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Bone transplant

Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some small or acute fractures can be cured without bone grafting, but the risk is greater for large fractures like compound fractures. Bone generally has the ability to regenerate completely but requires a very small fracture space or some sort of scaffold to do so. Bone grafts may be autologous (bone harvested from the patient's own body, often from the iliac crest), allograft (cadaveric bone usually obtained from a bone bank), or synthetic (often made of hydroxyapatite or other naturally occurring and biocompatible substances) with similar mechanical properties to bone. Most bone grafts are expected to be resorbed and replaced as the natural bone heals over a few months' time. The principles involved in successful bone grafts include osteoconduction (guiding the reparative growth of the natural bone), osteoinduction (encouraging undifferentiated cells to become active osteoblasts), and osteogenesis (living bone cells in the graft material contribute to bone remodeling). Osteogenesis only occurs with autograft tissue and allograft cellular bone matrices.

Osteoconduction is termed as "the property of a material to support tissue ingrowth, osteoprogenitor cell growth, and development for bone formation to occur". In the context of bone grafting it occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone. Osteoblasts from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone. The proper bonding of bioactive chemicals (Beta Tricalcium Phosphate) in implants used in bone grafting surgery allow the promotion of osteoconductivity in the area of a defect.

Osteogenesis occurs when vital osteoblasts originating from the bone graft material contribute to new bone growth along with bone growth generated via the other two mechanisms.

Autologous (or autogenous) bone grafting involves utilizing bone obtained from the same individual receiving the graft. Bone can be harvested from non essential bones, such as from the iliac crest, or more commonly in oral and maxillofacial surgery, from the mandibular symphysis (chin area) or anterior mandibular ramus (the coronoid process); this is particularly true for block grafts, in which a small block of bone is placed whole in the area being grafted. When a block graft will be performed, autogenous bone is the most preferred because there is less risk of the graft rejection because the graft originated from the patient's own body. As indicated in the chart above, such a graft would be osteoinductive and osteogenic, as well as osteoconductive. A negative aspect of autologous grafts is that an additional surgical site is required, in effect adding another potential location for post operative pain and complications. Autologous bone is typically harvested from intra oral sources as the chin or extra oral sources as the iliac crest, the fibula, the ribs, the mandible and even parts of the skull. All bone requires a blood supply in the transplanted site. Depending on where the transplant site is and the size of the graft, an additional blood supply may be required. For these types of grafts, extraction of the part of the periosteum and accompanying blood vessels along with donor bone is required. This kind of graft is known as a vital bone graft. An autograft may also be performed without a solid bony structure, for example, using bone reamed from the anterior superior iliac spine. In this case, there is an osteoinductive and osteogenic action, however, there is no osteoconductive action, as there is no solid bony structure. Chin offers a large amount of cortico cancellous autograft and easy access among all the intraoral sites. It can be easily harvested in the office settings under local anaesthesia on an outpatient basis. Proximity of the donor and recipient sites reduce operative time and cost. Convenient surgical access, low morbidity, elimination of hospital stay, minimal donor site discomfort and avoidance of cutaneous scars are the added advantages.

Dentin bone, made from extracted teeth, comprises more than 85% of tooth structure, the enamel consists of HA mineral and comprises 10% of tooth structure. Dentin is similar to bone in its chemical composition, by volume 70–75% is HA mineral and 20% organic matrix, mostly fibrous type I collagen. Dentin, like bone, may release growth and differentiating factors while being resorbed by osteoclasts. In order to make the dentin graft usable and bacteria free, some companies have developed clinical procedures which include grinding, sorting and cleaning of the teeth for immediate or future use. In Korea, the Korea Tooth Bank performed bio recycling of 38 000 patients' own teeth from January 2009 until October 2012.

Alloplastic grafts may be made from hydroxyapatite, a naturally occurring mineral that is also the main mineral component of bone. They may be made from bioactive glass. Hydroxylapatite is a synthetic bone graft, which is the most used now among other synthetic due to its osteoconduction, hardness and acceptability by bone. Tricalcium phosphate which is now used in combination with hydroxylapatite thus give both effect osteoconduction and resorbability. Polymers such as some microporous grades of PMMA and various other acrylates (such as polyhydroxylethylmethacrylate aka PHEMA), coated with calcium hydroxide for adhesion, are also used as alloplastic grafts for their inhibition of infection and their mechanical resilience and biocompatibility. Calcifying marine algae such as Corallina officinalis have a fluorohydroxyapatitic composition whose structure is similar to human bone and offers gradual resorption, thus it is treated and standardized as "FHA (Fluoro hydroxy apatitic) biomaterial" alloplastic bone grafts.

Artificial bone can be created from ceramics such as calcium phosphates (e. g. hydroxyapatite and tricalcium phosphate), Bioglass and calcium sulfate; all of which are biologically active to different degrees depending on solubility in the physiological environment. These materials can be doped with growth factors, ions such as strontium or mixed with bone marrow aspirate to increase biological activity. Some authors believe this method is inferior to autogenous bone grafting; It can be used to treat posttraumatic bone defects. and other types of coralline xenografts. Coral based xenografts are mainly calcium carbonate (and an important proportion of fluorides, useful in the context of grafting to promote bone development) while natural human bone is made of hydroxyapatite along with calcium phosphate and carbonate: the coral material is thus either transformed industrially into hydroxyapatite through a hydrothermal process, yielding a non resorbable xenograft, or simply the process is omitted and the coralline material remains in its calcium carbonate state for better resorption of the graft by the natural bone. The coral xenograft is then saturated with growth enhancing gels and solutions.

Studies show that xenografts can be used, however they are closely monitored due to their risk of rejection. Zoonoses, which are diseases that arise from the crossing of animal and human tissue, pose a threat to the success of xenograft implantation. Specifically, these diseases are referenced as “xenozoonoses”. They can be categorized in 3 different groups: viral infection, prion mediated infection, and bacterial infection. They have the potential to create a public health risk if they are not closely monitored, as they can cause diseases to be more easily transmissible through different species.

Growth Factor enhanced grafts are produced using recombinant DNA technology. They consist of either Human Growth Factors or Morphogens (Bone Morphogenic Proteins in conjunction with a carrier medium, such as collagen).

The time it takes for an individual to recover depends on the severity of the injury being treated and lasts anywhere from two weeks to two months, with a possibility of vigorous exercise being barred for up to six months. Distal femoral bone graft takes up to six months to heal. People who have been edentulous (without teeth) for a prolonged period may not have enough bone left in the necessary locations. In this case, autologous bone can be taken from the chin, from the pilot holes for the implants, or even from the iliac crest of the pelvis and inserted into the mouth underneath the new implant. Alternatively, exogenous bone can be used: xenograft is the most commonly used, because it offers the advantage of exceptional volume stability over time. Allograft offers the best regeneration quality but has lower volume stability. Often a mix of different kinds of bone grafts is used. In general, bone graft is either used en bloc (such as from the chin or the ascending ramus area of the lower jaw) or particulated, in order to be able to adapt it better to a defect. Dental bone grafting is a specialized oral surgical procedure that has been developed to reestablish lost jawbone. This loss can be a result of dental infection of abscess, periodontal disease, trauma, or the natural process of aging. There are various reasons for replacing lost bone tissue and encouraging natural bone growth, and each technique tackles jawbone defects differently. Reasons that bone grafting might be needed include sinus augmentation, socket preservation, ridge augmentation, or regeneration. There is currently some evidence supporting the use of autologous platelet concentrates (cell fragments containing growth factors to promote tissue regeneration) when bone grafting is used to treat gum disease.

Another common bone graft, which is more substantial than those used for dental implants, is of the fibular shaft. After the segment of the fibular shaft has been removed normal activities such as running and jumping are permitted on the leg with the bone deficit. The grafted, vascularized fibulas have been used to restore skeletal integrity to long bones of limbs in which congenital bone defects exist and to replace segments of bone after trauma or malignant tumor invasion. The periosteum and nutrient artery are generally removed with the piece of bone so that the graft will remain alive and grow when transplanted into the new host site. Once the transplanted bone is secured into its new location it generally restores blood supply to the bone in which it has been attached.

Bone grafts are used in hopes that the defective bone will be healed or will regrow with little to no graft rejection. Furthermore, bone grafts or substitutes are widely used for augmentation of spinal fusion procedures.

As with any procedure, there are risks involved; these include reactions to medicine, problems breathing, bleeding, and infection.

Bone graft procedures consist of more than just the surgery itself. The complete three month total cost of a complex posterolateral lumbar spine fusion bone graft supplemented with graft extenders ranges from a mean of approximately US$33,860 to US$37,227. This price includes all visits in and out of the hospital for three months. Besides the cost of the bone graft itself (ranging from US$250 to US$900) other expenses for the procedure include: outpatient rehabilitation fees (US$5,000 to US$7,000), screws and rods (US$7,500), room and board (US$5,000), operating room (US$3,500), sterile supplies (US$1,100), physical therapy (US$1,000), surgeon's fees (average US$3,500), anesthesiologist fees (approximately US$350 to US$400 per hour), medication charges (US$1,000), and additional fees for services such as medical supplies, diagnostic procedures, equipment use fees, etc.