The BESTT trial is a 450-patient, 49-center RCT testing rhBMP-2 delivered on an absorbable collagen sponge at wound closure in open tibial shaft fractures treated with intramedullary nailing. Patients were randomized to standard care, 0.75 mg/mL rhBMP-2 (6 mg total), or 1.50 mg/mL rhBMP-2 (12 mg total). The primary endpoint was need for secondary intervention for delayed union or nonunion within 12 months.
Open tibial shaft fractures treated with intramedullary nailing alone carry a 46% rate of secondary intervention in this trial — reflecting the persistent challenge of delayed union and nonunion even with modern fixation.
The BESTT trial provides Level I evidence that a single intraoperative addition of rhBMP-2 at 1.50 mg/mL (applied to a collagen sponge at definitive wound closure) meaningfully changes this trajectory. When you have a type IIIB tibial fracture in a smoker, the data support adding rhBMP-2: secondary intervention drops from 88% toward the rates seen in less severe injuries, and infection risk is cut nearly in half.
The 0.75 mg/mL dose did not reach significance. Dose matters. The clinically effective and FDA-relevant dose is 1.50 mg/mL (12 mg total).
This paper established rhBMP-2 (dibotermin alfa, InFUSE) as the first osteobiologic with Level I evidence in acute fracture management, directly enabling its clinical use in open tibial fractures and informing subsequent BMP literature across spinal fusion and long-bone surgery.
The BESTT trial is a 450-patient, 49-center RCT testing rhBMP-2 delivered on an absorbable collagen sponge at wound closure in open tibial shaft fractures treated with intramedullary nailing. Patients were randomized to standard care, 0.75 mg/mL rhBMP-2 (6 mg total), or 1.50 mg/mL rhBMP-2 (12 mg total). The primary endpoint was need for secondary intervention for delayed union or nonunion within 12 months.
Open tibial shaft fractures treated with intramedullary nailing alone carry a 46% rate of secondary intervention in this trial — reflecting the persistent challenge of delayed union and nonunion even with modern fixation.
The BESTT trial provides Level I evidence that a single intraoperative addition of rhBMP-2 at 1.50 mg/mL (applied to a collagen sponge at definitive wound closure) meaningfully changes this trajectory. When you have a type IIIB tibial fracture in a smoker, the data support adding rhBMP-2: secondary intervention drops from 88% toward the rates seen in less severe injuries, and infection risk is cut nearly in half.
The 0.75 mg/mL dose did not reach significance. Dose matters. The clinically effective and FDA-relevant dose is 1.50 mg/mL (12 mg total).
This paper established rhBMP-2 (dibotermin alfa, InFUSE) as the first osteobiologic with Level I evidence in acute fracture management, directly enabling its clinical use in open tibial fractures and informing subsequent BMP literature across spinal fusion and long-bone surgery.