Bone grafting is a surgical procedure by which new bone or a replacement material is placed into spaces between or around broken bone (fractures) or holes in bone (defects) to aid in healing.
Surgeons harvesting a sample of material for bone grafting.
Bone grafting is used to repair bone fractures that are extremely complex, pose a significant risk to the patient, or fail to heal properly. Bone graft is also used to help fusion between vertebrae, to correct deformities, or to provide structural support for fractures of the spine. In addition to fracture repair, bone graft is used to repair defects in bone caused by birth defects, traumatic injury, or surgery for bone cancer.
Bone is composed of a matrix mainly made up of a protein called collagen. It is strengthened by deposits of calcium and phosphate salts, called hydroxyapatite. Within and around this matrix are located four types of bone cells. Osteoblasts produce the bone matrix. Osteocytes are mature osteoblasts that serve to maintain the bone. Osteoclasts break down and remove bone tissue. Bone lining cells cover bone surfaces. Together, these four types of cells are responsible for building the bone matrix, maintaining it, and remodeling the bone as needed.
There are three ways in which a bone graft can help repair a defect. The first is called osteogenesis, the formation of new bone by the cells contained within the graft. The second is osteoinduction, a chemical process in which molecules contained within the graft (bone morphogenetic proteins) convert the patient's cells into cells that are capable of forming bone. The third is osteoconduction, a physical effect by which the matrix of the graft forms a scaffold on which cells in the recipient are able to form new bone.
New bone for grafting can be obtained from other bones in the patient's own body (e.g., hip bones or ribs), called autograft, or from bone taken from other people that is frozen and stored in tissue banks, called allograft. A variety of natural and synthetic replacement materials are also used instead of bone, including collagen, the protein substance of the white fibers of the skin, bone, and connective tissues; polymers, such as silicone and some acrylics; hydroxyapatite; calcium sulfate; and ceramics. A new material, called resorbable polymeric grafts, is also being studied. These resorbable grafts provide a structure for new bone to grow on; the grafts then slowly dissolve, leaving only the new bone behind.
To place the graft, the surgeon makes an incision in the skin over the bone defect and shapes the bone graft or replacementmaterial to fit into the defect. After the graft is placed into the defect, it is held in place with pins, plates, or screws. The incision is closed with stitches and a splint or cast is used to prevent movement of the bones while healing.
The timerequired for convalescence for fractures or spinal fusion may vary from one to 10 days, and vigorous exercise may be limited for up to three months.
Most bone grafts are successful in helping the bone defect to heal. The extent of recovery will depend on the size of the defect and the condition of the bone surrounding the graft at the time of surgery. Severe defects may take some time to heal and may require further attention after the initial graft. In one study of over 1,000 patients who received very large allografts after surgery for bone cancer, researchers found that approximately 85% of the patients were able to return to work or normal physical activities without using crutches. However, about 25% of these patients required a second operation, because the first did not heal properly. Less severe bone defects, though, should heal completely without serious complications.
The risks for any surgical procedure requiring anesthesia include reactions to the medications and breathing problems. The risks for any surgical procedure include bleeding and infection.
The drawbacks of autografts include: the additional surgical and anesthesia time (typically 30 minutes per procedure) to obtain, or harvest, the bone for grafting; added costs of the additional surgery; pain and infection that might occur at the site from which the graft is taken; and the relatively small amount of bone that is available for grafting.
The drawbacks of allografts include: variability between lots, since the bone is harvested from a variety of donors; the bone may take longer to incorporate with the host bone than an autograft would; the graft may be less effective than an autograft; and there is the possibility of transferring diseases to the patient. Other complications may result from the immune response mounted by the patient's immune system against the grafted bone tissue. With the use of antirejection agents (drugs to combat rejection of grafted bone tissue), immune rejection is less of a problem.