Temporal trends in the incidence, treatment and outcomes of hip fracture after first kidney transplantation in the United States.

It is currently unknown whether any secular trends exist in the incidence and outcomes of hip fracture in kidney transplant recipients (KTR). We identified first-time KTR (1997-2010) who had >1 year of Medicare coverage and no recorded history of hip fracture. New hip fractures were identified from corresponding diagnosis and surgical procedure codes. Outcomes studied included time to hip fracture, type of surgery received and 30-day mortality. Of 69,740 KTR transplanted in 1997-2010, 597 experienced a hip fracture event during 155,341 person-years of follow-up for an incidence rate of 3.8 per 1000 person-years. While unadjusted hip fracture incidence did not change, strong confounding by case mix was present. Using year of transplantation as a continuous variable, the hazard ratio (HR) for hip fracture in 2010 compared with 1997, adjusted for demographic, dialysis, comorbid and most transplant-related factors, was 0.56 (95% confidence interval [CI]: 0.41-0.77). Adjusting for baseline immunosuppression modestly attenuated the HR (0.68; 95% CI: 0.47-0.99). The 30-day mortality was 2.2 (95% CI: 1.3-3.7) per 100 events. In summary, hip fractures remain an important complication after kidney transplantation. Since 1997, case-mix adjusted posttransplant hip fracture rates have declined substantially. Changes in immunosuppressive therapy appear to be partly responsible for these favorable findings.

Heterotopic ossification after the use of commercially available recombinant human bone morphogenetic proteins in four patients.

Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results.

Recombinant human granulocyte macrophage-colony stimulating factor (rhGM-CSF) and autologous melanoma vaccine mediate tumor regression in patients with metastatic melanoma.

In mice, significant immunoprotection was achieved using B16 melanoma cells transfected with granulocyte-macrophage colony-stimulating factor (GM-CSF) as vaccines (Dranoff G, Jaffee E, Lazenby A, et al. Vaccination with irradiated tumor cells engineered to secrete murine granulocyte-macrophage colony-stimulating factor stimulates potent, specific, and long-lasting anti-tumor immunity. Proc Natl Acad Sci USA 1993;90:3539-43). The aim of this study is to test the hypothesis that recombinant human GM-CSF (rhGM-CSF) injected with autologous melanoma vaccine may result in tumor rejection in melanoma patients. Twenty stage IV melanoma patients were treated as outpatients with multiple cycles of autologous melanoma vaccine and bacillus Calmette-Guérin (BCG) plus rhGM-CSF injection in the vaccine sites. Two patients (10%) showed a complete response, with one patient showing resolution of subcutaneous, hepatic, and splenic metastases. In the second patient, buccal, subcutaneous, pulmonary, paraaortic, hepatic, splenic, and retroperitoneal metastases regressed completely. Two patients (10%) showed partial response, with regression of a paraaortic metastasis in one patient. In the second patient, there was shrinkage (> 75%) of a large hepatic lesion. One patient has been rendered free of disease after resection of a single pulmonary metastatic nodule. Three patients (15%) had stable disease during treatment but subsequently developed progression of disease. In 12 patients (60%), the disease progressed. Side effects were minimal. In a separate pilot study, 15 stage IV melanoma patients were also treated with autologous melanoma vaccine with BCG but not with rhGM-CSF; none responded. The fact that four patients showed objective responses to active specific immunotherapy with rhGM-CSF demonstrates that melanoma patients bearing a significant tumor burden may respond specifically to their autologous melanoma.

Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defects.

Thirty-six patients were treated by Ilizarov transport in conjunction with muscle and myocutaneous flaps coverage. Thirty-one free flaps and 5 rotation flaps were performed. In 13 patients the procedures were carried out in 1-stage or simultaneous manner. In 23 patients, soft tissue coverage proceeded as the initial step followed by Ilizarov reconstruction as a delayed procedure. All flaps survived the simultaneous and delayed procedures and there were no anastomotic complications, but partial flap necrosis occurred in 1 patient 3 months after the index procedure at the time of flap elevation for docking site bone graft placement. The mean segmental defects were 10 cm and 5.8 cm for the simultaneous and delayed groups, respectively. The followup interval from the time of free flap coverage ranged from 2 to 44 months in the simultaneous group with a mean and median of 22 and 24 months, respectively. Twelve patients completed treatment in the simultaneous group with the followup interval from frame removal ranging from 3 to 36 months with a mean and median of 18 and 14 months, respectively. In the delayed group this interval ranged from 1 to 36 months, with a mean and median of 16 and 12 months, respectively, and a mean and median of 24.5 and 21 months, respectively, from the time of the index procedure. Union and absence of infection were achieved in 35 of 36 patients presenting with an acute open fracture, infected nonunion, or aseptic nonunion without stable soft tissue coverage. The Ilizarov fixators remained in place for a median of 9.5 months for the simultaneous group and 8.5 months for the delayed group. When soft tissue defects accompany an infected nonunion or high grade open fracture, the traditional Ilizarov treatment approach of soft tissue recruitment into the wound from the distant corticotomy site is inconsistent with the proven benefit of early soft tissue coverage. The combined approach provides a more reliable soft tissue bed for early cancellous bone grafting of the docking site and permits the accurate restoration of limb length for these very difficult problems.

Magnetic resonance imaging diagnosis of discoid medial meniscus.

A case of discoid medial meniscus of the massive type diagnosed preoperatively by magnetic resonance imaging is presented. Additionally, the preoperative studies and arthroscopic findings are presented.

The Ilizarov method.

While the use of external fixators is not revolutionary, the Ilizarov apparatus has dramatically improved the application of the principles of external fixation to the management of bony defects, malunions, infections, and pseudarthroses. Since its formal introduction in Western Siberia in 1951 by Gavril Abramovich Ilizarov, an international cadre of surgeons has employed its methods to pioneer modern limb salvaging procedures. Such techniques are made possible by the numerous advantages, including immediate loading of the limb postoperatively, and the use of healthy viable bone to replace devascularized dead bone "in situ" by osteoclasis, localized transport and osteogenesis. Accordingly, leg length discrepancy, deformity and infected nonunions may all be treated effectively. The basic premise of the llizarov technique is that osteogenesis can occur at a surgical osteotomy site given the appropriate degree of retained vascularity, fixation and quantified distraction. This dogma is a function of many variables which Ilizarov classified into three categories; biological, clinical, and technical. First, biologic variables include preservation of endosteal and periosteal blood supply via corticotomy and stable fixation to prevent shear forces, but to permit axial dynamization with postoperative weight bearing. Distraction should occur at approximately 1 mm. per day divided into four times per day. At the termination of distraction, neutral fixation should be permitted to allow strengthening of the new bone. In essence, the technique fools the body into believing it is a child again. The corticotomy sites now act as physes.