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Bone Grafts and Bone Graft Substitutes

  • Reference work entry
  • First Online:
Handbook of Spine Technology

Abstract

Bone grafting has been uniquely practiced since the early 1600s. Historically, bone grafting includes autologous bone, a variety of allograft bone, and synthetic based-materials utilized in surgical interventions to treat spinal diseases or fractures. One of the most common uses of bone grafts is in spinal surgery to promote fusion between two functional vertebral segments. During a spinal surgery procedure wherein host bone is prepared, bone grafts are employed to optimize the biological environment to augment healing of the bony tissues for a desired outcome of a solid union – successful spinal fusion. State-of-the art bone graft materials have been effectively used to enhance bone induction and healing, providing more predictable outcomes resulting in spinal fusion.

Autograft has traditionally been recognized as the gold standard for bone grafts. However, differing grafting modalities are currently replacing autograft as the standard of care due to patient donor site morbidity, limitation to autograft, and the cessation of training young surgeons in the technique of autograft harvest. This has led to the research and development of various next-generation osteoconductive, osteoinductive, and osteogenic materials. In this chapter, various options to augment or replace autograft bone have been reviewed. Current options for spinal fusion discussed herein include autografts, allografts, and osteoconductive, osteoinductive, osteogenic, and osteostimulative materials. Further, novel materials such as engineered bioactive glass and peptide-based materials are presented. Choice of graft material with consideration of anatomical location, surgical application, spinal fusion technique, and patient characteristics will optimize bone healing and clinical outcomes.

The co-first authors Jae Hyuk Yang and Juliane D. Glaeser shares an equal contribution of this chapter.

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Abbreviations

AATB:

American Association of Tissue Bank

ABM:

Anorganic bone matrix

ACDF:

Anterior cervical discectomy and fusion

ACS:

Absorbable collage sponge, used as a carrier

AIBG:

Autologous iliac bone graft

ALIF:

Anterior lumbar interbody fusion

Allograft:

Graft derived from unrelated human donor and transplanted to another person/patient, cadaver via bone bank; live donor patients undergoing removal, i.e., hip replacement

APC, PRP:

Autologous platelet concentrate, serum derived from patient himself is concentrated via centrifugation (contains cytokines, growth factors; theorized to promote fusion)

Autograft, Autologous:

Bone harvested from patient self from one site of the body and implant to another site of same patient

BAG, BG:

Bioactive glass, a ceramic, biologically compatible synthetic material of crystalline components

BCG:

Biocompatible glass

BCP:

Biphasic calcium phosphate

BIC:

Bone-implant contact

BMA:

Bone marrow aspirate

BMC:

Bone marrow concentrate

BMP, rhBMP-2, rhBMP-7:

Bone morphogenetic protein, recombinant human bone morphogenetic protein

βTCP, β-TCP:

Beta-tricalcium phosphate

Cage:

Cages are cylindrical or square-shaped devices usually threaded. Used as instrumentation/fixation and to hold graft material in a surgical site, employed for interbody fusion, i.e., LT-Cage

Cell-based:

Bone grafts with viable cells preserved or substitutes wherein cells are added

CGTP:

Current Good Tissue Practice

CHO:

Chinese hamster ovary (used to derive rhBMP-2)

Collagen Carrier:

ACS, bovine type I collagen matrix

CS:

Calcium sulfate, synthetic ceramic material composed of calcium-sulfate (1:1)

DBM powder:

Demineralized bone matrix powder (human derived)

DBM, hDBM:

Demineralized bone matrix (allograft), bone powder (allograft), hDBM (human derived)

DBM-based product:

Demineralized bone matrix-based product, DBM powder (human derived) mixed with other material substances, or carriers

DFBA:

Freeze-dried bone allograft

E.BMP, E.BMP-2:

Escherichia coli-derived BMP-2 (used to derive rhBMP-2)

ECM:

Extracellular matrix

Enhancer:

Acts to add properties of osteogenicity or osteoinductivity to a graft material

Extender:

Bone graft extender, osteoconductive material, compounds, scaffolds added to other grafting materials (ideally inductive or osteogenic), to increase the volume of graft. May add structural support

FDA CFR:

Code of Federal Regulations

FDA, US-FDA:

Food and Drug Administration, US FDA

Growth factors/growth Differentiation factors:

BMP, rhBMP-2, rhBMP-7, bone morphogenetic protein, recombinant human bone morphogenetic protein

GvHD:

Graft-versus-host disease

h:

Human-derived or human-like version

HA:

Hydroxyapatite, calcium-containing porous crystal, accounts for a majority of bone natural mineral component

HCO:

Bicarbonate (Bae to review)

HCT/P:

Human cell and tissue product

ICBG:

Iliac crest bone graft, autograft – bone morsels harvested from iliac crest

ISO:

International Organization for Standardization

LBG, LAG:

Local bone graft, local autograft – bone morsels harvested from the surgical dissection site

LLIF:

Lateral lumbar interbody fusion

MED:

Minimally effective dose

MIS:

Minimally Invasive Surgery

MRI:

Magnetic resonance imaging

MSC:

Mesenchymal stem cell

ncHA:

Nanocrystal hydroxyapatite

OIF:

Osteoinductive factor

OLIF:

Oblique lumbar interbody fusion

Osteoconductive:

Provides structural scaffolding upon which matrix-producing cells deposit new bone

Osteogenic:

Presence of osteoblast precursor cells that contribute to new bone growth

Osteoinductive:

Presence of molecular growth factors that stimulate precursors cells to migrate to graft site, mature into osteoid-producing cells, increase production of bone matrix

PEEK:

Polyetheretherketone synthetic material, hydrophobic material to which cells have a limited ability to bond (polyaryletherketone family colorless organic thermoplastic polymer), used to fabricate spinal devices such as cages

Peptides/growth factors/growth differentiation factors:

BMP, rhBMP-2, rhBMP-7 (OP-1 osteogenic protein), bone morphogenetic protein, recombinant human bone morphogenetic protein

rh:

Recombinant human form

PLF:

Posterolateral fusion

PLIF:

Posterior lumbar interbody fusion

PLLF:

Posterolateral lumbar fusion

PRP:

Platelet-rich plasma (PRP) platelets (thought to have target growth factors) from patients’ own blood

Segment, spinal segment:

Spinal segment of the spine includes a superior vertebral body, disc, inferior vertebral body. Upper vertebral body, target vertebral body, lower vertebral body

Substitute:

Graft substitute used instead of autologous bone grafting

TCP:

Tricalcium phosphate, synthetic ceramic material composed of calcium and phosphate (3:2)

TI:

Titanium (Ti)

TLIF:

Transforaminal lumbar interbody fusion

TNF:

Tumor necrosis factor

UDI:

FDA rule that requires medical device manufacturers to update products with a unique device identifier

Xenograft:

Grafted from one species to another species (i.e., bovine to human; porcine to human)

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Acknowledgments

Authors thank Samantha Thordarson, BS, for her editorial comments.

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Authors and Affiliations

  1. Surgery, Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA

    Jae Hyuk Yang, Juliane D. Glaeser, Linda E. A. Kanim, Carmen Y. Battles & Hyun W. Bae

  2. Korea University Guro Hospital, Seoul, South Korea

    Jae Hyuk Yang

  3. Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA

    Juliane D. Glaeser, Linda E. A. Kanim & Hyun W. Bae

  4. Department of Surgery, Cedars-Sinai Spine Center, Los Angeles, CA, USA

    Juliane D. Glaeser, Linda E. A. Kanim, Carmen Y. Battles & Hyun W. Bae

  5. Chemical Engineering, Prosidyan, Warren, NJ, USA

    Shrikar Bondre

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  1. Jae Hyuk Yang
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Correspondence to Hyun W. Bae .

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  1. Neuroscience Institute, Allegheny Health Network, Drexel University, Allegheny General Hospital Campus, Pittsburgh, PA, USA

    Boyle C. Cheng

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  1. Co-founder & Treasurer, I.M.S. Society, Easten, MA, USA

    Hassan Serhan

  2. Department of Orthopedics, Boston University Medical Center, Boston, MA, USA

    Tony Tannoury

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Yang, J.H., Glaeser, J.D., Kanim, L.E.A., Battles, C.Y., Bondre, S., Bae, H.W. (2021). Bone Grafts and Bone Graft Substitutes. In: Cheng, B.C. (eds) Handbook of Spine Technology. Springer, Cham. https://doi.org/10.1007/978-3-319-44424-6_36

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