Terminology

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Bone is a dynamic biological tissue composed of
• • • • • • • • • Graft Vascularized bone graft Autograft Isograft Homograft (allograft) Heterograft (xenograft) Composite graft Implants Bone conduction, induction, integration

metabolically active cells that are integrated into a rigid framework.

Types of bone:
– Histological:
• Immature (Woven, Bundle) • Mature (compact, cancellous)

– Anatomical:
• Flat (skull, scapula, ) • Long (femur, tibia, ) • Sesamoid (patella)

– Healing:
• Membranous (enchondral)  cranial vault, facial bone, • Endochondral  skull base, long bones, ribs • Dual mechanism  mandible, sphenoid, occipital bones

Endochondral Ossification:
• Within cartilage. Interstitial growth. Cells swell, burst, replace by osteocytes with Ca+

Endochondral Ossification:
• Secondary ossification - epiphysis • Articular cartilage and epiphysial plate -

Membranous Ossification:
• Skull, mandible, clavicle. • Fibrous membrane, Os. center, trabeculae

Bone Structure

•65% inorganic (Ca) •35% organic (34% collagen, ..) (1% cells)

Bone cells

Osteocytes
• Derived from:
– Mesenchymal precursor cells – stem cells in bone marrow – osteoprogenitor cells of periosteum

Osteoclasts
• Derived from:
– Hematopoetic stem cells in bone marrow (GM-CFU) that undergo endoreduplication – old theory = fusion of monocytes

Remodeling
• Wolff’s law -“bone formed in response to mechanical load” dynamization/staged destabilizationincreased load can lead to increased bone formation -lamellar bone and marrow cavity form

Type of Fracture Healing
• Direct Healing
– Primary Osteonal Reconstruction
• Contact healing • Gap healing

– Secondary Osteonal Reconstruction

• Indirect Healing • Distraction Osteogenesis

Indirect Bone Healing
Stages: 1) the inflammatory stage (hematoma); 2) the repair stage (soft  hard callus); 3) the late remodeling stage. Types:
- Rigid - Semi-rigid - Non-fusion

Indirect Bone Healing(continue)
Factors affecting healing: I) General… II) Local… Complications: • Malunion – arthritis. • Delayed union. • Non union. • Joint involvement - ankylosis • Bone necrosis – nutrient artery • Pseudoarthrosis

Indications of bone graft
• • • • • Nonunion fractures Highly comminuted fractures Fractures with bone loss When expecting a delayed union Augmentation and normalization of facial contour • Creation of congenitally missing parts of skeleton

Why we do bone graft?
• Osteognesis
– 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

Types of autogenous graft
• Cancellous bone
– metaphyseal regions, increase surface area, 80% porosity

• Cortical bone
– Increase mechanical strength, 10% porosity – frequently corticocancellous

• Osteochondral
– cartilage attached to parent bone

• Composite
– fresh graft added to preserved allograft

• Vascularized grafts
– Vascularized corticocancellous grafts

Sources of autogenous grafts
• • • • • • • • Iliac creast Rib Calverial bone Scapula Radius Vascularized fibula Vascularized rib medial aspect of tibial diaphysis

Healing of autograft:
• Inflammation • Revascularization
– 2x time for Cancellous grafts due to porosity

• Osteoinduction
– decreased with cortical grafts

• Osteoconduction
– decreased with cortical grafts

• Remodeling
– initiated with osteoclasts (vs. osteoblasts) with cortical grafts

Healing of allograft:
• “Creeping substitution” • Basic bone remodeling at graft-host interface
– bone resorption is followed by bone production

• May take years

Bone Graft Substitute (BMP)
Bone Morphogenetic Protein
Only known extracellular protein known to be able to initiate new bone formation

BONE and CARTILAGE
• • • • • • • • • • • • Bone (osteo) vascular mesodermal origin cells and matrix osteoblasts osteocytes osteoclasts periosteum collagen type 1 appositional growth ----compact, cancellous, woven • • • • • • • • • • • • Cartilage (chondro) avascular - requires diffusion mesodermal origin cells and matrix chondroblasts chondrocytes ----*perichondrium collagen types 1,2 appositional growth interstitial growth hyaline, elastic, fibrocartilage

*except articular cartilage

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