Allograft reconstruction for bone sarcoma of the tibia in the growing child.

The outcome of tibial allograft reconstruction after resection of a tumour is inconsistent and has a high rate of failure. There are few reports on the use of tibial allografts in children with open growth plates. We performed 21 allograft reconstructions (16 osteoarticular, five intercalary) in 19 consecutive patients between seven and 17 years of age. Two had Ewing's sarcoma, one an adamantinoma and 16 osteosarcoma, one with multifocal disease. Five patients have died; the other 14 were free from disease at the time of follow-up. Six surviving patients (eight allograft reconstructions) continue to have good or excellent function at a mean of 59 months (14 to 132). One patient has poor function at 31 months. The other seven patients have a good or excellent function after additional procedures including exchange of the allograft and resurfacing or revision to an endoprosthesis at a mean of 101 months (43 to 198). The additional operations were performed at a mean of 47 months (20 to 84) after the first reconstruction. With the use of allograft reconstruction in growing children, joints and growth plates may be preserved, at least partially. Although our results remain inconsistent, tibial allograft reconstruction in selected patients may restore complete and durable function of the limb.

Effects of dimethylsulfoxide on the ultrastructure of fixed cells.

It has been reported that the use of dimethylsulfoxide (DMSO) as a solvent for fixatives enhances preservation of cellular ultrastructure. By contrast, we have shown that DMSO alters the ultrastructural integrity of glutaraldehyde fixed cells. The cell membrane, nuclear envelope, endoplasmic reticulum, ribosomes, microtubules and intracytoplasmic organelles are most susceptible to the action of DMSO. We hypothesize that DMSO exerts intracellular alterations via its interaction with remnant interfacial water in fixed cells. DMSO-induced alterations of these and related cellular components may result in the formation of artefactual structures and networks. Thus, it appears that DMSO containing glutaraldehyde neither accelerates fixation nor enhances stabilization of cellular ultrastructure. For these reasons, addition of DMSO to fixatives is not recommended.

Incidence of clostridial contamination in donors' musculoskeletal tissue.

Reports of infection by Clostridium sordellii associated with allograft transplantation have generated considerable interest. We report our experience in recognising clostridial contamination in cadaver donors of musculoskeletal tissue. Tissues obtained from 795 consecutive donors were excised using standard surgical techniques. Samples of blood and bone marrow were also obtained. Donors with clostridia recovered from any site were matched with the preceding donor without clostridia as a procedural and environmental control. The histories of the donors were analysed to determine which variables had a relationship to contamination by running a contingency table and chi-squared test on the variables against the event of a donor being contaminated. Sixty-four donors (8.1%) had clostridia, most commonly C. sordellii. Clostridia were grown from the blood, marrow and tissue samples of 52, 37 and 30 donors, respectively. In eight cases, they were cultured from the tissue samples alone. There was no significant difference in age or gender between the contaminated donors and the control group. Open wounds were more common in control than in contaminated subjects, but only death by drowning in the contaminated group was statistically significant (p = 0.02). The time between death and the excision of tissue which was contaminated (16 hrs 10 mins) compared with control (11 hrs 10 mins) donors was also significant (p < 10(-6)). We conclude that there is clostridial contamination in a significant number of tissue donors, particularly with increasing time between death and tissue excision. Among the most commonly encountered species is C. sordellii. Multiple microbiological cultures, including blood, are necessary in order to identify clostridial contamination.

Salvage of humeral nonunions with onlay bone plate allograft augmentation.

Eight women and one man were treated for 10 established diaphyseal humeral nonunions. Six patients sustained fractures in motor vehicle accidents and two patients sustained fractures in a fall. Two of the fractures were open. One patient with multiple myeloma originally was treated conservatively and received local radiation, followed by open reduction and internal plate fixation. The other patients previously were treated with fracture braces, intramedullary nails, dynamic compression plates, or a combination of these techniques. After removal of the surgical hardware and fibrous tissue at the nonunion site, stable fixation was accomplished using a cortical long bone plate allograft (femoral and tibial) or fibular shaft allograft and a dynamic compression plate. All humeral nonunions had united at an average of 2.9 months. Radiographic incorporation of the allograft cortical bone plate and fibular shaft into the host cortex occurred in all but one patient by 3 months. Graft to host junction healing was accomplished by incorporation of the cortical allograft plate into the host cortex, resulting in an increased diameter of the bone. Cortical allograft bone plates and fibular grafts provide structural and probably osteoinductive support to enhance healing of these nonunions.

Articular cartilage nutrition is mediated by subchondral bone: a long-term autograft study in baboons.

OBJECTIVE: To determine the relative importance of subchondral nutrition in cartilage in autologous transplants and its relation to the development of osteoarthritis (OA). METHOD: The study was performed in non-human primates with two types of autografts placed orthotopically. One type of autograft was placed into vascularized, viable cancellous bone well, and another in an identical bone well, but coated with methylmethacrylate. The latter prevented direct contact between the autograft and the host bone. Observations were continued for 3 years. RESULTS: Abrogation of the contact between subchondral bone and articular cartilage-bone autograft had little effect on the cartilage during the first 5-12 months. By 3 years, autografts in the methylmethacrylate wells had non-vascularized and non-viable subchondral bone. The cartilage in these wells underwent degenerative changes compatible with OA. CONCLUSION: Interruption of contact between articular cartilage and vascularized subchondral bone resulted in degeneration of the cartilage. The onset and detection of these degenerative changes required long time periods (3 years). Had the experiments been terminated at 1 year or sooner the above described changes would not be apparent.

Restoration of bone stock in revision surgery of the femur.

Three hundred and four femoral revisions were performed from 1987 to the end of 1990. All were done with cementless titanium calcar replacement prostheses, designed for proximal bone loading. Type III bone deficiencies were present in 160 femurs, all requiring supplemental cortical bone plates for bony augmentation. All grafts united and provided increased bone stock in the long term. Physiologic loading is important for graft remodeling and maturation. Hip scores have improved from an average Harris Hip Score of 44 to 84. Current survivorship at 10 years is 96%, and the revision rate is 3.2%. Thigh pain is mild in 3% of cases. There have been no late failures or distal lysis noted to date.

Results of onlay allografts.

Cortical onlay strut allografts provide a method for bone restoration when performing revision surgery in a patient with a structurally deficient femur. Between 1986 and 1990, 251 patients underwent femoral revisions using structural onlay bone grafts. The followup ranged between 8 and 12 years, with the average followup being 9.5 years. All of the grafts united to the host bone. The revision rate in the current series is 3%, with no complications related to the bone graft. The average Harris hip score improved 45 points. Cortical onlay grafts are used for patients with structurally deficient femurs. After union occurs, the graft undergoes adaptive remodeling, secondary to physiologic load bearing. This technique has proved to be a reliable method for bone restoration in the patient with a structurally compromised femur.

Structural bone grafting for femoral reconstruction.

Structural grafting for femoral reconstruction has been used in femoral revision surgery in connection with partial bone loss. In patients in whom the proximal femur is compromised significantly circumferentially, or is entirely absent, segmental proximal femoral allografts are indicated. Onlay cortical allografts have been used to supplement bone stock when the intact femur has advanced noncircumferential deficiencies attributable to osteoporosis, osteolysis, or other causes. The procedure using proximal femoral allografts was performed in 262 patients from 1983 to 1997. Satisfactory results were obtained in 85% of the patients. More than 1000 cortical onlay bone plate allografts were performed from 1984 to 1997. Detailed information was obtained on 251 patients who underwent surgery from 1984 to 1990. These constructs reliably united with the host bone and increased bone mass long-term.

Effects of epidural steroids on lumbar dura material properties.

Epidural steroid injections are commonly used in the treatment of low back pain and radiculopathy based on their antiinflammatory and analgesic benefits. However, steroids are known to affect collagen synthesis, material strength, and tissue healing. The purpose of this study was to assess the effects of serial epidural steroid injections on the material properties of the lumbar dura mater. Serial epidural steroid injections of saline or methylprednisolone at 2-week intervals were performed in three paired groups of canines; a separate noninjected group was used as controls. Postmortem, dural sample testing to failure and histologic analysis was performed. Mechanical failure testing revealed no clinically significant change in the transverse dorsal dura tensile strength between all saline-injected, steroid-injected, or noninjected controls. Histologic analysis demonstrated no overt disruption of collagen matrix organization; however, electron microscopy demonstrated a significant decrease in the number of intracytoplasmic mitochondria of dural fibroblasts in steroid-injected animals, suggesting a metabolic inhibitory effect within steroid-injected dura mater. In the clinical time frame of this study, serial epidural steroid injections appeared to produce no significant material or matrix changes in the lumbar dura.

Microscopic and histochemical manifestations of hyaline cartilage dynamics.

Structure and function of hyaline cartilages has been the focus of many correlative studies for over a hundred years. Much of what is known regarding dynamics and function of cartilage constituents has been derived or inferred from biochemical and electron microscopic investigations. Here we show that in conjunction with ultrastructural, and high-magnification transmission light and polarization microscopy, the well-developed histochemical methods are indispensable for the analysis of cartilage dynamics. Microscopically demonstrable aspects of cartilage dynamics include, but are not limited to, formation of the intracellular liquid crystals, phase transitions of the extracellular matrix and tubular connections between chondrocytes. The role of the interchondrocytic liquid crystals is considered in terms of the tensegrity hypothesis and non-apoptotic cell death. Phase transitions of the extracellular matrix are discussed in terms of self-alignment of chondrons, matrix guidance pathways and cartilage growth in the absence of mitosis. The possible role of nonenzymatic glycation reactions in cartilage dynamics is also reviewed.

Limb salvage with osteoarticular allografts after resection of proximal tibia bone tumors.

A retrospective study was performed between 1980 and 1995 on 38 recipients of proximal tibial allografts after wide resection of benign and malignant tumors. Twenty-one (55%) patients experienced one or more complications. Of the 26 patients who received chemotherapy, 15 (58%) experienced one or more complications, whereas of the 12 patients who did not receive chemotherapy, six (50%) experienced one or more complications. In the chemotherapy group, there were 12 (46%) fractures, four (15%) infections, three (12%) nonunions, and four (15%) instabilities. In the nonchemotherapy group there were three (25%) infections, two (17%) fractures, one (8%) instability, and one (8%) nonunion. These complications were managed adequately with multiple subsequent surgical procedures. Three patients underwent amputations for deep wound infections. Twelve (32%) patients underwent removal of the allograft, and the limb was salvaged by reallografting or by total knee arthroplasty. The results of both groups were 66% (25 of 38 patients) satisfactory (good or excellent). The chemotherapy group had a significantly higher incidence of fractures. All other complication rates and functional outcomes were not significantly different between these groups.

Quantification of the collagen fibre architecture of human cranial dura mater.

The purpose of this study was to quantify and map the gross fibre architecture of the cranial dura mater (CDM) using small angle light scattering (SALS). In SALS, HeNe laser light is passed through the tissue, and the resultant scattering pattern is analysed to determine the preferred fibre direction and degree of orientation. The dura mater was found to be a complex structure with fibre orientations ranging from highly aligned to nearly random. In the temporal region, 80% of the samples (n = 20) were found to have regions composed of highly oriented fibres with a mean fibre direction of 6.3 degrees +/- 0.8 degree with respect to the sagittal plane (i.e. almost parallel to the superior sagittal sinus). These highly aligned regions were found in symmetric anatomical locations about the median sagittal sinus and had similar fibre orientations over both hemispheres. Although our sample size was small, we found that the size of the symmetric regions, which covered 14.4 +/- 1.6% of the total CDM area, was not influenced by subject's age or sex. The presence of these highly oriented fibre regions in CDM may be due to mechanical forces exerted on dura mater during its development. These forces may have induced realignment of the collagen fibres in the direction of tensile pull, although the exact basis for the unique gross fibre architecture of CDM remains unknown.

Onlay cortical allografting for the femur.

Failed femoral total hip replacement components are frequently associated with bone loss. At the time of revision surgery, the goals are to create a construct that relieves pain, is stable, and preserves and enhances bone stock. This article discusses Materials and Methods, Indications, Operative Technique, and Results regarding onlay cortical allografting for the femur.

Transmission light microscopy of structurally colored semithin cartilage sections.

Conversion of osmified tracheal cartilage constituents into an array of laminar interference gratings has been attained by three tandem reactions. Oxidation of semithin, LR white-embedded cartilage sections by acetic anhydride in dimethyl sulfoxide is the first step in the conversion process. Subsequent addition reactions of oxidized cartilage pyranoses and furanoses with thiocarbohydrazide constitutes the second step. Reduction of silver proteinate by thiocarbohydrazones and the concomitant coating of cartilage constituents with silver gratings completes the conversion of cartilage sections into a system of layered interference filters. In transmitted light, all components of converted cartilage display vivid structural colors, which allow detailed microscopic analysis of structurally colored cellular and extracellular cartilage constituents.

Local mechanical anisotropy in human cranial dura mater allografts.

Human cranial dura mater (CDM) allograft's success as a repair biomaterial is partly due to its high mechanical strength, which facilitates its ability to form water-tight barriers and resist high in-vivo mechanical loads. Previous studies on CDM allograft mechanical behavior used large test specimens and concluded that the allograft was mechanically isotropic. However, we have quantified CDM microstructure using small angle light scattering (SALS) and found regions of well-aligned fibers displaying structural symmetry between the right and left halves (Jimenez et al., 1998). The high degree of fiber alignment in these regions suggests that they are mechanically anisotropic. However, identification of these regions using SALS requires irreversible tissue dehydration, which may affect mechanical properties. Instead, we utilized CDM structural symmetry to estimate the fiber architecture of one half of the CDM using computer graphics to flip the SALS fiber architecture map of the corresponding half about the plane of symmetry. Test specimens (20 mm x 4 mm) were selected parallel and perpendicular to the preferred fiber directions and subjected to uniaxial mechanical failure testing. CDM allografts were found to be locally anisotropic, having an ultimate tensile strength (UTS) parallel to the fibers of 12.76 +/- 1.65 MPa, and perpendicular to the fibers of 5.21 +/- 1.01 MPa (mean +/- sem). These results indicate that uniaxial mechanical tests on large samples used in previous studies tended to mask the local anisotropic nature of the smaller constituent sections. The testing methods established in this study can be used in the evaluation of new CDM processing methods and post-implant allograft mechanical integrity.

Lipids closely associated with bone morphogenetic protein (BMP)--and induced heterotopic bone formation. With preliminary observations of deficiencies in lipid and osteoinduction in lathyrism in rats.

An extensive literature on bone morphogenetic protein (BMP) induced generation and regeneration shows general agreement about one observation. The incidence and quantity of bone were greatest when BMP was delivered with a carrier of various biologic and non biologic polymers. In the present research, neutral lipids either endogenous in demineralized bone matrix (DBM) or exogenous in orign were employed as a delivery system for induced heterotopic bone formation in the rectus muscle in rats. Total neutral lipids including cholesterol were measured by correlated gravimetric and Sudan Black B dye binding methods. The heterotopic bone was measured by computer assisted radiomorphometric and histologic methods. Bone formation was measured by total calcium, DNA-P, and alkaline phosphatase activity. Composites of BMP and neutral lipids, separable from phospholipids by extraction with absolute acetone, were consistently osteoinductive. A significant quantity of the total bone lipid was closely associated with and extractable from the bone matrix non-collagenous protein fraction which had high levels of BMP activity. Lathyritic matrix was very low both in dye binding and osteoinductive activity. These observations suggest the possibility that lipids may serve as a BMP carrier in the process of induced bone development.

Neutral lipids facilitate transfer of bone morphogenetic proteins and other noncollagenous proteins.

In the process of separation of bone morphogenetic proteins from bone matrix, lipids were found in unexpected amounts closely associated with noncollagenous proteins soluble in guanidine hydrochloride. Lipids representing 33.7-49.9% by weight were recovered with various solvents. Composites of noncollagenous proteins and lipids soluble in either chloroform- methanol or acetone implanted in the hindquarter muscles of mice induced the formation of large deposits of heterotopic bone. The protein-lipid aggregates formed microspherules which were stained by Sudan Black B. Implants of bone morphogenetic proteins and noncollagenous proteins-lipid microspherules stained with Sudan Black B induced bone development in the same manner as unstained delipidized bone morphogenetic proteins associated with noncollagenous proteins. Lipid-free osteocalcein, osteonectin, albumin and other bone matrix proteins did not induce bone formation or bind Sudan Black B. The more highly purified the noncollagenous proteins, with or without activity of bone morphogenetic proteins, the lower the level of binding with Sudan Black B. Acetone-soluble bone matrix lipids consisted chiefly of triglycerides, cholesterol and saturated short chain fatty acids, and included little or no phospholipids or monounsaturated fatty acids. Composites of recombinant bone morphogenetic proteins-2 and acetone-soluble lipids induced larger deposits of bone than implants of recombinant bone morphogenetic proteins-2 without acetone-soluble lipids. The hypothesis that an association of bone lipids with protein facilitates the local transport of bone morphogenetic proteins warrants further investigation.