Cellular Aspects of Autologous Bone Graft. What are the components of intramedullary graft? Components. It sure looks like bone graft.

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1 Cellular Aspects of Autologous Bone Graft What are the components of intramedullary graft? It sure looks like bone graft Slurry Components Marrow fat, vascular network Small bone fragments And cells

2 Reaming debris Critical elements for osteogenesis Cells, scaffold, and inductive signals Contributions variable per patient and technique Are there osteogenic cells? Seems to help reamed nails

3 How does this compare to ICBG? Are we getting different things? Prospective ten nonunion patients Simultaneous ICBG and RIA Histology and genomewide transcriptional profiling

4 Histology Key findings regarding reamings viable osteoprogenitor cells are present Greater expression of stem cell markers similar transcriptional profile for bone forming genes potential alternative source of autologous bone graft Is the endosteum an unique niche for progenitor cells?

5 Intramedullary microenvironments Osteoblastic niche Osteoblasts HSC Vascular niche Sinusoids MSC Traditional schema Enzymatic separation central and endosteal Mesenchymal progenitors found in both locations

6 Endosteal progenitors Higher numbers than central marrow Superior proliferative ability Dramatically decreased in older animals Responsive to single dose PTH Can t the cells be damaged by the reaming process? Do they really survive this Potential damage Human reaming material Bone fragments between 0.2 and 2.0 mm EM showed many altered cells on fragments Most of the cells remained viable No functional assay performed Wenish, Bone 2005

7 Possible damage RIA is large caliber reaming Cells are exposed to harsh environment Cells are physically agitated before trap RIA in 25 patients ICBG in 21 patients 1 gm of graft material Initial cell viability >95% both groups Cell Viability

8 Typical progression Day 4 round cells Day 7-11 elongated cells Day confluence Flow Cytometry CD34 and CD45 = undifferentiated mesenchymal stem cells and hematopoetic cells CD90 and CD105 = mesenchymal lineage Osteocalcin Assay Osteocalcin = cell differentiation for osteogenesis Significant increase over time No significant difference between IC and RIA

9 Osteogenesis Alizarin red stain Binds calcium in the matrix in culture Calcium = osteogenesis All late cell cultures sta Can we improve cell harvest? Are we washing the good stuff away 5 older patients undergoing hemiarthroplasty 3-5 co-morbidities Reamed via femoral neck cut Ficoll gradient centrifugation of effluent

10 Reaming effluent Ideal graft solution? Conclusions

11 Cellular aspects of reaming material Reamings are source of multi-potent cells and similar to ICBG Endosteum may be source of unique progenitors Cells survive the reaming process Improved cell harvest may improve reaming grafts

12 RIA Cases: Bone Defects Brent L. Norris, MD Clinical Associate Professor University of Oklahoma Director, Orthopaedic Trauma Service St John Medical Center Tulsa OK Disclosures AONA: support Synthes/USA: Lilly: Fellowship grant Consultant Speakers Board Historical Options for Treating Defects Defects < 2cm Autogenous (Iliac Crest, Proximal Tibia) Bone Stimulators/Exchange Nailing? Defects 2-6cm Autogenous (Iliac Crest) Allograft + BMP Jones 2006 Ilizarov Bone Transport Defects > 6cm Autogenous (Iliac Crest) Bosse 1992 Ilzarov Bone Transport Free Vascularized Fibula 1

13 Bone Defects Where do they come from? Open Fractures with Bone Loss Non Union with Infected Bone After Debridement Tumor Resection Primary or Isolated Mets Masquelet Technique Background Induced membrane technique Stage 1 cement spacer to induce membrane Stage 2 spacer removal + bone 4-6wks Masquelet Technique PMMA Space Induces membrane around the spacer Membrane serves to contain graft Membrane has been shown to very bioactive (VEGF, TGFB, BMP) Compared to Bone Transport / Free Fibula Quicker, Easier, Fewer complications Also effective for large defects 2

14 Masquelet Technique Prerequisites Soft tissue Coverage Free tissue or Fasciocutaneous Systemic Disease / Biology (Corrected) Adequate Vascular Inflow» ABI» Trans-cutaneous Oxygen Tension Infection / Vitamin D / Diabetes (controlled) 45 yo male NIDDM Case 1 3B Open Tibia with Bone Lose Previous I and D, Plating, Flap Presents with draining wound Pre Op 3

15 Post Debridement ESR 78 CRP 3.5 WBC 11.8 Lab Studies Positive cultures for MRSA Post RIA 4

16 1 Year Post Op Case 2 33 yo male Smoker Closed Tibia Fx (high energy) IM Nail on day of injury Blistering, skin loss over fracture 3 months: Open wound w drainage Nonunion Debrided and then ORIF with allograft 5 months: Present with exposed HW, significant swelling and pus coming from ant tibia wound Infected Tibial Nonunion Presenting Films 5

17 Post Debridement Clinical Course Positive MRSA NIDDM (new diagnosis) ABX Nail plus small spacer 6 weeks IV Abx 6

18 Post op RIA 6 months 1 year Post Op 7

19 Case 3 42 yo male MVC Open segmental tibia 3b Bone loss at scene Smoker Head and Pulmonary Injury PE Intact DP and PT Wiggles toes Injury Film Post Debridement 8

20 6 weeks post RIA 3 months Post Op Diaphyseal Junction Non Union Back for additional RIA graft 10 months-wb with pain 9

21 CASE 4 31 year old truck driver Pedestrian Struck Car vs both legs vs trailer Right traumatic BKA Left segmental open tibia 14+ cm defect Neuro vascular intact STSG * Day 1 * Antibiotic Cement Spacer * Antibiotic Cement Nail * External Fixator * Week 5 * Removal of Spacers * IM Nail Tibia, ORIF Fibula * Bone Graft (RIA + ICBG + BMP) 10

22 CASE 5 Open Femur Defect 50 yo Car vs MC Open Open Open * Day 4 * ORIF * ABX Spacer * 6 weeks * Bone Graft (RIA + ICBG) 11

23 Case 6 7 wks post injury Transferred to our care 54 yo male Smoker Obese (450 lbs) IDDM 3 mo post RIA 6 months post RIA 12

24 1 year Post Op Case 7 Injury High speed MCC 3A open right distal radius fx Bone loss at scene Hemodynamically stable Associated ortho injuries LC2 pelvis left Femur shaft Left 13

25 Immediate Post-Op 10 weeks Post RIA Summary Large Bone Defects can be treated with autogenous bone grafting using specific treatment algorithms RIA bone graft harvest yields large amounts of very bioactive material Likely better than ICBG Masquelet technique is paramount for preparing wound for grafting and defect management 14

26 Summary Must maximize patients physiology while waiting to graft including correcting pathologic conditions when possible Low Vit D Uncontrolled DM Stop immunosuppressives Aggressively treat infection Summary Limb salvage and successful treatment of large bone defects is possible with autogenous bone grafting with RIA Success rates in the percent with initial grafting using Masquelet technique Stafford, Norris Injury Supplement 15

27 4/7/2014 Biological Properties of Various Bone Grafting Sites G. Schmidmaier No conflictes of interest Impaired Fracture Healing Complications in 5 10 %!!! Due to: Soft tissue trauma Poor biomechanics Impaired biology Osteoporoses Diabetes mellitus Micro-, Macroangiopathia Polyneuropathia Smoking, alkohol, drugs Rodriguez-Merchan et al. Clin Orthop Relat Res ;419:4-12 Tzioupis C et al. Injury ;38 Suppl 2:S3-9 1

28 4/7/2014 Impaired Fracture Healing Non union* 2-5% Infection** 3-33 % Mechancal reason Hyertrophic non union Biological reason Atrophic non union Critical Defect Defect non union + Infection Infect non union 3 open fracture Calori G et al., Injury 2008* Papakostidis C et al, Injury 2011** Biology Bone 65% anorganic: Hydroxyapatite 35% organisch: 90% Collagen 1 2,5% Osteonectin 1,5% Osteocalcin 1,5% Phosphoproteines <0.1% Growths Factors... M. Sandberg 1991 Annals of Medicine 23: Diamond Concept Mechanical Stability Vascularization Cells Scaffolds Growth factors Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury. 2007:38 Giannoudis PV, Einhorn TA, Schmidmaier G, Marsh D. The diamond concept--open questions. Injury. 2008:39 2

29 4/7/2014 Autologous Bone Transplantation + Osteoinductive + Osteoconductive + Osteogene Autologous bone graft Complications minor complication: 4-20,6 % Haematoma, Seroma, N. cut. femoris lateralis pain (15-39% 2 y postop) major complication: 3,4-8,6 % Fracture bleading JA Goulet, Clin. Orthop Robertson et al. Spine, 2001 Sasso et al. J. Spinal Dis., 2005 (Prospektive Studie, ALIF) Reaming debris Reaming debris contains vital cells Frölke JP et al. J Orthop Res. 2004, Wenisch S et al. Bone 2005 Cells after 10 days, express AP Cells after 3 weeks, v Kossa [Wenisch 2005] Reaming debris stimulates defect healing Frölke JP et al. J. Trauma

30 4/7/2014 RIA Reaming Irrigation Aspiration Irrigation port Aspiration port Collection canister Irrigation & aspiration: 1. Reduction of pressure and heat 2. Clearance of medullary canal of bone debris 3. Graft harvest RIA Reaming Irrigation Aspiration One step procedure Fast, efficient reaming Lower IM Pressure Lower fat embolisation Lower heat generated Removal of infected tissue Autograft harvesting (up to 80cc) RIA Literature Over 150 Publications Experimental and clinical papers 4

31 4/7/2014 RIA Reaming Irrigation Aspiration Irrigation port Aspiration port Irrigation & aspiration: 1. Reduction of pressure and heat 2. Clearance of medullary canal 3. Graft harvest RIA vs Iliac crest FGFa + (2.1) FGFb - (0.5) VEGF - (0.5) PDGFbb + (2.9) comparable GF concentration IGF-I + (1.6) vital osteogenic cells TGF-ß1 + (3.5) BMP-2 + (3) Schmidmaier et al. Bone 2006 Reaming material: a vital source for human mesenchymal stem cells with high osteogenic potential 1. Comparison of MSC from RIA-components, BMSC and ATSC from same donor on osteogenic potential 2. Comparison of Reaming material: native, filtrate and liquid supernatant RIA (N-RIA, F-RIA, L-RIA) on MSC characteristics Isolation of MSC from various tissues 5

32 4/7/2014 Colony forming unit - Fibroblast Assay (CFU-F Assay) n=5 **p times more CFU-F in F-RIA compared to L-RIA and BMSC Phenotype determination via flow cytometry n=5 *p 0.05 FACS more than 95% expression of CD73, CD90 and CD105 less than 5% expression of CD34 and CD45 Osteogenic differentiation in vitro - n=9 - *p on day 21 increased amount in RIA-components compared to BMSC and ATSC 6

33 4/7/2014 Osteogenic differentiation in vivo -n=9 -**p densitometric analyses nearly doubled amount of new bone formation within F-RIA new bone formation of every donor of F-RIA and N-RIA Conclusions Osteogenic potential of RIA-components, BMSC and ATSC in vitro and in vivo higher differentiation potential of Reaming material compared to BMSC and ATSC Reaming material is a vital source of MSC with high osteogenic potential additional to gold standard Infected atrophic non union 63 y, m Infect non union tibia 103 months after III open tibia fracture 31 revisions!!! smoker NSAR adipositas 7

34 4/7/2014 Masquelet Technique + RIA 63 y, m Infect non union tibia 103 months after III open tibia fracture 31 revisions!!! smoker NSAR adipositas Segment resection Debridement Maquelet-Technik Fixateur externe Masquelet Technique + RIA Cells (RIA) Growths factors (BMP-7) Antibiotica-coated implant (ETN Protect) 106 months after fracture 2 months after revision Masquelet Technique + RIA 4 weeks after revision 12 months after revision 8

35 4/7/2014 Masquelet Technique + RIA 15 months Thank You 9

36 Tipps and Tricks: The Reamer-Irrigator-Aspirator (RIA) System H.C. Pape MD, FACS Professor and Chairman Department of Orthopaedics and Trauma Surgery Aachen University Medical Center, Aachen, Germany Content Indication Technique Pitfalls Tricks Results Indications Autologous Bone Transplantation Delayed Union / Non-Union Intramedullary Reaming and Nailing in severely injured patients to avoid systemic complications Acute and chronic intramedullary osteomyelitis 1

37 IM reamers, how I know them Aggressive, end cutting, one pass reamer head Take home: razor sharp Technique Assessment of femoral anatomy canal Isthmus Antecurvation Setup of the RIA System: make sure that seal is tight 2

38 Technique central position of the guidewire Apply advance/withdraw/pause/advance technique While reaming, monitor the reaming head passage on both ap. and lat. plane to avoid bone perforation or excessive thinning Elevate flap, RIA bone graft The best graft Distal femur and condyles Step 1: central guide wire Technique then bend your guide wire Step 2: medial condyle, then pull back to mid shaft Step 3: lateral condyle 3

39 Technique Caution with RIA: Guide wire can penetrate into the knee, if pushed forward with too much effort! 4

40 RIA: originally designed to minimize fat extrusion during reaming. fat extrusion Technique Caution with RIA: Beware of blood loss! Powerful suction should be switched of when you are not reaming! Take home: intraosseous vessels are disrupted, bone acts as a drain Technique Removal of intramedullary bone graft from graft-filter 5

41 Pitfalls Pitfalls and Complications Intra-operative perforation Shaft Knee joint Intra-operative bleeding Intra- or post-operative fractures (mid shaft!) 6

42 7

43 Weak zone 8

44 9

45 Tip of plastic tube With Bone graft 10

46 SUMMARY Powerful reamer Pre op: 1. Measure inner diameter! 2. Entry point AND intraosseous central guide essential Intra op: 1. Go back and forth 2. flouroscopic control Pro: 1. osteogenic potential 2. Low local morbidity with harvesting Thank you 11