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To determine if the use of a narrower elastic tourniquet compared to a standard pneumatic tourniquet reduces operative blood loss in the operative fixation of humeral shaft fractures.This retrospective cohort study was performed at a level I trauma center and included 134 patients, aged 18 to 90 years, with a humeral shaft fracture treated with open reduction internal fixation (ORIF) from January 2007 through June 2018. The primary variable of interest was the application of a HemaClear™ elastic tourniquet versus a standard pneumatic tourniquet during the fixation of a humeral shaft fracture. The primary outcome was estimated blood loss (EBL) during the humerus ORIF surgery as recorded in the operative record. The secondary outcomes were total tourniquet time and operative time. The primary purpose of the study was to compare the above outcomes between the two tourniquet types.Estimated blood loss was 42% lower (95% CI: 11% to 73%, p0.01) in the elastic tourniquet group when compared to the standard pneumatic tourniquet group. The use of the elastic tourniquet was also associated with a 67% increase (95% CI: 35% to 100%, p0.01) in tourniquet time compared to the standard pneumatic tourniquet. No difference in the total operative time between the two groups (difference, -3%; 95% CI: -21 to 14, p = 0.72) was observed.Elastic tourniquet use was associated with 42% less blood loss in the fixation of humeral shaft fractures compared to use of a traditional pneumatic tourniquet, although this may be of unclear clinical importance given the relatively low estimated blood loss in this cohort. The potential benefit of reduced blood loss associated with the narrower elastic tourniquet is likely caused by the increased tourniquet time, without a change in overall operative time.

Background In 2016, the Centers for Disease Control and Prevention (CDC) changed the time frame for their definition of deep surgical site infection (SSI) from within 1 year to within 90 days of surgery. We hypothesized that a substantial number of infections in patients who have undergone fracture fixation present beyond 90 days and that there are patient factors that can predict who is more likely to present with SSI after 90 days. Methods A retrospective review yielded 452 deep SSI after fracture fixation. These patients were divided into two groups—those infected within 90 days of surgery (308 patients) and those infected beyond 90 days (144 patients). Data were collected on risk factors for infection. Univariate and multiple logistic regression analyses were performed to compare the two groups. A randomly selected control group was used to build infection prediction models for both outcomes. The two outcomes were then modeled against each other to determine whether differences in predictors for early versus late infection exist. Results Of the 452 infections, 144 occurred beyond 90 days (32%). No statistically significant patient factors were found in univariate analysis between the early and late infection groups. The need for flap coverage was the only injury characteristic that differed significantly between groups, with patients in the late infection group more likely to have needed a flap. In models of early versus late infection, there are no statistically significant predictors. When modeled against the control group and directly comparing the two models, predictors for early infection include male sex and fractures of the pelvis, acetabulum, or hip, whereas predictors of late infection include hepatitis C and/or human immunodeficiency virus (HIV) and admission to the intensive care unit (ICU). Conclusion Use of the recent CDC definition will underestimate the rate of actual postoperative infections when applied to orthopaedic trauma patients. Hepatitis C and/or HIV and ICU admission are predictors of late infection, whereas male sex and pelvis, acetabulum, or hip fractures are predictors of early infection. Patients who receive flap coverage may be more likely to present with late infection.

Introduction Femoral neck fractures in the young patient present a unique challenge. Most surgeons managing these injuries prefer a fixed angle implant, however these devices are fraught with problems. A dynamic hip screw (DHS) is one such fixed angle device that risks malreduction through rotational torque during screw insertion. To avoid this risk some surgeons utilize a dynamic helical hip system (DHHS), however little is known about the complication profile of this device. We hypothesized that the complication rate between these two devices would be similar. Patients and Methods All patients presenting to a single tertiary referral center with a femoral neck fracture were identified from a prospectively collected trauma database over an 11-year period. Patients were included if they were less than 60 years of age, treated with a DHS or DHHS, and had at least 6 months of follow-up. Demographic data, injury characteristics, and post-operative complications were obtained through chart review. Standard statistical comparisons were made between groups. A total of 77 patients met inclusion criteria. Results Average age of patients was 38 years (range: 18–59) and 56 (73%) were male. The DHS was used in 37 (48%) patients and the DHHS was used in 40 (52%) patients. Demographic data including average age, gender, body mass index, and smoking status did not differ between the groups. There were 29 (39%) total complications of interest (femoral neck shortening >5 mm, non-union requiring osteotomy, conversion to THA, and osteonecrosis. There were 19 (51%) complications in the DHS group and 10 (25%) in the DHHS group (p = 0.01, risk difference 25%, 95% CI 7–43). Comparisons of the individual complications about the DHS and DHHS cohort did not reach statistical significance for non-union (8% vs 3%) or THA (16% vs 13%) (p = 0.33, p = 0.64, respectively) but a difference was detected in the rate of shortening (27% vs 10%; p = 0.05). Conclusion This study demonstrates a high risk of complication when managing young femoral neck fractures in line with prior literature. The major complication rate of non-union requiring osteotomy or fixation failure resulting in THA was no different between the two groups, but the rate of shortening was greater the DHS group. This data suggests the DHHS may be a suitable device to manage the young femoral neck fracture and without increased risk of complication.

The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries.Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit.Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p0.01), higher admission lactate (4.4 and 3.0; p0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (XIn this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries.Level III.

Concern exists regarding the pulmonary effects of using tourniquets for secondary extremity fractures in patients also undergoing intramedullary nail (IMN) fixation of femoral or tibial shaft fractures. Our hypothesis was that tourniquet use would be associated with increased ventilator days.At a Level I trauma center, we conducted a retrospective review of 1966 patients with 2018 fractures (1070 femoral shaft and 948 tibial shaft) treated with IMN from December 2006 to September 2014. Medical record review and bivariate and multiple variable regression analyses were conducted, and the main outcome measurement was number of ventilator days.No statistically significant negative association was found between use of a tourniquet and number of ventilator days in the femoral or tibial fracture group. Use of tourniquets in the upper extremities showed a statistically significant decrease in amount of ventilator days in the femoral group (-2.2 days, p = 0.003) but no association in the tibial group (1.1 days, p = 0.36). Use of tourniquets concurrently in both upper and lower extremities of both femoral and tibial groups also had a protective effect (-6.8 days, p0.001 and -2.3 days, p = 0.009, respectively). Stratified and sensitivity analyses (to account for effects of mortality and missing data) showed consistently similar results.Tourniquet use for secondary extremity fractures, in patients also undergoing IMN fixation for femoral or tibial shaft fractures, was not associated with an increased number of ventilator days. A potential protective effect of tourniquet use was shown in patients with upper extremity fractures and in those with both upper and lower extremity fractures.Therapeutic Level III (Retrospective cohort study).

Predictive models are common in orthopedic research; however, most models are not validated in an external population. The Nonunion Risk Determination (NURD) score was developed using a single-center cohort of 382 patients to reliably predict tibia shaft nonunions at the time of initial intramedullary nail fixation. The purpose of this study was to externally validate the NURD score using data from the SPRINT Trial.The SPRINT trial was a multicenter study comparing reamed versus unreamed intramedullary nails in tibial shaft fracture patients. We assessed the prognostic performance of the NURD score in the SPRINT trial data with comparisons of the c-statistics, calibration plots, and a comparison of predicted probabilities at cut-points defined in the study to derive the NURD score. In addition, we compared the odds ratios of the NURD score components between the derivation (NURD) and external validation (SPRINT) data.The NURD score demonstrated significantly worse discrimination in the SPRINT data than was observed in the original data (c-statistic: 0.61 vs. 0.85, p0.01). The NURD score was well-calibrated in the derivation and SPRINT data. The SPRINT data had less heterogeneity, as determined by the standard deviation of the linear predictors (NURD: 1.4 vs.0.4). Once we adjusted for case-mix differences, the NURD score had similarly strong discrimination in the SPRINT data (c-statistic: 0.81 vs. 0.85, p = 0.17).Based on our external validation, the NURD score lacks generalizability as it underperforms with respect to discrimination in the SPRINT trial data. However, after adjusting for case-mix differences, the performance of the NURD score is comparable between the two datasets, suggesting robust reproducibility.

Introduction We assessed the outcome and safety of posterior plating of distal tibial fractures. Methods We conducted a retrospective case series at a Level I trauma center. Seventy-four consecutive patients with distal tibial fractures treated with anatomically contoured 3.5-mm T-shaped locking compression plate using a posterolateral approach from January 2008 through April 2018 were included in the study. The mean patient age was 48 years (range, 18−87 years). Fifty-nine percent of the patients were male patients, 47% of the fractures were open fractures; and 27% of the patients had multiple traumatic injuries. Eleven fractures were AO/OTA type 42, 22 were type 43A, and 41 were type 43C. Sixty-two (84%) patients were treated with initial spanning external fixation (median time, 23 days) and staged open reduction and internal fixation. The main outcome measure was unplanned reoperation to address implant failure, nonunion, deep surgical site infection, or symptomatic implant. Results Overall risk of unplanned reoperation was 15% (11 of 74 patients, 95% confidence interval, 9%–25%). Four (5%) reoperations were for nonunion, three (4%) were for surgical site infection, two (3%) were for infected nonunion, and two (3%) were for implant prominence. Loss of alignment >10 degrees occurred in one patient who underwent unplanned reoperation for nonunion. No plate breakage occurred. Median time to reoperation was 221 days (range, 22–436 days). Only one other complication was noted: wound dehiscence associated with the posterolateral approach, which was treated with irrigation and debridement and a 6-week regimen of oral antibiotics. Conclusions Use of a posterolateral approach with a pre-contoured locking compression T-plate for the treatment of distal tibial fractures led to reasonable outcomes with an acceptable risk of unplanned reoperation, even with a high proportion of open fractures commonly staged with external fixation.

Objectives Posterolateral bone grafting to treat nonunions of the distal two-thirds of the tibia avoids the often traumatized and more tenuous anterior soft-tissue envelope. Few modern reports of its effectiveness are available. We assessed whether posterolateral bone grafting leads to high union and low complication rates. Methods We conducted a retrospective review at a Level I trauma center. Our study group was 59 patients with distal two-thirds tibial fractures treated with posterolateral bone grafting. Patients included those with history of deep surgical site infection (SSI) before bone grafting (n = 17), established nonunions (n = 42), and impending nonunions associated with open fractures and bone gaps (n = 17). All patients were followed for a minimum of 12 months unless they achieved union before that time point. Our primary outcome measurement was fracture union. Secondary outcome measurements were any complication associated with the approach and infection requiring return to the operating room. Results Fracture union was achieved in 44 (75%) of 59 patients without further intervention. The mean interval to union was 9.9 months (range, 3–22). Of 11 infected nonunions treated, nine progressed to union. Seventeen of 23 patients with defects >2 cm, including defects up to 5.4 cm without infection, were successfully treated. Two patients who underwent grafting at least 10 years after initial injury achieved union. No complications were associated with the approach (specifically, no wound breakdown, vascular injury, or tendon injury). Fourteen percent of patients experienced SSI after bone grafting. Seven of eight deep SSI occurred in patients with previous infection or positive intraoperative cultures. Only one (3%) of 36 patients without infection pre- or intraoperatively experienced SSI. Conclusions Even in this relatively difficult patient cohort that included large bone gaps and history of infection, union was achieved at a relatively high rate with posterolateral bone graft. The approach seems to be safe, considering no known complications specifically associated with the approach occurred, and seems to reduce the risk of SSI in the absence of previous infection.

Removal of symptomatic implants is a common procedure performed by orthopaedic trauma surgeons. No guidance is available regarding which factors contribute to the likelihood of an implant becoming symptomatic. Our objective was to determine whether radiographic parameters associated with distal interlocks in retrograde femoral nails are associated with the rate of symptomatic screw removal.We conducted a retrospective review at a Level I trauma center. Study patients (n=442) had femoral fractures treated with retrograde intramedullary nails from 2007 to 2014 and at least 1year of follow-up. The main outcome measurement was symptomatic distal screw removal as predicted by radiographic parameters.Symptomatic screw removal occurred in 12% of the patients. Increased distance between the most distal screw and the articular surface of the femur significantly reduced likelihood of symptomatic screw removal. A cutoff of 40mm from the articular block was predictive of removal (≥40mm, 0% removal;40mm, 18% removal, p0.0001). In patients with distal screws placed within 40mm of the articular surface of the femur, a ratio of screw length to distance between medial and lateral femoral cortices that was ≥1 was a strong predictor of symptomatic screw removal (area under Receiver Operating Characteristic curve, 0.75; p0.0001).More distal screws and screws that radiographically extend to or beyond the medial cortex are more likely to cause pain and require removal in femoral fractures treated with retrograde intramedullary nails. We identified a specific distance from the joint (40mm) and a ratio of screw length to bone width (≥1) that significantly increased the likelihood of symptomatic screw removal. Clinicians can use these data to inform patients of the likely risk of implant removal and perhaps to better guide placement and length of screws when the clinical scenario allows some flexibility in location and length of screws.

Background Temporary external fixators are often used to stabilize fractures when definitive fracture surgery must be delayed. Sometimes, external fixators are left in place during repeat operations, including definitive internal fixation of tibial pilon and tibial plateau fractures. It is unknown how well current surgical preparation sterilizes these devices, which become part of the surgical field. Our hypothesis was that our institution’s standard surgical preparation creates a low rate of culture-positive environments on external fixators at the time of surgical skin incision. Methods We prospectively consented and enrolled patients to obtain cultures (48 patients, 55 external fixators, 165 sets of culture data). After standard preparation and immediately before incision, cultures were obtained from three sites on each external fixator: 1) most distal pin 1 cm from pin-skin interface, 2) most distal bar at midpoint between pin and clamp connectors, and 3) most distal clamp at bar-clamp interface. Our standard preparation for patients with external fixation in place is to don sterile gloves and wipe down all components of the external fixator with 70% alcohol-soaked sterile 4 × 4 in gauze sponges before skin preparation. The skin and external fixator are then prepped in the usual fashion with ChloraPrep for closed wounds or with povidone iodine scrub and paint for open wounds. Swabs were processed and organisms from cultures identified. Clinicians were blinded to study results until study completion. Results Two of 165 cultures (1.2%; 95% confidence interval [CI]: 0–2.9%) were positive for common pathogens sometimes observed in surgical site infection. Four cultures (2.4%; 95% CI: 0–4.8%) had pathogens that are rarely associated with surgical site infection, and four (2.4%; 95% CI: 0–4.8%) had nonpathogenic organisms. Conclusion Using 70% alcohol on external fixators plus either ChloraPrep for closed wounds or povidone iodine for open wounds seems to result in a low rate of positive cultures. Most species that were isolated are infrequently identified as sources of surgical site infections. This preparation protocol might be effective at producing a relatively clean environment at the time of surgery for patients with external fixators already in place.

Background Antibiotic-impregnated cement nails are used to treat postoperative deep infections after primary intramedullary nail insertion for the treatment of tibial fractures. Few data exist regarding the efficacy of this treatment strategy. We hypothesized that such treatment with antibiotic nails results in a high rate of infection clearance at intermediate follow-up. Methods We conducted a retrospective review at our Level I trauma center. Patients who received intramedullary nails to stabilize tibial fractures (from 2000 to 2011) and subsequently required antibiotic nails to treat deep postoperative infection (n = 55) were considered for study inclusion. Patients with less than 6 months of follow-up were excluded, leaving 41 patients in the study group (average age, 41 years; average follow-up, 20 months). Results Thirty-one patients (76%) had no evidence of infection after treatment. The 10 patients for whom treatment failed were shown to have infection within the first 6 months. Two experienced persistent infection after antibiotic nail removal, necessitating massive debridement and ring fixator placement. Four patients underwent repeat antibiotic nail insertion after persistent infection. Three infections resulted in eventual above-knee amputations, and one chronic infection resulted in the need for multiple debridement and saucerization procedures. No complications associated with use of the antibiotic nails were observed. Conclusion The use of antibiotic nails for treatment of tibial infections seems to be a reasonable option, clearing 76% of infections at the 6-month time frame. Further investigation is needed to compare this treatment algorithm with other strategies, such as antibiotic treatment without nail removal and massive debridement with ring fixator placement.

Background We sought to compare the incidence of complications after fixation of displaced femoral neck fractures in young adults treated with fixed-angle devices versus multiple cancellous screws and a trochanteric lag screw (Pauwel screw). Methods We conducted a retrospective cohort study at a level I trauma centre. Sixty-two skeletally mature patients (age range, 16–60 years) with displaced femoral neck fractures were included in the study. Forty-seven were treated with a fixed-angle device (sliding hip plate with screw or helical blade) and 15 with multiple cancellous screws placed in a Pauwel configuration. The main outcome measure was postoperative complication of osteonecrosis or nonunion treated with a surgical procedure. Results Significantly fewer failures occurred in the fixed-angle group (21%) than in the screws group (60%) ( p = 0.008). Osteonecrosis was rare in the fixed-angle group, occurring in 2% of cases versus 33% of cases in the screws group ( p = 0.002). Consistent with previous studies, good to excellent reductions were associated with a failure rate of 25% and fair to poor reductions were associated with a failure rate of 55% ( p = 0.07). The best-case scenario of a good to excellent reduction stabilised with a fixed-angle device yielded a success rate of 85%. Conclusion In young patients with displaced high-energy femoral neck fractures, fixed-angle devices resulted in fewer treatment failures than did Pauwel screws.

Complications, including nonunion and avascular necrosis, are relatively common after internal fixation of a femoral neck fracture. Young patients are particularly impacted by these complications as salvage options often result in a suboptimal functional result. The quality of reduction appears to be of primary importance; however, it is unknown whether the choice of internal fixation affects the incidence of complications. In this article, we present the rationale and evidence for available internal fixation options. Current evidence is insufficient to recommend an optimal method of internal fixation, and this review demonstrates the need for high-quality randomised, controlled trials to study this problem.

We evaluated whether the location of a ballistic femoral fracture helps predict the presence of arterial injury. We hypothesized that fractures located in the distal third of the femur are associated with a higher rate of arterial injury.We conducted a retrospective review of electronic medical records at our level I trauma centre and found 133 consecutive patients with femoral fractures from civilian gunshots from 2002 to 2007, 14 of whom sustained arterial injury. Fracture extent was measured with computerized viewing software and recorded with a standard technique, calculating proximal, distal, and central locations of the fracture as a function of overall length of the bone. Analyses were conducted with Student's t, Chi-squared, and Fisher's exact tests.The location of any fracture line in the distal third of the femur was associated with increased risk of arterial injury (P0.05). The odds ratio for the presence of arterial injury when the proximal fracture line was in the distal third of the femur was 5.63 (95% confidence interval, 1.7-18.6; P0.05) and when the distal fracture line was in the distal third of the femur was 6.72 (95% confidence interval, 1.78-25.44; P0.05).A fracture line in the distal third of the femur after ballistic injury is six times more likely to be associated with arterial injury and warrants careful evaluation. Our data show that fracture location can help alert clinicians to possible arterial injury after ballistic femoral fracture.

We compared the mechanical benefits and costs of 3 strategies that are commonly used to increase knee-spanning external fixator stiffness (resistance to deformation): double stacking, cross-linking, and use of an oblique pin. At our academic trauma centre and biomechanical testing laboratory, we used ultra-high-molecular-weight polyethylene bone models and commercially available external fixator components to simulate knee-spanning external fixation. The models were tested in anterior-posterior bending, medial-lateral bending, axial compression, and torsion. We recorded the construct stiffness for each strategy in all loading modes and assessed a secondary outcome of cost per 10% increase in stiffness. Double stacking significantly increased construct stiffness under anterior-posterior bending (109%), medial-lateral bending (22%), axial compression (150%), and torsion (41%) (p0.05). Use of an oblique pin significantly increased stiffness under torsion (25%) (p0.006). Cross-linking significantly increased stiffness only under torsion (29%) (p0.002). Double stacking increased costs by 84%, cross-linking by 28%, and use of an oblique pin by 15% relative to a standard fixator. All 3 strategies increased stiffness under torsion to varying degrees, but only double stacking increased stiffness in all 4 testing modalities (p0.05). Double stacking is most effective in increasing resistance to bending, particularly under anterior-posterior bending and axial compression, but requires a relatively high cost increase. Clinicians can use these data to help guide the most cost-effective strategy to increase construct stiffness based on the plane in which stiffness is needed.

Introduction and aim There is a paucity of literature regarding outcomes of open fractures of the distal radius. No study has detailed this injury or treatment strategy in the geriatric population. The purpose of this study was to determine the safety of immediate open reduction and internal fixation of geriatric open fractures of the distal radius. Methods A total of 21 geriatric patients with open fractures of the distal radius treated with a single definitive procedure were identified from a prospectively collected database. We reviewed patient demographics, injury characteristics and treatment specifics. Our primary outcome was surgical-site infection defined by need for antibiotics or repeat surgery. Our secondary outcome was need for other re-operation. Patients were contacted and functional scores obtained. Results Patients were followed up for an average of 26 months. One deep infection and one nonunion occurred, and they required repeat surgery. Four minor operative complications occurred, including stiffness requiring manipulation and prominent fixation devices requiring removal. Patients maintained an average wrist flexion–extension arc of 89° and pronation–supination arc of 137°. The average QuickDASH (shortened disabilities of the arm, shoulder and hand questionnaire) score was 17.4, indicating minimal disability of the upper extremity. Conclusions Immediate open reduction and internal fixation of geriatric open fractures of the distal radius yields adequate functional results with low risk of major complications.

Background We assessed the biomechanical performances of a trochanteric lag screw construct and a traditional inverted triangle construct in the treatment of simulated Pauwels type 3 femoral neck fractures. Methods An inverted triangle construct (three 7.3-mm cannulated screws placed in inverted triangle orientation) and a trochanteric lag screw construct (two 7.3-mm cannulated screws placed across the superior portion of the femoral neck and one 4.5-mm lag screw placed perpendicular to the fracture in superolateral to inferomedial orientation) were tested in nine matched pairs of non-osteoporotic human cadaveric femora. We used a previously described vertically oriented femoral neck fracture model and testing protocol that incrementally loaded the constructs along the mechanical axis of the femur to 1400 N. Specimens that survived incremental loading underwent cyclic loading. Apparent construct stiffness, force at 3 mm of displacement, and survival of incremental loading were recorded. Findings The trochanteric lag screw group had a 70% increase in stiffness (261 N/mm [29 standard deviation] versus 153 N/mm [16 standard deviation]; P = 0.026) and a 43% increase in force required for displacement (620 N versus 435 N; P = 0.018) compared with the inverted triangle group. One trochanteric lag screw and no inverted triangle specimen survived incremental loading. Interpretation A trochanteric lag screw construct applied to vertically oriented femoral neck fractures provides marked improvement in mechanical performance compared with the inverted triangle construct.

This article summarizes the evolution of literature and practice related to fracture care in polytrauma patients. Particular emphasis is given to the management of femoral shaft fractures and the concept of damage control in these complex patients. The application of these guidelines in common clinical practice is also discussed.

Purpose Fractures of the distal radius are among the most common injuries treated in hand surgery practice, and distal radius locking plates have become an increasingly popular method of fixation. Despite widespread use of this technology, it is unknown whether the subchondral placement of locking screws affects the loading profile of the distal radius. Our study was designed to determine whether subchondral locking screws change the articular contact pressures in the distal radius. Methods Twelve cadaveric forearms underwent a previously described axial loading protocol in a materials testing machine. We used an intra-articular, real-time computerized force sensor to measure peak contact pressure, total pressure, and contact area in the distal radius. Internal validation of sensor placement and reproducibility was conducted. Each specimen was tested before fixation (control), after application of a palmar distal radius locking plate, and after simulation of a metaphyseal fracture. Results We identified no statistically significant differences in maximum pressure, total pressure, and contact area among control, plated, and plated and fractured specimens. However, the contact footprint—represented by squared differences in force across the sensor—were significantly different between the control group and both plated groups. Conclusions The technique for measuring contact pressures produces highly repeatable values. Distal radius locking plates with subchondral hardware placement do not seem to significantly change articular contact pressures. Clinical relevance Although locking screws placed in subchondral bone of the distal radius for fracture fixation may alter the stress distribution across the radiocarpal joint, we found no evidence that peak stresses across the joint were changed. Therefore, it seems unlikely that periarticular locking screws contribute to long-term arthrosis after fixation of extra-articular distal radius fractures.

Splenectomy is sometimes necessary to achieve optimal cytoreduction or manage iatrogenic injury in the surgical management of epithelial ovarian cancer (EOC) and related conditions. To determine the place of splenectomy in cytoreductive surgery a retrospective review was made of patient hospital records. Between April 1989 and August 1994, 18 patients were found to have undergone a splenectomy as a component of their surgery leading to optimal debulking. Morbidity attributable to the splenectomy was minimal, with no significant increase in operative time or blood loss. The morbidity attributable to the splenectomy was as follows: atelectasis and/or effusion (8), pancreatic tail injury (4), thrombocytosis > 10(6)/microliters (3), pancreatic pseudocyst (1), partial left adrenalectomy (1), and pulmonary embolism (1). There were no instances of overwhelming postsplenectomy infection. Five patients were anticipated to require splenectomy and may have benefitted from preoperative vaccination against potential pathogens. Three patients were found to have splenic parenchymal metastases. Consistent with the international literature, these patients had other features consistent with stage IV disease, recurrent disease, or poor survival. Consideration should be given to expanding the FIGO stage IV classification to include splenic parenchymal disease. Splenectomy is a feasible and safe procedure to facilitate optimal tumor debulking; however, the potential associated morbidity mitigates against this procedure if significant, suboptimal residual disease is left elsewhere.

A phase II trial of the new anthrapyrazole piroxantrone was conducted by the Southwest Oncology Group in advanced ovarian carcinoma. The objectives were to evaluate its response rate and toxicity in patients who had disease persistence, progression, or recurrence either during or after platinum-containing chemotherapy. A two-stage statistical design targeted accrual to 15 eligible patients if no responses were observed. The piroxantrone starting dose was 120 mg/m 2 , with the provision to escalate to 150 and 180 mg/m 2 . There were 16 eligible patients, all of whom had received either one (12 patients) or two (4 patients) prior platinum-containing regimens; one patient had received doxorubicin. Fourteen of the 16 patients were enrolled either at the time of disease persistence/progression during initial chemotherapy or with recurrence or progression within 6 months of the previous platinum-based regimen. One to 5 cycles of piroxantrone were given. Dose escalation was feasible in 7 patients but was prevented in the other 9 by neutropenia. Maximum toxicity for all cycles was none or grade 1 in 2 patients; grade 2, 5; grade 3, 8; and grade 4, 1. All but one of the grade 3 or 4 events was from myelosuppression; there were no adverse cardiac events. No responses were observed. Thus, piroxantrone appears inactive in patients with persistent, progressive, or recurrent ovarian cancer who recently had received a platinum-based regimen.

A case of endometriosis with myxoid change is presented here which raised concern for metastatic adenocarcinoma and pseudomyxoma peritonei. This is the second case similar to the one described previously in the literature. A 51-year-old woman underwent repair for an umbilical hernia. The tissue sections of the hernia specimen contained isolated pools of mucin surrounded focally by cuboidal-type epithelium. Subsequent CT scan of the abdomen and pelvis revealed a large right adenexal mass. These clinicopathologic findings raised strong suspicion for adenocarcinoma and pseudomyxoma peritonei. Intraoperative frozen section of the right ovary showed an endometriotic cyst. She underwent hysterectomy, bilateral salpingoophrectomy, partial omentectomy, and lysis of adhesions. Permanent sections revealed foci of endometriosis in both ovaries and cervix. Pools of acellular mucin were present in the omentum and bladder peritoneum. There was no evidence of malignancy in any of the specimen. The case illustrates that endometriosis with myxoid change can simulate with mucinous adenocarcinoma and pseudomyxoma peritonei.

Sixty-eight patients with relapsing, epithelial type ovarian carcinoma were entered into a Phase II study of vinblastine. Vinblastine was administered as a continuous intravenous infusion over five days at a starting dose of 1.7 mg/m2/day every 3 weeks. There were 44 fully evaluable and 6 partially evaluable patients. Forty-one of these patients had had only one prior treatment regimen. Grade 3 or 4 leukopenia occurred in 12 patients (24%), but Grade 3 or 4 thrombocytopenia occurred in only 2 patients. There were two clinical complete responses of 18 and 36 weeks duration and one partial response of 6 weeks for an overall response rate of 7%. We conclude that vinblastine, administered in optimal dose and schedule, has little clinical activity in previously treated patients with ovarian cancer.

Vulvar intraepithelial neoplasias may be occurring more frequently among younger age groups. Six patients with carcinoma in situ or severe vulvar dysplasia are reported, as well as one patient with microinvasive carcinoma, all under the age of 30 years. The vulvar lesions were noted to be mostly multicentric. They were associated with other intraepithelial neoplasias of the cervix or vagina in four of the six cases. The lesions were most often mistaken for condyloma acuminatum. Histologic changes were primarily Bowen’s disease or Bowenoid dysplasia.

Preliminary data from this institution suggested that flow cytometric DNA analysis was an objective prognostic indicator in archival localized squamous cell carcinoma of the tongue. Technical improvements were made, including analysis of tumor, normal tissue, and a combination of the two; standardized cursor placement; mathematic determination of tetraploid populations; and development of a statistical analysis. A larger number of patients (60) with this disease were reviewed. DNA content was related to disease-free survival, local recurrence, regional metastasis, and incidence of second primary tumors. There was no significant difference between aneuploid and diploid tumors with respect to the variables analyzed. We believe these technical improvements will enhance flow cytometric DNA analysis of paraffin-embedded tissues. However, in this retrospective review of localized squamous cell carcinoma of the tongue, DNA analysis was not a valuable prognostic indicator. Only prospective studies will address this issue.

A combination of doxorubicin (30 mg/m2 iv), cisplatin (50 mg/m2 iv), and vinblastine (5 mg/m2 iv) repeated every 3-4 weeks was used to treat 55 patients with advanced stage III or IV or recurrent disease. Of the 42 fully evaluable patients, there were 3 complete responders (7%) and 10 partial responders (24%). Responses were of short duration (median of 8 months, range 3-15 months) and the median survival of all evaluable patients was only 10 months from the start of therapy. Leukopenia was the major toxicity and was at least moderate in two-thirds of patients. We conclude that the addition of cisplatin and vinblastine to doxorubicin does not improve the clinical utility of doxorubicin in patients with advanced endometrial cancer.