Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

[Is lymphography still relevant in seminoma?]

In the radiotherapist's point of view lymphography and computed tomography scan compete for staging and therapy planning of testicular seminoma. We investigated whether lymphogram can be replaced by computed tomography scan. 114 patients with histologically confirmed seminoma of the testis were treated by radiotherapy at the Nürnberg Community Hospital (n = 65) and the University of Erlangen (n = 49) from 1978 through 1991. Radiological staging included both computed tomography scan and lymphography in all cases. The results of both methods were similar in 79%. Computed tomography scan led to an upstaging in 4% while lymphography was negative. 17% of the patients showed negative results considering computed tomography scan while lymphogram was positive. In accordance with these data treatment portals or doses were altered in 21%. Using the M.D. Anderson Hospital clinical staging system a stage IIa (micrometastasis < 2 cm) is not safely identified by computed tomography scan. Just lymphography can safely identify a stage IIa patient. On the other hand, lymphography shows a very high amount of false positive interpretations. However, two conclusions are made: 1. Using a conventional technic (radiation of para-aortal and ipsilateral iliac region, dose about 30 Gy HD) lymphogram can be superseded by computed tomography scan. 2. In the case of reducing treatment volume and/or dose lymphogram should be added to computed tomography scan.

[Radiation therapy in the prevention of periarticular, heterotopic ossification following implantation of a total hip endoprosthesis]

From June 1988 to January 1991 the efficacy of a low-dose (5 x 2 Gy) versus a high-dose (10 x 2 Gy, resp. 5 x 3,5 Gy) prophylactic postoperative radiotherapy was assessed in a prospective randomized trial. 60 patients at the highest risk for formation of heterotopic ossification (HO) were included in this study, i.e. patients that presented already HO in the ipsi- or contralateral hip at the time of surgery. After both irradiation regimen the incidence and severity of HO was significantly less than without prophylaxis; there was no significant difference (regarding the severity of HO, the hip score (16) and the hip mobility) between the two regimen.

[Prevention of periarticular ossification following endoprosthetic hip replacement using postoperative irradiation]

The development of heterotopic ossification (HO) after total hip replacement or other surgical hip procedures can considerably impair the functional result and quality of life in up to 73% of all patients. Predisposing high risk factors for heterotopic ossification are severe pre-intra- and/or postoperative hip trauma, previous development of ipsi- and/or contralateral heterotopic ossification, hypertrophic osteoarthritis, active rheumatoid spondylarthritis as well as male sex. Over the past two decades a variety of surgical, pharmaceutical and radiotherapeutic prophylactic measurements have been proposed and tested in clinical trials. Since June 1988, we have treated 77 patients or 80 hips respectively with prophylactic irradiation. Individual risk factors included severe coxarthrosis grade IV, ipsi- or contralateral heterotopic ossification and severe hip trauma. As of July 1991 60 patients with a minimum follow-up of six months could be analyzed using clinical and radiological scoring systems. The patients had been prospectively randomized in two different treatment arms: 32 patients were treated with low dose (LD), five times 2 Gy daily fractions to a total dose of 10 Gy, whereas 28 patients were treated with high dose (HD), ten times 2 Gy (eight patients) or five times 3.5 Gy (20 patients). Operative procedures and individual risk factors were equally distributed in both groups. 23 patients (38% received indometacin three times 25 mg for six weeks, 19 patients (32%) diphosphonate EHDP 20 mg/kg body weight and 18 patients (30%) had no additional medication. 56/60 (93%) patients developed no significant heterotopic ossification and/or remained without impairment of their postoperative radiological and clinical hip status according to the applied Brooker and Harris Scores. Only 4/60 (7%) patients demonstrated treatment failures developing postoperative worsening one grade of Brooker score in two patients and two and three grades of Brooker score in the two others. Only 1/49 patients experienced a treatment failure, when radiotherapy had been initiated before and at postoperative day 4 compared to 3/11 patients initiated after postoperative day 4 (p less than 0.001). 3/32 patients (9.4%) in the LD group and 1/28 (3.6%) in the HD group were scored as treatment failures (nonsignificant). Radiotherapy treatment duration and additional medication had no impact on the outcome. In conclusion postoperative radiotherapy has shown high efficacy in prevention of heterotopic ossification as long as the treatment is initiated within the first four days after surgery. With respect to acute toxicity postoperative radiotherapy seems to be without any competition compared to surgical and pharmaceutical approaches including corticoid, diphosphonate and nonsteroid antiphlogistic drugs.

[The role of radio-oncology in the treatment of bronchial cancer]

The treatment results obtained in patients with both small and non small cell lung cancer have remained stagnant for years. Therefore, in order to select patients who will have a profit from radiotherapy the indication has to take into account prognostic factors such as tumor stage, extent of resection, patient's age, lymph node status, weight loss and the patient's performance status. Non small cell lung cancer: Postoperative radiotherapy seems to benefit only in patients with hilar or mediastinal lymph node involvement, where a five-year survival rate of up to 30% of cases can be achieved. Postoperative irradiation should not be applied following curative resection and negative lymph node status (R0 N0). In inoperable cases conventional fractionated radiotherapy may definitively have a favourable effect on the patient's survival time, even when the treatment was originally intended to be merely palliative. Only those patients will live five years, who received more than 50 Gy to the hilar and mediastinal nodes and at least 60 Gy to the primary lesion. The volume to be irradiated must include the primary tumor, the ipsilateral and contralateral hilum, the mediastinum, and both supraclavicular regions. If a Pancoast tumor is present, radiotherapy alone obtains a similar result as preoperative irradiation followed by resection. Small cell lung cancer: Radiation treatment of the primary tumor region and the lymph drainage area increases the remission rate by roughly 20% compared with chemotherapy alone, considerably reduces the incidence of local recurrences and exerts a beneficial effect on the survival of the patients. Recently, this has been confirmed by prospectively randomised protocols. Prophylactic brain irradiation has been found to decrease the risk of cerebral metastases to 4-6% in patients affected by limited disease and complete tumor remission under chemotherapy, and to improve the quality of life without, however, showing the benefit on survival time. Future efforts in radiotherapy should be aimed not only at increasing dose intensities but also at developing less toxic treatment modalities to the benefit of the quality of life.