Department of Orthopaedic and Traumatology, Cipto Mangunkusumo National General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia


Background: BMP-2 has a crucial role in the treatment of extensive bone defect. However, data about the optimal
dosage of BMP-2 in the massive bone defect casesis rare.
Methods: Twenty-five SD rats were randomly allocated into a control group of hydroxyapatite (HA) alone (Group I),
HA+BMP-2 1μg/mL (Group II), HA+BMP-2 5 ug/mL (Group III), HA+BMP-2 10 μg/mL (Group IV), and HA+BMP-2 20
ug/mL (Group V). Osteotomies were performed in each group with 10 mm bone defect in the right femur, followed by
fixation and filling the defect. The fracture healing was evaluated by histomorphometry, and radiographs using RUST
Results: We found there were significant differences in the mean total area of callus between the treatment groups
(P<0.001); there were significant differences in the mean area of woven bone between group II, III, IV, and V with the
control group (respectively P=0.009, P=0.016, P=0.009 and P=0.016), the area of the cartilage between the treatment
groups and control group (respectively P=0.009, P=0.009, P=0.009 and P=0.028). A statistically significant difference
was found in the average area of fibrosis between group II and control group, group IV and control group (respectively
P=0.047 and P=0.009). RUST scores showed significant differences between the control group and group II, III, IV, V
(respectively P=0.005, P=0.006, P=0.005 and P=0.006).
Conclusion: The administration of BMP-2 stimulates the formation of bone bridging in a massive bone defect. The
bone bridging filling massive bone defect depends on the dose or concentration of BMP-2. Administration of an optimal
dose (10 μg/mL) of BMP-2 demonstrates better result than lower or higher dose for massive bone defect healing in SD
Level of evidence: II


Main Subjects

1. Cheng A, Krishnan L, Tran L, Stevens HY, Xia B,
Lee N,et al. The effects of age and dose on gene
expression and segmental bone defect repair after
BMP-2 delivery. JBMR Plus. 2018; 3(2):e10068.
2. Rivera JC, Strohbach CA, Wenke JC, Rathbone CR.
Beyond osteogenesis: an in vitro comparison of the
potentials of six bone morphogenetic proteins. Front
Pharmacol. 2013; 4(1):125.
3. Peng KT, Hsieh MY, Lin CT, Chen CF, Lee MS, Huang Y, et
al. Treatment of critically sized femoral defects with
recombinant BMP-2 delivered by a modified mPEGPLGA
biodegradable thermosensitive hydrogel. BMC
Musculoskelet Disord. 2016; 17(1):286.

4. Ishida K, Haudenschild DR. Interaction between
FGF21 and BMP-2 in osteogenesis. Biochem Biophys
Res Commun. 2013; 432(4):677-82.
5. Blokhuis TJ, Calori GM, Schmidmaier G. Autograft
versus BMPs for the treatment of non-unions:what
is the evidence? Injury. 2013; 44(Supp 1):S40-2.
6. Schwabe P, Greiner S, Ganzert R, Eberhart J, Dähn K,
Stemberger A, et al. Effect of a novel nonviral gene
delivery of BMP-2 on bone healing. Sci World J. 2012;
7. Schwarz C, Wulsten D, Ellinghaus A, Lienau J, Willie
BM, Duda GN. Mechanical load modulates the
stimulatory effect of BMP-2 in a rat non union model.Tissue Eng Part A. 2013; 19(1-2):247-54.

8. Yilgor P, Yilmaz G, Onal MB, Solmaz I, Gundogdu
S, Sousa RA, et al. An in vivo study on the effect of
scaffold geometry and growth factor release on the
healing of bone defect. J Tissue Eng Regen Med.
2013; 7(9):687-96.
9. Tressler MA, Richards JE, Sofianos D, Comrie FK,
Kregor PJ, Obremskey WT. Bone morphogenetic
protein-2 compared to autologous iliac crest bone
graft in the treatment of long bone nonunion.
Orthopedics. 2011; 34(12):e877-84.
10. Doi Y, Miyazaki M, Yoshiiwa T, Hara K, Kataoka
M, Tsumura H. Manipulation of the anabolic and
catabolic responses with BMP-2 and zoledronic
acid in a rat femoral fracture model. Bone. 2011;
11. Finkemeier CG. Bone-grafting and bone graft
substitutes. J Bone Joint Surg. 2002; 84(3):454-64.
12. Brydone A, Meek D, Maclaine S. Bone grafting,
orthopaedics biomaterials, and the clinical need for
bone engineering. Proc Institut Mechan Eng J Eng
Med. 2010; 224(12):1329-43.
13. Noldsletten L, Madsen JE. The effect of bone
morphogenetic proteins in fracture healing. Scand J
Surg. 2006; 95(2):91-4.
14. Whelan DB, Bhandari M, Stephen D, Kreder H, McKee
MD, Zdero R, et al. Development of the radiographic
union score for tibial fractures for the assessment of
tibial fracture healing after intramedullary fixation. J
Trauma. 2010; 68(3):629-32.
15. Mokbel N, Bou Serhal C, Matni G, Naaman N. Healing
patterns of the critical size bony defect in rat
following bone graft. Oral Maxillofac Surg. 2008;
16. Laurencin CR, El-Amin SF. Xenotransplantation in
orthopaedic surgery. J Am Acad Orthop Surg. 2008;
17. Wutzl A, Rauner M, Seemann R, Milles W, Krepler P,
Pietschmann P, et al. Bone morphogenetic protein
2,5 and 6 in combination stimulate osteoblasts
but not osteoclasts in vitro. J Orthop Res. 2010;
18. Garrison KR, Donell S, Ryder J, Shemit I, Mugford
M, Harvey I, et al. Clinical effectiveness and costeffectiveness
of bone morphogenetic proteins in
the non-healing of fractures and spinal fusion: a
systematic review. Health Technol Assess. 2007;
19. Gerstenfeld LC, Wronski TJ, Hollinger JO, Einhorn
TA. Application of histomorphometric methods to
the study of bone repair. J Bone Miner Res. 2005;
20. Vaccaro AR. The role of the osteoconductive
scaffold in synthetic bone graft. Orthopedics. 2002;
21. Mont MA, Ragland PS, Biggins B, Friedlaender G,
Patel T, Cook S, et al. Use of bone morphogenetic
proteins for musculoskeletal applications. J Bone
Joint Surg Am. 2004; 86-A(Suppl 2):41-55.
22. Lieberman JR, Daluiski A, Einhorn TA. The role of
growth factors in the repair of bone. J Bone Joint Surg Am. 2002; 84(6):1032-44.

23. Mills LA, Simpson AH. In vivo models of bone repair.
J Bone Joint Surg Br. 2012; 94(7):865-74.
24. Carreira AC, Zambuzzi WF, Rossi MC, Filho RA,
Sogayar MC, Granjeiro JM. Bone morphogenetic
proteins: promising molecules for bone healing,
bioengineering, and regenerative medicine.Vitam
Horm. 2015; 99(1):293-322.
25. Sasso RC, LeHuec JC, Shaffrey C. Iliac crest bone
graft donor site pain after anterior lumbar
interbody fusion: a prospective patient satisfaction
outcome assessment. J Spinal Disord Tech. 2005;
26. Cuomo AV, Virk M, Petrigliano F, Morgan EF,
Lieberman JR. Mesenchymal stem cell concentration
and bone repair: potential pitfalls from bench to
bedside. J Bone Joint Surg Am. 2009; 91(5):1073-83.
27. Fauzi Kamal A, Hadisoebroto Dilogo I, Untung
Hutagalung E, Iskandriati D, Susworo R, Chaerani
Siregar N, et al. Transplantation of mesenchymal
stem cells, recombinant human BMP-2 and their
combination in accelerating the union after
osteotomy and increasing, the mechanical strength
of extracorporeally irradiated femoral autograft in
rat models. Med J Islam Repub Iran. 2014; 28(1):129.
28. Mumcuoglu D, Fahmy-Garcia S, Ridwan Y, Nicke
J, Farrell E, Kluijtmans SG, et al. Injectable BMP-
2 delivery system based on collagen-derived
microspheres and alginate induced bone formation
in a time- and dose-dependent manner. Eur Cell
Mater. 2018; 35(1):242-54.
29. Tazaki J, Murata M, Akazawa T, Yamamoto M, Ito K,
Arisue M, et al. BMP-2 release and dose-response
studies in hydroxyapatite and beta-tricalcium
phosphate. Biomed Mater Eng. 2009; 19(2-3):141-6.
30. Angle SR, Sena K, Sumner DR, Virkus WW, Virdi AS.
Healing of rat femoral segmental defect with bone
morphogenetic protein-2: a dose response study. J
Musculoskelet Neuronal Interact. 2012; 12(1):28-37.
31. Boyce AS, Reveal G, Scheid DK, Kaehr DM, Maar D,
Watts M, et al. Canine investigation of rhBMP-2,
autogenous bone graft, and rhBMP-2 with autogenous
bone graft for the healing of a large segmental tibial
defect. J Orthop Trauma. 2009; 23(10):685-92.
32. Jones AL, Bucholz RW, Bosse MJ, Mirza SK, Lyon TR,
Webb LX, et al. Recombinant human BMP-2 and
allograft compared with autogenous bone graft for
reconstruction of diaphysealtibial fractures with
cortical defects: a randomized controlled trial. J
Bone Joint Surg Am. 2006; 88(7):1431-41.
33. Sciadini MF, Johnson KD. Evaluation of recombinant
human bone morphogenetic protein-2 as a bonegraft
substitute in a canine segmental defect model. J
Orthop Res. 2000; 18(2):289-302.
34. Nandi SK, Roy S, Mukherjee P, Kundu B, De DK,
Basu D. Orthopaedic applications of bone graft &
graft substitutes: a review. Indian J Med Res. 2010;
35. Greenwald AS, Boden SD, Goldberg VM, Khan Y,
Laurencin CT, Rosier RN, et al. Bone-graft substitutes:
facts, fictions & applications. J Bone Joint Surg Am.2001; 83(2):98-103.

36. Moore WR, Graves SE, Bain GI. Synthetic bone graft
substitutes. ANZ J Surg. 2001; 71(6):354-61.
37. Leboucher J. Design and characterization of a
scaffold for bone tissue engineering. Nat Bio J. 2003;
38. Jahangir AA, Nunley RM, Mehta S. Bone-graft
substitutes in orthopaedics surgery. Orthop Surg.
1995; 90(1):111-9.