James P. Waddell, M.D., FRCSC
Toronto, ON

The Editor has asked me what I consider a rhetorical question - can we afford bone substitutes in 2002? My response to that would be that we cannot afford to be without bone substitutes in 2002! As the more learned contributors to this piece have already pointed out to you, the advantages of bone substitutes are significant and these advantages will only increase with improving technology in terms of research and engineering.  

Hospital cost accounting is the problem with the perception that bone substitutes are too expensive. While no one would quarrel that an invoice for several thousand dollars for a pharmaceutical agent which is applied on one occasion only is significant, the fact that this invoice is charged back to the Operating Room account and thus impacts on a discrete dollar budget is why hospitals feel that bone substitutes are too expensive.

Let’s look at the alternatives to bone substitutes. The two most commonly used are autogenous bone and allograft or banked bone.

Autogenous bone is arguably the gold standard in terms of bone restoration, but it has a number of problems. It is relatively scarce and limited in supply; its structural strength is often suspect and procurement is associated with considerable patient morbidity. Allograft bone, potentially available in unlimited amounts, is expensive (whether you do your own banking or buy it from a national tissue bank), of suspect structural strength and has the potential for disease transmission. Bone substitutes, on the other hand, are biochemically engineered and therefore truly available in unlimited quantity; they are disease free; they require no special storage or handling and pose no risk to the patient in terms of increased morbidity or possible disease transmission.

If hospital accounting could be changed to provide a comparison between the costs of autogenous bone grafting, allograft bone grafting and bone graft substitutes, a very different cost structure would be evident. If we could look at the true cost of autogenous bone grafting in terms of donor site morbidity, infection, increased length of stay, scarcity and increased length of operating time, the cost of autogenous bone grafting would be seen to be substantial - if a bone graft substitute shortened the patient’s hospital stay by even one day the overall cost saving would be significant. Similarly looking at the costs of allograft bone either the direct cost to the hospital from purchasing that bone from a tissue bank or the indirect cost associated with procurement, testing, storage, retrieval and implantation (not to mention all the laboratory costs and paperwork associated with testing of the bone to ensure safety) bone graft substitutes would be cost effective, I have no doubt.

As bone graft substitutes grow more sophisticated and structurally sound, and bone inductive and perhaps antibiotic carrying bone graft substitutes become available, substitutes will become an essential part of the armamentarium of every orthopaedic surgeon.

I would therefore answer the Editor’s question by saying not only can we afford them in 2002 but we must have them if we are to meet satisfactory practice standards.