Partridge osteosynthesis: a prospective clinical study on the use of nylon cerclage bands and plates in the treatment of periprosthetic femoral shaft fractures.

OBJECTIVE: To evaluate the clinical use of the Partridge osteosynthesis in periprosthetic femoral fractures. DESIGN AND SETTING: Prospective nonrandomized clinical study. PATIENTS: Over a ten-year period, 222 patients presenting with femoral fractures near the tip of a hip prosthesis were treated with the Partridge system, which employs elevated cerclage nylon bands and flexible elevated nylon plates. Sixty-five fractures were located cranial to the tip of the prosthesis (Whittaker Type I), 116 at the tip (type II), and forty-one distal to the tip of the prosthesis (Type III). The population consisted of 172 female and fifty male patients, with a mean age of 79.5 years. The mean duration between the index procedure and occurrence of the second fracture was 1.5 years. In 78 percent of the patients (173 out of 222), surgery was undertaken within forty-eight hours. Fracture reduction was open, and two nylon plates set at right angles to each other were secured to the femur with six to eight nylon bands. The mean operating time was fifty-five minutes, with an average blood loss of 550 milliliters. RESULTS: There were minor wound healing problems in eighteen patients (12.6 percent); there were no deep wound infections. Thirty-three elderly patients died within the first month from medical complications. Of the 189 remaining patients, 60 percent regained their prefracture functional level within six months postoperatively, whereas 25 percent required a higher level of care. The mean time of the in-hospital stay was thirty-three days. Ninety-three percent of the fractures consolidated with abundant callus during the follow-up period of one year. CONCLUSION: The indication for the use of this simple osteosynthesis method is swift convalescence by splinting the periprosthetic femoral fractures. Even with a loose prosthesis, the fracture often healed with abundant callus and the patient could be mobilized.

[Nothing gained from the determinations of plasma lactate levels in the evaluation of a patient with acute abdomen]. / Geen meerwaarde van bepaling lactaatplasmaconcentratie bij de beoordeling van een patiënt met een acute buik.

OBJECTIVE: To establish the diagnostic value of laboratory tests, especially the plasma lactate concentration, for determination of the indication for acute surgery in patients with an acute abdomen. DESIGN: Cross-sectional study. SETTING: Kennemer Gasthuis, location Elisabeth Gasthuis, Haarlem, the Netherlands. METHOD: The study group consisted of all 200 successive patients presenting at the emergency room with acute abdomen from June 1993 to December 1994 (19 months). Patients with suspected acute appendicitis were excluded. The diagnosis and indication for surgery if any were based on case history, physical examination, radiological examination if performed and standard laboratory tests: ESR, leukocyte count, haemoglobin, creatinine and amylase. The first matter considered was to what extent the indication for acute operation based on these clinical criteria was in agreement with the diagnosis at discharge. The next question studied was what would be the extra value of the plasma lactate concentration which, although determined, had not been reported to the clinician. Statistical analysis was performed using the two-sample Student t test and the chi 2 test. A p-value of < 0.05 was regarded as statistically significant. RESULTS: Fifty-four patients were operated within 24 hours for good reasons, six were incorrectly not operated within 24 hours, 128 correctly received conservative treatment and 12 were correctly treated conservatively and subsequently underwent operation after longer than 24 hours. Diagnostics based on the clinical criteria had a sensitivity of 90%. The mean plasma lactate concentration, temperature and ESR were statistically significant more often increased in the operated patients than in those treated conservatively. The sensitivities of these determinations were 75%, 67% and 40% (all: p < 0.05). The lactate concentration was increased in 50% of the patients who in retrospect had incorrectly not been subjected to acute surgery. CONCLUSION: Neither determination of the plasma lactate concentration nor the results of the separate standard laboratory tests in acute abdomen patients resulted in a better sensitivity for the determination of an indication for acute surgery than clinical examination combined with standard laboratory tests and, if desired, supplementary radiology.

Sensitivity, specificity and predictive values of breast imaging in the detection of cancer.

In an observational follow-up study we determined whether the combined use of mammography and breast ultrasonography is an appropriate diagnostic tool to select patients with symptomatic breast disease who need additional pathological evaluation. Mammography and ultrasound were used as complementary diagnostic modalities in 3014 consecutively referred and mainly symptomatic patients. Sensitivity, specificity, predictive values and likelihood ratios were calculated according to standard procedures. Virtually complete follow-up was obtained by correlating the radiological diagnosis with clinical records, final pathological findings, records from the Cancer Register and data from questionnaires sent to the general practitioners of all the referred patients. After an average follow-up period of 30 months, the sensitivity for breast cancer detection was 92.0% and the specificity 97.7%. A positive predictive value of 68.0%, a negative predictive value of 99.6%, a positive likelihood ratio of 40 and a negative likelihood ratio of 0.08 were found. The mean diagnostic delay as a result of false negative examinations was 9 months (range 0-20 months). We conclude that breast imaging in routine daily practice, consisting of the integral use of mammography and ultrasonography, is an appropriate tool in the detection of cancer and should be included in the work-up of symptomatic breast disease.

Vascular injury from external fixation: case reports.

The incidence of vascular injury from external fixation of fractures was studied retrospectively in two surgical departments during the period 1985-1990. A total of 1231 fractures of the lower limb were treated. External fixation was used in the initial stabilization of 28 femoral and 93 tibial fractures. In this series of 121 fractures four iatrogenic vascular injuries were seen: two arterial thromboses with distal ischemia and two incidents of the formation of a false aneurysm with bleeding along a pin. The diagnosis was made by angiography. Surgical intervention was necessary in all four cases. In one patient the injury resulted in amputation of the distal portion of the foot.

Accessory soleus muscle mimicking a soft tissue tumor. A report of 2 patients.

An accessory soleus muscle is rare, and may present as a soft tissue tumor at the ankle. We report 2 patients in whom the diagnosis was not considered until after surgical exploration. Magnetic resonance imaging (MRI) after biopsy clearly identified muscle tissue, and electromyography showed normal motor unit activity.

Hibernoma, a brown fat tumour.

The case history of a 41-year-old man with a hibernoma in the scapular area is presented. Hibernomas are rare tumours of brown fat origin. The brown colour is due to the rich vascularity and the high cytochrome content of the metabolic active brown-fat cells. In spite of the angiographic appearance, hibernomas are benign and treatment by local excision is curative. A survey of the literature is given.