BONE BANK.pptx

bone bank in bangladesh

1. Bone bank Dr Mohammod Ali Phase-A Resident Urology

2. Introduction Bone banks are necessary for providing biological material for a series of orthopedic procedures. The growing need for musculoskeletal tissues for transplantation has been increased due to the development of new surgical techniques and this has led to a situation in which a variety of hospital services have been willing to have their own source of tissue for transplantation.

3. History Historically, bone banks have existed in Brazil since the 1950s. In the mid-1990s, regulations were imposed on the practices followed by tissue banks. In bangladesh R&D work on human tissue grafts processing was started in late 1985

4. Biology of bone graft Consolidation of grafts into the host bone tissue takes place through the mediation of three biological phenomena: Osteogenesis Osteoinduction Osteoconduction

5. Osteogenesis is taken to be the capacity of live cells ( osteoblasts ) to maintain the production of osteoid substance, which may only occur with autologous grafts. Osteoinduction is the differentiation of pluripotent cells in the host into osteoblasts , through a series of mechanisms in which the various families of growth factors play an important role. Osteoconduction is the process in which the canaliculi of the transplanted bone act as a guide for the growth of osteoblast bridges of new bone tissue coming from the host. A large number of homologous grafts and bone substitutes are exclusively osteoconductive .

6. Indications of bone graft Assist in healing of fractures, delayed unions, or nonunions Assist in  arthrodeses and spinal fusions Replace bone defects from trauma or tumor

7. Options for graft Autografts Allografts Demineralized bone matrix (DBM) Synthetics Bone morphogenetic protein (BMP) Stem cells

8. Types of allograft 1. Fresh   Highest risk of disease transmission and immunogenicity BMP preserved and therefore osteoinductive 2. Fresh frozen Less immunogenicity than fresh BMP preserved and therefore osteoinductive 3. Freeze dried (croutons)  Least immunogenic Least structural integrity BMP depleted (purely osteoconductive ) Lowest likelihood of viral transmission

9. Technical consideration Donor selection is done carefully by the coordinator of the harvesting team and by the medical director of the tissue bank, taking into consideration of data such as the donor’s age and sex, cause of death, previous medical history, physical examination and numerous laboratory tests.

10. Donor exclusion criteria for live donor Patient unwilling to share information Under aged person (< 18 years) Active or recent systemic infection/sepsis Previously infected with tuberculosis Previous infection with HBV, HCV, HIV and AIDS or AIDS related complexes/sexual partner of these individuals Active/past syphilis infection and test positive for VDRL Autoimmune diseases

11. contd Treatment with immunosuppressive agents Existing insulin dependent diabetes mellitus Chronic neurological disorder, dementia Malignancies Hemophilia/blood diseases Men having homosexual intercourse Men and women active in prostitution Current or past drug abusers Recent (< 4 weeks) vaccination with live vaccine

12. Donor exclusion criteria for deceased donor Evidence of high-risk behavior, Cause of death unknown, Malignant disease, Multisystem auto-immune disease, Neuro -degenerative or neuro -psychiatric disease or diseases of unknown aetiology , Systemic infection , HIV, Acute or chronic hepatitis B, hepatitis C and HTLV I/II Systemic autoimmune disease.

13. Team Theatre nurse. A medical microbiologist. Pathologist. Haematological laboratory technician. Trainer. BB administrator and trainer responsible for training of bone bank employees.

14. Tissue procurement Raw bones (surgical discard) were retrieved from living donor undergoing orthopedic surgery Excised femoral head in fracture neck of femur (FNF) in replacement hemiarthoplasty or in total hip replacement (THR), Rejected bone slides from total knee replacement (TKR) operation, Corrective osteotomy and primary traumatic limb amputation

15. Tissue harvesting The harvesting teams need to be properly registered with the transplantation centers in order to have legal backing and to receive notifications regarding donors, not only in their own hospitals but also in other institutions. There are two types of donor of homologous tissues : Live donors , Cadaver donors ,

16. contd Tissue harvesting should be carried out very cautiously, and generally by a team formed by four members (two surgeons, one packer and one auxiliary) , following all the guidance for antisepsis and asepsis that would be observed in a large-sized orthopedic surgical procedure. After the material has been removed, material for testing is collected. The specimens are packed individually, identified and transported in thermally insulated boxes , packed in dry ice or ordinary ice . There is a legal requirement, as a matter of respect for the families of donors, that the body structure of the cadaver should be reconstructed: this is done using PVC pieces that were assembled beforehand.

17. Tissue processing After collection, tissues packs were labeled again with donor identification and batch number. Allograft tissues were processed aseptically using sterile equipment following standard protocol. Working areas were cleaned with antiseptic solution and the processing room was illuminated with ultraviolet light (UV-B) for 45 min before getting started processing. Initial bioburden of raw tissues were analyzed and the tissues were placed in the quarantine deep freezer at -40 °C till the result obtained.

18. Processing of lyophilised cancellous bone allografts Human femoral heads and patellar bone of femoral condyles were first thawed to room temperature and then aseptically immersed in sterile distilled water (DW) in glass beakers and pasteurized at 60 °C for 3 hr . Bones were kept in frozen condition (-40 ° C). The bones were then cut into small pieces (2 cc) using a surface sterilized electric band saw and surgical instruments.

19. contd The bone segments from individual donors were washed separately with sterile DW several times at room temperature (±25 ° C) using an electric shaker to remove blood. The bone pieces were then washed with sterile DW to remove fatty material using water bath shaker at 50 ° C . After final washing, the bone pieces were frozen at -40 ° C till freeze drying . Finally, the lyophilized bone chips from each donor were packaged in separate polyethylene packages (triple layer) under laminar airflow hood, labeled and vacuum sealed.

20. Processing of deep-frozen massive bone allografts The collected bones from different donors were packaged separately in polyethylene packages and wrapped with sterile fabric for storage in deep freezer (-80 ° C). For processing, cortical bones were first thawed to room temperature and then the bone marrow as well as the remnants of muscles attached to the long bones was removed using sterile surgical instruments under aseptic condition. Then these were washed several times with plenty of sterile DW and povidone iodine solution.

21. contd After proper washing, the bones were first packaged and vacuum sealed in polyethylene pouches and wrapped with fabric , and again vacuum sealed in another outer layer of polyethylene and labeled with graft identification number, dose and date of gamma irradiation, preservation conditions, expiry date etc. Finally, the bones were packaged and vacuum sealed in a third layer of polyethylene . The bones were then placed inside an insulated cool box filled with sterile ice , and then placed inside the deep freezer (-80 ° C) for at least overnight to get the bones frozen before sterilization.

22. Processing of demineralized bone granules Cancellous human bones were first thawed to room temperature and pasteurized at 60 ° C for 3 h . Then it was cut into pieces and washed with sterile DW at room temperature and washed again several times at 50 ° C . It was then crushed using mortar and pestle to form bone granules. The bone granules were demineralized using 0.6 N hydrochloric acid ( HCl ) for three consecutive cycles with each cycle consisting of 90 min.

23. contd After each cycle, the granules in HCl were subjected to centrifuge for 10 min at 4000 rpm. However, the bone granules were washed first with phosphate buffer solution (pH 7.0) to neutralize the activity of acid followed by washing again several times with sterile DW . The granules were then frozen overnight at -40 ° C and freeze dried at -55 ° C . Finally, freeze dried bone granules were dispensed in 2 cc plastic vials and wrapped in polyethylene pouches (triple layered ) and labeled properly.

24. Quality control and tissue sterilization To ensure sterility assurance level (SAL) of 10-6 , all the tissue allografts were sterilized at 25 kGy gamma radiations from Cobalt-60 gamma source . After irradiation, the massive bones were preserved at -80 ° C . Every donor tissues were tested for sterility after gamma irradiation. Sterility test were performed using four different culture media viz , nutrient broth, brain–heart infusion broth, thioglycollate broth, and sabouraud dextrose broth. Tubes were incubated under aerobic and anaerobic condition at 37 ° C for bacteria and 25 ° C for fungus. The tubes containing tissue samples were observed up to 14 days for any type of microbial growth. After comparing with the negative control tubes, if no contamination found, then the particular batch was released for the dispatch to the hospitals.

25. Figure-A: Cortical “rings”, which can be used to fill wedges in osteotomy cases, B: Patellar and quadricipital tendons, for multi-ligament reconstruction.

26. Figure: Osteochondral graft from the proximal tibia, for post-traumatic or post-tumor reconstructions.

27. Storage The tissues are generally kept in freezers at a temperature of 85 degrees Celsius below zero . The freezer have temperature control displays and are connected to the hospital’s generator as a precaution against possible power cuts. They also have an alarm and a supply of liquid CO2 for additional security. Under ideal conditions and at constant temperature, the tissues can be stored for a period of five years , according to the norms of Anvisa (Brazilian National Sanitary Surveillance Agency) and AATB (American Association of Tissue Banks).

28. Applications within orthopedics There are several reasons for this: Impossibility of obtaining large quantities of autologous bone; Morbidity at the graft harvesting site; Increased numbers of revision procedures on hip and knee arthroplasties ; Development of new surgical techniques that depend on homologous bone.

29. RISKS & COMPLICATIONS 1 . Disease Transmission hepatitis B risk of hepatitis B disease transmission in musculoskeletal fresh-frozen allograft transplantation is 1 in 63,000 hepatitis C risk of hepatitis C disease transmission in musculoskeletal fresh-frozen allograft transplantation is 1 in 100,000   

30. contd HIV risk of transmission of HIV in fresh-frozen allograft bone is 1 in 1,000,000 to 1,670,000  allografts are tested for HIV, HBV, HCV, HTLV-1, and syphilis  2 . Serous wound drainage calcium sulfate bone graft substitute associated with increased serous wound drainage 

31. Outcomes Allograft retrieval : Retrieval studies are helpful in understanding the body's response to allografts . 5 years after implantation, allograft articular cartilage is completely acellular  - no donor or recipient chondrocytes will be present. 

32. Bone bank in bangladesh The idea of establishing a human tissue bank in Bangladesh was started in 1985 . However, in 2003, with the active cooperation of International atomic energy agency (IAEA) and Bangladesh Atomic Energy Commission (BAEC) , a tissue bank laboratory was upgraded as a unit for tissue banking and research. Due to increasing demand of allograft, this unit was transformed as an independent institute ‘‘ Institute of Tissue Banking and Biomaterial Research (ITBBR)’’ in 2016.

33. Table: Annual bone allograft utilization from 2007 to 2018 in ITBBR

34. Figure: bone graft in bangladesh from 2007 to 2018

35. Figure: utilization of bone allograft in bangladesh from 2007 to 2018

36. Figure: utilization of bone allograft in Bangladesh from 2007 to2018

37. The amount of grafts produced by the ITBBR from 2007 to 2018 120,800 cc of bone chips, 277 vials of de-mineralized bone granules (DMB), 95 pieces of massive bones, and 134 pieces of cranial bones. Overall, 112,748 cc of bone chips, 174 vials of DMB, 44 pieces of massive bones, and 64 pieces of cranial bones were transplanted successfully.

38. Human tissue procurement, processing, graft production and supply Human tissues were collected (procurement/donation) from (medically discarded biomaterials- as surgical residues) live donors/patients with informed consent and following the regulation of Organ/Tissue Donation and Transplantation act adopted.

39. Limiting factors affecting tissue donors and tissue banking activities in Bangladesh Religious and personal beliefs Limited facilities of tissue procurement immediately after surgery Lack of appropriate support from national health system. Budget

40. Conclusion ITBBR with IAEA support is providing high quality tissue banking service in our country. We need to work in this field for expansion with professionalism and ensuring the quality.

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43. Thank you