- Email: [email protected]
PARATHYROID GLAND LOCALISATION
726
selective screening of proposed high-risk groups. The second was an opportunistic strategy in which screening would be offered to women, including those under 35, attending for other forms of medical care. Finally, in 1984, the ensuing chaos led to a realisation that simplicity is also a necessary objective, and a simple 5-yearly programme beginning at age 20 was adopted.8 The Government are now under strong pressure to reduce the screening interval to 3
years.9no Parkin and Moss" have evaluated nine screening policies, including the many official recommendations made between 1966 and 1984. Using a computer simulation model they examine the outcomes to be expected from these policies had they been implemented over the 30 years 1961-90, and they conclude that the original 1966 policy based on 5-yearly screening of women over 35 still represents the optimum use of health service resources. The extension of screening to younger women and the adoption of a 3-year interval reduces the estimate of years of life lost by a further 32-46% (depending on assumptions about natural history and attendance rates) but the cost-effectiveness of screening is halved. Moreover, Simulating an increase in population coverage from 50-80% produces a predicted reduction in mortality greater than that achieved by adopting any of the more complex selective or opportunistic strategies suggested during the past 20 years, and equal to that achieved by reducing the screening interval to 3 years. The detailed predictions of their model can be debated. For example, although it takes account of changes in cohort-specific disease incidence, the difficulty of modelling attendance patterns and of specifying differential prevalence rates suggests that the opportunistic policy may have been undervalued. However, the importance of this paper lies in the explicit recognition that difficult strategic choices have to be made. The primary strategic choice facing the Government is between commitment to a fixed level of expenditure on cervical screening or to specific targets in terms of prevention of cancer deaths. Despite the increase in disease in young women, the optimum strategy for reducing years of life lost cannot include screening younger women unless resources are increased greatly above current levels. Such an increase may be justified, but the opportunity cost to other health services must be made explicit. If breast cancer screening by mammography is adopted on a national scale, the competition for district resources will mean that this opportunity cost will be measured in terms of breast cancer deaths. The second important policy decision lies between the benefits of selectivity, opportunism, and simplicity. The case for selective screening is weak and the policy is difficult to implement. The case for opportunistic screening, particularly of women attending sexually transmitted disease and gynaecological clinics, is stronger partly because the disease incidence rate in women attending these clinics is high, and partly because such women may otherwise escape the screening net. The importance of simplicity is demonstrated by the administrative chaos which has characterised the cervical screening programme since its inception, and the
importance to outcome of high population coverage. It can be argued that the high level of screening coverage that can 8. 9. 10. 11.
DHSS Health Circular HC (84) 17. Deitch R. Serious deficiencies in cervical screening. Lancet 1985; i: 766. Slater D, Duke E. Cervical smear policy. Lancet 1985; ii: 1305. Parkin DM, Moss SM. An evaluation of screening policies for cervical cancer in England and Wales using a computer simulation model. J Epid Comm Health 1986; 40: 143-53.
be obtained when responsibility for regular screening is taken by general practitioners,12 renders an opportunistic approach unnecessary, but the difficulties faced in inner city areas cannot be ignored.13 The third and most important strategic choice is not for doing about what to do, but who should be it.14 The service continues to stagger towards structural objectives (such as computerised recall based on family practitioner committee registers) with little evaluation of operational feasibility (is the FPC population denominator and record linkage system adequate to this task?) and no consideration of opportunity cost (would it be more costeffective to operate an FPC "safety net" call-up system and leave recall to general practitioners?). Moreover, little attention has been paid to the increased laboratory workload.1s One constructive approach would be the recognition of domains of responsibility for specific stages within the preventive process, from primary prevention to follow-up of women with preinvasive lesions. If general practitioners were recognised as responsible for population coverage and follow-up, consultant cytologists for auditing the quality of the laboratory service, and community physicians for programme management, evaluation, and record systems, then the recommended screening strategies would have a better chance of implementation.
responsible
PARATHYROID GLAND LOCALISATION PRIMARY hyperparathyroidism is a common endocrine disorder1 that is potentially curable by surgical intervention. The diagnosis of hyperparathyroidism is usually straightforward with the sensitive and specific parathyroid hormone (PTH) assays now available, but PTH measurements alone will not reveal the underlying gland disorder-single or multiple adenomas or hyperplasia. Attempts have therefore been made to develop reliable and accurate means of localising diseased parathyroid glands preoperatively. Such localisation is not usually necessary in patients having-neck surgery for the first time but should theoretically be useful to the surgeon re-exploring a neck in which anatomical distortion and scarring make the parathyroid glands more difficult to find. The early techniques were selective arteriography and selective venous sampling for PTH measurement. Both are capable of localising abnormal glands in around threequarters of patients undergoing initial operation 2,3 but the success rate falls to about 50-60% in patients undergoing reoperation, since the parathyroid vasculature is distorted. The usefulness of arteriography is also limited by the size of the parathyroid glands and the technique is not without risk.’ Non-invasive methods are obviously much more
preferable. 12.
Standing P, Mercer S. Quinquennial cervical smears: every woman’s right and every general practitioner’s responsibility. Br Med J 1984; 289: 883-86. 13. Chapman MB, Vale JC. Failure of the cervical cytology screening programme. Br Med J 1985; 290: 76. 14. Editorial. Cancer of the cervix: death by incompetence. Lancet 1985; ii: 363-64. 15. Anonymous. Effective cervical screening programme in Britain. Lancet 1985; ii: 642. 1. Heath H, Hodgson SF, Kennedy MA. Primary hyperparathyroidism. N Engl J Med 2.
1980; 302: 189-93. Eisenberg H, Pallota J, Sherwood LM. Selective arteriography, venography and venous hormone assay in diagnosis and localization of parathyroid lesions. Am J
Med 1974; 56: 810-20. 3. Bilezikian JP, Doppman JL, Shimkin PM, et al. Preoperative localization of abnormal
parathyroid tissue. Cumulative experience with venous sampling and arteriography. Am J Med 1973; 55: 505-14. 4. Edis AJ, Sheedy PF, Beahrs OH, Van Heerden JA. Results of reoperation for hyperparathyroidism, with evaluation of preoperative localization studies. Surgery 1978; 84: 384-93.
727
Computed tomography (CT) is one technique that is non-invasive apart from the peripheral intravenous injection of contrast. In different series, CT scanning has identified
surgeons treating racehorses and greyhounds. The typical stress fracture presents with pain and tenderness over one of the long bones, most commonly the femur or tibia.
between 50% and 90% of abnormal parathyroid glands in patients undergoing initial operation. CT is particularly useful for identifying ectopically sited glands, but is not good at imaging glands between thyroid and clavicles (a common site).5 In patients who require reoperation, CT proves useful in less than SO%.6,7 Another technique is real-time ultrasonography. This has the advantage of identifying very small parathyroid glands and those situated within the thyroid gland itself. It does not image glands situated behind the sternum, trachea, and oesophagus and can readily miss lesions situated deep in the neck.s Whilst abnormal glands may be identified in up to 90% of patients before initial surgery, it is useful in only 50-70% undergoing reoperation. More recently, interest has centred on scintigraphic imaging. The usual technique is first to image the thyroid gland with technetium 99m pertechnetate (99mTc). With the patient remaining in the same position, thallium 201 (201TI)is then administered, an agent that is taken up by both the thyroid and the parathyroid glands. A computer is then used to subtract the 99rnTc image from the 201TI image which leaves only parathyroid uptake. Scintigraphy can identify parathyroid abnormalities in around 65-85% of patients before initial surgery. Again the results are poorer in patients with previous neck surgery. In part this may be due to disruption of the vasculature since this type of scan identifies parathyroid glands that have a rich blood flOW:8-lO However, false positives are also encountered, perhaps due to uptake of 2o1TI by thyroid nodules and hyperplastic lymph nodes. Parathyroid glands that are deeply situated or substernal are less frequently seen by this technique. With combinations of these various localisation techniques, overactive parathyroid glands can be identified in over 90% of patients, even those who have had previous neck surgery.7 All methods, however, yield the occasional false-positive result, and it is doubtful that any of them can localise abnormal parathyroid tissue as effectively and completely as the experienced parathyroid surgeon. When cost of equipment and examination is taken into account, it is difficult to justify the use of these methods in any but the most specialised of centres. A more practical approach is to entrust all parathyroid surgery to the expert parathyroid
Radiological changes are not always obvious, but the diagnosis may be confirmed by a "hot area" shown by bone scan. Treatment by rest, with or without a cast, is effective; Orava2 has suggested the 2-3 weeks’ rest is adequate for a metatarsal fracture, 6 weeks for a tibial fracture, and 8 weeks for a femoral stress fracture. Biopsy may occasionally be necessary if the diagnosis is in doubt, but in most cases surgical intervention is best avoided. Aro and Dahlstrom3 have now shown that conservative treatment gives good results, even in this difficult situation. Despite mechanisation of the modem army, recruits still undergo intensive training. This can give rise to an almost experimental situation in which a large number of healthy; subjects are simultaneously exposed to a training programme which appears calculated to produce as many stress fractures as possible. Although such studies have provided much interesting information; they have failed to answer two fundamental questions. Firstly, why are some individuals more susceptible than others to stress fractures, and, secondly, why should some bones be more susceptible than others in the same individual? Brudvig and colleagues,4 in a study of US army recruits, showed that white recruits were more likely to suffer from stress fractures than black recruits. It is possible that stress fractures are more likely to occur in those who will suffer from osteoporosis in later life; this might follow from the finding that 12% of female recruits suffered stress fractures compared with 2% of male recruits on the same training course.4
surgeon.
STRESS FRACTURES STRESS fracture of the metatarsal bones was first reported in German soldiers in 1855.1 Usually brought on by marching or training for sport, most stress fractures occur in the long bones of the lower limb, but have also been described in the upper limb, pelvis, and spine and even in the ribs. Such fractures are also well known to veterinary
There have been several studies of Israeli recruits
published by the Osteoporosis Institute in Jerusalem. The rigorous nature of the training programme is shown by the fact that in one group studied by Milgrom et al,5 31 % of recruits
were
found
to
have
one or more stress
fractures
during a 14-week training period. 40% of the fractures were in the middle tibia and 33% of fractures were diagnosed during the first 2 weeks of training. The susceptibility of certain
individuals to stress fractures has been assessed by Giladi et al6 in another paper from Jerusalem. A group of 66 soldiers who had sustained one or more stress fractures was followed up for one year after completion of basic military training. In 7 cases a further fracture developed during this time; in 6 of these cases stress fractures had initially occurred in more than one bone and invariably one of the initial fractures involved the femur. Further information about the group with recurrent stress fractures is anticipated from Jerusalem; it is hoped that detailed studies of calcium metabolism and measurements of bone density will become available. It will
5. Stark DS, Gooding GAW, Moss AA, Clark OH, Ovenfors CO. Parathyroid imaging: of high-resolution CT and high-resolution sonography. AJR 1983; 141: 633-38. 6. Brennan MF, Doppman JL, Krudy AG, Marx SJ, Spiegel AM, Aurbach GD. Assessment of techniques for preoperative parathyroid gland localization in
be especially interesting to learn details of bone quantity and quality in iliac crest biopsies from those with and without stress fractures. Perhaps the group of patients with stress fractures will go on to manifest obvious clinical features of osteoporosis, and continued study of stress fractures may even illuminate the pathogenesis of osteoporosis itself.
patients undergoing reoperation for hyperparathyroidism. Surgery 1981; 91: 6-11. 7. Krudy AG, Doppman JL, Brennan MF, et al. The detection of mediastinal parathyroid glands by computed tomography, selective arteriography, and venous sampling. Radiology 1981; 140: 739-44. 8. Clark OH, Okerlund MD, Moss AA, et al. Localization studies in patients with persistent or recurrent hyperparathyroidism. Surgery 1985; 98: 1083-94. 9. Okerlund MD, Sheldon K, Corpuz S, et al. A new method with high sensitivity and specificity for localization of abnormal parathyroid glands. Ann Surg 1984; 200:
2. Orava S. Stress fractures. Br J Sports Med 1980; 14: 40-44. 3. Aro H, Dahlström S. Conservative management of distraction-type stress fractures of the femoral neck. J Bone Joint Surg (Br) 1986; 68B: 65-67. 4. Brudvig TJ, Gudger TD, Obermeyer L. Stress fractures in 295 trainees: a one year study of incidence as related to age, sex and race. Milit Med 1983; 148: 666-67. 5. Milgrom C, Giladi M, Stein M, et al. Stress fractures in military recruits: a prospective
381-88. 10. Skibber JM, Reynolds JC, Spiegel AM, et al. Computerized technetium/thallium scans and parathyroid reoperation. Surgery 1985; 98: 1077-82. 1. Breithaupt MD. Zur pathologie des menschlichen Fusses.MedZeitung 1855;24: 169.
study showing an unusually high incidence. JBone Joint Surg (Br) 1985, 67B: 732-35. 6. Giladi M, Milgrom C, Kashtan H, et al. Recurrent stress fractures in military recruits. J Bone Joint Surg (Br) 1986; 68B: 439-41.
selective screening of proposed high-risk groups. The second was an opportunistic strategy in which screening would be offered to women, including those under 35, attending for other forms of medical care. Finally, in 1984, the ensuing chaos led to a realisation that simplicity is also a necessary objective, and a simple 5-yearly programme beginning at age 20 was adopted.8 The Government are now under strong pressure to reduce the screening interval to 3
years.9no Parkin and Moss" have evaluated nine screening policies, including the many official recommendations made between 1966 and 1984. Using a computer simulation model they examine the outcomes to be expected from these policies had they been implemented over the 30 years 1961-90, and they conclude that the original 1966 policy based on 5-yearly screening of women over 35 still represents the optimum use of health service resources. The extension of screening to younger women and the adoption of a 3-year interval reduces the estimate of years of life lost by a further 32-46% (depending on assumptions about natural history and attendance rates) but the cost-effectiveness of screening is halved. Moreover, Simulating an increase in population coverage from 50-80% produces a predicted reduction in mortality greater than that achieved by adopting any of the more complex selective or opportunistic strategies suggested during the past 20 years, and equal to that achieved by reducing the screening interval to 3 years. The detailed predictions of their model can be debated. For example, although it takes account of changes in cohort-specific disease incidence, the difficulty of modelling attendance patterns and of specifying differential prevalence rates suggests that the opportunistic policy may have been undervalued. However, the importance of this paper lies in the explicit recognition that difficult strategic choices have to be made. The primary strategic choice facing the Government is between commitment to a fixed level of expenditure on cervical screening or to specific targets in terms of prevention of cancer deaths. Despite the increase in disease in young women, the optimum strategy for reducing years of life lost cannot include screening younger women unless resources are increased greatly above current levels. Such an increase may be justified, but the opportunity cost to other health services must be made explicit. If breast cancer screening by mammography is adopted on a national scale, the competition for district resources will mean that this opportunity cost will be measured in terms of breast cancer deaths. The second important policy decision lies between the benefits of selectivity, opportunism, and simplicity. The case for selective screening is weak and the policy is difficult to implement. The case for opportunistic screening, particularly of women attending sexually transmitted disease and gynaecological clinics, is stronger partly because the disease incidence rate in women attending these clinics is high, and partly because such women may otherwise escape the screening net. The importance of simplicity is demonstrated by the administrative chaos which has characterised the cervical screening programme since its inception, and the
importance to outcome of high population coverage. It can be argued that the high level of screening coverage that can 8. 9. 10. 11.
DHSS Health Circular HC (84) 17. Deitch R. Serious deficiencies in cervical screening. Lancet 1985; i: 766. Slater D, Duke E. Cervical smear policy. Lancet 1985; ii: 1305. Parkin DM, Moss SM. An evaluation of screening policies for cervical cancer in England and Wales using a computer simulation model. J Epid Comm Health 1986; 40: 143-53.
be obtained when responsibility for regular screening is taken by general practitioners,12 renders an opportunistic approach unnecessary, but the difficulties faced in inner city areas cannot be ignored.13 The third and most important strategic choice is not for doing about what to do, but who should be it.14 The service continues to stagger towards structural objectives (such as computerised recall based on family practitioner committee registers) with little evaluation of operational feasibility (is the FPC population denominator and record linkage system adequate to this task?) and no consideration of opportunity cost (would it be more costeffective to operate an FPC "safety net" call-up system and leave recall to general practitioners?). Moreover, little attention has been paid to the increased laboratory workload.1s One constructive approach would be the recognition of domains of responsibility for specific stages within the preventive process, from primary prevention to follow-up of women with preinvasive lesions. If general practitioners were recognised as responsible for population coverage and follow-up, consultant cytologists for auditing the quality of the laboratory service, and community physicians for programme management, evaluation, and record systems, then the recommended screening strategies would have a better chance of implementation.
responsible
PARATHYROID GLAND LOCALISATION PRIMARY hyperparathyroidism is a common endocrine disorder1 that is potentially curable by surgical intervention. The diagnosis of hyperparathyroidism is usually straightforward with the sensitive and specific parathyroid hormone (PTH) assays now available, but PTH measurements alone will not reveal the underlying gland disorder-single or multiple adenomas or hyperplasia. Attempts have therefore been made to develop reliable and accurate means of localising diseased parathyroid glands preoperatively. Such localisation is not usually necessary in patients having-neck surgery for the first time but should theoretically be useful to the surgeon re-exploring a neck in which anatomical distortion and scarring make the parathyroid glands more difficult to find. The early techniques were selective arteriography and selective venous sampling for PTH measurement. Both are capable of localising abnormal glands in around threequarters of patients undergoing initial operation 2,3 but the success rate falls to about 50-60% in patients undergoing reoperation, since the parathyroid vasculature is distorted. The usefulness of arteriography is also limited by the size of the parathyroid glands and the technique is not without risk.’ Non-invasive methods are obviously much more
preferable. 12.
Standing P, Mercer S. Quinquennial cervical smears: every woman’s right and every general practitioner’s responsibility. Br Med J 1984; 289: 883-86. 13. Chapman MB, Vale JC. Failure of the cervical cytology screening programme. Br Med J 1985; 290: 76. 14. Editorial. Cancer of the cervix: death by incompetence. Lancet 1985; ii: 363-64. 15. Anonymous. Effective cervical screening programme in Britain. Lancet 1985; ii: 642. 1. Heath H, Hodgson SF, Kennedy MA. Primary hyperparathyroidism. N Engl J Med 2.
1980; 302: 189-93. Eisenberg H, Pallota J, Sherwood LM. Selective arteriography, venography and venous hormone assay in diagnosis and localization of parathyroid lesions. Am J
Med 1974; 56: 810-20. 3. Bilezikian JP, Doppman JL, Shimkin PM, et al. Preoperative localization of abnormal
parathyroid tissue. Cumulative experience with venous sampling and arteriography. Am J Med 1973; 55: 505-14. 4. Edis AJ, Sheedy PF, Beahrs OH, Van Heerden JA. Results of reoperation for hyperparathyroidism, with evaluation of preoperative localization studies. Surgery 1978; 84: 384-93.
727
Computed tomography (CT) is one technique that is non-invasive apart from the peripheral intravenous injection of contrast. In different series, CT scanning has identified
surgeons treating racehorses and greyhounds. The typical stress fracture presents with pain and tenderness over one of the long bones, most commonly the femur or tibia.
between 50% and 90% of abnormal parathyroid glands in patients undergoing initial operation. CT is particularly useful for identifying ectopically sited glands, but is not good at imaging glands between thyroid and clavicles (a common site).5 In patients who require reoperation, CT proves useful in less than SO%.6,7 Another technique is real-time ultrasonography. This has the advantage of identifying very small parathyroid glands and those situated within the thyroid gland itself. It does not image glands situated behind the sternum, trachea, and oesophagus and can readily miss lesions situated deep in the neck.s Whilst abnormal glands may be identified in up to 90% of patients before initial surgery, it is useful in only 50-70% undergoing reoperation. More recently, interest has centred on scintigraphic imaging. The usual technique is first to image the thyroid gland with technetium 99m pertechnetate (99mTc). With the patient remaining in the same position, thallium 201 (201TI)is then administered, an agent that is taken up by both the thyroid and the parathyroid glands. A computer is then used to subtract the 99rnTc image from the 201TI image which leaves only parathyroid uptake. Scintigraphy can identify parathyroid abnormalities in around 65-85% of patients before initial surgery. Again the results are poorer in patients with previous neck surgery. In part this may be due to disruption of the vasculature since this type of scan identifies parathyroid glands that have a rich blood flOW:8-lO However, false positives are also encountered, perhaps due to uptake of 2o1TI by thyroid nodules and hyperplastic lymph nodes. Parathyroid glands that are deeply situated or substernal are less frequently seen by this technique. With combinations of these various localisation techniques, overactive parathyroid glands can be identified in over 90% of patients, even those who have had previous neck surgery.7 All methods, however, yield the occasional false-positive result, and it is doubtful that any of them can localise abnormal parathyroid tissue as effectively and completely as the experienced parathyroid surgeon. When cost of equipment and examination is taken into account, it is difficult to justify the use of these methods in any but the most specialised of centres. A more practical approach is to entrust all parathyroid surgery to the expert parathyroid
Radiological changes are not always obvious, but the diagnosis may be confirmed by a "hot area" shown by bone scan. Treatment by rest, with or without a cast, is effective; Orava2 has suggested the 2-3 weeks’ rest is adequate for a metatarsal fracture, 6 weeks for a tibial fracture, and 8 weeks for a femoral stress fracture. Biopsy may occasionally be necessary if the diagnosis is in doubt, but in most cases surgical intervention is best avoided. Aro and Dahlstrom3 have now shown that conservative treatment gives good results, even in this difficult situation. Despite mechanisation of the modem army, recruits still undergo intensive training. This can give rise to an almost experimental situation in which a large number of healthy; subjects are simultaneously exposed to a training programme which appears calculated to produce as many stress fractures as possible. Although such studies have provided much interesting information; they have failed to answer two fundamental questions. Firstly, why are some individuals more susceptible than others to stress fractures, and, secondly, why should some bones be more susceptible than others in the same individual? Brudvig and colleagues,4 in a study of US army recruits, showed that white recruits were more likely to suffer from stress fractures than black recruits. It is possible that stress fractures are more likely to occur in those who will suffer from osteoporosis in later life; this might follow from the finding that 12% of female recruits suffered stress fractures compared with 2% of male recruits on the same training course.4
surgeon.
STRESS FRACTURES STRESS fracture of the metatarsal bones was first reported in German soldiers in 1855.1 Usually brought on by marching or training for sport, most stress fractures occur in the long bones of the lower limb, but have also been described in the upper limb, pelvis, and spine and even in the ribs. Such fractures are also well known to veterinary
There have been several studies of Israeli recruits
published by the Osteoporosis Institute in Jerusalem. The rigorous nature of the training programme is shown by the fact that in one group studied by Milgrom et al,5 31 % of recruits
were
found
to
have
one or more stress
fractures
during a 14-week training period. 40% of the fractures were in the middle tibia and 33% of fractures were diagnosed during the first 2 weeks of training. The susceptibility of certain
individuals to stress fractures has been assessed by Giladi et al6 in another paper from Jerusalem. A group of 66 soldiers who had sustained one or more stress fractures was followed up for one year after completion of basic military training. In 7 cases a further fracture developed during this time; in 6 of these cases stress fractures had initially occurred in more than one bone and invariably one of the initial fractures involved the femur. Further information about the group with recurrent stress fractures is anticipated from Jerusalem; it is hoped that detailed studies of calcium metabolism and measurements of bone density will become available. It will
5. Stark DS, Gooding GAW, Moss AA, Clark OH, Ovenfors CO. Parathyroid imaging: of high-resolution CT and high-resolution sonography. AJR 1983; 141: 633-38. 6. Brennan MF, Doppman JL, Krudy AG, Marx SJ, Spiegel AM, Aurbach GD. Assessment of techniques for preoperative parathyroid gland localization in
be especially interesting to learn details of bone quantity and quality in iliac crest biopsies from those with and without stress fractures. Perhaps the group of patients with stress fractures will go on to manifest obvious clinical features of osteoporosis, and continued study of stress fractures may even illuminate the pathogenesis of osteoporosis itself.
patients undergoing reoperation for hyperparathyroidism. Surgery 1981; 91: 6-11. 7. Krudy AG, Doppman JL, Brennan MF, et al. The detection of mediastinal parathyroid glands by computed tomography, selective arteriography, and venous sampling. Radiology 1981; 140: 739-44. 8. Clark OH, Okerlund MD, Moss AA, et al. Localization studies in patients with persistent or recurrent hyperparathyroidism. Surgery 1985; 98: 1083-94. 9. Okerlund MD, Sheldon K, Corpuz S, et al. A new method with high sensitivity and specificity for localization of abnormal parathyroid glands. Ann Surg 1984; 200:
2. Orava S. Stress fractures. Br J Sports Med 1980; 14: 40-44. 3. Aro H, Dahlström S. Conservative management of distraction-type stress fractures of the femoral neck. J Bone Joint Surg (Br) 1986; 68B: 65-67. 4. Brudvig TJ, Gudger TD, Obermeyer L. Stress fractures in 295 trainees: a one year study of incidence as related to age, sex and race. Milit Med 1983; 148: 666-67. 5. Milgrom C, Giladi M, Stein M, et al. Stress fractures in military recruits: a prospective
381-88. 10. Skibber JM, Reynolds JC, Spiegel AM, et al. Computerized technetium/thallium scans and parathyroid reoperation. Surgery 1985; 98: 1077-82. 1. Breithaupt MD. Zur pathologie des menschlichen Fusses.MedZeitung 1855;24: 169.
study showing an unusually high incidence. JBone Joint Surg (Br) 1985, 67B: 732-35. 6. Giladi M, Milgrom C, Kashtan H, et al. Recurrent stress fractures in military recruits. J Bone Joint Surg (Br) 1986; 68B: 439-41.