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- Discussion: (see fracture healing and management of tibial bone defects)
    - autograft: bone graft harvest techniques
    - allografts
    - induced membrane technique
    - bone marrow aspirates:
           - in order to maximum the concentration of osteoblast precursors, no more than 2 cc should be aspirated from any single anatomic site;
           - unless the surgeon has specific training in bone marrow harvest technique, then it is more likely that the aspiration
                    will yield blood rather than marrow;
           - references:
                  - Aspiration to obtain osteoblast progenitor cells from human bone marrow: The influence of aspiration volume
                  - Percutaneous Autologous Bone-Marrow Grafting for Nonunions. Influence of the Number and Concentration of Progenitor Cells. 
    - synthese reamer aspirator
           - Hemorrhagic induced cardiovascular complications during Reamer-Irrigator-Aspirator assisted femoral nonunion treatment.  

    - bone grafting for
open fractures:
           - it is controversial as to whether bone grafting should be performed in open fractures;
                  - Chapman, et al (1997) 31% of open frx treated w/ bone graft substitutes & 28% of open frx were treated w/ autogenous bone grafts;
                  - infection at frx site occured in 5% w/ bone graft substitutes were used vs 13% of fractures in which autogenous grafts were used;
                              - Treatment of acute fractures with a collagen-calcium phosphate graft material. A randomized clinical trial.
    - osteogenic proteins:
    - bone graft substitutes: 
           - used when there is stable fixation and no need for structural support;  
           - main disadvantage of these substitutues is that they cannot be easily "packed" into the frx or non union site (where as cancellous
                  allograft chips can be nicely impacted into the bone defect);
                  - with soft allograft substitutes (such as grafton), once the material fills the defect, it is difficult to stuff in additional graft;
           - demineralized bone matrix:
                  - hydrochloric acid is the agent of choice for demineralization;
                  - grafton: type of demineralized bone matrix from Osteotech, Inc. 
                  - ref: 
           - calcium phosphate:
                  - hydroxyapatite
                          - pro-osteon and interpore:
                                  - preparation includes heating a species specific coral (calcium carbonate) in an aqueous phosphate solution bath, the
                                             result of which is exchange of the calcium carbonate skeleton to a calcium phosphate skeleton;
                                  - disadvantages include poor osteoinduction, poor absorption, and poor handling (material is not moldable);
                  - moldable hydroxyapatite;
                          - bone source (orthofix):
                                  - made up of two compounds (tetracalcium phosphate and dicalcium dihydrate) which when mixed together with water
                                           causes them to solidify into a hardened cement over 10-15 min;
                          - collagraft (zimmer):
                                  - consists of type I collagen, a biphasic ceramic (hydroxyapatite and tricalcium phosphate), and bone marrow;
                                  - may be used in open fractures;
                                  - references:
                                            - Multicenter trial of Collagraft as bone graft substitute.  
                                            - Calcium phosphates: what is the evidence?

           - calcium sulfate:  (see properties of vancomycin in ca sulfate)
                 - biologically inert osteoconductive material which serves as a temporary scaffold for osteoblasts;
                 - osteoset (wright medical technology):
                          - typically dissolves in one to two months; 
                 - references:
                          - Calcium sulfates: what is the evidence?
                          - The use of calcium sulfate impregnated with vancomycin in the treatment of open fractures of long bones: a preliminary study.
                          - Calcium Sulfate- and Calcium Phosphate-Based Bone Substitutes. Mimicry of the Mineral Phase of Bone
                          - 50 Years Ago in CORR: The Use of Plaster of Paris to Fill Defects in Bone Leonard F. Peltier, MD CORR 1961;21:1–31