The art of bone grafting

Purpose of review: The purpose of the review is to highlight recent advances in bone graft techniques and make evidence-based recommendations concerning their surgical application. Recent findings: Extensive preclinical and clinical studies have led to a better understanding of bone osteogenesis resulting in the classification of bone graft materials as osteopromotive, osteoinductive, or osteoconductive. Of particular note is discovery of the osteoinductivity of demineralized bone matrix proteins and the eventual use of recombinant genetically engineered cells to produce a single human protein, bone morphogenetic protein. Preclinical research has demonstrated that when bone morphogenetic protein is combined with a specifically engineered osteoinductive carrier it is successful in achieving fusion rates comparable to autograft. Recent prospective, randomized human clinical trials have provided level 1 evidence that such combinations, when used in single-level instrumented posterolateral fusions, are indeed effective in achieving fusion rates equal to or superior to autograft and result in similar clinical success without significant adverse events. Summary: Although autograft has long been the standard for achieving a solid spinal fusion, recent studies have reported promising results when bone morphogenetic proteins are used as a bone replacement.