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Elenes EY, Hunter SA. Soft-tissue allografts terminally sterilized with an electron beam are biomechanically equivalent to aseptic, nonsterilized tendons. J Bone Joint Surg Am 2014; 96:1321-6. [PMID: 25143491 DOI: 10.2106/jbjs.l.00841] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Allograft safety is contingent on effective sterilization. However, current sterilization methods have been associated with decreased biomechanical strength and higher failure rates of soft-tissue allografts. In this study, electron beam (e-beam) sterilization was explored as an alternative sterilization method to preserve biomechanical integrity. We hypothesized that e-beam sterilization would not significantly alter the biomechanical properties of tendon allograft compared with aseptic, nonsterilized controls and gamma-irradiated grafts. METHODS Separate sets of forty fresh-frozen tibialis tendon allografts (four from each of ten donors) and forty bisected bone-patellar tendon-bone (BTB) allografts (four from each of ten donors) were randomly assigned to four study groups. One group received a 17.1 to 21.0-kGy gamma radiation dose; two other groups were sterilized with an e-beam at either a high (17.1 to 21.0-kGy) or low (9.2 to 12.2-kGy) dose. A fourth group served as nonsterilized controls. Each graft was cyclically loaded to 200 N of tension for 2000 cycles at a frequency of 2 Hz, allowed to relax for five minutes, and then tested in tension until failure at a 100%/sec strain rate. One-way analysis of variance testing was used to identify significant differences. RESULTS Tibialis tendons sterilized with both e-beam treatments and with gamma irradiation exhibited values for cyclic tendon elongation, maximum load, maximum displacement, stiffness, maximum stress, maximum strain, and elastic modulus that were not significantly different from those of nonsterilized controls. BTB allografts sterilized with the high e-beam dose and with gamma irradiation were not significantly different in cyclic tendon elongation, maximum load, maximum displacement, stiffness, maximum stress, maximum strain, and elastic modulus from nonsterilized controls. BTB allografts sterilized with the e-beam at the lower dose were significantly less stiff than nonsterilized controls (p = 0.014) but did not differ from controls in any other properties. The difference in stiffness likely resulted from variations in tendon size rather than the treatments, as the elastic moduli of the groups were similar. CONCLUSIONS The biomechanical properties of tibialis and BTB allografts sterilized with use of an e-beam at a dose range of 17.1 to 21.0 kGy were not different from those of aseptic, nonsterilized controls or gamma-irradiated allografts. CLINICAL RELEVANCE E-beam sterilization can be a viable method to produce safe and biomechanically uncompromised soft-tissue allografts.
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Affiliation(s)
- Egleide Y Elenes
- School of Biomedical Engineering and Sciences, Virginia Polytechnic Institute and State University, 317 ICTAS, Stanger Street (0298), Blacksburg, VA 24061. E-mail address:
| | - Shawn A Hunter
- Department of Research and Development, Community Tissue Services, 2900 College Drive, Kettering, OH 45420. E-mail address:
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Clark JC, Rueff DE, Indelicato PA, Moser M. Primary ACL reconstruction using allograft tissue. Clin Sports Med 2009; 28:223-44, viii. [PMID: 19306732 DOI: 10.1016/j.csm.2008.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
While bone-patellar tendon-bone (BPTB) autograft continues to be the "gold standard" and most popular graft choice for primary anterior cruciate ligament (ACL) reconstructions, the use of allograft tissues in ACL reconstruction has steadily increased over the last 2 decades. Advantages of allograft include a lack of donor-site morbidity, unlimited available sizes, shorter operative times, availability of larger grafts, smaller incisions, improved cosmesis, lower incidence of postoperative arthrofibrosis, faster immediate postoperative recovery, and less postoperative pain. Disadvantages include the potential for disease transmission and prolonged graft healing. Presented in this article are 2 techniques used at the authors' institution for primary ACL reconstruction with allograft. With the proper indications, knowledge of graft preparation and handling, and technique, allograft tissues in ACL reconstructions can provide the surgeon with clinical results equal to those of autograft reconstructions.
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Affiliation(s)
- J C Clark
- University of Florida Orthopaedic and Sports Medicine Institute, PO Box 112727, Gainesville, FL 32611, USA.
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Scheffler SU, Gonnermann J, Kamp J, Przybilla D, Pruss A. Remodeling of ACL allografts is inhibited by peracetic acid sterilization. Clin Orthop Relat Res 2008; 466:1810-8. [PMID: 18491201 PMCID: PMC2584264 DOI: 10.1007/s11999-008-0288-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 04/23/2008] [Indexed: 01/31/2023]
Abstract
Sterilization of allografts for anterior cruciate ligament (ACL) reconstruction has become an important prerequisite to prevent disease transmission. However, current sterilization techniques impair the biological or mechanical properties of such treated grafts. Peracetic acid (PAA) has been successfully used to sterilize bone allografts without these disadvantages and does not impair the mechanical properties of soft tissue grafts in vitro. We asked whether PAA sterilization would influence recellularization, restoration of crimp length and pattern, and revascularization of ACL grafts during early healing. We used an in vivo sheep model for open ACL reconstruction. We also correlated the histologic findings with the restoration of anteroposterior stability and structural properties during load-to-failure testing. PAA slowed remodeling activity at 6 and 12 weeks compared to nonsterilized allografts and autografts. The mechanical properties of PAA grafts were also reduced compared to these control groups at both time points. We conclude PAA sterilization currently should not be used to sterilize soft tissue grafts typically used in ACL reconstruction.
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Affiliation(s)
- Sven U. Scheffler
- Sports Medicine & Arthroscopy Service, Department for Orthopaedic Surgery and Traumatology, Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Charité Platz 1, 10117 Berlin, Germany
| | - Johannes Gonnermann
- Sports Medicine & Arthroscopy Service, Department for Orthopaedic Surgery and Traumatology, Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Charité Platz 1, 10117 Berlin, Germany
| | - Julia Kamp
- Sports Medicine & Arthroscopy Service, Department for Orthopaedic Surgery and Traumatology, Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Charité Platz 1, 10117 Berlin, Germany
| | - Dorothea Przybilla
- Institute for Laboratory Medicine and Pathobiochemistry, Charité University Medicine Berlin, Berlin, Germany
| | - Axel Pruss
- Tissue Bank Institute of Transfusion Medicine, Charité University Medicine Berlin, Berlin, Germany
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Bach BR, Aadalen KJ, Dennis MG, Carreira DS, Bojchuk J, Hayden JK, Bush-Joseph CA. Primary anterior cruciate ligament reconstruction using fresh-frozen, nonirradiated patellar tendon allograft: minimum 2-year follow-up. Am J Sports Med 2005; 33:284-92. [PMID: 15701616 DOI: 10.1177/0363546504267347] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are conflicting reports of allograft performance, immune response, tissue incorporation, and rerupture rates when used for anterior cruciate ligament reconstruction. PURPOSE To evaluate the clinical outcome of a fresh-frozen, nonirradiated, patellar tendon allograft for primary anterior cruciate ligament reconstruction surgery. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent endoscopic primary anterior cruciate ligament reconstruction with allograft tissue a minimum of 2 years ago were evaluated with physical examinations, the KT-1000 arthrometer, functional testing, radiographic evaluation, subjective assessment, and outcomes tools. RESULTS Fifty-nine patients (60 knees) were evaluated at an average of 51 months after surgery. Ninety-four percent of patients were mostly or completely satisfied. A negative pivot shift test result was noted in 90% of subjects. The KT-1000 arthrometer side-to-side differences were < or =3 mm in 95% of patients, and no patient exceeded 5 mm. The mean International Knee Documentation Committee score was 78 (SD = 19), and the mean Lysholm score was 82 (SD = 17). There were no clinical symptoms consistent with graft rejection or infection. Radiographic evaluation demonstrated infrequent significant tunnel widening. CONCLUSIONS Use of a fresh-frozen, nonirradiated allograft for primary reconstruction of the anterior cruciate ligament is a successful procedure both subjectively and functionally for restoring stability in patients selected for allograft reconstruction. In the patients selected for this surgical procedure, clinical, arthrometric stability testing, and subjective satisfaction were comparable to our previously published cohort studies using patellar tendon autograft at similar postoperative follow-up.
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Affiliation(s)
- Bernard R Bach
- Section of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.
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Vargel I, Tunçbilek G, Mavili E, Cila A, Ruacan S, Benli K, Erk Y. Solvent-Dehydrated Calvarial Allografts in Craniofacial Surgery. Plast Reconstr Surg 2004; 114:298-306. [PMID: 15277792 DOI: 10.1097/01.prs.0000131983.48201.e2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Craniofacial surgery almost always requires the use of bone grafting. Although autografts are the standard procedure for bone grafting, it is sometimes not possible to harvest bone, and autografts have particular risks. The use of allograft bone provides a reasonable alternative to meet the need for graft material. Solvent dehydration is a multistage procedure in which human cadaveric bone is processed by osmotic exchange baths and gamma sterilization. This processing avoids the risk of infection transmission, decreases antigenicity, and does not weaken the mechanical properties of the bone. Solvent-dehydrated, gamma-irradiated human calvarial bone allografts were used for reconstruction of craniofacial deformities in 24 patients between 1988 and 2002. Resorption of the allografts and results of the surgical intervention were evaluated with plain radiographs and three-dimensional computed tomography 12 months after surgery, in 21 patients. Serologic tests for human immunodeficiency virus-1 antibody, hepatitis B surface antigen, and hepatitis C antigen were also performed. Biopsy specimens were taken from the allografts. Average follow-up in this group was 30 months (range, 8 to 60 months), and results of serologic tests were negative in all patients. Seventy-one percent of the patients (15 of 21) showed no resorption, with partial and complete allograft fusion. One patient had nearly total graft loss and the remaining five patients had 10 to 25 percent graft resorption. Rigid fixation of the allograft, contact with the dura and periosteum, and prevention of dead spaces around the allograft are the most important factors in achieving a satisfactory result. In solvent-dehydrated bone allografts, sterilization and antigenic tissue cleaning are achieved after several steps with a minimal dose of radiation. The result is a nonantigenic, sterile mechanical scaffold that can tolerate external forces. Although autografts are the standard in craniofacial surgery, solvent-dehydrated calvarial bone allografts produced successful results in selected cases.
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Affiliation(s)
- Ibrahim Vargel
- Department of Plastic and Reconstructive Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
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Vangsness CT, Garcia IA, Mills CR, Kainer MA, Roberts MR, Moore TM. Allograft transplantation in the knee: tissue regulation, procurement, processing, and sterilization. Am J Sports Med 2003; 31:474-81. [PMID: 12750147 DOI: 10.1177/03635465030310032701] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Use of musculoskeletal allografts has become increasingly popular, with widespread use among knee surgeons. The advantages and disadvantages of their use have been documented. In the knee, allografts are used for ligament reconstruction, meniscal transplantation, and articular surface reconstruction. The purpose of this review is to present issues surrounding the allograft industry, including regulation of tissues and tissue banks and procurement, processing, sterilization, and storage of allograft tissue. Tissue bank regulation is ultimately under the jurisdiction and authority of the Food and Drug Administration; some individual states regulate tissue banks. The American Association of Tissue Banks is a scientific organization that encourages education, research, and voluntary accreditation of tissue banks. It promotes safety and standards for retrieval, processing, storage, and distribution of transplantable human tissue. Allograft tissues are generally harvested and processed aseptically, which may not prevent contamination. Tissue sterilization is difficult and controversial. Tissue banks historically have used one of two methods of sterilization, ethylene oxide or gamma radiation. Both methods have risks and benefits. Newer methods of sterilization are being developed. Allograft tissue that is not transplanted fresh can be freeze-dried or deep frozen for storage. Ultimately, allograft transplantation in the knee facilitates knee form and function and enhances the patient's quality of life. Orthopaedic surgeons who use allograft tissue must understand the tissue banking process to provide safe and effective tissues to their patients.
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Affiliation(s)
- C Thomas Vangsness
- Department of Orthopaedic Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California 90033-4608, USA
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Harris NL, Indelicato PA, Bloomberg MS, Meister K, Wheeler DL. Radiographic and histologic analysis of the tibial tunnel after allograft anterior cruciate ligament reconstruction in goats. Am J Sports Med 2002; 30:368-73. [PMID: 12016077 DOI: 10.1177/03635465020300031101] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Several problems have been reported with use of allogenic grafts in anterior cruciate ligament reconstruction, including local immune response to allograft tendon within the synovial fluid, delayed maturation and ligamentization, and progressive tibial tunnel enlargement. HYPOTHESIS There is a correlation between the use of allograft and tibial tunnel enlargement. STUDY DESIGN Controlled laboratory study. METHODS Twenty healthy adult female goats underwent allograft anterior cruciate ligament reconstruction and were followed with serial radiographs at 6-week intervals. Animals were randomly chosen for sacrifice between 18 and 36 weeks for histologic assessment. RESULTS Significant radiographic increases in tunnel size were noted within the first 6 weeks of healing and remained up to 36 weeks with no further remodeling noted. Histologic analysis showed progressive ligamentization of the allografts with tendon-to-tunnel wall biologic fixation with dense connective tissue. Remodeling and incorporation of the bone plug was seen in all cases. The allograft tendon underwent early fibrous attachment within the tunnel and remodeled toward ligament histologic structure. Remodeling and incorporation of the bone plug was seen by 18 weeks. CONCLUSION Tibial tunnel enlargement, consistent with that seen in humans after allograft anterior cruciate ligament reconstruction, did not appear to affect the ultimate incorporation of the allograft on a histologic level.
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Affiliation(s)
- N Lindsay Harris
- Department of Orthopedics, Sports Medicine Clinic, University of Colorado Health Sciences Center, Denver, CO, USA
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Lomas RJ, Gillan HL, Matthews JB, Ingham E, Kearney JN. An evaluation of the capacity of differently prepared demineralised bone matrices (DBM) and toxic residuals of ethylene oxide (EtOx) to provoke an inflammatory response in vitro. Biomaterials 2001; 22:913-21. [PMID: 11311010 DOI: 10.1016/s0142-9612(00)00255-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Demineralised bone matrix (DBM) is a form of allogeneic tissue graft widely used in oral and maxillofacial procedures. There is a long history of controversy relating to the suitability of ethylene oxide gas (EtOx) as a terminal sterilisation agent for this graft, relating to its effects on the clinical performance of the grafts. Furthermore, the generation of a toxic residual chemical (ethylene chlorohydrin, ECl) during the ethylene oxide sterilisation of patellar tendon allografts has been implicated in the failure of these grafts owing to the induction of a localised inflammatory response. In this study we have investigated the capacity of a range of different DBM preparations, and ECl dilutions, to induce the production of three pro-inflammatory cytokines, interleukin-6 (IL-6), interleukin-1beta (IL-1beta), and tumour necrosis factor alpha (TNF-alpha) from human peripheral blood mononuclear cells (PBMNCs). The levels of EtOx and ECl in EtOx terminally sterilised DBM and mineralised bone grafts were measured by gas chromatography. It was found that the only factor capable of rendering DBM pro-inflammatory was the presence of small (<20 micrometre diameter) DBM particles. No other processing or sterilisation technique resulted in the DBM becoming pro-inflammatory. Although it was also found that DBM, when EtOx-sterilised, retained more ECI than mineralised bone grafts following a standard EtOx sterilisation protocol, ECl did not provoke an inflammatory response in vitro at levels up to and including those which are cytotoxic to PBMNCs.
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Affiliation(s)
- R J Lomas
- Yorkshire Regional Tissue Bank, National Blood Service, Pinderfields General Hospital, Wakefield, UK.
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Harner CD, Olson E, Irrgang JJ, Silverstein S, Fu FH, Silbey M. Allograft versus autograft anterior cruciate ligament reconstruction: 3- to 5-year outcome. Clin Orthop Relat Res 1996:134-44. [PMID: 8595749 DOI: 10.1097/00003086-199603000-00016] [Citation(s) in RCA: 225] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Sixty-four patients whose knees underwent anterior cruciate ligament reconstruction with nonirradiated allograft tissue were compared with 26 patients whose anterior cruciate ligaments were reconstructed using autograft tissue 3 to 5 years after their operation. Detailed symptoms, activity-level, and functional outcomes, physical examination, and instrumented knee testing were recorded. No statistically significant differences were found except a higher incidence of loss of terminal extension in the autograft group. These differences were small and not considered clinically significant. Laxity and knee scores were similar in both groups. According to International Knee Documentation Committee ratings, overall outcome was normal or nearly normal in 48% of the allograft patients and in 38% of the autograft patients. Overall subjective rating with the Cincinnati Knee Score was 85.8 for the allograft patients and 84.5 for the autograft patients. Allograft tissue provides an acceptable alternative to autograft tissue for reconstruction of the anterior cruciate ligament.
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Affiliation(s)
- C D Harner
- Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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