HLA sensitization and allograft bone graft incorporation.

UNLABELLED: Achieving union between host bone and massive structural allografts can be difficult. Donor and recipient human leukocyte antigen (HLA) mismatches and recipient antibody response to donor HLA antigens might affect union. In a prospective multiinstitutional study, we enrolled a consecutive series of patients receiving cortex-replacing, massive structural bone allografts to determine the rate of donor-specific HLA antibody sensitization and to investigate the potential effect of such HLA alloantibody sensitization on allograft incorporation. HLA typing of patients and donors was determined by molecular typing methods. Donor-specific HLA sensitization occurred in 57% of the patients but had no demonstrable effect on graft incorporation or union. The type of host-allograft junction did have a major effect on graft incorporation. Cortical-to-cortical allograft-to-host junctions healed more slowly (mean, 542 days) than corticocancellous to corticocancellous allograft-to-host junctions (mean, 243 days). Although HLA sensitization does not appear to delay structural allograft bone incorporation, further followup is required to determine if there is an association between HLA sensitization and long-term graft survival. Based on these preliminary data, measures to further minimize or modulate HLA sensitization or response are not indicated at present for the purposes of improving structural bone allograft union. LEVEL OF EVIDENCE: Level II, prognostic study.

The female athlete.

Over time, women have become more extensively involved in athletic programs. The female athlete presents a unique challenge to sports medicine in general. Although specific types of injuries are the same as in the male athlete, the female athlete is at higher risk for some of these injuries. Injuries may be sport specific, but gender-related injuries are also related to morphologic and physiologic differences between the male and female athlete. This article reviews some of the differences between the male and female athlete and focuses on a few prominent injuries or risks related specifically to the woman athlete.

Diffuse pigmented villonodular synovitis: preliminary results with intralesional resection and p32 synoviorthesis.

Because of the high local recurrence rate associated with surgical resection alone, patients with diffuse intraarticular pigmented villonodular synovitis were treated with surgical resection followed by colloidal chromic P32 synoviorthesis. The medical records of nine consecutive patients treated in this manner were reviewed retrospectively to determine the recurrence rate of pigmented villonodular synovitis. All patients had either one or two surgical resections (arthroscopy in one patient, open resection in seven, arthroscopy and open resection in one). The involved joints included six knees and one each, ankle, elbow, and hip. Eight of the nine patients remained recurrence free at a mean followup of 38 months (range, 19-60 months) after surgery. One patient had a suspected asymptomatic recurrence documented by magnetic resonance imaging 29 months after surgery. Seven patients reported their normal activities as unrestricted. Five reported improved activity levels, one reported the activity level remained the same, and one reported activity as the same or better. None reported reduced activity levels. In these patients synoviorthesis with colloidal chromic P32 following gross resection of all obvious pigmented villonodular synovitis provided local disease control in all but one.

Biceps Brachii Compartment Contrast Media Extravasation with Surgical Correlation.

We describe a case in which 120 ml of contrast media was extravasated into the biceps brachii compartment with a power injector during the course of an attempted CT angiogram. The patient underwent surgical fasciotomy and drainage. The radiographic appearance and clinical implications of this event are discussed.

Human leukocyte antigen sensitization after structural cortical allograft implantations.

UNLABELLED: The incidence and significance of a donor-specific human leukocyte antigen antibody response to massive fresh-frozen human bone allograft implantation is not established. This study was a prospective, multicenter study of a cohort of consecutive patients who self-randomized themselves into two groups based on their alloantibody response to allograft bone transplant. The study hypothesis was that donor-directed antibodies are an independent risk factor influencing incorporation of massive frozen bone allografts. Pretransplant and posttransplant human leukocyte antigen alloantibody analysis was performed and correlated to determine pre-existing and graft-induced antibodies. The surgical outcomes of the two groups of patients were compared to determine the relationship between alloantibody response and bone graft incorporation. Preliminary results revealed that donor-specific human leukocyte antigen sensitization occurred in 17 of 32 (53%) of previously nonsensitized patients. A survival analysis of time to healing based on human leukocyte antigen status showed no evidence of an association between human leukocyte antigen status and time to healing. Longer followup in additional patients will be required to determine if this sensitization is correlated with an alteration in the time to union or with the quality or type of bone graft incorporation. LEVEL OF EVIDENCE: Therapeutic study, Level II. See the Guidelines for Authors for a complete description of levels of evidence.

Are plain radiographs of the spine necessary during evaluation after blunt trauma? Accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis.

BACKGROUND: Fracture of the thoracolumbar (TL) spine is reported in 8 to 15% of victims of blunt trauma. Current screening of these patients is done with conventional radiography. This may require repeated sets of films and take hours to days. It is imperative that these patients get timely, accurate evaluation to allow for treatment planning and early mobilization; alternatives to plain films would aid in this. The objective of this study is to determine whether the data obtained from admission chest/abdomen/pelvis (CAP) computed tomography (CT) scans after blunt trauma has utility in thoracolumbar spine evaluation. METHODS: The records of all patients admitted to a Level I trauma center over a 2-month period who underwent CAP CT were reviewed for the presence of TL spine fracture, time to completion of plain film evaluation, and clinical course. Admission CT scans were reviewed by an attending radiologist who was blinded to any previously diagnosed spine fractures. The two tests were compared for diagnostic accuracy and their discriminatory ability was compared using receiver operating characteristic (ROC) curves. Significance was defined as p < 0.05. RESULTS: In all, 103 patients were admitted from January 1, 2003 to February 28, 2003 and underwent CAP CT scan as part of their initial trauma evaluation. Of these, 26 (25%) had thoracolumbar fractures. Seven (27%) thoracolumbar fractures were not seen on plain radiographs taken during the trauma evaluation. Average time until plain film completion in this group was 8 hours (range, 44 minutes to 38 hours). All 26 (100%) patients with fractures, however, were diagnosed on CT scan performed shortly after admission. Of the remaining 77 patients, two (2.6%) were falsely read as positive for fracture on CT. Sensitivity and specificity of CT scan for thoracolumbar fracture were excellent at 100% and 97%, respectively, with a negative predictive value of 100%. Plain radiographs were 73% sensitive, 100% specific, and had a negative predictive value of 92%. Area under the ROC curve for CT was 0.98, but for plain film was 0.86 (p < 0.02). CONCLUSION: Admission CAP CT obtained as part of the routine trauma evaluation in these high-risk patients is more sensitive than plain radiographs for evaluation of the TL spine after blunt trauma. In addition, CAP CT can be performed faster. Omission of plain radiographs will expedite accurate evaluation allowing earlier treatment and mobilization.

Magnetic resonance characteristics of medial plica of the knee: correlation with arthroscopic resection.

OBJECTIVE: The purpose of this study was to determine if there are magnetic resonance (MR) characteristics of the medial plica that correlate with the likelihood of plica resection. METHODS: Sixty-six knee MR examinations from patients who underwent subsequent knee arthroscopy were evaluated retrospectively for the presence of a medial plica. The plicae were then characterized by relative width, thickness, relation to the trochlear cartilage, associated cartilage changes, and effusion. The arthroscopy reports from each knee were reviewed for the presence, description, and resection of medial plicae. RESULTS: A medial plica was demonstrated by MR in 46 of 66 (69.7%) cases. A medial plica was mentioned in 16 of 66 (24.2%) arthroscopic reports. No MR characteristics were significantly predictive of resection. Location of a plica adjacent to cartilage had a P value of 0.0786, plica width had a P value of 0.0858, and plica thickness had a P value of 0.1685. CONCLUSION: No MR characteristics of medial plicae were found to be predictive of subsequent resection at arthroscopy.

Nontraumatic avulsions of the pelvis.

OBJECTIVE: The purpose of this report is to describe the imaging findings of nontraumatic avulsions of the pelvis. CONCLUSION: A diagnosis of avulsion fracture of the pelvis in an adult without appropriate history of substantial trauma must raise the suspicion of an underlying malignancy. If a patient has not been diagnosed as having a primary neoplasm, additional imaging evaluation is recommended. Also, biopsy may be considered in the proper clinical setting.