Osteogenic augmentation is required in various orthopaedic conditions. Autograft is the gold standard but has limitations of increased morbidity and limited amount. Bone graft substitutes are costly and limited and don't integrate with host bone. Deep freezed allografts are a viable option, though not widely used in India and there are sparse reports in literature. This paper studies early efficacy of deep freezed bone allografts in treatment of fractures requiring bone graft. This is a prospective descriptive study. Strict inclusion and exclusion criteria as per standard guidelines were followed. We have a in-house facility of gamma irradiated deep freezed allografts available in hospital. 20 patients with comminuted fracture, delayed / malunion / nonunion, depressed intra articular fractures were operated during one year and followed up for at least 24 weeks. Sloof's Criteria was used for assessing osteointegration of grafts. Efficacy was authenticated by observing complications like serous discharge from surgical site, infection (superficial/deep), rejection of graft, clinical and radiological integration of graft, maintenance of articular reduction etc. Allografts have not only accepted well but fractures have healed and bone integration is at various stages. Only one patients got infected (5%). The overall success rate in terms of adequate osteointegration is 95 %. 19 out of 20 patients in our study group had either attained or at various stages of osteointegration and healing. We concluded that deep freezed bone allografts is a viable option in patients with fractures requiring bone grafts, thus give satisfactory surgical outcome, with no serious side effects

Purpose

The aim of this study was to compare the clinical outcomes of the revision TKA in which trabecular metal cones and femoral head allografts were used for large bone defect.

Background

Processing of allografts, which are used to fill bone defects in orthopaedic surgery, includes chemical cleaning as well as gamma irradiation to reduce the risk of infection. Viable bone cells are destroyed and denaturing proteins present in the graft the osteoconductive and osteoinductive characteristics of allografts are altered. The aim of the study was to investigate the mechanical differences of chemical cleaned allografts by adding blood, clotted blood, platelet concentrate and platelet gel using a uniaxial compression test.

Introduction

The reconstruction of the knee in growing children considers many options and the chosen solution is often patient (or surgeon) based. Megaprostheses represent a reliable solution but quite expensive in the non-invasive growing version and not free from complications. In an Italian reference center for Bone and Soft tissue sarcomas, following the experience of Rizzoli Institute in Bologna, we performed the reconstruction with a resurfaced allograft for the distal femur or the proximal tibia in selected patients. The aim of the study is to confirm the reliability of this technique and to identify its potential advantages and indications.

We present our mid-term results with the use of structural allografts in cases of revision of failed THA due to infection.

Eighteen patients with a deep infection at the site of a THA were treated with a two-stage revision, which included reconstruction with massive allografts. All the allografts were frozen and sterilised by gamma-irradiation. The mean age at the time of the revision was 65.9 years. A cement spacer containing 1 g of Gentamicin was used during the interval period. Parenteral antibiotics were administrated for a period of three to four weeks. Oral antibiotics were given for an average of 18 weeks. The patients were followed for a mean of 8.9 years (5.4–14.2).

Definite deep wound infection developed in one patient (5.6%), who underwent resection arthroplasty. An additional patient underwent re-revision of an acetabular component for mechanical loosening. The mean HHS improved from 34.2 points preoperatively to 70.7 points at the last review. Sixteen of the patients (88.9%) had a successful outcome. Kaplan-Meier survivorship analysis predicted 80.95% rate of survival at 14 years.

Radiographicly, all allografts were found to be united to host bone. There were no signs of definite loosening of any of the implants. The complications include one fracture and two postoperative recurrent dislocations.

The use of massive allografts in a two-stage reconstruction for infected THA gives satisfactory results and should be considered in cases complicated with severe bone stock loss, where standard revision techniques are not an option.

Objectives

Despite promising results have shown by osteogenic cell-based demineralized bone matrix composites, they need to be optimized for grafts that act as structural frameworks in load-bearing defects. The aims of this study is attempt to assess the effects of laser perforations on osteoinduction in cortical bone allografts.

We have followed a consecutive series of revision hip arthroplasties, performed for severe femoral bone loss using anatomic specific proximal femoral allografts

Forty-nine revision hip arthroplasties, using anatomic specific proximal femoral allografts longer than five centimetres were followed for a mean of 10.4 years.

The mean preoperative HHS improved from 42.9 points to 76.9 points postoperatively. Six hips (12.2%) were further revised, four for non-union and aseptic failure of the implant (8.2%), one for infection (2%), and one for host step-cut fracture (2%). Junctional union was observed in 44 hips (90%). Three hips underwent re-attachment of the greater trochanter for trochanteric escape (6.1%). Asymptomatic non-union of the greater trochanter was noticed in three hips (6.1%). Moderate allograft resorption was observed in five hips (10.2%). Two fractures of the host step-cut occurred (4.1%). There were four dislocations (8.2%), two of them developed in conjunction with trochanteric escape. By definition of success as increase of HHS by 20 points or more, and no need for any subsequent re-operation related to the allograft and/or the implant, a 75.5% rate of success was found. Kaplan-Meier survivorship analysis predicted 73% rate of survival at 12 years, with the need for further revision of the allograft and/or implant as the end point.

We conclude that the good medium-term results with the use of large anatomic- specific femoral allografts justify their continued use in cases of revision hip arthroplasty with severe bone stock loss.

Prosthetic joint infections are difficult to treat due to bacterial biofilm. Our group has developed a linezolid elution system by human cancellous bone delivering high concentrations the first 48 hours (Giannitsioti et al. 53rd ICAAC, 2013: A-1050). We tested the activity of this system to inhibit growth of one ica expressing isolate of Staphylococcus epidermidis (MRSE).

At a first step, sterile mesh cylinders containing bone particles of the femoral head of healthy volunteers (MCB) were impregnated into 3mg/ml linezolid for 1, 24 and 48 hours. Then log-phase inocula of 103, 105 and 107cfu/ml were exposed to MCB at 370C for 8 days with regular readings of bacterial growth. MCB were transferred into fresh Muller-Hinton Broth (MHB) every 24h to avoid material corrosion. At a second step, to simulate the ability of the system against biofilm-coated MCB, MCB without linezolid were incubated with 103 and 105 cfu/ml for 1 and 24h. MCB were daily transferred into fresh MHB containing 100μg/ml on day 1, 15 μg/ml on day 2, 3 μg/ml on day 3 and 0.5 μg/ml on day 4.

24h linezolid impregnated MCB achieved rapid bacterial killing of the 105 cfu/ml bacterial suspension followed by re-growth (Figure, n= 5). Similar results were observed for 1h and 48h impregnation and for both tested inocula. When biofilm-coated MCB generated by 24h exposure to 105 cfu/ml were exposed to linezolid, rapid bacterial killing was achieved followed by re-growth.

Linezolid local elution may inhibit biofilm-producing MRSE only when locally eluted concentrations exceed 10μg/ml.

Background

Despite promising results have shown by osteogenic cell-based demineralized bone matrix composites, they need to be optimized for grafts that act as structural frameworks in load-bearing defects. The purpose of this experiment is to determine the effect of bone marrow mesenchymal stem cells seeding on partially demineralized laser-perforated structural allografts that have been implanted in critical femoral defects.

Revision of total hip arthroplasty (THA) is being performed with increasing frequency. However, outcomes of repeated revisions have been rarely reported in the literature, especially for severe defects. Cup revision can be a highly complex operation depending on the bone defect. In acetabular defects like Paprosky types 1 and 2 porous cementless cups fixed with screws give good results. Modern trabecular metal designs improve these good results. Allografts are useful for filling cavitary defects. In acetabular defects Paprosky types 3A and 3B, especially the use of trabecular metal cups, wedges, buttresses and cup-cage systems can produce good results. Difficult cases in combination with pelvic discontinuity require reconstruction of the acetabulum with acetabular plates or large cup-cages to solve these difficult problems. However, there is still no consensus regarding the best option for reconstructing hips with bone loss. Although the introduction of ultraporous metals has significantly increased the surgeon's ability to reconstruct severely compromised hips, there remain some that cannot be managed readily using cups, augments, or cages. In such situations custom acetabular components may be required. Individual implants represent yet another tool for the reconstructive surgeon. These devices can be helpful in situations of catastrophic bone loss. Ensuring long-term outcome, mechanical stability has a greater impact than restoring an ideal center of rotation. However, despite our consecutive case series there are no mid- to long-term results available so far. Re-revision for failed revision THA acetabular components is a technically very challenging condition

Revision of total hip arthroplasty (THA) is being performed with increasing frequency. However, outcomes of repeated revisions have been rarely reported in the literature, especially for severe defects. Cup revision can be a highly complex operation depending on the bone defect. In acetabular defects like Paprosky types 1 and 2 porous cementless cups maybe fixed with screws give good results. Modern trabecular metal designs improve these good results. Allografts are useful for filling cavitary defects. In acetabular defects Paprosky types 3A and 3B, impacted morselised allografts with a cemented cup technique produce good results. Difficult cases with pelvic discontinuity require reconstruction of the acetabulum with acetabular plates or large cup-cages to solve these difficult problems. However, there is still no consensus regarding the best option for reconstructing hips with bone loss. Although the introduction of ultraporous metals has significantly increased the surgeon's ability to reconstruct severely compromised hips, there remain some that cannot be managed readily using cups, augments, or cages. In such situations custom acetabular components may be required. Individual implants represent yet another tool for the reconstructive surgeon. These devices can be helpful in situations of catastrophic bone loss. Ensuring long-term outcome mechanical stability has a greater impact than restoring an ideal center of rotation. We have done so far 15 3D Printed Individual Implants. All of them where Paprosky Type 3B defects, 10 with a additional pelvis discontinuity. The mean follow-up is 18 months. All implanted devices are still in place, no infection, no loosening. However, despite our consecutive case series, there are no mid- to long-term results available so far. Re-revision for failed revision THA acetabular components is a technically very challenging condition. The 3D Printed Individual Implants have a lot of advantages, like excellent surgical planning and a very simple technique (operative time, blood loss, instruments). They are a very stable construct for extensive acetabular defects and pelvic discontinuity

Bone is a dynamic organ with remarkable regenerative properties seen only otherwise in the liver. However, bone healing requires vascularity, stability, growth factors, a matrix for growth, and viable cells to obtain effective osteosynthesis. We rely on these principles not only to heal fractures, but also achieve healing of benign bone defects. Unfortunately we are regularly confronted with situations where the local environment and tissue is insufficient and we must rely on our “biologic tool box.” When the process of bone repair requires additional assistance, we often look to bone grafting to provide an osteoconductive, osteoinductive, and/or osteogenic environment to promote bone healing and repair. The primary workhorses of bone grafting include autogenous bone, cadaver allograft, and bone graft substitutes. Among the first types of bone graft used and still used in large quantities today include autogenous and cadaver allograft bone. Allografts are useful because it is present in multiple forms that conform to the desired situation. But autogenous bone graft is considered the gold standard because it possesses all the fundamental properties to heal bone. However, it has been associated with high rates of donor site morbidity and typically requires an inpatient hospitalization following the procedure only adding to the associated costs. The first bone graft substitute use was calcium sulfate in 1892, and over the past 122 years advancements have achieved improved material properties of calcium sulfate and helped usher in additional bioceramics for bone grafting. Today there are predominantly four types of bioceramics available, which include calcium sulfate, calcium phosphate, tricalcium phosphate, and coralline hydroxyapatite. They come in multiple forms ranging from pellets and solid blocks to injectable and moldable putty. In comparison to autogenous bone graft, the primary limitation of bioceramics are the lack of osteogenic and osteoinductive properties. Bioceramics work by creating an osteoconductive scaffold to promote osteosynthesis. The options of bone graft substitutes don't end with these four types of bioceramics. Composite bioceramics take advantage of the differing biomechanical properties of these four basis types of bioceramics to develop improved materials. To overcome the lack of osteoinductive and osteogenic properties growth factors or bone marrow aspirate can be added to the bioceramic. As a result, the list of combinations available in our “biologic tool box” continues to expand. More than 20 BMPs have been identified, but only BMP-2 and BMP-7 have FDA approval. As we look forward to areas of future research and need within orthobiologics, some will likely come in the near future while others are much further in the future. We will continue to strive for the ideal bone graft substitute, which will have similar osteoinductive properties as autograft. The ultimate bone graft substitute will likely involve stem cells because it will allow an alternative to autogenous bone with the same osteogenic potential

Introduction. BAG-S53P4 has similar mechanical properties as cortical bone tissue and can be used as an additive to bone allografts. The aim of this study was to evaluate the effect of adding BAG-S53P4 to chemically treated allografts with controlled grain size distribution. Methods. Allografts were prepared and chemically cleaned under sterile conditions. 30 samples were mixed with BAG-S53P4 additive (BG) and compared to a control group (CG) with similar grain size distribution and composition in weight. All samples underwent a uniaxial compression test after compaction with a dropped weight apparatus. The yield limit was determined by a uniaxial compression test and density was recorded. The two groups were tested for statistical differences with the student's t-Test. Results. Adding BAG-S53P4 to the chemically treated allografts with controlled grain size distribution did not affect the yield limit after compaction. No statistically significant difference regarding the yield limit could be found between CG and BG after compaction (p=0.432).). The yield limit yield limit showed an increase of approximately 96% in CG and 93 % in BG, which confirms the importance of impacting bone chips used for load bearing applications like in hip arthroplasty. Conclusions. Adding BAG-S53P4 seems to have a less profound impact on the yield stress limit. In BG particles smaller than 4 mm were substituted with BAG-S53P4. Achieving a high density may not be the major goal for the bone remodeling process as it may actually obstruct new osteocytes from growing into the allograft material. Adding BAG-S53P4 seems to have limited impact on the yield stress limit. From a biomechanical point of view, BAG-S53P4 can be used as a substitute in total hip replacement if access to bone allograft material is limited

Bone is a dynamic organ with remarkable regenerative properties seen only otherwise in the liver. However, bone healing requires vascularity, stability, growth factors, a matrix for growth, and viable cells to obtain effective osteosynthesis. We rely on these principles not only to heal fractures, but also achieve healing of benign bone defects. Unfortunately, we are regularly confronted with situations where the local environment and tissue is insufficient and we must rely on our “biologic tool box.” When the process of bone repair requires additional assistance, we often look to bone grafting to provide an osteoconductive, osteoinductive, and/or osteogenic environment to promote bone healing and repair. The primary workhorses of bone grafting includes autogenous bone, cadaver allograft, and bone graft substitutes. Among the first types of bone graft used and still used in large quantities today include autogenous and cadaver allograft bone. Allografts are useful because it is present in multiple forms that conform to the desired situation. But autogenous bone graft is considered the gold standard because it possesses all the fundamental properties to heal bone. However, it has been associated with high rates of donor site morbidity and typically requires an inpatient hospitalization following the procedure only adding to the associated costs. The first bone graft substitute use was calcium sulfate in 1892, and over the past 122 years advancements have achieved improved material properties of calcium sulfate and helped usher in additional bioceramics for bone grafting. Today there are predominantly 4 types of bioceramics available, which include calcium sulfate, calcium phosphate, tricalcium phosphate, and coralline hydroxyapatite. They come in multiple forms ranging from pellets and solid blocks to injectable and moldable putty. In comparison to autogenous bone graft, the primary limitation of bioceramics are the lack of osteogenic and osteoinductive properties. Bioceramics work by creating an osteoconductive scaffold to promote osteosynthesis. The options of bone graft substitutes don't end with these four types of bioceramics. Composite bioceramics take advantage of the differing biomechanical properties of these four basis types of bioceramics to develop improved materials. To overcome the lack of osteoinductive and osteogenic properties growth factors or bone marrow aspirate can be added to the bioceramic. As a result, the list of combinations available in our “biologic tool box” continues to expand. More than 20 BMPs have been identified, but only BMP-2 and BMP-7 have FDA approval. As we look forward to areas of future research and need within orthobiologics, some will likely come in the near future while others are much further in the future. We will continue to strive for the ideal bone graft substitute, which will have similar osteoinductive properties as autograft. The ultimate bone graft substitute will likely involve stem cells because it will allow an alternative to autogenous bone with the same osteogenic potential

Bone is a dynamic organ with remarkable regenerative properties seen only otherwise in the liver. However, bone healing requires vascularity, stability, growth factors, a matrix for growth, and viable cells to obtain effective osteosynthesis. We rely on these principles not only to heal fractures, but also achieve healing of benign bone defects. Unfortunately we are regularly confronted with situations where the local environment and tissue is insufficient and we must rely on our “biologic tool box.” When the process of bone repair requires additional assistance, we often look to bone grafting to provide an osteoconductive, osteoinductive, and/or osteogenic environment to promote bone healing and repair. The primary workhorses of bone grafting include autogenous bone, cadaver allograft, and bone graft substitutes. Among the first types of bone graft used and still used in large quantities today include autogenous and cadaver allograft bone. Allografts are useful because it is present in multiple forms that conform to the desired situation. But autogenous bone graft is considered the gold standard because it possesses all the fundamental properties to heal bone. However, it has been associated with high rates of donor site morbidity and typically requires an inpatient hospitalization following the procedure only adding to the associated costs. The first bone graft substitute use was calcium sulfate in 1892, and over the past 122 years advancements have achieved improved material properties of calcium sulfate and helped usher in additional bioceramics for bone grafting. Today there are predominantly 4 types of bioceramics available, which include calcium sulfate, calcium phosphate, tricalcium phosphate, and coralline hydroxyapatite. They come in multiple forms ranging from pellets and solid blocks to injectable and moldable putty. In comparison to autogenous bone graft, the primary limitation of bioceramics are the lack of osteogenic and osteoinductive properties. Bioceramics work by creating an osteoconductive scaffold to promote osteosynthesis. The options of bone graft substitutes don't end with these four types of bioceramics. Composite bioceramics take advantage of the differing biomechanical properties of these four basis types of bioceramics to develop improved materials. To overcome the lack of osteoinductive and osteogenic properties growth factors or bone marrow aspirate can be added to the bioceramic. As a result, the list of combinations available in our “biologic tool box” continues to expand. More than 20 BMPs have been identified, but only BMP-2 and BMP-7 have FDA approval. As we look forward to areas of future research and need within orthobiologics, some will likely come in the near future while others are much further in the future. We will continue to strive for the ideal bone graft substitute, which will have similar osteoinductive properties as autograft. The ultimate bone graft substitute will likely involve stem cells because it will allow an alternative to autogenous bone with the same osteogenic potential

Bone is a dynamic organ with remarkable regenerative properties seen only otherwise in the liver. However, bone healing requires vascularity, stability, growth factors, a matrix for growth, and viable cells to obtain effective osteosynthesis. We rely on these principles not only to heal fractures, but also achieve healing of benign bone defects. Unfortunately, we are regularly confronted with situations where the local environment and tissue is insufficient and we must rely on our “biologic tool box.” When the process of bone repair requires additional assistance, we often look to bone grafting to provide an osteoconductive, osteoinductive, and/or osteogenic environment to promote bone healing and repair. The primary workhorses of bone grafting include autogenous bone, cadaver allograft, and bone graft substitutes. Among the first types of bone graft used and still used in large quantities today include autogenous and cadaver allograft bone. Allografts are useful because they are present in multiple forms that conform to the desired situation. But autogenous bone graft is considered the gold standard because it possesses all the fundamental properties to heal bone. However, it has been associated with high rates of donor site morbidity and typically requires an inpatient hospitalization following the procedure only adding to the associated costs. The first bone graft substitute used was calcium sulfate in 1892, and over the past 122 years advancements have achieved improved material properties of calcium sulfate and helped usher in additional bioceramics for bone grafting. Today there are predominantly four types of bioceramics available, which include calcium sulfate, calcium phosphate, tricalcium phosphate, and coralline hydroxyapatite. They come in multiple forms ranging from pellets and solid blocks to injectable and moldable putty. In comparison to autogenous bone graft, the primary limitation of bioceramics are the lack of osteogenic and osteoinductive properties. Bioceramics work by creating an osteoconductive scaffold to promote osteosynthesis. The options of bone graft substitutes don't end with these four types of bioceramics. Composite bioceramics take advantage of the differing biomechanical properties of these four basis types of bioceramics to develop improved materials. To overcome the lack of osteoinductive and osteogenic properties growth factors or bone marrow aspirate can be added to the bioceramic. As a result, the list of combinations available in our “biologic tool box” continues to expand. More than 20 BMPs have been identified, but only BMP-2 and BMP-7 have FDA approval. As we look forward to areas of future research and need within orthobiologics, some will likely come in the near future while others are much further in the future. We will continue to strive for the ideal bone graft substitute, which will have similar osteoinductive properties as autograft. The ultimate bone graft substitute will likely involve stem cells because it will allow an alternative to autogenous bone with the same osteogenic potential

Structural bone allografts are a viable option in reconstructing massive bone defects in patients following musculoskeletal (MSK) tumour resection and revision hip/knee replacements. To decrease infection risk, bone allografts are often sterilised with gamma-irradiation, which consequently degrades the bone collagen connectivity and makes the bone brittle. Clinically, irradiated bone allografts fracture at rates twice that of fresh non-irradiated allografts. Our lab has developed a method that protects the bone collagen connectivity through ribose pre-treatment while still undergoing gamma-irradiation. Biomechanical testing of bone pretreated with our method provided 60–70% protection of toughness and 100% protection of strength otherwise lost with conventional irradiation. This study aimed to determine if the ribose-treated bone allografts are biocompatible with host bone. The New Zealand White rabbit (NZWr) radius segmental defect model was used, in which 15-mm critically-sized defects were created. Bone allografts were first harvested from the radial diaphysis of donor female NZWr, and treated to create 3 graft types: C=untreated controls, I=conventionally-irradiated (33 kGy), R=our ribose pretreated + irradiation method. Recipient female NZWr (n=24) were then evenly randomised into the 3 graft groups. Allografts were surgically fixed with a 0.8-mm Kirschner wire. Post-operative X-rays were taken at 2, 6, and 12 weeks, with bony healing assessed by a blinded MSK radiologist using an established radiographic scoring system. The reconstructed radii were retrieved at 12 weeks and analysed using bone histomorphometry and microCT. Kruskal-Wallis and Mann-Whitney tests were utilised to compare groups, with statistical significance when p<0.05. Radiographic analysis revealed no differences in periosteal reaction and degree of osteotomy site union between the groups at any time point. Less cortical remodeling was observed in R and I grafts compared to untreated controls at 6 weeks (p=0.004), but was no longer evident by 12 weeks. Radiographic union was achieved in all groups by 12 weeks. Histologic and microCT analysis further confirmed union at the graft-host bone interface, with the presence of mineralising callus and osteoid. Histomorphometry also showed the bridging external callus originated from host bone periosteum and a distinct cement line between allograft and host bone was present at the union site. Previous studies have shown that the presence of non-enzymatic glycation end products in bone can impair fracture healing. However, these studies investigated bony healing in the setting of diabetic states. Our findings showed that under normal conditions, ribose pretreated grafts healed at rates similar to controls via mechanisms also seen in retrieved human allografts clinically in use. These findings that grafts pretreated with our method are biocompatible with host bone in the rabbit help to further advance this technology for clinical trials

Introduction. Revision hip arthroplasty with massive proximal femoral bone loss remains challenging. Whilst several surgical techniques have been described, few have reported long term supporting data. A proximal femoral allograft (PFA) may be used to reconstitute bone stock in the multiply revised femur with segmental bone loss of greater than 8 cm. This study reports the outcome of largest case series of PFA used in revision hip arthroplasty. Methods. Data was prospectively collected from a consecutive series of 69 revision hip cases incorporating PFA and retrospective analyzed. Allografts of greater than 8 cm in length (average 14cm) implanted to replace deficient bone stock during revision hip surgery between 1984 and 2000 were included. The average age at surgery was 56 years (range 32–84) with a minimum follow up of 10 years and a mean of 15.8 years (range). Results. From the original cohort four patients had died with the original PFA, 21 (30.4%) patients required further surgery with 14 (20.3%) of these needing revisions of the femoral component. The mean time to femoral revision was 9.5 years and Kaplan-Meier survivorship analysis demonstrates a 79.9% PFA survivorship at 20 years. Discussion. Proximal femoral allograft affords long lasting reconstruction of the femoral component in revision hip surgery. We advocate PFA as an attractive option in the reconstruction of the hip in the presence of significant segmental bone loss in younger patients

Bone is a dynamic organ with remarkable regenerative properties seen only otherwise in the liver. However, bone healing requires vascularity, stability, growth factors, a matrix for growth, and viable cells to obtain effective osteosynthesis. We rely on these principles not only to heal fractures, but also achieve healing of benign bone defects. Unfortunately we are regularly confronted with situations where the local environment and tissue is insufficient and we must rely on our “biologic tool box.” When the process of bone repair requires additional assistance, we often look to bone grafting to provide an osteoconductive, osteoinductive, and/or osteogenic environment to promote bone healing and repair. The primary workhorses of bone grafting includes autogenous bone, cadaver allograft, and bone graft substitutes. Among the first types of bone graft used and still used in large quantities today include autogenous and cadaver allograft bone. Allografts are useful because it is present in multiple forms that conform to the desired situation. But autogenous bone graft is considered the gold standard because it possesses all the fundamental properties to heal bone. However, it has been associated with high rates of donor site morbidity and typically requires an inpatient hospitalization following the procedure only adding to the associated costs. The first bone graft substitute use was calcium sulfate in 1892, and over the past 122 years advancements have achieved improved material properties of calcium sulfate and helped usher in additional bioceramics for bone grafting. Today there are predominantly 4 types of bioceramics available, which include calcium sulfate, calcium phosphate, tricalcium phosphate, and coralline hydroxyapatite. They come in multiple forms ranging from pellets and solid blocks to injectable and moldable putty. In comparison to autogenous bone graft, the primary limitation of bioceramics are the lack of osteogenic and osteoinductive properties. Bioceramics work by creating an osteoconductive scaffold to promote osteosynthesis. The options of bone graft substitutes don't end with these four types of bioceramics. Composite bioceramics take advantage of the differing biomechanical properties of these four basis types of bioceramics to develop improved materials. To overcome the lack of osteoinductive and osteogenic properties growth factors or bone marrow aspirate can be added to the bioceramic. As a result, the list of combinations available in our “biologic tool box” continues to expand. More than 20 BMPs have been identified, but only BMP-2 and BMP-7 have FDA approval. As we look forward to areas of future research and need within orthobiologics, some will likely come in the near future while others are much further in the future. We will continue to strive for the ideal bone graft substitute, which will have similar osteoinductive properties as autograft. The ultimate bone graft substitute will likely involve stem cells because it will allow an alternative to autogenous bone with the same osteogenic potential

Study design. Economic evaluation alongside a prospective, randomised, controlled trial from a two-year National Health Service (NHS) perspective. Objective. To determine the cost-effectiveness of Titanium Cages (TC) compared to Femoral Ring Allografts (FRA) in circumferential lumbar spinal fusion. Summary of background data. A randomised controlled trial has shown the use of TC to be clinically inferior to the established practice of using FRA in circumferential lumbar fusion. Health economic evaluation is needed to justify the continued use of TC, given that this treatment is less effective and, all things being equal, is assumed more costly than FRA. Methods. Eighty-three patients were randomly allocated to receive either the TC or FRA between 1998 and 2002. NHS costs related to the surgery and revision surgery needed during the trial period were monitored and adjusted to the base year (2005/6 pounds sterling). The Short Form-6D (SF-6D) was administered pre-operatively and at 6, 12 and 24 months in order to elicit patient utility and subsequently Quality-Adjusted Life Years (QALYs) for the trial period. Return to paid employment was also monitored. Bootstrapped mean differences in discounted costs and benefits were generated in order to explore cost-effectiveness. Results. A significant cost difference of £1,942 (95% CI £849 to £3,145) in favour of FRA was found. Mean QALYs per patient over the 24 month trial period were 0.0522 (SD 0.0326) in the TC group and 0.1914 (SD 0.0398) in the FRA group, producing a significant difference of -0.1392 (95% CI 0.2349 to 0.0436). With regard to employment, incremental productivity costs were estimated at £185,171 in favour of FRA. Conclusion. From an NHS perspective, this data show that TC is not cost-effective in circumferential lumbar fusion. The use of FRA was both cheaper and generated greater QALY gains. FRA patients also reported a greater return to work rate