[The technic of fibrin glue in cancellous bone transplants (author's transl)]

In vivo biological performance of composites combining micro-macroporous biphasic calcium phosphate granules and fibrin sealant

INTRODUCTION

Fibrin glues are currently used by surgeons and can facilitate the handling of biomaterials. Combining fibrin glue with calcium phosphate bioceramics gives a mouldable composite that cements the granules into the implantation site. In addition to the mechanical aspect of the composite, it has been suggested that the mixture also promotes wound healing. These human blood derivatives contain natural (aprotinin) or synthetic (tranexamic acid) antifibrinolytic substances. We compared the bioactivity of two composites combining calcium phosphate granules with two different types of fibrin glue, one with aprotinin and the other with tranexamic acid.

MATERIALS AND METHODS

The composite was composed of fibrin glue (Tissucol) and 1 to 2 mm granules of biphasic calcium phosphate granules (MBCP) with a volume ratio of 1 for 2. Bone cavities were drilled in 12 New Zealand rabbits and filled with a composite with aprotinin-fibrin glue on the right condyle and one with tranexamic acid-fibrin glue on the left condyle. The rabbits were randomized into two groups: 3 and 6 weeks of delay. Light microscopy, scanning electron microscopy and image analysis were performed.

RESULTS

No adverse reactions were observed in either sample. Bony ingrowth associated with bioceramic resorption by osteoclastic TRAP-positive cells was noted. No significant difference was observed between the two composites. The bony ingrowth and ceramic resorption were qualitatively and quantitatively similar with both composites.

CONCLUSION

This study demonstrated that the choice of a natural (aprotinin) or synthetic (tranexamic acid) antifibrinolytic agent in the fibrin sealant associated with calcium phosphate granules and used as a bone substitute had no effect on the bioactivity of the composite. It remained efficient in bone reconstruction, no adverse effects were observed, and the bony ingrowth was qualitatively and quantitatively equivalent with the two types of fibrin sealant.

Nerve anastomoses with human fibrin. Preliminary clinical report (56 cases)

Since 1980, 56 peripheral nerve repairs have been done with fibrin. For technical reasons, combined anastomoses have been chosen in brachial plexus repairs (23 cases), fibrin alone being used in most other cases (8 free flaps, 17 main trunks, 8 digital nerves). As a whole, results compare evenly with the so-called classical repair methods using stitches. The adhesive method's main advantage is the gain in operative time, without impairing precision. Secondary benefits, such as hemostasis and easier stabilization of small grafts, can be achieved. One question remains: what becomes of fibrin? The survey of present cases would tend to prove that axonal growth through the second anastomosis is impeded proportionally to the length of the graft. The possible action of fibrin in the alteration process leading to a sclerotic diaphragm is not elucidated to this day. Experimental as well as clinical research must be carried on, in order to improve this new way of repairing nerves.

Pharmacokinetic study of fibrin clot-ciprofloxacin complex: an in vitro and in vivo experimental investigation

We prepared a composite of fibrin clot and ciprofloxacin for use as a biodegradable antibiotic delivery system with sustained effect for the treatment of chronic osteomyelitis. In vitro, ten experiments were performed in which 10 mg of ciprofloxacin were incorporated into 4 ml of fibrin clot. The clots were preserved in nutrient broth and incubated at 37 degrees C for a total of 60 days. Every 24 h a broth specimen was obtained, and the ciprofloxacin concentration was determined by microbiological assay. The maximum level of antibiotic was noted on the first day (49.9 +/- 5.1 mg/l). The ciprofloxacin-fibrin clot complexes usually disintegrated after 60 days. In vivo, the fibrin-ciprofloxacin clots were made as previously described. The composite was implanted in the medullary canal of rabbit tibiae, and the antibiotic concentration was measured in bone, muscle, skin and serum. In all tissues around the implant, the concentration of antibiotic exceeded the minimum inhibitory concentration against the common causative organisms of osteomyelitis for 10 days. The implant caused no systemic side-effects, and it is likely to prove clinically useful as a drug delivery system for treating chronic osteomyelitis.

Chronic staphylococcal osteomyelitis: a new experimental rat model

A rat model of chronic staphylococcal osteomyelitis was developed. Fibrin glue (5 microliters) and Staphylococcus aureus (2 x 10(6) CFU/5 microliters) were inoculated into the proximal metaphysis of the tibia. The rats were killed at intervals of between 1 and 6 months, and the tibias were removed. Induced lesions were evaluated by radiographic, macroscopic, and histological examinations and bacterial counts. Roentgenograms revealed osteomyelitis in more than 90% of the tibias. Gross bone pathology revealed skeletal deformation, new bone formation, abscesses, and draining skin fistulas in more than 80% of cases. Histological examination revealed osteomyelitis in more than 90% of cases, and bacterial counts were positive in 86% of cases. Only fibrin glue (5 microliters) was inoculated into controls. Controls showed no osteomyelitic lesions, and counts were negative in seven of eight control tibias. The main feature of this model is the use of fibrin glue instead of the sclerosing agents and foreign bodies used in other models. The model reproduces lesions similar to those of human posttraumatic osteomyelitis and can be reliably used in pathophysiological and therapeutic studies.

Apatite-wollastonite containing glass ceramic-fibrin mixture as a bone defect filler

The purpose of this study was to evaluate the usefulness of a mixture of apatite-wollastonite containing glass ceramic (A-W.GC, 42-60 mesh in granule size) with fibrin as a bone defect filler. A bone defect was drilled in the proximal metaphysis of the rat tibia and was filled with (1) fibrin glue, (2) A-W.GC granules, or (3) A-W.GC-fibrin mixture. Nothing was placed in the defect of the controls. The animals were serially sacrificed until 8 weeks after the operation, and the defect site was histologically examined and histomorphometrically analyzed for quantitative evaluation of newly formed bone and blood vessels. The use of fibrin glue as the binder markedly increased the ease of handling the A-W.GC granules. In the controls, little trabecular regeneration was observed in the defect site. Early vascularization (confirmed by microangiography) increased and the repairing process was accelerated in the defects filled with fibrin. In these defects filled with A-W.GC granules, good bone formation was observed around the granules. Bone formation was accelerated in the defects filled with A-W.GC fibrin mixture. Thus, the mixture showed good osteoconductive potential as well as acceleration of the repair process. Therefore, A-W.GC-fibrin mixture is considered to be a useful bone defect filler.

Experimental investigation into reparative osteogenesis with fibrin adhesive

An experimental investigation was carried out in order to evaluate the effects of fibrin adhesive on the reparative osteogenesis of bone grafts in the short, medium, and long term. Sixty fully developed New Zealand White rabbits under general anesthesia were grafted with homologous bone tissue in the proximal third of each tibias. Fibrin adhesive was used in one hind limb only. The animals were killed at a predetermined time. Both tibias were removed and subjected to radiographic and histologic analyses. The reparative process was observed and the differences between the fibrin adhesive-treated grafts and the reference group in the first few weeks were determined. No substantial difference was detected in the reparative osteogenetic process of the graft in the animals killed after 2 months.

Bone formation rate in osseointegrated titanium implants. Influence of locally applied haemostasis, peripheral blood, autologous bone marrow and fibrin adhesive system (FAS)

The influence of local application of haemostasis, peripheral blood, autologous bone marrow and Fibrin Adhesive System (FAS) on bone formation rate in osseointegrated titanium implants, were studied. The Bone Harvest Chamber (BHC) implant utilized has a penetrating canal, enabling osseous ingrowth in situ. After integration of one implant into the cortex of the proximal tibial metaphysis of a rabbit, newly formed bone was harvested in repetitive three-week periods. The specimens were quantified by microradiography-videodensitometry and subjected to further histological examination. The amounts of bone formed in two equally treated chambers in the same animal were compared. It was concluded, that the conditions for bone regeneration in an osseointegrated titanium implant are excellent, minimally influenced by locally applied haemostasis, peripheral blood and autologous bone marrow. FAS pretreatment on the other hand was found to impair bone formation.

The sustained release of cefotaxim from a fibrin-cefotaxim compound in treatment of osteitis. Pharmacokinetic study and clinical results

Following a survey of the literature regarding clinical examinations and experimental studies of local absorbable carrier for an antibiotic in treatment of osteitis, a study is presented concerning clinical experience with 46 patients treated with a cefotaxim-loaded fibrin sealant. In connection with simultaneous focal sanitation the clinical results were satisfying. When autogenous cancellous bone was added at the same time, only one surgical operation was necessary in some cases to show results equivalent to other methods. Postoperatively, the cefotaxim levels in the blood and in the wound drainage fluid were measured. The serum cefotaxim concentrations were low and only identifiable for a period of 36h, whereas the wound drainage fluid contained very highly effective antibacterial concentrations over a measured period of 3.5 days. The best results were seen in cases of hematogenic osteomyelitis. The disadvantage of this system is the quick release of the antibiotic by diffusion. Therefore, high concentrations can be obtained only for a short period of several days.

Glued periosteal grafts in the knee

Periosteal grafting was performed in 4 patients with osteochondritis dissecans of the medial femoral condyle and 1 patient with osteonecrosis of the lateral femoral condyle following prednisone therapy. The lesions were drilled out deep into the cancellous bone. The periosteal graft was taken from the medial facet of the tibia and fixed to the excavated bony defect by the tissue glue Fibrinkleber Human Immuno (Tisseel). The patients were followed clinically, by arthroscopic examination and by radiography at 3, 6, and 12 months. After 1 year the borderline between the new and surrounding cartilage was hardly visible.

Fibrin adhesive system (FAS) influence on bone healing rate: a microradiographical evaluation using the bone growth chamber

A dividable titanium implant containing two canals was inserted into both tibial metaphyses of 5 adult rabbits to test whether the Fibrin Adhesive System (FAS) can accelerate bone regeneration. On one side the implants were pretreated with FAS whereas the implants on the contralateral side were bathed in autologous blood and marrow. After a healing time of 4-5 weeks the assembled implants were removed and then taken apart. The amount of bone which had grown into the canals was quantified by microradiography and microdensitometry. The FAS-treated implants showed a tendency to contain less bone than the medullary cell-treated ones. It is concluded that more evidence should be gathered before recommending FAS treatment to accelerate bone regeneration. It is submitted in addition that the dividable titanium implant, the Bone Growth Chamber, may be useful for quantification of early bone formation under various experimental conditions.

The use of the fibrin adhesion system for local hemostasis in oral surgery

In 144 patients with bleeding disorders and in 11 patients with normal coagulation, 517 wound sealings were performed using the fibrin adhesion system (FAS) with the primary object of local hemostasis. Excellent results were obtained in patients with bleeding disorders caused by impaired thrombocyte function or anticoagulant therapy. Replacement therapy or the withdrawal of anticoagulant medication was thereby avoided. Ultimate hemostasis in patients with hemophilia was achieved by fibrin sealing in combination with low-dose replacement therapy with clotting factor concentrates. Though the risk of hepatitis transmission cannot be completely ruled out, the advantages, such as excellent tissue tolerance, complete resorption, and a wide spectrum of practical uses, speak in favor of the use of this physiologic tissue adhesive.

Surgical management of rhinophyma

The author's methods for the treatment of rhinophyma is described. Nasal lesions are removed in a three-step procedure. The resultant wound surfaces are sealed with fibrin sealant, consisting of highly concentrated human fibrinogen which is clotted with a thrombin solution. The resultant fibrin clot adheres firmly to the wound surface. Spot-bleeding from numerous small vessels is controlled by sealant application. Postoperative wound healing is accelerated and cosmetic results are excellent.

First clinical experience with heterologous cancellous bone grafting combined with the fibrin adhesive system (F.A.S.)

Heterologous bone grafts are mostly refused for bone transplantation because of the low osteogenic potency. The remodelling of the heterografts can be improved significantly by application of a fibrin-adhesive-system. Between 1977 and 1979 thirty-five bone defects caused by bone tumors resp. seven times by osteomyelitis were operated on and closed with cancellous Kiel-bone grafts (Braun, Melsungen) soaked thoroughly with fibrin-glue (Tissel/Tissucol TM, Immuno AG, Vienna). Postoperatively there were two infections, but none of them in our osteomyelitic cases. After an average follow-up period of 24.6 months (15-36), the highly satisfying, preliminary results were exactly analysed. Despite the relatively short postoperative time, in almost all cases the complete remodelling of the heterografts into new bone tissue could be observed. A formula to calculate the amount of fibrin-glue, necessary for the procedure, is given.

Experimental investigations of the effect of the fibrin adhesive on the Kiel heterologous bone graft

The influence by a fibrin-adhesive on healing has been investigated in heterologous cancellous transplants in the rabbit ilum. After 8 and 12 weeks the radiologic and histologic results were evaluated. In the control group the fibrously surrounded transplants were resorbed and replaced by metaplastic bone only to a little degree. Applicating the fibrin-adhesive system (FKS) the transplants were osseously connected to the bone bearing. The trabeculae wre surrounded by newly built lamellar bone and resorbed during the following periods. The osteogenic potency of heterologous transplants resp. the efficiency of the bone bearing can be improved by application of the FKS.