Trends in Clinical Breast Density Assessment From the Breast Cancer Surveillance Consortium

Changes to mammography practice, including revised Breast Imaging Reporting and Data System (BI-RADS) density classification guidelines and implementation of digital breast tomosynthesis (DBT), may impact clinical breast density assessment. We investigated temporal trends in clinical breast density assessment among 2 990 291 digital mammography (DM) screens and 221 063 DBT screens interpreted by 722 radiologists from 144 facilities in the Breast Cancer Surveillance Consortium. After age-standardization, 46.3% (95% CI = 44.1% to 48.6%) of DM screens were assessed as dense (heterogeneously/extremely dense) during the BI-RADS 4th edition era (2005-2013), compared to 46.5% (95% CI = 43.8% to 49.1%) during the 5th edition era (2014-2016) (P = .93 from two-sided generalized score test). Among DBT screens in the BI-RADS 5th edition era, 45.8% (95% CI = 42.0% to 49.7%) were assessed as dense (P = .77 from two-sided generalized score test) compared to 46.5% (95% CI = 43.8% to 49.1%) dense on DM in BI-RADS 5th edition era. Results were similar when examining all four density categories and age subgroups. Clinicians, researchers, and policymakers may reasonably expect stable density distributions across screened populations despite changes to the BI-RADS guidelines and implementation of DBT.

Breast Density and Risk of Invasive Breast Cancer among Older Women Undergoing Mammography: The Breast Cancer Surveillance Consortium Cohort Study

This study examined whether breast density is associated with risk of breast cancer in women age ≥65 years undergoing screening mammography in community practice. Methods: We used prospective cohort data between 1996 and 2012 from the Breast Cancer Surveillance Consortium (BCSC). We calculated separate cumulative incidence models for breast cancer incidence according to Breast Imaging Reporting and Data System (BI-RADS) breast density for women ages 65–74 and ages ≥75. Multivariable Cox proportional hazards regression models were fitted to determine the risk of invasive breast cancer adjusted for BCSC registry, race/ethnicity, BMI, hormone therapy use and benign breast disease. Results: Among the 403,268 women included in the study, approximately 40% were ages ≥75. The annual incidence rate of invasive breast cancer increased with increasing breast density among women ages 65–74 [BI- RADS fatty breasts: 2.2% (95% CI, 2.1%–2.4%) vs. heterogeneously or extremely dense breasts: 4.7% (95% CI, 4.6%–4.9%)] and women ages 75+ [BI-RADS fatty breasts: 2.3% (95% CI, 2.1%–2.5%) vs. heterogeneously or extremely dense: 4.3% (95% CI, 4.1%–4.5%)]. Women with BI-RADS fatty breasts had a decreased risk of breast cancer among women ages 65–74 [HR: 0.66 (95% CI: 0.58%–0.78%) and women ages ≥75 [HR: 0.73 (95% CI: 0.62%–0.87%). Women with BI-RADS heterogeneously or extremely dense breasts were found to have increased risk of breast cancer among women ages 65–74 [HR: 1.39 (95% CI: 1.28%–1.51%)] and women ages ≥75 [HR: 1.23 (95% CI: 1.10%–1.37%)]. Conclusions: Older women with higher BI-RADS density had a significantly increased risk of breast cancer. These findings add further evidence that breast density continues to be associated with an increased risk of breast cancer, even among women age ≥75 years.

Cumulative Incidence of Non-breast Cancer Mortality and Breast Cancer Risk by Comorbidity and Age among Older Women Undergoing Screening Mammography: The Medicare-linked Breast Cancer Surveillance Consortium Cohort Study

Due to an increasing comorbidity burden with aging, the margin of benefit from screening mammography in women ages ≥65 is highly variable. This study examined 10-year cumulative risk of non-breast cancer mortality and breast cancer by comorbidity and age in a screening population. Methods: We used prospective cohort data from the Breast Cancer Surveillance Consortium (BCSC), which included 198,362 women ages ≥65 years who have undergone at least one screening mammogram. We calculated cumulative incidence of non-breast cancer mortality and risk of breast cancer 10 years following the screening mammogram for women ages 65–74, 75–84 and ≥85 years stratified by the Charlson Comorbidity Index (CCI scores 0, 1 and ≥2). Results: During a median follow-up time of 8.1 years (interquartile range, 4.6 to 10 years), 34,768 died from non-breast cancer causes and 6,327 women were diagnosed with invasive breast cancer of whom 359 died from breast cancer and 942 from non-breast cancer causes. The 10-year cumulative risk of invasive breast cancer following a screening mammogram did not significantly decrease with elevating CCI score and age for women ages 65–74 [CCI 0 = 4.0% (95% CI, 3.9%–4.1%) vs. CCI ≥2 = 3.8% (95% CI, 3.3%–4.3%)], ages 75–84 [CCI 0 = 3.7% (95% CI, 3.5%–3.9%) vs. CCI ≥ 2 = 3.4% (95% CI, 2.8%–4.0%)], and ages ≥85 [CCI 0 = 2.7%, (95% CI, 2.3%–3.2%) vs. CCI ≥ 2 = 2.5% (95% CI, 1.4%–3.6%)]. Cumulative risk of non-breast cancer mortality significantly increased with increasing CCI and age for women ages 65–74 [CCI 0 = 11% (95% CI, 10%–11%] vs. CCI ≥ 2 = 45% (95% CI, [43%–46%)], ages 75–84 [CCI 0 = 29% (95% CI, 29%–30%) vs. CCI ≥2 = 62% (95% CI, 60%–63%)], and ages ≥85 [CCI 0 = 59%, (95% CI, 57%–60%) vs. CCI ≥2 = 84% (95% CI, 81%–86%)]. Conclusion: Risk of non-breast cancer mortality was high and significantly increased with rising comorbidity burden and age whereas breast cancer risk was low and non-significantly decreased with both. These results suggest that women with a CCI score of ≥2 or ages ≥75 years may experience minimal benefit from continuing routine screening mammography. Future research is needed to delineate the specific benefits and harms of screening mammography in subsets of older women defined by age and comorbidity burden.

Emerging Trends in Family History of Breast Cancer and Associated Risk

The impact of the rise in breast cancer incidence associated with mammography diffusion on the prevalence of breast cancer family history is unknown, and may attenuate risk associations between family history and breast cancer. Methods: The proportions of women 40–74 years reporting a first-degree family history of breast cancer were estimated in the Breast Cancer Surveillance Consortium (BCSC, N = 1,170,900) from 1996–2012 and Collaborative Breast Cancer Study (CBCS; cases N = 23,400; controls N = 25,460) from 1987–2007. Breast cancer (ductal carcinoma in situ and invasive) relative risk estimates associated with family history and 95% confidence intervals (CI) were calculated using multivariable Cox proportional hazard (BCSC) and logistic regression (CBCS) models. Results: The proportion of women reporting a family history increased from 11% in the 1980s to 16% in 2010–13. Family history was associated with a 60% increased risk of breast cancer in the BCSC (hazard ratio = 1.61, 95% CI = 1.55–1.66) and CBCS (odds ratio = 1.66, 95% CI = 1.58–1.74), with relative risks decreasing with age. Trends in relative risks were not evident over time or stage of disease at diagnosis, except among older women (60–74) where estimates were attenuated in more recent years (P-trend = 0.08 for both cohorts). Conclusion: The proportion of women with a first-degree family history of breast cancer increased over time and by age, nonetheless breast cancer risk associations with family history were constant over time for women 40–59. First-degree family history of breast cancer remains an important breast cancer risk factor, especially for younger women, despite its increasing prevalence in the mammography screening era

Abstract P3-01-01: Comparative performance of surveillance mammography and breast MRI in women with a history of breast cancer

This abstract was withdrawn by the authors.

How Have Breast Cancer Screening Intervals Changed Since the 2009 USPSTF Guideline Update?

Background: Beginning in 2009, the U.S. Preventives Services Task Force (USPSTF) breast cancer screening guidelines recommended biennial mammography screening for women aged 50–74 years, and shared-decision making for women aged 40–49 years. We evaluated changes in screening interval after release of the 2009 recommendations. Methods: We compared screening intervals over the period between 2006 and 2012, expecting that the screening interval would lengthen over this time period, using data from the Breast Cancer Surveillance Consortium on 909,972 screening mammograms among 351,271 women aged 40–89 years. We stratified intervals based on whether the exam at the end of the interval occurred before or after the 2009 USPSTF decision. Differences in mean interval length by woman-level characteristics were compared using linear regression. Results: Contrary to expectations, the mean interval length (in months) minimally decreased after the 2009 USPSTF guideline compared to prior. Among women aged 40–49 years, the mean interval length decreased from 17.3 months to 17.1 months (difference −0.16, 95% confidence interval [CI] -0.30 to -0.01). Similar small reductions were seen for most age groups. The largest decreases in interval length in the post-USPSTF period were observed among women with a first-degree family history of breast cancer (difference −0.68, 95% CI, −0.82–−0.54) or a 5-year breast cancer risk ≥ 2.5% (difference −0.58, 95% CI, −0.73–−0.44). Conclusions: The 2009 USPSTF guideline update did not lengthen the average mammography screening interval among women routinely participating in mammography screening. Future studies should evaluate whether breast cancer screening intervals lengthen towards biennial intervals following new national 2015 breast cancer screening recommendations, particularly among women under 50 years.

The Association Between Post-Diagnosis Health Behaviors and Quality of Life in Survivors of Ductal Carcinoma In Situ

Background: Survivors of ductal carcinoma in situ (DCIS), an early stage breast cancer, tend to decrease physical activity, gain weight, and maintain alcohol use following treatment. However, the impact of these health behaviors on long-term quality of life (QoL) in DCIS survivors has not been investigated. Methods: We examined the association of post-diagnosis body mass index (BMI), physical activity and smoking with QoL among 1,448 DCIS survivors aged 20–74, who were diagnosed during 1995–2006 and enrolled in the population-based Wisconsin In Situ Cohort. Health behaviors and QoL were self-reported during biennial post- diagnosis interviews. Physical and mental QoL were measured using the validated SF-36 questionnaire (higher scores reflect more positive QoL). Generalized linear regression was used to establish QoL mean scores in cross-sectional analyses, with multivariable adjustment for age, comorbidity status, education, and income. Results: Women reported 3,444 QoL observations over an average 7.9 years of follow-up. Physical health summary scale measures of QoL were significantly higher among women with healthy BMI (46.5 for healthy weight versus 40.5 for obese, P = 0.02) and those who were physically active (45.9 for active women versus 42.6 for inactive, P = 0.03). Mental health summary scale scores were significantly higher among non-smokers (51.2 for non-smokers versus 47.1 for current smokers, P < 0.01). These associations were consistent over increasing time since treatment up to 15 years. Conclusion: Our preliminary analysis suggests that maintaining healthy behaviors following DCIS treatment is associated with improved long-term QoL. Longitudinal analysis using cross-lagged regression is underway to evaluate the temporal association between health behavior and QoL. Understanding factors that impact QoL in DCIS survivors may inform interventions aimed at preventing negative health behaviors and optimizing long term quality of life following a DCIS diagnosis.

Abstract PD1-05: Aspirin use is associated with lower mammographic density in a large screening cohort

Background: Current breast cancer prevention agents have substantial side effects and do not prevent estrogen receptor negative (ER-) breast cancer. Aspirin is a promising breast cancer prevention therapy; it is cheap, safe, well tolerated, with strong biologic and epidemiologic evidence for a prevention effect on both ER- and ER+ breast cancers. However, clinical trials to date have failed to corroborate a prevention effect; these results are potentially related to study design (dose, duration of therapy and followup, population treated). We sought to evaluate the effect of aspirin on mammographic density, as breast density is a well-accepted, modifiable risk factor for both estrogen receptor positive (ER+) and ER- breast cancer. Methods: Electronic medical records from the University of Pennsylvania were retrospectively evaluated for women from a core set of 36 primary care/ObGyn practices. Individuals were selected if they had both undergone routine screening mammography during 2012-2013 and had an ambulatory visit within the year prior with a confirmed list of medication use. We selected the medication record closest to the screening exam. Logistic regression was performed to test for associations between clinically-recorded BIRADS breast density and aspirin use, after adjusting for the additional risk factors of age, body mass index (BMI) and ethnicity. Results: We identified 26000 women who fit the above criteria, of whom 19.7% reported current aspirin use and 41% were African American. Mean age was 57.3 (standard deviation [sd], 10.9) and mean BMI was 28.9 (sd, 7.3) kg/m2 for the entire cohort. Aspirin users were significantly older and had higher BMI (see Table). There was an independent, inverse association between aspirin use and mammographic density (Ptrend<0.001). Compared to women with extremely dense breasts, women with fatty (OR=1.73, CI: 1.33-2.25) or scattered fibroglandular (OR=1.50; CI: 1.17-1.92) breasts were more likely to be aspirin users. A dose-response pattern was observed, as there was a lower likelihood of having extremely or heterogeneously dense breasts with increasing aspirin dose (OR=0.62, CI: 0.50-0.76 for >300 mg; OR=0.84, CI=0.77-0.91 for <=300 mg; compared to non-users as reference group). The association between aspirin use and density was more pronounced for women <60 and for African American women (p=0.01). Conclusion: We demonstrate an independent association between aspirin use and lower mammographic density in a large, diverse screening cohort. Our results suggest that this association is stronger for younger and African American women: two groups at greater risk for ER- breast cancer. Future evaluation of this cohort will examine duration of aspirin use, and evaluate an automated measure of breast density. These results and others highlight the potential value and need for a randomized, controlled trial of aspirin as a preventive agent for breast cancer.

CharacteristicAspirin Non-UsersAspirin UsersPAge, mean (SD)55.3 (10.2)65.3 (9.8)<0.0001BMI, mean (SD)28.5 (7.2)30.4 (7.6)<0.0001Breast density, no. (%)  OR (95% CI)BIRADS 12006 (9.6)861 (16.9)1.73 (1.33 - 2.25)BIRADS 29346 (44.7)2859 (55.9)1.50 (1.17 - 1.92)BIRADS 38480 (40.6)1312 (25.7)1.22 (0.95 - 1.56)BIRADS 41057 (5.1)79 (1.6)1.00 (Reference)

Citation Format: Wood ME, Sprague BL, Oustimov A, Synnstvedt MB, Cuke M, Emily CF, Kontos D. Aspirin use is associated with lower mammographic density in a large screening cohort. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD1-05.

The Effect of Weight Change on Volumetric Measures of Mammographic Density

The association between changing body mass index (BMI) and mammographic breast density is important to better evaluate how to adjust for BMI gain/loss in longitudinal studies of density and breast cancer risk. Increasing BMI has been associated with decreasing percent dense area but the effect on absolute dense area is unclear. No studies have explored a longitudinal association using volumetric density measurement. Methods: We examined the association between change in BMI and change in volumetric breast density among 24,556 women who received breast imaging at the San Francisco Mammography Registry from 2007–2013. Height and weight were self-reported at the time of mammography. Breast density was assessed using single x-ray absorptiometry (SXA) volumetric measurement. The cross-sectional and longitudinal associations between BMI and absolute dense volume (DV) and percent dense volume (PDV) were assessed using multivariable adjusted regression. Results: Women were primarily Caucasian (66%) or Asian (25%) and most were postmenopausal (64%) at time of first mammogram. In cross-sectional analysis, BMI was positively associated with DV (β = 2.95 cm3, 95% CI, 2.69–3.21) and inversely associated with PDV (β = −2.03%, 95% CI, −2.09–−1.98). In longitudinal analysis, an annual increase in BMI was associated with an annual decrease in both DV (β = −1.01 cm3/year, 95% CI, −1.59–−0.42) and PDV (β = −1.17%/year, 95% CI, −1.31–−1.04). Findings were consistent between pre- and postmenopausal women. The annual decrease in DV was strongest among premenopausal women who were initially overweight or obese (P < 0.01 for interaction by initial BMI). Conclusion: Our findings support an inverse association between change in BMI and change in PDV. Longitudinal studies of PDV and breast cancer risk, or those using PDV as an indicator of breast cancer risk, should consider adjusting for change in BMI. The association between increasing BMI and decreasing DV is unexpected and will require confirmation using volumetric methods.

Changes in the Breast Cancer Risk Distribution among Women Utilizing Screening Mammography in Vermont Between 2001 and 2012

We previously reported a decline in overall breast cancer screening rates in Vermont following 2009. During this period, there has been debate regarding the role of patient context in decisions about when and how often to get screened, as well as increased interest in risk- based screening to optimize the balance between the potential benefits and harms of screening. The purpose of the current study was to evaluate whether the breast cancer risk distribution of the screened population in Vermont has changed during the observed decline in utilization rates. We examined the distribution of breast cancer risk among the screened population in Vermont from 2001 to 2012 using cross-sectional data from the statewide Vermont Breast Cancer Surveillance System. We employed the Breast Cancer Surveillance Consortium risk model to estimate each individual's risk of developing breast cancer within 5 years according to age, breast density, race/ethnicity, family history of breast cancer, and biopsy history. Among women ages 40 to 74 who received screening mammograms, the absolute number of visits dropped by 4,257, from 54,415 to 50,158 (−7.3%; 95% CI: −7.5, −7.1) between 2009 and 2012. Concurrently, the number of screened women who were estimated to be at low risk of developing breast cancer decreased by 4,240 (95% CI: 3,907, 4,573), representing the bulk of the overall decrease. There was no significant change in the aggregate number of women estimated to be at higher risk (−17 women; 95% CI: −350, 316). The outsized proportion of the decline attributed to women at low estimated risk held across younger and older age groups: among women ages 40 to 49, the absolute number screened dropped by 3,337, with 2,495 (95% CI: 2,389, 2,601) reflected by declines among women at low risk; among women ages 50 to 74, the absolute number screened dropped by only 920, however this value reflects a decrease of 1,763 (95% CI: 1,519, 2,007) for the low risk category, and gains totaling 843 (95% CI: 599, 1,087) among higher risk categories. We conclude that the observed decline in women screened in Vermont since 2009 is largely attributable to reductions in visits by women who are estimated to be at low risk of developing breast cancer, and that this trend generally holds across age groups.

Abstract P1-06-06: Alteration of stromal collagen fiber orientation in DCIS

Approximately 20% of new diagnoses of breast cancer are ductal carcinoma in situ (DCIS), a non-invasive form of breast cancer. Treatment decision-making for DCIS is challenging since current predictors of disease-free survival are limited, so that most women are presented with options for surgery, radiation and tamoxifen - all options with consequences for quality of life. Prior studies of prognostic factors for DCIS have focused on morphologic, genetic, and protein expression patterns of the DCIS cells. However, laboratory evidence suggests that the tumor microenvironment may play a key role in tumor invasion and progression. Collagen is the most abundant component of the stroma surrounding the breast ducts in which cancers develop. We previously observed that, in invasive breast cancer, tumors with greater numbers of collagen fibers aligned perpendicularly from the tumor were more likely to predict poor survival than tumors with collagen fibers in primarily parallel patterns near the tumor boundary (Conklin Am J Pathol 2011). To improve our ability to predict breast cancer outcomes in women with DCIS, we examined the alignment of collagen adjacent to ducts affected by DCIS to test whether alignment patterns were similar to patterns observed in tissue labeled as “normal” from biopsy and surgical sections. We evaluated collagen alignment in 255 Wisconsin women diagnosed with DCIS in 1997-2000 and followed for a median of 11.2 years (range 1-15). Stromal collagen alignment was evaluated from routine H&E tissue slides prepared at the time of diagnosis using second harmonic generation (SHG) microscopy, a label-free multiphoton laser scanning technique that selectively images collagen. SHG images were acquired and evaluated for 3-5 regions on each DCIS and normal slide for each patient; the angles of collagen fibers with respect to the DCIS lesion/stroma boundary were calculated using customized imaging software. Data for the distribution of angles were compared for normal ducts and DCIS lesions using compositional data analysis with the number of fibers totaled according to 5-angle bins (1-5, 6-10, 11-15, …, 86-90 degrees). Repeated measures linear regression models were fit to log-transformed ratios of binned counts as a function of tissue type. Dependence among repeated counts within a single region was modeled using an unstructured variance-covariance matrix. Dependence among measurements within a single subject was modeled using a compound symmetry correlation structure. Overall, the distribution of collagen fiber angles from DCIS lesions differed significantly (P = 0.0002) from the distribution of collagen fibers surrounding normal ducts. Collagen fibers surrounding DCIS lesions were 11-18% more likely to orient at 75-90 degrees relative to the lesion boundary than fibers surrounding normal ducts; fibers were more similarly aligned in both DCIS lesions and normal ducts at other smaller angles. These results underscore the relevance of the tumor microenvironment, in particular the arrangement of the collagen fiber matrix. Planned data analysis will next examine whether collagen fiber alignment patterns differ between DCIS patients who did and did not experience a second breast cancer diagnosis over the course of follow-up.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-06-06.

Socioeconomic Status and Survival after an invasive Breast Cancer Diagnosis

Significant progress has been achieved in the United States in improving survival rates following an invasive breast cancer diagnosis. Previous studies have shown, however, that women living in geographic areas with high poverty and low education levels experience poorer survival. However, nearly all of these studies have been restricted to use of community-level data (e.g. US Census) on socioeconomic status (SES), and thus have been limited in their ability to identify individual-level factors associated with the disparity in survival. We examined individual-level SES in relation to breast cancer survival in a population-based cohort of invasive breast cancer survivors, ages 20-69, diagnosed in Wisconsin during 1995-2003 (N = 5,865). Information on household income, household size, and education was obtained during telephone interviews conducted shortly after diagnosis. Vital status was determined through December 31, 2006, using automated searches of the National Death Index. A total of 676 deaths (461 from breast cancer) were observed during 41,751 person-years of follow-up. Compared to college graduates, women with no further education beyond high school were more likely to die from breast cancer (Hazard Ratio, HR: 1.39; 95% CI: 1.10, 1.76) and from all causes (HR 1.42; 95% CI: 1.17, 1.73) following their breast cancer diagnosis. Similarly, women with household income less than 2.5 times that of the poverty level were more likely to die from breast cancer (HR 1.46; 95% CI: 1.03, 2.08) and from all causes (HR 1.64; 95% CI: 1.20, 2.24) compared to women with household income at least 5 times the poverty level. Women with lower education and income levels were less likely to have had annual mammograms prior to diagnosis. There was little difference in stage at diagnosis according to education level, but women with low income levels were 2.7 (95% CI: 1.2, 6.2) times more likely than women with high income to be diagnosed with distant-stage breast cancer. Adjustment for these factors attenuated, but did not eliminate, the association between SES and survival after diagnosis. Thus, the disparities in breast cancer survival that exist according to individual-level SES cannot be fully explained by variation in mammography use and stage at diagnosis.

Hinged total elbow replacement

Total elbow arthroplasty using a hinged prosthesis was performed on 17 elbows in 12 patients. Clinical follow up ranged from 18 to 85 months, and averaged 56 months. Indications for surgery included disabling pain, restricted motion of the elbow, and roentgenographic evidence of joint destruction. We did not use this prosthesis in patients with restricted shoulder motion or in those with demanding occupational or recreational activities. Fifteen elbows showed good results; one elbow was complicated by ectopic ossification, and one prosthesis was removed for a deep wound infection. No other instances of symptomatic loosening were found, although radiographs demonstrated a lucent line around the cement in four elbows and a cement fracture in one elbow. All patients were relieved of their pain. The low incidence of loosening may be explained by the selective use of the hinged prosthesis. Index Terms: elbow, arthroplasty, hinged prosthesis.

Thoracolumbar spine fractures. Results of treatment

Sixty-three patients with thoracolumbar spine fractures treated between 1972 and 1978 were placed into six treatment groups: fusion and instrumentation alone, laminectomy with fusion and instrumentation, laminectomy alone, laminectomy with fusion without instrumentation, fusion alone, and no operation. Patients were interviewed and examined and their histories reviewed; new radiographs were obtained, and a detailed questionnaire was answered. No treatment method improved neurologic function. Fusion with instrumentation allowed earliest ambulation with least spinal deformity. Most patients in all treatment groups adjusted effectively to their injuries and remained active in employment and hobbies. A detailed, thorough rehabilitation program gave best functional results and patient attitudes.

Treatment of chronic elbow instability

Four patients developed chronic elbow instability following closed traumatic dislocations. All patients had disruption of the anterior capsule of the elbow joint with avulsion of the brachialis from its insertion on the coronoid process. Repair of the anterior soft tissues restored elbow stability with minimal difficulty and no significant complications.

Biomechanical evaluation of metacarpophalangeal joint prosthesis designs

A laboratory biomechanical analysis of metacarpophalangeal joint prosthesis designs was done with fresh cadaver finger rays. The center of rotation, range of motion, tendon excursion, and fingertip force were determined on the specimens before and after implanting Swanson, Niebauer, Steffee II, St. Georg-Buchholz, Schultz, and modified Strickland prostheses. Their biomechanical behavior varied considerably and none duplicated the normal metacarpophalangeal (MP) joint. Each has design characteristics that may be clinically advantageous as well as disadvantageous. Irrespective of the design, the studies done cannot be divorced from the following factors: (1) implant material properties--silicone rubber implants buckled with tendon loading; this deformity created a significant flexor mechanical advantage and an extensor mechanical disadvantage; (2) implant fixation--freely movable implant stems dampened part of the applied load; braided suture provided inadequate immediate fixation; (3) implantation technique--the articulated prostheses can be technically unforgiving; errors in technique resulted in alteration of their biomechanical behavior.

S-C joint disruption in an infant

An anterosuperior sternoclavicular disruption in a 7 month old female was caused by trauma. Good results were observed by concervative managment.

Overnight admission for psychiatric emergencies

Patients identified as psychiatric cases on the emergency ward of a 1036-bed teaching hospital are handled in one of three ways: released with outpatient referral, admitted to a psychiatric inpatient facility, or hospitalized in a general medical holding unit with a 24-hour stay. The authors obtained demographic and diagnostic data on 377 psychiatric patients seen consecutively on the ward and then compared those admitted to the holding unit (83) with those released (193) or hospitalized (101). The three groups were demographically similar but the patients in the holding group fell between the other two groups in severity of psychopathology. More than half the patients admitted to the holding unit were released the following day. The authors discuss the advantages of overnight admission as an alternative to hospitalization or release.

Clinical and experimental studies on the effect of extensor carpi radialis longus transfer in the rheumatoid hand

Digital ulnar drift in the rheumatoid hand is a complex problem. The radial deformity of the wrist causes abnormal forces on the extrinsic flexor and extensor tendons which aggravate metacarpophalangeal ulnar drift. Analysis of the results of the transfer of the extensor carpi radialis longus to the extensor carpi ulnaris in 20 wrists showed that 13 of 20 had significant correction of the wrist deformity. The transferred tendon did not contract during active ulnar deviation. Laboratory studies of the transfer on cadaveric rheumatoid wrist models showed correction of the wrist deformity. The dorsal ulnar capsule was determined to be a stabilizer of wrist position, as evidenced by deformity after transection.

Evaluation of the two-stage flexor-tendon reconstruction in severely damaged digits

From July 1971 to July 1974, the two-stage tendon-grafting procedure of Hunter and Salisbury was performed in thirty-two severely damaged digits in twenty-five patients. Of these digits, twenty-three fingers and five thumbs could be evaluated for gain in total active flexion (expressed as per cent of preoperative passive flexion) and for gain in total active motion (expressed as per cent of total preoperative passive motion) after follow-ups ranging from six to fifty months. The results for total active flexion were 60.9 per cent good, 21.7 per cent fair, and 17.4 per cent poor, and for total active motion 21.7 per cent good, 56.5 per cent fair, and 21.7 per cent poor. Complications were frequent after both stages and included infection, migration of the rod, and adhesions within the proximal end of the newly formed sheath. Flexion contractures were a significant problem.

Cast brace treatment of plateau and bicondylar fractures of the proximal tibia

Twenty-nine patients with 30 intraarticular proximal tibial fractures were treated with early application of a cast brace. All fractures united, knee motion was excellent or good in all but one patient. The fracture fragments did not lose position after cast brace application. Varus or valgus deformities could be corrected and maintained. Ninety per cent had no pain at follow-up. Hospital stay was as short as two days and generally under two weeks.

Treatment of distal femoral fractures with early weight-bearing. A preliminary report

Ten patients with 11 supracondylar fractures of the femur were treated with early weight-bearing and early knee motion. All fractures united. A good functional range of painless knee motion was restored in each case. No deformity or shortening developed during treatment in the cast-brace.

Proximal interphalangeal joint injuries and their initial treatment

Many PIP joint injuries which appear to be innocuous are actually very severe injuries to this small hinged joint and carry a high percentage of disability for the hand as well as the individual digit. A flexion contracture of the PIP joint of one digit may significantly reduce the functional capacity of the entire hand. To prevent such physical impairment, the type of PIP joint injury must be defined and the proper treatment for the particular injury must be initiated. Second, it is paramount that prolonged immobilization of this joint be prevented. It has been found, through clinical experience and experimental projects, that the early healing process is complete by 3 weeks and active motion may then be initiated without any detrimental effects. Extensor and flexor contractures of this joint are apt to occur in digits which have been immobilized for significantly longer than 3 weeks. Finally, the well-publicized "position of function" for the hand is not necessarily the ideal position for the rehabilitation of the hand. The "intrinsic plus position" is the position of choice for immobilization of the MP and PIP joints to prevent contractures. This concept has been confirmed by our clinical experience and the biomechanical studies performed in the laboratory.