Excised Femoral Heads in Hip Fracture Patients: Is Osteoporosis Worse Than Cancer?

Introduction Annually 80,000 hip fractures are treated at an estimated cost of two billion pounds. The 2011 guidance from the Royal College of Pathologists recommended all specimens where there is fracture through or below the articular surface should be examined to exclude/ identify an underlying cause (pathological fracture). The questions posed in this study are three-fold. Firstly, how does our practice for hip fracture patients comply with the above audit standards? Secondly, what is the prognostic significance of a past medical history of malignancy on survival? Thirdly, is there any other prognostic survival difference attributable to the diagnosis concluded from the histological analysis of the excised femoral head specimens? Methods A retrospective analysis of all hip fractures receiving joint arthroplasty was undertaken between January 2011 and March 2014. Mortality was recorded for a minimum follow-up of 30 months post-operatively. Each excised femoral head was histologically examined by a single consultant histopathologist, and all pre-operative X-rays were reviewed by a consultant radiologist. Histological diagnoses were recorded, and statistical analysis including Kaplan-Meier survival was performed. Results A total of 327 consecutive fractures were identified. Out of 187 specimens sent for analysis, only two revealed metastatic deposits in patients with known disseminated malignancy. A previous medical history of malignancy did not confer a significant increase in mortality over a five-year postoperative period (p = 0.42). A histological diagnosis of osteoporosis significantly increased mortality over a five-year postoperative period (p = 0.004). A comparative analysis found that patients with a histological diagnosis of osteoporosis had the poorest survival. Conclusion A histological femoral head analysis may diagnose previously undiagnosed osteoporosis, allowing the clinician to intervene in a disease process, which if left untreated, can lead to a significant increase in mortality.

Accuracy of magnetic resonance imaging in planning the osseous resection margins of bony tumours in the proximal femur: based on coronal T1-weighted versus STIR images.

OBJECTIVE: Assessment of the extent of tumours using magnetic resonance imaging (MRI) is the basis for bone resection in limb-salvage surgery. We aimed to compare the accuracy of T1-weighted MRI and STIR sequences in measuring the extent of proximal femoral tumours, using the macroscopic specimens as the gold standard for comparison. MATERIALS AND METHODS: We compared single coronal T1-weighted with STIR sequences in 34 proximal femoral tumours, using bivalved resected macroscopic tumours for comparison. After randomisation, four observers measured longitudinal osseous tumour extent using MRI and specimen photographs on two separate occasions, 3 weeks apart. RESULTS: There were 25 metastatic tumours, 8 chondrosarcomas and 1 myeloma. Eight patients presented with pathological fractures. The Pearson's correlation coefficient for comparison of T1 with macroscopic tumours was 0.91 (95% confidence interval [CI]: 0.83 to 0.96) for all observers and 0.90 (95% CI: 0.81 to 0.95) for STIR images. This difference was not statistically significant, and T1 and STIR sequence measurements had similar precision and accuracy. Bland-Altman plots showed T1-weighted imaging to be unbiased, whereas STIR sequences were biased and had systematic error. Moreover, STIR measurements overestimated tumour size by 6.4 mm (95% CI: -26.9 to 39.7 mm) and 2 patients were outliers. T1 measurements were closer to the macroscopic measurements with a mean difference of 1.3 mm (95% CI: -28.9 mm to 31.5 mm), with 3 patients falling outside of this. The variance was greater for STIR measurements. This difference between T1 and STIR measurements was statistically significant (p = 0.000003). The intra-observer reliability between separate measurements for MRI and specimen photographs achieved interclass correlation coefficients of 0.97, 0.96 and 0.95 (T1, STIR and macroscopic tumour respectively). T1 had greater interobserver correlation than for STIR and macroscopic tumour measurements (0.88 vs 0.85 and 0.85 respectively). These differences in interclass correlation were not statistically significant. CONCLUSION: This study has shown T1-weighted MRI sequences to be unbiased compared with STIR sequences at determining intra-osseous tumour extent. STIR overestimates the length of bone tumours. T1 is therefore preferred for pre-operative planning for the resection of bone tumours.

Nitinol-teflon stapes prosthesis improves low-frequency hearing results after stapedotomy.

OBJECTIVE: To determine if nitinol-Teflon shape-memory stapes prostheses offer a hearing result advantage compared with platinum-Teflon pistons that must be manually crimped. STUDY DESIGN: Retrospective chart review. PATIENTS: One hundred eighty-eight consecutive ears with either a platinum or a nitinol piston and primary stapes surgery between 1998 and 2009. SETTING: Subspecialty private practice. INTERVENTION: One hundred forty-four ears received a platinum 0.6-mm-diameter piston, and 44 ears received a nitinol 0.6-mm-diameter piston. MAIN OUTCOME MEASURES: American Academy of Otolaryngology-Head and Neck Surgery guidelines, including 4-frequency pure-tone average air-bone (AB) gap, and success (gap

Long-term impact of incus necrosis on revision stapes surgery: incus versus malleus reconstruction.

OBJECTIVE: To determine the effect of incus necrosis on the success of revision stapes surgery. STUDY DESIGN: Retrospective chart review. PATIENTS: Two hundred twenty-two ears in 174 consecutive patients who had revision stapes surgery from 1987 to 2007. INTERVENTION: The status of the incus was determined at revision surgery in all 222 ears. There were 68 ears with no incus damage and 154 ears with mild to severe incus necrosis. Based on surgical judgment, 58 ears had a reconstruction from the malleus to an oval window fenestra, and 96 ears had a reconstruction from the damaged incus. MAIN OUTCOME MEASURES: American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines, including 4-frequency pure-tone average, success rate (gap <10 dB), and Kaplan-Meier product-survival procedure. RESULTS: When success was defined as an air-bone gap of 10 dB or less at 1 year, patients with a reconstruction to a normal incus, necrotic incus, or malleus had similar success rates ranging from 47 to 54%. Success over time was significantly poorer for patients with a reconstruction to a necrotic incus (median failure at 30 mo) compared with reconstruction to a normal incus (144 mo) or malleus (75 mo; p < 0.05). Reconstruction to the malleus posed a greater risk of high-frequency hearing loss than reconstruction to the incus by an average of 2.3 dB. CONCLUSION: Incus necrosis bodes poorly for reconstruction from the incus. Reconstruction from the malleus provided a more stable long-term reconstruction but greater risk of surgical damage to the inner ear.

Success of five stapes prostheses evaluated by Kaplan-Meier product-survival procedure.

OBJECTIVE: To determine if modifications to a first-generation Teflon-wire piston stapes prosthesis improve results over time. STUDY DESIGN: Retrospective chart review. SETTING: Private practice. PATIENTS: Three hundred eleven ears in 277 consecutive patients who had primary stapedotomies with reconstruction to an open fenestra during 1989 to 2000 and in 2005 to 2006. INTERVENTION: The devices were examined sequentially as follows: Schuknecht piston (50), De La Cruz piston (30), Mangham piston (179), titanium CliP piston (32), and Teflon Robinson prosthesis (20). MAIN OUTCOME MEASURES: American Academy of Otolaryngology-Head and Neck Surgery guidelines including 4-frequency pure-tone average, success rate (gap

Titanium CliP piston versus platinum-ribbon Teflon piston: piston and fenestra size affect air-bone gap.

OBJECTIVE: To analyze if titanium material and a clip attachment to the incus offer a hearing result advantage over the traditional Teflon piston in stapes surgery. STUDY DESIGN: Retrospective chart review. SETTING: Subspecialty private practice. PATIENTS: One hundred seven ears in 97 consecutive patients who had primary stapes surgery during 2003 to 2005. INTERVENTION: The first 74 ears received either a Teflon 0.5- or 0.6-mm piston, and the last 33 received a titanium 0.6-mm piston. MAIN OUTCOME MEASURES: American Academy of Otolaryngology-Head and Neck Surgery guidelines, including 4-frequency pure-tone average air-bone gap and success rate (gap, 10 dB). RESULTS: Mean pure-tone average air-bone gap for the Teflon 0.6-mm piston (5.1 dB) was significantly smaller than for the titanium 0.6-mm piston (8.1 dB) and the Teflon 0.5-mm piston (7.5 dB). Success rate did not differ. Although labeled as 0.6-mm pistons, the Teflon piston diameter was 10% greater than the titanium piston. Results were comparable among devices when adjusted for true piston diameter. Results for the titanium piston were significantly better when the fenestra was no more than 0.05 mm larger than the piston diameter. CONCLUSION: Comparing 2 pistons designated 0.6 mm in diameter, the Teflon piston produced better hearing results than the titanium device. However, actual piston diameter differed between devices that contributed to the superior results with the larger Teflon piston. In addition, the titanium piston performed better with a small stapes fenestra diameter that suggests an advantage for titanium over Teflon in certain conditions. The clip design was problematic for a few patients.

Retrosigmoid versus middle fossa surgery for small vestibular schwannomas.

OBJECTIVES/HYPOTHESIS: The objective was to determine the effect of approach, middle fossa versus retrosigmoid, on the hearing and facial nerve outcome of surgery for small vestibular schwannomas. STUDY DESIGN: The study had two parts, a case study of patient data entered into a prospectively designed database at the author's institution, and a meta-analysis of similar published data. METHODS: There were 73 of the author's private practice patients who met the inclusion criteria of intracanalicular vestibular schwannoma and total tumor removal by a retrosigmoid approach. American Academy of Otolaryngology-Head and Neck Surgery standardized hearing and facial nerve classifications of these patients and similar data from 11 other institutions were used to compare results of the two surgical approaches. RESULTS: Median facial nerve results for all institutions were significantly better with the retrosigmoid approach (grade I: 95% for retrosigmoid and 81% for middle fossa). Median hearing results trended toward better outcome with the middle fossa approach (same preoperative hearing class: 48% for middle fossa and 39% for retrosigmoid). Individual institution had an equal or greater effect on outcome than the choice of surgical approach. CONCLUSION: Surgical team accounted for more variability in hearing and facial nerve outcome than did approach. Retrosigmoid approach yielded significantly better facial nerve outcome. The trend toward better hearing outcome with the middle fossa approach may never achieve statistical significance across institutions because of high variability among surgical teams and small numbers of teams reporting results.