The diagnostic accuracy of Böhler's angle in fractures of the calcaneus.

BACKGROUND: Böhler's historical tuber-joint angle of the calcaneus has been used since 1931. Surprisingly, there is a paucity of literature on its use. OBJECTIVES: To confirm the normal range for Böhler's angle and determine the angle with the highest accuracy in the diagnosis of calcaneal fractures. METHODS: A retrospective cohort study was performed. The study cohort comprised 424 patients spanning a 5-year period from April 2005 to March 2010. Böhler's angle was measured by two independent observers on lateral x-ray study using the digital angle tool from the Picture Archival and Communication System. Data were analyzed using Stata 8 statistical software package. RESULTS: The mean Böhler's angle in patients without calcaneal fracture was 29.4°. In this group there was no difference in Böhler's angle between male and female patients, left and right feet, or across age. In those patients with calcaneal fractures, a Böhler's angle below 25° was moderately predictive of calcaneal fracture (sensitivity = 100%, specificity = 82%), an angle below 23° was highly predictive of calcaneal fracture (sensitivity = 100%, specificity = 89%), and an angle below 21° was strongly suggestive of calcaneal fracture (sensitivity = 99%, specificity = 99%). A Böhler's angle of ≤ 20° had the highest diagnostic accuracy. CONCLUSION: A Böhler's angle of 20° or less is highly accurate in determining the presence or absence of calcaneal fracture. Böhler's angle serves as a useful screening tool in fracture diagnosis.

Predictive value of the Delphian and level VI nodes in papillary thyroid cancer.

BACKGROUND: Recent published data has shown that metastatic involvement of the prelaryngeal or Delphian lymph node (DLN), the highest of the central (level VI) cervical lymph nodes, is highly predictive of advanced nodal disease in papillary thyroid cancer (PTC). The aims of this study were to determine the diagnostic accuracy of all the level VI cervical nodes in PTC and to determine which node group, if any, is the most accurate in predicting lateral node (N1b) disease. METHODS: This was a retrospective cohort study. Data were obtained from the University of Sydney Endocrine Surgical Unit Database and through a review of the histopathology records. The study cohort was composed of 177 consecutive patients with a final diagnosis of PTC who underwent total thyroidectomy and lymph node dissection, spanning the period from May 2001 to December 2006. RESULTS: Of the 177 patients with PTC, 86 had the DLN removed, 51 had a pretracheal node removed and 76 had the paratracheal group removed. DLN, paratracheal and pretracheal node disease was present in 21%, 39% and 46%, respectively. Lateral node (N1b) disease was present in 35%. Paratracheal node involvement was mildly predictive of further disease with patients 1.7 times more likely to have lateral node involvement (sensitivity=55%, specificity=68%). Pretracheal node involvement was moderately predictive of further disease with patients three times more likely to have lateral node involvement (sensitivity=72%, specificity=74%). DLN involvement was highly predictive of further node involvement with patients nine times more likely to have lateral node disease (sensitivity=53%, specificity=94%) and 40 times more likely to have any nodal disease (sensitivity=41%, specificity=100%). CONCLUSION: This is the first study to examine the diagnostic accuracy of all level VI lymph nodes in PTC. While, metastatic involvement of all central nodal groups is indicative of further disease, the DLN is the most accurate predictor.

Femoral insufficiency fractures associated with prolonged bisphosphonate therapy.

BACKGROUND: Emerging evidence has linked the long-term use of bisphosphonates with femoral insufficiency fractures. It has been suggested that the prolonged effect on bone remodeling leads to the accumulation of microfractures and weakening of bone. QUESTIONS/PURPOSES: We investigated the association between bisphosphonate use and femoral insufficiency fractures. METHODS: We evaluated 100 patients with low-energy femoral shaft fractures before and after bisphosphonates became available for use. Twenty-one consecutive patients who presented between January 1995 and February 1997 were compared with 79 consecutive patients who presented between January 2007 and February 2009. The radiographs of all 100 patients were examined for evidence of preexisting insufficiency fractures. We identified insufficiency fractures by a transverse fracture line on the tension side of the femur with lateral cortical thickening immediately adjacent to the fracture. Relevant details from the history were recorded. RESULTS: Forty-one patients had an underlying femoral insufficiency fracture, all of whom had been receiving bisphosphonate therapy. Among the 21 patients with low-energy femoral fractures before the availability of bisphosphonates, none had insufficiency fractures. Of the 41 patients with insufficiency fractures, 29 (71%) had prodromal pain and 18 (44%) had bilateral insufficiency fractures. Bisphosphonate use was associated (odds ratio greater than 1000) with insufficiency fracture. The mean duration of bisphosphonate use in patients with insufficiency fractures was longer than in patients without fractures (7.1 versus 3.2 years). CONCLUSION: Long-term bisphosphonate use is associated with insufficiency fractures of the femoral shaft, which commonly present with prodromal thigh pain and may be bilateral. These fractures were not seen before bisphosphonates became available for use.

The Delphian lymph node in thyroid cancer.

OBJECTIVE: To determine the significance of Delphian lymph node (DLN) involvement in thyroid cancer. SUMMARY BACKGROUND DATA: The DLN has long been regarded as a predictor of thyroid malignancy and indicator of advanced disease; however, there are no published data in relation to the thyroid. METHODS: A retrospective cohort study with data obtained from the University of Sydney Endocrine Surgery database and histopathology records. The study cohort comprised 1000 consecutive patients undergoing total thyroidectomy. RESULTS: The DLN was separately removed and identified as such in 263 of 1000 (26.3%) patients. Of 1000 patients 203 (20.3%) had a diagnosis of papillary/medullary cancer. Of this group 150 patients had surgery performed for suspected cancer, and in 53 the diagnosis of cancer was unsuspected. In only 1 case did the DLN operative appearance alert the surgeon to an otherwise unsuspected thyroid cancer. The DLN was separately identified in 103 patients with cancer and, in this group, 22 of 103 (21.4%) had DLN metastases. DLN involvement was associated with greater nodal disease (9.8 vs. 1.6 nodes; P < 0.001), larger tumor size (19.4 vs. 11.1 mm; P < 0.003) and younger age (41 vs. 47 years; P = 0.058). DLN involvement was highly predictive of further disease in the central compartment (sensitivity = 41%, specificity = 95%), moderately predictive of further disease in the lateral compartment (sensitivity = 50%, specificity = 88%), and strongly suggestive of further nodal disease in the neck (sensitivity = 64%, specificity = 100%). CONCLUSIONS: Although the clinical appearance of the DLN is not an accurate indicator of the presence of unsuspected thyroid cancer, metastatic involvement of the DLN is an adverse prognostic marker in papillary/medullary thyroid cancer. The presence of DLN metastasis in patients with thyroid cancer should alert the surgeon to the high probability of advanced disease and need for greater attention to the central and lateral lymph node compartments.