In November 2000, a symposium organized as a cooperative endeavor between
the American Society for Testing and Materials International and the American
Academy of Orthopaedic Surgeons was convened in Orlando, Florida, as part of
an ongoing effort to create broad-based standards for tissue-engineered
products. This book is an outgrowth of the proceedings of that workshop and is
edited by Dr. Cato Laurencin, the workshop's organizer. Contributors to the
book were presenters at the meeting and are definitely among the leading
experts in their fields.
The foreword by Joshua Jacobs and Jack Lemons, chairman and past chairman,
respectively, of Committee F04 of the American Society for Testing and
Materials International, sets the stage by telling the reader, "This was
a proactive initiative borne out of the realization that in the near future a
large number of medical products will be introduced into the marketplace that
are fundamentally different from the current generation of products.... This
situation provides a unique opportunity for consensus standards to accelerate
the product development phase and regulatory processes... in order to bring
these promising treatment modalities to the patient in an expeditious
fashion."
The book begins with an explanation of the importance and need for bone
graft substitutes and a brief history of the evolutionary path that has led to
the state-of-the-art materials that are now being used and that are designed
to regenerate as well as replace bone. Although intended as an introduction
rather than an exhaustive, comprehensive overview of the field, the discussion
of cell-based and factor-based materials may be a bit dated and focuses on the
same set of factors we have been reading about for years, including the
transforming growth factor-ß family members, bone morphogenetic proteins
(BMPs), platelet-derived growth factors, and insulin-like growth factors. The
entire spectrum of promoters of angiogenesis, including vascular endothelial
growth factor and related molecules, is not discussed, and no mention is made
of prostaglandin agonists.
Section I, on allograft-based bone graft substitutes, is good, and the
chapter by Poynton and Lane provides a reasonably complete review of the
topic. This is followed by an excellent discussion of tissue banking and
safety, by Joyce and Joyce, which includes discussions on tissue processing
and disease transmission and provides some excellent appendices and
references. The chapter by Borden, which is a discussion of various types of
demineralized bone matrices, is a bit product-oriented but, given the
differences in formulation, may be the only way to present the topic. The
chapter on standards development for the use of bone graft substitutes based
on allografts is a great idea but does not seem to provide enough depth for
the topic.
Section II, on cellular and growth-factor-based systems, includes six
chapters and provides an accurate "snapshot in time" of the
developments in this field. Whang and Lieberman provide a chapter on clinical
issues, and this is the only chapter that discusses gene therapy in any depth.
Sampath and Reddi contribute their usual outstanding overview of the biology
of BMPs.
For the most part, the chapters in this book are of consistent quality,
although some go into more depth than others. My favorite chapter is the one
by Bucholz, in Section III, entitled "Clinical Issues in the Development
of Bone Graft Substitutes in Orthopedic Trauma Care." It is a discussion
of the difficulties and challenges associated with testing the clinical
efficacy of synthetic materials for bone graft substitutes, and it provides a
"reality check" on what these materials can do today and are
likely to do in the future.
There is not much in the way of overlap in this book, and this is a
strength. The editor, Cato Laurencin, is listed as an author of two chapters,
confirming his direct involvement with the content of the book. Other
strengths of the book include the authoritative tone, which is certainly
warranted given the expertise of the authors, and the fact that no particular
topic has been given more emphasis than another.
A major weakness of the book is the poor quality of the figures and images.
Many of the radiographs and photomicrographs are in poor focus, and even the
graphs and tables need more clarity. There are no specific topics that are
missing from the book, but more emphasis could have been placed on the
discussion of gene therapy. Although the lay public and the medical community
are still feeling the chilling effects of some of the early complications
associated with gene therapy in the treatment of chronic diseases, scientists
should be optimistic that these problems will be overcome. Eventually, genetic
engineering will be a common treatment for both acute and chronic conditions
and diseases; thus, more attention should be given to the progress that is
being made with regard to the use of gene therapy as a method to enhance
skeletal repair.
Bone Graft Substitutes provides a sound and sophisticated update
that is recommended for scientists who are working in this field. Many
practicing orthopaedic surgeons will also find it useful, particularly if they
make consistent use of allografts or have a specific interest in following the
progress of this research. The book belongs in the libraries of medical and
dental schools and in the libraries and reading rooms of academic departments
that are engaged in basic and clinical investigations in musculoskeletal
science. The text is easy to read, and this reviewer can say that I learned at
least one new fact from each chapter. I am sure I will reread this book in the
future and that I will loan it to residents, fellows, and colleagues who are
engaged in research in this field.