Allogeneic vascularized transplantation in cases of bone and joint defects

This paper presents preliminary results of allogeneic vascularized transplantations of three femoral diaphyses and four total human knee joints. Grafts were harvested from multi-organ-donors and immediately transplanted. Osteosyntheses were performed employing intramedullary nails. Vascular pedicles of the grafts were anastomosed in end-to-side technique. Immunosuppression mainly based on Cyclosporine and Azathioprine. Grafts' perfusion was demonstrated by DSA and Duplex-sonogramms, bone metabolism by SPECT-scintigraphy. Five months following transplantation osteotomies demonstrated consolidation in conventional X-rays. Biopsies of the grafted bone revealed intact osteocytes and arthroscopy demonstrated intact synovial, chondral and ligamentous structures. From the technical aspect vascularized transplantation of the femoral diaphyses and total knee joints is feasible. The main problems are of immunologic nature. Transplantations were performed respecting the ABO-compatibility but with a large HLA-mismatch. Acute and chronic rejection crises may damage the grafts. At least in synovial joints livelong immunosuppression of the recipients seems to be unavoidable.     

Clinical experience in allogeneic vascularized bone and joint allografting

The allotransplantation of vascularized femoral diaphyses and total knee joints is a novel approach in orthopedic surgery. Allogeneic femoral diaphyses were transplanted into three patients suffering from chondrosarcoma or posttraumatic defects. Total knee joints allografts were transplanted in five patients with large bone defects of the knee and loss of the extensor apparatus caused either by major trauma alone or infection after a major trauma. Bone segments and total joints were harvested from multi-organ donors, perfused with UW-solution and transplanted within cold ischemia times of 18-25 h. Patients were immunosuppressed postoperatively primarily with cyclosporine (Cyclosporin A) and azathioprine. Two allografts (1 femur, 1 knee) were lost due to infections. Seven of the eight patients are able to walk with full weight-bearing posttransplant. Two of the patients with transplanted joint allografts subsequently received total knee arthroplasty implantations. Vascularized bone and joint allotransplantation may serve as a last line of defense treatment before considering lower limb amputation.     

Allogenic grafting of vascularized bone segments under immunosuppression. Clinical results in the transplantation of femoral diaphyses

Trauma surgery lack, substitute, for the reconstruction of large defects of the long bones. Encouraged by the promising results of bone allotransplantation in animal models, we successfully performed vascularized bone transplantation in humans. Vascularized femoral diaphyses were allogenically transplanted into three patients suffering from chondrosarcoma or post-traumatic osteomyelitis with postoperative immunosuppression. The bone segments were harvested from multi-organ donors and perfused with UW solution. After back-table preparation, the grafts were transplanted into the defect zone. Interlocking devices were used in these operations. Vascular anastomoses were performed in end-to-side technique. The early clinical course of the patients was not free of anatomical, technical, or immunological complications. However, all patients are currently free of malignancy and infection. They are also free of pain and full weight bearing. We conclude that allogenic grafting of vascularized bone segments has the potential to become an alternative for the replacement of large bone defects. Received: 21 July 1997 Received after revision: 17 December 1997 Accepted: 9 January 1998     

Vascularized whole knee joint allografts in rabbits immunosuppressed with cyclosporin A

To develop the surgical model, whole knee joints including the distal femur, proximal tibia, and joint capsule, were raised on a vascular pedicle and then replanted at the same site. Rigid fixation of the bones was achieved using two mini-plates on the tibia and femur. Revascularization of the knee was accomplished by end-to-end anastomosis of the popliteal vessels using standard microvascular techniques, and the vascular and neural supplies to the lower leg and foot were preserved. A total of 21 vascularized whole knee allografts were then similarly performed on a microvascular pedicle between two incompatible strains of rabbit. In a control group of six adult animals, no immunosuppression was administered. Two of these joints were harvested at 1 week and had patent popliteal arteries. The remaining four joints were harvested at 2-3 weeks when they were deteriorating and were found to have occluded popliteal vessels by arteriography. Eight adult allograft recipients were immunosuppressed with cyclosporin A (CyA) at 15 mg/kg per day. One allograft failed at 10 days due to femoral fracture. None of the remaining seven were rejected acutely, and three of them had patent vessels by arteriography and live bone and cartilage by light microscopy when harvested 100 days after transplantation. In another group, seven knee joints were allografted into immature rabbits immunosuppressed with CyA. Again, none rejected acutely, and 90 days later two of the seven allografts had patent vessels by arteriography, growth by serial radiographs, and live bone and cartilage by histological examination. This pilot study suggests that CyA will be useful as an immunosuppressive agent in the study of vascularized bone and cartilage transplantation, and that experimental epiphyseal plate allografting is possible in rabbits.     

Experimental study of vascularized tibiofibula graft in inbred rats: a preliminary report

An experimental study of vascularized tibiofibula grafts in inbred rats was performed. Roentgenologic and histologic changes of the grafted bone in the first seven postoperative weeks were especially investigated. After preliminary experiments on the vascular anatomy of the lower limbs of rats, tibiofibular vascularized grafts with femoral artery and vein were utilized in Fischer strain F-344 rats. The rate of bony union in the vascularized graft group was superior to that in the nonvascularized control groups. Fluorochrome-labeling studies of the grafted bone at the mid-diaphysis showed active periosteal new bone formation, following the vascularized graft. In contrast, normal tibial bone growth at the mid-diaphysis was mainly endosteal. However, both vascularized graft and normal bone demonstrated evidence of a "drift phenomenon" in the direction of growth. Since the life cycle of the rat is very short, compared with other laboratory animals, this experimental model may be useful in investigating the postoperative course of vascularized bone grafts with a short follow-up period.     

Outcome of allogeneic vascularized knee transplants

Transplantation of vascularized knee joints is a novel approach in Composite Tissue Allotransplantation (CTA). In 1996 our group started a clinical knee transplantation project and six transplantations have been performed since. Key problems identified early were the monitoring of acute rejection and choice of an immunosuppressive regime. One graft was lost due to postoperative infection and one due to of noncompliance where the patient discontinued the immunosuppressant regime. In three cases late rejection lead to necrosis and graft dysfunction after 15, 16 and 24 months, respectively. Exit-strategies were arthrodesis in one patient and Above Knee Amputation in two cases. With retrospective analysis after initial five cases the treatment protocol was improved. The immunosuppressive drug regime was altered, femoral diaphysis and knee joint grafting was combined and a vascularized block of donor skin and subcutaneous tissue was harvested with the graft (sentinel skin graft). The sentinel skin graft enabled us to monitor acute rejection by clinical and histological examination and avoid late rejection by rapid treatment with high dose steroids. In summary, over a four-year period, one of six allogeneic vascularized knee transplants has survived, one was lost from a surgical site infection, one by noncompliance and three by late rejection. Analysis of our data leads us to suggest that knee transplantation should be limited to a combined injury consisting of extensive loss of cartilage and bone, deficient extensor mechanism and soft tissue and skin defects without any signs of infection. Transplantation should only be taken into consideration as last option before Above Knee Amputation in an otherwise healthy patient under 35 years of age.     

Histological characteristics of acute rejection in vascularized allografts of bone

Using a genetically defined rat model for the heterotopic transplantation of a vascularized knee in the rat, histological and histochemical studies of acute rejection in vascularized allografts of bone were carried out. The graft consisted of the knee joint with the distal end of the femur, the proximal part of the tibia, the cartilaginous growth plates, the articular cartilage, and a minimum cuff of muscle, which was transferred to a location under the abdominal skin. A total of 160 transplants, including vascularized and non-vascularized isografts, vascularized and non-vascularized allografts that were transplanted across a strong histocompatibility barrier, and vascularized allografts of bone that were transplanted across a weak histocompatibility barrier, were studied by light microscopy at intervals for as long as twelve weeks after transplantation. Vascularized allografts of bone that were transplanted across a strong histocompatibility barrier showed evidence of rapid rejection, similar to that after transplantation of allografts of visceral organs. This was manifested at one week by necrosis of osteocytes, cessation of microcirculatory flow, massive extravasation of red cells, and deposition of fibrin in the marrow. The large vessels demonstrated changes that were characteristic of vascular rejection. Allografts that were transplanted across a weak histocompatibility barrier showed a more gradual, less intense process of rejection that allowed observation of the evolution of the process. In these grafts, the osteoblasts and marrow in the primary spongiosa of the metaphysis were early targets of rejection, as indicated by necrosis of osteoblasts, extravasation of red blood cells, and deposition of fibrin in the marrow spaces. Loss of osteoblasts from the surfaces of osteoid as well as from bone on spicules of calcified cartilage resulted in the cessation of new-bone formation. Calcification of the longitudinal septa between the lowermost hypertrophic chondrocytes was decreased. However, the proliferation and maturation of chondrocytes in the zone of proliferating chondrocytes and in the upper hypertrophic zone continued and resulted in the formation of a thickened growth plate. The loss of osteocytes in other areas of the graft occurred later and only in the areas where the microcirculation had been lost. These data suggest that ischemic damage, which is probably secondary to an immune-related vascular compromise, is a significant factor in the failure of grafts. In the grafts that were transplanted across a weak histocompatibility barrier, the growth of new bone and revascularization by the host occurred by twelve weeks.     

带血管骨移植治疗股骨头无菌性坏死进展

股骨头无菌性坏死是骨科临床较常见的疾病，如能早期做出诊断（股骨头塌陷前），可采用钻芯减压（植骨或不植骨）、截骨、以及带或不带血管的骨移植治疗，尽力保存髋关节功能。局部带蒂骨移植与和游离带血管的骨移植能将带血运的骨组织植入股骨头骨坏死区，除用健康骨组织替代坏死骨外，还重建了股骨头新的血供来源。经5年观察，对各期患者治疗成功率为80％。应用游离带血管的骨移植治疗股骨头无菌性坏死，可获得较高的成功率。     

A comparison of vascularized and nonvascularized bone transfer in rabbits: a roentgenographic, scintigraphic, and histologic evaluation

Extensive bone defects caused by bone tumor resection, osteomyelitis, congenital pseudoarthrosis, post-traumatic bone loss, or femoral head necrosis, require large bone grafts. Such large defects usually are not amenable to conventional, nonvascularized cancellous grafts. By using vascularized bone grafts that do not undergo creeping substitution, that heal rapidly and are not depending on the surrounding tissue, better, safer, and faster results can be obtained. To compare recoveries after vascularized grafts with those after conventional, nonvascularized grafts, experiments were carried out in a rabbit model. They demonstrated good viability and better and faster healing of the microvascular grafts, using radiography, scintigraphy, light microscopy of bone osteocytes and vessels, and tetracycline double-labeling evaluation techniques.     

髌骨和髂骨移植修复膝部骨巨细胞瘤致大块骨缺损

目的 探讨髌骨和髂骨移植对股骨下端和胫骨上端大块骨缺损修复的治疗效果.方法 股骨下端和胫骨上端骨巨细胞瘤患者14例,男8例,女6例;年龄20～42岁,平均33.9岁;病史2～12个月,平均5.6个月;股骨下端6例,胫骨上端8例.按Ennecking外科分期,2期11例,3期3例.游离髌骨移植8例,带肌蒂髌骨移植2例,髂骨移植4例.股骨和胫骨肿瘤侵犯一侧髁软骨面时用游离或带肌蒂髌骨移植,胫骨肿瘤同时侵犯髁间部时用髂骨移植,修复和重建膝关节部骨缺损.结果 随访时间3个月～11年,平均4.5年.根据国际保肢学会功能评分标准,优3例,良8例,可2例,差1例.游离髌骨移植者关节功能较好.术后主要并发症为关节活动范围减小(活动范围,40°～120°,平均82°),关节不适,肌力下降,疼痛.带肌蒂髌骨移植者术后伸膝肌力有不同程度地下降,但随着时间的延长有一定的恢复.游离髌骨移植者术后伸膝肌力下降不明显.髂骨移植患者术后关节退行性改变明显.结论 膝关节周围骨巨细胞瘤侵犯关节软骨时,行包括肿瘤在内的股骨或胫骨一侧髁切除后,可以用髌骨和髂骨移植修复和重建骨缺损.     

Bone grafting in cemented knee replacement:45 primary and secondary cases followed for 2-5 years

From 1989 through 1993, we treated 36 knees in 30 patients by bone grafting (31 tibial and 14 femoral grafts) and a cemented total knee prosthesis. We used 23 morsellized and 22 solid bone grafts. After a mean follow-up period of 3 years, the mean clinical (IKS) knee score was 90. Radiographic signs of incorporation of the tibial bone graft were noted in 28 cases. Of the 8 solid femoral bone grafts, we observed twice a disintegration of the graft.     

Fate of vascularized and nonvascularized autografts

Controlled laboratory data demonstrate biologic and mechanical characteristics of orthotopically placed canine ulnar autografts. The pattern of bone repair was similar in vascular and nonvascular ulnar grafts beginning with resorption followed by appositional reactive bone formation. The time intervals in the sequence were accelerated in the vascularized grafts. Both the strength and stiffness of the vascularized grafts were found to be significantly greater in Groups studied from six weeks to six months postoperation. There was no statistical difference between the grafts for mechanical testing performed on dogs either one week or one year postoperation. The vascularized ulnar bone grafts fared better than comparably sized nonvascularized grafts and were more rapidly repaired. The mechanical testing demonstrated superior strength and stiffness of the vascularized grafts throughout the repair process.     

自体游离骨膜再造膝关节半月板的实验研究

目的：对于严重损伤的半月板全切除术后行自体游离骨膜重建半月板，以维持膝关节结构、生理及功能特性。方法：使用１７只成年犬，５只幼犬。外侧半月板全切除以后，胫骨内侧近端的骨膜游离并移植到外侧半月板部位。于２、４、８、１２、２４、４８周取下重建半月板及不同部位的关节面软骨进行大体、光镜及电镜观察。结果：术后２个月，重建半月板的大体形态、组织结构与正常半月板近似。外侧股骨软骨面及没有被覆盖的胫骨软骨面表现退行性改变，被移植物覆盖的软骨面退变较轻。幼犬的退变更早、更严重。结论：本研究说明了自体游离骨膜在滑液环境及受到合适的应力刺激会向纤维软骨演化，在半月板全切除后，应用游离骨膜重建半月板是可行的     

Allogenic transplants of bone revascularized by microvascular anastomoses: a preliminary study

An area of experimental bone grafting that needs further study is the use of free vascularized allografts of bone. In 35 outbred mongrel dogs, the viability of vascularized bone allografts with and without azathioprine immunosuppression was compared to vascularized autogenous bone grafts. Viability was assessed by histologic techniques, fluorochrome bone labeling, and electron microscopy. Autogenous vascularized bone grafts remained viable, and it was concluded that microvascular technique was not the limiting factor in attaining survival of the grafts. The behavior of autogenous vascularized bone grafts with and without the influence of azathioprine was similar. Allogenic vascularized bone transplants uniformly failed at a period between 2 and 3 weeks. Immunosuppression with azathioprine did not appreciably affect survival of the osteocytes. However, the host response to the foreign tissue was slightly modified. The clinical ramifications of bone transplantations in humans are not analogous to the clinical situation of transplantation of other organs. If vascularized bone transplants are performed in humans, a relatively safe form of immunosuppression is necessary. This study suggests that azathioprine alone does not offer sufficient immunosuppression to insure viability of the vascularized transplant.     

Allogenic transplants of bone revascularized by microvascular anastomoses: A preliminary study

An area of experimental bone grafting that needs further study is the use of free vascularized allografts of bone. In 35 outbred mongrel dogs, the viability of vascularized bone allografts with and without azathioprine immunosuppression was compared to vascularized autogenous bone grafts. Viability was assessed by histologic techniques, fluorochrome bone labeling, and electron microscopy. Autogenous vascularized bone grafts remained viable, and it was concluded that microvascular technique was not the limiting factor in attaining survival of the grafts. The behavior of autogenous vascularized bone grafts with and without the influence of azathioprine was similar. Allogenic vascularized bone transplants uniformly failed at a period between 2 and 3 weeks. Immunosuppression with azathioprine did not appreciably affect survival of the osteocytes. However, the host response to the foreign tissue was slightly modified. The clinical ramifications of bone transplantations in humans are not analogous to the clinical situation of transplantation of other organs. If vascularized bone transplants are performed in humans, a relatively safe form of immunosuppression is necessary. This study suggests that azathioprine alone does not offer sufficient immunosuppression to insure viability of the vascularized transplant.     

The effects of different schedules of total-body irradiation in heterotopic vascularized bone transplantation. An experimental study in the Lewis rat

To evaluate the effects of irradiation on heterotopically placed vascularized knee isografts, a single dose of 10 Gy of total-body irradiation was given to Lewis donor rats. Irradiation was delivered either 2 or 6 days prior to harvesting or subsequent transplantation, and evaluated at 1, 2, and 4 weeks after grafting. Irradiation caused endothelial depopulation of the graft artery, although vascular pedicle patency was maintained throughout the study. Bone graft viability and mineralization were normal. Dramatic changes in the bone marrow were seen that included an increase of its fat content (P less than 0.001), and a concomitant decrease in bone marrow-derived immunocompetent cells. These changes were more prominent in recipients of grafts from day -6 irradiated donor rats. Total-body irradiation did not prejudice the use of vascularized bone grafts, and exhibited an associated immunosuppresant effect over the vascular endothelium and bone marrow. This may be a further rational conditioning procedure to avoid recipient manipulation in vascularized bone allotransplantation.     

Postoperative results of vascularized double fibula grafts for femoral pseudoarthrosis with large bony defect

In open femoral bone fractures osteomyelitis may develop as a complication. Many difficulties are experienced in the treatment of those fractures because an extended bone defect may be formed after repeated operations, and then amputation of the femoral bone becomes necessary. Since 1981 the present authors have performed the vascularized double fibula grafts in the treatment of 18 patients with successful results. With this grafting method, both vascularized double fibula grafts are collected at the same time, one as an intramedullary graft and the other as an onlay graft. The most important point in carrying out grafting by this method is to prepare the recipient bone bed adequately. In many cases, it is necessary to carry out the primary operation to curette the focus, and resect necrotic tissues and sequestrated bone before the vascularized double fibula grafts, and then grafting is performed as a second operation after infection has been controlled following the initial operation. Although differences in time required for recovery cannot be eliminated completely, it becomes possible for 16 out of 18 patients to walk without the use of a brace and crutches within 13 months on average. © 1994 Wiley-Liss, Inc.     

Cartilage transplantation in the knee joint experiment - clinic - technique (author's transl)

In the knee joints of 195 animals autologous, stored and fresh homologous osteochondral grafts were implanted. Even after 2 years the ultrastructural examination indicates that autologous and fresh homologous grafts survive. The stored grafts are absorbed. The clinical results after transplantation of 38 patients as well as the technique of transplantation are demonstrated.     

Use of vascularized pedicle iliac bone graft in the treatment of avascular necrosis of the femoral head

A vascularized pedicle iliac bone graft was performed in patients with extensive necrosis in whom the necrotic area occupied more than two-thirds of the femoral head. The purpose of this procedure is to supply vascularity and mechanical strength to the avascular femoral head. Our series consisted of 18 hips. The patients’ age at surgery ranged from 21 to 55 years. Fourteen hips were identified as stage II and 4 hips as stage III. Iliac bone graft alone was performed in 4 stage II joints. Transtrochanteric anterior rotational osteotomy of the femoral head was done additionally in 10 stage II joints and 4 stage III joints. In the group who underwent iliac bone graft alone, the mean Japanese Orthopedic Association (JOA) score improved from 58.5 to 63.8 (mean follow-up 52 months). In the group who underwent combination procedure with osteotomy, the mean JOA score improved from 71.7 to 85.0 (mean follow-up 43 months). Stage progression was noted in 3 of 4 joints in the group who underwent iliac bone graft alone. In the group who underwent the combined procedure, stage progression was noted in 2 of 10 joints at more than 1 year after operation. A vascularized pedicle iliac bone graft to treat avascular necrosis of the femoral head is considered promising for joint preservation. Received: 19 October 2000     

带旋髂深血管蒂髂骨瓣和BMP人工骨移植治疗股骨头缺血性坏死

目的探讨带旋髂深血管蒂髂骨瓣和骨形态发生蛋白(bone morphogenetic prote in,BMP)人工骨移植治疗股骨头缺血性坏死的方法及临床疗效。方法2000年1月~2006年8月采用带旋髂深血管蒂髂骨瓣联合BMP人工骨移植治疗股骨头缺血性坏死25例(29髋),左髋18例,右髋11例。按F icat分期:Ⅰ期8例(10髋),Ⅱ期14例(16髋),Ⅲ期3例(3髋)。结果术后平均随访37.6(24~60)个月。移植骨瓣与股骨颈均愈合,平均愈合时间3.6(3~8)个月。按Harris评分,优15例16髋,良7例10髋,可3例3髋,优良率89.7%。结论带旋髂深血管蒂髂骨瓣和BMP人工骨移植能有效重建股骨头的血运、清除死骨、降低髓腔压力、支撑股骨头关节软骨面和BMP能诱导成骨的特点,能有效治疗股骨头缺血性坏死。