Complications and long-term results of ankle arthrodeses following trauma

A review of sixty patients who had undergone ankle fusion for post-traumatic arthritis revealed that thirty-five (58 per cent) had the procedure performed within the first year after injury. A total of forty-eight complications occurred in twenty-nine (48 per cent) of the patients. Frequent complication were infection (23 per cent), non-union (23 per cent), inadequate surgical alignment or early loss of position (15 per cent), malunion (12 per cent), and delayed union (7 per cent). The lateral transfibular approach had the highest incidence of complications, and a two-incision approach using the Charnley compression apparatus was the procedure with the fewest complications. Forty-one patients were followed for an average of 7.5 years after operation. Of these, thirty-four (83 per cent) were satisfied with the procedure. Examination of thirty of the forty-one patients at an average of 7.3 years after surgery revealed virtually no subtalar motion but motion of 13 degrees at Chopart's joint. With shoes, patients had a near-normal gait. The roentgenograms revealed a minimum amount of degenerative arthritis at Chopart's joint, which may worsen with time. Varus or valgus angulation of the hind part of the foot was associated with a greater degree of symptoms in the subtalar area as well as the middle of the foot. The neutral position in varus-valgus angulation as well as dorsiflexion-plantar flexion was the optimum position for both men and women. The results of the procedure did not deteriorate with time.     

A prospective experience with selective cholangiography

A prospective study of patients with symptomatic cholelithiasis was undertaken to determine the effectiveness of identifying clinically significant choledocholithiasis with selective cholangiography. Between 1991 and 1995, 262 patients presented to the senior author (K.W.M.) with acute or chronic cholecystitis. Sixteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for an elevated alkaline phosphatase or total bilirubin greater than twice the normal value or an ultrasound finding suspecting choledocholithiasis. Ten of the ERCP patients had choledocholithiasis, with eight patients having successful clearance by ERCP. Ninety other patients had intraoperative cholangiography for abnormal serum liver biochemistries, a history of jaundice or pancreatitis, or a dilated common bile duct (CBD) (>6 mm) on ultrasound. Fourteen of the intraoperative cholangiography patients and the two remaining ERCP patients had choledocholithiasis requiring CBD exploration for clearance of their stones. There were no false-positive cholangiograms, and there were no bile duct injuries in this series. With 100 per cent follow-up of at least 2 years, only one patient required ERCP clearance of a retained CBD stone 13 months after cholecystectomy. The positive predictive value and the negative predictive value for the selective cholangiography criteria are 23 per cent and 99 per cent, respectively. In conclusion, clinically significant choledocholithiasis can be found effectively with selective cholangiography. Also, utilizing selective cholangiography reduces the number of routine cholangiograms by 60 per cent.     

Magnetic resonance coronary angiography in heart transplant recipients

BACKGROUND: Magnetic resonance angiography (MRA) using segmented k-space fast low-angle shot imaging has recently been used to demonstrate the proximal coronary arteries in healthy subjects and in patients with coronary artery disease. We assessed the sensitivity and specificity of coronary MRA in heart transplant recipients and investigated the feasibility of coronary MRA in patients with metallic sutures and clips in the chest. MATERIALS AND METHODS: Sixteen cardiac transplant patients aged 57.2 +/- 7.9 years (mean +/- SD) were recruited. Forty-eight arterial segments were evaluated, including the left main artery (LMA), left anterior descending artery (LADA) and right coronary artery (RCA). We excluded the left circumflex artery which could not be imaged accurately. The average time between heart transplant operation and MRA was 6 years, whereas that between MRA and X-ray angiography was 4 months. The coronary MRA was interpreted by two experienced investigators who were blinded to the coronary X-ray angiography results. Similarly, the coronary X-ray angiography results were interpreted by two experienced investigators blinded to the MRA results. The coronary arterial segments were classified by MRA as being normal or as having an amount of disease that was significant (> 50% lesion) or insignificant (< 50% lesion). RESULTS: There were 28 true-negative, five true-positive, four false-negative and six false-positive results. Of the 28 true-negative cases, 13 were in the LMA, six in the LADA and nine in the RCA. There was one false-positive LMA, two false-positive LADA and three false-positive RCA stenoses. There were four false-negative results in the LADA and one in the RCA. Clips precluded evaluation in one LMA, one LADA and one RCA. One LMA and one LADA were not evaluated as a result of poor images. One false-positive RCA stenosis was caused by a metallic clip. Three of the false-negative LADA stenoses had lesions in the distal third of the artery. The sensitivity, specificity, negative and positive predictive values were generally poor for the left coronary artery. The best results were for the RCA (sensitivity 100%, specificity 75%, positive predictive value 50% and negative predictive value 100%). The specificity in the left coronary arteries (LMA and LADA) was 86%, but the other indicators were all poorer. For the RCA, LMA and LADA combined, the overall sensitivity was 56%, specificity 82%, predictive accuracy 45% and negative predictive value 88%. In three patients, < 50% RCA lesions were seen in the MRA data, which were all confirmed by angiography. No < 50% lesions were seen in the LMA or in the LADA by MRA or by X-ray angiography. CONCLUSION: Coronary MRA using the segmented fast low-angle shot technique is feasible in heart transplant recipients but the sensitivity and specificity of this method are limited. Further developments in coil design, rapid imaging techniques and respiratory monitoring methods are necessary to improve the accuracy of coronary MRA.     

Free-water clearance and the early recognition of acute renal insufficiency after cardiopulmonary bypass

The predictive value of free-water clearance measurements for the early recognition of acute renal insufficiency was evaluated in 59 patients immediately following cardiopulmonary bypass. Blood urea nitrogen and serum creatinine measurements were taken before and after operation. Intraoperatively, immediately after completion of bypass, urine and serum samples were obtained for osmolality. Duration of bypass, urine output, degree of hemolysis, and quality of perfusion were recorded. Fifty-four patients developed no signs of renal insufficiency following bypass, and all had free-water clearance values equal to or less than -20 ml per hour. Five patients who had free-water clearance values equal to greater than -8 ml per hour developed manifestations of an acute renal insufficiency state. There were no false-negative or false-positive determinations. Consequently, free-water clearance measurements appear to be a reliable indicator of those patients who will develop renal insufficiency following cardiopulmonary bypass. Early recognition provides an opportunity immediately after operation for initiating treatment consisting of administration of diuretics, potassium restriction, and oliguric fluid regimens.     

Can scintimammography reduce "unnecessary" biopsies?

99Tc-sestamibi prone scintimammography (SMM) is a new, noninvasive method of imaging breast tumors. A pilot study has suggested that SMM increases the specificity of mammography, and that SMM could be used as an adjunct to mammography to reduce the number of mammographically indicated biopsies. The goal of this study was to further evaluate the efficacy of SMM in diagnosing or excluding breast carcinoma. This was a prospective case series with each patient serving as her own control. All subjects who had an abnormal mammogram, a palpable breast mass, or both were eligible for inclusion. All patients underwent breast examination, conventional mammography, SMM, and breast biopsy. Of the 81 women originally enrolled, 79 women with 80 lesions completed the study. SMM produced the following results: a sensitivity of 81 per cent, a specificity of 81 per cent, a positive predictive value of 61 per cent, and a negative predictive value of 92 per cent. These values were significantly lower than the pilot study results at a power of 80 per cent and P = 0.05. Our results indicate that SMM does not increase the specificity of conventional mammography and has a low negative predictive value. We would not recommend it as a screening technique to avoid biopsy.     

Diagnostic value of myocardial thallium stress scintigraphy in the detection of coronary artery disease in patients undergoing chronic hemodialysis

Atherosclerotic heart disease is the leading cause of death in patients with end stage renal disease, but its non invasive detection remains difficult because of a low efficacy of exercise testing. The aim of the study was to evaluate diagnostic accuracy of thallium myocardial imaging after dipyridamole combined with exercise. Forty two chronic dialysis patients (34 men, 8 women) aged 55 +/- 11 years (range: 36 to 75) without symptom of angina nor myocardial infarction were studied. In each patient, an echocardiography, a myocardial scintigraphy with dipyridamole combined with symptom-limited exercise, and coronarography were performed. A coronary heart disease was diagnosed by coronarography in 10 patients (4.5 and 1 respectively with 1, 2 and 3 vessels diseased). Echocardiography detected a left ventricular hypertrophy (LVH) in 26 patients and a regional asynergia in 14 patients. A positive scintigraphy was present in 11 patients. Three false-positive and 2 false-negative on scintigraphy were noted. Sensibility, specificity, positive predictive value and negative predictive value were respectively evaluated at 80, 73, 73 and 93%. All the five patients with either false-positive or false-negative scintigraphy exhibited a LVH. CONCLUSION. In chronic dialysis patients, coronary heart disease may be detected by thallium myocardial imaging after dipyridamole combined with exercise.     

Diagnosis of gastric cancer up to three years after negative upper gastrointestinal endoscopy

BACKGROUND AND STUDY AIMS: The degree of accuracy of gastroscopy for the detection of gastric cancer is poorly understood. The aim of this retrospective study was to determine the accuracy of gastroscopy by using cancer registry records. PATIENTS AND METHODS: Gastroscopic examinations (n = 37094) conducted between 1984 and 1989 were studied by linking them with hospital-based and population-based (Fukui Prefecture, Japan) cancer registry records between 1984 and 1992. False-negative gastroscopies that had been carried out within the three years preceding the diagnosis of gastric cancer were identified. RESULTS: The numbers of true-positive, false-positive, and false-negative examinations carried out were 659, six and 155, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value were 81.0%, 100.0%, 99.1%, and 99.6%, respectively. The overall diagnostic accuracy of gastroscopy was 99.6%. There was little difference in sensitivity results between the patient groups with regard to reason for referral, type of endoscope used, experience of endoscopist, or location of gastric cancer. The percentage of tumours representing early gastric cancer, identified after false-negative gastroscopy, was lower for those situated in the cardia or gastric body than for those in the angular notch or the antrum. CONCLUSIONS: The accuracy of gastroscopy in the detection of gastric cancer is satisfactory, but false-negative results are sometimes obtained. We emphasize the importance of repeated endoscopic examination for the detection of gastric cancer.     

Assessment of the clinical usefulness of the 'Queenan' chart versus the 'Liley' chart in predicting severity of rhesus iso-immunization

In 1961 Liley developed a chart of changing amniotic fluid bilirubin levels (delta OD450) and gestation, with three zones delineating the severity of rhesus disease. This chart ranged from 27 to 40 weeks and was found to be clinically useful. Extrapolating the use of the Liley chart to earlier gestations however, was unsuccessful. Currently, cordocentesis is the only reliable means of assessing the fetal condition accurately prior to 27 weeks. In 1993, Queenan proposed a chart of delta OD450 from 14 to 40 weeks, with four zones to guide management. The aim of the current study is to assess the clinical usefulness of the 'Queenan' chart vs. the 'Liley' chart. There were 35 pregnancies affected by rhesus disease between 1990 and 1997 at the Mater Mothers' Hospital, Brisbane. The quantitative anti-D and delta OD450 levels obtained before intra-uterine transfusions were recorded. Each sample was labelled with the fetal condition at the time the sample was taken. Of the 72 delta OD450 samples, 36 (50 per cent) were performed before 27 weeks, and these included all four of the severely affected samples and 11 of the 13 moderately affected samples. The sensitivity of the Queenan chart in predicting the severely affected pregnancies was 100 per cent, with specificity of 79.4 per cent, positive predictive value of 22.2 per cent and negative predictive value of 100 per cent. For prediction of moderate/severely affected pregnancies, the sensitivity was 83.3 per cent, with specificity of 94.4 per cent, positive predictive value of 83.3 per cent and negative predictive value of 96.3 per cent. In conclusion, an delta OD450 chart which includes gestations less than 27 weeks is necessary with our changing caseload of rhesus iso-immunized patients, where severely affected pregnancies seemed to occur early and intervention even in moderately affected pregnancies seemed appropriate. We found that the Queenan chart is a suitable alternative to the Liley chart.     

Free fibular graft still has a place in the treatment of bone defects

We report on 27 patients illustrating the use of non-vascularized single fibular strut graft, augmented with a corticocancellous bone graft to bridge bone defects. The indications were varied and included infection, fracture with bone loss, non-union, bone tumour, bone cyst and congenital pseudarthrosis. Primary union was achieved in 92 per cent. Stress fracture occurred in 26 per cent and no significant fibular graft hypertrophy occurred. The aim of this paper is to show that the non-vascularized single fibular graft, if augmented with corticocancellous bone graft along its whole length, is a simple procedure that is still valid to bridge bone defects.     

Effect of allowing for ethnic group in prenatal screening for Down's syndrome

We conducted a study to investigate ethnic group differences in levels of serum markers used in screening for Down's syndrome [serum alpha-fetoprotein (AFP), unconjugated oestriol (uE3), total human chorionic gonadotrophin (hCG), free alpha- and free beta-hCG, and dimeric inhibin-A], to estimate the extent to which maternal weight differences between ethnic groups explain these differences, and to estimate the effect of adjusting for ethnic group and maternal weight on screening performance. Serum measurements were taken from women who were screened prenatally for Down's syndrome. AFP, uE3, and hCG concentrations were available from 9462 white, 4215 black, and 4392 South Asian women with singleton pregnancies without Down's syndrome or neural tube defects between 15 and 22 weeks' gestational age. Frozen serum samples were available from a subset of 922 white, 449 black, and 135 South Asian women and were used for measurement of free alpha-hCG, free beta-hCG, and inhibin. Values were expressed as multiples of the median (MOM) for women of the same gestational age. There were statistically significant differences in the serum marker levels between ethnic groups that were not explained by differences in maternal weight. The main differences were found in black women compared with white women; black women had serum AFP levels 22 per cent higher (95 per cent confidence interval 20-24 per cent), total hCG levels 19 per cent higher (16-22 per cent), and free beta-hCG levels 12 per cent (3-21 per cent) higher. The other differences were less than 10 per cent. Adjusting for ethnic group only had a small estimated effect on screening performance: a maximum of about 0.5 per cent extra detection at a 5 per cent false-positive rate. At a fixed risk cut-off level, the false-positive rate will not be materially different between different ethnic groups. Adjusting serum markers for ethnic groups improves Down's syndrome screening performance to a very small extent. It is worthwhile because of its established value in AFP screening for open neural tube defects.     

Atrial pacing in patients with sinus node dysfunction

Sinus nod recovery time (SNRT) at paced atrial rates of 100 (SNRT100) and 120 (SNRT120) beats/min, atrial effective refractory periods at spontaneous heart rates (AERP) and at paced rates of 100 (AERP100) and 120 (AERP120) beats/min, and premature atrial stimulation were among the studies in evaluating 33 patients with symptomatic sinus node disease and 42 normal subjects. Although mean SNRT100 and SNRT120 were statistically significantly greater in patients than in control subjects, there was a significant overlap between patient and control groups, and SNRT100 or SNRT120 was associated with a 30.3 per cent false-negative and 5 per cent false-positive incidence. Correction for heart rate (SNRT-spontaneous cycle length) failed to improve the sensitivity or specificity of this test. There was no significant difference in mean AERP, AERP100 or AERP120, or in sinoatrial conduction time in patients compared with control subjects. Analyses of curves derived from plots of test and return cycles showed abnormal curves in only five of the 24 patients studied by progressively premature atrial stimulation. Two of these five patients showed normal zone I and II phenomena followed by a progressive linear increase in the return cycle that was thought to be due to abnormal refractoriness of the perinodal fibers.     

The application of rigid internal fixation to the treatment of non-union and delayed union using the AO technique

This paper describes our experience over a period of 10 years (1966-76) with fractures showing non-union and delayed union. All were treated by the AO technique. The source of our patients, the management of their fractures and the results are described. From this experience we have drawn conclusions on which future policy will be based.     

Gene rearrangement and truncated mRNA in cell lines with 11q23 translocation

This study was done to evaluate the diagnostic accuracy of bedside chest radiography for pneumonia, adult respiratory distress syndrome (ARDS), or both in patients receiving mechanical ventilation. The series consisted of 40 patients; diagnostic accuracy was defined as the area under the receiver operating characteristic curve. Overall diagnostic accuracy for ARDS was 0.84. Overall diagnostic accuracy for pneumonia was 0.52. Review of previous radiographs and knowledge of clinical data did not enhance diagnostic accuracy for ARDS or pneumonia. Diagnostic accuracy for pneumonia was minimally reduced when ARDS was present. There was an increase in false-negative results because the diffuse areas of increased opacity in ARDS obscured the radiographic features of pneumonia. The authors conclude that chest radiography is of limited value for the diagnosis of pneumonia in patients receiving mechanical ventilation. The high false-negative and false-positive ratings for pneumonia resulted in a low diagnostic accuracy. The high diagnostic accuracy for ARDS was primarily due to the well-defined radiographic appearance of ARDS and few false-positive ratings.     

First-trimester urine free beta hCG, beta core, and total oestriol in pregnancies affected by Down's syndrome: implications for first-trimester screening with nuchal translucency and serum free beta hCG

We have examined maternal urine concentrations of beta core, free beta human chorionic gonadotrophin (hCG), and total oestriol in 373 control pregnancies and 43 pregnancies affected by aneuploidy (including 22 cases of Down's syndrome) in an attempt to see if any of the analytes have a value in Down's syndrome screening between the tenth and 14th week of pregnancy. We have compared the performance of these analytes against nuchal translucency measurement combined with maternal serum free beta hCG at the same period of pregnancy. Our results show that levels of urine free beta hCG and beta core are increased in Down's syndrome with average multiple of the median levels of 1.81 and 2.91, respectively. Urine total oestriol was reduced (0.83) whilst maternal serum free beta hCG was increased (1.72). In trisomy 18 the levels of all analytes were reduced, although serum free beta hCG was the most discriminating. The spread of results in the control and the Down's group for urine beta core was more than three times than that for serum free beta hCG and with urine free beta hCG it was two times wider. In combination with maternal age, urine total oestriol had a 32 per cent detection rate at a fixed 5 per cent false-positive rate; urine beta core 34 per cent, urine free beta hCG 36 per cent, maternal serum free beta hCG 44 per cent, and nuchal translucency 82 per cent. In combination with nuchal translucency, urine total oestriol added an extra 1 per cent detection, urine beta core an extra 2 per cent, urine free beta hCG an extra 3 per cent, and serum free beta hCG an extra 5 per cent. It is unlikely that any of the urine markers will be of value in first-trimester screening. Optimal first-trimester screening programmes will rely for the foreseeable future on nuchal translucency, serum free beta hCG, and possibly pregnancy-associated plasma protein A.     

Negative predictive value of imaging-guided abdominal biopsy results: cytologic classification and implications for patient management

OBJECTIVE: Our purpose was to assess the negative predictive value of imaging-guided abdominal biopsy results and correlate it with cytology classification, lesion size, needle gauge, and cancer history. MATERIALS AND METHODS: A retrospective study was performed of 100 patients with proven diagnoses who had undergone imaging-guided abdominal biopsies showing no cells that were malignant or suspicious for malignancy. Specimens were classified as normal or benign, nondiagnostic, or atypical. Negative predictive value was calculated for each cytologic category, lesion size, needle gauge, and cancer history. Logistic regression analysis was performed to allow us to identify predictors of false-negative results. RESULTS: Overall negative predictive value was 67%. Other negative predictive values were normal or benign result, 78%; nondiagnostic result, 66%; and atypical result, 29%. Negative predictive value was greater when the lesion was large (> or =3 cm) (p = .031). Logistic regression analysis allowed us to predict a 9.3% chance of a false-negative result for a specimen of normal or benign cytology that was taken from a large lesion in a patient with no cancer history but an 87% chance of a false-negative when a specimen of atypical cytology was taken from a small (<3 cm) lesion in a patient with a cancer history. CONCLUSION: Imaging-guided abdominal biopsy specimens containing atypical cells should be viewed with caution. In patients without cancer, if a lesion is large and the specimen contains normal target organ or benign cells, the likelihood of a false-negative result may be low enough that imaging surveillance at appropriate intervals may be sufficient.     

Evaluation on non invasive diagnostic tests for the second look in epithelial ovarian cancer

OBJECTIVE: To determine the usefulness of diagnostic tests performed before a second look laparotomy in patients with epithelial ovarian cancer. STUDY DESIGN: Thirty-three patients with epithelial ovarian cancer attended at Fundación Jiménez Díaz from 1984 to 1995 were studied. All patients initially underwent cyto-reducing surgery, followed by at least six platinum-based chemotherapy cycles. Prior to second look laparotomy all patients were evaluated by computerized tomography (CT) of the pelvis and abdomen, CA-125, pelvic-abdominal echography and gynecologic examination. To evaluate sensitivity, specificity, positive predictive value and negative predictive value for each test contingency tables were used. RESULTS: Eleven out of the 33 second look patients (33%) had histologic or cytologic evidence of disease. Six out of the eleven positive second look had a positive CT prior to second look (sensitivity of 55%). CT showed lack of disease in 21 out of the 22 negative second look cases (specificity 95%). Positive and negative predictive values of the test were 86% and 81%, respectively. Nine cases out of the 28 who had a CA-125 obtained had a positive second look. Four out of these nine patients had an increased CA-125 value (sensitivity 44%, specificity 95%, positive predictive value 80% and negative predictive value 78%). Sensitivity, specificity, positive predictive value and negative predictive value of physical examination and echography were 36%, 100%, 100%, 76% and 27%, 95%, 75%, 72%, respectively. On the other hand, sensitivity, specificity, positive predictive value and negative predictive value of all tests taken together were 64%, 91%, 78% and 83%, with a rate of false-negative results of 17% and a rate of false-positive results of 22%. CONCLUSION: Pelvic-abdominal computerized tomography, CA-125, pelvic-abdominal echography and gynecologic examination can be an alternative to second look laparotomy for the diagnosis of persistence or recurrence of the disease in patients with epithelial ovarian cancer.     

Radiography as an aid in the diagnosis of traumatic reticuloperitonitis in cattle

Radiographs of the reticulum, the medical records and the surgical and post mortem findings for 151 cattle were evaluated, and the radiographic findings in animals which had no pathological changes in the cranioventral abdomen were compared with those in animals with traumatic reticuloperitonitis. Features that were found to be reliable in the diagnosis of the condition included atypically positioned foreign bodies, abnormal gas shadows in the region of the reticulum, and depressions in the cranioventral margin of the reticulum. In addition to the reticulum, the remainder of the cranioventral abdomen was also assessed radiographically. An accumulation of gas or a gas-fluid interface outside the gastrointestinal tract, and intra-abdominal masses were typical findings in cattle with traumatic reticuloperitonitis. Various parameters were used to determine the reliability of radiography of the reticulum in the diagnosis of the condition; its prevalence was 50 per cent, the sensitivity of the radiographic diagnosis was 76 per cent, the specificity was 93 per cent, the accuracy was 85 per cent, the positive predictive value was 92 per cent and the negative predictive value was 80 per cent.     

Home pregnancy testing kits: prevalence of use, false-negative rates, and compliance with instructions

This study investigated the prevalence of home pregnancy kit use, incidence of false-negative results, and compliance with testing procedures. Among 144 pregnant women, identified through three health care settings, prevalence of test-kit use was 28.5 per cent. The false-negative rate was 24.3 per cent. Total compliance with instructions was reported by only 32 per cent of users. Women testing less than nine days after menstrual period was due had false-negative rates of 33 per cent contrasted with 21 per cent for those testing after the nine days.     

Biological parameters in major depression: effects of paroxetine, viloxazine, moclobemide, and electroconvulsive therapy. Relation to early clinical outcome

Mammography, whilst remaining the first line imaging investigation of suspected primary breast cancer, can be difficult to interpret in patients with fibrous or dense breasts. Radionuclide imaging of the breast (scintimammography) has been suggested as an additional test. The aim of this study was to perform prospectively a comparison of the two techniques in a population with suspected breast cancer. Seventy such patients, mean age 54 years (range 57 years, 28-85) with 74 suspicious breast lesions were studied. They were imaged 5-10 min after intravenous injection of 740 MBq of Tc-99m sestamibi. Prone lateral and anterior supine views with and without markers were performed. All patients had histological confirmation of the nature of the breast lesions by limited incisional biopsy or definitive wide local excision, or cytological confirmation on fine needle aspiration. All patients had X-ray mammography. There were 53 malignant breast tumours and 21 benign lesions. Scintimammography correctly diagnosed 47 breast cancers, and yielded true-negative results in 12 benign breast lesions. There were six cases of false-negative results and nine false-positive results. Four scans were reported as equivocal. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 89%, 52%, 84% and 67%, respectively. X-ray mammography diagnosed correctly 37 malignant tumours, and in 12 benign lesions the results were true negatives. Ten studies were reported as equivocal. The sensitivity, specificity, PPV and NPV were 70%, 57%, 80% and 43%, respectively. The accuracy of Tc-99m sestamibi scintimammography was better than X-ray mammography though this was not significant (McNemar's test). Fewer equivocal results were obtained with scintimammography. Scintimammography may therefore have a role in the diagnosis of primary breast cancer when X-ray mammography is equivocal or unhelpful.     

Total ankle arthroplasty: a unique design. Two to twelve-year follow-up

We evaluated the intermediate-term results of a novel total ankle arthroplasty that includes insertion of the components without cement and arthrodesis of the tibiofibular syndesmosis as part of the operative procedure. One hundred consecutive Agility ankle replacements were performed in ninety-five patients between 1984 and 1993. At the time of follow-up, eighty-three patients (eighty-six ankles) were alive and twelve patients (fourteen ankles) had died. Five (6 per cent) of the eighty-six ankles in the living patients had been revised. Including the components that had been revised for loosening, twenty-one (twelve tibial and nine talar) components had migrated. Delayed union of the syndesmosis (twenty-eight ankles) and non-union of the syndesmosis (nine ankles) were associated with the development of lysis around the tibial component. Non-union of the syndesmosis was also associated with migration of the tibial component and circumferential radiolucency around that component. In addition to the patients who died, one patient had a resection of the implant with subsequent arthrodesis. The remaining eighty-two patients (eighty-five ankles) were the basis for the clinical evaluation in the study. The average age at the time of the procedure was sixty-three years (range, twenty-seven to eighty-one years). At the time of the most recent follow-up (range, 2.8 to 12.3 years; average, 4.8 years), forty-seven (55 per cent) of the remaining eighty-five ankles were not painful and twenty-four (28 per cent) were only mildly painful. The range of motion of the fifty-six ankles that were examined at the time of follow-up averaged 36 degrees (range, 10 to 64 degrees), and the results for seventy-nine (93 per cent) of the eighty-five ankles were satisfactory to the patients.