Aims. Giant cell tumours (GCTs) of the proximal femur are rare, and there is no consensus about the best method of filling the defect left by curettage. In this study, we compared the outcome of using a fibular strut allograft and bone cement to reconstruct the bone defect after extended curettage of a GCT of the proximal femur. Methods. In a retrospective study, we reviewed 26 patients with a GCT of the proximal femur in whom the bone defect had been filled with either a fibular strut allograft (n = 12) or bone cement (n = 14). Their demographic details and oncological and nononcological complications were retrieved from their medical records. Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) score. Results. Mean follow-up was 116 months (SD 59.2; 48 to 240) for the fibular strut allograft group and 113 months (SD 43.7; 60 to 192) for the bone cement group (p = 0.391). The rate of recurrence was not significantly different between the two groups (25% vs 21.4%). The rate of nononcological complications was 16.7% in the strut allograft group and 42.8% in the bone cement group. Degenerative joint disease was the most frequent nononcological complication in the cement group. The mean MSTS score of the patients was 92.4% (SD 11.5%; 73.3% to 100.0%) in the fibular strut allograft group and 74.2% (SD 10.5%; 66.7% to 96.7%) in the bone cement group (p < 0.001). Conclusion. Given the similar rate of recurrence and a lower rate of nononcological complications, fibular strut grafting could be recommended as a method of reconstructing the bone defect left by curettage of a GCT of the proximal femur. Cite this article: Bone Joint J 2022;104-B(2):297–301

Background. Structural bone allografts are an established treatment method for long-bone structural defects arising from such conditions as trauma, sarcoma, and osteolysis following total joint replacement. However, the quality of structural bone allografts is difficult to non-destructively assess prior to use. The functional lifetime of structural allografts depend on their ability to resist cyclic loading, which can lead to fracture even at stress levels well below the yield strength. Because allograft bone has limited capacity for remodeling, optimizing allograft selection for bone quality could decrease long-term fracture risk. Raman spectroscopy biomarkers can non-destructively assess the three primary components of bone (collagen, mineral, and water), and may predict the resistance of donor bone allografts to fracture from cyclic loads. The purpose of this study was to prospectively assess the ability of Raman biomarkers to predict number of cycles to fracture (“cyclic fatigue life”) of human allograft cortical bone. Methods. Twenty-one cortical bone specimens were from the mid-diaphysis of human donor bone tissue (bilateral femurs from 4 donors: 63M, 61M, 51F, 48F) obtained from the Musculoskeletal Transplant Foundation. Six Raman biomarkers were analyzed: collagen disorganization, type B carbonate substitution (a surrogate for mineral maturation), matrix mineralization, and 3 water compartments. Specimens underwent cyclic fatigue testing under fully reversed conditions at 35 and 45MPa (physiologically relevant stress levels for structural allografts). Specimens were tested to fracture or to 30 million cycles (“run-out”), simulating 15 years of moderate activity (i.e., 6000 steps per day). Multivariate regression analysis was performed using a tobit model (censored linear regression) for prediction of cyclic fatigue life. Specimens were right-censored at 30 million cycles. Results. All of the 6 biomarkers that were evaluated were independently associated with cyclic fatigue life (p < 0.05). The multivariate model explained 70% of the variance in cyclic fatigue life (R2=0.695, p<0.001,). Increasing disordered collagen (p<0.001) and loosely collagen-bound water compartments (p<0.001) were associated with decreased cyclic fatigue life. Increasing type B carbonate substitution (p<0.001), matrix mineralization (p<0.001), tightly collagen-bound water (p<0.001), and mineral-bound water (p=0.002) were associated with increased cyclic fatigue life. In the predictive model, 42% of variance in cyclic fatigue life was attributable to degree of collagen disorder, all bound water compartments accounted for 6%, and age and sex accounted for 17%. Conclusions. Raman biomarkers of three bone components (collagen, mineral, and water) predict cyclic fatigue life of human cortical bone. Increased baseline collagen disorder was associated with decreased cyclic fatigue life, and was the strongest determinant of cyclic fatigue life. Increased matrix mineralization and mineral maturation were associated with increased cyclic fatigue life. Bound-water compartments of bone contributed minimally to cyclic fatigue life. These results are complementary with prior Raman studies of monotonic testing of bone that reported decreased toughness and strength with increased collagen disorder and increased stiffness with increased bone mineralization and mineral maturation. This model should be prospectively validated. Raman analysis is a promising tool for the non-destructive evaluation of structural bone allograft quality and may be useful as a screening tool for selection of allograft bone. Acknowledgements. Supported by a grant from the Musculoskeletal Transplant Foundation. The Dudley P. Allen Fellowship (JYD), Wilbert J. Austin Professor of Engineering Chair (CMR) and the Leonard Case Jr. Professor of Engineering Chair (OA) are gratefully acknowledged

Allograft materials have been the mainstay in addressing bone deficiencies in knee and hip replacement and revision surgery for decades because of the associated donor site morbidity of autografts. Bone graft substitutes have been developed to address allograft issues including potential contamination, disease transmission, and availability. Although non-autogenous products have no osteogenic potential, they do have a variable degree of osteoinductive and osteoconductive properties.

Unfortunately, there are limited reports regarding use of bone graft substitutes for use in total hip and knee arthroplasty. Bone graft substitutes have most frequently been used as an “extender”, in combination with morsellised allograft, to fill cavitary defects. Incorporation of this bone graft substitute and morsellised allograft combination appears to occur incompletely. Stable implant fixation appears to be a prerequisite for incorporation of bone graft substitutes, as these cannot be relied upon for structural support. Although bone graft substitutes appear to perform satisfactorily as “fillers” for contained cavitary bone defects, ultraporous metal augments have become the preferred method of providing structural support for some defects. In view of their substantial cost, high quality clinical, radiographic and retrieval data regarding performance of bone graft substitutes is needed.

Introduction. Reinforcement ring with allograft bone is commonly used for acetabular reconstruction of bone defects because it can achieve stable initial fixation of the prosthesis. It is not clear whether the allograft bone can function as a viable host bone and provide long-standing structural support. The purpose of this study was to assess to long-term survival of the reinforcement rings and allograft bone incorporation after acetabular revisions. Methods. We retrospectively reviewed 39 hips (37 patients) who underwent reconstruction of the acetabulum with a Ganz reinforcement ring and allograft bone in revision total hip arthroplasty. There were 18 females and 19 males with a mean age of 55.9 years (35–74 years). The minimum postoperative follow-up period was 10 years (10∼17 years). We assessed the acetabular bone defect using the Paprosky's classification. We determined the rates of loosening of the acetabular reconstructions, time to aseptic loosening, integration of the allograft bone, resorption of the allograft bone, and survival rate. Aseptic loosening of the acetabular component was defined as a change in the cup migration of more than 5 mm or a change in the inclination angle of more than 5° or breakage of the acetabular component at the time of the follow-up. Graft integration was defined as trabecular remodelling crossing the graft-host interface. Resorption of the allograft bone was classified as minor (<1/3), moderate (1/3–1/2) or severe (>1/2). Kaplan-Meier survivorship analysis was performed for aseptic loosening of the acetabular component. The results. The acetabular bone defects were classified as follows: 8 type II hips (4 type IIB, 4 type IIC), and 31 type III hips (17 type IIIA, 14 type IIIB). Fourteen (35.9%) of 39 hips was defined as aseptic loosening of an acetabular component. Loosening was more frequent in type IIIB (57.1%) than in type IIIA hips (29.4%). Mean time to aseptic loosening of the acetabular reconstructions was 6.3 years in type IIIA and from 5 years in type IIIB defects, respectively. Allograft bone incorporation was satisfactory in 66.7% of hips. There was minor bone resorption in 14.3% and moderate bone resorption in 10.2%. In 9 hips (23.1%), severe resorption of the allograft bone was observed and early component loosening was observed in these cases. The survival rate of acetabular component at 10 years of follow-up was 63.6% (95% confidence interval, 49–77%) with aseptic loosening as endpoints. Conclusions. The long-term survival rate of acetabular revision using the reinforcement ring and allograft bone in the reconstruction of severe acetabular bone defects was unsatisfactorily low due to loosening of acetabular components. Because of unfavorable graft incorporation into a host bone, an alternative component and structural support may be employed in the reconstruction of severe acetabular bone defects

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

Allograft bone is widely used in orthopaedic surgery, but peri-operative infection of the graft remains a common and disastrous complication. The efficacy of systemic prophylactic antibiotics is unproven, and since the graft is avascular it is likely that levels of antibiotic in the graft are low. Using an electrical potential to accelerate diffusion of antibiotics into allograft bone, high levels were achieved in specimens of both sheep and human allograft. In human bone these ranged from 187.1 mg/kg in endosteal (. sd. 15.7) to 124.6 (. sd. 46.2) in periosteal bone for gentamicin and 31.9 (. sd. 8.9) in endosteal and 2.9 (. sd. 1.1) in periosteal bone for flucloxacillin. The antibiotics remained active against bacteria in vitro after iontophoresis and continued to elute from the allograft for up to two weeks. Structural allograft can be supplemented directly with antibiotics using iontophoresis. The technique is simple and inexpensive and offers a potential means of reducing the rate of peri-operative infection in allograft surgery. Iontophoresis into allograft bone may also be applicable to other therapeutic compounds

Summary of background data: Lumbar interbody arthrodesis can be achieved by using autograft or allograft bone. One of the disadvantages of using autograft bone graft is complications related to the iliac crest donor site. Another option is using an allograft bone (ex.-femoral head from bone bank). There are few reports of using allograft bone for instrumented lumbar spinal fusion. Methods: Fifteen patients were treated at our institution by lumbar fusion in various indications. We used allograft bone and evaluated their outcome for an average period of 3 years. The recovery rate, complications and radiographic findings were evaluated. Results: Good radiographic and clinical results were achieved by using allograft bone graft. No complications were detected. Conclusions: The clinical and radiographic results of Allograft bone graft, for lumbar spine arthrodesis, are impressive. One of the advantages of this method, comparing to an autograft is avoiding any donor site complications

Implantation of allograft bone is an integral part of revision surgery of the hip. One major concern with its use is the risk of transmission of infective agents. There are a number of methods of processing allograft bone in order to reduce this risk. One method requires washing the tissue using pulsed irrigation immediately before implantation. We report the incidence of deep bacterial infection in 138 patients (144 revision hip arthroplasties) who had undergone implantation of allograft bone. The bone used was fresh-frozen, non-irradiated and pulse-washed with normal saline before implantation. The deep infection rate at a minimum follow-up of one year was 0.7%. This method of processing appears to be associated with a very low risk of allograft-related bacterial infection

Introduction. Hip and knee arthroplasty present surgeons with difficult bone loss. In these cases the use of morselized allograft is a well established way of optimizing early implant fixation. In revisions, the surgical field is potentially infected. The use of allograft bone creates a “dead space” in which the immune system has impaired access, and even a small amount of bacteria may therefore theoretically increase the risk of infection. In vivo studies have shown that allograft bone is suitable as a vehicle of local antibiotic delivery. We hypothesized that the allograft bone could be used as a local antibiotic delivery vehicle without impairing the implant fixation, tested by mechanical push-out. Material and Methods. Following approval of the Institutional Animal Care and use Committee we implanted a cylindrical (10×6 mm) porous-coated Ti implant in each distal femur of 12 dogs observed for 4 weeks. The implants were surrounded by a circumferential gap of 2.5 mm impacted with a standardized volume of morselized allograft. In the two intervention groups, 0.2ml tobramycin solution of high (800mg/ml) and low (200mg/ml) concentration was added to the allograft, respectively. In the control group 0.2ml saline was added to the allograft. ANOVA-test was applied followed by paired t-test where appropriate. A p-value < 0,05 was considered statistically significant. Results. The impregnation of allograft bone revealed a relative decrease in biomechanical fixation. The decrease was higher in the high dose group than in the low dose group. The most extreme difference was a decrease in strength by 18% (P = 0,511), stiffness 15% (P = 0,135) and energy absorption 27% (P = 0,784). Conclusion. The result shows a trend towards a decrease in implant fixation correlating with the antibiotic concentration. Although the results are not statistically significant the use of antibiotic impregnation should be used with caution until further reaserch has been conducted

Abstract. Introduction. Bone grafts are utilised in a range of surgical procedures, from joint replacements to treatment of bone loss resulting from cancer. Decellularised allograft bone is a regenerative, biocompatible and immunologically safe potential source of transplant bone. Objectives. To compare the structural and biomechanical parameters of decellularised and unprocessed (cellular) trabecular bone from the human femoral head (FH) and tibial plateau (TP). Methods. Bone pins were harvested from 10 FHs and 11 TPs (27, 34 respectively). Pins were decellularised (0.1% w/v sodium dodecyl sulphate) or retained as cellular controls. QA testing was carried out to assess protocol efficacy (total DNA and histological analysis). Cellular and decellularised FH (n=7) and TP (n=10) were uCT scanned. Material density (MD); apparent density (BV/TV); trabecular connectivity; trabecular number; trabecular thickness (Tb-t) and trabecular spacing were measured. Pins were then compression tested to determine ultimate compressive stress (UCS), Young's modulus and 0.2% proof stress. Results. Total DNA levels of decellularised bone were below 50 ng.mg. −1. dry weight. Cell nuclei and marrow were largely removed. No significant differences in properties were found between decellularised and cellular bone from either anatomical region (p>0.05, Mann-Whitney). No significant differences in biomechanical properties were found between cellular FH and cellular TP (p>0.05) though significant differences in structural properties were found (MD: TP>FH, p=0.001; BV/TV: FH>TP, p=0.001; and Tb-t: FH>TP, p=0.005). Significant differences were found between decellularised FH and decellularised TP (UCS: FH>TP, p=0.001; Young's modulus: FH>TP, p=0.002; proof stress; FH>TP, p=0.001; MD: TP>FH, p<0.001; BV/TV: FH>TP, p<0.001 and Tb-t: FHT>P p<0.001. Conclusion. Decellularisation did not affect the properties of human trabecular bone. Differences were found between the mechanical and structural properties of decellularised FH and TP which could facilitate stratified bone grafts for different applications. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Aim. Aim of this monocentric, prospective study was to evaluate the safety, efficacy, clinical and radiographical results at 24-month follow-up (N = 6 patients) undergoing hip revision surgery with severe acetabular bone defects (Paprosky 2C-3A-3B) using a combination of a novel phase-pure betatricalciumphosphate - collagen 3D matrix with allograft bone chips. Method. Prospective follow-up of 6 consecutive patients, who underwent revision surgery of the acetabular component in presence of massive bone defects between April 2018 and July 2019. Indications for revision included mechanical loosening in 4 cases and history of hip infection in 2 cases. Acetabular deficiencies were evaluated radiographically and CT and classified according to the Paprosky classification. Initial diagnosis of the patients included osteoarthritis (N = 4), a traumatic fracture and a congenital hip dislocation. 5 patients underwent first revision surgery, 1 patient underwent a second revision surgery. Results. All patients were followed-up radiographically with a mean of 25,8 months. No complications were observed direct postoperatively. HHS improved significantly from 23.9 preoperatively to 81.5 at the last follow-up. 5 patients achieved a defined good result, and one patient achieved a fair result. No periprosthetic joint infection, no dislocations, no deep vein thrombosis, no vessel damage, and no complaint about limbs length discrepancy could be observed. Postoperative dysmetria was found to be + 0.2cm (0cm/+1.0cm) compared to the preoperative dysmetria of − 2.4 cm (+0.3cm/−5.7cm). Conclusions. Although used in severe acetabular bone defects, the novel phase-pure betatricalciumphosphate - collagen 3D matrixshowed complete resorption and replacement by newly formed bone, leading to a full implant integration at 24 months follow-up and thus represents a promising method with excellent bone regeneration capacities for complex cases, where synthetic bone grafting material is used in addition to autografts

Objectives. The most concerning infection of allografts and operative procedures is methicillin resistant Staphylococcus aureus (MRSA) and no current iontophoresed antibiotics effectively combat this microbe. It was initially hypothesised that iontophoresis of vancomycin through bone would not be effective due to its large molecular size and lack of charge. The aim of this study was to determine whether this was a viable procedure and to find the optimum conditions for its use. . Methods. An iontophoresis cell was set up with varying concentrations of Vancomycin within the medulla of a section of sheep tibia, sealed from an external saline solution. The cell was run for varying times, Vancomycin concentrations and voltages, to gain information on optimisation of conditions for impregnating the graft. Each graft was then sectioned and dust ground from the exposed surface. The dust was serially washed to extract the Vancomycin and concentrations measured and plotted for all variables tested. Results. Vancomycin was successfully delivered and impregnated to the graft using the iontophoresis technique. The first order fit to the whole data set gave a significant result (p = 0.0233), with a significant concentration (p = 0.02774) component. The time component was the next most significant (p = 0.0597), but did not exceed the 95% confidence level. Conclusions. Iontophoresis is an effective method for delivering Vancomycin to allograft bone. The concentrations of the vancomycin solution affected the bone concentration, but results were highly variable. Further study should be done on the effectiveness of delivering different antibiotics using this method. Cite this article: Bone Joint Res 2014;3:101–7

Previously, radiostereometric analysis following hip revision performed using impacted morsellised allograft bone and a cemented Exeter stem has shown continuous subsidence of the stem for up to five years. It is not known whether the subsidence continues thereafter. In our study, 17 of 25 consecutive osteo-arthritic patients with aseptically loose stems who underwent first-time revision using impacted morsellised allograft bone and a cemented Exeter stem were followed by yearly radiostereometric examinations for nine years. The mean subsidence at six weeks was 1.1 mm (0.1 to 2.3), from six weeks to one year 1.3 mm (0 to 2.6), from one to five years 0.7 mm (0 to 2.0), and from five to nine years 0.7 mm (0.1 to 3.1). That from six weeks to nine years was 2.7 mm (0 to 6.4) (95% confidence interval 2.0 to 3.5). The Charnley pain score significantly improved after revision, and was maintained at nine years, but walking ability deteriorated slightly as follow-up extended. Of the eight patients who were not followed for nine years, two had early subsidence exceeding 11 mm. Our findings show that in osteo-arthritic patients who undergo revision for aseptic loosening of the stem using impacted morsellised allograft bone and a cemented Exeter stem, migration of the stem continues over nine years at a slower rate after the first year, but without clinical deterioration or radiological loosening

Posterior spinal fusion is performed for a variety of lumbar spine conditions for relief of low back pain. Success relies on an effective fusion. Autograft is associated with donor site comorbidity and limited supply. Allograft has the potential for infection and has limited osteoinductive activity. Bone morphogenic proteins (BMPs) have been promoted for use in posterior spinal fusion despite considerable cost and limited evidence to their efficacy.

The aim of this study was to compare the clinical response, donor site morbidity and radiologic rates of fusion in patients undergoing posterior spinal fusion looking at the choice of bone graft or substitute. A retrospective review of 141 patients undergoing instrumented posterior lumbar spinal fusion by a single surgeon for degenerative disc disease, degenerative spondylolithesis or lytic spondylolithesis between 2000 and 2005 was undertaken. Patients were contacted and assessed for donor site morbidity and scored with the Oswestry Disability Index (ODI). Radiographs were taken and assessed by an independent blinded radiologist using the Ferguson score. Simple analysis was performed of these results to compare bone grafting techniques.

One hundred and forty-one patients were available for review. Fusions were performed for lytic spondylolithesis in 12.4%, degenerative spondylolithesis in 46% and for degenerative disc disease in 41.6% of patients. BMP-2 was used in 19.6%, allograft in 59.8% and iliac crest bone graft in 20.5% of patients. The BMP-2 and non BMP-2 groups were equally spread between the diagnosis and levels of surgery. The overall Ferguson score radiographic fusion rates for these patients was A in 67.9%, B in 17.9% and C in 11.9%. The BMP-2 group patients scored 76.9% (A group) and 23.1% (B group). The non-BMP-2 group scored 57.1% (A group), 23.8% (B group) and 19.1% (C group). The Oswestry Disability Index for patients with BMP-2 improved from 49.7% to 19%, whereas with no BMP-2 improved from 50.0% to 20.9%. Donor site morbidity was not identified as a problem in patients who had an autograft procedure.

Over the course of several years a single spinal surgeon’s posterior lumbar spinal fusion practice has evolved as a variety of bone grafting techniques have been trialled in an effort to increase the rate of bony fusion. There was no obvious difference in Oswestry Disability Index score but there was a modest difference in the Ferguson radiologic fusion score for the BMP-2 group. Morbidity in the autograft group was not a problem. These results have confirmed the efficacy of both allograft and autograft in fusion.

A two-stage procedure was carried out on 57 patients with confirmed infection in a hip replacement. Allograft bone was used in the second stage. Pathogenic organisms were identified in all patients. In stage 1, the prosthesis was removed together with infected tissue. Antibiotics were added to customised cement beads. Systemic antibiotics were not used. At the second stage, 45 of the patients had either acetabular impaction grafting, femoral impaction grafting or a combination; 12 had a massive allograft. Eight patients suffered recurrent infection (14%), in six with the original infecting organism. The risk factors for re-infection were multiple previous procedures and highly resistant organisms. We believe that systemic antibiotic therapy should be considered for these patients. Allograft bone is shown to be a useful adjunct in most infected hip replacements with considerable loss of bone stock

Introduction and Objective. In recent years, along with the extending longevity of patients and the increase in their functional demands, the number of annually performed RSA and the incidence of complications are also increasing. When a complication occurs, the patient often needs multiple surgeries to restore the function of the upper limb. Revision implants are directly responsible for the critical reduction of the bone stock, especially in the shoulder. The purpose of this paper is to report the use of allograft bone to restore the bone stock of the glenoid in the treatment of an aseptic glenoid component loosening after a reverse shoulder arthroplasty (RSA). Materials and Methods. An 86-years-old man came to our attention for aseptic glenoid component loosening after RSA. Plain radiographs showed a complete dislocation of the glenoid component with 2 broken screws in the neck of glenoid. CT scans confirmed the severe reduction of the glenoid bone stock and critical bone resorption and were used for the preoperative planning. To our opinion, given the critical bone defect, the only viable option was revision surgery with restoration of bone stock. We planned to use a bone graft harvested from distal bone bank femur as component augmentation. During the revision procedure the baseplate with a long central peg was implanted “on table” on the allograft and an appropriate osteotomy was made to customize the allograft on the glenoid defect according to the CT-based preoperative planning. The Bio-component was implanted with stable screws fixation on residual scapula. We decided not to replace the humeral component since it was stable and showed no signs of mobilization. Results. The new bio-implant was stable, and the patient gained a complete functional recovery of the shoulder. The scheduled radiological assessments up to 12 months showed no signs of bone resorption or mobilization of the glenoid component. Conclusions. The use of bone allograft in revision surgery after a RSA is a versatile and effective technique to treat severe glenoid bone loss and to improve the global stability of the implant. Furthermore, it represents a viable alternative to autologous graft since it requires shorter operative times and reduces graft site complications. There are very few data available regarding the use of allografts and, although the first studies are encouraging, further investigation is needed to determine the biological capabilities of the transplant and its validity in complex revisions after RSA

AIM: To study bone healing and infection incidence using Allograft bone in acute comminuted fractures in elderly. METHOD: 21 cases of comminuted fractures of distal femur and proximal tibia requiring bone grafting at primary fixation between 1999 and 2004 were included. Out of 19 cases of proximal tibial fractures, 7 were Schatzker type III, 6 were type IV and 6 were type V. Mean patient’s age was 74 years. Rigid internal fixation with sterilized human Cadaveric allograft was used to fill the defect. No additional auto-bone grafting was done. All cases had 24 hours postop IV antibiotics and were followed up clinically and radiologically until the end point of union or nonunion. OUTCOME: 20/21 cases had fracture union within expected duration. 83 years old patient with Supracon-dylar fracture of femur with DCS fixation, failed to unite at 12 months post op and required revision surgery. 20/21 cases had no superficial or deep infection. 62 years old patient with Schatzker IV tibial plateau fracture had deep infection requiring wound debridement and removal of implant which revealed unabsorbed allograft at one year post op which also cleared the infection. CONCLUSION: Allograft bone graft can be a safe bone substitute for promoting bone healing in elderly patients in acute fracture management. We recommend using allograft bone in elderly patients to reduce morbidity by avoiding one more surgery of obtaining bone graft. Allograft bone in elderly used with internal fixation also provides a reasonable structural support along with it osteoinductive properties

Summary Statement. Supercritical fluid (SCF) sterilization produces clean and osteoconductive allograft bone capable of healing a critical-sised bony defect. SCF treated graft induces an increased anabolic response and decreased catabolic reponse compared to gamma irradiated graft. Introduction. 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) sterilization and gamma irradiation on the osteoconductivity of allograft bone in a bilateral critical-sised defect rabbit model. Methods. Cortical-cancellous allograft bone was milled, defatted and terminally sterilised with either gamma irradiation at 25kGy or SCF treatment. The graft was then implanted bilaterally into a critical-sised metaphyseal defect in 10 New Zealand White rabbits (n=5 sites per time point per group). Osteoconductivity was evaluated at 2 and 4 weeks to measure the early inflammatory response and early new bone formation respectively, using X-ray, CT, and both qualitative and quantitative histology and immunohistochemistry (Alkaline Phosphatase and Cathepsin-K). Results. Both grafts were well tolerated and osteoconductive. At 2 weeks, there were significant reductions in bone volume and density in the gamma irradiated graft compared to the SCF treated graft as measured by CT. Inside the defect this corresponded with a greater inflammatory response in the gamma irradiated graft, with a less organised fibrous tissue infiltration and mild granuloma reaction. Conversely, the SCF group had a highly organised and densely packed fibrous tissue infiltration around the allograft chips. Immunohistochemistry results supported these findings with an up-regulation in the expression and distribution of Cathepsin-K in the gamma irradiation group; while Alkaline Phosphatase expression was higher in the SCF group. At 4 weeks, resorptive behavior predominated in both groups. Radiographic and CT results detected no significant difference between groups. Histology at 4 weeks showed larger bone chips were undergoing substantial remodeling with areas of simultaneous osteoclastic resorption and osteoblastic new bone formation. Smaller allograft chips and areas of new bone formation were infiltrated by fibrous tissue and undergoing osteoclastic resorption. Quantitative immunohistochemistry showed an up-regulation of Cathepsin-K expression in both groups from 2 to 4 weeks. At both time points Cathepsin-K expression was higher in the gamma irradiated graft compared to the SCF group. This was greatest at 2 weeks where there was a substantial 82% increase in expression which was reduced to a 38% discrepancy at 4 weeks. Alkaline Phosphatase expression was greater in the SCF group at both time-points. Discussion/Conclusion. Allograft bone sterilised with either gamma irradiation or SCF treatment was osteoconductive and capable of healing a critical-sised defect in a rabbit. Gamma irradiated allografts elicited an acute inflammatory reaction when implanted which increased the amount graft resorption compared to the SCF treated bone. Increased osteoclastic resorption may be a concern for structural graft applications leaving the graft more susceptible to premature failure. SCF sterilization produced a clean, highly biocompatible graft with increased anabolic activity compared to gamma irradiation which may facilitate earlier healing clinically. These results suggest that SCF sterilization has considerable expediency for allograft processing and may facilitate more optimal extraction of the inherent properties of the graft compared to current practices

Aims: Irradiated allograft bone may help to reduce the risk of transmission of infectious agents from donor to recipient. The purpose of this study was to establish the results of impaction bone grafting of acetabular defects with froze, irradiated allograft bone. Methods: All patients treated by a single surgeon with impaction bone grafting of acetabular defects at revision total hip replacement were reviewed retrospectively. All operations were performed during the period 1994–2000. The mean follow-up was 50 months (range 30–96 months). Case notes and X rays were reviewed and analysed. The Paprosky grade of acetabular defects was determined from the pre-operative X rays and the surgeonñs operation note. Post-operative X rays were reviewed to establish the extent and rate of new bone in-growth. Functional outcomes were determined by way of self-administered questionnaires. Results: Complete records and X rays were obtained for 33 patients who underwent revision hip arthroplasty with impaction bone grafting of the acetabulum using frozen, irradiated allograft bone. There were no complications associated with the bone grafts and no patient required a re-operation. Review of serial X rays conþrmed in-growth of host bone and the functional outcome was satisfactory. Overall 29 patients (88%) declared themselves satis-þed with the outcome of their operation and 32 patients (97%) improved functionally after the operation. Conclusions: These results indicate that satisfactory results can be achieved with impaction bone grafting using frozen, irradiated allograft bone. The use of irradiated bone graft can potentially reduce the risk of disease transmission from donor to recipient without compromising the surgical results

Aims. Infections of bone usually require multiple surgery and prolonged periods of treatment. One reason for problems is found in the presence of stationary phase bacteria embedded in biofilms that show increased resistance against conventional antibiotic therapy (up to 1000x MIC). Biofilms adhere to surfaces of avital material making radical debridement a prerequisite for cure. Osseous defects are common in such conditions and need to be addressed. To avoid re-infection high local antbiotic concentrations are necessary. Allograft bone may be impregnated with high loads of antibiotics using a special incubation technique. The resulting antibiotic bone compound (ABC) provides high and long lasting concentrations at the site of infection and is likely to restore bone stock simultaneously. Based on this technology we have developed a new surgical technique. Methods. 42 patients (10–67yrs) with chronic osteitis were included into a prospective study using a standardized protocol. Infection was at the humerus (1x), femur (10x), tibia (29x) or femur+tibia (2x), respectively. Treatment consisted of removal of foreign material, radical sequestrectomy and soft-tissue debridement followed by pressurized lavage. Surfaces of sclerotic bone were trimmed down to vital areas. The remaining osseous defects were filled with ABC, using an impaction technique resulting in complete dead space management. The allograft was impregnated with vancomycin, in cases with mixed pathogens combinations with tobramycin were used. Internal fixation was performed the same time whenever applicable. Sites were drained and closed immediately; rehabilitation did not differ from uninfected procedures. Results. 1 patient died shortly after surgery from cardiac failure. 41 could be followed for a minimum of 2 and a maximum of 6years (mean 3,1years). In 2 patients wound healing was unsatisfactory requiring additional coverage with a muscle flap. 2 patients showed material failure after intramedullary nailing, requiring exchange of the implant. In those cases no sign of infection was present at the time of revision. There were 3 cases with recurrence of infection, all originating from foci not detected during the index operation and becoming apparent between 3 and 12 months after surgery. Two could successfully be revised using the same technique; one refused revision and shows continuing fistulation. Radiological incorporation of allografts appeared as after conventional bone grafting, union of pseudarthroses was achieved between 2 and 6 months after (re-) stabilization. 40 patients (95,2%) were fully weight bearing, painfree and without any sign of infection at the latest follow up. Conclusion. Using antibiotic impregnated allograft bone eradication of pathogens, grafting of defects, dead space management and insertion of osteosynthetic material may be accomplished in a one stage procedure. Since the graft gradually is replaced by healthy own bone improved long term results may be expected as well as improved conditions in the case of another revision. The new technique provides for quick rehabilitation, improved results and markedly reduced costs of treatment in cases of bone infection