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Romagnoli M, Casali M, Zaffagnini M, Cucurnia I, Raggi F, Reale D, Grassi A, Zaffagnini S. Tricalcium Phosphate as a Bone Substitute to Treat Massive Acetabular Bone Defects in Hip Revision Surgery: A Systematic Review and Initial Clinical Experience with 11 Cases. J Clin Med 2023; 12:jcm12051820. [PMID: 36902607 PMCID: PMC10003370 DOI: 10.3390/jcm12051820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/28/2023] [Accepted: 02/22/2023] [Indexed: 03/12/2023] Open
Abstract
The use of tricalcium phosphate (TCP) as a bone substitute is gaining increasing interest to treat severe acetabular bone defects in revision total hip arthroplasty (rTHA). The aim of this study was to investigate the evidence regarding the efficacy of this material. A systematic review of the literature was performed according to the PRISMA and Cochrane guidelines. The study quality was assessed using the modified Coleman Methodology Score (mCMS) for all studies. A total of eight clinical studies (230 patients) were identified: six on TCP used as biphasic ceramics composed of TCP and hydroxyapatite (HA), and two as pure-phase ceramics consisting of TCP. The literature analysis showed eight retrospective case series, of which only two were comparative studies. The mCMS showed an overall poor methodology (mean score 39.5). While the number of studies and their methodology are still limited, the available evidence suggests safety and overall promising results. A total of 11 cases that underwent rTHA with a pure-phase ceramic presented satisfactory clinical and radiological outcomes at initial short-term follow-up. Further studies at long-term follow-up, involving a larger number of patients, are needed before drawing more definitive conclusions on the potential of TCP for the treatment of patients who undergo rTHA.
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Affiliation(s)
- Matteo Romagnoli
- Ortopedia e Traumatologia Rizzoli Argenta, 44011 Argenta, FE, Italy
| | - Marco Casali
- Ortopedia e Traumatologia Rizzoli Argenta, 44011 Argenta, FE, Italy
- Correspondence:
| | - Marco Zaffagnini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, BO, Italy
| | - Ilaria Cucurnia
- Ortopedia e Traumatologia Rizzoli Argenta, 44011 Argenta, FE, Italy
| | - Federico Raggi
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, BO, Italy
| | - Davide Reale
- Ortopedia e Traumatologia Rizzoli Argenta, 44011 Argenta, FE, Italy
| | - Alberto Grassi
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, BO, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, BO, Italy
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Yang C, Zhu K, Dai H, Zhang X, Wang Q, Wang Q. Mid- to Long-term Follow-up of Severe Acetabular Bone Defect after Revision Total Hip Arthroplasty Using Impaction Bone Grafting and Metal Mesh. Orthop Surg 2023; 15:750-757. [PMID: 36644857 PMCID: PMC9977582 DOI: 10.1111/os.13651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE In revision total hip arthroplasty (THA), reconstruction of severe acetabular bone defect continues to be problematic for orthopedic surgeons. This study reports the mid- to long-term survivorship, radiological outcomes, and complications of impaction bone grafting (IBG) and metal mesh with a cemented acetabular component in the reconstruction of severe acetabular bone defects in revision THA. METHODS This retrospective consecutive study included 26 patients (29 hips: type II B, four; type II C, three; type III A, 10; and type III B, 12) who underwent revision THA, which was performed using IBG and metal mesh, between 2007 and 2014 in our institution. All patients were followed up regularly for clinical and radiographical assessments. Migration and loosening of prosthesis graft integration and complications were observed and analyzed. Survival analysis was performed using a Kaplan-Meier survival analysis. RESULTS At the time of revision, 75.9% of the hips (22 hips) were classified as type III bone defects. The average follow-up period was 9.4 ± 2.8 (range, 2.4-14.0) years. Of the 29 hips, four hips (13.8%) were assessed as clinical failures; at the last follow-up, two had undergone re-revision THA, and two had not been scheduled for re-revision THA despite radiological failure of the acetabular component. Among them, three clinical failures (10.3%) were due to aseptic loosening, and one (3.4%) was due to infection. Radiographic evaluation showed bone graft integration in all hips during the follow-up. The Kaplan-Meier survivorship analysis revealed an acetabular reconstruction survival rate of 86.5% (95% confidence interval, 61.4%-95.7%) at 10 years. CONCLUSION IBG and metal mesh with a cemented acetabular component for revision THA is an effective technique for treating severe acetabular bone defects, with effective mid- to long-term outcomes due to the solid reconstruction of the acetabular bone defect and restoration of the hip rotation center.
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Affiliation(s)
- Chao Yang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Kechao Zhu
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Huiyong Dai
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Xianlong Zhang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Qiaojie Wang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Qi Wang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
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Green CM, Buckley SC, Hamer AJ, Kerry RM, Harrison TP. Long-term results of acetabular reconstruction using irradiated allograft bone. Bone Joint J 2018; 100-B:1449-1454. [PMID: 30418060 DOI: 10.1302/0301-620x.100b11.bjj-2018-0478.r2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS The management of acetabular defects at the time of revision hip arthroplasty surgery is a challenge. This study presents the results of a long-term follow-up study of the use of irradiated allograft bone in acetabular reconstruction. PATIENTS AND METHODS Between 1990 and 2000, 123 hips in 110 patients underwent acetabular reconstruction for aseptic loosening, using impaction bone grafting with frozen, irradiated, and morsellized femoral heads and a cemented acetabular component. A total of 55 men and 55 women with a mean age of 64.3 years (26 to 97) at the time of revision surgery are included in this study. RESULTS At a mean follow-up of 16.9 years, there had been 23 revisions (18.7%), including ten for infection, eight for aseptic loosening, and three for dislocation. Of the 66 surviving hips (58 patients) that could be reassessed, 50 hips (42 patients; 75.6%) were still functioning satisfactorily. Union of the graft had occurred in all hips with a surviving implant. Survival analysis for all indications was 80.6% at 15 years (55 patients at risk, 95% confidence interval (CI) 71.1 to 87.2) and 73.7% at 20 years (eight patients at risk, 95% CI 61.6 to 82.5). CONCLUSION Acetabular reconstruction using frozen, irradiated, and morsellized allograft bone and a cemented acetabular component is an effective method of treatment. It gives satisfactory long-term results and is comparable to other types of reconstruction. Cite this article: Bone Joint J 2018;100-B:1449-54.
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Affiliation(s)
- C M Green
- Golden Jubilee National Hospital, Glasgow, UK
| | - S C Buckley
- Lower Limb Arthroplasty Unit, Northern General Hospital, Sheffield, UK
| | - A J Hamer
- Lower Limb Arthroplasty Unit, Northern General Hospital, Sheffield, UK
| | - R M Kerry
- Lower Limb Arthroplasty Unit, Northern General Hospital, Sheffield, UK
| | - T P Harrison
- Lower Limb Arthroplasty Unit, Northern General Hospital, Sheffield, UK
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11-Year Mean Follow-Up of Acetabular Impaction Grafting With a Mixture of Bone Graft and Hydroxyapatite Porous Synthetic Bone Substitute. J Arthroplasty 2018; 33:1481-1486. [PMID: 29291910 DOI: 10.1016/j.arth.2017.11.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/10/2017] [Accepted: 11/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We report an 11-year mean follow-up of the effectiveness of bone impaction grafting with bone and hydroxyapatite (HA) for large, uncontained acetabular defects in primary and revision hip surgeries. METHODS Over 5 years, 47 total hip arthroplasties with uncontained acetabular deficiencies were performed by augmentation using an impaction graft with 50:50 mixture of freeze-dried bone allograft and HA. Ten were primary total hip arthroplasties and 37 revision procedures. X-rays were taken postoperatively, 6 weeks, 3 months, and then annually to assess incorporation of the graft, radiolucent lines, resorption, or migration of components. Functional outcomes were assessed by annual pain and function parts of the Harris Hip Score. RESULTS At a mean follow-up of 10 years, the survivorship was 100%. All patients were accounted for; 6 had died. The Harris Hip Score for pain improved from 9 and 17 (primaries and revisions, respectively) to 39 and 41. For function, there was an improvement from 20 and 19 to 32 (both groups). There were lucent lines in 8 cases, 3 cups had minor/stable migration, and one cup had significant migration (>15 mm). Graft incorporation had occurred in 20 hips. CONCLUSION This is the longest survivorship of bone impaction grafting with morcellised bone and HA substitute. Although 11-year survivorship, function and pain are excellent, radiological findings of lysis in 8 and migration in 4 cases may be of concern for the immediate future and will need close monitoring. Even in these cases, revision may be easier because of restoration of bone stock.
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Deluiz D, Oliveira L, Fletcher P, Pires FR, Nunes MA, Tinoco EM. Fresh-Frozen Bone Allografts in Maxillary Alveolar Augmentation: Analysis of Complications, Adverse Outcomes, and Implant Survival. J Periodontol 2016; 87:1261-1267. [DOI: 10.1902/jop.2016.160155] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hernigou P, Dubory A, Roubineau F, Homma Y, Flouzat-Lachaniette CH, Chevallier N, Rouard H. Allografts supercharged with bone-marrow-derived mesenchymal stem cells possess equivalent osteogenic capacity to that of autograft: a study with long-term follow-ups of human biopsies. INTERNATIONAL ORTHOPAEDICS 2016; 41:127-132. [DOI: 10.1007/s00264-016-3263-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/25/2016] [Indexed: 11/30/2022]
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Guimarães RP, Yonamine AM, Faria CEN, Rudelli M. Is the size of the acetabular bone lesion a predictive factor for failure in revisions of total hip arthroplasty using an impacted allograft? Rev Bras Ortop 2016; 51:412-417. [PMID: 27517019 PMCID: PMC4974165 DOI: 10.1016/j.rboe.2015.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/25/2015] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine the acetabular bone lesion size (in millimeters) from which impacted bone graft failure starts to occur more frequently, through simple anteroposterior hip radiographs, and whether measurement of the defect on simple radiographs maintains the same pattern in inter and intraobserver assessments. METHODS Thirty-eight anteroposterior pelvic-view radiographs from patients undergoing revision of an acetabular prosthesis were retrospectively analyzed and assessed. In the vertical plane, the bilacrimal line was measured in millimeters from the farthest point found on the bone edge of the acetabular osteolysis to the top edge of the cementation or of the acetabular implant in uncemented cases. The base was taken to be a line perpendicular to bilacrimal line, with the aim of eliminating any pelvic tilt effects. This measurement was named the vertical size of failure. Radiographs produced four years after the operation were analyzed to investigate any failure of the technique. RESULTS The graft failure rate in the study group was 26.3%. The failures occurred in cases with an initial bone defect larger than 11 mm. No cases with measurements smaller than this evolved with failure of the revision. The highest incidence of graft failure occurred in cases described as advanced according to the "Paprosky" classification. CONCLUSION Failure of acetabular revision arthroplasty using an impacted graft did not present any statistically significant correlation with the vertical extent of the lesion on simple anteroposterior radiographs, as a predictor of treatment failure.
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O tamanho da lesão óssea acetabular é fator preditivo para a falha nas revisões de artroplastia total do quadril com enxerto impactado? Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Post-operative infection with fresh frozen allograft: reported outcomes of a hospital-based bone bank over 14 years. Cell Tissue Bank 2016; 17:269-75. [PMID: 26910111 DOI: 10.1007/s10561-016-9547-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
Abstract
Femoral head bone allografts have traditionally been used to provide mechanical stability to areas of bony deficiency, or for its osteoinductive and osteoconductive properties. Concerns have been raised over increased infection rates following the use of fresh-frozen graft tissue. This retrospective study aims to investigate the outcomes of fresh frozen femoral heads kept in a regulated, non-commercial bone bank at a university teaching hospital.The local bone bank database was used to identify released femoral heads during a 14 year study period (September 1999-December 2013) whereby a retrospective review of patient records was undertaken to determine clinical outcome. During the observed study period, 427 femoral heads were released from cold storage. Of these, 270 femoral heads had a mean follow-up of 347 days. 157 femoral heads were excluded due to insufficient follow-up data (n = 132) or discarded due to breaks in the cold chain prior to use (n = 25). Of the 270 included femoral heads, 231 (85.6 %) had no reported complications with good graft incorporation. In the remaining 39 with reported complications, only 5 (2.6 %) developed a postoperative infection. Our findings suggest that the use of fresh frozen allograft does not materially increase the risk of post-operative bacterial infection. Our reported post-operative infection rates are comparable with infection rates of other similar studies on fresh frozen allograft use.
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Gilbody J, Taylor C, Bartlett GE, Whitehouse SL, Hubble MJW, Timperley AJ, Howell JR, Wilson MJ. Clinical and radiographic outcomes of acetabular impaction grafting without cage reinforcement for revision hip replacement: a minimum ten-year follow-up study. Bone Joint J 2014; 96-B:188-94. [PMID: 24493183 DOI: 10.1302/0301-620x.96b2.32121] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (sd 1.5) (10.0 to 16.0). Kaplan-Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose.
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Affiliation(s)
- J Gilbody
- Royal Devon and Exeter Hospital, Princess Elizabeth Orthopaedic Centre, Exeter, UK
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11
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Supercharging irradiated allografts with mesenchymal stem cells improves acetabular bone grafting in revision arthroplasty. INTERNATIONAL ORTHOPAEDICS 2014; 38:1913-21. [PMID: 24509980 DOI: 10.1007/s00264-014-2285-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 01/13/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE The procedure of bone allografting associated with a reinforcement device is widely used for acetabulum revision. However in absence of biologic fixation of the allograft, failure of the reconstruction may occur. We made the hypothesis that it would be possible to load these grafts with bone marrow derived mesenchymal stem cells (MSC) to rescue the osteogenic capacity of an allogenic dead bone and therefore enhance incorporation of allografts with the host bone and decrease the number of failures related to the allograft. METHOD We identified 60 patients who had undergone acetabular component revision for aseptic failure of cemented implants associated with massive periacetabular osteolysis and Paprosky type 3A or 3B classification (without pelvic discontinuity) between 1996 and 2001. The study group of 30 patients received MSCs in the allograft and at the host graft junction. The average total number of MSCs received by each patient was 195,000 cells (range 86,000-254,000 cells). The control group of 30 patients had no MSCs in the allograft. Patients were matched for the size of periacetabular osteolysis (Paprosky type 3A or 3B). We compared the evolution of the allografts and evaluated cup migration and revision of the hips as end points at a minimum of 12 years or until failure. RESULT Better radiographic graft union rates and less allograft resorption were observed with allografts loaded with stem cells. Allograft resorption was significantly decreased in the group with allograft loaded with MSCs (1.2 cm(2) -range 0-2.3 cm(2)-of resorption on radiographs in the group with MSCs; versus 6 cm(2), range 2.1-8.5 cm(2) in the group without MSCs). The rate of mechanical failure was highest (p = 0.01) among the 30 patients with allograft without stem cells (9/30; 30 %) compared with no failures for patients with allograft loaded with stem cells. Revision of the cup was necessary in nine patients in the control group. No revision was performed in the 30 patients of the study group with MSCs. CONCLUSION For acetabular defect reconstruction, loading the allograft with MSCs has resulted in a lower rate of failure as compared with allograft without MSCs.
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Russell N, Oliver RA, Walsh WR. The effect of sterilization methods on the osteoconductivity of allograft bone in a critical-sized bilateral tibial defect model in rabbits. Biomaterials 2013; 34:8185-94. [PMID: 23891084 DOI: 10.1016/j.biomaterials.2013.07.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/06/2013] [Indexed: 11/29/2022]
Abstract
Clinically, allogeneic bone graft is used extensively because it avoids the donor site morbidity associated with autograft. However, there are concerns over the optimal sterilization method to eliminate immunological risks whilst maintaining the biological efficacy of the graft. This study compared the effect of Supercritical fluid (SCF) treatment and gamma irradiation at 25 kGy on the osteoconductivity of allograft bone in a bilateral critical sized defect rabbit model. Osteoconductivity was evaluated at 2 and 4 weeks using X-ray, CT, histology (qualitative and quantitative) and immunohistochemistry (Alkaline Phosphatase and Cathepsin-K). Both grafts were well tolerated and osteoconductive. At 2 weeks, there was decreased bone volume and density in the gamma irradiated graft compared to the SCF treated graft, corresponding with a greater inflammatory response histologically and increased Cathepsin-K expression. Catabolic activity predominated at 4 weeks, with both grafts undergoing significant resorption and remodeling inside the defect. Alkaline Phosphatase expression was greater in the SCF group at both time points indicative of a more anabolic response. Allograft bone sterilized with either gamma irradiation or SCF treatment was osteoconductive and capable of healing a critical sized tibial defect in a rabbit. Gamma irradiated allografts elicited an acute inflammatory reaction when implanted which may increase the amount of graft resorption compared to the SCF treated bone.
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Affiliation(s)
- Nicholas Russell
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
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Reconstruction of the edentulous mandible with fresh frozen bone grafts and implants: a 4-year report of a prospective clinical study. Cell Tissue Bank 2012. [DOI: 10.1007/s10561-012-9352-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Feng W, Fu L, Liu J, Li D, Qi X. The use of deep frozen and irradiated bone allografts in the reconstruction of tibial plateau fractures. Cell Tissue Bank 2012; 14:375-80. [PMID: 22986931 DOI: 10.1007/s10561-012-9342-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 09/03/2012] [Indexed: 12/26/2022]
Abstract
To investigate the clinical behavior of deep frozen and irradiated bone allografts in the treatment of depressed tibial plateau fractures. Twenty-two patients with a tibial plateau fracture were treated with cancellous bone allografts. The bone allograft preparation process included fresh-freezing at -70 °C for 4 weeks and gamma-irradiation at 25 kGy. All of the patients were followed for 1-2 years. The clinical effects were assessed using the Rasmussen score for tibial head fractures and X-rays. Postoperatively, the average excellent and fair Rasmussen scores were 88.9%. Only one patient developed an infection, with no integration between allograft and recipient bone observed. All of the other bone allografts were incorporated successfully, and no osteoporosis or sclerosis was observed. The frozen and gamma-irradiated bone allograft is a good alternative in the treatment of tibial plateau fractures, which we have shown can integrate with the surrounding host bone.
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Affiliation(s)
- Wei Feng
- Department of Orthopaedics, The First Hospital of Jilin University, Changchun, 130021, China
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Abstract
BACKGROUND AND PURPOSE Acetabular impaction grafting has been shown to be very effective, but concerns regarding its suitability for larger defects have been highlighted. We report the use of this technique in a large cohort of patients, and address possible limitations of the technique. METHODS We investigated a consecutive group of 339 cases of impaction grafting of the cup with morcellised impacted allograft bone for survivorship and mechanisms for early failure. RESULTS Kaplan Meier survival was 89.1% (95% CI 83.2 to 95.0%) at 5.8 years for revision for any reason, and 91.6% (95% CI 85.9 to 97.3%) for revision for aseptic loosening of the cup. Of the 15 cases revised for aseptic cup loosening, nine were large rim mesh reconstructions, two were fractured Kerboull-Postel plates, two were migrating cages, one was a medial wall mesh failure and one had been treated by impaction alone. INTERPRETATION In our series, results were disappointing where a large rim mesh or significant reconstruction was required. In light of these results, our technique has changed in that we now use predominantly larger chips of purely cancellous bone, 8-10 mm3 in size, to fill the cavity and larger diameter cups to better fill the aperture of the reconstructed acetabulum. In addition we now make greater use of i) implants made of a highly porous in-growth surface to constrain allograft chips and ii) bulk allografts combined with cages and morcellised chips in cases with very large segmental and cavitary defects.
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Fresh-frozen human bone allograft in vertical ridge augmentation: clinical and tomographic evaluation of bone formation and resorption. Cell Tissue Bank 2011; 13:577-86. [DOI: 10.1007/s10561-011-9274-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 07/26/2011] [Indexed: 10/17/2022]
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Garcia-Cimbrelo E, Cruz-Pardos A, Garcia-Rey E, Ortega-Chamarro J. The survival and fate of acetabular reconstruction with impaction grafting for large defects. Clin Orthop Relat Res 2010; 468:3304-13. [PMID: 20499294 PMCID: PMC2974860 DOI: 10.1007/s11999-010-1395-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Impaction bone grafting has been used for acetabular reconstruction in revision surgery. However, most series do not establish differences in survival in revisions with differing severity of bone loss. QUESTIONS/PURPOSES We therefore determined (1) the survival rate for rerevision associated with varying degrees of bone loss; (2) the frequency with which bone graft resorption occurred; and (3) whether the reconstruction restored the anatomic center of rotation of the hip. METHODS We retrospectively reviewed 165 patients (181 hips) who underwent rerevision for major bone loss. Using the classification of Paprosky et al. 98 hips had a Grade 3A defect and 83 a Grade 3B. We determined survival rates for revision and graft resorption. Cup position was determined measuring vertical and horizontal positions and the distance from the center of the prosthetic femoral head to the normal center of rotation of the hip in both groups according to Ranawat. The minimum followup until rerevision or the latest evaluation was 0.3 years months (mean, 7.5 years; range, 0.3-17.7 years). RESULTS The survival rate for revision at 8 years was 84% (95% confidence interval: 61-100) for Grade 3A and 82% (95% confidence interval: 68-100) for Grade 3B. Twelve hips were rerevised. Seventeen grafts showed bone resorption. Acetabular cup position was anatomically restored in both Grades 3A and 3B. CONCLUSIONS The midterm results for impacted bone allograft and cemented all-polyethylene cups were similar in both Grade 3A and Grade 3B hips. Acetabular reconstruction allows anatomic positioning of the cups and is associated with a low rate of rerevision.
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McNamara I, Deshpande S, Porteous M. Impaction grafting of the acetabulum with a mixture of frozen, ground irradiated bone graft and porous synthetic bone substitute (Apapore 60). ACTA ACUST UNITED AC 2010; 92:617-23. [PMID: 20435995 DOI: 10.1302/0301-620x.92b5.23044] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The clinical and radiological results of 50 consecutive acetabular reconstructions in 48 patients using impaction grafting have been retrospectively reviewed. A 1:1 mixture of frozen, ground irradiated bone graft and Apapore 60, a synthetic bone graft substitute, was used in all cases. There were 13 complex primary and 37 revision procedures with a mean follow-up of five years (3.4 to 7.6). The clinical survival rate was 100%, with improvements in the mean Harris Hip Scores for pain and function. Radiologically, 30 acetabular grafts showed evidence of incorporation, ten had radiolucent lines and two acetabular components migrated initially before stabilising. Acetabular reconstruction in both primary and revision surgery using a 1:1 mixture of frozen, ground, irriadiated bone and Apapore 60 appears to be a reliable method of managing acetabular defects. Longer follow-up will be required to establish whether this technique is as effective as using fresh-frozen allograft.
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Affiliation(s)
- I. McNamara
- West Suffolk Hospital, NHS Trust, Hardwick Lane, Bury St Edmunds, Suffolk IP33 2QZ, UK. and The Orthopaedic Research Unit Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - S. Deshpande
- West Suffolk Hospital NHS Trust, Hardwick Lane, Bury St Edmunds, Suffolk IP33 2QZ, UK
| | - M. Porteous
- West Suffolk Hospital NHS Trust, Hardwick Lane, Bury St Edmunds, Suffolk IP33 2QZ, UK
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Impaction bone grafting in revision hip surgery: past, present and future. Cell Tissue Bank 2010; 11:57-73. [PMID: 20077177 DOI: 10.1007/s10561-009-9147-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 07/10/2009] [Indexed: 10/20/2022]
Abstract
Joint replacement surgery can have excellent clinical results. However, as the number of patients undergoing surgery increases, the number of failed joint replacements is set to rise. One of the greatest challenges for the revision surgeon is the restoration of bone stock. This article focuses upon revision hip surgery, with particular reference to the scope of the problem; historical and current solutions to bone loss in the femur and acetabulum; the clinical results following revision surgery; and the basic science behind impaction bone grafting, before ending with possible future directions for improving the restoration of bone stock.
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20
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Costain DJ, Crawford RW. Fresh-frozen vs. irradiated allograft bone in orthopaedic reconstructive surgery. Injury 2009; 40:1260-4. [PMID: 19486972 DOI: 10.1016/j.injury.2009.01.116] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2008] [Revised: 12/22/2008] [Accepted: 01/19/2009] [Indexed: 02/02/2023]
Abstract
The use of allograft bone is increasingly common in orthopaedic reconstruction procedures. The optimal method of preparation of allograft bone is subject of great debate. Proponents of fresh-frozen graft cite improved biological and biomechanical characteristics relative to irradiated material, whereas fear of bacterial or viral transmission warrants some to favour irradiated graft. Careful review of the literature is necessary to appreciate the influence of processing techniques on bone quality. Whereas limited clinical trials are available to govern the selection of appropriate bone graft, this review presents the argument favouring the use of fresh-frozen bone allograft as compared to irradiated bone.
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Affiliation(s)
- D J Costain
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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21
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Emms NW, Buckley SC, Stockley I, Hamer AJ, Kerry RM. Mid- to long-term results of irradiated allograft in acetabular reconstruction. ACTA ACUST UNITED AC 2009; 91:1419-23. [DOI: 10.1302/0301-620x.91b11.22274] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Between 1990 and 2000, 123 hips in 110 patients were reconstructed for aseptic loosening using impaction bone grafting with frozen, irradiated, morsellised femoral heads and cemented acetabular components. This series was reported previously at a mean follow-up of five years. We have extended this follow-up and now describe the outcome of 86 hips in 74 patients at a mean of ten years. There have been 19 revisions, comprising nine for infection, seven for aseptic loosening and three for dislocation. In surviving acetabular reconstructions, union of the graft had occurred in 64 of 67 hips (95.5%). Survival analysis for all indications at ten years was 83.3% (95% confidence interval (CI) 68 to 89) and 71.3% (95% CI 58 to 84) at 15 years. Acetabular reconstruction using irradiated allograft and a cemented acetabular component is an effective method of reconstruction, providing results in the medium- to long-term comparable with those of reported series where non-irradiated freshly-frozen bone was used.
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Affiliation(s)
- N. W. Emms
- St Helens and Knowsley, Teaching Hospitals NHS Trust, Warrington Road, Prescot, Merseyside L35 5DR, UK
| | - S. C. Buckley
- The Lower Limb Arthroplasty Unit, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
| | - I. Stockley
- The Lower Limb Arthroplasty Unit, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
| | - A. J. Hamer
- The Lower Limb Arthroplasty Unit, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
| | - R. M. Kerry
- The Lower Limb Arthroplasty Unit, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
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22
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Board TN, Brunskill S, Doree C, Hyde C, Kay PR, Meek RMD, Webster R, Galea G. Processed versus fresh frozen bone for impaction bone grafting in revision hip arthroplasty. Cochrane Database Syst Rev 2009; 2009:CD006351. [PMID: 19821362 PMCID: PMC7386794 DOI: 10.1002/14651858.cd006351.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Impaction grafting is a technique to restore bone loss both in the femur and the acetabulum during revision hip arthroplasty surgery. Initially impaction grafting was undertaken using fresh frozen femoral head allografts that were milled to create morselized bone pieces that could be impacted to create a neo-cancellous bone bed prior to cementation of the new implant. Results of medium and long term outcome studies have shown variable results using this technique. Currently both processed and non-processed allograft bone are used and the purpose of this review was to analyse the evidence for both. OBJECTIVES To determine the clinical effectiveness of processed (freeze dried or irradiated) bone in comparison to fresh frozen (unprocessed) bone. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1985 to 2008), EMBASE (1985 to 2008), CINAHL(1985 to 2008) and the National Research Register. Additional sources were also searched. Handsearching of relevant journals and conference abstracts was also undertaken. Searches were complete to 31 August 2008. SELECTION CRITERIA Randomised controlled trials that compared different types of bone for impaction grafting. DATA COLLECTION AND ANALYSIS Three hundred and sixty references were identified from the searches. Following detailed eligibility screening, three hundred and fifty nine references did not meet the eligibility criteria. Further details are required about one trial in order to determine it's eligibility. MAIN RESULTS No trials were identified that met the criteria for inclusion in the review. AUTHORS' CONCLUSIONS Good quality randomised controlled trials are required in this area so that a surgeon's choice of bone graft can be informed by evidence rather than personal preference.
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Affiliation(s)
- Timothy N Board
- Wrightington HospitalThe Centre for Hip SurgeryAppley BridgeWiganLancashireUKWN6 9EP
| | - Susan Brunskill
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Chris Hyde
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Peter R Kay
- Wrightington HospitalHall LaneAppley BridgeWiganLancashireUKWN6 9EP
| | - RM Dominic Meek
- Southern General Hospital, South Glasgow University Hospitals NHS TrustOrthopaedic Department1345 Govan RoadGlasgowStrathclydeUKG51 4TF
| | | | - George Galea
- Scottish National Blood Transfusion ServiceEllen's Glen RoadEdinburghUKEH17 7QT
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23
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Schreurs BW, Keurentjes JC, Gardeniers JWM, Verdonschot N, Slooff TJJH, Veth RPH. Acetabular revision with impacted morsellised cancellous bone grafting and a cemented acetabular component: a 20- to 25-year follow-up. ACTA ACUST UNITED AC 2009; 91:1148-53. [PMID: 19721038 DOI: 10.1302/0301-620x.91b9.21750] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery.
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Affiliation(s)
- B W Schreurs
- Department of Orthopaedics, Nijmegen Medical Centre, Radboud University, Intern postcode 357, P. O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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24
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Mehendale S, Learmonth ID, Smith EJ, Nedungayil S, Maheshwari R, Hassaballa MA. Use of irradiated bone graft for impaction grafting in acetabular revision surgery: a review of fifty consecutive cases. Hip Int 2009; 19:114-9. [PMID: 19462367 DOI: 10.1177/112070000901900206] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Impaction bone grafting is a useful technique in the armament of a revision hip surgeon. Traditionally fresh frozen allograft has been used for this technique. However there are concerns about the transmission of viral proteins and prions through this form of allograft. As a result irradiated bone graft has been favoured in some centres. There is no long term series describing the results of impaction bone grafting using irradiated bone. This paper reviews a consecutive series of 50 cases of acetabular revision surgery performed between 1995 and 2001 and followed up over a mean period of 45 months. The preoperative bone defect was graded by the Paprosky classification. There were 2 cases of type 1a, 9 type 2a, 15 type 2b, 7 type 2c, 10 type 3a and 7 type 3b. All cases were followed up clinically and radiologically. Case notes were reviewed for primary prosthesis, operative details and reason for revision. The radiographs were evaluated for signs of bone incorporation, remodelling, loosening and migration of the acetabular component. There were 5 cases of aseptic loosening at the end of the follow up period. One patient had recurrent dislocation and was revised. 20 cases (40%) showed changes suggestive of bone incorporation, while only 3 cases (6%) showed remodelling. Clinically a good or excellent outcome with absence of pain was achieved in 35 patients (70%). The results suggested that acetabular impaction bone grafting using irradiated bone graft is comparable to fresh frozen allograft. The low percentage of remodelling remains a concern and warrants further studies.
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25
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Ochs BG, Schmid U, Rieth J, Ateschrang A, Weise K, Ochs U. Acetabular bone reconstruction in revision arthroplasty: a comparison of freeze-dried, irradiated and chemically-treated allograft vitalised with autologous marrow versus frozen non-irradiated allograft. ACTA ACUST UNITED AC 2008; 90:1164-71. [PMID: 18757955 DOI: 10.1302/0301-620x.90b9.20425] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Deficiencies of acetabular bone stock at revision hip replacement were reconstructed with two different types of allograft using impaction bone grafting and a Burch-Schneider reinforcement ring. We compared a standard frozen non-irradiated bone bank allograft (group A) with a freeze-dried irradiated bone allograft, vitalised with autologous marrow (group B). We studied 78 patients (79 hips), of whom 87% (69 hips) had type III acetabular defects according to the American Academy of Orthopaedic Surgeons classification at a mean of 31.4 months (14 to 51) after surgery. At the latest follow-up, the mean Harris hip score was 69.9 points (13.5 to 97.1) in group A and 71.0 points (11.5 to 96.5) in group B. Each hip showed evidence of trabeculation and incorporation of the allograft with no acetabular loosening. These results suggest that the use of an acetabular reinforcement ring and a living composite of sterile allograft and autologous marrow appears to be a method of reconstructing acetabular deficiencies which gives comparable results to current forms of treatment.
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Affiliation(s)
- B G Ochs
- BG Trauma Centre, University of Tuebingen, Schnarrenbergstrasse 95, 72076 Tuebingen, Germany.
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26
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Vargas B, Caton J. Acetabular revision with freeze-dried irradiated and chemically treated allograft: a minimum 5-year follow-up of 17 cases. INTERNATIONAL ORTHOPAEDICS 2007; 33:35-9. [PMID: 17828537 PMCID: PMC2899226 DOI: 10.1007/s00264-007-0444-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 07/09/2007] [Accepted: 07/10/2007] [Indexed: 12/25/2022]
Abstract
We reviewed the results of 17 consecutive revision total hip arthroplasties performed with the use of freeze-dried irradiated bone allograft in 15 patients. These allografts were used in conjunction with five Kerboull rings, two steel meshes and ten cemented isolated cups. All the patients have had a follow-up of at least 5 years. The patients were evaluated clinically and radiographically. No revisions were necessary and X-rays confirmed partial or total ingrowth of the allografts. In acetabular revision surgery, hip reconstruction can be successfully treated by freeze-dried irradiated and chemically treated allografts. Additional studies with longer term follow-up are necessary to confirm this outcome.
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Affiliation(s)
- Bernardo Vargas
- Hôpital Orthopédique de la Suisse Romande, Department of Orthopedic Surgery, 1005, Lausanne, Switzerland.
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27
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Hannink G, Schreurs BW, Buma P. Irradiation has no effect on the incorporation of impacted morselized bone: a bone chamber study in goats. Acta Orthop 2007; 78:31-8. [PMID: 17453390 DOI: 10.1080/17453670610013394] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Gamma irradiation has been widely used for sterilization of bone allografts. However, gamma irradiation alters proteins. This is favorable when it reduces immunogenicity, but is undesirable when osteoinductive proteins are damaged. Although the effect of gamma irradiation on BMPs has been studied, the effect of irradiation on the process of incorporation of morselized bone chips remains unclear. We studied the effects of sterilization by gamma irradiation on the incorporation of impacted morselized allografts. METHODS Bone chambers with impacted allografts, rinsed impacted allografts, allografts that were rinsed and subsequently irradiated, and an empty control were implanted in proximal medial tibiae of goats. Incorporation was evaluated using histology and histomorphometry. RESULTS Histology revealed evidence of bone graft incorporation, which proceeded in a similar way in unprocessed, rinsed, and both rinsed and irradiated bone grafts. After 12 weeks, no difference in bone and tissue ingrowth was found between the unprocessed, the rinsed, and the rinsed and subsequently irradiated allografts. The amount of unresorbed graft remnant was highest in the unprocessed bone grafts. INTERPRETATION We conclude that sterilization with gamma irradiation does not influence the incorporation of impacted rinsed bone allografts.
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Affiliation(s)
- Gerjon Hannink
- Orthopaedic Research Lab, Radboud University Nijmegen Medical Centre, P.O. Box 9101, Nijmegen, HB 6500, the Netherlands
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28
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Board TN, Rooney P, Kearney JN, Kay PR. Impaction allografting in revision total hip replacement. ACTA ACUST UNITED AC 2006; 88:852-7. [PMID: 16798983 DOI: 10.1302/0301-620x.88b7.17425] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- T N Board
- Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire WN6 9EP, UK.
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