Bone grafting is a surgical procedure used to place new bone or bone substitutes into spaces around broken bones or bone defects to stimulate healing. This procedure is typically performed when the bone is unable to heal on its own due to fractures, bone loss, or conditions like nonunions. The material used can be autograft (from the patient), allograft (from a donor), or synthetic alternatives.
How Common It Is and Who Gets It? (Epidemiology)
Approximately 1 million bone grafting procedures are performed in the United States each year, with an annual growth rate of about 13%. Bone grafting is commonly required for individuals with complex fractures, delayed unions, nonunions, and those undergoing procedures like spinal fusion or arthrodesis.
Why It Happens – Causes (Etiology and Pathophysiology)
Bone grafting is performed when the body cannot heal fractures or bone defects naturally. This may be due to:
- Delayed union: When the bone heals slower than expected.
- Nonunion: When the bone does not heal at all.
- Bone defects: Caused by trauma or disease.
- Spinal fusion or joint fusion: To provide stability.
How the Body Part Normally Works? (Relevant Anatomy)
Bone grafts can be placed in many parts of the body, most commonly in long bones like the tibia (shin), femur (thigh), and pelvis. Bone itself is made up of cancellous (spongy) bone and cortical (hard outer) bone. The cancellous bone, in particular, has a large surface area which promotes healing.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms for individuals requiring bone grafting generally include:
- Pain at the fracture site or bone defect.
- Difficulty moving the affected area, especially if it’s a joint.
- In some cases, swelling or redness can occur around the injured site.
How Doctors Find the Problem? (Diagnosis and Imaging)
Bone grafting is typically considered when fractures or bone defects fail to heal with conventional treatments. The diagnosis involves:
- X-rays to assess the extent of bone healing or bone loss.
- CT scans or MRI to examine bone defects and fractures in detail.
- Bone scans may sometimes be used for more complex cases.
Classification
Bone grafts can be classified based on the material used:
- Autograft: Bone from the patient’s own body.
- Allograft: Bone from a donor.
- Synthetic: Man-made materials designed to stimulate bone growth.
Other Problems That Can Feel Similar (Differential Diagnosis)
Other conditions that can mimic the need for a bone graft include:
- Osteomyelitis: Bone infection.
- Osteoarthritis: Joint degeneration causing pain and stiffness.
- Bone tumors: Benign or malignant growths in bones that can present similarly.
Treatment Options
Non-Surgical Care
- Rest and immobilization to allow healing of smaller fractures.
- Physical therapy to strengthen the affected area post-recovery.
- Pain management using over-the-counter or prescribed medications.
Surgical Care
- Bone grafting is performed when non-surgical treatments are ineffective.
- The bone graft is placed in the area where healing is delayed or where a defect exists.
Recovery and What to Expect After Treatment
Recovery after bone grafting depends on the severity of the defect and the location of the graft. It generally takes 2 to 3 months for the bone graft to heal sufficiently. Patients will need to follow weight-bearing restrictions and may require physical therapy to regain full function.
Possible Risks or Side Effects (Complications)
Possible complications include:
- Infection at the graft site.
- Pain at the donor or graft site.
- Delayed healing or failure of the graft.
- Fracture of the graft site.
Long-Term Outlook (Prognosis)
The long-term outlook for bone grafting is generally positive, with successful healing seen in 95% of patients. Healing time varies but typically takes 3 to 6 months depending on the type of graft and patient health.
Out-of-Pocket Costs
Medicare
CPT Code 27720 – Central Bone Grafting: $207.16
Medicare Part B typically covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover this remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved procedures. These plans work in coordination with Medicare to fill the coverage gap.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover any remaining coinsurance or deductibles, which generally range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your central bone grafting is required due to a work-related injury, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as payments are made directly by the employer’s insurance carrier.
No-Fault Insurance
If your bone grafting procedure is related to an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including surgery and postoperative care. The only possible out-of-pocket cost may be a small deductible or co-payment, depending on your policy terms.
Example
James Lee required central bone grafting (CPT 27720) after a severe injury to his lower leg. His estimated Medicare out-of-pocket cost was $207.16. Since James had supplemental coverage through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is Bone Grafting for Nonunion?
A. Bone grafting for nonunion involves transplanting bone tissue to the site of a nonunion (a fracture that has not healed properly) to stimulate healing and promote bone growth, often using bone from the iliac crest or synthetic graft material.
Q. What is the central bone grafting technique?
A. Central bone grafting is a specific technique used to treat difficult tibial nonunions. It involves creating a space in the tibia and filling it with bone graft material to stimulate healing.
Q. When is Bone Grafting used for Nonunion?
A. Bone grafting is used when a fracture fails to heal after standard treatments, especially in cases with bone loss, infection, or compromised blood supply that prevent the bones from fusing naturally.
Q. What is the recovery time for bone grafting surgery for nonunion?
A. Recovery typically involves several weeks of immobilization, with most patients able to bear weight on the leg once the fracture heals. Full recovery may take up to 20 weeks.
Q. What are the risks of bone grafting for nonunion?
A. Risks include infection, delayed union, pain at the graft site, failure of the bone to heal properly, and complications related to the donor site, especially if the iliac crest is used for harvesting the graft.
Q. How long does the Bone Grafting for Nonunion procedure take?
A. The surgery typically takes 2 to 3 hours, depending on the complexity of the nonunion and whether additional procedures, such as hardware placement or infection management, are needed.
Q. What is the success rate of Bone Grafting for Nonunion?
A. The success rate for bone grafting in nonunion cases is high, with approximately 95% of patients experiencing full healing of the fracture. The success largely depends on the patient’s overall health and adherence to rehabilitation protocols.
Q. Can bone grafting for nonunion be combined with other treatments?
A. Yes, bone grafting can be combined with other treatments, such as internal fixation (using screws or plates), to enhance the stability and healing process of the fractured bone.
Q. What are the types of bone grafts used in nonunion surgery?
A. The types of bone grafts include autografts (bone taken from the patient’s own body, typically from the iliac crest), allografts (bone from a donor), and synthetic or bioengineered grafts. Autografts are preferred for their higher success rates, but allografts and synthetic options are used in certain cases.
Q. What is the difference between an autograft and an allograft?
A. An autograft is bone taken from the patient’s own body, which reduces the risk of rejection but involves an additional surgical site. An allograft is bone taken from a donor, which avoids an additional incision but carries a slight risk of disease transmission and may have a higher failure rate.
Q. Can bone grafting for nonunion be performed minimally invasively?
A. In some cases, minimally invasive techniques may be used for bone grafting, depending on the location of the nonunion. However, traditional open surgery is often required for better access to the fracture site and for proper placement of the graft.
Q. Will I need to use crutches or a walker after bone grafting surgery for nonunion?
A. Yes, crutches, a walker, or a brace are typically needed to avoid putting weight on the operated leg during the initial recovery period, usually for 6 to 8 weeks, depending on the healing progress.
Q. How long will the bone graft material take to fully integrate into the bone?
A. Full integration of the bone graft typically takes several months. The graft will begin to fuse with the existing bone, and the patient will be monitored through follow-up appointments to ensure proper healing and graft acceptance.
Q. Will physical therapy be needed after bone grafting for nonunion?
A. Yes, physical therapy is an important part of recovery. It helps restore strength, flexibility, and mobility to the affected area once the bone has healed sufficiently. Rehabilitation usually starts after the initial healing phase.
Q. What can I do to ensure the success of bone grafting for nonunion?
A. Following post-surgical instructions, attending follow-up appointments, avoiding weight-bearing activities as instructed, and maintaining a healthy diet with adequate calcium and vitamin D intake are crucial for the success of the procedure.
Q. Can smoking affect the success of bone grafting for nonunion?
A. Yes, smoking can significantly impair the healing process by reducing blood flow to the bones and tissues, which may increase the risk of graft failure. It is strongly recommended to quit smoking before and after surgery to improve the chances of successful healing.
Summary and Takeaway
Bone grafting is a highly effective procedure for treating fractures, nonunions, and bone defects. With a variety of materials available, the procedure helps stimulate bone healing, allowing patients to regain normal function and return to their activities.
Clinical Insight & Recent Findings
A recent study compared two bone grafting methods for treating stubborn clavicle nonunions (fractures that fail to heal). Researchers evaluated granular bone grafts versus structured bone grafts, both combined with plate fixation.
The structured bone graft technique showed faster healing—averaging just over 15 weeks compared to nearly 19 weeks with granular grafts—and provided earlier pain relief and better arm function during recovery.
Both methods were safe, but structured grafting appears to offer a more reliable path to quicker bone union and earlier rehabilitation. (“Study on structured bone grafts for faster clavicle fracture healing – see PubMed”)
Who Performs This Treatment? (Specialists and Team Involved)
Bone grafting is typically performed by orthopedic surgeons, particularly those specializing in spine and joint surgery. A multidisciplinary team, including physical therapists and radiologists, is often involved in the recovery and monitoring process.
When to See a Specialist?
If a bone fracture or defect does not heal with standard treatments, or if there are signs of a nonunion, it’s essential to consult with an orthopedic specialist to evaluate whether bone grafting is necessary.
When to Go to the Emergency Room?
Seek emergency care if:
- There’s severe pain at the graft or fracture site.
- Signs of infection develop, such as fever or increased redness at the site.
- Severe bleeding occurs after surgery.
What Recovery Really Looks Like?
Recovery involves limiting weight-bearing on the affected area and following physical therapy to restore function. Most patients will need to avoid strenuous activity for up to 6 months.
What Happens If You Ignore It?
If bone grafting is delayed or not performed when necessary, it may lead to chronic pain, disability, or persistent nonunion. In some cases, further surgeries may be required.
How to Prevent It?
Preventing the need for bone grafting typically involves:
- Proper treatment of fractures or injuries.
- Maintaining bone health through a balanced diet with adequate calcium and vitamin D.
- Regular exercise to strengthen bones and prevent fractures.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and protein supports bone health. Weight-bearing exercises like walking and strength training also play a critical role in maintaining strong bones.
Activity and Lifestyle Modifications
After bone grafting surgery, avoid high-impact activities and follow your surgeon’s guidelines on weight-bearing restrictions. Gradual resumption of physical activities with the help of physical therapy will help in regaining strength and mobility.
Dr. Mo Athar
