Injury, Int. J.

Care Injured 42 (2011) S26–S29

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Bioactive and osteoinductive bone graft substitutes: Definitions, facts and myths
T.J. Blokhuis a,*, J.J. Chris Arts b
a
University Medical Centre Utrecht, Heidelberglaan 100, P.O. Box 85500, Utrecht, The Netherlands
b
Department of Orthopaedic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: The use of artificial bone grafts has been developed over recent years and is expected to increase further,
Bone graft substitutes for some indications even replacing the gold standard, autograft, in trauma and reconstructive surgery.
Autologous bone graft However, the effectiveness of these materials is still a subject of debate, mostly because of unclear
BMPs definitions or limited market surveillance. In this overview several facts and myths regarding bone-graft
Clacium Phospahtes
substitutes are summarized.
Allograft
DBM
ß 2011 Elsevier Ltd. All rights reserved.

Introduction phosphate ceramics, bone integration and bonding can be influ-

enced.1–3 From a cellular perspective, bioactivity reflects the
The complications associated with harvesting bone grafts from attachment and differentiation of osteogenic cells on ceramic
the iliac crest, as well as the limited availability in some patients, surfaces.4–6
suggest the need for bone-graft substitutes. Although still Osteogenic bone-graft materials have the intrinsic capacity to
considered the gold standard, autologous bone-graft harvesting stimulate bone healing by the presence of cells. In general these
is associated with chronic pain, operative complications, and cells are mesenchymal stem cells, or osteoprogenitors.
cosmetic consequences for patients. It is considered an ideal bone Osteoconductivity is the ability of a material to provide a scaffold
graft, as it is osteoconductive, osteogenic, and contains growth for bone formation. The material provides a surface for cells to
factors associated with osteoinduction. These characteristics are attach, proliferate, and deposit bone matrix, mostly collagen type 1.
therefore the requirements sought in bone-graft substitutes, and The cells responsible are either mesenchymal stem cells or
manufacturers often describe their materials as being bioactive or osteoblasts, and the environment or surface offered by the
osteoinductive. However, whether this is justified depends on the osteoconductive material should be favourable to the survival of
definition of osteoinduction, and this definition is not linked to the these cells.
clinical situation. This leads to discrepancies in reports and myths Osteoinduction has been defined in different ways. Marshal Urist
surrounding bone-graft substitutes. In this overview, properties was one of the first to describe this as a process which supports the
will be described for several groups of bone-graft substitutes, and mitogenesis of undifferentiated perivascular mesenchymal cells
the relevant literature will be summarized. leading to the formation of osteoprogenitor cells with the capacity to
form new bone.7 This definition was also adopted more recently
during the Orthopaedic Trauma Association (OTA) meeting in 2003.
Definitions
The term osteoinduction implies a mechanism by which mesenchy-
mal tissue is induced to change its cellular structure to become
The properties mentioned – bioactive, osteogenic, osteocon-
osteogenic: in other words, to form bone. Since the identification of
ductive, and osteoinductive – can be defined in different ways, and
bone morphogenetic proteins (BMPs), this process has been
several definitions have been provided in the literature.
elucidated to a large extent. The events occurring at a cellular level
Bioactivity can be described as the occurrence of an interaction
involve the differentiation of mesenchymal stem cells, or osteopro-
between a biomaterial and the surrounding tissue. In bone-graft
genitors, to osteoblasts, and hence the formation of bone. Although
substitutes, bioactivity describes the influence of a material on bone
the interaction between BMPs and osteoprogenitors has been well
formation. By changing surface properties of (especially) calcium
studied, the role of other factors involved in the process of bone
formation remains unclear. Dosage of BMPs and mixture of BMPs
* Corresponding author. Tel.: +31 88 755 9882; fax: +31 88 7555015.
are examples of factors that have not yet been investigated. For
E-mail address: [email protected] (T.J. Blokhuis). clinical purposes, the dosage of the two commercially available

0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2011.06.010
 T.J. Blokhuis, J.J.C. Arts / Injury, Int. J. Care Injured 42 (2011) S26–S29 S27

recombinant human BMPs, BMP-2 and BMP-7, has been determined considerations should be taken into account, such as transmission of
in dose-finding studies aiming at specific interventions. Also, we disease,13,14 decreasing supply, and a high failure rate.15
know that BMPs are expressed according to a specific temporal The AATB requires tissue banks to adopt a strict protocol for
pattern throughout bone formation.8 However, it is not clear screening of bone tissue. Harvesting techniques and donor
whether the expression of BMPs is evoked by other BMPs or screening must be rigorous in order to avoid transmission of
dependant on the expression of other BMPs. The clinical successes disease. Nucleic acid testing (NAT) has been introduced for
achieved with single-dose rhBMPs suggest that a mixture of BMPs is detection of human immunodeficiency virus (HIV) and hepatitis
not a prerequisite for bone formation. C virus.16 However, not all tissue banks have been accredited by
the AATB, and in other countries regulations are different and not
Facts obligatory for bone banks.17 Moreover, NAT screening is not
effective for bacterial infections, and indeed these infections have
Although various definitions of properties are used, several been reported.18,19 Also, living bone cells can be cultured from
characteristics of certain graft materials can be described based on deep-frozen allografts,20 indicating that transmission is more
the literature. This will be done for each group of graft substitutes. likely than some may assume. For these reasons safety of allograft
Groups of bone graft substitutes: remains a crucial factor in its application.
Allograft can be applied in several ways: as bone chips, or as
 autologous bone structural cortical allografts, which can be vascularized or non-
 bone-derived allografts vascularized. Incorporation depends on both host characteristics and
 demineralized bone matrix (DBM) graft characteristics.9 Allograft properties are influenced by the
 calcium phosphate (Ca-P) bone substitutes preparation and sterilization of the material. The preparation process
 BMPs of allograft material can be fresh-frozen, freeze-dried, or deminer-
alized. Mechanical strength and vascularization in freeze-dried
allografts are significantly reduced,21–23 but freezing is insufficient
Autologous bone for sterilization20 and therefore irradiation is often performed as
well.16,24 This affects the immunogenicity of the graft material, but it
Long considered the gold standard in bone grafting, autologous also affects the mechanical and biological properties,16,25 leading to a
bone is widely used. It is known to be osteoconductive (due to the reduction in incorporation to approximately 40%26,27 instead of 80–
presence of bone chips), osteoinductive (due to the presence of 100% in non-irradiated grafts.28–30 The reduced incorporation is a
growth factors) and osteogenic (due to the presence of cells). reflection of reduced osteoinduction, a property that is already
Nevertheless, its use is associated with disadvantages and limited in allografts.31,32 The limited osteoinduction of an allograft
morbidity. Chronic pain, infections, iatrogenic fractures, and poor contributes to the failure of the allograft, which is reported at 15–20%
cosmetic outcome are amongst the most frequently cited due to fracture or non-union.15,33
disadvantages in the literature. Less often mentioned disadvan-
tages include the decrease in biological activity in the elderly DBM
patient, and the bone loss in primary or secondary osteoporosis,
which affects the consistency of the autologous bone graft just as DBM is manufactured by acid extraction of allograft bone. After
much as it affects the rest of the skeleton. crushing the allograft bone, cells and minerals are removed from the
Another issue to consider is the volume of the graft. The volume matrix by acid extraction. Originally this process was performed
harvested from the iliac crest is not always sufficient to fill the using 0.5N HCl mEq/g, and many variations have been introduced
defects in the bone. Harvesting autologous bone with the Reamer– since.34 Collagen and proteins – including BMPs – are left behind in
irrigator–aspirator system (RIA) is promising in this respect; the the material, but the activity of BMPs is influenced by the processing
volume increases to 50 or 60 mL, which is substantially more than of the allograft. Other variations in the biological activity of DBM are
that reported for iliac crest harvesting. Growth factors are present caused by storage and sterilization or radiation processes. A
in abundance in the RIA product, and the first results are substantial decrease in osteoinductive capacity was described after
promising. For harvesting the bone with the RIA system, a one- sterilization by ethylene oxide or gamma irradiation
step procedure is used. Although not yet reported, this procedure The osteoinductive capacity of DBM was described by Urist in
can induce iatrogenic fractures, and cautious planning is therefore 1965 in his seminal experiments on induction of bone,7 and this
obligatory. Furthermore, diaphyseal blood flow is temporarily claim is often repeated by manufacturers of commercially
diminished, and the effect of RIA on erythropoiesis is a theoretical available DBM products. However, substantial scientific data are
concern that should be addressed.9,10 lacking, especially in comparative studies. In vitro studies have
In short, despite its advantages, the use of autologous bone shown repeatedly that the amounts of BMPs and other growth
brings about serious morbidity and is not always available or factors vary amongst different products.35,36 Moreover, concen-
feasible. For many involved in bone treatment the application of trations within one product are variable, with a coefficient of
autologous bone is a logical first step, if not a reflex. In our view, variation as high as 76% for the concentration of BMP-2 within one
this automatic reaction should be replaced by careful consider- product. One of the possible explanations for this variation is the
ation, and especially careful thoughts on the alternatives. Some fact that DBM is produced from allograft from one donor at a time,
authors even state that autografting is not justified in specific and different donors have different amounts of growth factors
indications, i.e. tibial plateau fractures.11 present. The variation in growth factors present in the product
adds up to the decrease in biological activity due to preparation
Bone-derived allograft and sterilization, making the osteoinductive capacity of DBM in
humans questionable and perhaps not efficacious.37
In 35% of all bone transplantations human allograft tissue is Evidence regarding the use of DBM is surprisingly limited. Most
used.12 The regulations for bone transplantation are mostly adopted studies are performed in animal experiments or in vitro, and
from the American Association of Tissue Banks (AATB). Allografts are clinical studies are mostly descriptive. The classification of DBM by
available in different preparations and forms, and handling is the Food and Drug Administration (FDA) is a factor that contributes
relatively easy. Nevertheless, some safety concerns and biological to this limited amount of evidence, meaning that only marketing is
S28 T.J. Blokhuis, J.J.C. Arts / Injury, Int. J. Care Injured 42 (2011) S26–S29

regulated by the FDA, and not, for example, efficacy. In the United by thorough analyses of cost effectiveness. Although the evidence
States, DBM is classified as a minimally manipulated tissue for regarding cost effectiveness is not as extensive as the clinical data,
transplantation, so historically there has been little regulatory the available studies show a tendency towards a better cost
control over the claims made by tissue processing facilities. In vitro effectiveness for BMPs compared to autograft. There are some
studies have shown osteoinduction in various models, but differences between European countries, and this reflects the local
translation of animal studies to clinical application is not always reimbursement policies. With ongoing analyses of various studies,
successful. The regulatory aspects limit a long term follow-up, and this issue will soon be resolved.
hence the evidence for clinical application is poor.
Calcium phosphate (Ca-P) bone substitutes are similar in Myths
composition to the mineral phase of native bone and mainly
consist of hydroxyapatite (HA) or tricalcium phosphate (TCP) or a The practical definition of a material as being osteoinductive is
biphasic mixture of both (BCP). Ca-P bone substitutes are available ectopic bone formation in athymic nude mice or an ectopic site in
as preshaped forms (wedges/blocks), granules, pastes and various animal models. Manufacturers claim osteoinductive
cements. Manufacturing techniques can provide porosity, influ- properties after bone formation in such models has been
ence surface area and pore size, all having an effect on the determined. However, translation of these results to the human
biological and healing potential. Whilst all Ca-P bone substitutes situation is not warranted. As a practical example, several calcium
are bioactive, biodegradable and osteoconductive, they are not phosphate bone substitutes have been marketed as osteoinductive
osteoinductive by themselves. Ca-P bone substitutes are brittle, on the basis of experiments in different animal models where they
possess little tensile strength, and offer limited structural integrity, possess the ability to form bone at ectopic sites. The osteoinductive
and their mechanical properties correlate closely with porosity properties of these materials appear to be based on their
percentage and pore size characteristics. architectural features – such as geometry, topography, and
It is well established that porosity is an essential factor in ostoid porosity – which allow entrapment and concentration of circulat-
formation, but only when pore size exceeds 100 mm.38 Degrad- ing BMPs. When this concentration of BMPs overtakes a certain
ability of Ca-P bone substitutes is mediated by cells such as threshold, which is a lengthy process, they will induce bone
osteoclasts or macrophages, or occurs by in vivo dissolution. formation independent of the calcium phosphate carrier.38 Hence,
Crystallinity, particle size, surface area, porosity of the material, as in reality we are observing delayed osteoinduction by BMPs
well as the mechanical and biological environment play a role in naturally occurring in the body. It must be stressed in this
the degradation process. perspective that translation of animal results to clinical situations
Ca-P bone substitutes are regulated under 510(k) premarket is not always appropriate, and the results achieved in animal
notification process, meaning that manufacturers must provide studies are not always reproducible in humans.39 It is therefore
data showing that the new product is substantially equivalent to simply not justified to state that the osteoinductive properties of
an already approved and legally marketed device. Yet there materials reflect their clinical application.
remains a large variance in established level of evidence between
products.
Conclusion
BMPs
Developments in the field of bone-graft substitutes have been
extensive over recent decades, leading to many confusing
Osteoinduction is achieved by the application of BMPs in both
statements regarding the properties of these substitutes. Osteoin-
experimental and clinical studies. The use of BMPs – either BMP-2
duction is frequently mentioned as a property, indicating the
or BMP-7 – is registered for specific indications. In long bones BMP-
ability of a material to induce bone formation. Although the term
2 is used for acute defects in the tibia, and BMP-7 is used for non-
itself may be appropriate, it does not necessarily describe the
unions in the tibia where prior bone grafting has failed or bone
capability of a material to form bone in a clinical situation. If the
grafting is not considered feasible. In the spine both BMP-2 and
term were used in this manner, only a few graft substitutes would
BMP-7 have registered indications. From a regulatory standpoint
live up to expectations. Careful screening of the literature is still
the difference from other bone-graft substitutes is the fact that
the responsibility of the treating physician, and such screening
BMP-2 and BMP-7 are registered as drugs, not as devices. This
brings to light significant differences between materials. Osteoin-
results in a significant amount of data for registration purposes,
duction in a clinical situation is only induced by supra-physiologi-
and thus a large amount of evidence is available. Currently, it is safe
cal dosages of BMPs, and to some extent by autograft. Given the
to say that level-I evidence is available for BMP-2 and BMP-7, at
low dosage of BMPs in DBM materials, and the variation within
least for the indications mentioned. The efficacy and safety of these
these materials, this cannot be stated for DBM preparations. A
grafts is well established, and in the near future the number of
stricter guideline is expected to be issued by the FDA, and this may
registered indications are expected to increase. A major drawback
provide more insight in this field.
in the evidence surrounding BMP efficacy is the sponsoring of trials
by industry, suggesting biased outcomes. Still, the size and costs of
these large trials make it virtually impossible for public institutions Conflicts of interest
to undertake such studies, so in general industrial involvement is
difficult to avoid. A study comparing treatment strategies is also None.
almost impossible to execute for the same reason of industry
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