Demineralized Bone Matrix Graft: A Scientific and Clinical Case Study Assessment

Osteoinductive demineralized bone matrix results from bone demineralization and is attributed to matrix-associated bone morphogenetic proteins. The osteoinductive potential can vary with donor. Many bioassay methods are available to screen donors, each with its own interpretation, so performance of more than one may be of value. Furthermore, little is known about the relationship between bioassay results and clinical outcomes. A study designed to meaningfully explore these issues would require assay of a large number of donors as well as clinical utilization in a large patient population. A preliminary study was undertaken to gain initial perspective. Using demineralized bone matrix derived from one 33-year-old female donor, 2 methods of bioassay and a clinical case study were performed. The levels of bone morphogenetic proteins 2, 4, and 7 in lyophilized demineralized bone matrix powder were measured (19.65 +/- 0.30 ng/g, 2.49 +/- 0.19 ng/g, and 82.03 +/- 6.89 ng/g, respectively). Also, putty (Osteostim DBM Putty), prepared from powder, was intramuscularly implanted in athymic rats and de novo bone formation quantified (6.7% +/- 3.5% new bone formation with 49% +/- 17% of the implant area associated with new bone formation). The putty, in conjunction with internal fixation, was used in the revision of a medial malleolar nonunion of an obese, 76-year-old woman. Radiographic union with excellent graft incorporation was achieved by 12 weeks postoperatively, with maintenance of an acceptable clinical result during the 14-month follow-up period. These results are interpreted in the broader context of demineralized bone grafting, in general, and an outline for further study is presented.     

复合珊瑚羟基磷灰石人工骨的研制和临床应用

目的　自行研制复合人工骨并评价其临床应用价值。方法　将天然海珊瑚碳酸钙在特定条件下经过“热液交换反应”先制成一种珊瑚羟基磷灰石 (CorallingHydroxyAptite,CHA)人工骨。再将此CHA人工骨与重组人BMP2 (rhBMP2 )和 2 %几丁糖复合 ,制备成rhBMP2 /CHA复合人工骨。将此新型复合人工骨分别植入 2 0只SD大白鼠体内 ,观察其生物相容性和成骨能力。并应用临床治疗骨缺损和椎间融合共 30例 ,观察术后局部伤口情况 ,全身反应和骨愈合情况。结果　随访观察平均 14个月 ,无全身性异常反应 ,仅 1例伤口有渗液 ,3周内伤口愈合 ,其余无不良反应 ,伤口均在 2周内一期愈合。骨愈合情况 :骨囊肿和胫骨干骺端骨折骨缺损植骨后 2个月愈合 ;脊柱椎间融合术后 3个月融合 ;骨不连术后 4～ 6个月愈合 ,无并发症发生。人工骨在观察期内未能完全降解。结论　自行研制的rhBMP2 /CHA复合人工骨生物相容性好 ,无毒性 ,成骨诱导作用优于单纯CHA和异体脱钙骨 ,临床应用满意 ,是一种比较理想的骨移植替代物。     

Semiquantitative mRNA Measurements of Osteoinductive Growth Factors in Human Iliac-Crest Bone: Expression of LMP Splice Variants in Human Bone

Although osteotropic growth factors are known to play an important role in bone metabolism, knowledge about their expression in relation to age, sex and smoking remains limited. In this study we report mRNA levels of the recently discovered Lim mineralization protein splice variants (LMP-1, LMP-2, LMP-3) and the established osteotropic growth factors BMP-2, BMP-6, BMP-7, TGF-, IGF-I, IGF-II and b-FGF in human iliac crest bone. Standardized bone biopsy specimens were obtained from the iliac crest during graft harvesting in 62 patients (38 males, 24 females, mean age 44.7 years, range 13–78 years) undergoing spinal surgery. Samples were immediately stored in liquid nitrogen for PCR analysis. Semi-quantitative RT-PCR was performed for TGF-, IGF-I, IGF-II, BMP2, BMP-6, BMP7, bFGF, LMP-1, LMP-2 and LMP-3 using -actin as internal standard. Triplicate measurements were made of each growth factor and -actin. mRNA for all examined growth factors was detected in 69% of the specimens. The lowest degree of detection was present for b-FGF and BMP-2, both of which were found in 85% of the specimens. LMP-1 was detected in 98% of the specimens. LMP-2 in 94% and LMP-3 in 27%, respectively. LMP-1 was generally expressed in higher amounts than LMP-2 and LMP-3. Nondetectable levels of the growth factors were more frequent in the >60-year-old males compared with >60-year-old females (P < 0.05) and <60-year-old males (P < 0.01). LMP-1 expression was more variable among young individuals, but mean values were similar between age groups. TGF-, BMP-2 and BMP-7 values did not differ between age groups, but generally a higher variation was found among older patients. IGF-I values were significantly higher (P < 0.05) in males over 60 years, whereas the highest level of bFGF mRNA was present in males younger than 20 years (P < 0.05) . In addition, regression analysis revealed correlation between BMP-2 and BMP-7 (R² = 0.74, P < 0.0005), LMP-2 and BMP-2 (R² = 0.27, P < 0.0005) and LMP-2 and bFGF (R² = 0.40, P < 0.0005). In conclusion, we have demonstrated expression of LMP-1 and LMP-2 in human bone. LMP-1 was expressed in higher amounts and showed a higher degree of variation among young individuals. LMP-2 was correlated to a number of other growth factors, suggesting that LMPs may also play a role in human bone metabolism. Higher variation in the expression of TGF-, BMP-2 and BMP-7 was found in the older age groups, but whether or not this can be correlated to age-related changes in bone turnover requires further studies.     

异体DBM复合rhBMP-2修复兔桡骨缺损的实验研究

目的探讨异体脱钙骨基质（demineralized bonematrix，DBM）复合重组人骨形态发生蛋白2（reconstruction humn bonemorphology protein-2，rhBMP-2）修复节段性骨缺损的能力。方法48只新西兰大白兔采用桡骨15mm节段性骨缺损模型，随机分为3组，A组植入异体DBM与rhBMP-2复合材料，B组植入异体DBM，C组为空白对照组。术后4周、8周、12周、16周．进行放射学和组织学检查。结果A组：术后4周宿主结缔组织长入植骨材料内的骨小梁间，并有岛状新生软骨、骨组织形成；术后8周，新生软骨及骨形成并融合成片；术后12周，新骨改建成熟，但仍能见到植骨材料；术后16周，管状骨结构形成，髓腔再通。B组：术后4周，植骨材料周围有软骨形成；术后8周，大量软骨形成；术后12周，大片状骨形成；术后16周，有髓腔形成。C组：各时问点仅见有纤维结缔组织，只在两端有新骨形成。X片示A组成骨量大，新骨改建、成熟迅速，术后16周全部达骨性愈合。B组成骨量少，仅2例达骨性愈合。C组未见骨性愈合。结论异体DBM复合rhBMP-2材料通过骨诱导和骨传导两种方式修复骨缺损，是一种较理想、具有高效成骨活性的植骨材料。     

Preventing Graft Thrombosis After Renal Transplantation: A Multicenter Survey of Clinical Practice

Background

Renal allograft vascular thrombosis is a complication that often results in graft loss. Since there are no guidelines on immediate postoperative thromboprophylaxis, we performed a telephone survey of clinical practice in all renal transplantation centers in France.

Methods

Each center considered 4 cases relating to renal transplant candidates on dialysis with an increasing risk of thrombosis: Case 1: patient with no identified risk factors; Case 2: patient with an earlier incidence of deep vein thrombosis; Case 3: patient with ischemic heart disease on antiplatelet therapy; Case 4: patient with atrial fibrillation taking a vitamin K antagonist (VKA) with lupus nephritis syndrome.

Results

The treatments proposed by the centers (%) were: Case 1: No anticoagulation therapy (57.1%), calcium heparin at prophylactic doses (P-dose) (40%), or unfractionated heparin (UFH); (P-dose; 2.9%). Case 2: No anticoagulation therapy (34.3%), calcium heparin (P-dose; 51.4%), or UFH (P-dose; 5.7%). Case 3: (A) Interruption of aspirin (65.7%), and either no anticoagulation therapy (21.7%) or substitution of aspirin by calcium heparin (P-dose; 56.6%) or by UFH (P-dose; 8.7%). (B) No interruption of aspirin (34.3%), and either no additional prophylaxis (58.3%) or calcium heparin (P-dose; 33.3%). Case 4: Interruption of VKA (100%), and UFH at a curative dose (68.6%), UFH (P-dose; 14.3%), or calcium heparin (P-dose; 11.4%).

Conclusions

Practices varied widely in the absence of studies of sufficiently high power. There is a need for a preoperative classification of thrombotic and hemorrhagic risk among renal transplant candidates and for consensus guidelines.     

关节镜下自体与同种异体肌腱重建前交叉韧带的临床对比分析

目的观察自体腘绳肌肌腱与同种异体移植物关节镜下重建膝关节前交叉韧带(ACL)的疗效与差异。方法将54例ACL损伤患者分为两组,自体腘绳肌肌腱移植组33例,男26例,女7例;年龄20～48岁。同种异体肌腱移植组21例,男16例,女5例;年龄18～52岁。均采用美国强生公司生产的Rigidfix及Intrafix系统固定,评价项目包括手术时间、发热天数、大腿周径患健侧比值、Lachman试验、中立位前抽屉试验(ADT)和国际膝关节评分委员会(IKDC)、Lysholm及Tegner评分。随访时间6～12个月,平均8个月。结果两组患者术后膝关节稳定性均得到明显好转,除手术时间外,物理检查及功能评分差异均无统计学意义(P0.05)。结论关节镜下自体及同种异体肌腱重建ACL都有较好的疗效,可根据患者的病情及主观要求灵活选择。     

颈长肌肌瓣交叉固定防止颈椎植骨块滑脱的生物力学研究及临床应用

目的　为防止颈椎前路减压植骨术后植骨块的滑脱 ,我们在对颈长肌的定量解剖学研究基础上 ,设计了切取双侧颈长肌内侧肌瓣交叉缝合固定植骨块的新术式。并进行了生物力学测试和临床应用。方法　采用成年尸体 10具 ,去除颈部浅层肌肉及软组织 ,显露双侧颈长肌及交感干 ,测量C3 ～C7节段颈交感干与颈长肌内缘的距离及双侧颈长肌内缘之间的距离。并在 10个颈椎上模拟了颈椎前路减压植骨 ,利用颈长肌肌瓣交叉缝合 ,在CSS - 110 1c型生物力学测试机上测定了该肌瓣对植骨块的阻挡效果。在此基础上 ,对 11例患者纵行切取颈长肌内侧肌瓣 ,交叉缝合至对侧颈长肌 ,防止颈椎前路减压植骨块滑脱。结果　①双侧颈长肌内缘之间的距离见正文表 1。②在植骨块向前方移位 1 0mm、 2 0mm、 3 0mm时 ,颈长肌肌瓣对植骨块的阻挡力分别为 4 10± 0 32N ,6 0 7± 1 0 9N及 10 2 8± 2 17N。③本组病例随访 0 5～ 6年 ,未出现食道瘘、食管痉挛 ,吞咽困难及呛咳等并发症 ,全部骨性愈合。 7例颈椎病 5例缓解 ;2例减轻 ;4例颈椎骨折脱位患者 3例好转 ,1例无效。所有植骨块均获骨性融合 ,无滑脱。所有患者颈部屈曲及旋转功能正常。结论　颈长肌肌瓣交叉缝合对颈椎前路减压植骨块有阻挡作用。     

两种内固定法加植骨融合治疗腰椎滑脱症临床疗效观察

目的　比较采用三椎体与二椎体内固定器提拉复位内固定治疗椎体滑脱的优越性。方法　将 4 3例下腰椎滑脱随机分为两组。A组用三椎体内固定法加椎间植骨融合术 ;B组用二椎体内固定法加椎间植骨融合术。将腰椎滑脱按传统方法分为四度 ,治疗后对其疗效、手术时间进行观察、比较。结果　本组 4 3例治疗后均得到随访 ,时间 1年 3个月～ 4年 2个月不等 ,平均 1年 4个月。滑脱椎体完全复位率 :Ⅰ度A组 10 0 % ,B组 91% ;Ⅱ度A组 10 0 % ,B组 72 % ;Ⅲ度A组 75 % ,B组 0 %。融合率A组 95 % ,B组 90 4 %。临床症状改善率 :A组 95 4 % ,B组 87%。平均手术时间 :A组为 2 12 5± 4 2 6分 ;B组为181 4 0± 3 4 5分。结论　Ⅰ度、Ⅱ度椎体滑脱两组临床疗效差异不大 ,Ⅲ度及Ⅲ度以上者两组临床疗效差异明显。故对Ⅰ度、Ⅱ度滑脱可任选三椎体内固定方法或二椎体内固定方法加椎间植骨融合术进行治疗。对Ⅲ度和Ⅲ度以上重度滑脱采用三椎体内固定方法加椎间植骨融合术进行治疗较好     

The Effect of the Use of Synthetic Mesh Soaked in Antibiotic Solution on the Rate of Graft Infection in Ventral Hernias: A Prospective Randomized Study

Wound infections and seroma formations are important problems in ventral hernia repair operations using synthetic mesh grafts. The aim of this study was to investigate the effect of the use of synthetic mesh soaked in vancomycin solution on the rate of graft infection. The total number of subjects was 52. The subjects were randomized into 2 groups using a software program. Group 1 (n = 26) was the control group. In group 2 (n = 26), synthetic mesh was soaked in a Vancomycin solution before it was implanted. The patients were compared with respect to demographic characteristics and preoperative, intraoperative, and postoperative variables. There were no significant differences between the groups with respect to the available variables. Seroma development was significantly more common in group 2 (P < 0.041). Three patients (5.7%) developed superficial wound infection, and 9 (17%) developed surgical site infection 2–type wound-site infection. No significant difference was found between the groups in terms of infection. The use of synthetic mesh soaked in vancomycin solution had no beneficial effects on the rate of wound-site infection. Future randomized, controlled, large-scale studies using the same mesh and suture types, and meshes soaked in larger spectrum antibiotics are needed.Key words: Ventral hernia, Surgical mesh, Vancomycin, Surgical wound infectionVentral hernia repair (VHR) is a common surgical procedure in general surgical practice. More than 365,000 VHR are performed in the United States alone each year.¹ Use of synthetic mesh significantly reduces recurrence rates, and it is the recommended standard for VHR.² VHR operation using mesh is associated with reduced early and late recurrences compared with repairs using primary suture.^3–5 However, the use of mesh may cause small bowel stenosis, surgical field infection, mesh-to-skin sinus formation, and enterocutaneous fistula.^6,7 As with all other synthetic materials, mesh use in VHR also carries a risk of infection.⁸ VHR with mesh use is associated with an infection rate of up to 16%.^2,8–10 This significant complication causes increased patient morbidity. Moreover, it leads to removal of synthetic material, prolonged antibiotic therapy, longer hospital stay, additional surgical interventions, and significantly higher costs.⁹ Methicillin-resistant Staphylococcus aureus (MRSA) is the most common microorganism isolated from the mesh infections.^11,12 Reducing the rate of infection with strains of staphylococcus, the members of skin flora, which are the most common pathogens in mesh infections, may be accomplished by using meshes soaked in Vancomycin solution.¹³ Ventral incisional hernia, one of the most important complications of abdominal surgical operations, and the umbilical hernia, commonly observed in obese patients, still cause trouble for surgeons despite technical advances. In particular, synthetic mesh infections after hernia repair lead to significant clinical (patient morbidity and mortality) and social (cost, loss of labor force, etc.) problems. An animal study aiming to reduce these high-morbidity complications found that the use of synthetic mesh materials soaked in Vancomycin (Vancomycin, Abbott, Chicago, Illinois) may reduce the infection rate.¹³ One inexpensive method commonly employed by surgeons to potentially reduce mesh infections is to soak the mesh in antibiotic solutions prior to implantation. Despite this common clinical practice, there was no available study to investigate the effect of use of synthetic mesh soaked in antibiotic solution on graft infection. So far, only 2 studies have investigated the effect of mesh soaked in antibiotic solution on infection rates, and both of them were animal studies.^13,14 Furthermore, no prospective clinical study has as yet explored the effect of the use of propylene mesh soaked in antibiotic solution on the infection rate.The aim of the present study was to investigate the impact of the use of synthetic mesh soaked in Vancomycin solution on the risk of graft infection in a homogenous patient population in which only polypropylene mesh was used.     

内固定对异体骨段移植愈合影响的实验与临床研究

目的：研究内固定对异体骨段移植愈合影响的实验与临床观察，方法：采用新西兰大白兔股骨中段切除1．5cm骨干和骨膜实验动物模型，将36只兔随机分成圆形髓内针内固定组和三棱形髓内针内固定组，于术后第12，3，个月行ECT检查，HE染色组织学观察异体骨愈合过程，比较普通非交锁髓内针和特制交锁针固定对异体骨修复骨肿瘤保肢术中瘤段切除大段骨缺损的治疗情况。结果：圆形髓内针内固定组和三棱形髓内针内固定组异体骨移植愈合组织学过程相似，但三棱形髓内针对固定组在第1，2个月时骨代谢活跃（P＜0．05），57例异体骨段移植随访7个-6\5上，平均2．6年，结果异体骨愈合52例，不愈合5例，其中普通非交锁髓内针12例，骨不连3例（25％），特制交锁髓内针47例，骨不连2例（4．3％），普通非交锁形髓内针易发生异体骨移植不愈合（P＜0．05），结论：稳固的髓内针固定有利于异体骨愈合。     

The Risk Factors of Delayed Graft Function and Comparison of Clinical Outcomes After Deceased Donor Kidney Transplantation: Single-Center Study

Introduction

The aim of this study was to analyze risk factors for delayed graft function (DGF) after deceased donor kidney transplantation and to compare the clinical outcomes of non-DGF versus DGF recipients.

Patients and methods

From January 2004 to June 2008, 75/154 kidneys were transplanted into 74 recipients. We classified the recipients into two groups: group 1 (n = 61) without DGF and group 2 (n = 13) with DGF.

Results

On univariate analysis, recipient age (P = .048) cause of brain death (traumatic brain injury vs disease, P = .016), blood urea nitrogen (P = .002), serum creatinine (P = .001), arterial pH (P = .019), and serum sodium level (P = .012) just before organ procurement showed significant differences. On multivariate analysis, the cause of brain death (P = .015, hazard ratio [HR]: 7.086), the terminal serum creatinine ≥1.5 mg/dL before organ procurement (P = .007, HR: 10.132), and recipient age over ≥50 years (P = .021, HR: 7.767) were independent risk factors for the development of DGF. Graft failures occurred among 5/74 recipients with 5-year graft survivals between group 1 and group 2 of 91.7% and 84.6%, respectively. Patient death occurred in five cases, most by due to infection. The 5-year patient survival between groups 1 and 2 were 93.9% and 84.6%, respectively (P = .106).

Conclusion

The independent risk factors for DGF were the cause of brain death, the terminal creatinine level, and the recipient age. In deceased donor kidney transplantation, DGF may have less effect on long-term patient and graft survivals.     

The Advantages of the Great Saphenous Vein as a Femoropopliteal Graft: A Report on Its Clinical Use

As a majority of vascular surgeons prefer the autologous saphenous vein as a bypass graft below the inguinal ligament, the need of alternative graft materials or reconstructive techniques is confined to patients with unavailable or unsuitable saphenous veins. The aim of this investigation was to ascertain how often these alternative procedures are necessary. From 1973 to June 1979, the great saphenous vein was used as a femoropopliteal graft without regard to fixed limitations in the diameter and the quality of the vein. During this period, vascular reconstruction was required in 148 limbs due to symptomatic atherosclerotic occlusion of the superficial femoral artery. In 144 of these cases, the ipsilateral (138) or the contralateral (6) great saphenous vein was used for a femoropopliteal bypass reconstruction. Thus, the vein could not be utilized in only 4 of 148 cases (2.7%).

As graft patency rate was not subject to the size and quality of the vein and as cumulative patency rates in the 144 grafts were most satisfactory (97.9, 92.0 and 81.9% at 1 month, 1 year and 5 years, respectively), although all these veins were used regardless of their calibre and quality, we conclude that the great saphenous vein can be used more liberally as a graft for femoropopliteal occlusion In approximately only 3% of patients requiring operation, alternative reconstructive techniques, such as ‘non-vein’ bypass grafts and thrombendarterectomy are needed.