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A Comparison of Mineral Bone Graft Substitutes for Bone Defects

US Oncology & Hematology, 2011;7(1):38-49 DOI: http://doi.org/10.17925/OHR.2011.07.1.38

Abstract:

Synthetic bone graft substitutes have evolved in response to the downsides of autograft and allograft. This article consolidates the literature regarding the use of mineral bone graft substitutes in the treatment of cavitary bone defects. No level I studies regarding their use in the treatment of bone tumors have been performed, but the clinical studies that have been published indicate that calcium sulfate resorbs too quickly and incites inflammatory reaction and hydroxyapatite resorbs too slowly and blocks new bone ingrowth; tricalcium phosphate and mineral bone graft composites have the biochemical profile that is most compatible with new bone formation. These studies also indicate that mineral bone grafts are safe and may be as effective as other graft options; however, radiographic interpretation may be inaccurate and no evidence exists to suggest that mineral bone graft substitutes are superior to no graft at all. The trauma literature has yielded numerous level I studies that indicate that calcium phosphate cements result in increased metaphyseal fracture stability, but have not yet detected any improvement in healing. Prospective randomized clinical trials in the treatment of bone tumors are necessary to properly delineate the real indications for bone grafting and to demonstrate the graft’s efficacy in this regard.
Keywords: Mineral ceramic bone graft substitute, bone defect, bone void
Disclosure: The authors have no conflicts of interest to declare.
Received: March 22, 2010 Accepted: January 29, 2011
Correspondence: Daniel C Allison, MD, MBA, Assistant Professor and Attending Surgeon, Assistant Director of USC Center for Orthopedic Oncology, University of Southern California and Los Angeles County Medical Center, 1200 N State St, Suite 3900, Los Angeles, CA, 90033. E

Cavitary bone defects are created in the curettage or debridement of benign bone tumors, infections, or low-grade malignancies. In order for new bone to fill these defects, the material that resides within must be osteoconductive, or an appropriate scaffolding that prevents non-osseous (fibrous) tissue infiltration, supports the attachment of new osteoblasts and osteoprogenitor cells, and sustains an interconnected structure through which new cells can migrate and new vessels can form.1 The subsequent substance that develops through this osteoconductive step must also be osteoinductive (facilitate the travel of factors and materials for cellular differentiation) and osteogenic (cause the cellular production of new bone) for new bone to form.1 Current US consensus dictates that in order for this cascade to develop in a bone defect, a graft must be used. In fact, over 500,000 bone graft procedures are performed annually in the US.2 In order to meet the first and crucial step of osteoconductivity, the graft must fill the void and provide a scaffolding on which stem cells can attach; in order to facilitate the next two critical steps, the graft must be non-inflammatory and non-toxic and resorb at a rate roughly equal to that of bone formation.1,3

Grafts that have been used to meet the aforementioned steps include autograft, allograft, and synthetic substitutes. Bone grafts constitute a large economic market, with over $1.5 billion in sales in 2007 in the US alone.2 Autograft has long been the gold standard of bone grafts and is the only graft option that has osteoconductive, osteoinductive, and osteogenic properties.2,4 Autologous bone grafting carries the disadvantages of pain at the donor site, variable quality, limited quantity, increased hospital stay, and a 15.8–29.2% complication rate. Complications include, but are not limited to, lateral femoral cutaneous or cluneal nerve injury, superior gluteal artery injury, wound problems, infection, need for further surgery, pelvic fracture, hematoma, and gait disturbances.4–8 Allogenic bone graft is the most commonly used bone graft material. It has osteoconductive and osteoinductive properties and no donor site morbidity, and is relatively low-cost. Allografts have the disadvantages of limited supply, potential antigenic response, lack of uniformity, and potential disease transmission—the most concerning being the documented instances of HIV and hepatitis C virus (HCV) transmission with fresh-frozen tendon and bone allografts.4,5,9–12 No consensus on the actual rate of disease transmission with bone allograft exists, though one study estimates the ‘viral transmission risk’ associated with bone allografting to be one in 1.6 million;13 there have, however, been no documented instances of HIV or HCV transmission through irradiated bone.14
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Keywords: Mineral ceramic bone graft substitute, bone defect, bone void