Bone Healing and Grafting

Mike Conzemius, DVM, PhD

Diplomate ACVS
 Type of Fracture Healing

• Direct Healing
– Primary Osteonal Reconstruction
• Contact healing
• Gap healing
– Secondary Osteonal Reconstruction
• Indirect Healing
• Distraction Osteogenesis
Primary Osteonal Reconstruction

• Not required for good outcome

• goal for articular fractures
• Not faster; slower early mechanical strength
• Requires absolute stability
• Interfragmentary strain <2%
• Occurs with anatomic alignment of fracture
ends
• Contact healing
• Gap healing (gaps < 1 mm)
 Interfragmentary Strain Theory
• Strain: ε = ∆L/L

• Different tissues have different strain tolerances

before they yield and fail
• Bone = 2%
• Cartilage = 10%
• Granulation Tissue = 100%
 Interfragmentary Strain Theory
• Theory
– pluripotential cells are responsive to the local
deformation within the fracture gap
– bone can form only if the interfragmentary
strain is less than the yield tolerance
• ε = ∆L/L
– if L = 1 mm and desired ε is < 2% than ∆L at
fracture gap must be < 0.02 mm
 Contact Healing
• Cutting cones are formed at ends of osteons
nearest the fracture
• Osteoclasts line the spearhead of the cutting cone
for bone resorption
• Osteoblasts line the rear of the cutting cone for
bone formation
• Resorption and formation occur simultaneously at
50-80 um/day
• Osteonal remodeling across location of cortical
contact of fracture pieces
 Gap Healing
• Gap is filled by blood vessels and loose
connective tissue
• After ~2 weeks vascular supply is established;
osteoblasts deposit lamellar bone in gap
perpendicular to fragment ends
• Cutting cones cross area formed by new osteons
within the gap and those at fracture ends
• Cutting cone cross fracture ends and new bone is
remodeled along lines of load (Wolff’s Law)
 Secondary Osteonal Reconstruction

• Interfragmentary strain is >2% within gap

• Bone cannot form directly within gap
• Bone resorption occurs at fracture end, increasing
size of gap and decreasing strain
• External bony callus stabilizes fragment ends
decreasing strain
• If gap or strain are too large indirect healing
occurs
 Indirect Bone Healing

• Inflammation
• Soft Callus
• Hard Callus
• Remodelling
 Inflammation

• Hemorrhage and hematoma formation

• White cells clean dead bone, debris,
bacteria
• Release of growth factors and other proteins
for angiogenesis and cell differentiation
• Granulation tissue forms
 Soft Callus
• Fibrous tissue forms at periphery where blood
supply is abundant
• Fibrocartilage forms at center where blood supply
is limited
• Increased instability results in increased callus size
• Tissues bridge fracture and decrease
interfragmentary strain
 Hard Callus

• Intramembranous ossification
• bone from fibrous tissue
• Endochondral ossification
• bone from cartilage
 Remodeling

• Wolff’s law
– bone formed in response to mechanical load
• dynamization/staged destabilization-increased load
can lead to increased bone formation
– lamellar bone and marrow cavity form
• Will reduce callus size
• size and location can impede function
• Requires months to years
 Distraction Osteogenesis

• Bone forms under the law of tension stress

• Wolff’s Law occurs even with tension
• Typically intramembranous ossification
 Bone Grafting

• A bone graft is a transfer a living tissue

• An implant is nonviable material placed

into the body
 Why do we graft?

• Osteogenesis
• viable cells contribute to new bone formation
• Osteoinduction
• proteins, factors, hormones are transferred that
modulate host cells
• Osteoconduction
• matrix upon which new bone can be formed
• implants can be osteoconductive
 What do we graft?
• Cancellous bone
• metaphyseal regions, ↑ surface area, 80% porosity
• Cortical bone
• ↑ mechanical strength, 10% porosity
• frequently corticocancellous
• Osteochondral
• cartilage attached to parent bone
• Composite
• fresh graft added to preserved allograft
 What do we graft?

• Implants
– allograft
– bone morphogenic proteins
– recombinant materials
 Where do we get graft?
• Autograft
• same individual, allows for osteogenesis,
osteoinduction and osteoconduction
• Free (10%) or Vascularized (90%)
• Isograft
• same family
• Allograft
• same species
• Xenograft
• different species
 How do I collect “free” grafts?
• Free cancellous and corticocancellous autografts
• metaphyseal regions
– proximal humerus, shaft of ilium, ribs, proximal tibia
• aseptic collection
• can regraft in 8 weeks
• avoid oscillating equipment
• place directly onto host bone-air kills cells
• place into blood soaked sponge-saline kills cells
• be generous
• must be in stable, sterile environment
How do I collect “Vascularized” grafts?

• Vascularized corticocancellous grafts

• medial aspect of tibial diaphysis (mandible defects)
• distal ulna (humeral, femoral defects)
• fibular strut (femoral head osteonecrosis in man)
• Increased cell survival
• Increased patient morbidity
• Generally for large bony defects
• Must be in stable environment
 Allograft Bone Banks
• Any bone, any size
• Cancellous bone chips are popular and effective
• Aseptic collection, storage, administration
• Freeze @ -70°C
• Cost effectiveness vs. autograft morbidity
 How do Autografts Heal?
• Inflammation
• Revascularization
• 2x time for cortical grafts b/c of porosity
• Osteoinduction
• decreased with cortical grafts
• Osteoconduction
• decreased with cortical grafts
• Remodeling
• initiated with osteoclasts (vs. osteoblasts) with cortical grafts
 How do Allografts heal?

• “Creeping substitution”

• Basic bone remodeling at graft-host interface

• bone resorption is followed by bone production

• May take years

 When should we graft?

• Nonunion fractures
• Highly comminuted fractures
• Fractures with bone loss
• When expecting a delayed union
• Arthrodesis
• Limb salvage
• When in doubt?
 Biomaterials as Implants

• Plasma sprayed
– hydroxyapatite, AlO, TiO
• Bioglass, Coral
• Tantalum trabecular metal (Hedrocel)