Bone-Marrow Aspiration
The procedure is performed with the patient under general anesthesia. The
patient is placed on the operating table in a supine position with the arms
stretched out to the sides. Under strictly sterile conditions and following
the intravenous administration of prophylactic antibiotics, a 3-mm incision is
made at the level of the anterior iliac crest on both sides. The needles for
bone-marrow aspiration are introduced by hand deep into both iliac crests
(Fig. 1), and the bone marrow
is aspirated with 10-mL syringes rinsed with a buffer solution containing 400
mL of phosphate-buffered saline solution, 25,000 U of heparin, and 100 mL of
human albumin to avoid clotting. The contents of each syringe are then
transferred into the bag of the bone-marrow-collection kit (R4R 2107; Baxter,
Deerfield, Illinois) to obtain a final volume of 400 mL of bone marrow
(Fig. 2). The rest of the
bone-marrow preparation takes place in a sterile room in the cellular and
molecular therapy unit, as described below. In the meantime, the second step
of the procedure, the core decompression, is accomplished.
Core Decompression
A c-arm fluoroscope is draped with a sterile sleeve and is positioned over
the hip region to allow an anteroposterior view and, after flexion of the knee
and abduction of the hip, a frog-leg lateral view of the proximal part of the
femur (Fig. 3). Under
fluoroscopic control, a 5-mm incision is made laterally through the skin and
the fascia at the level of, or just distal to, the greater trochanter
(Fig. 4). A drill hole is made
manually in the lateral femoral cortex. A 3-mm trephine (Chirurgical
Maintenance, Brussels, Belgium) is then inserted manually under fluoroscopic
control through the trochanter, the femoral neck, and the femoral head to the
necrotic lesion (Fig. 5), as
described by one of us (J.-P.H.) and
colleagues4,5.
The direction of the trephine must be adjusted in both planes so that it is
pointing toward the necrotic zone (Fig.
6). The position of the trephine must be checked on both the
anteroposterior and the lateral fluoroscopic view. Finally, the tip of the
trephine is placed at a distance of 2 to 3 mm from the articular cartilage
(Fig. 7).
Bone-Marrow Grafting
In the cellular and molecular therapy unit, the bone marrow is filtered to
eliminate bone spicules, fat, and cellular debris. The bone-marrow cells are
then gravity-filtered through a series of successively smaller-diameter mesh
filters and are collected in a sterile plastic transfer pack. Mononuclear
cells are sorted on a Spectra cell separator (777006-300; Cobe, Lakewood,
Colorado) and are concentrated to a final volume of 50 mL. Bacterial and
fungal cultures are performed routinely.
CRITICAL CONCEPTSINDICATIONS:Stage-I or II osteonecrosis of the femoral head, according to the system of
the Association Research Circulation
Osseous6.CONTRAINDICATIONS:Skin lesions affecting the lower limbActive infectionCoagulopathyAnemia (hemoglobin level of <100 g/L) and leukopenia (total leukocyte
count of <4000/mm3 [<4.0 × 109/L])PITFALLS:Pain at the site of the bone-marrow aspirationHematoma at the site of the core decompressionThe trephine can be inserted too close to the articular cartilage.
Therefore, the position of the trephine must be checked carefully on both the
anteroposterior and the frog-leg lateral fluoroscopic view.Because of the small diameter of the trephine, it is possible to bend it,
especially in the region of the femoral neck. Therefore, the trephine should
be introduced very carefully by hand.AUTHOR UPDATE:There have been no changes in the surgical technique since the time of
publication of the original paper.
CRITICAL CONCEPTS
INDICATIONS:
Stage-I or II osteonecrosis of the femoral head, according to the system of
the Association Research Circulation
Osseous6.
CONTRAINDICATIONS:
Skin lesions affecting the lower limbActive infectionCoagulopathyAnemia (hemoglobin level of <100 g/L) and leukopenia (total leukocyte
count of <4000/mm3 [<4.0 × 109/L])
Skin lesions affecting the lower limb
Active infection
Coagulopathy
Anemia (hemoglobin level of <100 g/L) and leukopenia (total leukocyte
count of <4000/mm3 [<4.0 × 109/L])
PITFALLS:
Pain at the site of the bone-marrow aspirationHematoma at the site of the core decompressionThe trephine can be inserted too close to the articular cartilage.
Therefore, the position of the trephine must be checked carefully on both the
anteroposterior and the frog-leg lateral fluoroscopic view.Because of the small diameter of the trephine, it is possible to bend it,
especially in the region of the femoral neck. Therefore, the trephine should
be introduced very carefully by hand.
Pain at the site of the bone-marrow aspiration
Hematoma at the site of the core decompression
The trephine can be inserted too close to the articular cartilage.
Therefore, the position of the trephine must be checked carefully on both the
anteroposterior and the frog-leg lateral fluoroscopic view.
Because of the small diameter of the trephine, it is possible to bend it,
especially in the region of the femoral neck. Therefore, the trephine should
be introduced very carefully by hand.
AUTHOR UPDATE:
There have been no changes in the surgical technique since the time of
publication of the original paper.
The mean number of leukocytes (and standard error of the mean) injected in
our study was 2.0 ± 0.3 × 109, including 1.0% ±
0.2% of CD34+ cells, which are precursors of hematopoietic cells.
Fibroblast colony-forming units were used as an indicator of stromal cell
activity. The mean number of fibroblast colony-forming units was 92 ±
9/107 cells. The sorted bone marrow-mononuclear cells contained
lymphocytoid cells (mean, 29% ± 2.2%), monocytoid cells (4% ±
1%), and myeloid cells (6% ±
1.3%)3.
Injection of the Bone Marrow
The 50 mL of mononuclear cells is then injected through the trephine that
was placed into the necrotic lesion. It is possible to inject 50 mL since the
necrotic zone contains intertrabecular spaces that can be filled with bone
marrow. The injection is performed slowly over a few minutes
(Fig. 8). In some but not all
cases, the pressure required to inject the marrow is quite high and leakage of
marrow may occur through the trephine site. However, this has not been a
problem.
Postoperative Care
Postoperatively, all patients are treated prophylactically for twenty-four
hours with an intravenous infusion of cefazolin. The average hospital stay is
three days. Patients remain non-weight-bearing on the operatively treated side
for three weeks, after which total weight-bearing is permitted. Sutures are
removed seven days after the surgery.
Note: The authors thank Dr. M. Toungouz and Ms. M. Lambermont
for their help in the bone-marrow preparation.