Minimally invasive treatment of pilon fractures with a low profile plate: preliminary results in 17 cases.

OBJECTIVE: To determine the results of "biologic fixation" with a minimally invasive plating technique using a newly designed low profile "Scallop" plate in the treatment of pilon fractures. DESIGN: Retrospective case series. SETTING: A tertiary referral center. PATIENTS/PARTICIPANTS: Seventeen patients were treated between 1999 and 2001 for a tibial plafond fracture at the Hospital for Special Surgery with a newly designed low-profile plate. Eleven of the fractures (65%) were high-energy injuries. Two fractures were open. INTERVENTION: Staged surgical treatment with open reduction and fixation of the fibular fracture and application of an external fixator was performed in 12 cases. As soon as the soft tissues and swelling allowed, i.e. skin wrinkling, the articular surface was reconstructed and simply reduced, if necessary through an small incision, and the articular block was fixed to the diaphysis using a medially placed, percutaneously introduced flat scallop plate. In the remaining five cases the operation was performed in one session. MAIN OUTCOME MEASUREMENTS: Time to healing and complications including delayed union, non-union, instrument failure, loss of fixation, infection, quality of reduction and number of reoperations were evaluated. Quality of results and outcome were graded using the ankle-hindfoot-scale and a modified rating system. RESULTS: All patients went on to bony union at an average time of 14 weeks. There were no plate failures or loss of fixation/reduction. Two superficial wound-healing problems resolved with local wound care. At an average follow up of 17 months (range 6-29 months) eight patients (47%) had an excellent result; seven (41%) had a fair result whereas two (12%) had a poor result. The average ankle-hindfoot-score was 86.1 (range 61-100). Four patients have had the hardware removed and one of them is awaiting an ankle arthrodesis. CONCLUSIONS: Based on these initial results, it appears that a minimally invasive surgical technique including new low profile plate can decrease soft tissue problems while leading to fracture healing and obtaining results comparable with other more recent series. We believe that this new "Scallop Plate" is effective for the treatment of pilon fractures and should be used in conjunction with a staged procedure in the acute trauma setting.

Palliation or Prolongation? The Impact of a Peer-Review Intervention on Shortening Radiotherapy Schedules for Bone Metastases.

PURPOSE: Shorter fractionation radiation regimens for palliation of bone metastases result in lower financial and social costs for patients and their caregivers and have similar efficacy as longer fractionation schedules, although practice patterns in the United States show poor adoption. We investigated whether prospective peer review can increase use of shorter fractionation schedules. METHODS: In June 2016, our practice mandated peer review of total dose and fractionation for all patients receiving palliative treatment during our weekly chart rounds. We used descriptive statistics and Fisher's exact test to compare lengths of treatment of uncomplicated bone metastases before and after implementation of the peer review process. RESULTS: Between July 2015 and December 2016, a total of 242 palliative treatment courses were delivered, including 105 courses before the peer review intervention and 137 after the intervention. We observed greater adoption of shorter fractionation regimens after the intervention. The use of 8 Gy in one fraction increased from 2.8% to 13.9% of cases postadoption. Likewise, the use of 20 Gy in five fractions increased from 25.7% to 32.8%. The use of 30 Gy in 10 fractions decreased from 55.2% to 47.4% ( P = .002), and the use of ≥ 11 fractions decreased from 16.2% before the intervention to 5.8% after ( P = .006). CONCLUSION: Prospective peer review of palliative regimens for bone metastases can lead to greater adoption of shorter palliative fractionation schedules in daily practice, in accordance with national guidelines. This simple intervention may therefore benefit patients and their caregivers as well as provide value to the health care system.

Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: a report of 4 cases.

Stress fracture of the anterior tibial cortex is an extremely challenging fracture to treat, especially in the high-performance female athlete who requires rapid return to competition. Previous reports have not addressed treating these fractures in the world-class athlete with anterior plating. We hypothesize that anterior plating is a biomechanically sound approach to treatment of these fractures, and will lead to an earlier return to full activity than either nonoperative treatment or intramedullary nailing. We present a retrospective series of 4 case reports of 4 world-class female athletes with stress fractures of the anterior tibial cortex treated by anterior plating between 2001 and 2004. Average follow-up was 15 months (range 12 to 48 mo). Anterior tension band plating resulted in fracture healing in all 4 cases and return to full activity at a mean of 10 weeks. All patients returned to preinjury competitive levels. There were no complications of infection, nonunion, or malunion. Anterior tension-band plating of an anterior tibial stress fracture leads to rapid fracture healing and return to competition for high-performance female athletes. This approach should be considered in those athletes who wish to avoid the more prolonged convalescence associated with nonoperative treatment, or the problems, especially of the knee, associated with intramedullary nailing.

Hip fracture outcomes in patients with Parkinson's disease.

In a prospective, consecutive study conducted at a university teaching hospital, we evaluated the effects of Parkinson's disease (PD) on hip fracture outcomes. We followed 920 community-dwelling patients, aged 65 or older, who sustained a hip fracture that was operatively treated between July 1, 1987, and June 30, 1998. Presence or absence of PD had no bearing on type of surgery performed. Examined outcomes were postoperative complication rates; in-hospital mortality; length of hospital stay; discharge status (to home or to a skilled nursing facility); and mortality rate, place of residence, recovery of prefracture ambulatory ability, and return to prefracture activities of daily living (ADLs) 1 year after surgery Thirty-one patients (3.4%) had a history of PD before hip fracture. Patients with PD were more likely to be male, to live with another person, to have less ambulatory ability, and to be dependent in ADLs before hip fracture. Compared with patients without PD, they were hospitalized significantly longer and were more likely to be discharged to a skilled nursing facility. In addition, they declined more in level of independence in basic ADLs but not as much in instrumental ADLs at 1-year follow-up. Rates of postoperative complications, recovery of ambulatory ability within 1 year, and mortality within 1 year did not differ. These findings may guide orthopedic surgeons in counseling patients with PD and a hip fracture.

Nonunions of the distal tibia treated by reamed intramedullary nailing.

OBJECTIVE: The purpose of this study is to determine the efficacy of reamed intramedullary nailing in the treatment of nonunions of the distal one-fourth of the tibia. Nonunions of the distal tibia are particularly difficult to treat given the short distal segment, the proximity to the ankle joint, and the fragile soft-tissue envelope. Intramedullary nailing is an attractive solution to this problem because it avoids extensive dissection, and the implant remains intraosseous, posing minimal problem for the soft tissues. DESIGN: Retrospective review of patient charts and radiographs. SETTING: Tertiary care orthopaedic hospital. PATIENTS/PARTICIPANTS: Thirty-two patients with nonunions of the distal one-fourth of the tibia. Prior treatments included casting, internal fixation with plates and screws, intramedullary nailing, and external fixation. Seven patients had a history of infection, but no patient had signs of active infection at the time of surgery. INTERVENTION: Study patients were treated by reamed, locked intra-medullary nailing. MAIN OUTCOME MEASUREMENTS: Main outcome measurements included time to union, correction of deformity, and complications including infection and reoperation. RESULTS: Average length of follow-up was 25 months (range 4-81 months). Twenty-nine out of 32 patients achieved union at an average of 3.5 months after reamed, locked intramedullary nailing. Of the remaining three, 2 patients united after dynamization (one at 4 months after dynamization and the other at 7 months), and the third patient united 4 months after exchange nailing. Deformity was corrected to a maximum of 4 degrees in all planes. Four patients had positive intraoperative cultures, and only 2 required removal of the nail after achieving union to control infection. There were no signs of chronic osteomyelitis in these 2 patients at the date of the last follow-up visit; 5.5 years and 2 years following nail removal. CONCLUSIONS: Reamed, locked intramedullary nailing is a reliable and safe procedure in the treatment of nonunions in the distal one-fourth of the tibia, even in the setting of prior infection or external fixation. It allows for excellent correction of deformity, which is an essential component of the procedure.

Mortality risk after hip fracture.

OBJECTIVE: To determine the mortality risk following hip fracture and identify factors predictive of increased mortality. DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary care orthopaedic hospital. BACKGROUND: Approximately 250,000 hip fractures occur annually in the United States. The greatest mortality risk following hip fracture has been demonstrated to be within the first 6 months of fracture, and some studies report that the risk approaches expected mortality after 6 months. However, more recent studies have demonstrated that an increased risk of mortality may persist for several years postfracture. The purpose of this study was to assess the excess mortality associated with hip fracture at up to 2 years postinjury. METHODS: All patients with a hip fracture who were admitted to our institution over a 10-year period were evaluated. Criteria for inclusion included: Caucasian, age 65 or older, previously ambulatory, and home dwelling. Patients were followed prospectively to determine the mortality risk associated with hip fracture over a 2-year follow-up period. Mortality was compared to a standardized population and standardized mortality ratios were calculated. RESULTS: Eight hundred thirty-six patients met the inclusion criteria and were included. The mortality risk was highest within the first 3 months following fracture, with standardized mortality ratios approaching that of the control population by two years. Patients age 65-84 had higher mortality risk when compared with patients age > or =85. American Society of Anesthesiologists classification was predictive of increased mortality risk in younger patients, with these patients having triple the mortality risk when compared to the reference population at 2-year follow-up. More elderly patients had minimal excess mortality associated with hip fracture at 1- and 2-year follow-up, regardless of ASA classification. CONCLUSION: The data demonstrate that hip fracture is not associated with significant excess mortality amongst patients older than age 85. Amongst younger patients, however, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury.

New variants of epithelial-myoepithelial carcinoma: oncocytic-sebaceous and apocrine.

CONTEXT: Recently described variants of epithelial-myoepithelial carcinoma have not been well characterized but raise a distinct set of differential diagnostic considerations than the classic type. OBJECTIVE: To report a detailed analysis of oncocytic-sebaceous epithelial-myoepithelial carcinoma (OEMCa) and a similar, but novel, variant, apocrine epithelial-myoepithelial carcinoma (ApEMCa). DESIGN: Clinical, histologic, and immunophenotypic features of 5 OEMCas and 5 ApEMCas were analyzed. Ultrastructural examination was also performed on 3 OEMCa and 1 ApEMCa tumors. RESULTS: The mean age for OEMCa (74.4 years; range, 58-82 years) was slightly higher than for ApEMCa (61.6; range, 46-79 years). All tumors arose in the parotid glands and demonstrated a multinodular pattern of growth with an average size of 3.3 cm (range, 2.3-6.5 cm). Available follow-up (n = 6; 3 OEMCas, 3 ApEMCas) shows a favorable course (no evidence of disease; mean, 17.4 months). Both were morphologically similar, but only OEMCa had sebaceous elements. Phosphotungstic acid hematoxylin staining, antimitochondrial antibody immunohistochemistry, and ultrastructural examination confirm the abundance of mitochondria in OEMCa but not in ApEMCa. The ductal component in ApEMCa was distinguished from that of OEMCa by apical snouts, intracytoplasmic vacuoles, nuclear pleomorphism, prominent nucleoli, and androgen receptor immunoreactivity. CONCLUSIONS: Oncocytic-sebaceous epithelial-myoepithelial carcinoma and ApEMCa should be considered in the differential diagnosis of oncocytic/oncocytoid salivary gland tumors. Oncocytic-sebaceous epithelial-myoepithelial carcinoma morphology may reflect a senescent phenotype, similar to other oncocytic lesions. The ductal component of ApEMCa shares some similarities with salivary duct carcinoma and supports the notion that epithelial-myoepithelial carcinoma can serve as the progenitor tumor for hybrid tumors.

FISH detection of t(14;18) in follicular lymphoma on Papanicolaou-stained archival cytology slides.

BACKGROUND: The t(14;18)(q32;q21) translocation is present in about 85% of follicular lymphomas (FL) and can be identified using fluorescence in situ hybridization (FISH). In the diagnostic laboratory setting, the cytologic archival material consists of stained slides, and only rarely is material saved for molecular testing. The authors proposed FISH for FL using Papanicolaou-stained archival cytology material as a practical ancillary technique for diagnosing FL. METHODS: Cases included 35 FL, 6 small lymphocytic lymphomas/chronic lymphocytic leukemias (SLL/CLL), 4 mantle cell lymphomas (MCL), 4 marginal zone lymphomas (MZL), 1 lymphoplasmacytic lymphoma (LPL), and 10 reactive lymphoid tissues (RLT). FISH was performed on Papanicolaou-stained archival cytology slides using probes for immunoglobulin heavy chain (IGH) on chromosome 14 and BCL2 on chromosome 18. RESULTS: In all, 25 of 32 (81%) FL cases exhibited the t(14;18) translocation, whereas 7 of 32 (19%) lacked the translocation. No cases of non-FL were positive for t(14;18). This series shows a sensitivity of 81% and specificity of 100% for detecting the t(14;18) translocation as a diagnostic tool in FL. CONCLUSIONS: When performed on Papanicolaou-stained cytology slides, FISH for t(14;18) is relatively sensitive and quite specific for FL. These findings are similar to those reported on other specimens, such as paraffin-embedded tissue and unstained cytology slides. The authors proposed that their technique would allow the pathologist and clinician the flexibility to utilize previously stained fine-needle aspiration slides for FISH evaluation.

Death certification errors at an academic institution.

CONTEXT: The correctly completed death certificate provides invaluable personal, epidemiologic, and legal information and should be thorough and accurate. Death certification errors are common and range from minor to severe. OBJECTIVE: To determine the frequency and type of errors by nonpathologist physicians at a university-affiliated medical center. DESIGN: Fifty random patients were identified who died at this academic medical center between January 2002 and December 2003 and did not undergo an autopsy. From medical chart review, clinical summaries were produced. Two pathologists used these summaries to create mock death certificates. The original and mock death certificates were then compared to identify errors in the original certificate. Errors were graded on a I to IV scale, with grade IV being the most severe. RESULTS: Of the 50 death certificates reviewed, grade I, II, and III errors were noted in 72%, 32%, and 30%, respectively. Seventeen certificates (34%) had grade IV errors (wrong cause or manner of death). Multiple errors were identified in 82% of the death certificates reviewed. CONCLUSIONS: The rate of major (grade IV) death certification errors at this academic setting is high and is consistent with major error rates reported by other academic institutions. We attribute errors to house staff inexperience, fatigue, time constraints, unfamiliarity with the deceased, and perceived lack of importance of the death certificate. To counter these factors, we recommend a multifaceted approach, including an annual course in death certification and discussion of the death certificate for each deceased patient during physician rounds. These measures should result in increased accuracy of this important document.

Gastrointestinal stromal tumor of the stomach with rhabdoid phenotype: immunohistochemical, ultrastructural, and immunoelectron microscopic evaluation.

A variety of neoplasms with rhabdoid differentiation have been reported in many sites. The authors describe a case of gastrointestinal stromal tumor (GIST) of the stomach that exhibited prominent rhabdoid features. Immunohistochemically, the tumor cells displayed positive staining for vimentin, c-kit, CD34, and alpha smooth muscle actin. Ultrastructural examination of the rhabdoid tumor cells revealed paranuclear whorls of intermediate filaments, which were immunoreactive for vimentin by both light microscopic immunohistochemical and protein A gold immunoelectron microscopic techniques. On H&E light microscopic examination alone, such a tumor could be mistaken for a variety of epithelial, mesenchymal, or other neoplasms that may show rhabdoid features. One report of GIST with a rhabdoid histologic phenotype has been described. This is the second known report of such a case with immunophenotypic and ultrastructural evaluation, and the first case with immunoelectron microscopic examination.