Recommendations for the management of septic arthritis after ACL reconstruction

Purpose

To evaluate the current evidence for the management of septic arthritis after anterior cruciate ligament (ACL) reconstruction, the factors that affect the outcome after treatment and the retention of graft and implants.

Methods

A systematic literature search of the PubMed database was performed on septic arthritis after ACL reconstruction. A total of 301 publications were initially identified, and 17 papers were found to fulfil the criteria to be included in the review.

Results

There were 196 cases of septic arthritis after ACL reconstruction in over 30,000 ACL reconstructions, making the proportion of infection 0.6 %. Most patients (114/123, 92.6 %) had an acute or subacute infection at an average of 16.8 ± 10.5 days after ACL reconstruction. Coagulase-negative Staphylococci (CNS) was the most common organism (67/147, 45.6 %) followed by Staphylococcus aureus (SA) (35/147, 23.8 %); 86.9 % underwent surgical treatment of which 92.8 % had an average of 1.54 (up to 4) arthroscopic debridements. The group with SA infection had a higher graft removal rate (33.3 %, p = 0.019), a longer antibiotic duration (35.4 days, p = 0.047) and a worse range of flexion (111.5°, p = 0.036) than the CNS group.

Conclusions

CNS was the most common organism in septic arthritis after ACL reconstruction followed by SA. For most authors, arthroscopic debridement combined with intravenous antibiotic therapy was the initial treatment of choice. Antibiotic therapy with or without multiple irrigations of the joint is not recommended based on the high failure rates. Delayed diagnosis of more than 7 days or SA infection required a longer duration of antibiotic therapy and increased the likelihood for graft removal and restricted range of motion. Fungal infection and tubercular infection had a high prevalence of late diagnosis and open debridement.

Level of evidence

Systematic review, Level IV.     

Similar survival between screw cementless and cemented tibial components in young patients with osteoarthritis

Purpose

The aim of this study was to compare the outcomes of tibial fixation with either a cemented or cementless with screw augmentation component in young patients with non-inflammatory arthritis.

Methods

Ninety-three patients aged 55 or younger with non-inflammatory arthritis were randomized to compare outcomes between cemented tibial fixation (48 patients) and cementless fixation with screw augmentation (45 patients). The femoral component was cementless in both groups. Post-operative evaluation was assessed by the clinical and radiological criteria of The Knee Society and WOMAC questionnaire.

Results

The median follow-up was 6.7 (5–12) years. Significant differences were found for knee score (p = 0.02), range of motion (p = 0.04), and WOMAC score (p = 0.03). In the cemented group, there was one deep wound infection, four tibial aseptic loosening, and one polyethylene wear, all of which were revised. In the cementless group there was one tibial aseptic loosening and one polyethylene wear, both being revised. There was no difference in revision rate, and the cumulative survival at 9-year for aseptic reason was 93.7 % (95 % CI, 82–100 %) in the cementless group and 90.0 % (95 % CI, 80–100 %) in the cemented group (n.s.).

Conclusions

Cementless total knee arthroplasty was found to be a reliable option in younger patients with osteoarthritis. Although the revision rate and survival were similar in both groups, better clinical outcomes were obtained with cementless tibial components.

Level of evidence

I.     

High-resolution ultrasound evaluation of extrinsic wrist ligaments in patients affected by rheumatoid arthritis

Objectives

To evaluate the ultrasound features of the extrinsic wrist ligaments in rheumatoid arthritis (RA) patients in comparison with healthy volunteers.

Methods

Twenty-one consecutive patients affected by RA (12 men, 9 women; mean age 57?±?14.6 years) were compared with 21 controls (12, 9; 54?±?12.1, respectively). Wrists were evaluated using ultrasound on both palmar and dorsal sides along each ligament, using carpal bones as references. The following ligaments were studied: radioscaphocapitate, radiolunotriquetral, palmar ulnolunate, palmar ulnotriquetral, dorsal radiotriquetral, dorsal ulnotriquetral, and radial collateral ligament. Ligament number and thickness were noted. Echotexture was rated as fibrillar, fragmented, or heterogeneous; the surface was rated as smooth or blurred.

Results

The number of palmar ulnolunate and palmar ulnotriquetral ligaments detected by ultrasound in patients was significantly lower than in controls (P?=?0.031 and P?=?0.037, respectively). All ligaments had significantly more fragmented or heterogeneous echotexture and blurred surface and were significantly thinner in patients than in controls (P?Conclusions Extrinsic wrist ligaments were less detectable and thinner in patients affected by RA compared with healthy volunteers matched for age and sex. Ligament thinning did not directly correlate with RA duration and clinical parameters.

Key Points

? Ultrasound is increasingly used to evaluate normal anatomy of extrinsic wrist ligaments. ? Extrinsic wrist ligaments are thinner in rheumatoid arthritis patients than in controls. ? Extrinsic wrist ligaments are less easy to detect in rheumatoid arthritis patients. ? Ligament thinning and detectability are not related to clinical parameters.     

Characterisation of hand small joints arthropathy using high-resolution MRI—Limited discrimination between osteoarthritis and psoriatic arthritis

Objective

To test the hypothesis that microanatomical differences in joint disease localisation could be exploited using high-resolution MRI to better differentiate among rheumatoid arthritis (RA), spondyloarthritis/psoriatic arthritis (SpA/PsA) and osteoarthritis (OA) in clinical practice.

Methods

Sixty-nine patients with suspected inflammatory joint disease of the hand or feet underwent high-resolution MRI using a small loop coil. Images were scored blinded to the clinical status. Various joint changes like periostitis, osteitis, erosions, enthesitis and synovitis were recorded. The image-based diagnosis was compared with the clinical diagnosis.

Results

In 59.4 % of the patients the clinical diagnosis was confirmed on image analysis. This was high for OA (80 %), moderately good for RA (67 %) but only 50 % for SpA/PsA. The major difficulty was to distinguish OA from SpA/PsA where common imaging findings are evident including periostitis (SpA/PsA 45 %, OA 40 % compared with RA 0 %; P?=?0.015). Likewise, osteitis was frequently detected in SpA/PsA (79 %) and OA (80 %) and less frequently in RA (42 %) (P?=?0.014).

Conclusion

Characterisation of inflammatory disorders of small joints merely using high-resolution MRI remains challenging especially in the differentiation between OA and PsA. These findings are likely explained by common microanatomical similarities in disease expression rather than limitations of imaging techniques.

Key Points

? High-resolution MRI is increasingly used to investigate joint disease. ? Osteitis and periostitis occur in psoriatic and osteoarthritis (but not rheumatoid arthritis). ? In severely affected patients the amount of synovitis and erosions is similar.     

Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes

Purpose

Septic arthritis after an ACL reconstruction is a rare but serious complication. Functional outcomes of these patients have not been studied in depth in large series. The aim of this study was to determine the prevalence and management of knee joint infection following ACL reconstruction and to assess the functional outcomes.

Methods

A retrospective assessment of knee joint infections occurring after arthroscopically assisted ACL reconstructions done from 2006 to 2009 in two hospitals by the same surgical team is presented. Patients with signs and symptoms of joint infection along with blood and synovial effusion laboratory parameters suggestive of infection were considered as septic arthritis. All the patients were treated with antibiotic therapy according to antibiotic sensitivity and had at least one arthroscopic lavage. Final outcomes were assessed and compared with a control group using the KT-1000 arthrometer, functional testing and radiological examination.

Results

Fifteen (1.8 %) out of 810 patients included in the study were considered as a joint infection. Microbiology showed that coagulase-negative Staphylococcus was present in 10 patients, Staphylococcus Aureus in three patients (2 MSSA and 1 MRSA) and Propinebacterium sp. in one patient. In one patient, the micro-organism was unknown. At a mean follow-up of 39.3 ± 13 months, the Lysholm score was 77.7 ± 15.3, the IKDC score was 70.4 ± 19.5, and the KT-1000 compared to the non-injured contralateral knee showed a mean difference of 1.3 ± 2 mm. Functional outcomes in the control group were slightly better than those obtained in the infected group (Lysholm score; 90.7 ± 9.4, p = 0.007. IKDC score; 86.6 ± 6.8, p = 0.004). All but one patient retained their reconstructed ACL.

Conclusions

The prevalence of septic arthritis after an ACL reconstruction in this series was 1.8 %. Arthroscopic lavages along with antibiotic treatment led us to preserve all but one graft. Functional outcomes in the infected patients were not as good as those obtained in patients without infection.

Level of evidence

Therapeutic case series, Level IV.     

MRI findings of treated bacterial septic arthritis

Introduction

The purpose of this study was to report the MRI findings that can be encountered in successfully treated bacterial septic arthritis.

Materials and methods

The study included 12 patients (8 male and 4 female; mean age 38?years, range 9–85) with 13 proven cases of bacterial septic arthritis. The joints involved were hip (n?=?3), knee (n?=?3), shoulder (n?=?2), sacroiliac (n?=?2), ankle (n?=?1), wrist (n?=?1), and elbow (n?=?1). MRI examinations following surgical debridement and at initiation of antibiotic therapy and after successful treatment were compared for changes in effusion, synovium, bone, and periarticular soft tissues. Imaging findings were correlated with microbiological and clinical findings.

Results

Joint effusions were present in all joints at baseline and regressed significantly at follow-up MRI (p?=?0.001). Abscesses were present in 5 cases (38?%), and their sizes decreased significantly at follow-up (p?=?0.001). Synovial enhancement and thickening were observed in all joints at both baseline and follow-up MRI. Myositis/cellulitis was present in 10 cases (77?%) at baseline and in 8 cases (62?%) at follow-up MRI. Bone marrow edema was present in 10 joints (77?%) at baseline and persisted in 8 joints (62?%). Bone erosions were found in 8 joints (62?%) and persisted at follow-up MRI in all cases.

Conclusion

The sizes of joint effusions and abscesses appear to be the factors with the most potential for monitoring therapy for septic arthritis, since both decreased significantly following successful treatment. Synovial thickening and enhancement, periarticular myositis/cellulitis, and bone marrow edema can persist even after resolution of the infection.     

Arthroscopic treatment for acute septic arthritis of the hip joint in adults

Purpose

The purpose of our study was to evaluate the efficacy and safety of the arthroscopic management of septic arthritis of the hip joint.

Methods

From October 2009 to October 2010, nine patients with septic arthritis of the hip were treated with arthroscopic debridement and drainage and systemic antibiotics according to bacterial sensitivity or with empiric antibiotics if no bacteria was isolated from the cultures. All patients were placed in the supine position on a fracture table, and two or three arthroscopic portals were used. The medical records were retrospectively reviewed to determine the efficacy and safety of hip arthroscopy for septic arthritis.

Results

There were 4 men and 5 women, with a mean age of 49.8 years (SD 12.1). No major complication related to arthroscopy of the hip was encountered. Staphylococcus aureus was identified in 4 patients. Average follow-up was 19.4 months (SD 4.1). Septic arthritis relapsed in one patient, but the other 8 patients experienced no recurrence during the follow-up period.

Conclusions

Arthroscopic lavage and debridement is a safe and effective procedure for septic arthritis of the hip joint.

Level of evidence

IV.     

Accuracy of the second metatarsal as a landmark for the extramedullary tibial cutting guide in total knee arthroplasty

Purpose

The purpose of this study was to evaluate the accuracy of the second metatarsal (MT2) as a landmark for proximal tibial cutting in total knee arthroplasty (TKA). It was hypothesized that the accuracy of the MT2 is not high, especially in rheumatoid arthritis (RA) patients whose foot joints are apt to be involved.

Methods

Computer simulation studies on 48 RA knees and 45 osteoarthritis (OA) knees were performed. The deviations from the mechanical axis (MA) of the tibia when the guide rod was pointed toward the base of the MT2 or the distal part of the MT2 were measured.

Results

The mean deviation from MA was 0.8° ± 2.1° valgus (range 8.1°–6.3° valgus) and 1.2° ± 2.9° valgus (range 11.6°–7.9° valgus) at the base of the MT2, and at the distal part of the MT2, respectively. The outlier rate when using the base of the MT2 was lower than when using the distal part of the MT2 (12.9 vs 32.3 %, p = 0.0032). The outlier rate was equivalent in OA and RA patients (n.s.). However, foot involvement in RA patients demonstrated a trend toward significance (base of MT2 p = 0.078, distal part of MT2 p = 0.068).

Conclusions

The major clinical relevance was to raise caution about using the MT2. Surgeons should aim toward the base of the MT2, but avoid using it in RA patients with foot involvement. The accuracy of the MT2 is not high and it should be used only to supplement other landmarks.

Level of evidence

II.     

Dual molecular imaging for targeting metalloproteinase activity and apoptosis in atherosclerosis: molecular imaging facilitates understanding of pathogenesis

Background

Macrophage apoptosis and MMP activity contribute to vulnerability of atherosclerotic plaques to rupture. By employing molecular imaging techniques, we investigated if apoptosis and MMP release are interlinked.

Methods

Atherosclerosis was produced in rabbits receiving high-cholesterol diet (HC), who underwent dual radionuclide imaging with ^99mTc-labeled matrix metalloproteinase inhibitor (MPI) and ¹¹¹In-labeled annexin A5 (AA5) using micro-SPECT/CT. %ID/g MPI and AA5 uptake was measured, followed by histological characterization. Unmanipulated animals were used as disease controls. Correlation between MPI and AA5 uptake was undertaken and relationship confirmed in culture study of activated THP-1 monocytes.

Results

MPI and AA5 uptake was best visualized in HC diet animals (n = 6) and reduced significantly after fluvastatin treatment (n = 4) or diet withdrawal (n = 3). %ID/g MPI (.087 ± .018%) and AA5 (.03 ± .01%) uptake was higher in HC than control (n = 6) animals (.014 ± .004%, P < .0001; .0007 ± .0002%, P < .0001), and reduced substantially after diet or statin intervention. There was a significant correlation between MPI and AA5 uptake (r = .62, P < .0001), both correlated with pathologically verified MMP-9 activity, macrophage content, and TUNEL staining. In vitro studies demonstrated MMP-9 release in culture medium from apoptotic THP-1 monocytes.

Conclusions

The present study suggests that apoptosis and MMP are interrelated in atherosclerotic lesions and the targeting of more than one molecular candidate is feasible by molecular imaging.     

Intensity and interval of recovery in strength exercise influences performance: salivary lactate and alpha amylase as biochemical markers. A pilot study

Purpose

The aim of the present study was to evaluate the effects of intensity and interval of recovery on performance in the bench press exercise, and the response of salivary lactate and alpha amylase levels.

Methods

Ten sportsman (aged 29 ± 4 years; body mass index 26 ± 2 kg/cm²) were divided in two groups: G70 (performing a bench press exercise at 70 % one repetition maximum—1RM), and G90 (performing a bench press exercise at 90 %—1RM). All groups were engaged in three intervals of recovery (30, 60 and 90 s). The maximum number of repetitions (MNR) and total weight lifted were computed, and saliva samples were collected 15 min before and after different intervals of recovery. For the comparison of the performance and biochemistry parameters, ANOVA tests for repeated measurements were conducted, with a significance level set at 5 %.

Results

In G70, the 30 s MNR was lower than the 60 and 90 s intervals of recovery (p < 0.05) and the MNR with the 60 s interval of recovery was lower than the 90 s interval of recovery (p < 0.041). Similarly, in G90 with the 30 s of interval of recovery, the sets were lower than observed with the 60 and 90 s (p < 0.05), and MNR with the 60 s interval of recovery was lower than the 90 s interval of recovery (p < 0.05). The salivary lactate showed an increase after exercise (p < 0.05) when compared with the rest period for all groups, and no effects were observed for salivary alpha amylase.

Conclusions

Based on this result, the sets and reps can be modified to change the recovery time. This effect is very useful to improve the performance in relationship to different fitness levels.     

Yttrium-90 distribution following radiosynoviorthesis of the knee joint in rheumatoid arthritis patients: a SPECT/CT study

Objective

To examine yttrium-90 distribution 1 and 72 h following its injection into a knee joint in patients with rheumatoid arthritis (RA).

Methods

In 14 RA patients we injected yttrium-90 into the affected knee joint using lateral approach. To assess the radioisotope distribution in the joint, the superimposed sequential SPECT and CT imaging was performed 1 and 72 h after the injection. We analyzed the percentage of radioisotope distribution in three predefined compartments of the knee joint (lower, upper medial, upper lateral).

Results

After 1 and 72 h, the mean percentage distributions were, respectively, 7.14 and 23.07 % in lower; 21.42 and 15.38 % in upper medial, and 71.42 and 61.53 % in upper lateral compartment. The percentage of isotope deposition did not change significantly with time in any of the compartments (all p > 0.26). The deposition of isotope, both at 1 and 72 h, was significantly greater in upper lateral compartment, where the injection was performed, than in all other compartments (all p < 0.05).

Conclusions

Using the SPECT/CT hybrid method, we proved that the majority of isotope is located at the compartment adjacent to the injection. Two injections targeting different compartments might improve the clinical efficacy of the procedure.     

The iliotibial band in acute knee trauma: patterns of injury on MR imaging

Objective

To delineate the spectrum of knee injuries associated with sprains and tears of the distal iliotibial band (ITB).

Materials and methods

A retrospective review of 200 random MRI scans undertaken for acute knee trauma was performed. Scans were excluded if there was a history of injury over 4 weeks from the time of the scan, septic arthritis, inflammatory arthropathy, previous knee surgery, or significant artefact. In each scan, the ITB was scored as normal, minor sprain (grade 1), severe sprain (grade 2), and torn (grade 3). The menisci, ligaments, and tendons of each knee were also assessed.

Results

The mean age was 27.4 years (range, 9–69 years) and 71.5 % (n?=?143) of the patients were male. The ITB was injured in 115 cases (57.5 %). The next most common soft tissue structure injured was the anterior cruciate ligament (ACL) in 53.5 % of cases (n?=?107). Grade 1 ITB injury was seen in 90 of these 115 cases (45 %), grade 2 injury in 20 cases, and grade 3 injury in only five cases. There is a significant association between ITB injury and ACL rupture (p?p?Conclusions ITB injury is common in acute knee trauma and is associated with significant internal derangement of the knee, especially cruciate ligament rupture, posterolateral corner injury, and patellar dislocation.     

Correlation of 18F-FDG PET/CT assessments with disease activity and markers of inflammation in patients with early rheumatoid arthritis following the initiation of combination therapy with triple oral antirheumatic drugs

Purpose

This study evaluated the potential of functional imaging to monitor disease activity and response to treatment with disease-modifying antirheumatic drugs (DMARD) in DMARD-naive patients with early rheumatoid arthritis (RA).

Methods

The study involved 17 patients with active RA in whom combination therapy was initiated with methotrexate, sulfasalazine, hydroxychloroquine, and low-dose oral prednisolone. Clinical disease activity was assessed at screening, at baseline and after 2, 4, 8 and 12 weeks of therapy. ¹⁸F-FDG PET/CT of all joints was performed at baseline and after 2 and 4 weeks of therapy.

Results

¹⁸F-FDG maximum standardized uptake values showed a reduction of 22?±?13 % in 76 % of patients from baseline to week 2 and a reduction of 29?±?13 % in 81 % of patients from baseline to week 4. The percentage decrease in ¹⁸F-FDG uptake from baseline to week 2 correlated with clinical outcome, as measured by the disease activity score (DAS-28) at week 12. In addition, changes in C-reactive protein levels and erythrocyte sedimentation rate were positively associated with changes shown by PET.

Conclusion

¹⁸F-FDG PET/CT findings after 2 and 4 weeks of triple combination oral DMARD therapy correlated with treatment efficacy and clinical outcome in patients with early RA. ¹⁸F-FDG PET/CT may help predict the therapeutic response to novel drug treatments.     

Mid-term survival following primary hinged total knee replacement is good irrespective of the indication for surgery

Purpose

The use of ‘hinged’ knee prostheses for primary knee arthroplasty procedures is increasing. This analysis reports the rates of implant survival, modes of failure, revision details and functional outcomes with particular reference to the primary indication for surgery for a cohort of patients treated with primary hinged knee replacement.

Methods

Systematic review with supplementary analysis using data from the National Joint Registry and Department of Health. Analysis included 964 patients undergoing primary hinged knee replacement between April 2003 and December 2010. Survival at a maximum of 7 years was calculated for the group as a whole and dependent upon the indication for surgery (osteoarthritis vs. rheumatoid/inflammatory arthritis vs. post-traumatic arthritis). Functional outcomes (pre- and post-operative Oxford Knee and Euroqol-5D scores and post-operative satisfaction) were available for 46 patients.

Results

In total, 20 cases required revision. The 5-year survival rate (96.8 % [95 % CI 95.1–98.4 %]) was not dependent upon the primary surgical indication (p = n.s.). The commonest reasons for revision were infection (8 cases), peri-prosthetic fracture (4 cases) and aseptic loosening (3 cases). Patients reported substantial improvements in their Oxford Knee Score (mean improvement = 17.6, [95 % CI 14.4–20.8]) and EQ5D index (mean improvement = 0.357, [95 % CI 0.248–0.467]). Levels of post-operative satisfaction were high.

Conclusions

Hinged knee replacement can be considered as a viable alternative to more traditional unconstrained designs in the complex primary setting. These findings are clinically relevant as they support the increasing use of hinged knee replacements for the arthritic knee in which there is concomitant severe bone loss, deformity or instability. Surgeons using these implants can have confidence that their mid-term performance is comparable to more conventional knee designs.

Level of evidence

Prospective cohort study, Level II.     

Aseptically processed and chemically sterilized BTB allografts for anterior cruciate ligament reconstruction: a prospective randomized study

Purpose

To compare the clinical outcomes of bone-patellar tendon-bone (BTB) allografts processed via a novel sterilization system with the traditional aseptically processed BTB allografts for anterior cruciate ligament (ACL) reconstruction.

Methods

A total of 67 patients undergoing ACL reconstruction at 6 independent investigation sites were randomized into one of two intervention groups, BioCleanse-sterilized or aseptic BTB allografts. Inclusion criteria included an acute, isolated, unilateral ACL tear, and exclusion criteria included prior ACL injury, multi-ligament reconstruction, and signs of degenerative joint disease. Post-op examiners and patients were blinded to graft type. Patients were evaluated at 6, 12, and 24 months. Clinical outcomes were compared using the IKDC, a KT-1000 knee arthrometer, level of effusion, and ranges of motion (ROM).

Results

After randomization, 24 patients received aseptic BTB allografts and 43 patients received BioCleanse-sterilized allografts. Significant improvement in IKDC scores (P < 0.0001) as well as KT-1000 results (P < 0.0001) was noted over the 24-month period for both groups. IKDC or KT-1000 results were not significantly different between groups at any time point. Active flexion ROM significantly improved from pre-op to 24-month follow-up (P < 0.0001) with no difference between groups at any time point. Active extension ROM did not differ significantly between the two groups.

Conclusions

These results indicate that the sterilization process, BioCleanse, did not demonstrate a statistical difference in clinical outcomes for the BTB allograft at 2 years. The BioCleanse process may provide surgeons with allografts clinically similar to aseptically processed allograft tissue with the benefit of addressing donor-to-recipient disease.

Level of evidence

II.     

Distal femur and proximal tibia replacement with megaprosthesis in revision knee arthroplasty: a limb-saving procedure

Purpose

The aim of the present study was to assess whether using megaprostheses in revision knee arthroplasty procedures allows limb salvage with an acceptable outcome and complication rate, in comparison with other limb-saving procedures.

Methods

Between 2000 and 2010, megaprosthesis implantation was required for non-oncologic indications in 20 patients (21 knees) (average age 73 years). Reconstructions involved the distal femur (n = 15), proximal tibia (n = 4), and both femur and tibia (n = 2). The indications, type, and numbers of previous operations and implants, as well as complications associated with megaprosthesis implantation, were reviewed, and the clinical and radiographic outcomes after an average follow-up period of 34 months (range 10–84 months) were evaluated.

Results

The indications for megaprosthesis implantation were periprosthetic infection (n = 5), fracture (n = 9), nonunion (n = 5), and aseptic loosening (n = 2). The types of implant placed before the megaprosthetic reconstruction were a cemented rotating-hinge arthroplasty (n = 16) and a primary total knee arthroplasty (n = 5). Six patients had an additional osteosynthesis of the distal femur. An average of 3.8 operations (range 1–7) had been carried out before megaprosthesis implantation. Complications developed in 11 patients. The Knee Society Score improved significantly, from 43 (±15) to 68 (±16.8); P < 0.05.

Conclusions

Megaprosthesis implantation in revision knee arthroplasty is an exceptional indication. Despite the high complication rate, the patients can be spared amputation in most cases, and rapid mobilization with full weight-bearing is possible.     

Adrenal gland volume measurement in septic shock and control patients: a pilot study

Objectives:

To compare adrenal gland volume in septic shock patients and control patients by using semi-automated volumetry.

Methods:

Adrenal gland volume and its inter-observer variability were measured with tomodensitometry using semi-automated software in 104 septic shock patients and in 40 control patients. The volumes of control and septic shock patients were compared and the relationship between volume and outcome in intensive care was studied.

Results:

The mean total volume of both adrenal glands was 7.2?±?2.0 cm³ in control subjects and 13.3?±?4.7 cm³ for total adrenal gland volume in septic shock patients (p?<?0.0001). Measurement reproducibility was excellent with a concordance correlation coefficient value of 0.87. The increasing adrenal gland volume was associated with a higher rate of survival in intensive care.

Conclusion:

The present study reports that with semi-automated software, adrenal gland volume can be measured easily and reproducibly. Adrenal gland volume was found to be nearly double in sepsis compared with control patients. The absence of increased volume during sepsis would appear to be associated with a higher rate of mortality and may represent a prognosis factor which may help the clinician to guide their strategy.     

Prevalence and risk factors of lumbar spondylolisthesis in elderly Chinese men and women

Objective

A screening survey for osteoporotic fractures in men and women in Hong Kong represents the first large-scale prospective population-based study on bone health in elderly (≥65 years) Chinese men and women. This study aims to identify the prevalence and potential risk factors of lumbar spondylolisthesis in these subjects.

Methods

The lateral lumbar radiographs of 1,994 male and 1,996 female patients were analysed using the Meyerding classification.

Results

Amongst the men, 380 (19.1 %) had at least one spondylolisthesis and 43 (11.3 %) had slips at two or more levels; 283 had anterolisthesis, 85 had retrolisthesis, whereas 12 subjects had both anterolisthesis and retrolisthesis. Amongst the women, 499 (25.0 %) had at least one spondylolisthesis and 69 (13.8 %) had slips at two or more levels; 459 had anterolisthesis, 34 had retrolisthesis, whereas 6 subjects had both anterolisthesis and retrolisthesis. Advanced age, short height, higher body mass index (BMI), higher bone mineral density (BMD) and degenerative arthritis are associated with spondylolisthesis. Lower Physical Activity Scale for the Elderly (PASE) score was associated with spondylolisthesis in men; higher body weight, angina and lower grip strength were associated with spondylolisthesis in women.

Conclusion

The male/female ratio of lumbar spondylolisthesis prevalence was 1:1.3 in elderly Chinese. Men are more likely to have retrolisthesis.

Key Points

? The prevalence of spondylolisthesis is 19.1 % in elderly Chinese men. ? The prevalence of spondylolisthesis is 25.0 % in elderly Chinese women. ? Men are more likely to have retrolisthesis. ? Anterolisthesis is most commonly seen at the L4/L5 level. ? Retrolisthesis is most commonly seen at the L3/L4 level.     

Assessment of sarcopenia and changes in body composition after neoadjuvant chemotherapy and associations with clinical outcomes in oesophageal cancer

Objectives

Sarcopenia and changes in body composition following neoadjuvant chemotherapy (NAC) may affect clinical outcome. We assessed the associations between CT body composition changes following NAC and outcomes in oesophageal cancer.

Methods

A total of 35 patients who received NAC followed by oesophagectomy, and underwent CT assessment pre- and post-NAC were included. Fat mass (FM), fat-free mass (FFM), subcutaneous fat to muscle ratio (FMR) and visceral to subcutaneous adipose tissue ratio (VA/SA) were derived from CT. Changes in FM, FFM, FMR, VA/SA and sarcopenia were correlated to chemotherapy dose reductions, postoperative complications, length of hospital stay (LOS), circumferential resection margin (CRM), pathological chemotherapy response, disease-free survival (DFS) and overall survival (OS).

Results

Nine (26 %) patients were sarcopenic before NAC and this increased to 15 (43 %) after NAC. Average weight loss was 3.7 %?±?6.4 (SD) in comparison to FM index (?1.2?±?4.2), FFM index (?4.6?±?6.8), FMR (?1.2?±?24.3) and VA/SA (?62.3?±?12.7). Changes in FM index (p?=?0.022), FMR (p?=?0.028), VA/SA (p?=?0.024) and weight (p?=?0.007) were significant univariable factors for CRM status. There was no significant association between changes in body composition and survival.

Conclusions

Loss of FM, differential loss of VA/SA and skeletal muscle were associated with risk of CRM positivity.

Key Points

? Changes in CT body composition occur after neoadjuvant chemotherapy in oesophageal cancer. ? Sarcopenia was more prevalent after neoadjuvant chemotherapy. ? Fat mass, fat-free mass and weight decreased after neoadjuvant chemotherapy. ? Changes in body composition were associated with CRM positivity. ? Changes in body composition did not affect perioperative complications and survival.