This 2002 JBJS Current Concepts Review by Finkemeier surveys the full spectrum of bone graft options — autologous cancellous and cortical bone, bone marrow injection, DBM, and calcium-based ceramics. It asks which material best fits which clinical scenario based on defect size, biology of the recipient bed, and structural demands.
5–6 cm: cortical graft required for structural support
12 cm: vascularized cortical graft cuts failure rate in half vs nonvascularized (25% vs 50%)
The graft you choose must match what the biology actually requires. Stable, well-vascularized metaphyseal voids (tibial plateau, pilon) tolerate purely osteoconductive substitutes — coralline hydroxyapatite performed equivalently to autograft in one RCT of tibial plateau fractures. Nonunions and diaphyseal defects require osteoinduction or osteogenesis, which ceramics and allograft chips cannot provide.
When you see a hypertrophic nonunion, stabilize it first. Bone graft is not always the answer. When you see an atrophic nonunion or a defect >6 cm requiring structural support, autologous cancellous graft or a vascularized fibula is indicated, and no substitute compensates for inadequate fixation.
For bone marrow aspiration, technique matters: four 1-mL aliquots from the posterior iliac wing maximize osteoprogenitor cell delivery. Waiting 6–12 weeks after acute injury allows the inflammatory phase to subside before injecting.
This paper establishes the foundational decision framework still taught today: match the graft to the defect size, structural demand, and biologic environment. And remember that the evidence base for DBM in nonunions, while promising, lacked RCT support even at the time of writing.
This 2002 JBJS Current Concepts Review by Finkemeier surveys the full spectrum of bone graft options — autologous cancellous and cortical bone, bone marrow injection, DBM, and calcium-based ceramics. It asks which material best fits which clinical scenario based on defect size, biology of the recipient bed, and structural demands.
5–6 cm: cortical graft required for structural support
12 cm: vascularized cortical graft cuts failure rate in half vs nonvascularized (25% vs 50%)
The graft you choose must match what the biology actually requires. Stable, well-vascularized metaphyseal voids (tibial plateau, pilon) tolerate purely osteoconductive substitutes — coralline hydroxyapatite performed equivalently to autograft in one RCT of tibial plateau fractures. Nonunions and diaphyseal defects require osteoinduction or osteogenesis, which ceramics and allograft chips cannot provide.
When you see a hypertrophic nonunion, stabilize it first. Bone graft is not always the answer. When you see an atrophic nonunion or a defect >6 cm requiring structural support, autologous cancellous graft or a vascularized fibula is indicated, and no substitute compensates for inadequate fixation.
For bone marrow aspiration, technique matters: four 1-mL aliquots from the posterior iliac wing maximize osteoprogenitor cell delivery. Waiting 6–12 weeks after acute injury allows the inflammatory phase to subside before injecting.
This paper establishes the foundational decision framework still taught today: match the graft to the defect size, structural demand, and biologic environment. And remember that the evidence base for DBM in nonunions, while promising, lacked RCT support even at the time of writing.