Types Of Bone Graft Materials Research Articles

Long-Term Histopathologic Evaluation of Bioactive Glass and Human-Derived Graft Materials in Macaca fascicularis Mandibular Ridge Reconstruction

To evaluate the long-term clinical and histologic characteristics of alveolar ridge bone regenerated by 2 different types of bone graft materials in a Macaca fascicularis (nonhuman primate) species animal. Bilateral osseous defects created in edentulous mandibular alveolar ridges in a nonhuman primate were grafted with bioactive glass (alloplast) on 1 side, and with human demineralized bone matrix (xenograft) on the contralateral side, with each covered by a dermomatrix barrier membrane before mucoperiosteal tissue flap closure and suturing. At 4 years posttreatment, surgical re-entry was performed, and bone core biopsies were obtained from each of the grafted edentulous alveolar ridges, placed in 10% formalin, and processed for light microscopic analysis. Normal alveolar bone was clinically noted at all sites on surgical re-entry at 4 years posttreatment, and mature cortical and cancellous bone formation was histologically observed with both types of bone graft materials. Residual bioactive glass particles (histologic sections) were found embedded in close contact with lamellar bone where bioactive glass was grafted. Xenograft-treated sites yielded remnants of residual human demineralized bone matrix particles and no foreign body reactions or inflammation. Numerous particles of nonresorbed bioactive glass graft material, but not human demineralized bone matrix, were found in 4-year posttreatment bone core biopsies of regenerated bone in M. fascicularis mandibular alveolar ridge reconstructions.

50 Years Ago in CORR: Physiologic Basis of Bone-Graft Surgery Marshall R. Urist MD CORR 1953;1:207–216

Bone graft surgery has a long and at times controversial history. According to Bick [1] bone grafts were vaguely noted in early Hindu, Egyptian, and Greek sources, but the first clear description was from 1682, when Jobi Meekren replaced a skull defect in a soldier with pieces of a dog’s skull. John Hunter experimented with various sorts of grafts, but the major debates began in the late 1800s with the experiments of Ollier, Duhamel, and others [4]. Lexer, in this month’s republished Classic from 1908 [5], reported success in a number of patients using fresh allografts; he took grafts mostly from elderly patients undergoing amputations for dry gangrene from vascular disease (evidently quite common at the time). However, Bick suggests most clinical cases were unsuccessful until about 1910 [1]. Most of the subsequent successes appear to have been autografts taken from the same patient. Marshall Urist, the second Editor-in-Chief of Clinical Orthopaedics and Related Research (1966–1993), had a particular life-long interest in bone grafting. In the article we highlight this month [8] he reviewed the experimental evidence on the various mechanisms influencing success and failure of autografts, allografts (homografts), and zenografts (heterografts or grafts from other species). Urist noted “at least 9 different types of bone-graft materials…in clinical use…(1) osteoperiosteal bone, (2) autogenous cancellous bone, (3) autogenous cortical bone, (4) boiled autogenous cancellous or cortical bone, (5) homogenous fresh cancellous or compact bone, (6) frozen or lyophilized (frozen-drive) homogenous cancellous or cortical bone, (7) fresh or frozen heterogenous (calf) bone, (8) chemically preserved homogenous cancellous or cortical bone, and (9) homogenous or heterogenous embryonic bone” [8]. In our symposium this month, one can find an array of studies on several of these sorts of grafts, most of which are still in use or at least studied in various places in the world. Urist [8] emphasized the importance of “induction”: “the physical-chemical effect which one tissue exerts upon another in contact with it.” The literature he cited (including some of his own) strongly supported such a concept, but he noted, “Induction…appears to be a more complex mechanism than a direct humoral effect of a diffusible chemical substance…Isolation or characterization of ‘inductor substances’ from extracts has not been satisfactorily accomplished…and may not be possible until further knowledge of the process of endochondral ossification…and endosteal bone formation…has been gained from experiments…” However, through a variety of experiments [2, 3, 7, 9, 12, 14–16], Dr. Urist eventually did exactly that: isolate and characterize the inductor substance in bone graft [6, 10, 11, 13, 14, 17]. What all of these grafts appear to have in common is this inducing protein—“bone morphogenetic protein” or BMP—one which is remarkably conserved across species. There is a vast literature on bone grafting: using the search term “graft[ti] AND bone[ti]” in PubMed yielded 3580 articles, and these are obviously do not reflect the entire literature. While this month’s symposium reflects crucial ongoing research to identify the best ways to use bone grafts, autografts and allografts are remarkably safe and effective for many applications, thanks to the efforts of hundreds of individuals exploring the techniques of procuring, processing, and applying these grafts.

The effects of ketorolac injected via patient controlled analgesia postoperatively on spinal fusion.

Lumbar spinal fusions have been performed for spinal stability, pain relief and improved function in spinal stenosis, scoliosis, spinal fractures, infectious conditions and other lumbar spinal problems. The success of lumbar spinal fusion depends on multifactors, such as types of bone graft materials, levels and numbers of fusion, spinal instrumentation, electrical stimulation, smoking and some drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs). From January 2000 to December 2001, 88 consecutive patients, who were diagnosed with spinal stenosis or spondylolisthesis, were retrospectively enrolled in this study. One surgeon performed all 88 posterolateral spinal fusions with instrumentation and autoiliac bone graft. The patients were divided into two groups. The first group (n=30) was infused with ketorolac and fentanyl intravenously via patient controlled analgesia (PCA) postoperatively and the second group (n=58) was infused only with fentanyl. The spinal fusion rates and clinical outcomes of the two groups were compared. The incidence of incomplete union or nonunion was much higher in the ketorolac group, and the relative risk was approximately 6 times higher than control group (odds ratio: 5.64). The clinical outcomes, which were checked at least 1 year after surgery, showed strong correlations with the spinal fusion status. The control group (93.1%) showed significantly better clinical results than the ketorolac group (77.6%). Smoking had no effect on the spinal fusion outcome in this study. Even though the use of ketorolac after spinal fusion can reduce the need for morphine, thereby decreasing morphine related complications, ketorolac used via PCA at the immediate postoperative state inhibits spinal fusion resulting in a poorer clinical outcome. Therefore, NSAIDs such as ketorolac, should be avoided after posterolateral spinal fusion.

Bone graft substitutes for spinal fusion

Arthrodesis of the spine is the preferred surgical treatment for various types of spinal pathology, including deformity, instability and degenerative diseases. In addition to numerous systemic risk factors, such as advanced age of the patient, concomitant use of tobacco or other drugs, and metabolic comorbidities (eg, diabetes or osteoporosis) that are all known to inhibit bone formation, successful fusion of the spine may also be limited by structural instability, improper preparation of host bone, poor vascularity and other local considerations. The presence of any of these detrimental conditions may diminish the osteogenic potential of the fusion site and contribute to the development of a pseudarthrosis. In order to optimize the biological environment of the spinal segment to be fused, in the vast majority of cases some type of bone graft material is employed to enhance bone healing and reduce the risk of nonunion. As a result, arthrodesis of the spinal column is clearly influenced by the cellular, biochemical and mechanical properties of the bone graft substance that is implanted.