Bone morphogenetic proteins in critical-size bone defects: what are the options?

The recent development of new orthopaedic devices and advanced techniques for soft-tissue reconstruction have clearly improved the outcome in trauma and orthopaedic surgery. Nevertheless, large bone defects are still difficult to treat and require a careful analysis of the situation. Individual planning of the reconstructive strategy is desirable. Bone morphogenetic proteins (BMPs) have successfully been applied in the clinical setting for the treatment of spinal fusion, fracture healing and delayed and non-unions. Following the 'diamond concept', surgeons have begun using BMPs for treatment of critical-size defects also--in most cases, 'off label'; different treatment strategies are currently being evaluated. BMPs are often used in combination with autogenic, allogenic, xenogenic or synthetic grafting materials and even with mesenchymal stem cells. In addition, gene therapy approaches present an attractive option. Experimental studies and first clinical results are promising in the use of BMPs for treatment of critical-size defects; however, there is obvious need for further controlled studies to define strategies.