Sterilization of allograft bone: effects of gamma irradiation on allograft biology and biomechanics

Autograft versus sterilized allograft for lateral calcaneal lengthening osteotomies: Comparison of 50 patients

Sterilized allografts may be less resistant to collapse and prone to nonunion leading to loss of correction in open wedge osteotomies. These adverse events usually occur at early time points (i.e., < 9 months postoperatively). The goal of this study was to compare sterilized allografts to autologous grafts in respect to secondary loss of hindfoot alignment and graft incorporation after lateral calcaneal lengthening osteotomies.Fifty patients (22 F/ 28 M, age: 16-69 years) who had undergone 50 lateral calcaneal lengthening osteotomies for adult flatfoot deformity were included in this retrospective study. Cortical sterilized allografts were used in 25 patients, autologous grafts in the remaining 25. Patients' preoperative, 6 and 12 weeks, and 6 to 9 months follow-up weight-bearing radiographs of the affected foot were analyzed by 2 blinded radiologists: on each radiograph, graft incorporation, the talo-first metatarsal angle (TFMA), the talo-navicular coverage angle (TNCA), and the calcaneal pitch angle (CPA) were assessed. Loss of hindfoot alignment was defined as an increase of the TFMA or the TNCA or a decrease of the CPA, each by 5°.Inter- and intraclass correlation coefficients for TFMA, TNCA, and CPA measurements ranged from 0.93 to 0.99. At all follow-up visits, the ratio of patients with loss of hindfoot alignment and graft incorporation was not significantly different between the allograft and autograft group. However, loss of correction was associated with failure of graft incorporation.Compared with autografts, sterilized allografts do not increase the risk for loss of hindfoot alignment in lateral column lengthening of the calcaneus. With respect to mechanical resistance, allografts thus mean an equal and valid alternative without risk of donor site morbidities.

Large osteochondral lesions of the femoral condyles: Treatment with fresh frozen and irradiated allograft using the Mega OATS technique

BACKGROUND

The purpose of this study was to review the clinical results of irradiated fresh frozen osteochondral allografts for large osteochondral defects of the knee using the Mega-OATS technique.

METHODS

Nine patients with a mean age of 32.1±6.6 (18 to 44) underwent Mega-OATS transplantation with irradiated (2.5Mrad), fresh frozen distal femur allograft. Three patients also underwent ACL-reconstruction; one patient a high tibial osteotomy. The underlying indication was osteochondrosis dissecans in four and trauma in five patients. The defect size was 25×25mm in three patients and 30×30 in six patients and the depth ranged from eight to 14mm. All OCD lesions were located on the medial femoral condyle; two of the traumatic lesions were located on the lateral femoral condyle. Clinical outcome was assessed using the Lysholm and IKDC scores. Radiographic incorporation was evaluated using serial radiographs and MR imaging at one year post surgery. All patients were reviewed at three, six, 12, and 24months following surgery.

RESULTS

The Lysholm (IKDC) score improved significantly (p=0.02 resp. p=0.007) within and between patients during the follow-up period from 40.9 (37) to 90.9 (87.1) at 2years. Radiographic union was observed in all patients at three months; on MR imaging at one year osseous integration was observed in eight patients. Graft subsidence with loss of the overlying cartilage was observed in one and subchondral cystic changes at the implantation side were seen in another patient.

CONCLUSION

The results of this case series suggest that irradiated osteochondral allograft provides significant medium-term clinical improvement in patients treated for large osteochondral lesions of the femoral condyles.

LEVEL OF EVIDENCE

IV, case series.

Radiation sterilization of tissue allografts: A review

Tissue substitutes are required in a number of clinical conditions for treatment of injured and diseased tissues. Tissues like bone, skin, amniotic membrane and soft tissues obtained from human donor can be used for repair or reconstruction of the injured part of the body. Allograft tissues from human donor provide an excellent alternative to autografts. However, major concern with the use of allografts is the risk of infectious disease transmission. Therefore, tissue allografts should be sterilized to make them safe for clinical use. Gamma radiation has several advantages and is the most suitable method for sterilization of biological tissues. This review summarizes the use of gamma irradiation technology as an effective method for sterilization of biological tissues and ensuring safety of tissue allografts.

Gamma Radiation Sterilization Reduces the High-cycle Fatigue Life of Allograft Bone

BACKGROUND

Sterilization by gamma radiation impairs the mechanical properties of bone allografts. Previous work related to radiation-induced embrittlement of bone tissue has been limited mostly to monotonic testing which does not necessarily predict the high-cycle fatigue life of allografts in vivo.

QUESTIONS/PURPOSES

We designed a custom rotating-bending fatigue device to answer the following questions: (1) Does gamma radiation sterilization affect the high-cycle fatigue behavior of cortical bone; and (2) how does the fatigue life change with cyclic stress level?

METHODS

The high-cycle fatigue behavior of human cortical bone specimens was examined at stress levels related to physiologic levels using a custom-designed rotating-bending fatigue device. Test specimens were distributed among two treatment groups (n = 6/group); control and irradiated. Samples were tested until failure at stress levels of 25, 35, and 45 MPa.

RESULTS

At 25 MPa, 83% of control samples survived 30 million cycles (run-out) whereas 83% of irradiated samples survived only 0.5 million cycles. At 35 MPa, irradiated samples showed an approximately 19-fold reduction in fatigue life compared with control samples (12.2 × 10(6) ± 12.3 × 10(6) versus 6.38 × 10(5) ± 6.81 × 10(5); p = 0.046), and in the case of 45 MPa, this reduction was approximately 17.5-fold (7.31 × 10(5) ± 6.39 × 10(5) versus 4.17 × 10(4) ± 1.91 × 10(4); p = 0.025). Equations to estimate high-cycle fatigue life of irradiated and control cortical bone allograft at a certain stress level were derived.

CONCLUSIONS

Gamma radiation sterilization severely impairs the high cycle fatigue life of structural allograft bone tissues, more so than the decline that has been reported for monotonic mechanical properties. Therefore, clinicians need to be conservative in the expectation of the fatigue life of structural allograft bone tissues. Methods to preserve the fatigue strength of nonirradiated allograft bone tissue are needed.

CLINICAL RELEVANCE

As opposed to what monotonic tests might suggest, the cyclic fatigue life of radiation-sterilized structural allografts is likely severely compromised relative to the nonirradiated condition and therefore should be taken into consideration. Methods to reduce the effect of irradiation or to recover structural allograft bone tissue fatigue strength are important to pursue.

Effects of ionizing radiation on proteins in lyophilized or frozen demineralized human bone

Objective

The aim was to study the effects of application of ionizing radiation (gamma and electrons) as sterilizing agents at doses of 15 kGy, 25 kGy and 50 kGy, on lyophilized or frozen demineralized bone tissue for use in transplants.

Methods

Five human femoral diaphyses from different donors of musculoskeletal tissue were demineralized and preserved as lyophilized or frozen at −80 °C. The samples were divided into two groups: non-irradiated (control) and irradiated by means of gamma rays or an electron beam. The bone proteins were extracted and used to determine the concentrations of total protein and BMP 2 and 7.

Results

Decreases in total protein and BMP 2 and 7 concentrations were observed. The decreases in total protein concentrations, in comparison with the respective control groups, were significant in the lyophilized and frozen samples that were irradiated at a dose of 50 kGy of gamma radiation and electron beam, with reductions of more than 30%. Significant decreases in the levels of BMP 2 and 7 were also observed at higher doses and especially through use of the electron beam.

Conclusion

The reductions in the concentrations of total proteins and osteoinductive proteins (BMP 2 and 7) were related to the radiation dose, i.e. they increased with higher doses of ionizing radiation type and the type of bone preservation. The largest reductions in concentrations were observed in the bones irradiated by means of an electron beam and at a dose of 50 kGy. However, this type of radiation and this high dose are not usual practices for sterilization of bone tissue.

Direct Sinus Lift and Immediate Implant Placement Using Piezosurgical Approach- A Case Report

Numerous studies have shown that placement of implants in the maxillary region with resultant successful osseointegration can be achieved by the use of sinus lift procedures using piezosurgical technique. In this case report a middle aged patient had come to the outpatient department of A. J. Institute of Dental Sciences with a chief complaint of missing right posterior molar. Since the radiographic ball marker showed only 4 mm bone below the sinus in #16 region, direct sinus lift procedure was done for placement of a dental implant. Piezosurgery was performed, as it reduces the risk of damaging vital soft tissues such as nerves, dura matter and blood vessels. To stabilize the implant in the maxillary sinus region and also to stimulate bone regeneration, gamma irradiated cancellous allograft was used. Periapical radiographs were taken 10 months after implant placement which showed good bone growth over the implant collar. Bone formation in the maxillary antrum was seen clearly in the panoramic radiograph. Using piezosurgical unit, sinus lift procedure with sinus grafting proved to be less traumatic and more successful.

Time-dependent changes in dynamic mechanical properties of irradiated bone

The increased use of allograft tissue for musculoskeletal repair has brought more focus to the safety of allogenic tissue and the efficacy of various sterilization techniques. The currently available literature contains few examples of studies on long-lasting strains of bones but no example for irradiated bones. In this study the bovine femurs from a 2-year-old animal were machine cut and irradiated with the doses of 10, 15, 25, 35, 45 and 50 kGy. The dynamic mechanical analysis was performed at 1 Hz at the room temperature in a 3-point bending configuration for 2880 minutes. The final values of E' and E″ were dose independent but they were reached at different periods. For this reason, so called "critical point" was introduced for the further analysis. All the examined sample groups were characterized by statistically significant lower values of the critical point in comparison with the control samples (p<0.05) but the biggest differences were observed between the control samples and the samples irradiated with the doses of 10, 15 and 25 kGy. Current results and literature review suggest that the dose of 35 kGy is the optimal dose for ionizing radiation sterilization.

Bioabsorbable fish scale for the internal fixation of fracture: a preliminary study

Fish scales, which consist of type I collagen and hydroxyapatite (HA), were used to fabricate a bioabsorbable bone pin in this study. Fresh fish scales were decellularized and characterized to provide higher biocompatibility. The mechanical properties of fish scales were tested, and the microstructure of an acellular fish scale was examined. The growth curve of a myoblastic cell line (C2C12), which was cultured on the acellular fish scales, implied biocompatibility in vitro, and the morphology of the cells cultured on the scales was observed using scanning electron microscopy (SEM). A bone pin made of decellularized fish scales was used for the internal fixation of femur fractures in New Zealand rabbits. Periodic X-ray evaluations were obtained, and histologic examinations were performed postoperatively. The present results show good cell growth on decellularized fish scales, implying great biocompatibility in vitro. Using SEM, the cell morphology revealed great adhesion on a native, layered collagen structure. The Young's modulus was 332 ± 50.4 MPa and the tensile strength was 34.4 ± 6.9 MPa for the decellularized fish scales. Animal studies revealed that a fish-scale-derived bone pin improved the healing of bone fractures and degraded with time. After an 8-week implantation, the bone pin integrated with the adjacent tissue, and new extracellular matrix was synthesized around the implant. Our results proved that fish-scale-derived bone pins are a promising implant material for bone healing and clinical applications.

Extracorporeal irradiation of tumorous calvaria: a case series

OBJECT

When intracranial tumors invade the overlying skull, gross resection typically includes removal of the involved bone. Methods used to repair the resulting structural defect in the cranium include artificial prostheses, allogeneic bone grafts, and autoclaving the autologous graft. The authors have previously reported a case involving high-dose extracorporeal ionizing radiation to treat the tumorous calvaria intraoperatively, followed by reimplantation of the treated bone flap. In this paper the authors report the long-term follow-up of that case, as well as results of using extracorporeal irradiation of tumorous calvaria (EITC) for an additional 20 patients treated similarly.

METHODS

The decision to undergo EITC was typically anticipated preoperatively, but determined intraoperatively, if upon inspection the bone flap was invaded by tumor. The bone flap was then delivered to the radiation oncology department, where a total dose of 120 Gy was delivered, using a clinical linear accelerator, over a period of approximately 15 minutes. After the intracranial tumor resection was completed, the irradiated craniotomy bone flap was reimplanted and the wound was closed in a standard fashion. A retrospective review of patients who had undergone EITC was performed for evidence of calvarial tumor recurrence or other complications.

RESULTS

Since the originally reported case, 20 additional patients have received EITC during craniotomy for invasive tumors. Eighteen (86%) of 21 patients were diagnosed with meningioma: 12 (67%) with WHO Grade I, 5 (28%) with WHO Grade II, and 1 with WHO Grade III (6%). The remaining 3 patients presented with dural-based B-cell lymphoma with extensive adjacent bone invasion (n = 2) and metastatic adenocarcinoma of the lung (n = 1). Follow-up of the 21 patients ranged from 1 to 132 months, with a mean of 41 months and a median of 23 months. No patients have experienced tumor recurrence, infection associated with the treated calvaria, or evidence of bone flap resorption.

CONCLUSIONS

Calvaria reconstructions represent an important component in structural and cosmetic outcome following craniectomy for tumorous bone. The authors' long-term experience with EITC has been excellent with no local tumor recurrence or complications. Therefore, EITC represents an excellent and efficient option for cranial reconstruction in such patients.

γ-Irradiation sterilized bone strengthened and toughened by ribose pre-treatment

OBJECTIVE

This study tested the hypothesis that a ribose-based pre-treatment would protect the strength, ductility and toughness of γ-irradiation sterilized cortical bone.

METHODS

Experiment 1: The effects of ribose pre-treatment (1.8M in PBS at 60°C for 24h) prior to 33 kGy of irradiation on strength, ductility and toughness (beams in three-point bending) and fracture toughness (J-integral at instability in single edge notched (bending)) were tested against matched non-irradiated and irradiated controls from bovine tibiae. Experiment 2: Three-point bending tests were conducted using beams from human femora (males, 59-67 years). Bone collagen thermal stability and network connectivity were examined using hydrothermal isometric tension testing.

RESULTS

Ribose pre-treatment protected the strength, ductility and toughness of irradiation sterilized bovine and human specimens to differing degrees. Their ultimate strength was not detectably different from non-irradiated control levels; toughness in bovine and human specimens was protected by 57 and 76%, respectively. Untreated human bone was less affected by irradiation and ribose pre-treatment was more effective in human bone than bovine bone.

CONCLUSIONS

This paper presents the first proof-of-principle that irradiation-sterilized bone with improved mechanical properties can be produced through the application of a ribose pre-irradiation treatment, which provides a more stable and connected collagen network than found in conventionally irradiated controls.

Evaluation of porcine xenograft in collateral ligament reconstruction in beagle dogs

This study evaluated the effectiveness of irradiated porcine tendon xenografts for lateral collateral ligament (LCL) reconstruction. Twenty healthy adult beagle dogs underwent LCL reconstruction using irradiated porcine tendons treated with poly-gamma-glutamic acid. Serological and histological assessments were performed to evaluate host immunological response at 3 and 12 months after surgery. The healing and functional integrity of the LCL reconstructions were assessed by mechanical testing and gait analysis. Histological assessment of the porcine xenografts showed gradual host cellular infiltration and graft collagen remodeling during the healing process. Porcine xenografts showed angiogenesis and no signs of inflammatory reaction. Additionally, biomechanical and gait evaluations supported graft functional integration with no differences between normal and porcine xenograft reconstruction at 12 months after surgery. Irradiated porcine xenografts showed greater cellular responses and healing properties in short- and long-term evaluations. Irradiated porcine tendons appear to be useful as xenografts for the reconstruction of damaged ligaments.

Growth factors in orthopaedic surgery: demineralized bone matrix versus recombinant bone morphogenetic proteins

During recent decades the utilisation of growth factors, especially BMPs, has received an increasing interest in orthopaedic surgery. For clinical implantation the two main options are demineralised bone matrix (DBM) and recombinant bone morphogenetic proteins (rhBMP). Many clinical studies agree on an equivalent osteoinductive effect between DBM, BMPs and autologous bone graft; however, the different origins and processing of DBM and rhBMP may introduce some fluctuations. Their respective characteristics are reviewed and possible interactions with their effectiveness are analysed. The main difference concerns the concentration of BMPs, which varies to an order of magnitude of 10(6) between DBM and rhBMPs. This may explain the variability in efficiency of some products and the adverse effects. Currently, considering osteoinductive properties, safety and availability, the DBM seems to offer several advantages. However, if DBM and rhBMPs are useful in some indications, their effectiveness and safety can be improved and more evidence-based studies are needed to better define the indications.

Porcine bone grafts defatted by lipase: efficacy of defatting and assessment of cytocompatibility

Defatting is an important procedure for the preparation of bone grafts because lipids in bone grafts strongly influence the osteointegration. Lipases have been widely used in different fields. However, study on the application to defatting process for bone grafts preparation has never been found so far. In this study, bone samples were treated respectively by lipase, NaHCO(3)/Na(2)CO(3), acetone and deionized water. The lipids content of processed bone grafts was calculated in Soxhlet extractor method. Surface morphology of the bone grafts was observed under scanning electron microscope (SEM). DNA content of processed bone grafts was measured. Cytocompatibility was evaluated by co-culturing mouse preosteoblasts (MC3T3-E1) on defatted bone cubes. Proliferation rates of MC3T3-E1 were examined by cell counting kit-8 (CCK-8) assay. No statistically significant difference was found between lipids amount of bone processed by lipase (0.46 ± 0.16 %) and acetone (1.11 ± 0.13 %) (P > 0.05). Both of them were significantly lower than that in groups processed by Na(2)CO(3)/NaHCO(3) (3.46 ± 0.69 %) and deionized water (8.88 ± 0.18 %) (P = 0.000). Only cell debris were discovered over the surface of bone processed by lipase or acetone, while lipid droplets were observed on bone processed by Na(2)CO(3)/NaHCO(3) or water by SEM. The difference of DNA concentration between the bone processed by lipase (3.16 ± 0.81 ng/μl) and acetone (4.14 ± 0.40 ng/μl) is not statistically significant (P > 0.05). Both of them are significantly lower than that groups processed by Na(2)CO(3)/NaHCO(3) (5.22 ± 0.38 ng/μl) and water (7.88 ± 0.55 ng/μl) (P < 0.05). MC3T3-E1 cells maintained their characteristic spreading on the trabecular surfaces of bone processed by lipase. There were no statistically significant differences among absorbance of lipase, acetone groups in CCK-8 assay. The application of lipase to bone tissue defatting appears to be a very promising technique for bone grafts preparation.

Mechanical properties of acellular mouse lungs after sterilization by gamma irradiation

Lung bioengineering using decellularized organ scaffolds is a potential alternative for lung transplantation. Clinical application will require donor scaffold sterilization. As gamma-irradiation is a conventional method for sterilizing tissue preparations for clinical application, the aim of this study was to evaluate the effects of lung scaffold sterilization by gamma irradiation on the mechanical properties of the acellular lung when subjected to the artificial ventilation maneuvers typical within bioreactors. Twenty-six mouse lungs were decellularized by a sodium dodecyl sulfate detergent protocol. Eight lungs were used as controls and 18 of them were submitted to a 31kGy gamma irradiation sterilization process (9 kept frozen in dry ice and 9 at room temperature). Mechanical properties of acellular lungs were measured before and after irradiation. Lung resistance (RL) and elastance (EL) were computed by linear regression fitting of recorded signals during mechanical ventilation (tracheal pressure, flow and volume). Static (Est) and dynamic (Edyn) elastances were obtained by the end-inspiratory occlusion method. After irradiation lungs presented higher values of resistance and elastance than before irradiation: RL increased by 41.1% (room temperature irradiation) and 32.8% (frozen irradiation) and EL increased by 41.8% (room temperature irradiation) and 31.8% (frozen irradiation). Similar increases were induced by irradiation in Est and Edyn. Scanning electron microscopy showed slight structural changes after irradiation, particularly those kept frozen. Sterilization by gamma irradiation at a conventional dose to ensure sterilization modifies acellular lung mechanics, with potential implications for lung bioengineering.

High-dose electron beam sterilization of soft-tissue grafts maintains significantly improved biomechanical properties compared to standard gamma treatment

Allografts have gained increasing popularity in anterior cruciate ligament (ACL) reconstruction. However, one of the major concerns regarding allografts is the possibility of disease transmission. Electron beam (Ebeam) and Gamma radiation have been proven to be successful in sterilization of medical products. In soft tissue sterilization high dosages of gamma irradiation have been shown to be detrimental to biomechanical properties of grafts. Therefore, it was the objective of this study to compare the biomechanical properties of human bone-patellar tendon-bone (BPTB) grafts after ebeam with standard gamma irradiation at medium (25 kGy) and high doses (34 kGy). We hypothesized that the biomechanical properties of Ebeam irradiated grafts would be superior to gamma irradiated grafts. Paired 10 mm-wide human BPTB grafts were harvested from 20 donors split into four groups following irradiation with either gamma or Ebeam (each n = 10): (A) Ebeam 25 kGy, (B) Gamma 25 kGy, (C) Ebeam 34 kGy (D) Gamma 34 kGy and ten non-irradiated BPTB grafts were used as controls. All grafts underwent biomechanical testing which included preconditioning (ten cycles, 0-20 N); cyclic loading (200 cycles, 20-200 N) and a load-to-failure (LTF) test. Stiffness of non-irradiated controls (199.6 ± 59.1 N/mm) and Ebeam sterilized grafts did not significantly differ (152.0 ± 37.0 N/mm; 192.8 ± 58.0 N/mm), while Gamma-irradiated grafts had significantly lower stiffness than controls at both irradiation dosages (25 kGy: 126.1 ± 45.4 N/mm; 34 kGy: 170.6 ± 58.2 N/mm) (p < 0.05). Failure loads at 25 kGy were significantly lower in the gamma group (1,009 ± 400 N), while the failure load was significantly lower in both study groups at high dose irradiation with 34 kGy (Ebeam: 1,139 ± 445 N, Gamma: 1,073 ± 617 N) compared to controls (1,741 ± 304 N) (p < 0.05). Creep was significantly larger in the gamma irradiated groups (25 kGy: 0.96 ± 1.34 mm; 34 kGy: 1.06 ± 0.58 mm) than in the Ebeam (25 kGy: 0.50 ± 0.34 mm; 34 kGy: 0.26 ± 0.24 mm) and control (0.20 ± 0.18 mm) group that did not differ significantly. Strain difference was not different between either control or study groups (controls: 1.0 ± 0.03; Ebeam 34 kGy 1.04 ± 0.018; Gamma 34 kGy 1.0 ± 0.028; 25 kGy: 1.4 ± 2,0; 34 kGy: 1.1 ± 1.1). The most important result of this study was that ebeam irradiation showed significantly less impairment of the biomechanical properties than gamma irradiation. Considering the results of this study and the improved control of irradiation application with electronic beam, this technique might be a promising alternative in soft-tissue sterilization.

The effect of terminal sterilization on structural and biophysical properties of a decellularized collagen-based scaffold; implications for stem cell adhesion

Terminal sterilization induces physical and chemical changes in the extracellular matrix (ECM) of ex vivo-derived biomaterials due to their aggressive mechanism of action. Prior studies have focused on how sterilization affects the mechanical integrity of tissue-based biomaterials but have rarely characterized effects on early cellular interaction, which is indicative of the biological response. Using a model fibrocartilage disc scaffold, these investigations compare the effect of three common sterilization methods [peracetic acid (PAA), gamma irradiation (GI), and ethylene oxide (EtO)] on a range of material properties and characterized early cellular interactions. GI and EtO produced unfavorable structural damage that contributed to inferior cell adhesion. Conversely, exposure to PAA resulted in limited structural alterations while inducing chemical modifications that favored cell attachment. Results suggest that the sterilization approach can be selected to modulate biomaterial properties to favor cellular adhesion and has relevance in tissue engineering and regenerative medicine applications. Furthermore, the study of cellular interactions with modified biomaterials in vitro provides information of how materials may react in subsequent clinical applications.

Radioprotective effect of N-acetyl-L-cysteine free radical scavenger on compressive mechanical properties of the gamma sterilized cortical bone of bovine femur

Gamma sterilization of bone allografts is used as a gold standard method to provide safety against disease transmission. However, it is well documented that high dose levels of ionizing radiation can degrade bone mechanical properties. This effect, which is attributed to the formation of free radicals through radiolysis of the water content of collagen, can lead to post-implantation difficulties such as pre-failure and/or secondary fractures of bone allografts. Recently, treatment of irradiated allografts with free radical scavengers is used to protect them against radiation-induced damages. This study aimed to investigate the radioprotective role of N-acetyl-L-cysteine (NAC) during the gamma sterilization of the cortical bone of bovine femurs using the compressive test. Totally, 195 cubic specimens with a dimension of 5 × 5 × 3 cubic mm were divided into 13 groups including a control and 12 experimental groups exposed to 18, 36, and 70 kGy at three different NAC concentrations (1.25, 12.5, and 25 mM for 18 kGy; 5, 50, and 100 mM for 36 kGy; 10, 100, and 200 mM for 70 kGy). The mechanical behavior of the sterilized specimens was studied using the uniaxial compressive test. The results indicated a concentration-dependent radioprotection effect of NAC on the plastic properties of the cortical bones. The concentration dependency of NAC was in turn related to radiation dose levels. In conclusion, treatment of bone specimens with a characteristic concentration of NAC during exposure to specific radiation dose levels can provide an efficient radioprotection window for preserving the mechanical stability of gamma sterilized allografts.

Bone embrittlement and collagen modifications due to high-dose gamma-irradiation sterilization

Bone allografts are often used in orthopedic reconstruction of skeletal defects resulting from trauma, bone cancer or revision of joint arthroplasty. γ-Irradiation sterilization is a widely-used biological safety measure; however it is known to embrittle bone. Irradiation has been shown to affect the post-yield properties, which are attributed to the collagen component of bone. In order to find a solution to the loss of toughness in irradiated bone allografts, it is important to fully understand the effects of irradiation on bone collagen. The objective of this study was to evaluate changes in the structure and integrity of bone collagen as a result of γ-irradiation, with the hypothesis that irradiation fragments collagen molecules leading to a loss of collagen network connectivity and therefore loss of toughness. Using cortical bone from bovine tibiae, sample beams irradiated at 33kGy on dry ice were compared to native bone beams (paired controls). All beams were subjected to three-point bend testing to failure followed by characterization of the decalcified bone collagen, using differential scanning calorimetry (DSC), hydrothermal isometric tension testing (HIT), high performance liquid chromatography (HPLC) and gel electrophoresis (SDS-PAGE). The carbonyl content of demineralized bone collagen was also measured chemically to assess oxidative damage. Barium sulfate staining after single edge notch bending (SEN(B)) fracture testing was also performed on bovine tibia bone beams with a machined and sharpened notch to evaluate the fracture toughness and ability of irradiated bone to form micro-damage during fracture. Irradiation resulted in a 62% loss of work-to-fracture (p≤0.001). There was significantly less micro-damage formed during fracture propagation in the irradiated bone. HPLC showed no significant effect on pentosidine, pyridinoline, or hydroxypyridinoline levels suggesting that the loss of toughness is not due to changes in these stable crosslinks. For DSC, there was a 20% decrease in thermal stability (p<0.001) with a 100% increase (p<0.001) in enthalpy of denaturation (melting). HIT testing also showed a decrease in thermal stability (20% lower denaturation temperature, p<0.001) and greatly reduced measures of collagen network connectivity (p<0.001). Interestingly, the increase in enthalpy of denaturation suggests that irradiated collagen requires more energy to denature (melt), perhaps a result of alterations in the hydrogen bonding sites (increased carbonyl content detected in the insoluble collagen) on the irradiated bone collagen. Altogether, this new data strongly indicates that a large loss of overall collagen connectivity due to collagen fragmentation resulting from γ-irradiation sterilization leads to inferior cortical bone toughness. In addition, notable changes in the thermal denaturation of the bone collagen along with chemical indicators of oxidative modification of the bone collagen indicate that the embrittlement may be a function not only of collagen fragmentation but also of changes in bonding.

Effects of different doses of gamma irradiation on oxygen and water vapour transmission rate of preserved human amniotic membrane

Preserved human amniotic membrane either air dried or glycerol preserved has been used effectively to treat superficial and partial thickness wounds without leaving any obvious hypertrophic scar. The preserved amnion, sterilised by ionising radiation, is known as an effective barrier for heat, fluid and protein loss while adheres nicely on wound. Air drying slightly reduced the oxygen transmission rate (OTR) of the amnion and the value significantly dropped after 15 kGy (p < 0.05). Glycerol preservation significantly reduced (p < 0.05) the OTR indicating less oxygen transmitted through the well structured cells of the amnion. Increase in the OTR with the increasing radiation doses up to 35 kGy possibly due to direct effects of radiation that resulted in large intercellular gaps. Both preservation methods significantly increased (p < 0.05) the water vapour transmission rate (WVTR). However, the low WVTR in the air dried amnion at 15 and 25 kGy was postulated due to cross-linking of collagen. Changes in the biophysical properties can be linked to direct and indirect effects of radiation on collagen bundles. The radiation dose of 25 kGy caused no adverse effect on biophysical properties hence it is still acceptable to sterilize both the air dried and the glycerol preserved amnions.

Influence of sterilisation methods on collagen-based devices stability and properties

Sterilisation is essential for any implantable medical device in order to prevent infection in patients. The selection of the most appropriate sterilisation method depends on the nature and the physical state of the material to be sterilised; the influence of the sterilisation method on the properties of the device; and the type of the potential contaminant. In this context, herein we review the influence of ethylene oxide, γ-irradiation, e-beam irradiation, gas plasma, peracetic acid and ethanol on structural, biomechanical, biochemical and biological properties of collagen-based devices. Data to-date demonstrate that chemical approaches are associated with cytotoxicity, whilst physical methods are associated with degradation, subject to the device physical characteristics. Thus, the sterilisation method of choice is device dependent.

Comparative biomechanical and microstructural analysis of native versus peracetic acid-ethanol treated cancellous bone graft

Bone transplantation is frequently used for the treatment of large osseous defects. The availability of autologous bone grafts as the current biological gold standard is limited and there is a risk of donor site morbidity. Allogenic bone grafts are an appealing alternative, but disinfection should be considered to reduce transmission of infection disorders. Peracetic acid-ethanol (PE) treatment has been proven reliable and effective for disinfection of human bone allografts. The purpose of this study was to evaluate the effects of PE treatment on the biomechanical properties and microstructure of cancellous bone grafts (CBG). Forty-eight human CBG cylinders were either treated by PE or frozen at −20°C and subjected to compression testing and histological and scanning electron microscopy (SEM) analysis. The levels of compressive strength, stiffness (Young's modulus), and fracture energy were significantly decreased upon PE treatment by 54%, 59%, and 36%, respectively. Furthermore, PE-treated CBG demonstrated a 42% increase in ultimate strain. SEM revealed a modified microstructure of CBG with an exposed collagen fiber network after PE treatment. We conclude that the observed reduced compressive strength and reduced stiffness may be beneficial during tissue remodeling thereby explaining the excellent clinical performance of PE-treated CBG.

Effects of gamma radiation sterilization and strain rate on compressive behavior of equine cortical bone

OBJECTIVES

Gamma radiation has been widely used for sterilization of bone allograft. However, sterilization by gamma radiation damages the material properties of bone which is a major clinical concern since bone allograft is used in load bearing applications. While the degree of this damage is well investigated for quasi-static and cyclic loading conditions, there does not appear any information on mechanical behavior of gamma-irradiated cortical bone at high speed loading conditions. In this study, the effects of gamma irradiation on high strain rate compressive behavior of equine cortical bone were investigated using a Split Hopkinson Pressure Bar (SHPB). Quasi-static compression testing was also performed.

METHODS

Equine cortical bone tissue from 8year old retired racehorses was divided into two groups: non-irradiated and gamma-irradiated at 30kGy. Quasi-static and high strain rate compression tests were performed at average strain rates of 0.0045/s and 725/s, respectively.

RESULTS

Agreeing with previous results on the embrittlement of cortical bone when gamma-irradiated, the quasi-static results showed that gamma-irradiation significantly decreased ultimate strength (9%), ultimate strain (27%) and toughness (41%), while not having significant effect on modulus of elasticity, yield strain and resilience. More importantly, contrary to what is typically observed in quasi-static loading, the gamma-irradiated bone under high speed loading showed significantly higher modulus of elasticity (45%), ultimate strength (24%) and toughness (26%) than those of non-irradiated bone, although the failure was at a similar strain.

SIGNIFICANCE

Under high speed loading, the mechanical properties of bone allografts were not degraded by irradiation, in contrast to the degradation measured in this and prior studies under quasi-static loading. This result calls into question the assumption that bone allograft is always degraded by gamma irradiation, regardless of loading conditions. However, it needs further investigation to be translated positively in a clinical setting.

Dependence of optical attenuation coefficient and mechanical tension of irradiated human cartilage measured by optical coherence tomography

As banked human tissues are not widely available, the development of new non-destructive and contactless techniques to evaluate the quality of allografts before distribution for transplantation is very important. Also, tissues will be processed accordingly to standard procedures and to minimize disease transmission most tissue banks will include a decontamination or sterilization step such as ionizing radiation. In this work, we present a new method to evaluate the internal structure of frozen or glycerol-processed human cartilages, submitted to various dosis of irradiation, using the total optical attenuation coefficient retrieved from optical coherence tomography (OCT) images. Our results show a close relationship between tensile properties and the total optical attenuation coefficient of cartilages. Therefore, OCT associated with the total optical attenuation coefficient open a new window to evaluate quantitatively biological changes in processed tissues.

Stem micromotion after femoral impaction grafting using irradiated allograft bone: a time zero in vitro study

BACKGROUND

A gamma irradiation dose of 15kGy has been shown to adequately sterilise allograft bone, commonly used in femoral impaction bone grafting to treat bone loss at revision hip replacement, without significantly affecting its mechanical properties. The objective of this study was to evaluate whether use of 15kGy irradiated bone affects the initial mechanical stability of the femoral stem prosthesis, as determined by micromotion in a comprehensive testing apparatus, in a clinically relevant time zero in vitro model of revision hip replacement.

METHODS

Morselised ovine bone was nonirradiated (control), or irradiated at 15kGy or 60kGy. For each dose, six ovine femurs were implanted with a cemented polished taper stem following femoral impaction bone grafting. Using testing apparatus that reproduces stem loading, stems were cyclically loaded and triaxial micromotion of the stem relative to the bone was measured at the proximal and distal stem regions using non-contact laser transducers and linear variable differential transformers.

FINDINGS

There were no significant differences in proximal or distal stem micromotion between groups for all directions (p≤0.80), apart for significantly greater distal stem medial-lateral micromotion in the 60kGy group compared to the 15kGy group (P=0.03), and near-significance in the anterior-posterior direction (P=0.08, power=0.85).

INTERPRETATION

Using a clinically relevant model and loading apparatus, irradiation of bone at 15kGy does not affect initial femoral stem stability following femoral impaction bone grafting.

Dependence of optical attenuation coefficient and mechanical tension of irradiated human cartilage measured by optical coherence tomography

As banked human tissues are not widely available, the development of new non-destructive and contactless techniques to evaluate the quality of allografts before distribution for transplantation is very important. Also, tissues will be processed accordingly to standard procedures and to minimize disease transmission most tissue banks will include a decontamination or sterilization step such as ionizing radiation. In this work, we present a new method to evaluate the internal structure of frozen or glycerol processed human cartilages, submitted to various dosis of irradiation, using the total optical attenuation coefficient retrieved from optical coherence tomography (OCT) images. Our results show a close relationship between tensile properties and the total optical attenuation coefficient of cartilages. Therefore, OCT associated with the total optical attenuation coefficient open a new window to evaluate quantitatively biological changes in processed tissues.

Radioprotection provides functional mechanics but delays healing of irradiated tendon allografts after ACL reconstruction in sheep

Successful protection of tissue properties against ionizing radiation effects could allow its use for terminal sterilization of musculoskeletal allografts. In this study we functionally evaluate Achilles tendon allografts processed with a previously developed radioprotective treatment based on (1-ethyl-3-(3-dimethylaminopropyl)carbodiimide) crosslinking and free radical scavenging using ascorbate and riboflavin, for ovine anterior cruciate ligament reconstruction. Arthroscopic anterior cruciate ligament (ACL) reconstruction was performed using double looped allografts, while comparing radioprotected irradiated and fresh frozen allografts after 12 and 24 weeks post-implantation, and to control irradiated grafts after 12 weeks. Radioprotection was successful at preserving early subfailure mechanical properties comparable to fresh frozen allografts. Twelve week graft stiffness and anterior-tibial (A-T) translation for radioprotected and fresh frozen allografts were comparable at 30 % of native stiffness, and 4.6 and 5 times native A-T translation, respectively. Fresh frozen allograft possessed the greatest 24 week peak load at 840 N and stiffness at 177 N/mm. Histological evidence suggested a delay in tendon to bone healing for radioprotected allografts, which was reflected in mechanical properties. There was no evidence that radioprotective treatment inhibited intra-articular graft healing. This specific radioprotective method cannot be recommended for ACL reconstruction allografts, and data suggest that future efforts to improve allograft sterilization procedures should focus on modifying or eliminating the pre-crosslinking procedure.

Remineralization of demineralized bone matrix (DBM) via alternating solution immersion (ASI)

In order to achieve successful clinical outcomes, biomaterials used for bone grafts must possess a number of traits including biocompatibility and osteoconductivity. These materials must also demonstrate appropriate mechanical stability to withstand handling as well as support potentially significant stresses at the implant site. Synthetic and natural polymer scaffolds used for bone tissue engineering (BTE) often lack necessary mechanical properties. Our goal was to internally mineralize natural collagenous matrix, thereby increasing mechanical properties of the material to useful levels. Published methods for intrafibrillar collagen mineralization were applied to clinically relevant-sized constructs but did not successfully deposit mineral in the interior of the constructs. To address this limitation, we developed a new technique for the remineralization of demineralized bone matrix (DBM) based on alternating solution immersion, or ASI. Mineral was removed from equine bone specimens, leaving behind a demineralized bone matrix (DBM). This matrix provides a framework for the nucleation and growth of a replacement mineral phase. Plain film radiography and microcomputed tomography (microCT) indicated accumulation of mineral within the DBM, and mechanical testing (3 point bending and compression) revealed a significant increase in stiffness between the DBM and the remineralized bone matrix (RBM). We believe this remineralization process will be useful in the preparation of stiff and strong allografts for clinical application.

Specific biomimetic hydroxyapatite nanotopographies enhance osteoblastic differentiation and bone graft osteointegration

Impaired healing of cortical bone grafts represents a significant clinical problem. Cadaveric bone grafts undergo extensive chemical processing to decrease the risk of disease transmission; however, these processing techniques alter the bone surface and decrease the osteogenic potential of cells at the healing site. Extensive work has been done to optimize the surface of bone grafts, and hydroxyapatite (HAP) and nanotopography both increase osteoblastic differentiation. HAP is the main mineral component of bone and can enhance osteoblastic differentiation and bone implant healing in vivo, while nanotopography can enhance osteoblastic differentiation, adhesion, and proliferation. This is the first study to test the combined effects of HAP and nanotopographies on bone graft healing. With the goal of identifying the optimized surface features to improve bone graft healing, we tested the hypothesis that HAP-based nanotopographic resurfacing of bone grafts improves integration of cortical bone grafts by enhancing osteoblastic differentiation. Here we show that osteoblastic cells cultured on processed bones coated with specific-scale (50-60 nm) HAP nanotopographies display increased osteoblastic differentiation compared to cells on uncoated bone, bones coated with poly-l-lactic acid nanotopographies, or other HAP nanotopographies. Further, bone grafts coated with 50-60-nm HAP exhibited increased formation of new bone and improved healing, with mechanical properties equivalent to live autografts. These data indicate the potential for specific HAP nanotopographies to not only increase osteoblastic differentiation but also improve bone graft incorporation, which could significantly increase patient quality of life after traumatic bone injuries or resection of an osteosarcoma.

Substitutes of structural and non-structural autologous bone grafts in hindfoot arthrodeses and osteotomies: a systematic review

Background

Structural and non-structural substitutes of autologous bone grafts are frequently used in hindfoot arthrodeses and osteotomies. However, their efficacy is unclear.

The primary goal of this systematic review was to compare autologous bone grafts with structural and non-structural substitutes regarding the odds of union in hindfoot arthrodeses and osteotomies.

Methods

The Medline and EMBASE and Cochrane databases were searched for relevant randomized and non-randomized prospective studies as well as retrospective comparative chart reviews.

Results

10 studies which comprised 928 hindfoot arthrodeses and osteotomies met the inclusion criteria for this systematic review. The quality of the retrieved studies was low due to small samples sizes and confounding variables. The pooled random effect odds for union were 12.8 (95% CI 12.7 to 12.9) for structural allografts, 5.7 (95% CI 5.5 to 6.0) for cortical autologous grafts, 7.3 (95% CI 6.0 to 8.6) for cancellous allografts and 6.0 (95% CI 5.7 to 6.4) for cancellous autologous grafts. In individual studies, the odds of union in hindfoot arthrodeses achieved with cancellous autologous grafts was similar to those achieved with demineralised bone matrix or platelet derived growth factor augmented ceramic granules.

Conclusion

Our results suggest an equivalent incorporation of structural allografts as compared to autologous grafts in hindfoot arthrodeses and osteotomies. There is a need for prospective randomized trials to further clarify the role of substitutes of autologous bone grafts in hindfoot surgery.

Effect of X-ray irradiation on the elastic strain evolution in the mineral phase of bovine bone under creep and load-free conditions

Both the load partitioning between hydroxyapatite (HAP) and collagen during compressive creep deformation of bone and the HAP residual strain in unloaded bone have been shown in previous synchrotron X-ray diffraction studies to be affected by the X-ray irradiation dose. Here, through detailed analysis of the X-ray diffraction patterns of bovine bone, the effect of X-ray dose on (i) the rate of HAP elastic strain accumulation/shedding under creep conditions and (ii) the HAP lattice spacing and average root mean square (RMS) strain under load-free conditions are examined. These strain measurements exhibit three stages in response to increasing X-ray dose. Up to ∼75 kGy (stage I) no effect of dose is observed, indicating a threshold behavior. Between ∼75 and ∼300 kGy (stage II) in unloaded bone the HAP d-spacing increases and the RMS strain decreases with dose, indicating strain relaxation of HAP. Furthermore, under constant compressive load creep conditions, the rate of compressive elastic strain accumulation in HAP decreases with increasing dose until, at ∼115 kGy, it changes sign, indicating that the HAP phase is shedding load during creep deformation. These stage II behaviors are consistent with HAP-collagen interfacial damage, which allows the HAP elastic strain to relax within both the loaded and unloaded samples. Finally, for doses in excess of ∼300 kGy (stage III, measured up to 7771 kGy) the HAP lattice spacing and RMS strain for load-free samples and the rate of HAP elastic strain shedding for crept samples remain independent of dose, suggesting a saturation of damage and/or stiffening of the collagen matrix due to intermolecular cross-linking.

The use of deep frozen and irradiated bone allografts in the reconstruction of tibial plateau fractures

To investigate the clinical behavior of deep frozen and irradiated bone allografts in the treatment of depressed tibial plateau fractures. Twenty-two patients with a tibial plateau fracture were treated with cancellous bone allografts. The bone allograft preparation process included fresh-freezing at -70 °C for 4 weeks and gamma-irradiation at 25 kGy. All of the patients were followed for 1-2 years. The clinical effects were assessed using the Rasmussen score for tibial head fractures and X-rays. Postoperatively, the average excellent and fair Rasmussen scores were 88.9%. Only one patient developed an infection, with no integration between allograft and recipient bone observed. All of the other bone allografts were incorporated successfully, and no osteoporosis or sclerosis was observed. The frozen and gamma-irradiated bone allograft is a good alternative in the treatment of tibial plateau fractures, which we have shown can integrate with the surrounding host bone.

Sterilization of tendon allografts: a method to improve strength and stability after exposure to 50 kGy gamma radiation

Terminal sterilization of tendon allografts with high dose gamma irradiation has deleterious effects on tendon mechanical properties and stability after implantation. Our goal is to minimize these effects with radio protective methods. We previously showed that radio protection via combined crosslinking and free radical scavenging maintained initial mechanical properties of tendon allografts after irradiation at 50 kGy. This study further evaluates the tissue response and simulated mechanical degradation of tendons processed with radio protective treatment, which involves crosslinking in 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide followed by soaking in an ascorbate/riboflavin-5-phosphate solution. Control untreated and treated tendons were irradiated at 50 kGy and implanted in New Zealand White rabbit knees within the joint capsule for four and 8 weeks. Tendons were also exposed to cyclic loading to 20 N at one cycle per 12 s in a collagenase solution for 150 cycles, followed by tension to failure. Control irradiated tendons displayed increased degradation in vivo, and failed prematurely during cyclic processing at an average of 25 cycles. In contrast, radio protected irradiated tendons displayed greater stability following implantation over 8 weeks, and possessed strength at 59 % of native tendons and modulus equivalent to that of native tendons after cyclic loading in collagenase. These results suggest that radio protective treatment improves the strength and the stability of tendon allografts.

Evolution of load transfer between hydroxyapatite and collagen during creep deformation of bone

While the matrix/reinforcement load-transfer occurring at the micro- and nanoscale in nonbiological composites subjected to creep deformation is well understood, this topic has been little studied in biological composites such as bone. Here, for the first time in bone, the mechanisms of time-dependent load transfer occurring at the nanoscale between the collagen phase and the hydroxyapatite (HAP) platelets are studied. Bovine cortical bone samples are subjected to synchrotron X-ray diffraction to measure in situ the evolution of elastic strains in the crystalline HAP phase and the evolution of viscoelastic strains accumulating in the mineralized collagen fibrils under creep conditions at body temperature. For a constant compressive stress, both types of strains increase linearly with time. This suggests that bone, as it deforms macroscopically, is behaving as a traditional composite, shedding load from the more compliant, viscoelastic collagen matrix to the reinforcing elastic HAP platelets. This behavior is modeled by finite-element simulation carried out at the fibrillar level.

Characterization of the effects of x-ray irradiation on the hierarchical structure and mechanical properties of human cortical bone

Bone comprises a complex structure of primarily collagen, hydroxyapatite and water, where each hierarchical structural level contributes to its strength, ductility and toughness. These properties, however, are degraded by irradiation, arising from medical therapy or bone-allograft sterilization. We provide here a mechanistic framework for how irradiation affects the nature and properties of human cortical bone over a range of characteristic (nano to macro) length-scales, following x-ray exposures up to 630 kGy. Macroscopically, bone strength, ductility and fracture resistance are seen to be progressively degraded with increasing irradiation levels. At the micron-scale, fracture properties, evaluated using insitu scanning electron microscopy and synchrotron x-ray computed micro-tomography, provide mechanistic information on how cracks interact with the bone-matrix structure. At sub-micron scales, strength properties are evaluated with insitu tensile tests in the synchrotron using small-/wide-angle x-ray scattering/diffraction, where strains are simultaneously measured in the macroscopic tissue, collagen fibrils and mineral. Compared to healthy bone, results show that the fibrillar strain is decreased by ∼40% following 70 kGy exposures, consistent with significant stiffening and degradation of the collagen. We attribute the irradiation-induced deterioration in mechanical properties to mechanisms at multiple length-scales, including changes in crack paths at micron-scales, loss of plasticity from suppressed fibrillar sliding at sub-micron scales, and the loss and damage of collagen at the nano-scales, the latter being assessed using Raman and Fourier Transform Infrared spectroscopy and a fluorometric assay.