Clinical outcomes of autologous platelet-rich plasma and bone marrow mononuclear cells grafting combined with core decompression for Association Research Circulation Osseous II-IIIA stage non-traumatic osteonecrosis of the femoral head

PURPOSE

This study aimed to investigate the efficacy and safety of autologous platelet-rich plasma (PRP) and bone marrow mononuclear cells (BMMCs) grafting combined with core decompression (CD) in the treatment of Association Research Circulation Osseous (ARCO) II-IIIA stage non-traumatic osteonecrosis of the femoral head (ONFH).

METHODS

The clinical data of 44 patients (44 hips) with non-traumatic ONFH from December 2018 to December 2019 were retrospectively reviewed. Twenty-four patients underwent CD combined with autologous PRP and BMMCs grafting (PRP+BMMCs group), and 20 patients underwent core decompression alone (CD group). During a minimum follow-up of 36 months, radiographic outcomes were evaluated using X-ray, radiographic failure rates were compared, and Harris hip score (HHS) and visual analog scale (VAS) were selected to evaluate clinical outcomes. The percentage of patients with minimal clinically important difference (MCID) in both groups was analyzed. Clinical failure was defined as further total hip arthroplasty (THA) with Kaplan-Meier survival analysis. Surgical complications were recorded.

RESULTS

All patients had well healed wounds, and no complications such as infection and thrombosis occurred. HHS and VAS scores in both the PRP+BMMCs and CD groups were better than those preoperatively (P<0.05). At the last follow-up, the HHS and VAS scores of the PRP+BMMCs group were significantly better than those of the CD group (P<0.05). In ARCO II-IIIA stage, 66.7% of the PRP+BMMCs group and 30.0% of the CD group achieved the MCID (P<0.05). The clinical and imaging failure rates in the PRP+BMMCs group were 12.5% and 20.8%, respectively, compared with 40.0% and 50.0% in the CD group (P<0.05). In ARCO II stage, the MCID, clinical and imaging failure rates of PRP+BMMCs group and CD group were 66.7% and 33.3% (P<0.05), 4.8% and 33.3% (P<0.05), 14.3% and 44.4% (P<0.05), respectively. The PRP+BMMCs group had better hip survival rate compared with CD group (P<0.05).

CONCLUSION

CD combined with autologous PRP and BMMCs grafting is a safe and effective method for the treatment of ARCO II-IIIA stage non-traumatic ONFH, especially for ARCO II stage, effectively reducing the collapse rate of the femoral head and delaying or even avoiding THA.

Editorial Commentary: Biologic Stimulation Using Marrow Venting for Meniscus Repair is Cost Effective and Recommended

Current literature offers little guidance on the most cost-effective approach to intraoperative biologic stimulation in the setting of arthroscopic meniscus repair. Combining data from robust systematic reviews into a Markov Decision Making Model reveal the ideal strategy: Strong consideration should be given to biologic stimulation for all meniscal repairs, and the most cost effective technique is marrow stimulation.

Femoral Head Core Decompression and Bone Marrow Concentrate Injection in Pediatric Sickle-cell Related Avascular Necrosis

BACKGROUND

Femoral head avascular necrosis affects 10% to 40% of patients with sickle cell disease (SCD). The purpose of this study was to evaluate the results of femoral head core decompression and bone marrow aspirate concentrate (CD-BMAC) injection in pediatric patients with SCD.

METHODS

Eligible patients were enrolled in this retrospective study of patients undergoing CD-BMAC. Patients with SCD who were younger than 18 at the time of surgery and had >1 year of follow-up were included in this analysis. Hips were staged based on the Ficat system by 2 raters. The visual analog score for pain, hip outcome score, modified Harris hip score, and the University of California, Los Angeles activity score were used as patient-reported outcome measures preoperatively, at 5 to 9 months postoperatively, and final follow-up. Treatment failure was defined as total hip arthroplasty or visual analog score >3 at the final follow-up.

RESULTS

Twenty-three hips in 17 patients were included, with a median age at the time of surgery of 15.8 years (interquartile range: 13.1 to 17.8 y). Patients were followed for 4.25 ± 1.7 years. Ten hips showed a 1-stage increase in the Ficat stage at the final follow-up, whereas 11 retained the same stage, and 1 hip had a 1-stage regression. All patient-reported outcome measures showed significant improvement from the preoperative visit to short-term follow-up, but the preoperative to final follow-up improvement was not significant. Six treatment failures were recorded, including 3 total hip arthroplasties and 3 painful hips at the final follow-up. In a multivariate logistic regression model, only skeletal maturity (odds ratio = 16.2, 95% CI: 1.44-183.0, P = 0.024) and femoral head collapse (odds ratio = 12.0, 95% CI: 1.1-130.5, P = 0.041) were significant predictors of treatment failure.

CONCLUSIONS

In the largest study on pediatric SCD patients undergoing CD-BMAC, we found that CD-BMAC injection offers significant improvement in pain and functional outcomes in the short term, with a very low risk for complications. Skeletal maturity and femoral head collapse were significant predictors of treatment failure. Patients with a collapsed femoral head experienced functional deterioration over time after initial improvement, whereas precollapse hips maintained their functional improvement up to the latest follow-up.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Bone marrow stimulation for talar osteochondral lesions at long-term follow-up shows a high sports participation though a decrease in clinical outcomes over time

PURPOSE

Although bone marrow stimulation (BMS) as a treatment for osteochondral lesions of the talus (OCLT) shows high rates of sport resumption at short-term follow-up, it is unclear whether the sports activity is still possible at longer follow-up. The purpose of this study was, therefore, to evaluate sports activity after arthroscopic BMS at long-term follow-up.

METHODS

Sixty patients included in a previously published randomized-controlled trial were analyzed in the present study. All patients had undergone arthroscopic debridement and BMS for OCLT. Return to sports, level, and type were assessed in the first year post-operative and at final follow-up. Secondary outcome measures were assessed by standardized questionnaires with use of numeric rating scales for pain and satisfaction and the Foot and Ankle Outcome Score (FAOS).

RESULTS

The mean follow-up was 6.4 years (SD ± 1.1 years). The mean level of activity measured with the AAS was 6.2 pre-injury and 3.4 post-injury. It increased to 5.2 at 1 year after surgery and was 5.8 at final follow-up. At final follow-up, 54 patients (90%) participated in 16 different sports. Thirty-three patients (53%) indicated they returned to play sport at their pre-injury level. Twenty patients (33%) were not able to obtain their pre-injury level of sport because of ankle problems and eight other patients (13%) because of other reasons. Mean NRS for pain during rest was 2.7 pre-operative, 1.1 at 1 year, and 1.0 at final follow-up. Mean NRS during activity changed from 7.9 to 3.7 to 4.4, respectively. The FAOS scores improved at 1 year follow-up, but all subscores significantly decreased at final follow-up.

CONCLUSION

At long-term follow-up (mean 6.4 years) after BMS for OCLT, 90% of patients still participate in sports activities, of whom 53% at pre-injury level. The AAS of the patients participating in sports remains similar pre-injury and post-operatively at final follow-up. A decrease over time in clinical outcomes was, however, seen when the follow-up scores at 1 year post-operatively were compared with the final follow-up.

LEVEL OF EVIDENCE

Level II.

How Ancestry Influences the Chances of Finding Unrelated Donors: An Investigation in Admixed Brazilians

A match of HLA loci between patients and donors is critical for successful hematopoietic stem cell transplantation. However, the extreme polymorphism of HLA loci - an outcome of millions of years of natural selection - reduces the chances that two individuals will carry identical combinations of multilocus HLA genotypes. Further, HLA variability is not homogeneously distributed throughout the world: African populations on average have greater variability than non-Africans, reducing the chances that two unrelated African individuals are HLA identical. Here, we explore how self-identification (often equated with "ethnicity" or "race") and genetic ancestry are related to the chances of finding HLA compatible donors in a large sample from Brazil, a highly admixed country. We query REDOME, Brazil's Bone Marrow Registry, and investigate how different criteria for identifying ancestry influence the chances of finding a match. We find that individuals who self-identify as "Black" and "Mixed" on average have lower chances of finding matches than those who self-identify as "White" (up to 57% reduction). We next show that an individual's African genetic ancestry, estimated using molecular markers and quantified as the proportion of an individual's genome that traces its ancestry to Africa, is strongly associated with reduced chances of finding a match (up to 60% reduction). Finally, we document that the strongest reduction in chances of finding a match is associated with having an MHC region of exclusively African ancestry (up to 75% reduction). We apply our findings to a specific condition, for which there is a clinical indication for transplantation: sickle-cell disease. We show that the increased African ancestry in patients with this disease leads to reduced chances of finding a match, when compared to the remainder of the sample, without the condition. Our results underscore the influence of ancestry on chances of finding compatible HLA matches, and indicate that efforts guided to increasing the African component of registries are necessary.

Arthroscopic repair of horizontal cleavage meniscus tears provides good clinical outcomes in spite of poor meniscus healing

PURPOSE

The purpose of this study was to evaluate the clinical outcomes and meniscus healing after arthroscopic repair of horizontal-cleavage meniscus tears, compared with vertical-longitudinal meniscus tears.

METHODS

This was a retrospective review of a consecutive series of 52 meniscal repairs for horizontal-cleavage tears (n = 27) or vertical-longitudinal tears (n = 25); the groups were compared with respect to clinical symptoms and meniscal healing. Arthroscopic meniscal repair was performed using the inside-out technique with a marrow-stimulating technique. Clinical symptoms were evaluated using the Lysholm score and Knee injury and osteoarthritis outcome score (KOOS). Meniscus healing was evaluated by MRI.

RESULTS

The mean follow-up periods were 35.4 ± 8.9 months in the horizontal-cleavage tear group and 39.8 ± 8.3 months in the vertical-longitudinal tear group. There were no significant differences in Lysholm score and KOOS, including each subscale, between the horizontal-cleavage tear- and vertical-longitudinal tear-groups at the final follow-up. At the final follow-up, MRI meniscus grades 0 and 1 were significantly more frequent in the vertical-longitudinal tear-group than in the horizontal-cleavage tear-group, while grade 3 was significantly more frequent in the horizontal-cleavage tear group than in the vertical-longitudinal tear group (p < 0.0001).

CONCLUSIONS

Although meniscus healing of horizontal-cleavage tears may be poor, arthroscopic repair should be considered for horizontal-cleavage tears because it does provide good clinical outcomes.

LEVEL OF EVIDENCE

IV.

Intra-bone bone marrow transplantation from hCD47 transgenic pigs to baboons prolongs chimerism to >60 days and promotes increased porcine lung transplant survival

BACKGROUND

We have recently demonstrated that human-CD47 (hCD47) expressed on endothelial cells of porcine lung xenografts extended median graft survival from 3.5 days to 8.7 days in baboons. Intra-bone bone marrow transplantation (IBBMTx) in a pig-to-baboon model was previously shown to markedly prolong the duration of macrochimerism up to 21 days from 1 to 4 days by intravenous BMTx. We now examined whether the use of hCD47 transgenic (Tg) BM further prolonged the duration of chimerism following IBBMTx. We then tested if lung xenograft survival was prolonged following IBBMTx.

METHODS

Baboons received GalTKO-hCD47/hCD55Tg (n = 5) or -hCD55Tg (n = 1) or -hCD46/HLA-E Tg (n = 1) pig IBBMTx. Macrochimerism, anti-pig T cells and antibody responses were assessed. Animals received lung xenografts from either hCD47+ or hCD47- porcine lungs 1-3 months later.

RESULTS

All baboons that received hCD47Tg porcine IBBM maintained durable macrochimerism >30 days, and two maintained chimerism for >8 weeks. Notably, anti-pig antibody levels decreased over time and anti-pig cellular unresponsiveness developed following IBBMTx. Lungs from hCD47Tg IBBMTx matched pigs were transplanted at day 33 or day 49 after IBBMTx. These animals showed extended survival up to 13 and 14 days, while animals that received lungs from hCD47 negative pigs displayed no prolonged survival (1-4 days).

CONCLUSION

This is the first report demonstrating durable macrochimerism beyond 8 weeks, as well as evidence for B cell tolerance in large animal xenotransplantation. Using hCD47Tg pigs as both IBBMTx and lung donors prolongs lung xenograft survival. However, additional strategies are required to control the acute loss of lung xenografts.

High reported rate of return to play following bone marrow stimulation for osteochondral lesions of the talus

PURPOSE

The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return to play guidelines and subsequent rates and timing of return to play following bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT).

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched according to the PRISMA guidelines in September 2017. The rate and timing of return to play was assessed. The rehabilitation protocols were recorded, including time to start range of motion, partial weight-bearing and complete weight-bearing.

RESULTS

Fifty-seven studies with 3072 ankles were included, with a mean age of 36.9 years (range 23-56.8 years), and a mean follow-up of 46.0 months (range 1.5-141 months). The mean rate of return to play was 86.8% (range 60-100%), and the mean time to return to play was 4.5 months (range 3.5-5.9 months). There was large variability in the reported rehabilitation protocols. Range of motion exercises were most often allowed to begin in the first week (46.2%), and second week postoperatively (23.1%). The most commonly reported time to start partial weight-bearing was the first week (38.8%), and the most frequently reported time of commencing full weight-bearing was 6 weeks (28.8%). Surgeons most often allowed return to play at 4 months (37.5%).

CONCLUSIONS

There is a high rate of return following BMS for OLT with 86.8% and the mean time to return to play was 4.5 months. There is also a significant deficiency in reported rehabilitation protocols, and poor quality reporting in return to play criteria. Early weightbearing and early postoperative range of motion exercises appear to be advantageous in accelerated return to sports.

LEVEL OF EVIDENCE

Level IV.

Mesenchymal stem and progenitor cells of rats' bone marrow under chronic action of ionizing radiation

Under the influence of ionizing radiation on hematopoietic system, the level of its injury is determined not only by the radiosensitivity of hematopoietic stem cells, but also by radiation induced changes in microenvironment func tioning, in particular, mesenchymal stem cells as its components.

OBJECTIVE

to define functioning characteristics of mesenchymal stem and progenitor cells of rats' bone marrow under prolonged action of ionizing radiation as a result of 90Sr incorporation.

MATERIALS AND METHODS

We applied the model of Wistar rats' internal irradiation with 90Sr radionuclide and per formed the in vitro cultivation of their bone marrow mesenchymal cells. Colony forming efficiency in the in vitro cell culture was determined, as well as the possibility of these cells to form feeder layers and to support rat bone mar row hematopoietic cells in the culture of diffusion chambers in vitro.

RESULTS AND CONCLUSIONS

We established that chronic action of incorporated 90Sr radionuclide induced considerable decrease in proliferative activity of mesenchymal stem cells comparing to control, as well as the inhibition of the capability to prolonged support of hematopoietic processes in vitro by their feeder layers.Thus, bone marrow mesenchymal stem cells and their closest progeny - progenitor cells were characterized by rather high radiosensitivity under the influence of ionizing radiation, which was revealed in considerable decline of their functional activity in cell culture in vitro comparing to control indices as a result of irradiation.

Human Cord Blood-Derived Mesenchymal Stem Cells Home and Survive in the Marrow of Immunodeficient Mice after Systemic Infusion

Bone marrow is the residence site of mesenchymal stem cells (MSC), which upon commitment and maturation develop into several mesenchymal phenotypes. Recently, we have described the presence of MSC in human cord blood (cbMSC) and informed that their properties are the same as those for MSC obtained from adult bone marrow. In this study we have investigated the capability of transplanted cbMSC to home and survive in the marrow of unconditioned nude mice. cbMSC utilized for transplantation studies were characterized by morphology, differentiation potential, and immunophenotype. After transplantation by systemic infusion, human DNA (as detected by PCR amplification of human-specific β-globin gene) was detected in the marrow of recipients as well as in ex vivo-expanded stromal cells prepared from the marrow of transplanted animals. These results demonstrate homing and survival of cbMSC into the recipient marrow and also suggest a mesenchymal-orientated fate of engrafted cells, because human DNA was also detected in cells of other recipient tissues, like cardiac muscle, teeth, and spleen.

PET/CT Scanner and Bone Marrow Biopsy in Detection of Bone Marrow Involvement in Diffuse Large B-Cell Lymphoma

Evaluation of bone marrow involvement (BMI) is paramount in diffuse large B-cell lymphoma (DLBCL) for prognostic and therapeutic reasons. PET/CT scanner (PET) is now a routine examination for the staging of DLBCL with prognostic and therapeutic implications. This study evaluates the role of PET for detecting marrow involvement compared to bone marrow biopsy (BMB). This monocentric study included 54 patients diagnosed with DLBCL between 2009 and 2013 and who had FDG PET/CT in a pre-treatment setting. A correlation analysis of the detection of BMI by PET and BMB was performed. A prognostic evaluation of BMI by BMB and/or PET/CT and correlation with an overall 2-year survival were analyzed. PET was more sensitive for the detection of BMI than BMB (92.3% vs. 38.5%). It can be considered a discriminatory Pre-BMB test with a negative predictive value of 97.6%. In addition, BMI by PET had a prognostic value with strong correlation with progression-free survival (PFS) (HR = 3.81; p = 0.013) and overall survival (OS) (HR = 4.12; p = 0.03) while the BMB had not. PET shows superior performance to the BMB for the detection of marrow involvement in DLBCL. It may be considered as the first line examination of bone marrow instead of the biopsy.

Sequential CCR5-Tropic HIV-1 Reactivation from Distinct Cellular Reservoirs following Perturbation of Elite Control

Background

HIV Elite Controllers may reveal insights into virus persistence given they harbour small reservoir sizes, akin to HIV non-controllers treated early with combination antiretroviral therapy. Both groups of patients represent the most promising candidates for interventions aimed at sustained remission or ‘cure’. Analytic treatment interruption (ATI) in the latter group leads to stochastic rebound of virus, though it is unclear whether loss of elite control is also associated with similar rebound characteristics.

Methods

We studied three discrete periods of virus rebound during myeloma related immune disruption over 2.5 years in an elite controller who previously underwent autologous stem cell transplantation (ASCT) in the absence of any antiretroviral therapy. Single genome sequencing of the V1-V4 region of env in PBMC and plasma was performed and phylogenies reconstructed. Average pairwise distance (APD) was calculated and non-parametric methods used to assess compartmentalisation. Coreceptor usage was predicted based on genotypic algorithms.

Results

122 single genome sequences were obtained (median 26 sequences per rebound). The initial rebounding plasma env sequences following ASCT represented two distinct lineages, and clustered with proviral DNA sequences isolated prior to ASCT. One of the lineages was monophyletic, possibly indicating reactivation from clonally expanded cells. The second rebound occurred 470 days after spontaneous control of the first rebound and was phylogenetically distinct from the first, confirmed by compartmentalisation analysis, with a different cellular origin rather than ongoing replication. By contrast, third rebound viruses clustered with second rebound viruses, with evidence for ongoing evolution that was associated with lymphopenia and myeloma progression. Following ASCT a shift in tropism from CXCR4-tropic viruses to a CCR5-tropic population was observed to persist through to the third rebound.

Conclusions

Our data highlight similarities in the viral reservoir between elite and non-controllers undergoing ATI following allogeneic transplantation. The lack of propagation of CXCR4 using viruses following transplantation warrants further study.

Bone marrow ablation demonstrates that estrogen plays an important role in osteogenesis and bone turnover via an antioxidative mechanism

To assess the effect of estrogen deficiency on osteogenesis and bone turnover in vivo, 8-week-old mice were sham-operated or bilaterally ovariectomized (OVX), and after 8 weeks, mechanical bone marrow ablation (BMX) was performed and newly formed bone tissue was analyzed from 6 days to 2 weeks after BMX. Our results demonstrated that OVX mice following BMX displayed 2 reversed phase changes, one phase observed at 6 and 8 days after BMX delayed osteogenesis accompanied by a delay in osteoclastogenesis, and the other phase observed at 12 and 14 days after BMX increased osteoblastic activity and osteoclastic activity. Furthermore, we asked whether impaired osteogenesis caused by estrogen deficiency was associated with increased oxidative stress, and oxidative stress parameters were examined in bone tissue from sham-operated and OVX mice and OVX mice were administrated with antioxidant N-acetyl-l-cysteine (NAC) or vehicle after BMX. Results demonstrated that estrogen deficiency induced oxidative stress in mouse bone tissue with reduced antioxidase levels and activity, whereas NAC administration almost rescued the abnormalities in osteogenesis and bone turnover caused by OVX. Results from this study indicate that estrogen deficiency resulted in primarily impaired osteogenesis and subsequently accelerated bone turnover by increasing oxidative stress and oxidative stress promises to be an effective target in the process of treatment of postmenopausal osteoporosis.

Overview of biological mechanisms and applications of three murine models of bone repair: closed fracture with intramedullary fixation, distraction osteogenesis, and marrow ablation by reaming

Fractures are one of the most common large-organ, traumatic injuries in humans, and osteoporosis-related fractures are the fastest growing health care problem of aging. Elective orthopedic surgeries of the bones and joints also represent some of most common forms of elective surgeries performed. Optimal repair of skeletal tissues is necessary for successful outcomes of these many different orthopedic surgical treatments. Research focused on post-natal skeletal repair is therefore of immense clinical importance and of particular relevance in situations in which bone tissue healing is compromised due to the extent of tissue trauma or specific medical co-morbidities. Three commonly used murine surgical models of bone healing, closed fracture with intramedullary fixation, distraction osteogenesis (DO), and marrow ablation by reaming, are presented. The biological aspects of these models are contrasted and the types of research questions that may be addressed with these models are presented.

Engineering bone grafts with enhanced bone marrow and native scaffolds

The translation of tissue engineering approaches to the clinic has been hampered by the inability to find suitable multipotent cell sources requiring minimal in vitro expansion. Enhanced bone marrow (eBM), which is obtained by reaming long bone medullary canals and isolating the solid marrow putty, has large quantities of stem cells and demonstrates significant potential to regenerate bone tissues. eBM, however, cannot impart immediate load-bearing mechanical integrity or maintain the gross anatomical structure to guide bone healing. Yet, its putty-like consistency creates a challenge for obtaining the uniform seeding necessary to effectively combine it with porous scaffolds. In this study, we examined the potential for combining eBM with mechanically strong, osteoinductive trabecular bone scaffolds for bone regeneration by creating channels into scaffolds for seeding the eBM. eBM was extracted from the femurs of adult Yorkshire pigs using a Synthes reamer-irrigator-aspirator device, analyzed histologically, and digested to extract cells and characterize their differentiation potential. To evaluate bone tissue formation, eBM was seeded into the channels in collagen-coated or noncoated scaffolds, cultured in osteogenic conditions for 4 weeks, harvested and assessed for tissue distribution and bone formation. Our data demonstrates that eBM is a heterogenous tissue containing multipotent cell populations. Furthermore, coating scaffolds with a collagen hydrogel significantly enhanced cellular migration, promoted uniform tissue development and increased bone mineral deposition. These findings suggest the potential for generating customized autologous bone grafts for treating critical-sized bone defects by combining a readily available eBM cell source with decellularized trabecular bone scaffolds.

Planned labial plate advancement with simultaneous single implant placement for narrow anterior ridges followed by reentry confirmation

This article reports on the efficacy of a technique involving expansion of edentulous ridges of less than 3 mm in width by means of a planned green stick fracture of the labial plate and simultaneous implant placement without the need for membranes. This retrospective case series includes long-term results from 21 patients with 36 sites and 37 implants with a mean follow-up of 4 years, 5 months from the date of restoration. Freeze-dried bone allograft was used in 22 sites (61%) to augment the ridge. Reentry at stage-two surgery confirmed the preservation of the displaced labial plate after implant integration. Three implants were removed prior to the planned uncovering because of incomplete healing of the overlying gingival tissue; therefore, the survival rate of the labial advancement was 92%. No implants failed after definitive prosthetic loading; therefore, the cumulative survival rate of loaded implants was 100%. No significant bone loss was detected at the final follow-up visit. Follow-up after loading ranged from 9 to 148 months. Advancement of the labial plate with simultaneous implant placement to gain horizontal ridge width dimension was shown to be a reliable and practical procedure for single-tooth sites where other grafting methods are often difficult.

Pain in pediatric oncology - children's and parents' perspectives

There is a lack of valid epidemiological data on malignancy-associated pain in modern pediatric oncology. Pediatric oncology patients (self-assessment) and their parents from 28 hospitals were questioned using age-adapted, structured interviews and validated pain assessment tools. Pain intensity was measured by the NRS and Bieri faces scale. We conducted 363 interviews with patients and their parents, and 46 with the parents alone (if patients <2.5 years). Pain was reported at the time of the interview or within the last 24 h, 7 d, or 4 weeks in 15%, 28%, 50% and 58% of cases, respectively. The proportion of patients suffering severe to maximal pain (NRS>3; Bieri>2) increased significantly (p=0.001, chi2 test). The median pain intensity for the most severe pain episode within the last 4 weeks was 6.7 (NRS 0-10). Adverse effects of anti-tumor therapy were the most frequent cause of pain. Multivariate analyses depicted general physical condition either "severely reduced" (ASA status 3) (OR 4.0, 95% CI 1.1-14.7, p=0.037) or "moderately reduced" (ASA status 2) (OR 1.8, 95% CI 1.1-2.9, p=0.018), "in-patient status" (OR 1.8, 95% CI 1.2-2.9, p=0.010), and "co-morbidity present" (OR 3.5, 95% CI 1.1-10.7, p=0.030) as risk factors for severe to maximal pain. General anesthesia was the only factor significantly (OR 0.14, 95% CI 0.05-0.39, p<0.01) associated with a reduction in the proportion of patients suffering severe to maximal pain during bone marrow aspiration. Our data emphasize both the importance of in-house acute pain control and the need for general anesthesia during painful procedures in pediatric oncology.

Autologous bone marrow stem cell transplant in acute myocardial infarction

OBJECTIVE

To evaluate the effects of autologous bone marrow stem cell transplant on clinical symptoms, overall left ventricle ejection fraction and myocardial perfusion in patients with recent anterior myocardial infarction in left anterior descending artery territory.

METHODS

The study was conducted in the department of interventional cardiology of Armed Forces Institute of Cardiology, National Institute of Heart Diseases (AFIC/NIHD), Rawalpindi from June 2004 to November 2006. There were 26 male patients with recent anterior myocardial infarction, having anterior/apical hypokinesia and disease process involving only left anterior descending artery, who were recruited. The whole procedure was explained to the patients in the language of their best understanding and informed consent was obtained. Stem cell harvest was obtained from both posterior superior iliac crests, which were processed to note total and mean mononuclear cell counts. Stem cells were transplanted into the damaged myocardium using stop flow technique through lumen of over-the-wire balloon catheter, placed in mid left anterior descending artery. All patients tolerated the procedure well except for a few complications which were tackled by the experienced operators. The patients were advised to continue conventional medical therapy. The efficacy of stem cell transplant was objectively assessed by comparing effects on three parameters--clinical, left ventricle cineangiographic, and nuclear scintigraphic status--at baseline and at 12 weeks after transplantation.

RESULTS

There is improvement in general well being, left ventricle ejection fraction and myocardial perfusion after stem cell therapy.

CONCLUSION

Autologous bone marrow stem cell transplant seems to be a favourable and secure way of treatment for improvement of post-myocardial infarction ejection fraction and perfusion. There is dire need to conduct larger randomised controlled trials to assess efficacy of this cost-effective mode of therapy, especially in our part of the world.

Comparison of bone marrow aspiration at the sternum and the tuber coxae in middle-aged horses

The objective of this study was to compare bone marrow (BM) aspirates from the sternum and the tuber coxae of middle-aged horses. Bone marrow was obtained from the sternum and both tubera coxae of 12 healthy, 13-year-old geldings. Two different puncture techniques were used for the tuber coxae. The 2 syringes used for sternal sampling were evaluated separately. The mononuclear cell (MNC) fraction of the BM was isolated and the mesenchymal stem cells (MSCs) were culture-expanded. At the sternum, BM aspiration was always possible. Bone marrow aspiration at the tuber coxae required straight and deep needle penetration combined with high negative pressure. With this technique a median sample amount of 11.0 mL with large individual variation was obtained. A median of 3.06 × 10(6) MNC/mL BM (1st syringe) and 2.46 × 10(6) MNC/mL BM (2nd syringe) was isolated from sternal samples. In contrast, the tuber coxae yielded a median of 0.27 × 10(6) MNC/mL BM. The first passage yielded a median of 2.19 × 10(6) MSC (1st syringe) and 1.13 × 10(6) MSC (2nd syringe) from sternal samples, compared to a significantly lower median number of MSC from tuber coxae BM (0.06 × 10(6) MSC). The number of MNC and MSC obtainable from the BM aspirates taken from the tuber coxae is significantly lower than that obtained from the sternal BM aspirates. Autologous BM for the equine athlete is particularly clinically relevant at an advanced age. Based on our findings, the tuber coxae cannot be recommended for BM aspiration in middle-aged horses.

Two-year outcome of hydroxyapatite mixed with autogenous bone marrow and local bone graft for posterolateral lumbar fusion

OBJECTIVE

To determine the outcome of hydroxyapatite (HA) mixed with autogenous bone marrow (BM) and local bone graft in posterolateral lumbar fusion.

MATERIAL AND METHOD

Twenty-three patients who had posterolateral fusion with posterior instrument using HA mixed with BM and local bone graft between December 2003 and August 2005 were prospective analyzed. Degree of pain using visual analog scale (VAS) was evaluated at preoperative and 2, 4, 6, 9, 12, and 24 postoperative months. Radiographs were assessed for spinal fusion at 4, 6, 9, 12, and 24 postoperative months.

RESULTS

The improvement of pain was demonstrated in all patients postoperatively. Radiographic outcomes revealed solid and doubtful fusion in one of 23 patients (4.3%) and 13 of 23 patients (56.5%) at six months respectively. After two-year follow-up, one patient had solid fusion while 22 patients (95.6%) had doubtful fusion.

CONCLUSION

Despite the posterolateral lumbar fusion using HA mixed with BM and local bone graft provided good clinical results, the radiographic results of spinal fusion were questionable in most cases.

Bone marrow cavity: a supportive environment for islet engraftment

An important goal in advancing islet transplantation for the treatment for type 1 diabetes, is to discover transplantation sites that promote long-term islet engraftment. Here, we investigate the bone marrow cavity in rats as a potential site for islet transplantation. Dark agouti streptozotocin diabetic recipients received DA islets to one of three sites: to the renal subcapsular, intrahepatic or bone marrow cavity site. Assessment of graft function was made by measuring blood glucose concentrations using a wireless continuous glucose monitoring system (CGM), performing a glucose tolerance test (GTT), and histological analysis. To determine if bone tissue secretes factors supportive to islet function and survival, human islets were cultured in the presence of osteoblast conditioned medium. Gene expression, insulin secretion and content were assessed in islets after culture. All transplant recipients with islets transplanted to the bone marrow cavity site had reversal of hyperglycemia and remained diabetes free until the end of the experiment at four months. Mean blood glucose concentrations, glucose variability and GTT, using CGM in recipients, yielded similar results between all transplantation sites. Histological assessments at four months after transplantation showed viable islets within the bone marrow space. Incubation of human islets in the presence of osteoblast conditioned medium resulted in positive changes in gene expression, insulin secretion and content. These positive changes were mediated by osteocalcin which was present in the conditioned medium. In summary, islets transplanted to the bone marrow cavity in diabetic rats showed good engraftment. In addition, the bone marrow cavity may provide an environment that is protective against post-transplant cellular stress thus increasing the chances of long-term islet function and survival.

The effect of intramedullary bone endoscopy on the endosteal blood supply in long bones. An experimental study in sheep

This study investigated whether the Intramedullary Bone Endoscopy (IBE) procedure within the cavity of an intact long bone will interfere with the local endosteal blood supply. In a sheep model, 10 animals underwent the IBE procedure with complete perioperative anaesthesiology monitoring. After the femora were harvested, histological analysis was performed to examine destruction of the endosteum and consecutive reduction in perfusion. Only one animal showed evidence of detachment of the endosteum with destruction of several microns of the endosteum, although this did not interfere with the cortical perfusion. None of the vessels were occluded by fat or other causes of occlusion, e.g. blood coagulation. Our findings indicate that with the IBE procedure under visual control there is a potential risk to damage the endosteum. However, the interference was limited to a small part of the endosteum and did not lead to a reduction in the cortical perfusion. Clinical use could be in localized intramedullary lesions such as osteomyelitis or benign bone tumours.

Caspase inhibitor ZVAD-fmk facilitates engraftment of donor hematopoietic stem cells in intra-bone marrow-bone marrow transplantation

When bone marrow transplantation (BMT) is carried out, survival of the donor hematopoietic stem cells is crucial to maintain donor hematopoiesis in the recipients. We have shown that intra-bone marrow-bone marrow transplantation (IBM-BMT) can induce the rapid recovery of donor hematopoiesis and allow a reduction in radiation doses as a pretreatment for BMT. If IBM-BMT methodology can be further improved, BMT could be carried out more safely and more easily. In this experiment, we attempted to suppress apoptosis of donor hematopoietic cells using a caspase inhibitor, ZVAD-fmk, upon IBM-BMT in mouse allogeneic IBM-BMT. IBM-BMT with ZVAD-fmk induced superior engraftment of donor hematopoietic cells and greater numbers of day-12 colony-forming units of spleen (CFU-S) than IBM-BMT without ZVAD-fmk upon allogeneic BMT (C57BL/6 into BALB/c mice). ZVAD-fmk slightly suppressed apoptosis of whole BMCs, whereas it significantly suppressed apoptosis of c-kit+/Sca-1+/lineage(-) cells (KSL cells) in vitro. These results suggest that ZVAD-fmk can suppress apoptosis of hematopoietic stem cells and/or immature progenitor cells of the donor bone marrow cells, thereby accelerating the donor hematopoiesis.

The role of the donor in the repair of the marrow vascular niche following hematopoietic stem cell transplant

Bone marrow sinusoids maintain homeostasis between developing hematopoietic cells and the circulation, and they provide niches for hematopoietic progenitors. Sinusoids are damaged by chemotherapy and radiation. Hematopoietic stem cells (HSCs) have been shown to produce endothelial progenitor cells that contribute to the repair of damaged blood vessels. Because HSCs home to the marrow during bone marrow transplant, these cells may play a role in repair of marrow sinusoids. Here, we explore the role of donor HSCs in the repair of damaged sinusoids following hematopoietic stem cell transplant. We used three methods to test this role: (a) expression of platelet endothelial cell adhesion molecule to identify endothelial progenitors and the presence of the Y chromosome to identify male donor cells in female recipients; (b) presence of the Y chromosome to identify male donor cells in female recipients, and expression of the panendothelial marker mouse endothelial cell antigen-32 to identify sinusoidal endothelium; and (c) use of Tie-2/green fluorescent protein mice as donors or recipients and presence of Dil-Ac-LDL to identify sinusoids. We found that sinusoids were predominantly host-derived posttransplant. Donor cells spread along the marrow vasculature early post-transplant in a pattern that matched stromal-derived factor-1 expression. Furthermore, these engrafting progenitors were positioned to provide physical support, as well as growth and survival signals in the form of vascular-endothelial growth factor-A. Occasionally, donor cells provide cellular "patches" in the damaged sinusoids, although this occurred at a low level compared with hematopoietic engraftment. Donor support for the repair of the marrow vascular niche may be a critical first step of hematopoietic engraftment.

Isolated juvenile xanthogranuloma in the bone marrow: report of a case and review of the literature

We report a case of juvenile xanthogranuloma limited to involvement of the bone marrow in a 6-week-old male infant. Evaluation of the bone marrow was a part of the workup for peripheral blood cytopenia. Examination showed hypercellular marrow with paratrabecular clusters of lipidized histiocytes positive for CD68, CD4, and factor XIII(a) and negative for S100 and CD1a. Clinical and radiological workup showed no associated skin lesions or osseous or visceral involvement. The patient was started on chemotherapy with clinical improvement and gradual decreased bone marrow involvement. The child is alive and well at 16 months of age. This case represents, to the best of our knowledge, the 1st documented case of juvenile xanthogranuloma with isolated bone marrow involvement sparing skin and viscera.

CD5-positive B-cell acute lymphoblastic leukemia

CD5-positive B-cell acute lymphoblastic leukemia (ALL) is an exceedingly rare entity, with only a single case report in the literature. We report 2 additional cases of CD5-positive B-cell ALL in a 16-year-old male and a 15-year-old female. The 1st case was initially misdiagnosed as Ewing sarcoma due to a lack of CD45 expression and weak expression of CD99. Cytogenetic analysis of the 2nd case revealed trisomy 22, the 1st time this finding has been reported in ALL. Both patients had poor outcomes, as did the patient in the previously published case report. We conclude that CD5-positive B-cell ALL is a rare, aggressive malignancy with a poor prognosis that presents in adolescence. Pathologists and clinicians should be aware of this entity to avoid confusion with other small blue-cell tumors.

The role of cement viscosity on cement-bone apposition and strength: an in vitro model with medullary bleeding

We compared the mechanical and morphological characteristics of cement-bone structures created with either standard- or low-viscosity cement using a human cadaver model that simulated intramedullary bleeding. The goal is to determine if the viscosity of the cement would affect the strength of the cement-bone interface and the degree of apposition between the cement and bone. The tensile strength of cement-bone constructs with standard-viscosity cement (2.42 +/- 1.55 MPa) was 21% stronger than with low-viscosity cement (2.00 +/- 1.51 MPa, P = .034). Cement-bone apposition was positively correlated (r2 = 0.29, P <. 0001) with the strength of the interface. There was 15% greater apposition between cement and bone (P = .036) for standard-viscosity cement. Low-viscosity cement may be less effective in displacing bone marrow and in preventing hemodynamic backflow, resulting in less apposition and a weaker interface.

Crucial role of SDF-1/CXCR4 interaction in the recruitment of transplanted dermal multipotent cells to sublethally irradiated bone marrow

Our previous study indicated that dermal multipotent cells (DMCs) could engraft into bone morrow (BM) of rats with sublethal irradiation and promote hematopoietic recovery after being transplanted systemically, but the mechanisms determining the recruitment of DMCs to the irradiation injured BM remain unclear. In the present study, we investigated the role of stromal cellderived factor-1 (SDF-1)/CXCR4 interaction in this process. Male DMCs were isolated and transplanted into female rats systemically, and by employing quantitative real-time TaqMan polymerase chain reaction for the sex-determining region of Y chromosome, it was found that the amount of DMCs in BM of rats with sublethal irradiation was about 3 times more than that of normal rats (P < 0.01). Incubation of DMCs with AMD3100 before transplantation, which specifically blocks binding of SDF-1 to its endogenous receptor CXCR4, diminished recruitment of DMCs to the injured BM by 57.2 +/- 5.5% (P < 0.05). In addition, it was confirmed that the expression of SDF-1 in injured BM was up-regulated when compared with that in normal BM, and in vitro analysis revealed that BM extracts from irradiated rats had a strong chemotactic effect on DMCs, which decreased significantly when DMCs were pre-incubated with AMD3100 (P < 0.05). These data suggest that transplanted DMCs were recruited more frequently to irradiation-injured BM than normal BM and the interactions of SDF-1/CXCR4 played an important role in this process.

High dose glucocorticoid hampers bone formation and resorption after bone marrow ablation in rat

We analyzed the effect of glucocorticoid on bone regeneration after bone marrow ablation in tibiae of 8-week-old rats. Methylprednisolone sodium succinate (MPSS) was injected intramuscularly at a dose of 100 mg/kg/day for 3 days. Tibiae on days 1, 3, 5, 7, 10, 12, and 14 after ablation were subjected to tartrate-resistant acid phosphatase staining, immunohistochemistry, in situ hybridization, and transmission electron microscopy (TEM), and measurement of the volume of newly-formed bone and the osteoclast number. MPSS significantly decreased the newly-formed bone volume on day 7, and immature bone still remained on day 10 in the MPSS-treated group. The volume of this bone was significantly higher than that in the control group. However, there were no differences between the groups in the osteoclast number, the expression of mRNAs for osteoblast differentiation markers, and alkaline phosphatase and cathepsin K judged by immunohistochemistry. TEM findings showed no difference in the form of osteoblasts, whereas osteoclasts in the MPSS-treated group had less developed ruffled borders, compared to those in the control group. These results suggest that MPSS treatment affects neither the differentiation nor the shape of osteoblasts, and does not change the osteoclast number or the cathepsin K level. However, high dose MPSS inhibits both bone formation and resorption during bone regeneration after rat tibial bone marrow ablation, and inhibits ruffled border formation in osteoclasts. These data will be useful to develop bone regenerative therapies for bone diseases due to high dose steroid administration.

Surgical bone marrow aspiration in Aotus lemurinus griseimembra

Aotus lemurinus griseimembra are highly susceptible to infection by human malaria parasites and reproduce some of its clinical manifestations, including anemia. We developed a new surgical technique to obtain bone marrow samples from Aotus by surgical aspiration of the femur. First, we determined that the femur offered advantages over other bones, primarily due to lower fracture vulnerability. We tested a surgical technique using 20 G IV catheters in formaldehyde-preserved animals, then conducted the procedure on 27 live animals. This technique provided easy, quick surgical access to adequate volumes of bone marrow and was safe for almost all animals: only one died; another developed nervous impairment of the lower limb. Adequate cell samples were obtained in all animals and allowed cytological studies. This procedure offers a useful tool for bone marrow research in Aotus and helps overcome current limitations of such research in human where these studies are limited by ethical and technical issues.

Destiny of autologous bone marrow-derived stromal cells implanted in the vocal fold

OBJECTIVES

The aim of this study was to investigate the destiny of implanted autologous bone marrow-derived stromal cells (BSCs) containing mesenchymal stem cells. We previously reported the successful regeneration of an injured vocal fold through implantation of BSCs in a canine model. However, the fate of the implanted BSCs was not examined. In this study, implanted BSCs were traced in order to determine the type of tissues resulting at the injected site of the vocal fold.

METHODS

After harvest of bone marrow from the femurs of green fluorescent transgenic mice, adherent cells were cultured and selectively amplified. By means of a fluorescence-activated cell sorter, it was confirmed that some cells were strongly positive for mesenchymal stem cell markers, including CD29, CD44, CD49e, and Sca-1. These cells were then injected into the injured vocal fold of a nude rat. Immunohistologic examination of the resected vocal folds was performed 8 weeks after treatment.

RESULTS

The implanted cells were alive in the host tissues and showed positive expression for keratin and desmin, markers for epithelial tissue and muscle, respectively. The implanted BSCs differentiated into more than one tissue type in vivo.

CONCLUSIONS

Cell-based tissue engineering using BSCs may improve the quality of the healing process in vocal fold injuries.

Full-thickness flap/subepithelial connective tissue grafting with intramarrow penetrations: three case reports of lingual root coverage

Three case reports are presented that demonstrate the use of full-thickness flap/subepithelial connective tissue grafting for root coverage on the lingual surfaces of the mandibular anterior teeth. This is accomplished using an envelope full-thickness flap technique with intramarrow penetrations at the recipient site. Miller Class I, II, and III gingival recession defects and gingival perforation defects were treated. Complete root coverage was achieved in two Miller Class I gingival recession defects, in one Miller Class II gingival recession defect, and in two gingival perforation defects in areas that exhibited no radiographic evidence of bone loss. Partial root coverage was achieved in two Miller Class III gingival recession defects in an area that exhibited radiographic evidence of bone loss. Although the majority of the exposed root surface was covered in these two Miller Class III defects, about 1 mm of root surface remained exposed, which seemed to closely correspond to the amount of bone loss that was noted radiographically. A grafting technique has been presented that can be used to restore the functional properties of the lingual gingiva of the mandibular anterior teeth by repairing gingival defects and re-establishing the continuity and integrity of the zone of keratinized gingiva. Our clinical impression is that this has made it easier for the three patients presented in this report to maintain the lingual surfaces of the mandibular anterior teeth with routine oral hygiene measures.

Two-month ciprofloxacin implants for multibacterial bone infections

A ciprofloxacin implant formulation composed of 12% hydroxyapatite, 36% tricalcium phosphate, 12% poly(DL-lactide) (PLA) and 40% ciprofloxacin was characterized in vivo for use in treatment of multibacterial bone infection. After the implant was inserted in the femur of rabbits, approximately 90% of the total ciprofloxacin was released within 8 weeks, maintaining therapeutic levels in the femur and tibia. Throughout the femoral cortex and marrow these remained higher than the minimum inhibitory concentrations (MIC) against the most common pathogens causing osteomyelitis. Levels in tibia cortex were also above MIC for 6 weeks. The implant was characterized in terms of polymer degradation and morphological and crystallographic changes. X-ray analyses confirmed the osteoconductivity and biocompatibility of these materials. The sequential changes in the femur were those of a normal surgical trauma reaction followed by a repair process. All the results confirmed that ciprofloxacin release is limited by its low solubility, and that implant erosion and bone ingrowth into the implants enhance the antibiotic release.

Prevention of amputation caused by rheumatic diseases following a novel therapy of exposing bone marrow, occlusive dressing and subsequent epidermal grafting

BACKGROUND

Wounds with exposed bones caused by rheumatic diseases commonly result in amputation despite progress in our understanding of wound-healing mechanisms.

OBJECTIVES

To determine whether an experimental therapy of bone marrow exposure, an occlusive dressing and subsequent grafting of epidermal sheets accelerates healing and reduces the need for amputation in patients with rheumatic diseases.

METHODS

Fifteen patients, including those with rheumatoid arthritis or systemic sclerosis, who had wounds with exposed bones were treated either with the standard procedure, consisting of local wound care, debridement with a scalpel, bed rest and parenteral antibiotics (n = 8), or with a newly developed experimental procedure (n = 7). In that new procedure, the affected bone was initially exposed by debridement with a scalpel, followed by partial excision with a bone scraper until bleeding was observed from the exposed bone. The lesions were immediately covered with an occlusive dressing, and were eventually treated with epidermal grafts obtained from suction blisters.

RESULTS

A comparison with standard therapy demonstrated that the time needed for wound healing was similar, but that the newly developed combination therapy reduced the risk of amputation (P = 0.020). No skin ulcers or erosions were observed for at least 1 year in five of seven patients (72%) due to the adoption of stable palmoplantar-type characteristics in grafts derived from the trunk epidermis.

CONCLUSIONS

Our study indicates that exposure of bone marrow cells plus an occlusive dressing accelerates the healing of skin ulcers at least partly through the preparation of a healthy well-granulated wound bed and that subsequent epidermal grafting achieves site-specific differentiation through epithelial-mesenchymal interactions.

Effects of the enamel matrix derivative and β-tricalcium phosphate on bone augmentation within a titanium cap in rabbit calvarium

In vitro studies suggest that enamel matrix derivative (EMD) affects the early stages of osteogenic maturation by stimulating bone cell proliferation. In the present study, we evaluated the effects of EMD and beta-tricalcium phosphate (beta-TCP) on bone augmentation within a titanium cap in rabbit calvaria, using 14 adult male Japanese white rabbits. The calvarium was exposed, a circular groove prepared, the marrow penetrated, and a standard hemispherical titanium cap placed in the groove. The cap was filled with a mixture of beta-TCP and EMD at the experimental site, and was filled with beta-TCP alone at the control site. At 1 and 3 months after cap implantation, animals were euthanized, and histological sections prepared. The sections were stained with basic fuchsin and methylene blue, and were examined using light microscopy. At 1 month, EMD tended to increase the amount of bone, but there was no significant difference in the amount of new tissue and mineralized bone between the experimental and control sites. The present findings indicate that the present mixture of EMD and beta-TCP does not accelerate bone formation, compared with beta-TCP alone.

[Stimulation of lower extremity peripheral circulation in patients with obliterating arteriosclerosis by the wire insertion into the bone marrow canal]

The method of applying the Ilizarov apparatus on the injured segment of the lower extremities introduced from below into the marrowy cavity in 16 patients with a precritical degree of blood circulation impairment (II and III stages according to Pokrovsky classification) resulted in stable compensation of ischemic derangements.

Targeting the bone marrow: applications in stem cell transplantation

Therapeutic doses of radiation can be selectively directed to the bone marrow either directly using vectors that bind to myeloid and/or lymphoid specific antigens or indirectly by targeting bone matrix. The combination of an accessible target tissue and relatively radiation sensitive malignant cells favours the use of targeted radiotherapy in the treatment of haematopoietic malignancies. Dose escalation of targeted radiation can increase tumour cell destruction and has led to the use of myelosuppressive and possibly myeloablative doses of targeted radiation. A natural development has been the use of targeted radiation in conditioning prior to haematopoietic stem cell transplantation (HSCT). Several groups are actively exploring the use of targeted radiotherapy in the context of HSCT as treatment for haematological malignancies. Although no randomised trials using targeted radiotherapy in HSCT have been published, phase I and II trials have shown very encouraging results stimulating further clinical research in this field. After more than a decade of translational research the optimal combination of therapeutic radioisotope and vector has not been determined. This review summarises the clinical experience of targeted radiotherapy in HSCT and discusses the problems that still need to be solved to maximise the potential of this new treatment modality in HSCT.

Performing bone marrow harvest on an outpatient basis: a single center UK experience

Bone marrow harvest (BMH) has historically been performed on an inpatient basis with a minimum of overnight inpatient stays. We commenced a program of outpatient (day case) BMH in 1999, performing 54 day case BMHs over a 3-year period. Of the total of 54 cases, 51 were known patients with hematological malignancies and 3 were healthy normal donors. Seven were excluded from day case BMH. Five (10.6%) of 47 patients/donors who were accepted for day case BMH required overnight admission. Two developed hypotension requiring intravenous fluid resuscitation. Two had excessive vomiting and 1 a difficult and prolonged harvest and was admitted at the request of the anesthetist. None of the patients admitted required more than overnight admission and 42 (89.4%) were discharged the same evening. In conclusion, day case BMH is safe, cost-effective, and reduces the pressure on inpatient beds.

Osteopontin-deficiency suppresses growth of B16 melanoma cells implanted in bone and osteoclastogenesis in co-cultures

Tumor metastasis and invasion to bone is one of major medical issues in our modern societies. Osteopontin deficiency decreased tumor invasion in bone based on knockout mouse study. In bone, osteopontin is a positive factor to increase tumor invasion.

INTRODUCTION

Osteopontin is an arginine-glycine-aspartate (RGD)-containing protein and is recognized by integrin family members. Osteopontin promotes cell attachment to bone, where it is abundantly present. Because osteopontin levels were reported to be elevated in patients bearing highly metastatic tumors, this molecule has been implicated in the metastasis of tumors. However, the effect of osteopontin on the invasion of tumor cells in bone microenvironment has not been clear. The purpose of this paper is to elucidate the effect of host osteopontin on the behavior of tumor cells in bone.

MATERIALS AND METHODS

Bone marrow ablation was conducted in the femora of mice, and B16 melanoma cells were injected directly into the ablated bone marrow space of the osteopontin-deficient and wildtype mice.

RESULT

Invasion foci of B16 melanoma cells in the cortical bone was observed 7 weeks after tumor cell implantation. The number of the foci was 5-fold less in osteopontin-deficient mice compared with that in wildtype mice. In wildtype mice, trabecular bone formation was not observed in the ablated marrow space where tumor cells were injected. In contrast, significant levels of trabecular bone were observed in the marrow space of osteopontin-deficient mice even after tumor cells were injected. To examine cellular mechanisms underlying these observations, co-cultures of bone marrow cells and B16 cells were conducted. While the presence of B16 cells promoted TRACP+ cell development in wildtype bone marrow cells, such enhancement in TRACP+ cell formation by the co-cultures with B16 cells was reduced in the case of bone marrow cells from osteopontin-deficient mice.

CONCLUSIONS

Osteopontin deficiency reduced the bone loss caused by tumor cell implantation into the bone marrow space.

A histological evaluation of the involvement of Bio-OssR in osteoblastic differentiation and matrix synthesis

This study was designed to investigate the responses of bone cells to a deproteinized bovine bone material, Bio-Oss (Geistlich-Pharma, Wolhunsen, Switzerland), which was grafted in artificial bone defects of rat femurs. Standardized bone defects in the cortical bone of the right femurs were grafted with Bio-Oss particles. Narrow penetrations were prepared on the bottom of the cavity, enabling osteogenic cells to migrate from the bone marrow. A defect in the left femur without Bio-Oss was used as a control. The treated femurs were histochemically examined at 1, 3, 5, 7, and 14 days after the operation. At day 1, no osteogenic migration into the cavities occurred in either the control or experimental groups. At day 3, alkaline phosphatase (ALPase) immunohistochemistry showed a migration of the positive cells at the bottom of the cavities of the experimental groups, but not in the control ones. At day 5, new bone formation was recognized at the bottom of the cavity of both groups. In the experimental group, ALPase-positive cells were localized on Bio-Oss and/or on the thin bone matrix that covered this material. The superficial layer of Bio-Oss underlying the newly formed bone exhibited osteocalcin immunoreactivity. Transmission electron microscopy revealed osteoblasts depositing bone matrices--including collagen fibers--on the surface of Bio-Oss. At days 7 and 14, woven bone occupied the previous cavities of both control and experimental groups, accompanied by osteoclasts. Thus, Bio-Oss appears to serve as a scaffold for osteogenic cells as well as to promote osteoblastic differentiation and matrix synthesis.

Intramedullary pressure during endoscopy of the long bone: experimental results of a new endoscopic technique

This study shows the local changes in intramedullary pressure during a new endoscopic technique for the medullary canal of the long bone. The procedure of intramedullary bone endoscopy (IBE) was performed on 4 tibial amputations. By slowly pushing the endoscope distally under visual control and endoscopic preparation of the medullary canal, a "neocavum" for endoscopy was created. During the procedure, the intramedullary pressure was continuously measured: Highest peak pressure was 125 mm Hg. We therefore conclude that the procedure of IBE is a safe intervention within the medullary canal of the long bone. Local or systemic side effects, common to intramedullary reaming in fracture treatment (fat-embolism, local bone necrosis, reduction in cortical blood flow) should not be expected.

Experimental approach to improving early postirradiation restoration in the hemopoietic system of irradiated canines

Experiments on mongrel canines exposed to total body irradiation in free-in-air dose of 3.85 (LD 95/45) or 4.05 Gy were carried out to evaluate the therapeutic effectiveness of some of bone marrow immediate-after-irradiation extraction, incubation in the presence of protein synthesis inhibitor and reimplantation in the organism (the reimplantation method) or bone marrow extraction alone (the extraction method). There were tested various kinds of methods that differed in bone marrow-blood mix volume extracted, in large or in small volumes. It has been determined that the reimplantation method in large volumes and the extraction method in small volumes are equally effective. Being supplemented with supportive therapy by antibiotics during d8-d24, the methods allowed the rescue at 4.05 Gy irradiation significantly more animals than in the case of therapy alone or its combination with ineffective variants of the methods. The positive effect of the methods manifested in a higher level of leukocyte nadir on d17, earlier reaching 0.5 x 10(9) and 1 x 10(9) leukocytes per liter, and increasing 45 days survival. The mechanism of positive influence of the methods on the radiation injury of hemopoesis seems to be related to increased cytokine producing because of the irritation of bone marrow stromal cells and thus favorable interference in the early restoration processes.

Percutaneous catheterization of the long bones: experimental study

The objective of this study was to develop a technique which would permit access to the entire contents of long bones using a minimally invasive approach. Vascular catheterization techniques were used to allow access to the entire marrow cavity through a minimal percutaneous approach. A new device was also developed to reach the epiphysis of the long bone. The study was performed on animal and human anatomical specimens. A percutaneous approach was made through the bone shaft from a remote entry site using principles from endoscopy in an ex vivo experiment. This method may become an alternative technique when a direct approach to lesional sites in long bones is dangerous or impossible. For example, it could be used in cases of preventive cement injections in weakened bones.

The mechanical or electrical induction of medullary angiogenesis: will it improve sternal wound healing?

We induced angiogenesis in the tibial medulla and cortex of rabbits by electrical and mechanical stimulation, with the aim of future application to ischemic disease. Sixteen New Zealand rabbits were divided into 4 groups: in Group 1, a K wire was inserted into the medullary channel; in Group 2 a hole was drilled into the tibia; in Group 3, electrical stimulation was applied to the medullary channel; and in Group 4 (the control group), nothing was done. The interventions were applied during a 21-day period, after which all animals were evaluated scintigraphically and histopathologically. All 3 interventional groups were significantly superior to the control group in regard to medullary and cortical vascularity: the P values were 0.021 in all comparisons to control. However, the most fibrotic changes in the medulla occurred in the group that had been treated with electricity (P = 0.008). Slight fibrotic changes occurred in the hole group (P = 0.040), and none occurred in the K-wire group. In sum, all 3 interventions are capable of inducing medullary angiogenesis, but electricity is inferior in regard to fibrotic change. We believe that this present study can establish a baseline for further work that explores clinical applications to problematic ischemic conditions, including delayed sternal wound healing after cardiac surgery.

Second dorsal metacarpal artery muscle flap: an adjunct in the treatment of chronic phalangeal osteomyelitis

We describe a surgical approach for treating chronic osteomyelitis of the proximal phalanx in the hand. The procedure consisted of inserting the second dorsal metacarpal reverse adipofascial flap, including a small amount of interosseous muscle, into the bone marrow space of the phalanx after complete removal of the focus of infection. Two years after the procedure, the patient had full range of motion of the finger with no signs of infection or drainage. This operation resulted in minimal morbidity and a full range of motion of the finger.