Harold Schoenhaus, DPM, FACFAS reviews the role of orthobiologics in foot and ankle surgery. Dr Schoenhaus discusses the different types of biologics, their indications for use and advantages and disadvantages. He provides multiple case examples supporting his clinical experience and conclusions.
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Harold Schoenhaus, DPM
Surgical Editor for PRESENT e-Learning
Penn-Presbyterian Medical Center
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Male Speaker: Just give an overview and talk on the use of biologics in foot and ankle surgery. Certainly, residents are in a situation where you’re provided an opportunity to be exposed to various modalities, techniques that can help improve our outcomes and our results. Certainly, companies from all over come out with new products, orthobiologics, enhancing drugs for healing processes and you have the opportunity as residents to experiment with some of these things. When you get out to practice, you’re going to make your own decisions as to what you found to be most effective in treating these different problems. Obviously, we’re talking about problems that exist. We’re looking in orthobiology, the inclusion of biology and biochemistry in development of bone and soft tissue replacement materials for skeletal and tissue healing. You can go back to the days of Heppenstall talking about stages of bone healing. We, as foot and ankle surgeons, obviously do a lot of things to bone. We see patients who have had significant trauma, fractures, fracture dislocation, Charcot disease, iatrogenic problems. Bone is a tissue that you think easily heals but unfortunately, there are times that there are problems. Some of which are immunosuppressed, the smoker, et cetera. We’re always trying to do something to enhance the endstage, get the bone to heal. Obviously, infective processes, influence affect that combination. We’re looking at things of induction that initiate osteogenic precursors to promote bone healing, bone forming cells. We know there’s a process of inflammation when bone is broken or injured that is going to take place and we’re going to proceed from soft callus to hard callus to eventually remodeling. When it comes to bone, there are certain terms that we use very frequently and you’re I’m sure aware of osteoconduction, osteoinduction and ultimately osteogenesis, which is primary bone formation. We’re still trying to improve the environment, utilizing materials that may stimulate bone production as opposed to other materials that are going to act as a scaffold onto which bone production will take place and that’s the difference in terms such as osteoinductive and osteoconductive. When one looks at osteogenic promoters, we look at bone grafts for example and we talk about autograft versus allograft. We start looking at things called DBMs, demineralized bone matrix containing grafts. Certainly, we need cortical grafts at times. We need cancellous grafts and the biologic response of a graft is the result of the type of graft used. Sometimes we use grafts that are never incorporated and you’ll always see them as still present and yet the bone may heal over. There is the controversy of whether you should use allograft or autograft and think of terms of your own self if somebody told you, you needed a graft, would you go to the bone bank and get inner dead bone or you’re going to take bone or harvest bone from your own body if possible and place it into a site which is going to have these cells that are going to promote the most efficacious healing without the problem of putting in a foreign substance into your body. Other osteogenic promoters include bone stimulators. You can use them internally and externally we’ll see some of those. What’s the role of orthobiologics? Bone producing bone. Morphogenetic proteins, bone filling and support is a void. We got to fill it. What are you going to fill it with? Avoid donor-site morbidity. At times, instead of going to get a graft, you can inject something or put something into the space that will promote bone healing. You could enhance fusion rates and certainly arthrodesis techniques. In the reconstructive procedures that I do that are difficult or maybe compromised or maybe a pseudoarthrosis, I am going to do everything I can to help the body go on to heal.
Bone morphogenetic proteins where identified by Dr. Urist many years ago and I’m not going to bore you with it but it’s important when somebody brings a product into you and to your office and tells you this is the greatest thing since sliced bread. You want to know about the bone morphogenetic proteins and what the contents are. There are all types of BMPs which I’m not going to bore you with but you will see that certain ones are for bones, certain ones are for cartilage, et cetera. Here all the different types of BMPs by the way. Again, I’m not going to bore you with those. How the actions of these BMPs have direct influence and effect on healing process. Let’s look at cortical grafts, the structural. Use to fill large defects on arthrodesis procedures. Stronger than cancellous bone but less osteogenic potential. When I put a cortical graft in an area, I usually drill through it multiple times to make it look like Swiss cheese. There’s a permeability capability of the graft itself. It incorporates into surrounding bone more slowly than cancellous graft, there’s no question. I have already stated there are times when you’ll see the residue or the residual...
...of that cortical graft. Maybe obtained as an autograft from iliac crest, proximal tibia and fibula. Examples of use, interpositional graft for arthrodesis purposes, lateral column lengthening such as Evans procedures, metatarsal lengthenings. Majority of my Evans I used to use bone bank bone for, I don’t do that anymore. Cancellous graft, these are the guys. I like cancellous bone. This is spongy stuff. It’s hard when you get it from the bone bank. You can mix it with other products. You can mix it with autologous platelet gel, you can mix it with bone marrow aspirate to try to kick start it or activate it because in it of itself it’s going to take some time for the body to accept it. But it’s good in small defects that you don’t need structural component to it. It has more osteogenic potential in cortical bone, but obviously not as strong and where you can get this if you want to do it from the patient themselves, iliac crest, the calcaneus or the fibula, so you can cut a little window actually in the calcaneus or take sections of it out. One of the advantages of autograft, promotes the most rapid healing, provides viable cells, eliminates the problems of histocompatibility and disease transmission. In certain types of autograft such as cancellous bone are readily available. Disadvantages, collection increases surgical anesthetic time. You need a donor site if you take it from the patient, risk of infection at the donor site and intraoperative blood loss and obviously, damage at the site. I gave you an example of this before, here’s that iliac crest. Keep it well saturated with the patient’s blood so this is viable graft material that has a cortical and a cancellous component, excellent graft and there it was, I showed you this before. Allografts, the advantage, eliminate donor-site morbidity. You have larger volume that you can get without dealing with the morbidity. It’s an unlimited supply. It’s obviously a long shelf life. The disadvantage is prolonged incorporation into the surrounding bone. Allografts may be freeze-dried and when that happens they’re no longer osteoinductive or incorporate it with DBM to become osteoinductive. Here, you could take an allograft and saturate it with these PRP autologous gel or bone marrow aspirate. DBM containing allografts, you have a whole bunch of products that are available that can be used to enhance the healing process and every company you could think of has a product that they think is advantageous for you and you will determine which of those is best for you. Some products have come in and out. Here’s an example of a Cancello-Pure wedge that was being used for Evans procedures, Cotton procedures and it was bovine bone. Young cattle were actually slaughtered to get this material and not too many people are using that anymore. Now here’s an example of Cancello-Pure. I used it a number of times in an Evans procedure with an associated Kouts or Cotton. It looks great. It’s identical to what cancellous bone looks like. There are times that you want to inject putty or materials into a site because of irregular shape or you may have a comminuted fracture that you want to inject product that will…