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Graft Substitutes
Dr. Rajat Kumar Mathur
Fellow Arthroplasty
Sunshine Hospitals
Cancellous
Cortical
Free vascular transfers
Muscle pedicle bone graft
Bone marrow aspirate
Autogenous Cancellous
Bone Grafts
Three dimensional scaffold
(osteoconductive)
Osteocytes and stem cells (osteogenic)
A small quantity of growth factors
(osteoinductive)ss
CREEPING SUBSTITUION: process by
which graft is replaced by new bone (I
year)
Used in boneloss: depressed tibial
plateau fractures, revision hip and
knee arthroplasty
Creeping Substituition
Creeping substitution, the process of
bone remodeling by osteoclastic
resorption and creation of new
vascular channels with osteoblastic
bone formation resulting in new
haversian systems, is the method by
which strong cortical bone is formed
from grafted material.
Sources:
Ribs
Fibula
Crest of the ilium (also called as
tricortical graft)
It can be of two types:
Conventinal nov vascular
Vascularised bone graft
Vascular
It has immediately
restored blood
supply
More viable, more
survival of
osteocytes
Can be used in
defects upto 12 cm
or even in
inadequate host.
Advantages of RIA
Provides enriched osteogenesis
Decrease intramedullary canal pressure
Minimal risk of fat embolism
Potential source of autologous bone,
mesenchymal cells and bone growth
factors.
Complications of RIA
Perforation of the meduallary canal
which may require prophylactic
intramedullary fixation.
Significant blood loss
existing callus
Bone graft is taken by elevating the
osteoperiosteal flaps.
fracture site
The mobility at the fracture site should
be minimal
The fracture should have an acceptable
alignment
The knee joint should have a good
range of motion
Allograft
The morbidity and limited amount of
autogenic
bone graft calls for a need of allogenic bone
Graft.
They are indicated in
1.Children
Allograft types
Cortical
Frozen
Freeze dried
Cancellous
Frozen
Freeze dried
Bone Allografts
Cancellous or cortical
Plentiful supply
Limited infection risk (varies based on
processing method)
Provide osteoconductive scaffold
May provide structural support
Bone Allografts
Freeze-dried
Even less antigenic
Time to test for diseases
Strictly regulated by FDA
Can be stored at room temperature up
to 5 years
Mechanical properties degrade
Bone Bank
It is a facilitiy to provide safe and
efficient allograft material.
Hosts should be screened for :
infections,malignancies(except for
basal cell carcinoma of the skin),
collagen vascular diseases,
metabolic bone diseases and
presence of toxins.
Technique
Bone is collected in clean and unsterile
environment.
It is nibbled to remove the articular
cartilage.
It can be sterilized by irradiation, ethylene
oxide or strong acid( 0.55 % HCl)
It is subject to deep freeze upto -70 to -80
degrees celcius(frozen)
Freeze drying involves removal of water
and vacuum packaging of the tissue
Demineralized Bone
Matrix
Prepared from cadaveric human bone
Acid extraction of bone leaving
Collagen(type 1)
Noncollagenous proteins
Bone growth factors
BMP quantity extremely low and variable
Sterilized which
availability of BMP
may
decrease
the
Demineralized Bone
Matrix
Demineralized Bone
Matrix
Growth factor activity varies between
tissue banks and between batches
While they may offer some
osteoinductive potential because of
available growth factors, they mainly
act as an osteoconductive agents
Graft Incorporation
Hematoma formation
Release of cytokines and growth
factors
Graft Incorporation
Hematoma formation
Release of cytokines and growth
factors
Inflammation
Development of fibrovascular tissue
(18 hours)
Graft Incorporation
Hematoma formation
Release of cytokines and growth
factors
Inflammation
Development of fibrovascular tissue
Vascular ingrowth
Often extending Haversian canals
Graft Incorporation
Hematoma formation
Release of cytokines and growth factors
Inflammation
Development of fibrovascular tissue(18
hours)
Vascular ingrowth
Often extending Haversian canals (10
-12 days)
Graft Incorporation
Hematoma formation
Release of cytokines and growth factors
Inflammation
Development of fibrovascular tissue
Vascular ingrowth
Often extending Haversian canals
Graft Incorporation
Cortical allograft
strut graft placed
next to cortex of
host
After 4 years of
incorporation
Enhancer
To improve success of autogenous bone
graft
Substitute
To replace autogenous bone graft
Classification
Laurencin et al,
classification
Allograft based
Factor based
Cell based
Ceramic based
Polymer based
Composite
Allograft based
Includes allograft bone used alone or
in combination with other materials
Available as demineralised bone
matrix
Factor based
Involves natural or recombinant factors
Factors responsible for differentiation of
progenitor cells and regulation of
activities
Mechanism of action: based mostly on
activation of protein kinase
Combined and simultaneous activity of
various factors controlled resorption and
formation of new bone
BMP 2 and 7
BMP 2
Acts as a disulfide
linked homodimer
and helps in bone
and cartilage
formation
It is a candidate
as retinoid
mediator and
helps osteoblastic
differentiation
BMP 7
It plays a key role in
osteoblastic
differentiation
It induces the
prodution of SMAD 1
It plays a key role in
renal development
and repair
Bone Morphogenetic
Proteins
Produced by recombinant
technology
Two most extensively studied and
commercially available
BMP-2 (Infuse) Medtronics
BMP-7 (OP-1)
Stryker ss
BMP-2 and BMP-7 are water soluble
and require a carrier to remain in the
operative area to be effective
BESTT Study Group, et al. J Bone Joint Surg 84A: 2123, 2002.
Results
44% reduction in risk of
nonunion/delayed union
with high dose BMP-2
Significantly faster fracture
healing
Significantly fewer
invasive interventions
hardware failures
infections
BESTT Study Group, et al. J Bone Joint Surg 84A: 2123, 2002.
Cell Based
Based on in vitro differentiation of
mesenchymal stem cells to
osteoblastic lineage
They have been used along with
ceramics
Proposed to be used in bone repair
prosthetic setting
Ceramic based
About 60% BGS involves ceramicsalone or in combination
Eg : calcium sulfate, calcium
phosphate, bioactive glass
Primary inorganic componet is
calcium hyroxyapatite
Property of osteointegration, newly
formed mineralised tissue forms
intimate bond with implant materials
Calcium Phosphate
Ceramics
Calcium Phosphat
Ceramics
It is produced by the process of
Calcium
Sulfate(plaster of
paris)
Osteoconductive void filler
Low compressive strength no structural
support
Rapidly and complete resorption
May be used as a autogenous graft extender
- Available from numerous companies
- Osteoset, Calceon 6, Bone Blast, etc.
Calcium Sulfate
Pellets
Pellet injectors
Bead kits
Allows addition of
antibiotics
Injectable
May be used to augment
screw purchase
Combination of DMB and
calcium sulfate
Hydroxyapatite(HA)
It is a slowly resorbing compound of
calcium phosphate
Source :synthetic and animal
Hydrothermal process converts it
from its native coral form to more
stable HA form with pore diameters
between 200 to 400 micron
Hydroxyapati
te
Interconnected porous
structure closely
resembles the porosity of
human cancellous bone
Cancellous Bone
Coralline hydroxyapatite
Hydroxyapatite
Interpore(Interpore International,
Irvine,CA):first calcium phosphate based BGS
approved by FDA
Marketed as ProOsteon by Interpore Cross
Available in various size blocks & granules
ProOsteon 500
Very slow resorption
ProOsteon 500 R
Only a thin layer of HA
Faster resorption
Hydroxyapatite:indications
Valgus instability following lateral
tibial plateau fracture
Varus instability following medial
condyle fracture of tibia
Articular incongruence of 10 mm or
more
Translation of major condylar
fragment of more than 5mm
Tricalcium Phosphate(TCP)
TCP composition is similar to calcium
and phosphate phase of human bone
and has porous nature
TCP undergoes partial resorption and
some of it may be converted to HA
once implanted in the human body
Complete resorption at 6 months
Tricalcium Phosphate
Wet compressive strength slightly less
than cancellous bone
Available as blocks, wedges, and granules
Numerous tradenames
Vitoss (Orthovita)
ChronOS (Synthes)
Conduit (DePuy)
Cellplex TCP (Wright Medical)
Various Theri__ names (Therics)
Calcium Phosphate
Cements(CPC)
CPC is used as void filler in defects
It consists of inorganic calcium and
phosphate combined to form an
injectable paste
Polymer based
Can be divided: natural/synthetic
Further divided into:
biodegradable/non biodegradable
eg: Healoss(depuy)-natural
Eg :Cortoss- injectable resin based
product
Eg : Rhakoss(Orthovita)
Collagen Based
Matrices
Highly purified Type 1
bovine dermal fibrillar
collagen
Bone marrow is added to
provide bone forming cells
Collagraft (Zimmer)
Collagen / HA / Tricalcium
phosphate
Healos (Depuy)
Collagen / HA
Composite graft
In this two or more type of bone graft
substitutes combined together
So that osteoconductive and
osteoinductive properties of different
BGS, is combined
Calcium Phosphate-Collagen
Composite
Collagen provides binding sites for
matrix proteins
Type I and III is added to HA,TCP and
autologous bone marrow to form a
graft material
Although no structural support but
augments frature healing