Bone

Graft
Substitutes
Moderators:
Prof. R.M.Shenoy

Presenter:
Dr. Neeraj
Date:01/12/09

INTRODUCTION

The treatment of delayed unions,

malunions, and nonunions
requiresrestoration of
alignment, stable fixation, and in
many casesadjunctive measures
such as bone-grafting or use
ofbone-graftsubstitutes.

Contd...

There are two processes, osteoconduction

and osteoinduction based on which termed as
osteoconductive and osteoinductive material.
Osteoconductive material : Acts as a
scaffold, supporting ingrowth of capillaries,
perivascular tissue and osteoprogenitor cells
from the recipient bed.
Osteoinductive material :Induce
nondifferentiated stem cells or
osteoprogenitor cells to differentiate into
osteoblasts.

BONE GRAFT
CLASSIFICATION SYSTEM
Modified from Laurencin et
al - 2006 Allogro,
Allograft
Osteoconduct
based

Ceramic
based

Polymer
based
Factor based

ive
(Natural)
Osteoconduct
ive
(Synthetic)

OrthoBlast

Osteoconduct
ive
(synthetic)
Osteoinductiv

Cortoss,
OPLA, Immix

Osteograf,
Norian SRS,
ProOsteon,
Osteoset

TGF-b, PDGF,

ALLOGRAFT BASED
SUBSTITUTES

Advantages : Ready availability in various

shapes and sizes and avoidance of donorsite morbidity.

Disadvantages :
>Concerns about the transmission of bloodborne diseases.
>Freezing and irradiation affect the process
of graft incorporation and structural
strength.

Contd

Demineralizedbone matrix, morselized

and cancellouschips, corticocancellous
and cortical gratfs, and osteochondral
andwhole- bonesegments.
DEMINERALIZED BONE MATRIX : The
desired factors and proteins removed
by using a demineralizing agent such
as hydrochloric acid . > Acts as an
osteoconductive material and possibly a
weak osteoinductive material.

FACTOR BASED BONE

GRAFT SUBSTITUTES

Growth factors : Shown to influence

cellular proliferation, differentiation,

chemotaxis, and protein synthesis. Acts
as osteoinductive material.
> Includes Bone morphogenic
protein(BMP- esp. BMP 2&7-belongs to
TGF beta family), Fibroblast Growth
Factor, Platelet-derived Growth
Factor,Insulin like growth factor.

Contd

Growth factors are proteins that serve as

signaling agents for cells.
Three types of action
>Autocrine
>Paracrine
>Endocrine
>Growth factor binds to target cell receptor
induces intracellular signal transduction
system ultimately reaches nucleus
biological response.

Contd

The specifis growth factor (ligand)

binds to the extracellular domain of
the receptor, and the intracellular
domain of the receptor activates the
signal-transduction system. A
transcription factor, an intracellular
protein, is activated as part of this
process. The transcription factor
migrates to the nucleus, binds to the
nuclear DNA, and induces the

Diagram

demonstrating the mechanism by which

growth factors influence cell activity

Diagram demonstrating the

mechanism by which growth factors

CELL BASED BONE GRAFT

SUBSTITUTES

Bone marrow : Stimulates bone

formation in skeletal defects and nonunions

>Major advantage : Performed
percutaneously, without almost any patient
morbidity.
Mesenchymal stem cells seeded onto
bioactive ceramics conditioned to induce
differentiation to osteoblasts.
> Proposed for use in bone repair prosthetic
coatings.

CERAMIC BASED BONE

GRAFT SUBSTITUTES

Calcium phosphate:
An injectable calcium
paste
Highest mechanical
compression strength
of any of the
oseteoconductive
bone-graft substitutes
95 percent resorbed
in 26 to 86 weeks

Contd

Calcium
Phosphate
Coatings:
Wellboundtometal
implants.
Increased
osteointegrativeability
ofscrews.
Increasefixation

HA coated external fixation pin

HA coated AO/ASIF cortical bone s

HA coated AO/ASIF cancellous bon

Contd
Coralline hydroxyapatite
: Produced from marine
coral exoskeleton.
> Have pore structures
resembling cancellous
bone .

Contd

High power photograph of

cancellous bone
demonstrating its
interporous structure

High power photograph of

Interpore, a coralline
hydroxyapatite

Contd
Calcium sulfate : First introduced
as plaster of paris in 1892.
First used as a bone filler in the
early 1900s
Calcium sulfate resorbs in 4 to 12
weeks, making it the quickest of any
of the osteoconductive products
currently available

Contd
Tricalcium phosphate (TCP) : Fast
resorbing ceramic that undergoes
partial conversion to HA once
implanted into the body
Bioactive glass (bioglass) :
Biologically active silicate-based glass.
Collagen-based matrices :
Xenografts consisting of sponge like
strips of bovine collagen combined with
hydroxyapatite

POLYMER BASED BONE

GRAFT SUBSTITUTES
>Natural polymers
>Synthetic polymers.
Divided further into
>Degradable
>Nondegradable

FUTURE DIRECTIONS

Genetic engineering
>New bone via gene therapy in
animals.
>The vehicle for gene delivery can be
either viral (adenovirus, retrovirus) or
non-viral (liposomes, DNA-ligand
complexes).
>The gene can be selectively
transferred to a targeted cell
(osteoblast, fibroblasts) at the bone

SUMMARY

Osteoconductive + Osteoinductive materials

= Osteogenic material
Allograft : DBM
Factor based
Cell based
Ceramic based: Ca Phosphate, Ca Sulphate,
Hydroxyapetite - G Bone , Tricalcium
phosphate, Bioactive glass.
Polymer based
Latest studies

Thank
you