A Guide To Orthobiologics In Podiatric Surgery
In our ongoing quest to find viable graft alternatives in bone fracture and primary osseous repair, the technology of orthobiologic bone substitutes continues to evolve. Traditionally, we have looked for replacement bone from sources within the patient’s own body. Indeed, autograft is widely considered the gold standard for grafting. While autograft bone is superior in its ability to provide osteogenic mesenchymal stem cells, it does have a couple of inherent problems, namely, a limited supply and morbidity associated with harvesting from donor sites.
Accordingly, we have brought together a panel of experts with broad and practical experience in using state-of-the-art alternatives to traditional bone autografts for bone defect management in podiatric surgery. In addition to discussing their use of orthobiologics as graft enhancers, the panelists review key indications for the three classes of orthobiologic materials and offer pertinent insights on bioceramic materials. They also speculate about the future potential of orthobiologics. Here are their thoughts.
Mark Dollard, DPM: What are the unique uses or surgical techniques in which you currently use orthobiologic materials as graft enhancers or expanders?
Glenn Weinraub, DPM, has used orthobiologics extensively and touts the use of autologous platelet gel concentrate (PGC) systems for their many applications. He notes that he impregnates all allogenic bone graft material with the platelet gel concentrate. Doing so enhances local inductivity, according to Dr. Weinraub. Dr. Weinraub also utilizes PGC on split thickness skin grafts, noting that the concentrate mimics the first phase of graft take. He says surgeons may also mix PGC with demineralized bone matrix (DBM) materials.
D. Scot Malay, DPM, routinely uses DBM in combination with either calcium phosphate or calcium sulfate bioceramic at the donor site after harvesting cancellous bone graft. He also employs this combination after evacuation and curettage of a solitary or aneurysmal bone cyst.
Another “very valuable” byproduct of the PGC system is its fibrinogen rich but platelet poor content, notes Dr. Weinraub. He adds that the combination of PGC with thrombin is an excellent natural hemostatic agent. Dr. Weinraub cites research by Mooar, et. al., who demonstrated a significant decrease in pain level and narcotic use as well as less change in hemoglobin and hematocrit in the early post-op period when surgeons used platelet poor plasma in total knee replacement surgery.1
When it comes to bone graft substitutes, surgeons would use them in place of corticocancellous and/or cancellous allograft or autograft bone, according to Thomas Zgonis, DPM. He says one may use bone graft substitutes for patients who have a prolonged history of nicotine use and autoimmune diseases including diabetes mellitus. Kieran Mahan, DPM, concurs, noting that he will use orthobiologic materials for fusions and “in situations in which there might be difficulty healing.”
Dr. Zgonis has used orthobiologics to stimulate a fracture site that has failed to heal by conventional means and to stimulate bone healing in an arthrodesis site on a diseased joint. Whenever an osseous defect or interface cleft is present during an arthrodesis or bone grafting procedure, Dr. Malay notes he will use DBM in combination with either calcium phosphate or calcium sulfate. Surgeons may place DBM gel into arthroscopic ankle fusion sites under direct arthroscopic visualization, adds Dr. Weinraub.
Dr. Weinraub notes that one may use the aforementioned PGC for backfill of large half-pin sites with an antibiotic-impregnated, ceramic-like triphosphate. Luis Leal, DPM, notes that he utilizes orthobiologics for potential packing defects that may occur during deformity correction with open osteotomies or arthrodesis of the hindfoot and ankle.