1. Bone banks provide biological materials like bone grafts for orthopedic procedures. They have existed in Brazil since the 1950s and regulations were imposed in the 1990s. 2. Bone grafts integrate into the host bone through osteogenesis, osteoinduction, and osteoconduction. They are used to assist in fracture healing, spinal fusions, and replace bone defects. 3. The document discusses the types of grafts available, processing techniques, storage, risks, and an example of a bone bank in Bangladesh that has provided over 100,000 grafts since 2007.

1. 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:
1. Osteogenesis
2. Osteoinduction
3. 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
1. Assist in healing of fractures, delayed unions, or
nonunions
2. Assist in arthrodeses and spinal fusions
3. Replace bone defects from trauma or tumor

7. Options for graft
1. Autografts
2. Allografts
3. Demineralized bone matrix (DBM)
4. Synthetics
5. Bone morphogenetic protein (BMP)
6. 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:
1. Live donors,
2. Cadaver donors,

17. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

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

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

30. 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).

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

34. 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

35. 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

36. 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.

37. 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.

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

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

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

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

43. 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.

44. 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.

45. 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

46. 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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49. Thank you