Return of immunohematopoietic impairment a long time after murine syngeneic bone marrow transplantation

We have tested the immunologic status and hematologic parameters of mice 2 months (short-term survivors) or 18 months (long-term survivors) after lethal total body irradiation and syngeneic bone marrow transplantation (SBMT), and of normal mice of corresponding age. Long-term SBMT survivors showed significantly lowered bone marrow and spleen cellularities, decreased numbers of CFU-S in hemopoietic organs and severe impairment in the formation of CFU-F colonies compared with short-term SBMT survivors and normal mice. The peripheral blood parameters (hematocrit, erythrocytes, reticulocytes, platelets, white blood cells and granulocyte counts), however, remained unaltered. In long-term SBMT survivors we also observed a relative increase of Lyt-2+ lymphocytes (CD8+, cytotoxic/suppressor) and Mac-1+ cells among splenocytes. At the same time the L3T4+/Lyt-2+ ratio (CD4+/CD8+) was decreased. Relative contents of Ig+, Thy-1+ and L3T4+ cells were unchanged. The ability of splenocytes to generate IL-2R+ cells after in vitro stimulation with concanavalin A was greatly diminished. In summary, the immunohematopoietic status after initial normalization is again impaired in long-term SBMT survivors.

Anesthesia for bone marrow harvesting in the prone position in a patient with preexisting pericardial tamponade

Refractory pericardial tamponade developed in an 18-year-old man with recurrent lymphoma. Invasive monitoring guided anesthetic management for bone marrow harvesting for autologous transplantation. The use of the prone position did not lead to adverse hemodynamic effects. The presence of a double pulse was demonstrated by pulse oximetry.

The value of intramedullary reaming in the treatment of chronic osteomyelitis of long bones

Between 1985 and 1990 25 patients with chronic osteomyelitis (osteitis) of long bones were treated by intramedullary reaming. In most cases the aetiology of the osteomyelitis was posttraumatic. 22 of these patients who had undergone intramedullary reaming at least 6 months ago were evaluated. The average postoperative observation period was 26 months, range (7-60 months). During this time, 21 patients showed no signs of recurrence. One patient produced a little extraosseous sequestrum 3 months after the operation but since then has had no recurrence. The purpose of this study is to propose intramedullary reaming as an excellent treatment for chronic osteomyelitis of long bones and show the pathophysiological background that led to this modality.

In situ hybridization detection of light chain mRNA in routine bone marrow trephines from patients with suspected myeloma

A method for the detection of immunoglobulin light chain mRNA by situ hybridization has been applied to routine bone marrow trephines, from patients suspected of having multiple myeloma. The principle aim was to define monoclonal populations even in cases lacking a paraprotein or an obvious atypical plasma cell proliferation. The expression of light chain mRNA in plasma cells in routine bone marrow trephines from 14 patients with suspected myeloma was studied. Plasma cells in the marrow ranged from 4% to 99%. Clonal populations based on light chain restriction were delineated in 12 patients, using biotinylated probes to kappa and lambda mRNA and visualized using an alkaline phosphatase/fast red naphthol capture method. Normal tonsil and bone marrow trephines were used as controls. In situ hybridization was found to be a specific, safe and rapid technique. It could be applied to both fixed and fresh tissue. It was found to lack the background staining of interstitial immunoglobulin, particularly in sclerotic cases, which is so often encountered with immunocytochemistry. Additionally, this technique will type plasma cell neoplasms (undetected by routine immunocytochemistry) in post-transcriptional block or non-secretory myeloma.

[Bone marrow transplantation: current perspectives]

Bone marrow transplantation was introduced over thirty years ago in the treatment of several immuno-hematological conditions. During the last decade, there has been a substantial increase in the number of transplanted patients. However, results over the last five years have not significantly improved. Clinical indication conditioning regimens and related complications are reviewed and new developments pointed out.

Efficacy of plasma-sprayed tricalcium phosphate in enhancing the fixation of smooth titanium intramedullary rods

The osseous tissue response to intramedullary rods plasma-sprayed with TCP was investigated. TCP-sprayed smooth titanium rods and unsprayed controls were bilaterally implanted into the medullary canals of rabbit tibiae. Rabbits in the short-term study were sacrificed at 3 weeks; rabbits in the long-term study were sacrificed at 12 weeks. Pull-out tests were performed and histological sections prepared. The TCP-sprayed titanium rods exhibited significantly higher pull-out strengths than unsprayed contralateral rods at both 3 and 12 weeks, suggesting the bonding of bone to the TCP layer. The TCP-sprayed titanium rods at 3 weeks showed significantly greater osseous tissue response than unsprayed contralateral controls. At 12 weeks, the osseous tissue response was greater than at 3 weeks, and, surprisingly, the response to TCP-sprayed and unsprayed titanium rods was comparable.

Alternative donor sources in HLA-mismatched marrow transplantation: T cell depletion of surgically resected cadaveric marrow

Allogeneic bone marrow transplantation has been largely confined in its application to patients with an HLA-matched marrow donor, thereby limiting potential therapeutic benefits for patients with diseases amenable to treatment by marrow transplantation who lack effective alternative therapies and an identified matched marrow donor. T cells in the donor marrow generate graft-versus-host disease which is a major consideration in attempts to widen the application of allogeneic marrow transplantation to the minimally HLA-matched or mismatched setting. The method of marrow harvest influences both the number of such T cells in the donor marrow inoculum and the functional capacity of T cells in murine marrow. We have therefore evaluated surgically resected cadaveric marrow for T cell content and for T cell depletion. Surgically resected marrow is more easily depleted of T cells than aspirated marrow and clinically useful quantities of marrow have been obtained and cryopreserved in a bank of characterized donor marrow for future use in HLA minimally matched or unmatched marrow transplantation.

Osteogenesis by canine and rabbit bone marrow in diffusion chambers

Osteogenic activity of canine and rabbit bone marrow and marrow stromal fibroblasts (MSF) derived from marrow cultured in vitro was evaluated using diffusion chambers. Marrow from young dogs and rabbits grown in cell culture produced confluent layers of MSF. Diffusion chambers containing 0.18-7.6 x 10(6) allogeneic MSF were inserted into the peritoneal cavities of 5 dogs and 6 rabbits. Chambers recovered from the dogs (15/16) contained only loose fibrous tissue while chambers from rabbits (9/13) contained membranous bone and cartilage. Diffusion chambers implanted with 1.0-32.4 x 10(7) fresh allogeneic marrow cells suspended in cell culture medium were inserted into the peritoneal cavities of 11 dogs and 9 rabbits for 3-8 weeks, and after recovery examined histologically. Membranous bone was formed in 4/40 chambers containing canine marrow while bone and hyaline cartilage was formed in 21/27 chambers containing rabbit marrow. This apparent species difference in incidence of bone marrow osteogenesis may relate to a lower concentration of osteogenic precursor cells in canine marrow, a failure of osteogenic precursor cells to differentiate to osteoblasts in a somewhat artificial environment in vivo (viz diffusion chambers), a lack of cell-matrix interaction to stimulate cell differentiation, inappropriately short diffusion chamber implantation times post grafting, or a difference in ontogenetic stage of development of marrow donors with rabbit cells being physiologically younger.

Improved cementation in total hip replacement

Insufficient cementation has been suggested to be the most common cause of loosening of the femoral component after total hip arthroplasty. A clinical and radiographic study of 129 consecutive, primary total hip replacements was performed 5 years after surgery, in order to evaluate the significance of femoral plugging, special attention being focused on cementation and radiographic loosening. A polyethylene medullary plug was used in 78 hips which were compared with 51 non-plugged hips with respect to the clinical course and radiographic appearance. The cement mantle around the femoral component was thicker, and the packing of cement significantly improved when the plug was used. The frequency of radiographic loosening was smaller in the plugged group but with no statistical significance. There was no difference in clinical results between the compared groups. Our results indicate that medullary plugging improves the cementation and in particular prevents insufficient cementation of the femoral component.

Pulmonary marrow embolism: a dog model simulating dual component cemented arthroplasty

The cardiopulmonary changes resulting from cemented arthroplasty procedures were monitored in 11 dogs with a single prosthesis implanted and nine dogs with a dual arthroplasty procedure. These changes were characterized by decreased BP, elevated PPA, and elevated PVR, associated with decreases in PaO2, cardiac output and mixed venous oxygen tension. All changes were more pronounced and prolonged in the dual component arthroplasty group. Histologic lung examination and morphometry demonstrated significant degrees of marrow (fat) microembolism in the dual arthroplasty model. Cardiopulmonary collapse has been associated with Guepar dual component arthroplasties clinically and these patients are at increased risk and should be monitored continuously. Prophylactic measures include meticulous lavage of the intramedullary cavity, increased FIO2, and maintenance of intravascular volume and cardiac output. The bilateral arthroplasty model is useful in investigating therapeutic interventions which may detect and prevent the marrow microembolism syndrome intraoperatively.

Gentamicin-loaded plaster of Paris as a treatment of experimental osteomyelitis in rabbits

In this study, implantation of gentamicin-loaded plaster of paris after a debridement of the marrow cavity was tested in rabbits with established Staphylococcal osteomyelitis. The animals were observed for clinical and roentgenographic signs of infection after killing. The infections were evaluated by bone cultures and antibiotic levels. The implanted antibiotics alone resulted in only two of ten culture-proven cures. However, clinical and roentgenographic data showed overall improvement in the treated group as compared to controls. A valuable feature of gentamicin-loaded plaster of paris, warranting further investigation, is the elimination of dead space while the antibiotic is locally absorbed by the tissue fluids.

Bone marrow pressure chamber: a permanently inserted titanium implant for intramedullary pressure measurements

We describe a titanium implant for repeated intramedullary pressure measurements. The implant has been inserted permanently in the tibia of rabbits. Pressure is transmitted through a membrane in the chamber to a transducer connected to a meter. During the recordings no penetration of the cortex is necessary. The measured intact intramedullary pressure in the tibia was approximately 12 cmH2O.

Value of the head-at-risk concept in assessing the prognosis in Legg-Calvé-Perthes disease

Seventy-five hips affected by Legg-Calvé-Perthes disease were reviewed. Three therapeutic groups were defined: conservative treatment, marrow emptying of the femoral neck, and varus derotation femoral osteotomy. Results were analyzed according to head-at-risk concept. Patients with head not at risk had better results regardless of treatment. Results in other groups were worse, but improved significantly with varus derotation femoral osteotomy. In children greater than 9 years of age, the results were almost invariably poor, irrespective of head-at-risk designation.

Mechanical effects of intramedullary reaming on osteotomy healing in rats

The effect of intramedullary reaming on the healing of stable femoral osteotomies was studied. In one group of rats reaming of the medullary cavity was performed, and a partial, transverse osteotomy was made at the mid-shaft. In the control group only the osteotomy was made. At 0, 15, 30, 60, and 90 days following operation the bending moment and the bending rigidity of the osteotomies were evaluated. There were no significant differences in these biomechanical parameters between the two groups during the experimental period. The results indicate that reaming of the medullary cavity of diaphyseal bone does not significantly impair the healing of fractures that are rigidly fixated.

Trans-gluteal approach for hemiarthroplasty of the hip

An approach to the hip through the anterior capsule via a lateral incision is described, which gives excellent access to the medullary canal of the upper femur and is, therefore, suitable for hip hemiarthroplasty. It utilizes the principle that gluteus medius and vastus lateralis are in anatomical continuity. The gluteus medius is split vertically and the anterior portion detached from the greater trochanter. After reattachment its position, as shown by marking clips and post-operative radiographs, remains unaltered. A new retractor, specially designed for use with this approach, is described. A series of 40 hemiarthroplasties using this technique is presented.

[Optically controlled bone marrow removal in osteomyelitis treatment]

The present paper reports on the various methods of treating osteomyelitis and the development of an aid to visual monitoring of surgical findings in long bones. With this instrument a true-color assessment of bone cavities is possible without major cortical fenestrations causing impairment of biomechanics. On the basis of examples of treatment of various cases of hematogenous and chronic osteomyelitis, as well as infected total replacements, the potential of this instrument and the necessity of painstaking and visually monitored removal of marrow from the cavities is demonstrated. Results so far, after 6 years of use, admit the conclusion that the chances of success in the treatment of osteomyelitis are increased with this instrument.

Evaluation of osteogenesis following immediate and delayed reimplantation of frozen autogenous mandibular bone

A follow-up study of the feasibility of delayed reimplantation of frozen autogenous mandibles after ablative surgery for oral carcinomas with mandibular involvement was performed. Fifteen young adult mongrel dogs were used and evaluated clinically, bacteriologically, radiographically, histologically, and by radionuclide imaging. The animals were divided into two groups according to whether they underwent immediate or delayed reimplantation. These were subdivided into those who received grafts with and without autogenous marrow augmentation. The results were positive and suggested clinical evaluation. Twelve patients had undergone delayed reimplantation along with marrow augmentation over the past 3 years. Again, the results are most promising and we believe that, with further refinement, this technique will offer a new and acceptable modality for facial reconstruction in the cancer patient.

Morphological changes in bone following intramedullary implantation of methyl methacrylate. Effects of medullary occlusion: a morphometrical study

Using a computerized, semi-automatic morphometrical system, the morphological effects on diaphyseal rat femur following intramedullary implantation of methyl methacrylate were studied. Furthermore a comparison with the effects of periosteal elevation and removal of the bone marrow by suction was made. The changes in bone morphology were studied with the aid of microangiography, microradiography, fluorescence microscopy and histology. The results showed that there were evident differences between the postoperative course of the three procedures regarding vascular changes in the femoral cortex, bone remodelling and extent and duration of cortical necrosis. Implantation of methyl methacrylate caused greater vascular disturbance than elevation of the periosteum and removal of the bone marrow.

Bone marrow curettage in myelodysplastic disorders. A stimulus for regeneration in disturbed hematopoiesis

Bilateral bone marrow curettage of the iliac crest was performed in eight patients with marked anemia resulting from various myelodysplastic syndromes. The procedure was performed with the idea that an element of faulty hematopoietic microenvironment existed and that regeneration of normal marrow might occur in areas distant from the site of curettage. Four of the eight failed to respond to this procedure and no long-term response was obtained. One of the "failed" patients had a delayed response 18 months after the curettage was performed. In four patients, the procedure proved to be successful and adequate hemoglobin levels were achieved (10 to 14 g/dL) with reduction of the blood transfusion requirement. The diseases of two of these patients are still in remission 26 to 96 months after the procedure was performed. The procedure is recommended for patients with anemia refractory to conventional therapy and in whom a faulty hematopoietic microenvironment may be present.

Intramedullary nerve implantation in amputation and other traumatic neuromas

✓ A simple and effective method of eliminating pain as a result of amputation and traumatic neuroma is described. Following excision of the neuroma, intramedullary long-bone implantation of the proximal nerve is performed. This technique has been used in five patients and there has been no recurrence of pain.

Intramedullary pressure patterns

The insertion of cement and femoral prosthesis in total hip replacement produces biochemical abnormalities. These are thought to be caused by a marked rise in intramedullary pressure. Surgeons aim to reduce these pressures by using different methods of insertion and venting. The present investigation was undertaken to establish if any one method was superior to the others. The greatest modification of acrylic pressure was obtained by means of a drill hole. Thie highest rise in pressure was produced by the insertion of the femoral prosthesis and this was little modified by any of the alternatives of the use of a 3/16 inch drill hole, a 16-gauge catheter, and cement gun.

[Morphologic analysis of guinea pig bone regeneration following curettage]

Interrelation of stromal and hemopoietic elements in the regenerative process of the guinea-pig bone marrow at different time after curettage has been morphologically studied. The bone marrow regenerative process in the depleted medullary cavity of the guinea-pig tibial bone passes through several phases following each other: blood clot formation, rough-fibrillary osseous tissue formation, its resorption, development of sinusoids and formation of reticular stroma with subsequent repopulation of hemopoietic elements in it. The leading role in the process of the bone marrow restoration belongs to the reticular stroma creating specific microconditions for hemopoiesis.

The acute effects of periosteal stripping and medullary reaming on regional bone blood flow

The immediate effects of surgical dissection on regional bone blood flow were studied using the hydrogen washout technique and the results were compared in mature and immature rabbits. Epiphyseal circulation in young animals was eliminated by stripping the epiphyseal periosteum, and even in mature rabbits epiphyseal blood flow was markedly reduced by periosteal stripping. This suggests that after skeletal maturity blood supply crossing from the metaphysis into the epiphysis is limited. The blood flow rate was not altered by wide reaming of the epiphyseal center in either young or old animals. The rates of bone blood flow in the metaphysis and diaphysis were not altered by separate periosteal stripping or medullary reaming in either age group. Combined reaming and stripping eliminated blood flow in the diaphyseal cortical bone, but in the metaphysis fairly rapid blood flow remained even after reaming and periosteal stripping were done. These findings suggest that arterial supply and venous drainage traverse both endosteal and periosteal surfaces, and either system is capable of sustaining adequate bone tissue circulation.

Sustained haematological remission after bone marrow curettage in a case of primary myelofibrosis

This brief case report describes a sustained haematological remission obtained in a patient with primary myelofibrosis treated by bone marrow curettage after previous therapy with androgens was unsuccessful. The patient remains in haematological remission 5 years after the procedure. It is suggested that this procedure be attempted in more cases of myelofibrosis.

Fat embolism in patients with fractured hips

Fat embolism was assessed at necropsy and correlated with clinical findings in the patients who died among 854 with fractured hips admitted to hospital between 1967 and August 1971. Sixteen cases of clinical importance were found, eight of which were judged to have been fatal or to have seriously contributed to death. Frequencies were as follows: 2.4 to 3.3% among 424 patients with subcapital fractures; 0.7 to 0.8% in the 405 with trochanteric fractures; 4.1 to 7% among subjects treated without operation, representing 30% of those who died within seven days; and 0.9 to 1.1% among patients treated by pinning, nailing, or nail-plating. The higher frequency in the conservatively treated group is probably related to selection of poor-risk subjects. Fat embolism was found in 6.8 to 8.0% of those with subcapital fractures treated by primary Thompson's arthroplasty which utilizes acrylic cement, and in none of those given Moore's prostheses for which cement is not used. Study of a larger group after Moore's prosthesis is required to establish its lack of special risk. Fat embolism accounted for all the deaths within seven days of Thompson's arthroplasty and for most within 14 days; it was clearly related to surgery in some cases.A possible explanation of the hazard of Thompson's arthroplasty is that fat globule entry is enhanced by a rise of intramedullary pressure due to proximal occlusion of the reamed marrow cavity. A controlled trial of the effect of venting the marrow cavity on the frequency of fat embolism is warranted. It is possible that the acrylic monomer may also contribute to venous entry of medullary fat. The higher-age group of those with subcapital fractures and associated chronic cardiac and pulmonary disease might make them more susceptible to fat embolization than those in whom arthroplasty is also carried out for chronic hip disease.