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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
AUTOLOGOUS BONE GRAFT
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
HOWARDROSEN, M.D.
(1925-2000)
DEDICATED TO MY
MENTOR
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
NONUNIONS
BONE DEFECTS
ARTHRODESES
WHY DO WE EVEN USE A BONE GRAFT?
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
VIABLE NONUNIONS
ELEPHANTFOOT
HORSEHOOF OLIGOTROPHIC
Need mechanical stability
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
NONVIABLE NONUNIONS
DYSTROPHIC DEFECT ATROPHIC
NEEDS VASCULARITY & VOID FILLER
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
Flourens conclusively
showed that
periosteumwas
osteogenic and was
the chief agent in the
healing of bone defects
Flourens (1842)
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
De la production artificielle des os au moyen de la transplantation de periosteet des greffes osseux.
Ollier, L.X.Comp Rend Soc de Biol 5: 145.
1858
FIRST BONE GRAFT - 1858
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
OSTEOPERIOSTEAL GRAFTS(Delageniere = 1921)
AKA “Judet Decortication”
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
NO PLATESAVAILABLE
KANGAROOTENDON
INLAY GRAFTS
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
Onlay with screws
Simple Inlay
Sliding Inlay
Diamond Inlay
Intramedullary Peg
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
1917
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FIBULA ALLOGRAFT
2007
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
1946
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
1950’s
RIGHT TIBIA
LEFT TIBIA
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
TOOK FOREVER TO HEAL
OFTEN FRACTURED
DONOR SITE PROBLEMS
CORTICAL GRAFTS
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
CANCELLOUS GRAFTS
LACK STRENGTH SO
USED WITH PLATES
VASCULAR INVASION
BY HOST IN 2 DAYS
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ILIAC CRESTGRAFT
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
HARVESTING ILIAC CREST
1946
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ORIGINALLY USEDFOR ITS
FASTER HEALINGPROPERTIES
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
in the 1960’s the osteogenicpotential of red bone marrow
became known.
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
A BONE GRAFT MATERIAL IS ANY IMPLANTED
MATERIAL THAT ALONE OR IN COMBINATION
WITH OTHER MATERIALS PROMOTES A
HEALING RESPONSE BY PROVIDING
OSTEOGENIC, OSTEOCONDUCTIVE, OR
OSTEOINDUCTIVE ACTIVITY TO A LOCAL SITE
MUSCHLER & LANE 1992
DEFINITION
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
OSTEOGENIC = contains living cells that can differentiate into bone
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ASPIRATE TRICORTICAL GRAFT
OSTEOGENIC
(BOTH CONTAIN OSTEOPROGENITOR CELLS)
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
OSTEOCONDUCTIVE = promotes bone apposition to act as a scaffolding to allow bone formation
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ALLOGRAFT TRICORTICAL GRAFT
OSTEOCONDUCTIVE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
OSTEOINDUCTIVE = induces cells to turn into osteoblasts
(TGF superfamily)
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ILIAC CREST BONE GRAFT
NO DISEASE TRANSMISSION
NO IMMUNE RESPONSE
AMPLE SUPPLY
NO DISEASE TRANSMISSION
NO IMMUNE RESPONSE
AMPLE SUPPLY
NO DISEASE TRANSMISSION
NO IMMUNE RESPONSE
AMPLE SUPPLY
REMEMBER:REMEMBER:
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ILIAC CREST BONE GRAFT
SIMPLY IS
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
CANCELLOUS BONE GRAFT
STANDARD ILIAC CREST
CALC, PLATEAU, RADIUS
FEMORAL & TIBIAL SHAFTS
STANDARD ILIAC CREST
CALC, PLATEAU, RADIUS
FEMORAL & TIBIAL SHAFTS
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
1989
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
1. OUTER TABLE
2. CANCELLOUS BONE
3. STOP@ INNER TABLE!
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ILIAC CREST BONE GRAFT
MAJOR 2.5 – 10%
MINOR ~ 40%
PAIN 20%
COMPLICATIONS
Hill et al Aust J Surg 1999 (10):726-8
Goulet et al CORR 1997 (339): 76-81
Arrington et al CORR 1996 (329):300-309
Banwart et al Spine 1995 (9):1055-1060
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
INTRAMEDULLARY REAMING
KÜNTSCHER:
Extended the length of the Isthmus by reaming
Increased contact between nail and endosteum.
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
INCREASED STABILITY
INCREASED PERIOSTEAL FLOW.
IMPROVED HEALING.
DECREASED MAL & NON‐UNIONS
POTENTIAL BENEFITS OF REAMING
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
EFFECTS OF REAMING
REAMING STIMULATES
PERIOSTEAL BLOOD FLOW
EVEN THOUGH THERE IS A LOSS OF ENDOSTEAL BLOOD FLOW
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
REAMING +
NAIL
BIO +
MECHANICS
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
POTENTIAL DISADVANTAGES OF REAMING
THERMAL NECROSIS
MEDULLARY PRESSURIZATION
(WEAKENS THE BONE).
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ENDOSTEAL THERMAL NECROSIS
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
INJURY, 1993. VOLUME 24
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
MAIN DETERMINANTS ARE:
MEDULLARY VISCOSITY
REAMER – CORTEX SPACE
PRESSURE IN THE CANAL IS A HYDRAULIC SYSTEM (PISTON)
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
EXTRACT REAMER
OPEN CANAL
MEDULLARY PRESSURIZATION WITH REAMING
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
AWL OPENING OF CANAL
PASSAGE OF GUIDE WIRE
FIRST PASS REAMERS
AWL OPENING OF CANAL
PASSAGE OF GUIDE WIRE
FIRST PASS REAMERS
PRESSURE INCREASES WITH:
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
DANKWARDT-LILLIESTROM Acta Orthop Scand 1970
SUBPERIOSTEAL BLOOD LUNG
PRESSURIZATION 20 REAMING
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
REDUCES MEDULLARY PRESSURE
ALLOWS SINGLE‐PASS REAMING
BONE HARVESTING APPLICATION
REAMER IRRIGATOR ASPIRATOR SYSTEM (RIA)
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
UNIQUE HEAD DESIGN
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RULER FOR CANAL SIZE
PLACE RULER AT ISTHMUS
SELECT HEAD 1 – 1.5 mmABOVE NAIL SIZE
CANAL MEASUREMENT
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ONE PASS REAMING
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA REAMING
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA REAMINGRIA REAMING
IRRIGATION OBVIATES THERMAL PROBLEMSIRRIGATION OBVIATES THERMAL PROBLEMS
DOES ASPIRATIONPROTECT AGAINSTMARROW EMBOLI ?
DOES ASPIRATIONPROTECT AGAINSTMARROW EMBOLI ?
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
JBJS Vol 87 A # 11,
Nov 2005
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA REAMINGRIA REAMING
IRRIGATION ASPIRATION PROTECTS AGAINST EMBOLIC PROBLEMS
IRRIGATION ASPIRATION PROTECTS AGAINST EMBOLIC PROBLEMS
DOES IT PREVENT HEALING BY REMOVING ALL THE MARROW REAMINGS ?
DOES IT PREVENT HEALING BY REMOVING ALL THE MARROW REAMINGS ?
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
Frolke , Acta Ortho Bel 2000
Reaming debris accumulate at fracture site
Trinkaus, Unfallchirurg 2005
Reaming debris a source of viable stem cells
Frolke , Acta Ortho Bel 2000
Reaming debris accumulate at fracture site
Trinkaus, Unfallchirurg 2005
Reaming debris a source of viable stem cells
DOES “ASPIRATION” OF MARROW NEGATIVELY AFFFECT HEALING?
DOES “ASPIRATION” OF MARROW NEGATIVELY AFFFECT HEALING?
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
NO EFFECT IN ANIMALS…
C Klein ARI, Vienna
RIA Unreamed
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA AS GRAFTRIA AS GRAFT
CAN THE REAMINGS BE SAVED FOR GRAFT?CAN THE REAMINGS BE SAVED FOR GRAFT?
ARE RIA REAMINGSEQUAL TO ICBG ? ARE RIA REAMINGSEQUAL TO ICBG ?
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA AS GRAFTRIA AS GRAFT
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA vs ICBG: CONSISTENCY
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
JBJS, December 2012
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
PEPTIDES IN REAMINGS > ICBG
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA AS GRAFTRIA AS GRAFT
REAMINGS SIMILAR TO ICBG IN VOLUME & CONSISTENCYREAMINGS SIMILAR TO ICBG IN VOLUME & CONSISTENCY
RIA REAMINGS ARE EQUAL TO ICBG BIOLOGICALLY RIA REAMINGS ARE EQUAL TO ICBG BIOLOGICALLY
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
MUST BE VIGILANTWITH SIZE OF REAMER
& TECHNIQUE
MUST BE VIGILANTWITH SIZE OF REAMER
& TECHNIQUE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
SO HOW DO WE
USE RIA
BONE GRAFT TODAY
?
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
2004
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
INDUCED MEMBRANE – EXPRESSION OF VEGF, TGF‐Β1 AND BMP‐2 AT 2, 4, 6 & 8 WEEKS
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
EDGES OF DEFECT
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
Free flap and cement spacer
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
Result at two years
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
MCA
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
IRRIGATE
DEBRIDE
STABILIZE
SEVERE TYPE IIIB
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
7 DAYS LATER,
ANTIBIOTIC SPACER
ANATOMIC PLATING
FREE LAT FLAP
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
6 WEEKS LATER,
SPACER REMOVED
FLAP LIFTED
ICBG PLACED
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
6 MONTHS LATER,
BACK FROM MIAMI
SLIGHT PROBLEM…..
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA
GRAFT
&
IM NAIL
3 MONTHS LATER
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
6 MONTHSLATER
17 MONTHSFROM MCA
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
CONCLUSIONSCONCLUSIONS
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
We have come a long way
in ourunderstandingof bone healing
and defect treatment
over the lastcentury,
AND CERTAINTRUTHS HAVE
APPEARED
We have come a long way
in ourunderstandingof bone healing
and defect treatment
over the lastcentury,
AND CERTAINTRUTHS HAVE
APPEARED
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ILIAC CREST BONE GRAFT
SIMPLY IS
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ILIAC CREST BONE GRAFT
OSTEOGENIC
OSTEOCONDUCTIVE
OSTEOINDUCTIVE
OSTEOGENIC
OSTEOCONDUCTIVE
OSTEOINDUCTIVE
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
ILIAC CREST BONE GRAFT
NO DISEASE TRANSMISSION
NO IMMUNE RESPONSE
AMPLE SUPPLY
NO DISEASE TRANSMISSION
NO IMMUNE RESPONSE
AMPLE SUPPLY
NO DISEASE TRANSMISSION
NO IMMUNE RESPONSE
AMPLE SUPPLY
REMEMBER:REMEMBER:
(AND YOU ACTUALLY GET PAID TO DO IT!)
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
RIA AS GRAFTRIA AS GRAFT
REAMINGS SIMILAR TO ICBG IN VOLUME & CONSISTENCYREAMINGS SIMILAR TO ICBG IN VOLUME & CONSISTENCY
RIA REAMINGS ARE EQUAL TO ICBG BIOLOGICALLYRIA REAMINGS ARE EQUAL TO ICBG BIOLOGICALLY
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
MASQUELET TECHNIQUE
CEMENT SPACERPROTECTS CAVITYFROM FIBROUS TISSUE
STIMULATES FORMATION OF A MEMBRANE THATRELEASES BMPs
CEMENT SPACERPROTECTS CAVITYFROM FIBROUS TISSUE
STIMULATES FORMATION OF A MEMBRANE THATRELEASES BMPs
FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE
MASQUELET TECHNIQUE
&&
RIAGRAFT
CURRENT STATE OF THE ART
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FLORIDA ORTHOPAEDIC INSTITUTEFLORIDA ORTHOPAEDIC INSTITUTE