages and carriers or 4 weeks later to compare the efficacy of recombinant human bone morphogenetic protein-2 in achieving spinal fusion compared with using autogenous bone graft. Inspection, manual palpation, radiography, histology, and biomechanic testing were used to assess the fusion. All rabbits implanted with recombinant human bone morphogenetic protein-2 achieved solid spinal fusion by manual palpation and were fused radiographically, whereas only 42% of the autograft control fusions were solid. More mature fusions with greater trabecular bone formation were shown radiographically and histologically in rabbits implanted with the high-dose recombinant human bone morphogenetic protein-2 than with the low-dose recombinant human bone morphogenetic protein-2. Fusions achieved using recombinant human bone morphogenetic protein-2 delivered in the collagen carrier were more remodeled and homogeneous compared with using recombinant human bone morphogenetic protein-2 delivered in autograft +/- collagen carrier. Fusions achieved with recombinant human bone morphogenetic protein-2 were biomechanically stronger and stiffer than fusions achieved using autogenous bone graft. Recombinant human bone morphogenetic protein-2 successfully and reliably achieved lumbar intertransverse process fusion in a validated rabbit model for posterolateral spinal fusion. Radiographically and histologically, greater and more rapid bone formation, consolidation, and remodeling were shown with recombinant human bone morphogenetic protein-2 compared with autogenous bone graft. Fusions achieved with recombinant human bone morphogenetic protein-2 were biomechanically stronger and stiffer than autograft fusions.

Secondary Bone Grafting for Unilateral Alveolar Clefts: A Review of Surgical Techniques

For the past 5 years we have been performing the closure of the oronasal fistula with alveolar bone grafting in the early-to-late secondary time period. The final decision as to whether early or late grafting should be done is based on if a grafting is needed to support the eruption of a functional lateral incisor. Generally the Moczair type buccal flap, with a "Z" release for wide clefts, is used for the buccal flap. This is combined with lateral releasing incisions on the palate for palatal closure. Separate nasal and oral closures are performed in all cases, with bone placed between the two layers in the alveolar defect. It is believed that this treatment sequence best fulfills the criteria for successful alveolar bone grafting outlined at the beginning of this chapter. Figure 8 demonstrates an alveolar bone grafting procedure in a 10-year-old girl just before eruption of the canine tooth treated with a buccal Moczair flap, lateral releasing incisions on the palate, two-layered closure, and the placement of an iliac bone graft.

Percutaneous Iliac Bone Grafting of Secondary Alveolar Clefts

Secondary bone grafting of residual alveolar clefts has become an integral part of the comprehensive care of children born with facial clefting. Although indications and timing may remain somewhat controversial, bone grafting during the period of mixed dentition has gained widespread acceptance. A number of bone graft sites have been proposed; each has its enthusiastic proponents. We believe that cancellous bone harvested from the ilium provides optimal material to achieve successful alveolar bone grafting. Unfortunately, this site has been associated with significant morbidity, primarily pain, which can prolong a patient's hospitalization. We relate our experience from two centers encompassing 24 patients who underwent percutaneous harvesting of corticocancellous bone grafts from the ilium. With this method we were successful in obtaining adequate quantities of corticocancellous bone with the Craig bone biopsy needle regardless of the cleft size. Each patient was able to ambulate without difficulty within hours of surgery. We are currently performing alveolar bone grafting as an outpatient procedure employing this technique. In addition, we believe this method has particular usefulness in Third World countries.

Iliac Versus Cranial Bone for Secondary Grafting of Residual Alveolar Clefts

Secondary bone grafting of the maxilla in the mixed transitional dentition stage has become a well-accepted procedure in the surgical protocol for rehabilitation of patients with residual alveolar clefts. This retrospective study was undertaken to evaluate and compare the long-term results obtained with iliac or cranial cancellous bone graft material in the area of alveolar clefts and was based on the independent experience of two plastic surgeons from the same center using exclusively cranial or iliac cancellous bone, respectively. The criteria for surgery were similar. The surgical technique, with the exception of the bone-grafting material, also was similar, and all patients were treated by the same group of orthodontists. Fifteen patients from each group, from a total of over 100 patients, were randomly selected and included in the study. All patients were followed up from 18 to 60 months. Operative and perioperative parameters, donor-site morbidity, and long-term results were evaluated, compared, and analyzed. There were no significant differences between the two groups, and equally good results in terms of bone incorporation, tooth eruption, and appearance were obtained with both iliac and cranial bone grafts. We conclude from our study that successful bone grafting is primarily achieved by adherence to meticulous surgical technique, simultaneous closure of coexisting oronasal or palatal fistulae, use of cancellous bone particles only, and coverage of the grafts with well-vascularized flaps. The source of bone graft does not seem to primarily influence the success of the outcome.

骨原発悪性腫ようにおける患肢温存治療 放射線照射部位への自家骨移植

Correlation between the dosage of preoperative irradiation and the successful methods of bone graft were observed radiologically in nine patients with limb salvage procedures for malignant bone tumors. As radiotherapy, four patients were treated with around 30 Gy of irradiation and the other with more than 60 Gy of irradiation. For reconstruction of the skeletal defect following the resection of tumors, conventional or vascularized bone grafts were performed in six and three patients, respectively.All of four patients who received around 30 Gy of irradiation got successful bone grafts. In contrast, three out of five patients who underwent more than 60 Gy of irradiation failed in bone grafts, except for two successful results obtained by vascularized bone grafts.It is suggested that the optimal dose of preoperative irradiation to get successful bone graft is around 30 Gy for limb salvage procedure.

Repair of Segmental Defects of the Tibia with Cancellous Bone Grafts Augmented with Human Bone Morphogenetic Protein

Human bone morphogenetic protein (hBMP) is a bone cell differentiation-inducing factor. Six patients with traumatic segmental three- to 17-cm tibial defects developed solid union by implantation of hBMP and autogeneic cancellous grafts and stabilization. There were no allergic, infectious, or surgical complications. If hBMP augmentation in biodegradable delivery systems can be established by a prospective, randomized, double-blind investigation, the incidence of successful bone graft operations for treatment of large segmental defects would be measurably improved.