REJECTION STUDY OF CANCELOUS ALLOGRAFT IN

RisalahPeltemuan Ilmiah Penelilian dan PengembanganAplikasi IsOlop dan Radias~ 2{X)1
REJECTION STUDY OF CANCELOUS ALLOGRAFT IN
EMERGENCY ORffiOP AEDIC OPERATION
MenkllerManjas*, andNazly Hilmy**
* Dr. M. Djamil HospitalTissueBank,Dept. Of SurgeryFacultyOf Medicine AndalasUniversity,Padang
** BatanResearchTissueBank, CentreForR & D Of IsotopsAnd RadiationTeclmology,BATAN, Jakarta
ABSTRACT
The fast developmentof nationaland internationaltissuebank,increasedthe useof boneallografts in
orthopaedic surgery including emergency open reduction and internal fixation at fresh bone fractures.
The
aim of this work is to evaluate rejection and usefulness of cancelous bone allografts which have been used in
emergencyorthopaedicoperation. During Februaryuntil June 2000 two group of 20 patients each,were
studied, after performing emergencyopen reductionand internal fixation. The first group was treated with
cancelousallograft transplantationat the site of the fracture, but the secondgroup did not get any graft.
Radiation sterilized alllograft were used at this study. Parametersobservedwere local reactionof wound
operation,local rejectionand callusformation.The resultsshow that thereis no rejectionof cancelousbone
allograft detectedfrom local and systemicreactionof woundoperation.After threeweek, operationthere was
no significant differentnumberof callus formationcanbe detectedby conventionalradiologyexaminationbut
after 6 weeks there was a significant increasingin number of callus formation in the group of cancelous
allograft transplantation(P < 0.05).
Keyword: Radiationsterilization,boneallograft,internal fIXation,rejectionstudy,callus formation.
ABSTRAK
Perkembangan pesat dari bank jarillgan baik secaranasional maupun intemasional telah meningkatkan
pemakaian allograft tulang pada bedah ortopedi, temIasuk penggunaannya pada operasi emergensi patah
tulang. Penelitian ini bertujuan untuk menilai tingkat penolakan dari tulang kmlselous allograft pada operasi
patah tulang emergensi. Selama Februari sampai Juni 2000 dilakukan penelitian terhadap dua kelompok
penderita patah tulang masing-masing 20 pasien dengan operasi emergensi untuk reposisi terbuka dan
pemasangan fiksasi interna. Kelompok pertarna mendapat graft tulang berupa kanselus allograft yang
disterilkan dengan radiasi tempat patahnya sesudah pemasangan flksasi intema. Sedangkan kelompok kedua
tanpa graft. Parameter yang digunakan adalah reaksi lokal dari luka operasi, reaksi penolakan tubuh terhadap
pemakaian graft serta pengarnh graft terhadap tingkat penyembuhan patah tulang atau pembentukan kallus.
Tidak terlihat adanya reaksi lokal dan reaksi penolakan tubuh terhadap pemakaian kanselus allograft yang
dilihat baik pada luka operasi ataupun pada seluruh tubuh (sistemik). Melalui pemeriksaan radiologis sesudah
3 minggu operasi, tidak terlihat perbedaan yang nyata dalam jwnlah kallus yang terbentuk diantara kedua
kelompok yang diteliti, tetapi sesudah 6 minggu operasi ternyata ditemukan jumlah kallus lebih banyak pada
kelompok yang diberikan tulang kanselus allograft. (P < 0.05). Kanselus allograft dapat digunakan pada
operasi patah tulang emergensi untuk merangsang pembentukan callus dan mempercepat penyembuhan patah
tulang.
Kata kunci : Sterilisasi radiasi, Kanselus allograft, Fiksasi interna, Pembentukan kallus.
INTRODUCTION
Bone grafting representsone of the earliest
reconstruction approaches to the musculoskeletal
systemand remainsamongthe most commonlyusedin
orthopaedicprocedures.(1,2) Bone grafts are used in
conjunction with the repair of fractures, bridging of
large bone defectsand stimulation of bone formation.
Although there are several forms available such as
autografis, allografts, demineralized bone matrix,
composite graft (collagrafi), xenograft, none of these
possessthe ideal characteristicbecauseeach of them
has its own advantagesand disadvantages
etc (1,3,4,5).
The original method like autograft (bone harvesting
procedure)is associatedwitll increasedmorbidity such
as bleeding, infection and pain at the donor site. On
the other hand by using allograft it can prevent that
morbidity, besidesthere is no problem with technique
and the source of graft.(6,7,S,9,U)
Mechanism action of this grnft in stimulating
new bone fonnation is still unknown. It might be act
as osteogenic induction. Meanwhile cancelous allograft
can corpornte more rnpidly than cortical allogrnft. (8,9,U)
By tile development of national, regional and
international tissue banks, allografts are increasingly
being more produced and used in orthopaedic surgery
including emergency operation such as in early open
reduction and internal fixation for bone frnctures.
For some emergency cases either from technical
operntion or condition of fracture itself, the bone may
be in danger for vascularization and can cause delay in
bone union. At this condition, grnft for stimulating
bone union or for filling bone loss as bone bridging are
needed.(I.z,12)
This paper will report the preliminary studies on
the effect and rejection of cancelous allograft in
emergency open reduction and internal fixation for long
bones fractures.
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MATERIALS AND METHODS
A trial has beenconductedin patientwith closed
long bonefracture (femur, tibia and humerus)between
18- 40 years of age who were admittedto our hospital
during the period of Februaryto June2000.
All patients underwent emergencY open
reduction and internal fixation witIl plate and screw
were randomly divided into two groups. An even
nurnber of the patient had undergoneopen reduction
and internal fixation followed by radiation sterilized
cancelousallograft transplantationat tile site of fracture
near plate and screw and this group served as the
experimentalgroup. The othergroup with odd nurnber
of patients without any bone graft were servedas the
control group. The two groups of patient received
similar post operative care and allowed to early
mobilization. Radiationsterilizedboneallograftsbeing
used were produced Batan ResearchTissue Bank
(BRTB)BAT AN Jakarta.
Rejection reactionbecauseof using cancelous
allograft were evaluated from sisternic and local
reactionsuchas localwound infectionand localallergic
reaction after three days until fifteen days of post
operation. Callus formation were evaluatedafter three
weeksup to six weekspostoperation.
The assessmentrejection reaction of using
cancelousgraft for emergencyorthopaedicoperation
was evaluated by using criteria and score method
shownat table la.
P values
Male
4.14:!:,O.52
n=14
4.00:!:,O.41
n=12.
P > OO5
Score
Fema1e
4.33:!:,O.47
0-6
4.13:!:,O.33
0-8
P > OO5
.
3
2
I
Total
4.20+0.51
4.00+ 0.45
N~O
P> 0.05
3
2
1
Table l.b Callus fonnation score
Score
I
2
fracture
More callus but still demarcatedat the site
3
fracture
More callus that bridging betweentwo
Table2. Rate of male and female rejection score
between group of cancelous allograft and
without any graft. in emergencyorthopaedic
operation
Non graft
~
This criteria and score method were also been
used for the detection of callus fonnation using
conventional radiology examinationas can be seenat
Table l.b.
Parameterand description
No callus fonnation
Thereis callus fonnation betweentwo fragment
During that period 40 patients underwent
emergencyopenreductionand internalfixation for long
bone fractures. Half of them were treated with
cancelousallograft while the rest did not get any graft
at all .The patientsevaluatedconsisted of 26 menand
14womenand 19 casesof them ie. 47.5 % were below
30 yearsold.
Of the 26 male patients,14casesusedcancelous
allograft,while of 12femalepatients,8 caseswere done
withoutanygraft.
The averagerejection scorein non ~
groupis
not significanly lower than cancelousa11o~ group
(table2).
Cancelous
II
ft
allogran
reaction
No sign allergic reaction
RESULTS
Sex
Table l.a Rejection score
-Parai1t~
description
Local infection
Local infection with sistemicmanifestation
Local infection without sistemicreaction
No sign of infection
Allergic reaction
Local allergic reactionwith sistemic
manifestation
Local allergic reactionwithout sistemic
were as follow: the total scoreof the group patientwas
obtainedby multiplying the number of casesallocated
to eachgradeandaddingthe resultantfigures.
For rejectionscorewe just multiplied the score
of local infection and local allergic reaction, where
callus formationthe scorewas takenby itself.
4
N=20
The average rejection score of the cancelous
allograft group is 4.20, while in non allograf group is
4.00. The averagerejection score using cancelous
allograft and without any graft almost the same for
femaleand malepatient.(P> 0.05)
Probably the difference in average rejection
scorewasdue to the age patient,which were divided in
tllose age of under 30 and those over 31 years old. as
shown in Table 3. However the cancelousallograft
group did not give higller averagerejectionscore in all
ages betweenthose under 30 years old and over 31
yearsold (P>0.05)
Table3. Rate of rejection score between cancelous
allograft and without any graft in emergency
orthopaedicoperationbasedon age
~
Cancelous
ft
Age
-allogran II
< 30 y.o
4.38 :t 0.48
n=8
>31 y.o
In analyzing and comparingthe effect of graft
from the two groups of patients, tIle statistical used
162
4.25:t0.37
n-l1
Non graft
-
P values
4.18:t 0.39
P> 0.05
n-ll
4.11:t0.31
n=9
P>0.05
Risalah Peltemuan Ilmiah Penelilian dan Pengembangan -'\Ollkasilsalop dan Radi3si, 2(X)1
After tllfee weeks operation, in both of two
groups of patient, callus fonnation could not be
evaluated using conventional radiology examination.
Only one case ie 18 years old patient in cancelous
allograft group gave a minimal callus fonnation. After
six weeks, the average score of callus fonnation in
cancelousallograft groups is significantly higller tllan
non cancelousallograft (P < 0,05), as can be seenat
Table4.
Cancelous allograft is able to increase tile
averagescore of callus fonnation from 2.45 to 3.35 in
both sexes. According to our finding, there is also
higher averagescoreof callus fonnation in tile group
of cancelousallograft at both age group of under 30
years and those over 31 years old as can be seenat
Table 5 (P>0.05).
Table4. Rate of callus formation accordingmale and
female after 6 weeks between cancelous
allograft and without any graft
--Sex
Male
-~
Female
Cancelous
11 + 0.45
ft
3.29
allO1!,fan
Non+~graft
2.42
0.49
Ji='14
";-12
3.33+ 0.47
2.38+ 0.48
IF 6
Ji='s
PP values
< 0.05
P < 0.05
The average score of callus fonnation in
cancelous allogrnft group is higller in group of age
below 30 years old comparedto ot11ergroup, that is
increasingfrom 2.45 to 3.38. While in the age of over
31 yearsold could only increasefrom 2.67to 3.17.
Table 4. Rate of callus fonnation according to age
group after 6 weeksof operation
Age
< 30 y.o
Cancelous
allograft
Non graft
P values
3.38:!: 0.48
2.45 :!:0.50
P < 0.05
n=8
>31 y.o
n=]]
3.17:!:0.37
2.67:!:0.47
n=12
n=9
P<0.05
DISCUSSION
Many cases of emergencyorthopaedicoperation
with internal fixation can causevasculardisturbanceat
the site of fractures in achieving stable fixation and
anatomical reduction. So there is no stilnulus for
productionof either externalcallus from the periosteum
or internal callus from endosteumand becauseof that
the fractures healing maybedelayed. (1,z,11,13)In that
case we have to stimulatecallus fonnationby applying
bone grafting. Severalmethods have beendescribed
for callus fonnation and one of them is by using
cancelousallograft.(2,4,6,8,9,11,14).
We found that local infection, local allergic
reactionand sistemic reaction after using cancelous
allograft are not significantlydifferent than that without
using any graft for both male and female in all patients
observed. Its easyto understandthat there is no local
and sistemicrejectionof using cancelousallograft. It is
alsoprovedthat cancelousallograft can stimulatecallus
foffilation in all of the patientsobserved.
CONCLUSION
As there is no complication and significant
increasingcallus formation in all of observedpatients
using allograft, it can be concluded as well as
recommended that this method can be used in
emergencyorthopaedicoperation.
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