Detection of living cells in non-processed but deep-frozen bone allografts

Allogenic Bone Graft in Dentistry: A Review of Current Trends and Developments

In an effort to prepare non-autologous bone graft or biomaterial that would possess characteristics comparable to autologous bone, many different allogenic bone derivatives have been created. Although different existing processing methods aim to achieve the very same results, the specific parameters applied during different stages material preparation can result in significant differences in the material's mechanical and biological properties The properties, including osteoconductive, osteoinductive, and even osteogenic potential, can differ vastly depending on particular preparation and storage techniques used. Osteogenic properties, which have long been thought to be characteristic to autogenic bone grafts only, now seem to also be achievable in allogenic materials due to the possibility to seed the host's stem cells on a graft before its implantation. In this article, we aim to review the available literature on allogenic bone and its derivatives as well as the influence of different preparation methods on its performance.

Study of Cell Viability and Etiology of Contamination in Decalcified Bone Allograft: A Pilot Study

BACKGROUND

Bone allografts can elicit immune responses which is correlated with the presence of Human Leukocyte Antigen (HLA) and cellular DNA. It also has risk of causing occult infection arising out of contamination during its processing and storage. The presence of immunogenic materials like cells, cellular remnants and DNA in a decalcified bone allograft during different phases of processing has never been studied. Present study was conducted to explore- the cell viability using routine Hematoxylin and Eosin, presence of DNA using Feulgen staining and etiology of contamination in decalcified bone allograft during procurement, demineralization and ethanol preservation.

METHODS

The harvested bones from patients undergoing hemireplacement/THR/TKR were processed to prepare decalcified bone allografts. The samples during procurement (A), HCL treatment (B) and ethanol preservation (C) were sent for histopathological analysis (number of osteocytes in the maximum density field under 40x and the cells demonstrating presence of DNA on feulgen stain) and microbiological assessment (aerobic/anaerobic/fungal cultures).

RESULTS

Histopathological study demonstrated the presence of osteocytes and other cells like bone marrow, adipocytes, endothelial cells in the decal bone allograft. The average number of osteocytes gradually decreased from 55.47, 9.6, 0.86 in sample A, B, C, respectively. Feulgen staining confirmed the presence of DNA in osteocytes and other cells which decreased both qualitatively and quantitatively in subsequent stages of processing. Rate of contamination demonstrated at the procurement was 6.67% (Staphylococcus aureus). After treatment with HCl (demineralisation), 7.14% of non-contaminated allografts were found contaminated (Staphylococcus epidermidis). None of the remaining 13 non-contaminated allografts showed contamination after storage in ethanol. Overall 13% of the patients had positive cultures on microbiological assessment.

CONCLUSION

The population of osteocytes in the harvested bone reduced significantly after processing with HCl and ethanol preservation. Presence of DNA, demonstrated by using Feulgen staining, was observed in bone marrow cells, adipocytes along with osteocytes which showed quantitative reduction on processing. Hence, antigenicity, conferred by cells and their DNA, reduced significantly after processing of decal bone. Contamination rate of banked decalcified allograft was 13%. Thus, culture and sensitivity tests should be carried out at each step of processing of decal bone allograft.

The storage of skull bone flaps for autologous cranioplasty: literature review

The use of autologous bone flap for cranioplasty after decompressive craniectomy is a widely used strategy that allows alleviating health expenses. When the patient has recovered from the primary insult, the cranioplasty restores protection and cosmesis, recovering fluid dynamics and improving neurological status. During this time, the bone flap must be stored, but there is a lack of standardization of tissue banking practices for this aim. In this work, we have reviewed the literature on tissue processing and storage practices. Most of the published articles are focused from a strictly clinical and surgical point of view, paying less attention to issues related to tissue manipulation. When bone resorption is avoided and the risk of infection is controlled, the autograft represents the most efficient choice, with the lowest risk of complication. Otherwise, depending on the degree of involvement, the patient may have to undergo new surgery, assuming further risks and higher healthcare costs. Therefore, tissue banks must implement protocols to provide products with the highest possible clinical effectiveness, without compromising safety. With a centralised management of tissue banking practices there may be a more uniform approach, thus facilitating the standardization of procedures and guidelines.

Factors related to failure of autologous cranial reconstructions after decompressive craniectomy

PURPOSE

Cranioplasty is customary after decompressive craniectomy. Many different materials have been developed and used for this procedure. The ideal material does not yet exist, while complication rates in cranioplasties remain high. This study aimed to determine factors related to autologous bone flap failure.

MATERIALS AND METHODS

In this two-center retrospective cohort study, 276 patients underwent autologous bone cranioplasty after initial decompressive craniectomy between 2004 and 2014. Medical records were reviewed regarding patient characteristics and factors potentially related to bone flap failure. Data were analyzed using univariable and multivariable regression analysis.

RESULTS

Independent factors related to overall bone flap failure were: duration of hospitalization after decompressive craniectomy [OR: 1.012 (95%CI: 1.003-1.022); p = 0.012], time interval between decompressive craniectomy and cranioplasty [OR: 1.018 (95%CI: 1.004-1.032); p = 0.013], and follow-up duration [OR: 1.034 (95%CI: 1.020-1.047); p < 0.001]. In patients with bone flap infection, neoplasm as initial diagnosis occurred significantly more often (29.2% vs. 7.8%; RD 21.3%; 95%CI 8.4 -38.3%; NNH 5; 95%CI 3 -12) and duration of hospitalization after decompressive craniectomy tended to be longer (means 54 vs. 28 days, MD 26.2 days, 95%CI -8.6 to 60.9 days). Patients with bone flap resorption were significantly younger (35 vs. 43 years, MD 7.7 years, 95%CI 0.8-14.6 years) and their cranial defect size tended to be wider than in patients without bone flap resorption (mean circumference 39 vs. 37 cm; MD 2.4 cm, 95% CI -0.43-5.2 cm) and follow-up duration was significantly longer (44 vs. 14 months, MD 29 months, 95%CI 17-42 months).

CONCLUSION

A neoplasm as initial diagnosis, longer hospitalization after decompressive craniectomy, larger time interval between decompressive craniectomy and cranioplasty, and longer follow-up duration are associated with a higher risk of failure of autologous bone flaps for cranioplasty. Patients with these risk factors may be better served with an early recovery program after decompressive surgery or an alloplastic material for cranioplasty.

Presence of Cells in Fresh-Frozen Allogeneic Bone Grafts from Different Tissue Banks

Bone replacement materials have been widely used to reconstruct atrophic jawbones. Based on previous reports demonstrating the presence of viable cells in bone blocks even after processing by musculoskeletal tissue banks for orthopedic use, the aim of this study was to evaluate the presence of cells in bone blocks from three Brazilian tissue banks for maxillary reconstructions. All samples were processed by the respective tissue banks, according to the guidelines of the Brazilian National Sanitary Surveillance Agency. Three samples were removed from each block for subsequent histological processing and stained using hematoxylin & eosin. Further evaluation included section staining by the Feulgen method and ultrastructural analysis using scanning electron microscopy (SEM). Light microscopy images from all bone samples showed presence of osteocyte-like cells in all groups and intense Feulgen staining, demonstrating presence of DNA in bone even after tissue processing. The ultrastructural analysis showed red blood cells in lacunae within the bone tissue. In conclusion, despite bone tissue processing by the musculoskeletal tissue banks, cells may be found within the bone used for allogeneic grafts.

Cryopreservation of Autologous Cranial Bone Flaps for Cranioplasty: A Large Sample Retrospective Study

OBJECTIVE

To clarify the clinical outcomes of cranioplasty with cryopreserved bone flaps and identify risk factors related to bone flap infection and resorption after cranioplasty with cryopreserved bone flaps.

METHODS

A total of 946 patients (989 bone flaps) underwent decompressive craniectomy and delayed cranioplasty via the use of cryopreserved autogenous cranial bone flaps. Cranial bone flaps were removed during the initial craniectomy and reserved in liquid nitrogen (-196°C) with dimethyl sulfoxide as a cryoprotectant. Cranioplasty subsequently was performed once the brain injury had healed. Data regarding complications and clinical outcomes were recorded and the potential risk factors were analyzed.

RESULTS

Data from 960 flaps were available for analysis. The overall complication rate was 15.83% (152 of 960). Bone resorption occurred in 42 flaps in 37 patients (4.38%). The bone flaps resorption rate was greater in patients ≤18 years than in patients >18 years (9.38% vs. 3.61%, P < 0.05). Cryopreservation for more than 365 days tended to result in a greater bone resorption rate (6.88% vs. 2.92%, P < 0.01). Skull bone grafts infection occurred in 39 flaps in 34 patients (4.06%). The bone graft infection rate was greater in emergency craniectomy cases (8.81% vs. 2.59%, P < 0.01) and in patients with diabetes (10.53% vs. 3.07%, P < 0.01).

CONCLUSIONS

Cryopreservation of autologous cranial bone flaps is safe and effective for cranioplasty. Cranioplasty with cryopreserved autologous cranial bone flaps should be performed no more than 1 year after craniectomy. Emergency craniectomy and patients with diabetes require special attention.

Iliac Crest Fresh-Frozen Allografts Versus Autografts in Oral Pre-Prosthetic Bone Reconstructive Surgery: Histologic and Histomorphometric Study

PURPOSE

The aim of this work was to compare histologically bone biopsies obtained during dental implant placement in atrophic jaws reconstructed with fresh-frozen bone (FFB) or autologous bone blocks.

MATERIALS AND METHODS

Twenty partially or totally edentulous patients were treated either with iliac crest FFB grafts (14 patients; group A) or with iliac crest autografts (6 patients; group B). Seven to 9 months later, dental implants were placed in the reconstructed jaws and bone biopsies were harvested.

RESULTS

The reconstructive procedure was uneventful in 9 patients of group A and in all patients of group B. Samples from both groups did not show relevant differences concerning the proportion of lamellar bone, newly formed bone, and bone marrow. In group A, the decreasing proportion of blood vessels from the apical to the coronal portion, the larger amount of lacunae in the apical portion, and the fewer vessels in the coronal portion than in group B evoke an effort of the host bone to "integrate" the graft from the apical portion.

CONCLUSIONS

FFB cannot be considered as successful and safe in alveolar bone reconstruction as autogenous bone grafting.

Bone regeneration strategies with bone marrow stromal cells in orthopaedic surgery

Bone is the most transplanted tissue human with 1 million procedures every year in Europe. Surgical interventions for bone repair are required for varied reasons such as trauma resulting non-union fractures, or diseases including osteoporosis or osteonecrosis. Autologous bone grafting is the gold standard in bone regeneration but it requires a second surgery with associated pain and complications, and is also limited by harvested bone quantity. Synthetic bone substitutes lack the osteoinductive properties to heal large bone defects. Cell therapies based on bone marrow or ex vivo expanded mesenchymal stromal stem cells (MSCs) in association with synthetic calcium phosphate (CaP) bone substitutes may be alternatives to autologous bone grafting. This manuscript reviews the different conventional biological and synthetic bone grafting procedures as well as the more recently introduced cell therapy approaches used in orthopaedic surgery for bone regeneration. Some clinical studies have demonstrated safety and efficacy of these approaches but regeneration of large bone defects remain challenging due to the absence of rapid and adequate vascularisation. Future directions in the field of bone regeneration are presented, such as testing alternative cell sources or in situ fabrication of vascularized bone grafts in patients.

Clinical trial and in-vitro study comparing the efficacy of treating bony lesions with allografts versus synthetic or highly-processed xenogeneic bone grafts

Background

Our study aim was to compare allogeneic cancellous bone (ACB) and synthetic or highly-processed xenogeneic bone substitutes (SBS) in the treatment of skeletal defects in orthopedic surgery.

Methods

232 patients treated for bony lesions with ACB (n = 116) or SBS (n = 116) within a 10-year time period were included in this case–control study. Furthermore, both materials were seeded with human osteoblasts (hOB, n = 10) and analyzed by histology, for viability (AlamarBlue®) and protein expression activity (Luminex®).

Results

The complication rate was 14.2 %, proportion of defects without bony healing 3.6 %; neither outcome parameter differed comparing the intervention groups. Failed consolidation correlated with an increase in complications (p < 0.03). The rate of complications was further highly significant in association with the location of use (p < 0.001), but did not depend on age, ASA risk classification, BMI, smoking behavior or type of insurance. However, those factors did significantly influence the bony healing rate (p < 0.02). Complication and consolidation rates were independent of gender and the filling substances employed within the different locations. Histological examination revealed similar bone structures, whereas cell remnants were apparent only in the allografts. Both materials were biocompatible in-vitro, and seeded with human osteoblasts. The cells remained vital over the 3-week culture period and produced microscopically typical bone matrix. We observed initially increased expression of osteocalcin, osteopontin, and osteoprotegerin as well as leptin and adiponectin secretion declining after 1 week, especially in the ACB group.

Conclusion

Although both investigated materials appeared to be similarly suitable for the treatment of skeletal lesions in-vivo and in-vitro, outcome was decisively influenced by other factors such as the site of use or epidemiological parameters.

Prefabricated bone flap: an experimental study comparing deep-frozen and lyophilized-demineralized allogenic bones and tissue expression of transforming growth factor β

BACKGROUND

Extensive bone defects are still a challenge for reconstructive surgery. Allogenic bones can be an alternative with no donor area morbidity and unlimited amount of tissue. Better results can be achieved after allogenic bone preparation and adding a vascular supply, which can be done along with flap prefabrication. The purpose of this study was to evaluate demineralized/lyophilized and deep-frozen allogenic bones used for flap prefabrication and the tissue expression of transforming growth factor β (TGF-β) in these bone fragments.

METHODS

Fifty-six Wistar rat bone diaphyses were prepared and distributed in 4 groups: demineralized/lyophilized (experimental group 1 and control group 2) and deep freezing (experimental group 3 and control group 4). Two bone segments (one of each group) were implanted in rats to prefabricate flaps using superficial epigastric vessels (experimental groups) or only transferred as grafts (control groups). These fragments remained in their respective inguinal regions until the death that occurred at 2, 4, and 6 weeks after the operation. Semiquantitative histologic (tetracycline marking, cortical resorption, number of giant cells, and vascularization) and histomorphometrical quantitative (osteoid thickness, cortical thickness, and fibrosis thickness) analyses were performed. Transforming growth factor β immunohistochemistry staining was also performed.

RESULTS

Group 1 fragments presented an osteoid matrix on their external surface in all periods. Cartilage formation and mineralization areas were also noticed. These findings were not observed in group 3 fragments. Group 1 had more mineralization and double tetracycline marks, which were almost not seen in group 3. Cortical resorption and the number of giant cells were greater in group 3 in all periods. Vascularization and fibrosis thickness were similar in both experimental groups. Group 1 had more intense TGF-β staining within 2 weeks of study. Nevertheless, from 4 weeks onward, group 3 presented statistically significant stronger staining.

CONCLUSIONS

Although there are some differences between the preparation methods of allogenic bone, it is possible to prefabricate flaps with demineralized/lyophilized and deep-frozen bones.

Thermal processing of bone: in vitro response of mesenchymal cells to bone-conditioned medium

The autoclaving, pasteurization, and freezing of bone grafts to remove bacteria and viruses, and for preservation, respectively, is considered to alter biological properties during graft consolidation. Fresh bone grafts release paracrine-like signals that are considered to support tissue regeneration. However, the impact of the autoclaving, pasteurization, and freezing of bone grafts on paracrine signals remains unknown. Therefore, conditioned medium was prepared from porcine cortical bone chips that had undergone thermal processing. The biological properties of the bone-conditioned medium were assessed by examining the changes in expression of target genes in oral fibroblasts. The data showed that conditioned medium obtained from bone chips that had undergone pasteurization and freezing changed the expression of adrenomedullin, pentraxin 3, BTB/POZ domain-containing protein 11, interleukin 11, NADPH oxidase 4, and proteoglycan 4 by at least five-fold in oral fibroblasts. Bone-conditioned medium obtained from autoclaved bone chips, however, failed to change the expression of the respective genes. Also, when bone-conditioned medium was prepared from fresh bone chips, autoclaving blocked the capacity of bone-conditioned medium to modulate gene expression. These in vitro results suggest that pasteurization and freezing of bone grafts preserve the release of biologically active paracrine signals, but autoclaving does not.

Effect of Platelet-Rich Plasma on the Healing of Mandibular Defects Treated With Fresh Frozen Bone Allograft: A Radiographic Study in Dogs

The purpose of this study was to radiographically analyze the effect of autologous platelet rich plasma (PRP) on the healing of fresh frozen bone allograft (FFBA) placed in surgically created resection defects in mandibles of dogs. Bilateral resection defects measuring 1.5 cm × 1 cm were surgically created on the inferior border of the mandible in 10 adult male dogs. The defects were randomly divided into three groups: C, FFBA, and FFBA/PRP. In Group C, the defect was filled by blood clot only. In Group FFBA, the defect was filled with particulate fresh frozen bone allograft. In Group FFBA/PRP, it was filled with particulate fresh frozen bone allograft combined with PRP. At 90 days postoperative, standardized radiographs of the mandibles were obtained and results were quantitatively evaluated. Analysis of digitized radiographs indicated that non-PRP grafts were significantly less dense than the PRP grafts. Group FFBA/PRP also presented a statistically greater mineralized tissue area than Groups C and FFBA. Within the limits of this study, it can be concluded that PRP enhanced the healing of FFBA in resection defects in mandibles of dogs.

Influence of thermodisinfection and duration of cryopreservation at different temperatures on pull out strength of cancellous bone

Thermodisinfection of human femoral heads from living donors harvested during hip joint replacement is an established processing procedure. This study was designed to examine the influence of heat sterilization on pull out strength of cancellous bone and storage at different temperatures up to 2 years since we had previously studied the storage of unprocessed cancellous bone. Porcine cancellous bone resembling human bone structure was obtained from 140 proximal humerus of 6-8 months old piglets. Pull out strength of screws after thermodisinfection was compared with unprocessed cancellous bone and tested immediately and after 6, 12 and 24 months of storage at -20 and -80 °C. A three-way ANOVA was performed and significance level was 5 %. The thermodisinfected bone showed a pull out force of 2729 N (1657-3568 N). The reduction of pull out strength compared with unprocessed bone over all periods of storage was 276 N on average with 95 % confidence interval ranging from 166 N to 389 N (p < 0.0001). Different freezing temperatures did not influence this mechanic property within 24 months storage and showed no difference compared with fresh frozen bone. Thermodisinfection of cancellous bone preserves tensile strength necessary for clinical purposes. The storage at -20 °C for at least 2 years did not show relevant decrease of pull out strength compared with -80 °C without difference between thermodisinfected and fresh frozen bone. The increase of the storage temperature to -20 °C for at least 2 years should be considered.

The value of frozen cartilage tissues without cryoprotection for genetic conservation

Animal tissues frozen without cryoprotection are thought to be inappropriate for use as a donor for somatic cell nuclear transfer (SCNT) studies. Cells in tissues that have been frozen without a cryoprotectant are commonly thought to be dead or to have lost genomic integrity. However, in this study we show that the frozen auricular cartilage tissues of anatolian buffalo contain a considerable number of viable healthy cells. The cells in auricular cartilage tissues are resistant to cryo-injury at -80°C. Primary cell cultures were established from defrosted ear tissues which were frozen without cryoprotectant. The growth and functional characteristics of primary cell cultures are characterized according to cell growth curve, cell cycle analysis, karyotype and GAG synthesis. The results indicate that frozen cartilage tissues could be valuable materials for the conservation of species and SCNT technology.

Volumetric changes after sinus augmentation using blocks of autogenous iliac bone or freeze-dried allogeneic bone. A non-randomized study

OBJECTIVES

To compare volumetric bone changes after sinus augmentation for implant positioning using blocks of autogenous iliac bone or freeze-dried allogeneic bone (FDBA) from the hip. Variables were compared between the two sources and for each surgical procedure at set times (pre- and post-augmentation procedure).

PATIENTS AND METHODS

A non-randomized retrospective chart review of 7 patients who had autogenous and 7 allogeneic block grafts was carried out (1 procedure per patient). Analysis of Computer Tomographic (CT) data of maxillary sinuses, acquired with high-speed, double-detector CT scanner, was performed using dentascan software. The change between the preoperative (T0) and postoperative volume was measured at 4-6 months (T2) and 1.5 year after transplantation (T3). Annual- and overall-rates of bone change were calculated for the two sources.

RESULTS

All patients were partially edentulous with a residual maxillary floor thickness in the planned implant insertion sites of 2.7 (0.5) mm and 2.8 (0.5) mm for allogeneic and autogenous procedures respectively. From identical intraoperative volume of grafts (2.25 cc at T1), volumetric changes were recorded at T2 and T3. The final volume of the grafts was 1.44 cc for allogeneic group and 1.78 cc for the autogenous group. Significant volumetric changes over time of transplanted grafts for both sources (23% for autograft and 18% for allograft) were found at T2. At 1.5-years post-operatively comparisons of volumes and rates of bone loss between sources were not statistically significant. No failure was recorded for either bone grafts or dental implants.

CONCLUSIONS

Short-term sinus grafting procedure for dental implant placement performed with FDBA showed an outcome close to that reported for autogenous bone. Volumetric changes were comparable between the sources. These data suggest that performing maxillary sinus augmentation with dry-preserved bone allogeneic materials in block form could be considered even when the residual floor thickness is less than 3 mm.

Blastocysts cloned from the Putian Black pig ear tissues frozen without cryoprotectant at -80 and -196 degrees Celsius for 3 yrs

The Putian Black pig, as one of elite cultivars of endemic species in China, has been on the verge of extinction and urgently needs protection. Somatic cell nuclear transfer (SCNT) and noncryoprotected frozen tissue technology have successfully resurrected several mammalian species. Therefore, this study explored the primary feasibility of conserving this breed using a combination of both technologies. Skin tissues obtained from the ears of adult Putian Black boars were frozen without cryoprotectant at -20, -80, or -196 °C and stored for 3 yrs. Primary cell culture, passage and subculture were performed on frozen samples after being rapidly thawed at 39 °C and on fresh pig ear tissues (control). Cloned embryos were reconstructed using fibroblasts (from frozen and fresh tissues) with enucleated oocytes. Live cell lines were obtained from tissues frozen at -80 and at -196 °C and appeared to have normal proliferative activity after passage; furthermore, they directed cloned embryos to develop to the blastocyst stage after nuclear transfer. We concluded that the population of Putian Black pig might be increased in the future by transferring cloned blastocysts into synchronized recipient pigs.

Effect of Storage Temperature on Allograft Bone

BACKGROUND: The recommendations for storage temperature of allogeneic bone are varying between -20 °C and -70 °C and down to -80 °C. The necessary temperature of storage is not exactly defined by scientific data, and the effect of different storage temperatures onto the biomechanical and the biological behavior is discussed controversially. METHODS: The historical development of storage temperature of bone banks is described. A survey on literature concerning the biomechanical and biological properties of allograft bone depending on the procurement and storage temperature is given as well as on national and international regulations on storage conditions of bone banks (European Council, American Association of Tissue Banks (AATB), European Association of Tissue Banks (EATB)). RESULTS: Short-term storage up to 6 months is recommended with -20 °C and -40 °C for a longer period (AATB), and EATB recommends storage at -40 °C and even -80 °C while the regulations of the German German Medical Association (Bundesärztekammer) from 2001 recommend storage at -70 °C. Duration of storage at -20 °C can be maintained at least for 2 years. The potential risk of proteolysis with higher storage temperatures remains, but a definite impairment of bone ingrowth due to a storage at -20 °C was not shown in clinical use, and no adverse biomechanical effects of storage at -20 °C could be proven. CONCLUSION: Biomechanical studies showed no clinically relevant impairment of biomechanical properties of cancellous bone due to different storage temperatures. Sterilization procedures bear the advantage of inactivating enzymatic activity though reducing the risk of proteolysis. In those cases a storage temperature of -20 °C can be recommended for at least a period of 2 years, and the risk of undesired effects seems to be low for native unprocessed bone.

Healing of fresh frozen bone allograft with or without platelet-rich plasma: a histologic and histometric study in rats

PURPOSE

This study histomorphometrically analyzed the effect of autogenous platelet-rich plasma (PRP) on healing of fresh frozen bone allograft (FFBA) in bony defects in rat calvaria.

MATERIALS AND METHODS

A 5mm-diameter defect was created in the calvarium of 30 rats. Animals were divided into three groups: C (defect was filled by blood clot only), FFBA (defect was filled with 0.01mL of FFBA), and FFBA/PRP (defect was filled with 0.01mL of FFBA combined with 100µL of PRP). All animals were euthanized at 30 days postoperatively. Histomorphometry and histology analyses were performed. Data were statistically analyzed (analysis of variance, Tukey, p<.05).

RESULTS

FFBA had a statistically smaller new bone area than groups FFBA/PRP and C. No statistically significant differences were observed between groups FFBA and FFBA/PRP with regard to remaining bone graft particle area.

CONCLUSION

It can be concluded that (1) PRP improved the incorporation of FFBA, increasing the amount of new bone formed; (2) PRP has not influenced the resorption of nonviable particles of the FFBA; and (3) presence of remaining FFBA particles might have accounted for the smaller amount of new bone observed in group FFBA when compared with control group.

Intraoperative cooling of iliac bone graft: an experimental evaluation of cell viability

PURPOSE

A cancellous iliac bone graft is used to treat alveolar clefts. A few hours can exist between graft harvest and placement into the alveolar defect. The purpose of this study was to determine whether intraoperative cooling of bone optimizes viability and to evaluate cellular preservation of cooled graft over time.

PATIENTS AND METHODS

Twelve cancellous iliac bone graft specimens were obtained prospectively from consecutive patients undergoing alveolar cleft repair. Each sample was collected during graft procurement and divided into 3 groups: group 1 (immediate analysis), group 2 (analysis after 2 hours at room temperature), and group 3 (analysis after 2 hours on ice). To generate a viability curve, iliac bone specimens were stored on ice and assayed immediately and hourly for 8 hours. Resazurin, an oxidation-reduction indicator of metabolically active cells, was used to assess cellular viability (normalized relative fluorescence units).

RESULTS

Group 1 (n = 7,370) had more active cells than did group 2 (n = 4,104) or group 3 (n = 5,005; P = .03). Group 3 had greater viability than group 2 (P = .03). Cellular preservation of the cooled graft was 100% at the immediate analysis, 98.4% ± 13.9% at 1 hour, 91.8% ± 9.8% at 2 hours, 83.1% ± 31.8% at 3 hours, 71.8% ± 27.2% at 4 hours, 71.4% ± 16.9% at 5 hours, 69.9% ± 19.0% at 6 hours, 70.0% ± 22.5% at 7 hours, and 66.7% ± 13.3% at 8 hours.

CONCLUSIONS

Storing iliac bone graft on ice rather than at room temperature optimizes cellular viability, with cooled bone demonstrating 22.0% more active cells after 2 hours. Cellular loss of cooled graft plateaued after 4 hours. Clinically, the iliac graft should be maintained on ice until placed into the alveolar cleft.

Quality assessment for processed and sterilized bone using Raman spectroscopy

To eliminate the potential for infection, many tissue banks routinely process and terminally sterilize allografts prior to transplantation. A number of techniques, including the use of scanning electron microscopy, bone graft models, and mechanical property tests, are used to evaluate the properties of allograft bone. However, as these methods are time consuming and often destroy the bone sample, the quality assessment of allograft bones are not routinely performed after processing and sterilization procedures. Raman spectroscopy is a non-destructive, rapid analysis technique that requires only small sample volumes and has recently been used to evaluate the mineral content, mineral crystallinity, acid phosphate and carbonate contents, and collagen maturity in human and animal bones. Here, to establish a quality assessment method of allograft bones using Raman spectroscopy, the effect of several common sterilization and preservation procedures on rat femoral bones were investigated. We found that freeze-thawing had no detectable effects on the composition of bone minerals or matrix, although heat treatment and gamma irradiation resulted in altered Raman spectra. Our findings suggest Raman spectroscopy may facilitate the quality control of allograft bone after processing and sterilization procedures.

Bioactive and osteoinductive bone graft substitutes: definitions, facts and myths

The use of artificial bone grafts has been developed over recent years and is expected to increase further, for some indications even replacing the gold standard, autograft, in trauma and reconstructive surgery. However, the effectiveness of these materials is still a subject of debate, mostly because of unclear definitions or limited market surveillance. In this overview several facts and myths regarding bone-graft substitutes are summarized.

Histopathology of femoral head donations: a retrospective review of 6161 cases

BACKGROUND

Although total hip arthroplasty is one of the most common orthopaedic surgical procedures, it remains unclear whether histopathological examination of the excised femoral head adds to the quality of patient care. We propose that assessment of femoral heads resected during total hip arthroplasty and donated for allograft use may provide a profile of femoral head pathology that benefits total hip arthroplasty patients and bone donors.

METHODS

We retrospectively analyzed the histological findings reported for 6161 femoral heads donated for allograft use between 1993 and 2006. Specimens obtained during total hip arthroplasty and specimens donated at death were reviewed. Follow-up investigations that resulted from abnormal histopathological findings were also reviewed. The Western Australian Cancer Registry was used to determine whether patients with a suspected neoplasm were subsequently diagnosed with such a disease. A retrospective review of the histopathological findings was conducted to evaluate and reclassify all previous observations of abnormalities.

RESULTS

One hundred and five femoral heads demonstrated abnormal or reactive histopathological features not reported prior to surgery and were rejected for allograft use. A reactive lymphocytic infiltrate, most likely due to osteoarthritis, was the most commonly identified feature (forty-five cases). Other features observed in twenty-seven cases were also most likely due to the presence of severe osteoarthritis. Ten femoral heads demonstrated plasmacytosis, which may have been related to osteoarthritis. Two patients were diagnosed with Paget's disease, and two, with rheumatoid arthritis. Nineteen patients had a suspected neoplasm. Of these nineteen, eight cases of non-Hodgkin's lymphoma or chronic lymphocytic leukemia and one case of myelodysplastic syndrome were confirmed on further investigation. One subsequently confirmed malignancy was detected per 770 femoral heads examined.

CONCLUSIONS

Our findings indicate that, even with a detailed medical history and careful physical examination, clinically important diseases including neoplasms and Paget's disease are observed in patients diagnosed with osteoarthritis prior to total hip arthroplasty. Histological examination plays an integral role in quality assurance in femoral head banking, and it also represents a possible early diagnostic test for bone and bone-marrow-related diseases in patients undergoing total hip arthroplasty.

Maintenance of phenotype and function of cryopreserved bone-derived cells

The emerging fields of tissue engineering and regenerative medicine require large numbers of cells for therapy. Although the properties of cells obtained from a variety of fresh tissues have been delineated, the knowledge regarding cryopreserved grafts-derived cells remains elusive. Previous studies have shown that living cells could be isolated from cryopreserved bone grafts. However, whether cryopreserved bone-derived cells can be applied in regenerative medicine is largely unknown. The present study was to evaluate the potential application of cryopreserved grafts-derived cells for tissue regeneration. We showed that cells derived from cryopreserved bone grafts could maintain good proliferation activity and osteogenic phenotype. The biological phenotype of these cells could be well preserved. The transplantation of cryopreserved bone-derived cells on scaffold could promote new bone formation in nude mice and enhance the osteointegration for dental implants in canine, which confirmed their osteogenic capacity, and showed that cells derived from cryopreserved bone were comparable to that of fresh bone in terms of the ability to promote osteogenesis in vivo. This work demonstrates that cryopreserved bone grafts may represent a novel, accessible source of cells for tissue regeneration therapy, and the results of our study may also stimulate the development of other cryopreservation techniques in basic and clinical studies.

Repeated freeze-thaw cycles reduce the survival rate of osteocytes in bone-tendon constructs without affecting the mechanical properties of tendons

Frozen bone-patellar tendon bone allografts are useful in anterior cruciate ligament reconstruction as the freezing procedure kills tissue cells, thereby reducing immunogenicity of the grafts. However, a small portion of cells in human femoral heads treated by standard bone-bank freezing procedures survive, thus limiting the effectiveness of allografts. Here, we characterized the survival rates and mechanisms of cells isolated from rat bones and tendons that were subjected to freeze–thaw treatments, and evaluated the influence of these treatments on the mechanical properties of tendons. After a single freeze–thaw cycle, most cells isolated from frozen bone appeared morphologically as osteocytes and expressed both osteoblast- and osteocyte-related genes. Transmission electron microscopic observation of frozen cells using freeze-substitution revealed that a small number of osteocytes maintained large nuclei with intact double membranes, indicating that these osteocytes in bone matrix were resistant to ice crystal formation. We found that tendon cells were completely killed by a single freeze–thaw cycle, whereas bone cells exhibited a relatively high survival rate, although survival was significantly reduced after three freeze–thaw cycles. In patella tendons, the ultimate stress, Young’s modulus, and strain at failure showed no significant differences between untreated tendons and those subjected to five freeze–thaw cycles. In conclusion, we identified that cells surviving after freeze–thaw treatment of rat bones were predominantly osteocytes. We propose that repeated freeze–thaw cycles could be applied for processing bone-tendon constructs prior to grafting as the treatment did not affect the mechanical property of tendons and drastically reduced surviving osteocytes, thereby potentially decreasing allograft immunogenecity.

Biological therapy of bone defects: the immunology of bone allo-transplantation

IMPORTANCE OF THE FIELD

Bone is one of the most transplanted tissues worldwide. Autograft is the ideal bone graft but is not widely used because of donor site morbidity and restricted availability. Allograft is easily accessible but can transmit infections and elicit an immune response.

AREAS COVERED IN THIS REVIEW

This review identifies all in vitro and in vivo evidence of immune responses following bone transplantation and highlights methods of improving host tolerance to bone allotransplantation.

WHAT THE READER WILL GAIN

In humans, the presence of anti-HLA specific antibodies against freeze-dried and fresh-frozen bone allografts has been demonstrated. Fresh-frozen bone allograft can still generate immune reactions whilst freeze-dried bone allografts present with less immunogenicity but have less structural integrity. This immune response can have an adverse effect on the graft's incorporation and increase the incidence of rejection. Decreasing the immune reaction against the allograft by lowering the immunogenic load of the graft or lowering the host immune response, would result in improved bone incorporation.

TAKE HOME MESSAGE

It is essential that the complex biological processes related to bone immunogenicity are understood, since this may allow the development of safer and more successful ways of controlling the outcome of bone allografting.

Autogenous femoral head as grafting material for mandibular augmentation

Bone grafting is commonly used for augmentation of the atrophic edentulous maxilla and mandible. Although bone substitutes and allogeneic frozen bone grafts have been applied successfully, fresh autogenous bone grafts remain the 'gold standard' in maxillofacial reconstructive surgery. A disadvantage of harvesting autogenous bone is the resulting donor-site morbidity. The authors present a case in which an autogenous femoral head, which was removed because of a prosthetic hip replacement, was used for augmentation of the extreme atrophic mandible. Using this procedure avoids donor-site morbidity.

B-cell lymphoma in retrieved femoral heads: a long term follow up

Background

A relatively high incidence of pathological conditions in retrieved femoral heads, including a group of patients having low grade B-cell lymphoma, has been described before. At short term follow up none of these patients with low-grade B-cell lymphoma showed evidence of systemic disease. However, the long term follow up of these patients is not known.

Methods

From November 1994 up to and including December 2005 we screened all femoral heads removed at the time of primary total hip replacement histopathologically and included them in the bone banking protocol according to the guidelines of the American Associations of Tissue Banks (AATB) and the European Association of Musculo-Skeletal Transplantation (EAMST). We determined the percentage of B-cell lymphoma in all femoral heads and in the group that fulfilled all criteria of the bone banking protocol and report on the long-term follow-up.

Results

Of 852 femoral heads fourteen (1.6%) were highly suspicious for low-grade B-cell lymphoma. Of these 852 femoral heads, 504 were eligible for bone transplantation according to the guidelines of the AATB and the EAMST. Six femoral heads of this group of 504 were highly suspicious for low-grade B-cell lymphoma (1.2%). At long term follow up two (0.2%) of all patients developed systemic malignant disease and one of them needed medical treatment for her condition.

Conclusion

In routine histopathological screening we found variable numbers of low-grade B-cell lymphoma throughout the years, even in a group of femoral heads that were eligible for bone transplantation. Allogenic transmission of malignancy has not yet been reported on, but surviving viruses are proven to be transmissible. Therefore, we recommend the routine histopathological evaluation of all femoral heads removed at primary total hip arthroplasty as a tool for quality control, whether the femoral head is used for bone banking or not.

Resurrection of a bull by cloning from organs frozen without cryoprotectant in a -80 degrees c freezer for a decade

Frozen animal tissues without cryoprotectant have been thought to be inappropriate for use as a nuclear donor for somatic cell nuclear transfer (SCNT). We report the cloning of a bull using cells retrieved from testicles that had been taken from a dead animal and frozen without cryoprotectant in a −80°C freezer for 10 years. We obtained live cells from defrosted pieces of the spermatic cords of frozen testicles. The cells proliferated actively in culture and were apparently normal. We transferred 16 SCNT embryos from these cells into 16 synchronized recipient animals. We obtained five pregnancies and four cloned calves developed to term. Our results indicate that complete genome sets are maintained in mammalian organs even after long-term frozen-storage without cryoprotectant, and that live clones can be produced from the recovered cells.

Clinical, histologic, and histomorphometric analyses of regenerated bone in maxillary sinus augmentation using fresh frozen human bone allografts

BACKGROUND

The purpose of the present study was the clinical and the histologic evaluation of fresh frozen human bone (FFB) allografts used for maxillary sinus-augmentation procedures.

METHODS

Ten subjects were treated with maxillary sinus augmentations using FFB. Radiologic measurements were recorded on computed tomography scans preoperatively and 5 months after the sinus surgeries. At 5 months, during implant placement, 10 core biopsies were retrieved and processed for histomorphometric evaluation under light microscopy (LM). Clinical and histomorphometric measurements are presented as mean +/- SD.

RESULTS

At baseline, the height of the alveolar ridge measured 4.3 +/- 1.3 mm (mean); after augmentation procedures, at implant positioning, it had a mean height of 16.0 +/- 1.8 mm. All 22 dental implants were clinically healthy after 5 months. LM showed that most of the specimens presented newly formed bone that was completely integrated with preexisting bone. The interface areas between new and old bone were not discernible. Woven bone was present in some areas of the biopsies; however, in the majority of the examined regions, there was mature osseous tissue presenting features of trabecular bone. There was no evidence of an acute inflammatory infiltrate. Histomorphometry revealed that the percentage of bone was 48.15% +/- 14.32%, whereas marrow spaces occupied the rest of the area.

CONCLUSION

FFB is a biocompatible material that can be successfully used for maxillary sinus augmentations without interfering with normal reparative bone processes.

Allograft and bone morphogenetic proteins: an overview

Allograft is frequently used in orthopaedic and trauma surgery. On top of safety issues its biological activity is limited also due to processing. Consequently, the combination of allograft with osteoinductive substances may increase its effectiveness and decrease failure rates. In particular Bone Morphogenetic Proteins (BMPs) seem to be a promising partner for clinical applications. This overview focuses on the combined application of allograft/BMPs. Current points of view from available literature are summarized.

Bone metabolism after total hip revision surgery with impacted grafting: evaluation using H2 15O and [18F]fluoride PET; a pilot study

Purpose

To evaluate bone blood flow and bone formation in patients after total hip revision surgery with impacted bone grafting using H₂¹⁵O and [¹⁸F]fluoride positron emission tomography (PET).

Procedures

To asses bone blood flow and bone metabolism in bone allograft after impaction grafting, four patients treated with total hip revision surgery were enrolled prospectively in this study. Six patients scheduled for primary hip arthroplasties were included as a control group. The study protocol consisted of three H₂¹⁵O and [¹⁸F]fluoride PET scans in each patient.

Results

Bone blood flow increased significantly compared to the preoperative state in patients treated for primary hip arthroplasty. In patients undergoing revision surgery, bone blood flow was twofold to threefold higher compared to the preoperative state, but did not reach significance. Bone metabolism in patients undergoing revision was threefold higher 2 weeks postoperatively compared to the primary hip group. We found a significant correlation between Ki and bone blood flow.

Conclusions

Allogeneic bone grafts induce a higher rate of local periprosthetic bone formation compared to periprosthetic bone formation after a primary total hip placement. In vivo coupling between bone blood flow and bone metabolism suggests that bone metabolism in allogeneic bone grafts may partly rely on bone blood flow adaptations.

Donor derived malignancy following transplantation: a review

Organ and tissue transplant is now the treatment of choice for many end stage diseases. In the recent years, there has been an increasing demand for organs but not a similar increase in the supply leading to a severe shortage of organs for transplant resulted in increasing wait times for recipients. This has resulted in expanded donor criteria to include older donors and donors with mild disease. In spite of implementation of more stringent criteria for donor selection, there continues to be some risk of donor derived malignancy. Malignancy after transplantation can occur in three different ways: (a) de-novo occurrence, (b) recurrence of malignancy, and (c) donor-related malignancy. Donor related malignancy can be either due to direct transmission of tumor or due to tumor arising in cells of donor origin. We will review donor related malignancies following solid organ transplantation and hematopoeitic progenitor cell transplantation. Further, we will briefly review the methods for detection and management of these donor related malignancies.

Sterilization of allograft bone: effects of gamma irradiation on allograft biology and biomechanics

Gamma irradiation from Cobalt 60 sources has been used to terminally sterilize bone allografts for many years. Gamma radiation adversely affects the mechanical and biological properties of bone allografts by degrading the collagen in bone matrix. Specifically, gamma rays split polypeptide chains. In wet specimens irradiation causes release of free radicals via radiolysis of water molecules that induces cross-linking reactions in collagen molecules. These effects are dose dependent and give rise to a dose-dependent decrease in mechanical properties of allograft bone when gamma dose is increased above 25 kGy for cortical bone or 60 kGy for cancellous bone. But at doses between 0 and 25 kGy (standard dose), a clear relationship between gamma dose and mechanical properties has yet to be established. In addition, the effects of gamma radiation on graft remodelling have not been intensively investigated. There is evidence that the activity of osteoclasts is reduced when they are cultured onto irradiated bone slices, that peroxidation of marrow fat increases apoptosis of osteoblasts; and that bacterial products remain after irradiation and induce inflammatory bone resorption following macrophage activation. These effects need considerably more investigation to establish their relevance to clinical outcomes. International consensus on an optimum dose of radiation has not been achieved due to a wide range of confounding variables and individual decisions by tissue banks. This has resulted in the application of doses ranging from 15 to 35 kGy. Here, we provide a critical review on the effects of gamma irradiation on the mechanical and biological properties of allograft bone.