Bone repair and Grafting

Dr.Sudipta Bera
PDT(Mch Plastic Surgery)
SSKM & IPGMER
 Mechanism of Bone repair
1. Primary bone repair
2. Secondary (callus) bone repair
3. Bone remodeling
Osteoinduction:
Osteoconduction :
Osseointegration:
Distraction osteogenesis
4.Creeping substitution
• Osteoinduction:
Process by which undifferentiated pluripotent cells are
stimulated to become cells within the osteoblast lineage.
• Osteoconduction : Ability of a material to serve as a
scaffold on to which bone can attach and grow
• Osseointegration: Stable anchorage between bone and
implant that results in a structural and functional
connection between the two
• Distraction osteogenesis: Formation of new bone from the
gradual separation of osteotomized fronts
• Creeping substitution :Process of graft resorption and
replacement of necrotic bone by vascular ingrowths and
new bone formation,
 Variables influencing bone repair
1. Blood supply
2. Age
3. Fracture fixation
4. Local infection, osteomyelitis,irradiation
contracture
 Primary bone repair
• Primary bone repair involves the direct
deposition of woven bone by osteoblasts to
re-establish mechanical continuity between
fracture fragments.
• usually accomplished through rigid internal
fixation.
 Secondary (callus) bone repair

• Fractures left untreated or those that are

treated without rigid fixation heal by
secondary bone repair
• Seen with external or intramedullary fixation
or by sling or cast immobilization.
 Distraction osteogenesis
• Gradual controlled separation of osteotomized
bone results in a “tension stress effect”
leading to angiogenesis and new bone
formation.
• Craniofacial distraction in congenital cases to
cases of craniofacial skeletal deficiency with
tumor, trauma, or iatrogenic-related
etiologies.
 Bone Transfer
Autologous bone Transfer
• Non vascularised cortical and cancellous bone
graft
• Vascularized flap (pedicled or free)

Allogeneic bone grafts

Xenogeneic bone grafts
 Cortical versus Cancellous bone
Cortical Bone
• Limited osteogenic properties ,less osteoconductive and
less osteoinductive .
• Creeping substitution is the main mechanism of cortical
bone graft incorporation
• The incorporation and revascularization of cortical grafts
usually takes 1–2 months
• Provide immediate structural support
• Able to bridge defects up to 12 cm in length.
• Rigid fixation is needed
• Typical grafts sites arise from the fibula, the rib, and the
iliac crest.
 Cancellous bone
• higher osteogenic, osteoinductive, and
osteoconductive properties.
• quickly incorporated and revascularized , usually within
2 weeks.
• Cancellous bone grafts serve as an osteoconductive
substrate to support creeping.
• Indicated to bridge gaps less then 5–6 cm in nonstress-
bearing areas.
• Typical sources are the iliac crest, the cranial diploe,
the upper tibial epiphysis, and the distal radius.
 Indication for bone transfers
• Bone gaps as a result of trauma or comminuted
fractures
• Delayed or nonunion of fractures
• Bony defects after benign or malignant lesion resection
• Reconstruction of functional and contour deficits in the
craniofacial skeleton.
• Arthrodeses, limb-lengthening procedures, and spinal
fusion
• Composite tissue loss
• Bony nonunion,avascular necrosis,osteomyelitis.
 Nonvascularized Graft
1. Ilium
• Most commonly used site for cortico cancellous
bone graft
• A large subcrest corticocancellous graft up to 11
cm, a 6 × 10 cm corticocancellous inner plate,
and an approximately 5 × 8 cm corticocancellous
outer plate can also be harvested.
• Complications:hematoma, hernia, paresthesia of
the lateral femoral cutaneous nerve, broken wires
with bursa formation, and late sponge removal
2.Tibia
• Tibia remains a favorable donor site when
only small amounts of cancellous bone are
needed
3.Fibula
• Fibula is mainly used for mandible
reconstruction, as well as midface and
extremity reconstruction.
4.Greater trochanter
5. olecranon
potential sites of cancellous bone harvest, specifically
when small amounts are needed.
6.Calvarium
Calvarial bone grafts are ideal for calvarial, midfacial,
nasal, and orbital reconstruction.
7.Rib
Advantages of rib grafts are the flexibility of the bone,
which allows for easy bending and wire fixation.
 Vascularized bone flaps
Indications
• Prior irradiation, extensive trauma, or chronic scarring.
• Reduced blood flow to compromised recipient sites
• Utilization of composite tissue flaps including skin, muscle,
and nerves;
• Growth potential when including a growth plate in the
graft
• Segmental defects of greater than 6–8 cm after traumatic
or oncologic bone loss
• Composite tissue loss
• Bony nonunion, avascular necrosis, osteomyelitis or after
biologic failure due to infection, scarring or irradiation
Vascularized iliac transfer
• Based on Deep circumflex iliac vessels or
superficial circumflex iliac vessels.
• Furthermore, a piece of vascularized iliac crest
can be harvested in conjunction with the
anterolateral thigh flap based off the lateral
femoral circumflex system.
Vacularized fibula
• Free fibula transfer is utilized mainly in
mandibular and occasionally in midface
reconstruction as well as for long-bone defects or
nonunions.
• Provides a straight cortical piece of bone up to 30
cm in length. Fasciocutaneous perforators allow
for a skin paddle up to 10 × 20 cm in size.
• Blood supply to the fibula is via the nutrient
artery, a branch of the peroneal artery
 Vascularized scapula

• Based on the lateral or medial border (lateral

or medial scapular osteocutaneouflap)
supplied by the circumflex scapular circulation
• Further be based on an additional branch of
the thoracodorsal system called the angular
branch.
 Vascularized Rib
• Provides a curved, malleable piece of bone up to
30 cm long
• Receives vascular supply through nutrient vessels
and arising from the posterior intercostal vessels
• Periosteal vessels from various surrounding
sources (intercostal perforators from the
thoracodorsal system, the superior epigastric
system, the internal mammary vessels the lateral
thoracic vessels and the thoracoacromial vessels)
 Vacularized calvarium
• useful for unfavorable recipient sites
(irradiated or scarred tissue) as well as in
midface reconstruction.
• Different flap types based off the superficial
and deep temporal system can be useful to
reconstruct facial defects
 Carpal vascularized bone grafts
• Vascularized grafts are applied to treat
scaphoid fractures, pseudarthroses and
Kienbock’s disease.
• Sources of vascularized bone grafts for carpal
pathology include a pedicle from the pisiform,
metacarpal head, proximal second metacarpal
metaphysis, palmar and dorsal radial aspect of
the radial metaphysis or diaphysis of the ulna
or radius.
• Dorsal Radius Grafts
• Medial Femoral Condyle Periosteal or
Corticoperiosteal Flap
 Allogeneic bone grafts
• Taken from different individuals of the same
species.
• Act as a scaffold for ingrowth of recipient
mesenchymal cells which repopulate the donor
by creeping substitution.
• Advantages over autogenous bone grafts include
an unlimited supply, a lack of donor site
morbidity.
• Disadvantages include the lack of osteogenic
properties in prepared allografts as well as the
immunologic response of fresh bone allografts.
 Bone substitutes
• Cement pastes
Calcium phosphates
BoneSource
Norian SRS/CRS
• Osteoactive materials
Bioactive glass (Nova Bone)
DBM.
• Prefabricated polymers
Methylmethacrylate
Medpor
Thank You