Comparison of contamination of femoral heads and pre-processed bone chips during hip revision arthroplasty.

With bone impaction grafting, cancellous bone chips made from allograft femoral heads are impacted in a bone defect, which introduces an additional source of infection. The potential benefit of the use of pre-processed bone chips was investigated by comparing the bacterial contamination of bone chips prepared intraoperatively with the bacterial contamination of pre-processed bone chips at different stages in the surgical procedure. To investigate baseline contamination of the bone grafts, specimens were collected during 88 procedures before actual use or preparation of the bone chips: in 44 procedures intraoperatively prepared chips were used (Group A) and in the other 44 procedures pre-processed bone chips were used (Group B). In 64 of these procedures (32 using locally prepared bone chips and 32 using pre-processed bone chips) specimens were also collected later in the procedure to investigate contamination after use and preparation of the bone chips. In total, 8 procedures had one or more positive specimen(s) (12.5 %). Contamination rates were not significantly different between bone chips prepared at the operating theatre and pre-processed bone chips. In conclusion, there was no difference in bacterial contamination between bone chips prepared from whole femoral heads in the operating room and pre-processed bone chips, and therefore, both types of bone allografts are comparable with respect to risk of infection.

Epidiaphyseal versus other intercalary allografts for tumors of the lower limb.

Epidiaphyseal intercalary reconstruction has become possible for bone tumors that extend into the epiphysis because advances in magnetic resonance imaging and chemotherapy allow close resection while sparing the juxtaarticular bone and joint. In a retrospective study, we questioned whether epidiaphyseal reconstructions around the knee had a clinical outcome (measured as long-term survival, complication rate, and functional score) comparable with metadiaphyseal and diaphyseal reconstructions. Between 1988 and 1999, 14 epidiaphyseal, nine metaphyseal, and 12 diaphyseal reconstructions were done, and the median followup was 7.2 years. Kaplan-Meier analysis showed a 10-year survival rate of 79% for epidiaphyseal reconstructions, which did not differ from an 89% rate for metadiaphyseal and a 75% rate for diaphyseal reconstructions. Epidiaphyseal complications included two infections, five fractures, and three nonunion treatments. Complications for all 35 grafts included three infections, 12 fractures, and nine nonunion treatments. Ultimately, six grafts failed, with infection and length of resection as predisposing factors. All epiphyseal osteotomies had tumor-free margins and no local recurrences. The mean Musculoskeletal Tumor Society score for each type of intercalary reconstruction was between 23 and 24. Because the epidiaphyseal reconstruction avoids complications associated with joint reconstruction and the results are comparable with those of other types of intercalary grafts, these reconstructions should be considered if at least 1 cm of tumor-free juxtaarticular bone can be maintained.

Hemicortical allograft reconstruction after resection of low-grade malignant bone tumours.

Low-grade surface tumours of bone may theoretically be treated by hemicortical resection, retaining part of the circumference of the cortex. An inlay allograft may be used to reconstruct the defect. Since 1988 we have performed 22 hemicortical procedures in selected patients with low-grade parosteal osteosarcoma (6), peripheral chondrosarcoma (6) and adamantinoma (10). Restricted medullary involvement was not a contraindication for this procedure. There was no evidence of local recurrence or distant metastasis at a mean follow-up of 64 months (27 to 135). Wide resection margins were obtained in 19 patients. All allografts incorporated completely and there were no fractures or infections. Fractures of the remaining hemicortex occurred in six patients and were managed successfully by casts or by osteosynthesis. The functional results were excellent or good in all except one patient. Hemicortical procedures for selected cases of low-grade surface tumours give excellent oncological and functional outcomes. There was complete remodelling and fewer complications when compared with larger intercalary procedures. The surgery is technically demanding but gives good clinical results.

Microbiological screening of post-mortem bone donors - two case reports.

This study assesses the value of blood cultures in combination with swab culturing techniques in association with bone banking procedures. The results of blood and swab cultures of two postmortem bone donors were compared with procured grafts, cultured in their entirety. In one donor, who died of drowning, three of the 12 entire graft cultures were positive with the same microorganism of high pathogenicity as the blood culture, whilst the swab culture of only one graft was positive. In the second donor, who died from myocardial infarction, four entire cultures were positive with the same organism of high pathogenicity as the blood culture, whilst the swab cultures of three grafts were positive. In both donors identical organisms were cultured from the myocardium of the pulmonary or aortic heart valve. The results confirm the limited sensitivity of swab culturing techniques. Especially micro-organisms inside a graft, disseminated through the bloodstream, can remain unnoticed. Blood cultures seem to provide additional information on micro-organisms that have spread haematogenously pre-mortem and may even provide information on the source from which they have spread.

A comparative study of blood and bone marrow cultures in cadaveric bone donation.

The results of blood cultures taken from cadaveric bone donors were compared with bone marrow and also swab cultures of the procured grafts. In eight of the 95 donors evaluated, pathogenic micro-organisms were detected in the blood sample. In two, identical micro-organisms were cultured from the blood and bone marrow sample whilst the swab cultures were negative. Considering the low sensitivity of the swab culture, the organisms detected in the blood culture were likely to have spread haematogenously and considered to be present in the explanted grafts. Bacteriological screening of bone donors is extremely important since the transmission of micro-organisms via an allograft can lead to serious complications in the recipient. Positive blood cultures provide important information on the presence of pathogenic micro-organisms in grafts obtained from cadaveric bone donors and are therefore essential in deciding whether a graft is bacteriologically acceptable for transplantation.

Successful excision of a pseudotumour in a congenitally factor V deficient patient.

We report a patient with congenital homozygous factor V deficiency in whom a large pseudotumour in the right upper leg was successfully surgically excised under continuous substitution with fresh-frozen plasma.

Contamination of bone allografts: analysis of incidence and predisposing factors.

We analysed the bacterial contamination of 1999 bone allografts retrieved from 200 cadaver donors under sterile operating conditions. The effect of various factors on the relative risk of contamination was estimated using a multiple logistic regression model. Organisms of low pathogenicity were cultured from 50% of the grafts and of high pathogenicity from 3%. The risk of contamination with low pathogenic organisms (mainly skin commensals) increased by a factor of 1.6 for each member added to the procurement team. The risk of contamination with high pathogenic organisms (mainly contaminants from the gastrointestinal tract) was 3.4 times higher in donors with a traumatic cause of death and 5.2 times higher in those with a positive blood culture. Preceding organ procurement did not significantly influence the risk of contamination. Rinsing the graft with an antibiotic solution was not an effective decontamination method. The major source of contamination is exogenous and is strongly influenced by the procurement team. Contamination from endogenous sources can be controlled by donor selection. We discuss methods that can be used to decrease contamination and the rate of discarding of bone allografts.

[5-year experience with a central bone bank]. / Vijf jaar ervaring met een centrale botbank.

Since December 1988 the Leiden Bone Bank Foundation, in cooperation with the BIS Foundation, makes allogeneic bone and related soft tissue available for transplantation. Bone banking has become a scientifically high level medical activity in which international standards are established in order to provide safe and effective allografts. Careful donor selection and extensive laboratory testing are the cornerstones for the prevention of disease transmission. In the first 5 years of the existence of the Leiden Bone Bank 450 deep frozen massive bone allografts, of which 221 osteoarticular and intercalary allografts, were shipped to different clinics inside and outside the Netherlands. Furthermore, 322 deep frozen soft tissues, 1877 units of freeze dried bone grafts and 5629 units of demineralized grafts were distributed. The number of transplants with allogeneic bone and related soft tissue from the Leiden Bone Bank increased each year by at least 30% Bone and related soft tissue allografts were used in orthopaedic surgery, neurosurgery and maxillofacial surgery. There are no known cases of transmission of infectious diseases by grafts distributed by the Leiden Bone Bank.

[The use of allogeneic bone and tendon tissue from a central bone bank]. / Het gebruik van allogeen bot- en peesweefsel uit een centrale botbank.

During the period January 1989 to December 1990 the use of bone and related soft tissue allografts from our bone bank was reviewed retrospectively. Data were complete for 278 patients, who received 403 allografts in total. Forty-nine patients were transplanted with a massive deep frozen bone allograft, 41 patients received a deep frozen soft tissue allograft, while 313 units of freeze dried bone allografts were transplanted into 188 patients. Massive deep-frozen bone allografts were used mainly in patients with bone tumours, fibrous dysplasia of the neck of the femur and for revision arthroplasty. Soft tissues were used mainly for reconstruction of ruptured cruciate ligaments. Freeze dried bone allografts such as cancellous chips as well as cortical cancellous chips were used for spinal fusion, arthroplasty, treatment of pseudarthrosis, fractures, tumours and fibrous dysplasia, and in maxillofacial defects. Cancellous blocks were used specifically for spinal fusion. Demineralized cortical dust was used mainly in maxillofacial surgery.

Sequential magnetic resonance imaging in Perthes' disease.

Forty-eight images using magnetic resonance imaging (MRI) in 16 hips with Perthes' disease were evaluated over a mean period of two years. MRI depicted exactly the infarcted zone in the femoral head before typical radiological changes were evident. Early determination of the extent of the infarcted bone on MRI benefits those patients who require treatment. Follow-up MRI scans at six-monthly intervals, reflected the chronological stages of the repair process in each group classified according to Catterall.

Osteoarticular allografts.

Over the past eighty years, osteoarticular allografts have provided the possibility of limb-sparing procedures in tumor surgery. Several authors have now reported up to 80 per cent successful use of these types of grafts, and large well-documented series give evidence that limb reconstruction following extensive resection of bone and joints has been possible with their use. In conjunction with their successful applications, studies of the fate of osteoarticular allografts have provided useful information on their associated problems. Infection has been a major complication, affecting up to 12 per cent of recipients and frequently resulting in re-operations and occasionally amputations. Studies have suggested however that almost half of these infections are due to soft-tissue complications rather than to the allografts. Fractures and non-unions, affecting up to 10 per cent of recipients, have proven easier to treat, and few if any patients lose their grafts after fractures. A recent study of retrieved osteoarticular allografts has shown that incorporation of these massive bone segments is slow but progressive, and ultimate incorporation of the grafts can be expected in most patients. The fate of the cartilaginous portion of the grafts has also been evaluated. Our laboratory has suggested that although cryopreservation of the articular portion of the grafts appears feasible in vitro, the fate of transplanted cryopreserved cartilage is dependent on many factors, including accurate sizing and ligamentous reconstruction around the replaced joints. In determining indications for massive osteoarticular allografts, we have found that these grafts are not a panacea for all problems encountered in bone tumor resection, but should be used advisedly for the treatment of specific problems.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma of the colon and rectum: a report on 624 cases.

A total of 624 patients with adenocarcinoma of the large bowel and operated between 1958 and 1978 were retrospectively studied. According to the period of operation, patients were divided into group A (1958 to 1968, n = 259) and group B (1969 to 1978, n = 365). Symptoms were closely related to tumour location. Blood loss and change in bowel habits were most frequent in patients with left-sided cancer, while anaemia, loss of body weight and abdominal pain turned out to be the predominant symptoms in patients with right-sided cancer. Patients with cancer of the transverse colon or splenic flexure showed a high incidence of ileus (19%). Resection of the primary tumour was possible in 86% of the cases. The overall morbidity was 48% and the postoperative mortality was 8%. Anastomotic dehiscence occurred in 4% of our patients. There was no significant difference in postoperative mortality between the two patient groups. The mortality is closely related to the Dukes stage (Dukes A 4%, Dukes D 19%). The overall crude survival was 45%, the corrected survival 57%. Patients with cancer of the descending colon or (recto)sigmoid had a higher corrected 5-year survival when compared to patients with cancers in other tumour sites (65% versus 52%, p less than 0.01). Dukes stage, ileus as primary symptom were also correlated with survival, while sex distribution, age and duration of symptoms were not.