ISSN 0001-6012/2019/61/2/77-80 Acta Médica Costarricense, © 2019 Colegio de Médicos y Cirujanos de Costa Rica

Living donor bone bank: Costa Rican experience

(Banco de huesos a partir de donantes vivos: experiencia costarricense)

Nefertiti Chaves-Solano

Abstract

Aim: The use of bone grafts is a common practice in orthopedic surgeries. However, the daily problem in traumatology is the limited access to adequate bone grafts. These grafts provide mechanical stability in the affected area of the bone, as well as repair and regeneration of weaknesses through osteoinductive, osteogenic and osteoconductive properties. The main objective of this report is to provide information about the experiences and the importance of establishing a Bone Bank in Costa Rica.

Method: all relevant information was gathered to provide a brief overview of the establishment of a Bone Bank in Costa Rica. First, legal issues were taken into consideration; followed by the definition of the donor exclusion criteria according to international standards. Potential donors were defined as all patients undergoing hip or knee replacement surgeries. In order to select the right donors, blood samples from all potential donors were tested for transmittable diseases. Bone tissues were obtained in the operating room to be processed later, under strict standardized conditions. Once the tissues were processed, allografts were stored at -80°C until the transplantat procedures were carried out.

Results: Between 2016 and 2019, the bone bank had a total of 69 donors and 258 bone allograft recipients, all of them were patients at the Trauma Hospital.

Conclusion: The establishment of the bone bank in Costa Rica has been a challenge for the National Insurance Institute (INS). The goal is to make the Bone Bank available to the medical community in general, in order to strengthen the tissue donation and transplant network in Costa Rica.

Keywords: Allografts, tissue banking, tissue donation, bone.

Author’s affiliation: Trauma Hospital’s Bone Bank, Instituto Nacional de Seguros-Red de Servicios de Salud, Costa Rica. neferchavesrss@ins-cr.com

Resumen

Objetivo: el uso de injertos óseos es una práctica común en cirugías ortopédicas. Sin embargo, el problema diario en traumatología es el acceso limitado a injertos óseos adecuados. Estos injertos permiten proporcionar estabilidad mecánica en el área del defecto óseo, así como reparar y regenerar los defectos a través de sus propiedades osteoinductivas, osteogénicas y osteoconductivas. El objetivo principal de este trabajo fue proporcionar información a la población sobre las experiencias y la importancia de establecer un Banco de Huesos en Costa Rica.

Metodología: se recopiló toda la información relevante para proporcionar un breve resumen del establecimiento de un banco de huesos en Costa Rica. En primer lugar, se tomó en cuenta consideraciones legales, seguido por la definición de los criterios de exclusión de donantes de acuerdo a los estándares internacionales. Los potenciales donantes se definieron como los pacientes sometidos a reemplazo de cadera y de rodilla. Con el fin de elegir los donantes adecuados, a todos los

Living donor bone bank / Chaves-Solano

answered a questionnaire in order to detect potential risks of any transmittable diseases. Medical records were also analyzed to detect exclusion criteria for bone donation (Table 1).

Laboratory tests: serology and NAT blood tests were performed on samples from all of the initially screened donor candidates to detect antibodies to human immunodeficiency virus (HIV), Hepatitis B and C Virus, Chagas´s disease, Human T-cell lymphotropic virus (HTLV type I and II) and syphilis. All these test were performed according to Costa Rican policy No. 30697S “Norms for the habilitation of immunohematology divisions and blood bank” and following the guidelines of “Standards for Blood Banks and Transfusion Services”, 31st Ed of AABB.

Bone specimens: approximately 50g of bone tissues from femoral heads and tibial plateaus were aseptically obtained from living donors. Tissues were collected in the operating room and placed in two sterile bags that were identified with the patient´s name, age, surgeon´s name, and the date of the surgery. The bags containing the tissues were immediately transported in a cooler to the bone bank where they were stored at -80°C in an isolated area until processed. 13,14

Table 1. Main criteria for the exclusion of bone donors(15)
Under 18 years of age Active or recent systemic infection Active or recent coxitis and / or osteomyelitis. Active infection of ‘’ slow virus ‘’ or anamnesis in the past Recent vaccination (<4 weeks) against attenuated viruses such as measles, yellow fever, mumps, polio, oral typhoid fever or rubella. Rheumatoid arthritis Autoimmune diseases Metabolic disorders Growth hormone treatments Chronic medication (especially corticosteroids) Recent exposure to toxic substances Malignant neoplasms Recent exposure to radiation Dementia Barrier of language, or when the patient does not understand the information for some reason (for example psychiatric patients). Recent tattoo or piercings (last 6 months) Medical history of diseases such as syphilis, tuberculosis, brucellosis, Chagas, HBV, HCV, HIV / AIDS and HTLV Use of intravenous drugs People who work in prostitution or their sexual partner does, in the last 6 months. Hemophiliac patients managed with coagulation factors Hospitalization time longer than 8 days

Bone tissue processing: all procedures were performed under sterile conditions following aseptic and antiseptic techniques. The Bone Bank is located in an area of the Trauma Hospital with restricted access. Tissues were processed in a class II biosafety cabinet. Cartilage and muscle tissue were removed manually from the bone by using sterile scalpels and tweezers. Bone tissue was cut using an orthopedic saw, into small pieces of approximately 5cm2, followed by a milling procedure. The tissue was placed into a bottle containing sterile water at 60°C; it was incubated for 40 minutes in order to remove fat, bone marrow, and blood remains. Disinfection procedures were also carried out with several alcohol and hydrogen peroxide washes. At the end of the process, a sample tissue was collected and transported to an external microbiology laboratory where aerobic and anaerobic bacteria and fungal cultures were performed following the 4th edition of Clinical Microbiology Procedures Handbook of American Society for Microbiology standards. Any bone allograft with a positive bacteria culture result would be discarded.

Bone allografts were dispensed into 1, 5 and 10 cc vials and packed within two sterile polyethylene bags using vacuum sealing. Finally, the bagged allografts were stored in a freezer at -80°C, until receiving the results of the sample specimen’s cultures. Due to high demand in the Hospital, bone allografts are rapidly being used in patients and do not last more than 2 months in storage; although, bone allografts can be stored for up to five years. 16

Data control: All the information, including lab tests, informed consent, questionnaire, and clinical information, was coded and archived under controlled access at the Bone Bank administrative office, and will be kept for 10 years, in accordance with the Costa Rican regulation for donation and transplant of organs and tissues. All relevant information about the donors was both physically and digitally stored in order to have easy access to the data.

Results

Sixty nine (69) donated bones were received during the first three years of operation, (2016-2019). Sixty two percent (62%) of these tissues were femoral heads and the other 38% corresponded to femoral condyle and tibial plateau segments. Of all donated bones, only 70% were adequate to be processed and used as a final product. The remaining 30% of the bones were discarded. Principal causes for rejection were positive serology test results or history of contraindicated diseases for bone donation, being the most frequent Hepatitis B.

Two hundred fifty eight (258) patients at the Trauma Hospital were implanted with these bone allografts, mainly in joint fusion, open reduction and osteosynthesis surgical procedures, without presenting any complications related to the use of the bone allograft (Table 2). According to Nosocomial