Autologous bone graft: Is it still the gold standard?

•Autologous bone-grafting has over a century of successful clinical use.•The process of bone-graft incorporation involves the same basic mechanisms that take place during fracture healing, and requires the viable osteoprogenitor cells, cytokines and other signaling molecules (collectively referred to as growth factors), and an appropriate connective tissue matrix to support bone formation. These functions are referred to as osteogenesis, osteoinduction, and osteoconduction, respectively.•The largest disadvantage of autologous bone grafting has been the limited quantities available and donor-site morbidity. The recent introduction of the Reamer Irrigator Aspirator (RIA) technique has greatly reduced the morbidity of autologous bone graft harvest.•With respect to efficacy, autologous bone-grafting remains the “gold-standard”. Bone grafting has over 100 years of successful clinical use. Despite the successes of autograft bone transplantation, complications of bone grafting are significant, mostly at the donor site. This article reviews the biology of fracture healing, the properties of bone grafts, and reviews the specific advantages and problems associated with autograft bone. Recent techniques such as the Reamer Irrigator Aspirator are described, which has dramatically reduced complications of bone autograft harvesting.