Modern issues in bone graft substitutes and advances in bone tissue technology

Autogenous bone grafting is the gold standard in repair of bony defects, fracture nonunion, and promoting arthrodesis. The complications related to obtaining autogenous grafts can be significant, and numerous materials are now available for augmentation or substitution. Allograft materials are highly effective for most applications; however, the surgeon needs to be acutely aware of the source of the tissue, for some tissue banks still use unacceptable processing techniques that destroy the structural and osteoinductive capacities of the graft. DBM products are unregulated and serious concerns exist as to the distribution of inactive products as commercially available to the practicing surgeon. Pressure from the orthopedic community has caused some manufacturers to test their products for activity before distribution. Calcium-based ceramic materials are effective as osteoconductive agents and work well alone as bone void fillers; however, augmentation of these implants with osteoinductive materials should be considered for use in nonunions and arthrodesis. Composite materials that incorporate osteoinductive materials in osteoconductive scaffolds are promising. New technology in isolation and creation of recombinant human bone morphogenic proteins and growth factors, and in the application of autogenous stem cells are emerging as the future of bone grafting procedures.