Bone Graft Substitutes in the Treatment

of Distal Radius and Upper Limb Injuries

Jeffrey Yao, MD, and Andrew M. Ho, MD, PhD
Over the years, autologous and allogeneic bone grafts have been used to supplement
techniques in internal and external fixation to treat fractures in the upper extremity. The
development of a variety of bone graft substitutes has allowed the use of these materials
when there are significant comorbidities in harvesting autograft or when the use of allograft
is undesirable. With recent advances in the synthesis, testing, and employment of bone
graft substitutes, these materials have been used in the treatment of upper extremity
fractures to fill a bony defect, to correct skeletal deformity, to restore structural integrity,
and to stimulate bone healing. In this chapter, we will identify the major types of graft
substitutes available or in development and review their unique features and capabilities.
The authors have no financial interest in any of these products; rather, the cases included
in this review are included solely as examples of the various types of commercially available
products. The indications and potential applications for graft substitutes in the distal radius
and the upper limb will be discussed, as we contemplate the future direction in the research
and development of new graft substitutes.
Oper Tech Orthop 19:77-87 2009 Elsevier Inc. All rights reserved.
KEYWORDS bone graft, distal radius, substitutes, osteoporosis

utologous and allogeneic bone grafts have long been

used in orthopedic surgery to augment fixation in the
treatment of challenging fractures and skeletal deformities.
However, when autograft harvest presents significant comorbidities or when allograft use is undesirable, alternatives to
conventional bone graft materials are needed. With recent
advances in biochemistry and material science, bone graft
substitutes promise to revolutionize the surgical treatment of
fractures and challenging deformities.
An extensive variety of bone graft substitutes exists to
fill bony gap, restore structural integrity, correct deformity, and stimulate bone healing. Currently, surgeons
may choose graft substitutes ranging from synthetic agents
to biological-based materials and from inorganic substances, such as calcium sulfate or silicate to physiological
compounds, such as collagen and hydroxyapatite (HA).
Increases in patient demands coupled with further advances in technology will lead to more routine use of these
materials in the future (Fig. 1).

With an expansion in the indication and incidence of bone

graft substitute use, medical device companies are motivated
to create innovative and effective products. However, much
of the corporate-sponsored research has focused on gaining
regulatory approval for wider indications in product application, and a noticeable absence of well-designed and controlled studies exists to compare the various agents in terms
of their efficacy and safety. Furthermore, prohibitive expenses currently limit routine use of many biologically active
agents.
In this chapter, we will identify the major types of bone
graft substitutes available or in development and review their
unique features and capabilities. The indications and potential indications for graft substitutes in the distal radius and
the upper limb will be discussed. We will end by talking
about some of the challenges facing the use of bone graft
substitutes, as well as the future directions in research and
development of graft substitutes and tissue engineering.

Bone Composition and Biology

Department of Hand and Orthopaedic Surgery, Stanford University School
of Medicine, Palo Alto, CA.
Address reprint requests to Jeffrey Yao, MD, Department of Hand and Orthopaedic Surgery, Stanford University School of Medicine, 770 Welch
Road, Suite 400, Palo Alto, CA 94304. E-mail: [email protected]

1048-6666/09/$-see front matter 2009 Elsevier Inc. All rights reserved.

doi:10.1053/j.oto.2009.07.003

In the 1960s, Urist demonstrated the remarkable ability of

bone to induce the formation of itself (autoinduction).1 Since
then, bone has been found to be a physiological composite of
mineral, protein, and cellular elements with unique proper77

J. Yao and A.M. Ho

78

Figure 1 US sales of bone graft and bone substitutes, 1998-2007.

Source: Orthopedic Network News.

ties. The structural mineral and protein matrix provides a

scaffold for new bone formation (osteoconduction). Proteins,
including growth factors and cytokines, stimulate and signal
new bone growth (osteoinduction). New bone formation,
that is, osteogenesis, requires the presence of osteoprogenitor
cells in some milieu that favors osteoinduction and osteoconduction.
HA is the most abundant form of calcium phosphate in the
mineral phase of bone (Fig. 2). Its weakly crystalline structure
permits ionic exchange with carbon and the hydroxide ion and
flux between different mineral precursors, such as calcium
phosphate and tricalcium phosphate (TCP). This instability allows bone activity and tolerance of bone substitutes. HA deposits on a matrix of type I collagen in which cellular activity occurs
to create the underlying latticework of mammalian bone.
Bone resorption refers to the disappearance of native
bone or bone graft after initial implantation. Acute resorption can occur by chemical dissolution, by physical disruption, such as microfracture, or by phagocytosis as seen
in a foreign body reaction. The slower process of bone
remodeling may also account for resorption. True remodeling is a cellular activity of bone deposition and removal
based on environmental and physiological stresses. Because different materials have varying resistance to dissolution and remodeling, the surgeon must consider these
effects when choosing a substitute.

Confusing Nomenclature
and Confounding Regulation
Biological graft materials have been used to fill bone voids, to
augment fixation of fractures, and to stimulate bone growth.
Clear indications for their use are often lacking, despite the
substantial growth of the industry in the past few years. Limited clinical studies and scientific data, coupled with questionable advertising claims, produce a confusing landscape of
bone substitutes and proteins. For example, the simple name
of the product often changes from the time of development to
the time of marketing, and is further altered when the manufacturer changes hands or is purchased by another company.

Even more confounding is how bone graft materials are

categorized and regulated. Various agencies in the Food and
Drug Administration (FDA) are charged with regulating bone
products. The Center for Biologics Evaluation and Research
of the FDA monitors the processing of human and animal
bone and soft tissues, whereas biological cements are monitored by the Center for Devices and Radiological Health. The
orthopedic panel of the Center for Devices and Radiological
Health reviews and regulates growth factors as well as conventional internal fixation devices, but the Center for Drug
Evaluation and Research reviews and regulates injectable
proteins. Future genetically altered materials will be reviewed
and regulated by the Center for Biologics Evaluation and
Research.
The lack of a single government agency to regulate bone
graft materials has led to confusion in their nomenclature,
classification, and regulation. For example, the different arms
of the FDA categorize these similar products at the same time
as devices, drugs, or biological materials. Rather than treating
these materials as related substances with shared properties,
these products are regulated as separate entities, each with its
separate codes and regulations.

Bone Grafting in
Distal Radius Fractures
Trials of many bone-graft substitutes have focused on the
treatment of distal radius fractures, as this classic osteoporotic fracture represents a common injury with a reliable
mechanism and reproducible fracture pattern for study. This
fracture typically presents with a displaced comminuted dorsal radial cortex, and variations, including involvement of the
medial column, radiocarpal joint, radial styloid, and the distal radioulnar joint. Anatomic reduction in the articular surface with restoration of the radial height, radial inclination,
and volar tilt is the central tenet to current treatment. Treatment modalities are selected depending on the fracture pattern and patient factors, and range from closed reduction and
casting to various surgical techniques, including percutaneous pinning, open reduction internal fixation, and external
fixation.
Autogenous bone grafting has played an important role in
the treatment of complex fractures of the distal radius. In
cases of severe fracture comminution or bone gaps, loss of
bony integrity or alignment, and patients with poor bone
stock secondary to advanced age or osteoporosis, the use of
autogenous graft has supplemented fixation techniques and
led to improved bone healing.2 However, graft site morbidi-

Figure 2 HA: the mineral backbone.

Bone graft substitutes to treat upper limb injuries

Table 1 Advantages and Disadvantages of Autologous Bone
Graft
Advantages of
Autograft

Disadvantages of
Autograft

Osteoinductive and
osteoconductive
Osteogenic
Available in cortical and
cancellous forms
Provides structural
support
Biocompatible
Incorporates into host
site

Problems associated with

harvest:
Increased operative time,
hospital stay, cost
Increased blood loss,
postoperative pain, risk of
infection, risk of fracture
Avascular bone: potential nidus
for infection
Limited supply
Variable quality

Remodels to become normal bone.

ties in autograft harvest (Table 1) have led surgeons to seek

alternatives to autograft for graft material.

Types of Bone Graft Substitutes

Numerous osteoconductive, osteoinductive, and osteogenic
materials are available for the clinician or are in development.
An overview of the available types is provided, followed by
examples of currently marketed materials and materials in
development.

Osteoconductive Materials
Most osteoconductive materials available are mineral based
with some complement of the HA backbone. These may be
generated from allograft human bone, xenograft bone, or
synthetically manufactured. Blocks and granules of coral or
synthetic minerals and synthetic injectable cements are the
major mineral formulations. Collagen-based materials also
exist as both a framework and a carrier matrix for other
substances. These materials provide the structural scaffold
for host cells and growth factor to induce bone formation.

Osteoinductive Materials
Demineralized bone matrix (DBM) is the most popular form
of what is purported to be osteoinductive bone. It is the
collagen matrix of allograft bone that is created after extensive
processing to remove donor blood, cells, and mineral content. Available in a variety of forms, its carrier material provides texture and pliability to match the properties in recipient bone, and it is used primarily as a graft extender.
Whether it is truly osteoinductive in humans has not been
established.

Osteogenic Materials
Autogenous materials range from the readily obtainable bone
marrow aspirate (BMA) to cancellous and corticocancellous
bone harvested from various sites, including the iliac crest,
distal radius, olecranon process, and other anatomical sites.
Bone harvested from these sites has the structural matrix,
proteins, growth factors, and cells to confer osteoconductive,

79
osteoinductive, and osteogenic capabilities at the recipient
site. Other osteoconductive or osteoinductive materials,
when mixed with autologous blood products, such as platelets or marrow aspirate during surgery, have also been purported to have osteogenic potentials.

Examples of
Bone Graft Substitutes
Allograft Bone
Endowed with both osteoconductive and osteoinductive
properties, allograft bone in its different forms is commonly
used in the distal radius and upper limb. It may be considered in patients with highly comminuted fractures, fracture
patients with osteopenia, osteoporosis, or with poor healing
potential, and in cases of fracture nonunion. Banked human
bone can be processed in different ways. Fresh frozen bone
has stronger mechanical properties3 but potentially greater
immunogenicity and infection risk,4 whereas freeze-dried
bone is biomechanically weaker but potentially less immunogenic.
Allograft bone is available in various formulations. Corticocancellous allograft is classically used to fill bone voids
from nonunions of long bones, to act as structural struts in
prosthesis revision cases, or to fill large defects in reconstructive surgery after tumor resections. Cancellous allograft chips
are used more commonly for smaller nonunions and metaphyseal voids, either as an autograft extender or replacement.
Advantages of allograft bone include ease of use and its
potentially unlimited supply. However, it lacks the cellular
components and rich osteogenic potential in autografts. Furthermore, the quality of bone can be variable and carries a
theoretical risk of disease transmission.

Demineralized Bone Matrix

DBM is processed allograft bone that has been demineralized.
The processing includes chemical and radiation treatment
that weakens the biomechanical property of the bone and
potentially reduces its bone formation potential, but reduces
its immunogenic potential and infection risk.5 Matrix proteins and growth factors may survive processing, as DBM
confers osteoinduction in animal models.6 Dry, moldable, or
injectable forms exist as powder, paste, or putty, using a
carrier, such as hyaluronic acid, collagen, glycerol, or gelatin
to render the DBM suitable for placement. Different formulations of DBM manufactured by different companies carry
varying claims on their efficacy, half-life, allergic and immunogenic potentials, and side effects.
Grafton DBM (Osteotech, Eatontown, NJ; http://www.
graftondbm.com) comes in several formulations, including
gel, putty, paste, and semirigid forms for optimal delivery
and integrity. In corporate-sponsored research, the manufacturer reports that there is no confirmed incident of communicable disease transmission attributed to Grafton DBM in
more than 800,000 procedures since its introduction to the
market in 1991. An animal study has raised concerns about a
dose-dependent toxicity with Grafton use that may be related

J. Yao and A.M. Ho

80
to its glycerol carrier,7 although this toxicity has not been
documented in humans.
Dynagraft II (Cytagenix, Laval, Quebec, Canada; http://
www.citagenix.com) is another form of DBM and comes in
gel and putty forms dispensed from vials and syringes. Its
carrier is a unique reverse phase medium that is more viscous at body temperature, but less viscous at cooler temperatures. Therefore, it is more malleable at operating room
temperatures, but stiffens when placed in the operative site.
This potentially allows the DBM to be contained at the graft
site with minimal loss through irrigation and suction. The
company claims that every lot of Dynagraft II DBM has
passed an in vitro assay demonstrating its osteoinductive

ability to induce a mouse muscle cell line to an osteoblastic

lineage and produce alkaline phosphatase.
DBX (Synthes, Paoli, PA; http://us.synthes.com) is a human
DBM that comes in putty and paste formulations packaged in
syringes. Its carrier is touted to be bio-inert, pH-balanced, and
isotonic. Its manufacturer claims that DBX has the highest demineralized bone content of all DBMs on the market (up to 32%
by weight and 93% by volume). Whether this translates to better
osteogenic potential remains to be proven. DBX are processed
through a viral inactivation protocol and screened through a
HIV-PCR test. Corporate-sponsored research has confirmed the
osteoinductive ability of DBX in a mouse model, and its potential in bone healing in a femur defect rat model (Fig. 3).

Figure 3 DBX induces bone formation in an athymic mouse model and bone healing in a femoral defect model in rats.
Source: Synthes Inc.

Bone graft substitutes to treat upper limb injuries

81

Other DBM products exist in the market today. Many

products are similar in their formulations and applications.
They vary mostly in the processing of the allograft bone (most
claim some proprietary processing methods that render their
DBM more osteoinductive and physiological and less immunogenic). Other differences exist in the form of the carrier
used, the method of viral and pathogen inactivation, and the
assay used to provide consistency and quality control for
different batches of their products. Patent infringement suits
are common among the different manufacturers of these
products in an environment of intense competition.

Ceramics and Corals

Ceramics are formed when mineral salt is heated to high
temperatures, greater than 1000C, in a process known as
sintering. Sintering provides strength to the finished material, but when sintered material is applied to bone, it decreases remodeling and resorption capabilities of the surrounding bone. When ceramics were first introduced as bone
graft substitutes, many surgeons expressed concern that the
slow integration of the implanted ceramic substances may
impair bone healing and alter the mechanics of joints and soft
tissue.
Recent studies have shown that an increase in porosity of
ceramics permits faster bony ingrowth but weakens the material.8 The ideal pore size is thought to be between 150 and
500 m.8 Both sintered and nonsintered porous substances
exist, the latter of which permits faster resorption. Current
ceramic graft design focuses on architectural control, sintering temperature, fluid flow properties of the scaffold, and
how they affect cell recruitment, signaling, mechanotransduction, and angiogenesis.9 The best ceramic materials balance these features to provide ceramic material with the optimal strength and biointegration profile.
Endobon (Biomet, Zwijndrecht, Netherlands) is a natural,
osteoconductive HA ceramic composite derived from bovine
bone (Fig. 4). The sintering process removes all organic components and leaves only the mineral contents, increasing the
strength of the composite and reducing its immunogenicity.
The interconnecting pore system has micro- and macro-sized

Figure 5 The microstructure of Pro Osteon 500 (left) and human

cancellous bone (right). Source: Interpore Cross International/Biomet
Inc.

pores ranging from 100 to 1500 m to allow the new bone to

grow through the whole implant, leading to a stable osseous
integration into natural bone. A large European experience
for use of Endobon in the treatment of distal radius metaphyseal defects exists.10
Coralline HA is coral that is thermochemically treated with
ammonium phosphate and demonstrates porosity similar to
cancellous bone (Fig. 5). The thermochemical conversion
process for Pro Osteon (Interpore Cross International/Biomet, Irvine, CA; http://www.interpore.com) converts 95%
of the calcium carbonate in marine coral exoskeletons into
more slowly resorbed HA. Bone ingrowth has been demonstrated in the interconnected pores, with increased biomechanical strength11 and osteoblast ingrowth12 evident in the
material. Its compressive strength is reported as approximately 4 MPa.11 Recent formulation with calcium carbonate
on its surface (Pro Osteon R) permits better resorption and
potentially better ingrowth. A corporate-sponsored clinical
trial has been set up in 2009 to study the effects of Pro Osteon
in treating tibial voids in revision total knee surgeries.

Mineral-Based Substitutes
Calcium sulfate, better known as plaster of Paris, results from
the calcination of gypsum (CaSO42H2O), which partially
dehydrates to produce a hemihydrate (CaSO41/2 H2O) (Fig.
6). Because the clinical use of calcium sulfate predated the
existence of the FDA, it was designated a class II special
controls device in 1998, requiring institution of voluntary
consensus standards for its use. This consensus is known as
surgical grade, reflecting a certain standard of purity and
consistency of the material.
The first calcium sulfate marketed was Osteoset (Wright
Medical Technology, Arlington, TN; http://www.wmt.com),
available in pellet, bead, and injectable forms. These preparations are compatible with the addition of antibiotic powder

Figure 4 Endobon is a HA ceramic composite that comes in blocks,

cylinders, and granules. Source: Biomet Inc.

Figure 6 Calcium sulfate from gypsum.

J. Yao and A.M. Ho

82

Figure 7 The microstructure of Vitoss Tricalcium Phosphate with

its polyporosity. Source: Orthovita Inc.

and are therefore useful in the local delivery of antibiotics for

the treatment of infected bone in nonunions or joint prosthesis explantations. The recently formulated Osteoset2 DBM
graft incorporates DBM (53% by volume) into Osteoset
pellets. The DBM encapsulated in the calcium sulfate is gradually released over the period of resorption, purportedly allowing
a steady release of osteoinductive factors found in DBM.
Other marketed calcium sulfate products include Calceon
(Synthes, Paoli, PA) in pellet form, and BonePlast (Interpore
Cross International/Biomet, Irvine, CA) available in pellet,
block, and injectable forms.
Resorption of calcium sulfate is rapid, with total resorption
observed as early as a few weeks to months.13 The rate of
resorption depends on the formulation and configuration of
the material, as well as the size and local environment of the
host defect. Calcium sulfate can render immediate stability in
distal radius and long-bone defects,14 but augmented fixation
is required because of its rapid resorption.
TCP is a physiological mineral salt that exchanges readily
with HA molecules. Available in blocks, granules, and powders, its initial use was in the dental industry in the 1980s.
The structure, particularly its porosity, strongly influences its

ability to be resorbed or remodeled. The first TCP product

released in the United States in 2001 is Vitoss (Orthovita,
Malvern, PA; http://www.vitoss.com). Vitoss grafts contain
pores of a wide range of diameters, ranging from 1 to 1000
m (Fig. 7). This size range of pores may theoretically be able
to accommodate the migration of cells of varying sizes to the
material, with histologic studies showing large osteoclasts in
the large pores and platelets and leukocytes in smaller pores.
ChronOS (Synthes, Inc, Paoli, PA) is a -TCP bone graft
substitute released in 2002. It is a fully synthetic and resorbable material with variable pore sizes and compressive
strength similar to cancellous bone. It resorbs in 6 to 18
months according to company studies. Cerasorb (Curasan
AG, Kleinostheim, Germany; http://www.curasan.com) is
another -TCP used extensively in Europe in dental and
orthopedic applications. Recent studies have reported success in using -TCP in total wrist arthrodesis in rheumatoid
patients15 and in distal radius corrective osteotomies.16

Biocements
The first calcium phosphate cement approved in 1998 by the
FDA is the skeletal repair system (SRS) (Norian/Synthes, Paoli, PA). It is powdered calcium phosphate and calcium carbonate mixed with soluble sodium phosphate. Initially approved for augmenting fractures of the distal radius, it is now
approved for general orthopedic use in metaphyseal defects
(Fig. 8). Norian SRS has a long track record of success in
treating upper extremity injuries. In a prospective randomized study, distal radius fractures treated with Norian SRS vs
immobilization demonstrated less pain, earlier restoration of
movement and grip strength, and lower rates of malunion in
the SRS group.17 Another prospective randomized study of
over 300 distal radius fractures treated with closed reduction
and fixation (Kirschner wires [K-wires] or external fixation)
with or without SRS cement augmentation showed significant clinical differences in the immediate postoperative period with better grip strength, wrist range of motion, digital
motion, use of the hand, and social and emotional function,
and less swelling in the patients treated with Norian SRS than

Figure 8 (Left) Osteoblastic and osteoclastic activity are seen with Norian SRS in a human hip fracture at 2 weeks after
implantation (Courtesy of Thomas Bauer MD). (Right) The appearance of Norian SRS at 2 weeks (A) and 2 years (B) after
implantation in the distal radius (Source: Norian Corp).

Bone graft substitutes to treat upper limb injuries

in the control group, although no difference was found at the
1-year follow-up.18
Injectable cements have an advantage over blocks, granules, and pellets, in that a custom fill of the defect is possible.
Its compressive strength is greater than that of cancellous
bone. The surgeon must be vigilant in application technique,
as unwanted material may extrude into the joint and soft
tissues in comminuted fractures if the fracture pattern is not
understood properly.
BoneSource (Stryker, Kalamazoo, MI; http://www.stryker.
com) is another calcium phosphate cement initially approved
for craniofacial defects. A multicenter study demonstrated
the effectiveness of BoneSource in filling metaphyseal voids
in various long-bone fractures, showing union rates comparable to autograft.19 However, 2 independent studies concluded that using cement alone without fixation augmentation (K-wires or external fixators) leads to worse clinical
outcomes compared with fixation alone.20,21
Another calcium phosphate cement named Alpha-BSM
(ETEX, Inc/Depuy, Cambridge, MA; http://www.etexcorp.
com) is manufactured using a proprietary double component decomposition method at low temperatures rather than
sintering under high temperatures. The result is a bioresorbable self-setting calcium phosphate substitute that undergoes
endothermic setting at body temperature. ETEX recently
came out with an injectable form (Beta-BSM) and a moldable
putty form (Gamma-BSM). A corporate-sponsored multicenter randomized study showed that tibial plateau fractures
treated with Alpha-BSM had similar union rates but a lower
rate of subsidence compared with autograft.22
New formulations of existing cements focus on improving
their handling properties as well as their biomechanical resistance to torsional and shear stresses. Callos (Skeletal Kinetics, Cupertino, CA; http://www.skeletalkinetics.com) is a
calcium phosphate cement that, according to its manufacturer, is easy to mix, highly flowable, does not wash out, set
in a wet environment, and can be manipulated post-implantation. Published corporate data claim that Callos has higher
tensile strength compared with other calcium phosphate cements when combined with DBM, though peer-reviewed
published reports supporting these claims in human patients
are presently lacking.

Bone and Mineral Composites

Cancellous bone combined with DBM provides a structural
matrix with osteoconduction and osteoinduction potentials.
Opteform (Exatech, Alachua, FL; http://www.exac.com) includes DBM and corticocancellous bone chips in a gelatin
carrier, which can be molded into a nonwater-soluble solid.
Allomatrix (Wright Medical Technology, Arlington, TN;
http://www.wmt.com) incorporates DBM and cancellous
chips recovered from the same donor. The composite is
blended at the time of surgery to allow the surgeon to control
the structural consistency of the mixture to suit the particular
application.
Mineral composites are osteoconductive products augmented with mineral components to mimic the chemical

83
composition of native bone. Collagraft (Zimmer, Warsaw,
IN; http://catalog.zimmer.com) is one of the first mineral
composite substitutes approved by the FDA in 1993. It consists of a mixture of porous beads composed of 60% HA and
40% TCP ceramic and fibrillar collagen. It was approved for
treatment of diaphyseal and metaphyseal defects to provide
osteoconduction, and when mixed with autologous BMA can
confer osteoinductive and osteogenic potentials. Indeed, a
prospective, randomized study comparing autograft and collagraft used in 267 long-bone fractures showed that Collagraft performed as well as did autograft by radiographic assessment, with similar complication rates.23 A head-to-head
comparison between coralline ceramic ProOsteon, DBM, and
Collagraft in a rabbit femoral defect model showed superior
bony ingrowth and resorption in Collagraft than the other 2
graft materials,24 although similar data in human patients are
lacking at this point.

Bioactive Glass
Long being of interest in the dental industry, bioactive glass
represents a combination of silica-based material with a biocompatible material, such as calcium phosphate, forming a
bond between the implant and the host tissue. The bond
comprised a carbonated apatite, as with the calcium phosphate cements. The material bioglass (Novabone, Alachua,
FL; http://www.novabone.com) has been used extensively to
fill human maxillofacial and periodontal defects, and in a
rabbit distal femoral cancellous defect model has shown bony
ingrowth, slow resorption, and biomechanical stiffness similar to cancellous bone by 8 weeks post implantation.25
Cortoss (Orthovita, Malvern, PA; http://www.orthovita.
com) is an injectable, nonresorbable polymeric cement with
bioactive glass composite that mimics cortical bone. Cortoss
Bone Augmentation Material is approved by the FDA for
treatment of vertebral compression fractures. These and
other polymeric injectables are often as strong as poly-methyl
methacrylate, but with less toxic side effects.

Bioactive Proteins
The fractured bone triggers a cascade of inflammatory and
cellular activities that ultimately promotes bone healing. The
effects of various proteins in the cascade of inflammation and
bone healing represent an intense area of research. Cytokines
are proteins that regulate the gene expression and cellular
activity of cells. Growth factors are polypeptides that regulate
cell growth and activity by binding to specific receptors on
the cell surface. The transforming growth factor- family of
growth factors is involved in regulating biological processes
from embryonic development to wound inflammation and
bone healing.26 Its members include the bone morphogenetic
proteins (BMPs), a subclass of transforming growth factor-
members that has been shown to induce and regulate cartilage and bone formation.27 Other factors that are involved in
bone healing include fibroblast growth factor (FGF), vascular
endothelial growth factor (VEGF), platelet-derived growth
factor, growth and differentiation factor (GDF), and many
others.

84

J. Yao and A.M. Ho

Growth factors that promote bone formation are readily

found in autogenous bone harvest. Autogenous BMA is easily
obtainable from the anterior iliac crest. The aspirate contains
osteoprogenitor cells and protein factors that stimulate bone
growth in favorable conditions. A Jamshidi needle, commonly used for core biopsies, is used with a syringe for the
aspiration of the BMA. A packaged harvest system also exists
called Imbibe (Orthovita, Malvern, PA; http://www.orthovita.
com), marketed along with the -TCP substitute Vitoss. Indeed, BMA can be mixed with an osteoconductive material
such as Vitoss or an osteoinductive agent, such as collagraft,
to confer osteogenic potentials to these bone graft substitutes.
Another rich autogenous source of growth factors is in the
ultra-concentrate of centrifuged blood. To collect the blood
lost during surgery, a blood-saving centrifuge system (Cell
saver 5, Haemonetics, Braintree, MA; http://www.haemonetics.
com) can be used. Conventionally known as the buffy coat,
this ultra-centrifuged blood product comprises leukocytes,
platelets, and various growth factors, and is now often referred to as platelet-rich plasma (PRP).28 Several systems
are marketed to collect and process PRP during surgery: Autologous Growth Factor (Interpore Cross International, Irvine, CA; http://www.interpore.com), Symphony II (DePuy/
Acromed, Cambridge, MA; http://www.depuyacromed.com),
and the Cell saver 5 (Haemonetics). Success has been reported
in using PRP in the treatment of fractures,29 especially in the
diabetic population,30 as well as in other orthopedic applications, such as lateral epicondylitis.31 However, in upper limb
surgeries, with the routine use of tourniquets, the blood loss
in a typical upper limb surgery distal to the humerus is usually minimal, creating a practical challenge in using PRP in
these cases, unless the blood is harvested via an intravenous
line.

BMPs and Other Growth Factors

With better understanding of the molecular processes that
regulate bone formation, specific proteins have been identified and synthesized to promote bone healing in patients. A
family of growth factors called the BMPs has been shown to
be crucial in regulating many aspects of development, including bone formation.26 Current BMPs in clinical use include BMP-7 and BMP-2. BMP-7 is also known as OP-1 (Osteogenic protein 1, Stryker Biotech, Hopkinton, MA; http://
www.stryker.com) and is synthesized as a recombinant
human protein (rhBMP-7 or rhOP-1) for clinical use. rhBMP-7 (OP-1 Implant) is Humanitarian Use Device-approved as an autograft substitute for long-bone nonunions,
and OP-1 Putty is Humanitarian Use Device-approved as an
alternative to autograft in compromised patients requiring
revision lumbar spinal fusions.32 OP-1 has shown dramatic
bone healing effects in animal studies (Fig. 9), and has been
shown to be advantageous over autograft in tibial nonunions.33 Antibodies to OP-1 have been identified in spinal
fusion patients using OP-1 early after implantation, but antibody levels resolved with no clinical sequelae, and its significance is unclear at this point.34
BMP-2 is another BMP synthesized as a recombinant hu-

Figure 9 OP-1 application in a monkey ulna defect model at 2

weeks (A) and 20 weeks (B and C). Source: Stryker Biotech.

man protein (rhBMP-2) and marketed as INFUSE (Medtronic

Sofamor Danek, Memphis, TN; http://www.infusebonegraft.
com). rhBMP-2 is currently FDA-approved as an autograft
replacement in anterior lumbar interbody spinal fusion,
treatment of open tibial fractures, and in certain oral surgeries.32 In a prospective randomized study involving 450 patients, rhBMP-2 was demonstrated to be safe and effective in
reducing the frequency of secondary interventions and the
overall invasiveness of the procedures, accelerating fracture
and wound-healing, and reducing the infection rate in patients with open tibial fractures.35 In another prospective,
randomized trial evaluating lumbar spinal fusion, patients
treated with rhBMP-2 demonstrated consistent fusion and

Bone graft substitutes to treat upper limb injuries

quicker patient clinical outcome improvement compared
with instrumentation with autograft.36
The use of rhBMP proteins in many other orthopedic applications, such as noncomplicated fracture healing, joint arthrodesis, and correction of skeletal deformities is still controversial. Both BMP products on the market currently
require superphysiologic doses to be effective (10-20 mg).
Further, both proteins have elicited antibody formation in
humans, although the antibody levels tend to normalize over
time with no clinical sequelae.34 Recently, off-label use of
rhBMP-2 in anterior cervical spine fusions has led to an increased rate of swelling complications.37 Other reported
complications with recombinant BMP use include ectopic
bone formation, bone resorption or remodeling at the graft
site, hematoma, and painful seroma at the implantation
site.38
FGF and platelet-derived growth factor promote bone regeneration through the early healing phase. FGF is both mitogenic and angiogenic and has been shown in animal studies
to act synergistically with BMPs to promote bone healing.39
Bone graft substitutes embedded with FGF are under development.
The cytokine VEGF has been shown to stimulate bone
repair by promoting angiogenesis and bone turnover in animal studies.40 Some of these studies have also demonstrated
a synergistic effect in bone formation and fracture healing
when VEGF is applied in combination with BMPs.41 Trials are
underway to test the efficacy of VEGF in human fracture
healing.
Chrysalin is a synthetic 23-amino acid peptide that contains the receptor binding domain of the human thrombin
protein (Capstone Therapeutics, Tempe, AZ; http://www.
capstonethx.com). Chrysalin has been shown in several studies to stimulate cellular events leading to angiogenesis, revascularization, and repair of dermal and musculoskeletal tissues.42 It is currently being evaluated in disorders that
involve vascular endothelial dysfunction, such as acute myocardial infarction and chronic myocardial ischemia.43 Phase
I/II double-blind studies of Chrysalin in radius fractures
showed a stimulatory effect in bone healing when the peptide
is percutaneously injected into a distal radius fracture that is
treated with cast or external fixation, with or without Kwires.42
Recombinant human growth and differentiation factor 5
(rhGDF-5) has also been shown to be a useful growth factor,
when combined with -TCP in the treatment of rat calvarial
defects.44 MD05, or -TCP coated with rhGDF-5, was shown
to form 5 times more bone than other bone substitutes in this
animal model.44 Further studies are needed to assess the efficacy in using rhGDF-5 in fracture healing and bone formation in human patients.

Genetic and Tissue Engineering

With better knowledge of the mechanisms that regulate bone
formation and fracture healing, research has focused on inducing and controlling these biological processes at the molecular level. Although genetic engineering has been studied

85
as a potential treatment modality in many diseases and conditions, there remain 3 main goals in all tissue engineering
applications: to deliver the appropriate growth factors for the
biological process at hand, to deliver or recruit the appropriate cells to mediate those processes, and to find the right
scaffold material to deliver these proteins and cells to the
target tissue in an efficient, reliable, and safe manner.
One aspect of this research aims to deliver these factors
directly to the sites where bone growth or fracture healing is
required via adenoviral or lentiviral vectors.45 An ideal vector
for the delivery of proteins and growth factors mentioned in
the last section to promote bone healing should have several
attributes. First, the vector should reach the target tissue
efficiently and specifically. Second, the expression of the factors should be under strict regulation with specific mechanisms for turning expression on and off. Third, the vector
should allow protein expression throughout the period required for bone formation or healing. Finally, the vector
should be safe, with little or no adverse side effects. Research
is ongoing to develop the ideal vector to deliver these factors
for bone healing.46
Apart form the presence of the appropriate proteins and
growth factors, bone formation requires the recruitment of
appropriate cells. Stem cells are pluripotent cells that have
the potential of differentiating into different lineages and are
uniquely suited in applications of bone formation and fracture healing. Historically, stem cells were isolated from embryonic tissue, but recent research has focused on using stem
cells derived from adult tissue in various orthopedic applications.47 Adult-derived stem cells have the advantage over
embryonic stem cells in easier accessibility and more abundant supply, without the bioethical conundrums facing the
use of embryonic tissue in research and clinical applications.
The appropriate carrier material to deliver these proteins
and cells to the target tissue is also an area of focus in genetic
engineering. The carrier material has to provide the right
biomechanical properties for the tissue considered and to
deliver proteins and cells to the target tissue in a reliable,
efficient, and safe manner. Furthermore, this material should
be biocompatible with the host tissue. Recent studies have
shown that the type of scaffold material used can have significant effect on bone formation and fracture healing in an
animal model.48
Osteocel (AlloSource, Centennial, CO; http://www.allosource.
org) is an allogeneic bone matrix containing viable stem cells.
Bone marrow is processed under a proprietary protocol to
isolate a population of stem cells with osteogenic potential, as
tested by in vitro cell culture assays. Corporate immunogenicity studies have shown that Osteocel does not lead to a
change in the immune response in a mixed lymphocytic reaction assay. Clinical trials are needed to determine whether
Osteocel offers superior bone formation and fracture healing
over conventional bone graft substitutes.

Discussion
An ideal bone graft substitute should confer osteoconductive,
osteoinductive, and osteogenic potentials. In general, osteo-

86
conductive materials are used for metaphyseal defects in conjunction with internal or external fixation. Osteoinductive
materials are used alone or as a graft extender in areas in
which healing may be deterred: diaphyseal fractures and defects as well as nonunions. Composites of osteoinductive and
osteoconductive materials may prove useful for both periarticular metaphyseal defects and diaphyseal defects, and proteins and growth factors that promote healing may someday
be used with any common fracture. Osteogenic grafts include
most autografts and a recent allogeneic bone matrix containing stem cells that may prove to be useful in situations with
impaired bone healing potentials.
The last decade has witnessed the development of many
types of graft substitutes, ranging from versatile DBM products to mineral substitutes and growth factors. Refinement of
these products and development of carrier substances have
spawned a new generation of substitutes, ones that may be
tailored to fit the specific clinical condition and the specific
needs of the patient, in much the same way we choose different internal fixation devices for different types of fractures.
Products that are cost-effective in comparison with autograft
harvest and hasten healing and patient independence will
likely be at the center of the marketing race in the next decade.
Several challenges face the future development of bone
graft substitutes. Although the increase in clinical need and
patient demand has fueled development and marketing of
many bone graft substitutes in the past decade, much of the
science and clinical data are shrouded in protection of proprietary information and competitive marketing. Furthermore, although the FDA regulates safety and efficacy of all
bone graft products, different agencies within the FDA oversee and regulate allografts, cements, proteins, and other genetic engineering products, further hampering efforts to coordinate research and comparison among products.
Better outcome studies and psychometric analyses may
prove helpful in assessing the utility of different substitutes,
but a true comparison of different products will require a
well-designed prospective, randomized, head-to-head trial
of different graft materials. Instituting a multicenter prospective study of this magnitude will require considerable organizational and financial effort. Due to the lack of objective
scientific data derived from large-scale trials, sound clinical
judgment must prevail when choosing a bone graft substitute
that will aid the patient in bone formation and fracture healing in the most effective, efficient, safe, and cost-effective
manner.

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