Recent developments in the use of bone morphogenetic protein in orthopaedic trauma surgery.

Delayed healing and non-union remain common problems in the treatment of open tibial shaft fractures. Additional surgical treatments may be required to facilitate healing. The efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2), as an adjunct to the standard of care, has been investigated in the BMP-2 Evaluation in Surgery for Tibial Trauma (BESTT) study. This prospective, randomised, multicentre, controlled study included 450 patients with acute, diaphyseal, open tibial fractures. A significant reduction in the risk of secondary intervention was observed in the 1.50 mg/mL rhBMP-2 group compared with the standard of care alone group (p = 0.0005). In a subgroup analysis of 131 patients with Gustilo-Anderson grade IIIA or IIIB open tibial fractures, using data combined from the BESTT study and a study conducted at 10 level I US trauma centres, a significant reduction in the incidence of secondary autologous bone graft procedures was observed with 1.50 mg/mL rhBMP-2 compared with the standard of care (p = 0.0005). The influence of fracture gap on the re-operation rate has also been examined in the BESTT study. In the 1.50 mg/mL rhBMP-2 group, patients with a 0 mm fracture gap had significantly less re-operations compared with those patients with a greater than 2 mm gap (p = 0.048).