Bone grafting
Encyclopedia
Bone grafting is a surgical procedure that replaces missing bone
in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly.
Bone generally has the ability to regenerate completely but requires a very small fracture space or some sort of scaffold to do so. Bone grafts may be autologous (bone harvested from the patient’s own body, often from the iliac crest
), allograft (cadaveric bone usually obtained from a bone bank), or synthetic (often made of hydroxyapatite or other naturally occurring and biocompatible substances) with similar mechanical properties to bone. Most bone grafts are expected to be reabsorbed and replaced as the natural bone heals over a few months’ time.
The principles involved in successful bone grafts include osteoconduction (guiding the reparative growth of the natural bone), osteoinduction (encouraging undifferentiated cells to become active osteoblasts), and osteogenesis (living bone cells in the graft material contribute to bone remodeling). Osteogenesis only occurs with autografts.
s from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone. In the very least, a bone graft material should be osteoconductive.
s (BMPs). A bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger the formation of new osteoblasts, theoretically promoting faster integration of the graft.
has been shown to enhance the osteoinductive effect of demineralized freeze dried bone allograft
(DFDBA), but will not stimulate de novo
bone growth alone.
, or more commonly in oral and maxillofacial surgery, from the mandibular symphysis (chin area) or anterior mandibular ramus (the coronoid process
); this is particularly true for block grafts, in which a small block of bone is placed whole in the area being grafted. When a block graft will be performed, autogenous bone is the most preferred because there is less risk of the graft rejection because the graft originated from the patient's own body. As indicated in the chart above, such a graft would be osteoinductive and osteogenic, as well as osteoconductive. A negative aspect of autologous grafts is that an additional surgical site is required, in effect adding another potential location for post-operative pain and complications.
Autologous bone is typically harvested from intra-oral sources as the chin or extra-oral sources as the iliac crest
, the fibula, the ribs, the mandible and even parts of the skull
.
All bone requires a blood supply in the transplanted site. Depending on where the transplant site is and the size of the graft, an additional blood supply may be required. For these types of grafts, extraction of the part of the periosteum
and accompanying blood vesels along with donor bone is required. This kind of graft is known as a vital bone graft.
An autograft may also be performed without a solid bony structure, for example using bone reamed from the anterior superior iliac spine
. In this case there is an osteoinductive and osteogenic action, however there is no osteoconductive action, as there is no solid bony structure.
s that have donated their bone so that it can be used for living people who are in need of it; it is typically sourced from a bone bank
.
There are three types of bone allograft available:
can be created from ceramics such as calcium phosphates (e.g. hydroxyapatite and tricalcium phosphate
), Bioglass
and calcium sulphate; all of which are biologically active to different degrees depending on solubility in the physiological environment. These materials can be doped with growth factors, ions such as strontium
or mixed with bone marrow
aspirate to increase biological activity. Some authors believe this method is inferior to autogenous bone grafting however infection and rejection of the graft is much less of a risk, the mechanical properties such as Young's modulus
are comparable to bone. The presence of elements such as strontium
can result in higher bone mineral density and enhanced osteoblast
proliferation in vivo
.
. Xenografts are usually only distributed as a calcified matrix. In January 2010 Italian scientists announced a breakthrough in the use of wood
as a bone substitute, though this technique is not expected to be used for humans until at the earliest 2015.
, a naturally occurring mineral that is also the main mineral component of bone. They may be made from bioactive glass
.
Hydroxylapetite is a Synthetic Bone Graft, which is the most used now among other synthetic due to its osteoconduction, hardness and acceptability by bone. Some synthetic bone grafts are made of calcium carbonate
, which start to decrease in usage because it is completely resorbable in short time which make the bone easy to break again. Finally used is the tricalcium phosphate which now used in combination with hydroxylapatite thus give both effect osteoconduction and resorbability.
enhanced grafts are produced using recombinant DNA technology. They consist of either Human Growth Factors or Morphogens (Bone Morphogenic Proteins in conjunction with a carrier medium, such as collagen).
(without teeth) for a prolonged period may not have enough bone left in the necessary locations. In this case, bone can be taken from the chin or from the pilot holes for the implants or even from the iliac crest of the pelvis and inserted into the mouth underneath the new implant.
In general, bone grafts are either used en block (such as from the chin or the ascending ramus area of the lower jaw) or particulated, in order to be able to adapt it better to a defect.
Another common bone graft, which is more substantial than those used for dental implants, is of the fibular shaft. After the segment of the fibular shaft has been removed normal activities such as running and jumping are permitted on the leg with the bone deficit. The grafted, vascularized fibulas have been used to restore skeletal integrity to long bones of limbs in which congenital bone defects exist and to replace segments of bone after trauma or malignant tumor invasion. The periosteum and nutrient artery are generally removed with the piece of bone so that the graft will remain alive and grow when transplanted into the new host site. Once the transplanted bone is secured into its new location it generally restores blood supply to the bone in which it has been attached.
Besides the main use of bone grafting – dental implants – this procedure is used to fuse joints to prevent movement, repair broken bones that have bone loss, and repair broken bone that has not yet healed.
Bone grafts are used in hopes that the defective bone will be healed or will regrow with little to no graft rejection.
, neurosurgeons, craniofacial surgeons, oral and maxillofacial surgeons, Podiatric Surgeons and periodontists.
, and infection
. Infection is reported to occur in less than 1% of cases and is curable with antibiotics. Overall, patients with a preexisting illness are at a higher risk of getting an infection as opposed to those who are overall healthy.
as a donor site include:
Bone grafts harvested from the posterior iliac crest in general have less morbidity, but depending on the type of surgery, may require a flip while the patient is under general anesthesia.
fees (approximately $350 to $400 per hour), hospital charges (these vary; averaging about $1,500 to $1,800 a day), medication charges ($200 to $400), and additional fees for services such as medical supplies, diagnostic procedures, equipment use fees, etc.
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...
in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly.
Bone generally has the ability to regenerate completely but requires a very small fracture space or some sort of scaffold to do so. Bone grafts may be autologous (bone harvested from the patient’s own body, often from the iliac crest
Iliac crest
-External links: - "Superficial muscles of the gluteal region and posterior thigh." - "Anterior Abdominal Wall: Osteology and Surface Anatomy " - "The Back, Posterior View" * *...
), allograft (cadaveric bone usually obtained from a bone bank), or synthetic (often made of hydroxyapatite or other naturally occurring and biocompatible substances) with similar mechanical properties to bone. Most bone grafts are expected to be reabsorbed and replaced as the natural bone heals over a few months’ time.
The principles involved in successful bone grafts include osteoconduction (guiding the reparative growth of the natural bone), osteoinduction (encouraging undifferentiated cells to become active osteoblasts), and osteogenesis (living bone cells in the graft material contribute to bone remodeling). Osteogenesis only occurs with autografts.
Biological mechanism
Bone grafting is possible because bone tissue, unlike most other tissues, has the ability to regenerate completely if provided the space into which to grow. As native bone grows, it will generally replace the graft material completely, resulting in a fully integrated region of new bone. The biologic mechanisms that provide a rationale for bone grafting are osteoconduction, osteoinduction and osteogenesis.Osteoconduction
Osteoconduction occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone. OsteoblastOsteoblast
Osteoblasts are mononucleate cells that are responsible for bone formation; in essence, osteoblasts are specialized fibroblasts that in addition to fibroblastic products, express bone sialoprotein and osteocalcin.Osteoblasts produce a matrix of osteoid, which is composed mainly of Type I collagen...
s from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone. In the very least, a bone graft material should be osteoconductive.
Osteoinduction
Osteoinduction involves the stimulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators are bone morphogenetic proteinBone morphogenetic protein
Bone morphogenetic proteins are a group of growth factors also known as cytokines and as metabologens . Originally discovered by their ability to induce the formation of bone and cartilage, BMPs are now considered to constitute a group of pivotal morphogenetic signals, orchestrating tissue...
s (BMPs). A bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger the formation of new osteoblasts, theoretically promoting faster integration of the graft.
Osteopromotion
Osteopromotion involves the enhancement of osteoinduction without the possession of osteoinductive properties. For example, enamel matrix derivativeEnamel matrix derivative
In dentistry, enamel matrix derivative is an extract of porcine fetal tooth material used to biomimetically stimulate the soft and hard tissues surrounding teeth to regrow following tissue destruction....
has been shown to enhance the osteoinductive effect of demineralized freeze dried bone allograft
Demineralized freeze dried bone allograft
Demineralized freeze dried bone allograft, referred to as DFDBA, is a bone graft material known for its de novo bone formation properties. It is used extensively in bone grafting of alveolar bone in oral and periodontal surgery....
(DFDBA), but will not stimulate de novo
De novo
In general usage, de novo is a Latin expression meaning "from the beginning," "afresh," "anew," "beginning again." It is used in:* De novo transcriptome assembly, the method of creating a transcriptome without a reference genome...
bone growth alone.
Osteogenesis
Osteogenesis occurs when vital osteoblasts originating from the bone graft material contribute to new bone growth along with bone growth generated via the other two mechanisms.Autograft
Autologous (or autogenous) bone grafting involves utilizing bone obtained from the same individual receiving the graft. Bone can be harvested from non-essential bones, such as from the iliac crestIliac crest
-External links: - "Superficial muscles of the gluteal region and posterior thigh." - "Anterior Abdominal Wall: Osteology and Surface Anatomy " - "The Back, Posterior View" * *...
, or more commonly in oral and maxillofacial surgery, from the mandibular symphysis (chin area) or anterior mandibular ramus (the coronoid process
Coronoid process of the mandible
The mandible's coronoid process is a thin, triangular eminence, which is flattened from side to side and varies in shape and size....
); this is particularly true for block grafts, in which a small block of bone is placed whole in the area being grafted. When a block graft will be performed, autogenous bone is the most preferred because there is less risk of the graft rejection because the graft originated from the patient's own body. As indicated in the chart above, such a graft would be osteoinductive and osteogenic, as well as osteoconductive. A negative aspect of autologous grafts is that an additional surgical site is required, in effect adding another potential location for post-operative pain and complications.
Autologous bone is typically harvested from intra-oral sources as the chin or extra-oral sources as the iliac crest
Iliac crest
-External links: - "Superficial muscles of the gluteal region and posterior thigh." - "Anterior Abdominal Wall: Osteology and Surface Anatomy " - "The Back, Posterior View" * *...
, the fibula, the ribs, the mandible and even parts of the skull
Human skull
The human skull is a bony structure, skeleton, that is in the human head and which supports the structures of the face and forms a cavity for the brain.In humans, the adult skull is normally made up of 22 bones...
.
All bone requires a blood supply in the transplanted site. Depending on where the transplant site is and the size of the graft, an additional blood supply may be required. For these types of grafts, extraction of the part of the periosteum
Periosteum
Periosteum is a membrane that lines the outer surface of all bones, except at the joints of long bones. Endosteum lines the inner surface of all bones....
and accompanying blood vesels along with donor bone is required. This kind of graft is known as a vital bone graft.
An autograft may also be performed without a solid bony structure, for example using bone reamed from the anterior superior iliac spine
Anterior superior iliac spine
The anterior superior iliac spine is an important landmark of surface anatomy. It refers to the anterior extremity of the iliac crest of the pelvis, which provides attachment for the inguinal ligament, and the sartorius muscle...
. In this case there is an osteoinductive and osteogenic action, however there is no osteoconductive action, as there is no solid bony structure.
Allografts
Allograft bone, like autogenous bone, is derived from humans; the difference is that allograft is harvested from an individual other than the one receiving the graft. Allograft bone is taken from cadaverCadaver
A cadaver is a dead human body.Cadaver may also refer to:* Cadaver tomb, tomb featuring an effigy in the form of a decomposing body* Cadaver , a video game* cadaver A command-line WebDAV client for Unix....
s that have donated their bone so that it can be used for living people who are in need of it; it is typically sourced from a bone bank
Tissue bank
A Tissue Bank, as used in this article, is a term most commonly used to describe an establishment that collects and harvests human cadaver tissue for the purposes of medical research and education....
.
There are three types of bone allograft available:
- Fresh or fresh-frozen bone
- Freeze-dried bone allograft (FDBA)
- Demineralized freeze-dried bone allograft (DFDBA)
Synthetic variants
Artificial boneArtificial bone
Artificial bone refers to bone-like material created in a laboratory that can be used in bone grafts, to replace human bone that was lost due to severe fractures, disease, etc.-Overview:...
can be created from ceramics such as calcium phosphates (e.g. hydroxyapatite and tricalcium phosphate
Tricalcium phosphate
Tricalcium phosphate is a calcium salt of phosphoric acid with the chemical formula Ca32. It is also known as tribasic calcium phosphate or "bone ash" ....
), Bioglass
Bioglass
Bioglass is a commercially available family of bioactive glasses, composed of SiO2, Na2O, CaO and P2O5 in specific proportions. The proportions differ from the traditional soda-lime glasses in low amount of silica , high amount of sodium and calcium, and high calcium/phosphorus ratio.High ratio of...
and calcium sulphate; all of which are biologically active to different degrees depending on solubility in the physiological environment. These materials can be doped with growth factors, ions such as strontium
Strontium
Strontium is a chemical element with the symbol Sr and the atomic number 38. An alkaline earth metal, strontium is a soft silver-white or yellowish metallic element that is highly reactive chemically. The metal turns yellow when exposed to air. It occurs naturally in the minerals celestine and...
or mixed with bone marrow
Bone marrow
Bone marrow is the flexible tissue found in the interior of bones. In humans, bone marrow in large bones produces new blood cells. On average, bone marrow constitutes 4% of the total body mass of humans; in adults weighing 65 kg , bone marrow accounts for approximately 2.6 kg...
aspirate to increase biological activity. Some authors believe this method is inferior to autogenous bone grafting however infection and rejection of the graft is much less of a risk, the mechanical properties such as Young's modulus
Young's modulus
Young's modulus is a measure of the stiffness of an elastic material and is a quantity used to characterize materials. It is defined as the ratio of the uniaxial stress over the uniaxial strain in the range of stress in which Hooke's Law holds. In solid mechanics, the slope of the stress-strain...
are comparable to bone. The presence of elements such as strontium
Strontium
Strontium is a chemical element with the symbol Sr and the atomic number 38. An alkaline earth metal, strontium is a soft silver-white or yellowish metallic element that is highly reactive chemically. The metal turns yellow when exposed to air. It occurs naturally in the minerals celestine and...
can result in higher bone mineral density and enhanced osteoblast
Osteoblast
Osteoblasts are mononucleate cells that are responsible for bone formation; in essence, osteoblasts are specialized fibroblasts that in addition to fibroblastic products, express bone sialoprotein and osteocalcin.Osteoblasts produce a matrix of osteoid, which is composed mainly of Type I collagen...
proliferation in vivo
In vivo
In vivo is experimentation using a whole, living organism as opposed to a partial or dead organism, or an in vitro controlled environment. Animal testing and clinical trials are two forms of in vivo research...
.
Xenografts
Xenograft bone substitute has its origin from a species other than human, such as bovineCattle
Cattle are the most common type of large domesticated ungulates. They are a prominent modern member of the subfamily Bovinae, are the most widespread species of the genus Bos, and are most commonly classified collectively as Bos primigenius...
. Xenografts are usually only distributed as a calcified matrix. In January 2010 Italian scientists announced a breakthrough in the use of wood
Wood
Wood is a hard, fibrous tissue found in many trees. It has been used for hundreds of thousands of years for both fuel and as a construction material. It is an organic material, a natural composite of cellulose fibers embedded in a matrix of lignin which resists compression...
as a bone substitute, though this technique is not expected to be used for humans until at the earliest 2015.
Alloplastic grafts
Alloplastic grafts may be made from hydroxylapatiteHydroxylapatite
Hydroxylapatite, also called hydroxyapatite , is a naturally occurring mineral form of calcium apatite with the formula Ca53, but is usually written Ca1062 to denote that the crystal unit cell comprises two entities. Hydroxylapatite is the hydroxyl endmember of the complex apatite group...
, a naturally occurring mineral that is also the main mineral component of bone. They may be made from bioactive glass
Bioactive glass
Bioactive glasses are a group of surface reactive glass-ceramic biomaterials and include the original bioactive glass, Bioglass. The biocompatibility of these glasses has led them to be investigated extensively for use as implant materials in the human body to repair and replace diseased or damaged...
.
Hydroxylapetite is a Synthetic Bone Graft, which is the most used now among other synthetic due to its osteoconduction, hardness and acceptability by bone. Some synthetic bone grafts are made of calcium carbonate
Calcium carbonate
Calcium carbonate is a chemical compound with the formula CaCO3. It is a common substance found in rocks in all parts of the world, and is the main component of shells of marine organisms, snails, coal balls, pearls, and eggshells. Calcium carbonate is the active ingredient in agricultural lime,...
, which start to decrease in usage because it is completely resorbable in short time which make the bone easy to break again. Finally used is the tricalcium phosphate which now used in combination with hydroxylapatite thus give both effect osteoconduction and resorbability.
Growth Factors
Growth FactorGrowth factor
A growth factor is a naturally occurring substance capable of stimulating cellular growth, proliferation and cellular differentiation. Usually it is a protein or a steroid hormone. Growth factors are important for regulating a variety of cellular processes....
enhanced grafts are produced using recombinant DNA technology. They consist of either Human Growth Factors or Morphogens (Bone Morphogenic Proteins in conjunction with a carrier medium, such as collagen).
Uses
The most common use of bone grafting is in the application of dental implants, in order to restore the edentulous area of a missing tooth. Dental implants require bones underneath them for support and to have the implant integrate properly into the mouth. People who have been edentulousEdentulism
Edentulism is the condition of being toothless to at least some degree; it is the result of tooth loss. Loss of some teeth results in partial edentulism, while loss of all teeth results in complete edentulism....
(without teeth) for a prolonged period may not have enough bone left in the necessary locations. In this case, bone can be taken from the chin or from the pilot holes for the implants or even from the iliac crest of the pelvis and inserted into the mouth underneath the new implant.
In general, bone grafts are either used en block (such as from the chin or the ascending ramus area of the lower jaw) or particulated, in order to be able to adapt it better to a defect.
Another common bone graft, which is more substantial than those used for dental implants, is of the fibular shaft. After the segment of the fibular shaft has been removed normal activities such as running and jumping are permitted on the leg with the bone deficit. The grafted, vascularized fibulas have been used to restore skeletal integrity to long bones of limbs in which congenital bone defects exist and to replace segments of bone after trauma or malignant tumor invasion. The periosteum and nutrient artery are generally removed with the piece of bone so that the graft will remain alive and grow when transplanted into the new host site. Once the transplanted bone is secured into its new location it generally restores blood supply to the bone in which it has been attached.
Besides the main use of bone grafting – dental implants – this procedure is used to fuse joints to prevent movement, repair broken bones that have bone loss, and repair broken bone that has not yet healed.
Bone grafts are used in hopes that the defective bone will be healed or will regrow with little to no graft rejection.
Procedure
Depending on where the bone graft is needed, a different doctor may be requested to do the surgery. Doctors that do bone graft procedures are commonly orthopedic surgeons, otolaryngology head and neck surgeonsOtolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....
, neurosurgeons, craniofacial surgeons, oral and maxillofacial surgeons, Podiatric Surgeons and periodontists.
Risks
As with any procedure, there are risks involved; among these include reactions to medicine and problems breathing, bleedingBleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
, and infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
. Infection is reported to occur in less than 1% of cases and is curable with antibiotics. Overall, patients with a preexisting illness are at a higher risk of getting an infection as opposed to those who are overall healthy.
Risks for grafts from the iliac crest
Some of the potential risks and complications of bone grafts employing the iliac crestIliac crest
-External links: - "Superficial muscles of the gluteal region and posterior thigh." - "Anterior Abdominal Wall: Osteology and Surface Anatomy " - "The Back, Posterior View" * *...
as a donor site include:
- acquired bowel herniation (this becomes a risk for larger donor sites (>4 cm)). About 20 cases have been reported in the literature from 1945 till 1989 and only a few hundred cases have been reported worldwide
- meralgia paresthetica (injury to the lateral femoral cutaneous nerve also called Bernhardt-Roth's syndrome)
- pelvic instability
- fractureHip fractureA hip fracture is a femoral fracture that occurs in the proximal end of the femur , near the hip.The term "hip fracture" is commonly used to refer to four different fracture patterns and is often due to osteoporosis; in the vast majority of cases, a hip fracture is a fragility fracture due to a...
(extremely rare and usually with other factors) - injury to the clunial nervesClunial nervesThe clunial nerves are cutaneous nerves of the buttocks. They are often classified according to where on the buttocks they innervate. Specifically, the nerves are as follows:* Superior clunial nerves* Medial clunial nerves...
(this will cause posterior pelvic pain which is worsened by sitting) - injury to the ilioinguinal nerveIlioinguinal nerveThe ilioinguinal nerve is a branch of the first lumbar nerve . It separates from the first lumbar nerve along with the larger iliohypogastric nerve....
- infection
- minor hematomaHematomaA hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
(a common occurrence) - deep hematomaHematomaA hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
requiring surgical intervention - seromaSeromaA seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid....
- ureteral injury
- pseudoaneurysm of iliac artery (rare)
- tumor transplantation
- cosmetic defects (chiefly caused by not preserving the superior pelvic brim)
- chronic pain
Bone grafts harvested from the posterior iliac crest in general have less morbidity, but depending on the type of surgery, may require a flip while the patient is under general anesthesia.
Recovery and Aftercare
The amount of time it takes for an individual to recovery depends on the severity of the injury being treated and lasts anywhere from 2 weeks to 2 months with a possibility of vigorous exercise being barred for up to 6 months.Costs
Bone graft procedures consist of more than just the surgery. The average cost of bone graft procedures ranges from approximately $33,860 to $37,227. US Example pricing: Besides the cost of the bone graft itself (ranging from $250 to $900) other expenses for the procedure include: surgeon's fees (these vary), anesthesiologistAnesthesiologist
An anesthesiologist or anaesthetist is a physician trained in anesthesia and peri-operative medicine....
fees (approximately $350 to $400 per hour), hospital charges (these vary; averaging about $1,500 to $1,800 a day), medication charges ($200 to $400), and additional fees for services such as medical supplies, diagnostic procedures, equipment use fees, etc.
See also
- Bone healingBone healingBone healing, or fracture healing, is a proliferative physiological process in which the body facilitates the repair of a bone fracture....
- Dental bone graft
- Graft-versus-host diseaseGraft-versus-host diseaseGraft-versus-host disease is a common complication after a stem cell transplant or bone marrow transplant from another person . Immune cells in the donated marrow or stem cells recognize the recipient as "foreign". The transplanted immune cells then attack the host's body cells...
- Hydroxyapatite
- Periodontics
- Oral and Maxillofacial SurgeryOral and maxillofacial surgeryOral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is an internationally recognized surgical specialty...
- Orthopedic surgeryOrthopedic surgeryOrthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system...
- Osteosynt
- OsseointegrationOsseointegrationOsseointegration derives from the Greek osteon, bone, and the Latin integrare, to make whole. The term refers to the direct structural and functional connection between living bone and the surface of a load-bearing artificial implant...