Fixator-assisted nailing of tibial fractures: New surgical technique and presentation of first 30 cases

Background

Intramedullary nailing is considered a “gold standard” for treatment of tibial shaft fractures. However, some types of fractures are typically considered as “difficult for nailing”. This group includes the periarticular fractures, fractures of both bones at the same level, comminuted and segmental fractures of the tibia. Fixator-assisted nailing (FAN) is an effective method treatment of these types of fractures. The main requirements for the ideal reduction device are an ease of its installation and an ability of multiplanar fracture reduction. Fixator-assisted nailing (FAN) with the use of two perpendicular to each other monolateral tubular frames perfectly meets these requirements. In this study we present this new surgical technique and the analysis of first 30 cases.

Lung and heart volumes by three-dimensional ultrasound in normal fetuses at 12-32 weeks' gestation.

OBJECTIVE: To establish reference intervals for the fetal right, left and total lung volumes and heart volume between 12 and 32 weeks of gestation. METHODS: Fetal lung and heart volumes were measured using three-dimensional (3D) ultrasound in 650 normal singleton pregnancies at 12-32 weeks. The VOCAL (Virtual Organ Computer-aided AnaLysis) technique was used to obtain a sequence of six sections of each lung and the heart around a fixed axis, each after a 30 degrees rotation from the previous one. The rotation axis for the lungs extended from the apex to the upper limit of the diaphragm dome, and the rotation axis for the heart extended from its apex to its connection to the great vessels. The contour of each of these organs was drawn manually in the six different rotation planes to obtain the 3D volume measurement. In 60 cases the fetal lungs and heart volumes were measured by the same sonographer twice and also by a second sonographer once in order to compare the measurements and calculate intra- and interobserver agreement. RESULTS: The total lung volume and heart volume increased with gestation, from respective mean values of 1.6 and 0.6 mL at 12 weeks to 10.9 and 4.3 mL at 20 weeks and 49.3 and 26.6 mL at 32 weeks. The right to left lung volume ratio did not change significantly with gestation (median, 0.7), whereas the heart to total lung volume ratio increased with gestation from about 0.3 at 12 weeks to 0.5 at 32 weeks. In the Bland-Altman plot, the difference between paired measurements by two sonographers was, in 95% of the cases, less than 0.05, 0.5 and 1.9 mL for each lung at 12-13, 19-22 and 29-32 weeks, respectively, and the corresponding values for the heart volumes were 0.04, 0.4 and 2.3 mL. CONCLUSIONS: In normal fetuses the lung and heart volumes increase between 12 and 32 weeks of gestation. The extent to which in pathological pregnancies possible deviations in these measurements from normal prove to be useful in the prediction of outcome remains to be determined.     

Solitary bronchioloalveolar carcinoma: CT criteria

The computed tomographic (CT) scans of 30 patients with solitary bronchioloalveolar carcinoma were reviewed. Common features at CT included the peripheral or subpleural location of a pulmonary mass (25 cases), pseudocavitation (18 cases), heterogeneous attenuation (17 cases), irregular margins forming a star pattern (22 cases), and pleural tags (21 cases). Using these CT criteria, four independent observers attempted to identify cases of bronchioloalveolar carcinoma from a larger sample of lung cancers and benign lesions by categorizing a series of test cases into four probability categories. Although the bronchioloalveolar carcinomas were correctly ranked in the two highest probability categories 75% of the time (in 45 of 60 cases), there was considerable overlap with other lung lesions, particularly with adenocarcinoma and large cell undifferentiated carcinoma. However, even though the typical features of bronchioloalveolar carcinoma are not invariable or highly specific, they are characteristic enough to suggest the diagnosis.     

Assessment of lung area in normal fetuses at 12-32 weeks.

OBJECTIVE: To establish reference intervals with gestation for the right and left lung areas and lung area to head circumference ratio (LHR). METHODS: This was a cross-sectional study of 650 normal singleton pregnancies at 12-32 weeks of gestation. We measured the left and right lung areas on the cross-sectional plane of the thorax, used for examination of the four-chamber view of the heart, by three different techniques: firstly, manual tracing of the limits of the lungs; secondly, multiplication of the longest diameter of the lung by its longest perpendicular diameter; thirdly, multiplication of the anteroposterior diameter of the lung at the mid-clavicular line by the perpendicular diameter at the midpoint of the anteroposterior diameter. RESULTS: The respective mean left and right lung areas (manual tracing) increased with gestational age, from 36 and 58 mm(2) at 12 weeks to 220 and 325 mm(2) at 20 weeks and 594 and 885 mm(2) at 32 weeks. This 16-fold increase in lung area was accompanied by a four-fold increase in head circumference. Consequently, the left and right LHR increased with gestational age. The most reproducible way of measuring the lung area was by manual tracing of the limits of the lungs and the least reproducible was by multiplying the longest diameter of the lungs by their longest perpendicular diameter. Furthermore, the method employing the longest diameter, compared with the tracing method, overestimated both the left and the right lung areas by about 45% and the method employing the anteroposterior diameter overestimated the area of the right lung by about 35%, but not that of the left lung. CONCLUSIONS: In the antenatal prediction of pulmonary hypoplasia by the assessment of lung area it is important to take gestational age into account. Dividing the lung area by the head circumference does not correct for the gestation-related increase in lung area. Reproducible measurement of the lung area is provided by manual tracing of the limits of the lungs, rather than by multiplication of lung diameters.