Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy

Breast cancer guidelines advise sentinel lymph node biopsy (SLNB) in patients with ductal carcinoma in situ (DCIS) on core biopsy at high risk of invasive cancer or in case of mastectomy. This study investigates the incidence of SLNB and SLN metastases and the relevance of indications in guidelines and literature to perform SLNB in order to validate whether SLNB is justified in patients with DCIS on core biopsy in current era. Clinically node negative patients diagnosed from 2004 to 2013 with only DCIS on core needle biopsy were selected from a national database. Incidence of SLN biopsy and metastases was calculated. With Fisher exact tests correlation between SLNB indications and actual presence of SLN metastases was studied. Further, underestimation rate for invasive cancer and correlation with SLN metastases was analysed. 910 patients were included. SLNB was performed in 471 patients (51.8 %): 94.5 % had pN0, 3.0 % pN1mi and 2.5 % pN1. Patients undergoing mastectomy had 7 % SLN metastases versus 3.5 % for breast conserving surgery (BCS) (p = 0.107). The only factors correlating to SLN metastases were smaller core needle size (p = 0.01) and invasive cancer (p < 0.001). Invasive cancer was detected in 16.7 % by histopathology with 15.6 % SLN metastases versus only 2 % in pure DCIS. SLNB showed metastases in 5.5 % of patients; 3.5 % in case of BCS (any histopathology) and 2 % when pure DCIS was found at definitive histopathology (BCS and mastectomy). Consequently, SLNB should no longer be performed in patients diagnosed with DCIS on core biopsy undergoing BCS. If definitive histopathology shows invasive cancer, SLNB can still be considered after initial surgery.

[Fewer x-rays while maintaining quality of clinical care using clinical protocols for physical diagnosis of ankle injuries]

OBJECTIVE

To determine whether it is possible to decrease the number of X-rays in acute ankle injury while keeping the health care constant, using a scoring system.

DESIGN

Prospective.

METHOD

Patients presenting in the emergency department of the University Hospital Utrecht (AZU), the Netherlands, over a one-year period of time with acute ankle injuries were subjected to a thorough physical examination based on a scoring system developed at Leiden University Hospital. The score was calculated and X-ray examination was indicated when this score was > or = 8 points. Radiological investigation or telephone interviews six weeks after injury achieved verification of the clinically relevant ankle fractures. Specificity and sensitivity were calculated from every possible cut-off point and drawn in a 'receiver operating characteristics' (ROC) curve.

RESULTS

Of the 514 patients included 81 patients had a score of 8 or higher and 24 of them had a clinically relevant fracture. In 34 patients an ankle X-ray was made although their score was < 8 points. The positive and negative predictive values of the system were 30% (95% confidence interval (95% CI): 20-41) and 99% (95% CI: 97-100) respectively. The score yielded an area under the ROC curve of 91% (95% CI: 84-98). A cut-off point of 8 led to a reduction of X-rays by 60% (using the 'Ottawa ankle rules' the decrease in this population would have been 28%). On the other hand, 5 clinically relevant fractures were missed.

CONCLUSION

Radiological examination in patients wit acute ankle complaints was reduced while health care remained almost constant. In the AZU, a decision was made for a major reduction in X-rays while accepting that some fractures would be missed.

Three-dimensional dynamic external fixation of distal radial fractures. A prospective study

This prospective study describes the experience with a new dynamic external fixator which provides three degrees of freedom, while the centre of rotation of all these movements is located in the wrist. 44 patients with unstable fractures of the distal radius were included. During the period of dynamisation, with a median flexion of 30 degrees, extension of 18 degrees, radial deviation of 0 degree and ulnar deviation of 20 degrees the range of motion needed to perform activities of daily living was approached. In spite of early mobilisation reduction was maintained. The radiological result was excellent or good in 82% of the patients and the functional result was excellent or good in 92% of the cases. Pin track infections were noted rather frequently, possibly related to the interaction between the soft tissues and the fixator pins. Based on the experiences of the study the device needs further improvement.

Subfascial plate fixation of comminuted diaphyseal femoral fractures: a report of three cases utilizing biological osteosynthesis

Internal fixation with preservation of tissues and vascularization, as in intramedullary fixation and bridging plate osteosynthesis, so-called biological osteosynthesis, has become increasingly popular. Our experiences, in three patients, using a technique of internal fixation of comminuted diaphyseal femoral fractures with an AO plate in subfascial position without exposure of the fracture site is presented. Though based on unorthodox mechanical principles, the safety and efficacy of bridging plates, even when applied in unusual situations, are illustrated.

[Moderate results of the treatment of femoral shaft fractures in children using intramedullary fixation]

OBJECTIVE

To evaluate the results of treatment of femoral shaft fractures in children with intramedullary nailing.

DESIGN

Retrospective.

SETTING

Department of Surgery, University Hospital Utrecht, Department of Paediatric Surgery, Wilhelmina Children's Hospital, Utrecht.

METHOD

Between 1982 and 1993, 27 femoral shaft fractures in 27 patients under the age of 16 were treated by intramedullary nailing. The charts and radiographs of these patients were reviewed and 24 patients were seen for follow-up examination (mean 7.5 years). Leg length was measured radiographically and anteversion of the affected and normal femora was determined by a standard computed tomography (CT) study.

RESULTS

The average hospital stay was 34 days. There were no postoperative complications. At follow-up 10 patients had a leg length discrepancy < 1 cm and a rotational deformity < 10 degrees. Three patients had a shortening of the injured leg > 1 cm (max. 1.7 cm), in 6 patients the injured leg was more than 1 cm longer (max. 3.5 cm). The difference in rotation between fracture side and unaffected side was > 10 degrees in 9 patients. In 6 patients this was due to increased exorotation (max. 22 degrees) and in 3 patients to increased endorotation (max. 27 degrees). Iatrogenic injury of the epiphyseal line was not seen.

CONCLUSION

Regarding leg length differences and rotational deformities intramedullary nailing was not superior to the known results of conservative treatment. The indication for operation should be carefully considered and during an operation there should be perfect control of reduction.

Bursae communicating with the hip joint. A report on 2 cases

We present two patients in whom abnormal masses in the groin caused diagnostic difficulty. Synovial cysts and iliopsoas bursa enlargement may be more common than previously reported and should be considered in patients with unexplained hip pain and unusual ilioinguinal swelling.

Dynamic circle traction for severely comminuted intra-articular finger fractures

Treatment of severely comminuted unstable intra-articular finger fractures has three goals: reconstruction of the articular surfaces, prevention of redislocation of those surfaces, and proper healing of the capsuloligamentous apparatus. Dynamic circle traction (DCT), as described by Schenck (1986), is based on these principles and is the first method of treatment combining traction with intermittent or continuous passive motion. In order to improve on this method we applied continuous, instead of intermittent, passive motion in a newly developed DCT-device (continuous dynamic circle-traction = CDCT). Its first clinical use is discussed below. Our results with DCT, in eight patients, and CDCT, in four patients, are encouraging. Full function was regained at follow-up, in both groups, in three-quarters of the metacarpophalangeal (MCP) and half of the proximal interphalangeal (PIP) joints involved. Average loss of range of motion of the other MCP and PIP joints was 3.7 degrees and 5.6 degrees respectively. Treatment with CDCT may yield better results than DCT; the small number of patients treated and the relatively short period of follow-up does not justify comparison of both methods.