Bone Bank

Introduction

• A bone bank is a specialized facility that collects, processes, stores, and supplies bone grafts for clinical use.
• Bone grafts provided by bone banks are:
  • Available on demand
  • Screened for transmissible diseases
  • Processed under controlled and standardized conditions

Why Bone Grafting Is Required

• To promote fracture union and fill bone defects in:
  • Fresh fractures
  • Delayed unions
  • Malunions and corrective osteotomies
• To fill cavities and defects following:
  • Bone cyst excision
  • Tumor resection
• To bridge joints for the purpose of arthrodesis
• To limit joint motion using bone blocks, such as in arthroereisis

Why a Bone Bank Is Necessary

• Autologous bone graft alone cannot meet the demand in:
  • Large tumor resections
  • Complex articular and extra-articular reconstructions during revision arthroplasty
  • Complex spinal fusion procedures
  • Tumor reconstruction and revision surgeries
• Bone banks provide an essential alternative source of graft material.

Functions of a Bone Bank

• Acquisition of donor bone
• Screening of donor tissue
• Processing of bone grafts
• Storage under controlled conditions
• Effective allocation and utilization of donor bone

Advisory Committee Structure

• Director of the institute as chairperson
• Hospital chief or medical superintendent
• Head of the Department of Orthopaedics
• Head of the Department of Pathology
• Head of the Department of Microbiology
• Two faculty members from the Department of Orthopaedics
• Two external members, including one woman, as per regulatory specifications
• One member nominated by the chairperson

Methods of Bone Banking

• Freezing at temperatures ranging from minus twenty degrees Celsius to minus eighty degrees Celsius
• Defatting followed by freeze drying and ethylene oxide sterilization
• Ionizing radiation to produce freeze-dried, gamma-irradiated bone allografts
• Autoclaving and boiling are not recommended due to:
  • Impairment of mechanical strength
  • Loss of osteoinductive capacity
  • Reduced graft incorporation

Bone Donation Sources

• Cadaveric donors, with retrieval performed as early as possible after death
• Live donors, where bone is obtained as surgical residue, including:
  • Femoral head from total hip replacement
  • Tibial bone from total knee replacement
  • Bone wedges from tibial osteotomies
  • Bone obtained during primary limb amputation

Cadaveric Bone Graft Retrieval

• Harvesting should be performed rapidly and, where possible, simultaneously
• Strict aseptic precautions equivalent to major orthopaedic surgery must be followed
• Bone is packed and transported in thermally insulated containers with dry ice
• Commonly retrieved bones include:
  • Ilium
  • Femur
  • Humerus
  • Tibia
  • Ribs
  • Vertebrae

Other Recoverable Tissues

• Stem cells
• Soft tissues such as tendons and ligaments
• Skin
• Fresh articular cartilage:
  • Initially refrigerated
  • Stored in culture medium
  • Maintains viability for up to twenty-eight days

Ethical Considerations

• Donors or next of kin must be fully informed
• Written informed consent is mandatory
• All donor samples must be screened for:
  • Human immunodeficiency virus
  • Hepatitis B
  • Hepatitis C
  • Syphilis

Donor Investigations

• Blood group and Rhesus factor
• Complete blood count
• Erythrocyte sedimentation rate
• C-reactive protein
• Viral screening for hepatitis B, hepatitis C, and human immunodeficiency virus
• Syphilis testing
• Malaria serology
• Microbiological culture reports
• Histopathological examination reports

Contraindications for Bone Donation

• Positive serology for human immunodeficiency virus, hepatitis B, or hepatitis C
• Septicaemia or systemic infection
• Active tuberculosis
• Fungal infections
• Presence or history of malignancy
• Significant autoimmune connective tissue disorders
• Significant exposure to toxic substances
• Recent major surgery or extensive burns
• Unknown cause of death
• Evidence of irradiation at the donor site

Age Criteria for Donation

• No upper age limit for morselized grafts or non-weight-bearing use
• Structural grafts for load bearing:
  • Preferred donor age less than fifty-five years without osteoporosis
• Metaphyseal and epiphyseal grafts:
  • Epiphyseal plate closure must be confirmed
• Osteochondral grafts, viable cartilage, or meniscus:
  • Donor age less than forty-five years
• Tendons or fascia lata:
  • Donor age less than sixty-five years

Types of Bone Grafts

Fresh Grafts

• High immunogenicity
• High risk of disease transmission
• Strong osteoinductive potential

Fresh Frozen Grafts

• Lower immunogenicity than fresh grafts
• Retain osteoinductive properties

Freeze-Dried Grafts

• Lowest immunogenicity
• Reduced structural strength
• Primarily osteoconductive

Donor Exclusion Criteria

Specific

• Confirmed human immunodeficiency virus infection
• History of intravenous drug abuse
• Hemophilia treated with clotting factor concentrates
• Recent tattooing or body piercing within six months

General

• Age below eighteen years
• Recent sepsis or systemic infection
• Active infection at the donor tissue site
• History of tuberculosis
• Acquired immunodeficiency syndrome
• Hepatitis B or hepatitis C
• Syphilis
• Recent live vaccination

Bone Processing Principles

• Removal of:
  • Soft tissue
  • Blood
  • Bone marrow
  • Fat
  • Periosteum
• Processing temperature should not exceed thirty-seven degrees Celsius for prolonged periods
• All processing steps for a bone segment should be completed in a single work period before freeze drying
• Freeze drying is performed for approximately one week until moisture content is below five percent
• Testing for ethylene oxide residues and residual moisture is mandatory
• Bone may be cut, crushed, or ground according to clinical requirements

Bone Processing Steps

• Bone is immersed in sterile distilled water and pasteurized at sixty degrees Celsius for three hours
• Frozen at minus forty degrees Celsius
• Washed using sterile distilled water with mechanical agitation to remove blood and fat
• Refrozen at minus forty degrees Celsius
• Stored in triple-layer polyethylene packaging

Sterilization and Quality Control

• Sterilization using gamma radiation at twenty-five kilogray from a Cobalt-sixty source
• Storage at minus eighty degrees Celsius
• Sterility testing using:
  • Nutrient broth
  • Brain heart infusion medium
  • Thioglycolate medium
  • Sabouraud dextrose medium
• Cultures incubated under:
  • Aerobic and anaerobic conditions at thirty-seven degrees Celsius for bacteria
  • Twenty-five degrees Celsius for fungi
• Observation period of fourteen days

Allocation and Clinical Use

• Written recipient consent is mandatory
• Expiry date of graft must be verified before use
• Graft thawing in physiological saline for thirty to sixty minutes
• Culture swab taken from graft prior to implantation
• Thorough washing with three to six litres of saline
• Antibiotic soaking using gentamicin before implantation
• All freeze-dried and frozen grafts require reconstitution
• Lyophilized grafts should be reconstituted aseptically at four degrees Celsius
• Structural or load-bearing grafts should be reconstituted for up to twenty-four hours
• Reconstituted grafts must be used within twenty-four hours

Bone and Tissue Bank Documentation

• Standard operating procedures
• Donor and recipient records
• Inventory and stock registers
• Graft usage and quality control records
• Clinical indication documentation
• Material and chemical inventory records

Challenges in Bone Banking

• Lack of uniform standardization and regulation
• Low donor awareness and persistent myths
• Infrastructure limitations
• Transport and cold chain maintenance
• Inter-institutional coordination difficulties
• Shortage of trained personnel
• Limited public and professional awareness

Bone Banks in India

• Parvathy Ortho Hospital
• Ganga Medical Centre and Hospitals Private Limited
• Rajiv Gandhi Government General Hospital
• Adyar Cancer Institute
• Kasturba Medical College and Hospital

Conclusion

• Bone banks play a critical role in modern orthopaedic surgery.
• They provide safe, readily available graft material for complex reconstructive procedures.
• Proper donor screening, meticulous processing, and strict quality control are essential.
• Expansion of bone banking services requires improved awareness, regulation, and infrastructure.