Prognostic value of coronary atherosclerosis progression evaluated by coronary CT angiography in patients with stable angina

Objectives

To investigate the progression of coronary atherosclerosis burden by coronary CT angiography (CCTA) and to demonstrate its association with the incidence of major adverse cardiac events (MACE).

Methods

We retrospectively studied patients with stable angina who had undergone repeat CCTA due to recurrent or worsening symptoms. Lipid-rich, fibrous, calcified and total plaque burden as well as coronary diameter stenosis were quantitatively analysed. The incidence of MACE during follow-up was determined.

Results

The final cohort consisted of 268 patients (mean age 52.9 ± 9.8 years, 71 % male) with a mean follow-up period of 4.6 ± 0.9 years. Patients with lipid-rich, fibrous, calcified and total plaque burden (%) progression, as well as coronary diameter stenosis (%) progression had a significantly higher incidence of MACE than those without (all p < 0.05). The progression of lipid-rich plaque (HR = 1.601, p = 0.021), total plaque burden (HR = 2.979, p = 0.043) and coronary diameter stenosis (HR = 4.327, p <0.001) were independent predictors of MACE (all p < 0.05).

Conclusions

Patients presenting with recurrent or worsening symptoms associated with coronary artery disease who have coronary atherosclerosis progression on CCTA are at an increased risk of future MACE.

Key Points

? Repeat CCTA can provide information regarding the progression of coronary atherosclerosis. ? Coronary atherosclerosis progression at CCTA is independently associated with MACE. ? CCTA findings could serve as incremental predictors of MACE.

     

Clinical implementation of an emergency department coronary computed tomographic angiography protocol for triage of patients with suspected acute coronary syndrome

Objectives

To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience.

Methods

Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure.

Results

One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %.

Conclusions

Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS.

Key points

? ED Coronary CTA using advanced systems is associated with low radiation exposure. ? Negative coronary CTA is associated with low rates of MACE. ? CTA in ED patients enables short median time to discharge home. ? CTA strategy is characterized by few downstream tests including unnecessary ICA.

     

Better 4-year outcomes for anterior cruciate ligament reconstruction with double-layer versus single-layer bone-patellar tendon-bone allografts

Purpose

To evaluate the results of anterior cruciate ligament reconstruction using a double-layer bone-patellar tendon-bone (DBPTB) graft.

Methods

Between 2010 and 2011, 98 patients underwent anterior cruciate ligament reconstruction with an allograft. Forty-seven of these patients received a DBPTB allograft and 51 received a traditional monolayer BPTB graft. Outcomes were evaluated at the end of a minimum 4-year follow-up in both groups using KT 1000 arthrometer measurements, Lachman and pivot-shift tests, the International Knee Documentation Committee form, and Lysholm scores.

Results

One patient (1/47, 2 %) in the DBPTB allograft group and six patients (6/51, 12 %) in the traditional monolayer BPTB graft were lost during follow-up because of graft rupture (n.s.). The mean side-to-side differences in the DBPTB and monolayer BPTB graft groups 4 years post-operatively were significantly different at 1.4 ± 1.3 and 1.7 ± 1.6 mm, respectively (p < 0.05). The DBPTB group performed significantly better than the BPTB group on the Lachman test, International Knee Documentation Committee knee score, and Lysholm scores (p < 0.05).

Conclusions

The DBPTB allograft group achieved better outcomes than the traditional BPTB allograft group regarding success rate, anterior stability, and knee function.

Level of evidence

Level II.

     

Hypofractionated stereotactic radiotherapy (HFSRT) for who grade I anterior clinoid meningiomas (ACM)

Purpose

While microsurgical resection plays a central role in the management of ACMs, extensive surgery may be associated with substantial morbidity particularly for tumors in intimate association with critical structures. In this study, we evaluated the use of HFSRT in the management of ACM.

Materials and methods

A total of 22 patients with ACM were treated using HFSRT. Frameless image guided volumetric modulated arc therapy (VMAT) was performed with a 6 MV linear accelerator (LINAC). The total dose was 25 Gy delivered in five fractions over five consecutive treatment days. Local control (LC) and progression free survival (PFS) rates were calculated using the Kaplan–Meier method. Common Terminology Criteria for Adverse Events, version 4.0 was used in toxicity grading.

Results

Out of the total 22 patients, outcomes of 19 patients with at least 36 months of periodic follow-up were assessed. Median patient age was 40 years old (range 24–77 years old). Median follow-up time was 53 months (range 36–63 months). LC and PFS rates were 100 and 89.4 % at 1 and 3 years, respectively. Only two patients (10.5 %) experienced clinical deterioration during the follow-up period.

Conclusion

LINAC-based HFSRT offers high rates of LC and PFS for patients with ACMs.

     

Good clinical results with autologous matrix-induced chondrogenesis (Amic) technique in large knee chondral defects

Purpose

Autologous matrix-induced chondrogenesis (AMIC) is a treatment for focal full-thickness cartilage defects combining microfracturing with an exogenous I/III collagen matrix (Chondro-Gide). The aim of the present study was to determine the 7 years outcomes of patients treated with the AMIC technique for knee chondral defects larger than 2 cm². The hypothesis was that the positive short-term outcomes achieved in the previous series would not deteriorate at a 7-year follow-up.

Methods

Twenty-one patients treated with the AMIC technique were retrospectively analysed. Patients were assessed through the IKDC subjective knee evaluation questionnaire and the Lysholm scoring system. All patients underwent a complete imaging study including radiographs and magnetic resonance. The median defect size was found to be 4.3 (range 2.9–8) cm².

Results

At a median follow-up of 7 (±1.4) years, the mean IKDC score improved from 31.7 (±8.9) points preoperatively, to 80.6 (±5.3) at the latest follow-up (p < 0.05). The mean Lysholm score improved from 38.8 (±12.4) points preoperatively to 72.6 (±19.5) points at the last follow-up (p < 0.05). At the last follow-up, 76.2% of patients were satisfied or extremely satisfied with their outcomes, while 66.6% of patients showed good quality repair tissue on magnetic resonance imaging.

Conclusion

AMIC was found to be an effective method to treat full-thickness knee chondral defects larger than 2 cm², with significant clinical and functional improvement maintained over a 7-year follow-up.

Level of evidence

IV.

     

Clinical Long-Term Outcome and Reinterventional Rate After Uterine Fibroid Embolization with Nonspherical Versus Spherical Polyvinyl Alcohol Particles

Purpose

This study was designed to evaluate the long-term clinical outcome and frequency of reinterventions in patients with uterine fibroids treated with embolization at a single center using polyvinyl alcohol microparticles.

Methods

The study included all patients with symptomatic uterine fibroids treated with uterine fibroid embolization (UFE) with spherical (s-PVA) and nonspherical (ns-PVA) polyvinyl alcohol microparticles during the period January 2001 to January 2011. Clinical success and secondary interventions were examined. Hospital records were reviewed during follow-up, and symptom-specific questionnaires were sent to all patients.

Results

In total, 515 patients were treated with UFE and 350 patients (67 %) were available for long-term clinical follow-up. Median time of follow-up was 93 (range 76–120.2) months. Eighty-five patients (72 %) had no reinterventions during follow-up in the group embolized with ns-PVA compared with 134 patients (58 %) treated with s-PVA. Thirty-three patients (28 %) underwent secondary interventions in the ns-PVA group compared with 98 patients (42 %) in s-PVA group (χ ² test, p < 0.01).

Conclusions

Spherical PVA particles 500–700 µm showed high reintervention rate at long-term follow-up, and almost one quarter of the patients underwent secondary interventions, suggesting that this type of particle is inappropriate for UFE.

     

Trans-physeal anterior cruciate ligament reconstruction in adolescents

Purpose

The aim of the study was to evaluate, in a group of adolescents, the onset of varus–valgus deviations in the sagittal plane after performing a trans-tibial trans-epiphyseal technique of ACL reconstruction with a follow-up of at least 2 years.

Methods

Seventy-one patients aged 12–15 years old (Tanner scale 3 and 4) have undergone ACL reconstruction with STG using arthroscopy. All patients were evaluated clinically using the visual analogue scale (VAS), the Lysholm score and the Tegner activity score at the time of surgery. All patients were reevaluated after a follow-up period of at least 2 years (T1) using the VAS, the Lysholm score, the Tegner activity score and radiographic studies in order to compare the operated limb with the healthy control limb.

Results

Valgus difference exceeding 2° in the knee axis between the operated limb and the healthy control limb was observed only in three patients (4.2 %: 95 % CI 0.88–11.86 %). The average difference was <1° (0.3°, 95 % CI 0.0–0.55).

Conclusion

The trans-tibial trans-epiphyseal technique of ACL reconstruction, according to the results obtained, seems to be a valid alternative procedure, when performed by a skilled orthopaedic surgeon, offering an excellent safety profile and at the same time very good clinical results.

Level of evidence

IV.

     

Renal Angiomyolipoma: Mid- to Long-Term Results Following Embolization with Onyx

Purpose

Percutaneous transcatheter embolization is currently the preferred treatment for ruptured or enlarging renal angiomyolipoma (AML), although the optimum choice of embolic material has not yet been established. We present mid- to long-term outcomes following embolization of AMLs with Onyx.

Materials and Methods

Ten AMLs in seven patients (including two with tuberous sclerosis) were embolized with Onyx. Patients were followed-up clinically, with tumour size and renal function measured pre- and post-procedure.

Results

Mean pre-treatment AML size was 63.4 mm (range 42–100). Mean clinical follow-up was 431.4 days (range 153–986) and imaging follow-up 284.2 days (range 30–741). There was no haemorrhage from treated lesions within the follow-up period. Of patients who had cross-sectional imaging pre- and post-procedure, mean decrease in AML size of 22 mm was seen after Onyx embolization (p = 0.0058, 95 % CI 9.13–34.87). No significant difference between serum creatinine was seen pre- and post-procedure (p = 0.54, 95 % CI 8.63–4.85).

Conclusions

Onyx embolization of renal AMLs is effective in the medium to long term, with theoretical benefits in safety and durability of result.

     

Assessment of the treatment response of spinal meningiomas after radiosurgery focusing on serial MRI findings

Purpose

This study evaluated the response of spinal meningiomas to treatment, by monitoring changes in magnetic resonance imaging (MRI) findings after stereotactic radiosurgery (SRS).

Materials and methods

Serial follow-up MRIs of 11 patients with spinal meningiomas who underwent SRS were retrospectively reviewed. Changes in tumor volume, T2 signal intensity (T2SI), and contrast enhancement were evaluated.

Results

The mean MRI follow-up period was 46.9 months (range 13–108 months). The local tumor control rate was 100 % in overall tumor volume, although boost SRS was performed for marginal recurrence in case 8 and rapid decompression in case 5. Seven tumors showed decreased T2SI. Each of the remaining four tumors showed variable T2SIs. In most tumors, the enhancement patterns did not change. Two of three patients with en plaque type meningiomas showed increased intramedullary T2SI, thought to be due to compressive myelopathy and peritumoral edema.

Conclusions

SRS resulted in successful local tumor control in all patients, although the follow-up period was not long. Changes in T2SI and contrast enhancement patterns of the tumors were evaluated on serial MRI. In addition, close follow-up with MRI is desirable to monitor intramedullary signal changes in cases of spinal meningiomas with a wider contact area with the spinal cord.

     

Surgical versus conservative management of acute patellar dislocation in children and adolescents: a systematic review

Purpose

The goal of this study was to perform a comparative review to determine whether there is a significant difference in the rate of repeat dislocation and clinical outcome between surgical and conservative management of acute patellar dislocation in children and adolescents.

Methods

A systematic review of the MEDLINE database was performed. English-language clinical outcome studies with a primary outcome/treatment specific to acute patella dislocation in a paediatric population were included. Eleven studies met inclusion criteria; Chi-square analysis, independent t tests and weighted mean pooled cohort statistics were performed where appropriate.

Results

A total of 470 conservatively managed and 157 operatively treated knees were included. Conservatively managed patients were on average 17.0 years and had a mean follow-up of 3.9 years; surgically managed patients were on average 16.1 years and had a mean follow-up of 4.7 years. Conservatively managed knees had a 31 % rate of recurrent dislocation rate compared to 22 % in surgical knees (p = 0.04). Trochlear dysplasia and skeletal immaturity confer greater risk for recurrent instability. Surgical treatment may provide clinically important quality of life and sporting benefit.

Conclusions

Surgical treatment of first time patella dislocation in children and adolescents is associated with a lower risk of recurrent dislocation and higher health-related quality of life and sporting function. There is a paucity of evidence on MPFL reconstruction for first time traumatic patella dislocation in this population.

Level of evidence

IV.

     

Rebound adenoid hyperplasia after chemotherapy in pediatric patients with head and neck lymphoma: MR imaging findings

Purpose

To assess MR imaging findings of rebound adenoid hyperplasia after chemotherapy in pediatric patients with head and neck lymphoma.

Materials and methods

Eight pediatric patients with head and neck lymphoma treated with chemotherapy alone or concurrent chemoradiotherapy were included. All patients underwent pre-therapeutic assessment and post-therapeutic follow-up by MR imaging. The maximum thickness of the adenoid was assessed on transverse T2-weighted images. Rebound adenoid hyperplasia was defined as more than half of the pre-therapeutic thickness after severe atrophy.

Results

The pre-therapeutic maximum thickness of the adenoid ranged from 10 to 18 mm (mean, 15 mm). In all patients, the thickness of the adenoid dramatically decreased (mean 1 mm) within 1 year after the cessation of chemotherapy. On follow-up MR imaging, rebound adenoid hyperplasia was observed in five patients (63 %). Re-atrophy following rebound adenoid hyperplasia was observed in two patients (25 %), and no re-atrophy was observed in three patients (37 %). Rebound adenoid hyperplasia was not observed in three patients (37 %) who were in their late teens, and who had been treated with concurrent chemoradiotherapy.

Conclusion

Rebound adenoid hyperplasia was often observed after chemotherapy in pediatric patients with lymphoma. MR imaging was useful for the assessment of rebound adenoid hyperplasia.

     

Randomized comparison of tape versus semi-rigid and versus lace-up ankle support in the treatment of acute lateral ankle ligament injury

Purpose

Functional treatment is the optimal non-surgical treatment for acute lateral ankle ligament injury (ALALI) in favour of immobilization treatment. There is no single most effective functional treatment (tape, semi-rigid brace or lace-up brace) based on currently available randomized trials.

Methods

This study is designed as a randomized controlled trial to evaluate the difference in functional outcome after treatment with tape versus semi-rigid versus lace-up ankle support (brace) for grades II and III ALALIs. The Karlsson score and the FAOS were evaluated at 6-month follow-up.

Results

One hundred and ninety-three patients (52 % males) were randomized, 66 patients were treated with tape, 58 patients with a semi-rigid brace and 62 patients with a lace-up brace. There were no significant differences in any baseline characteristics between the three groups. Mean age of the patients was 37.3 years (35.1–39.5; SD 15.3). Ninety-five males (49 %) were included. One hundred and sixty-one (59 + 50 + 52) patients completed the study through final follow-up; 32 % lost at follow-up. In two patients treated with tape support, the treatment was changed to a semi-rigid brace because of dermatomal blisters. Except for the difference in Foot and Ankle Outcome Score sport between the lace-up and the semi-rigid brace, there are no differences in any of the outcomes after 6-month follow-up.

Conclusion

The most important finding of current study was that there is no difference in outcome 6 months after treatment with tape, semi-rigid brace and a lace-up brace.

Level of evidence

I.

     

Clinical outcome of exercise therapy and early post-operative rehabilitation for treatment of neglected Achilles tendon rupture: a randomized study

Purpose

Treatment of neglected Achilles tendon rupture is very challenging. This randomized study aimed to compare the clinical outcome of early post-operative rehabilitation (EPR) with post-operative cast immobilization (PCI).

Methods

Fifty-seven patients with neglected Achilles tendon rupture were randomized to receive EPR (n = 26) or PCI (n = 31) management following surgery. Clinical outcome was monitored by follow-up at weeks 8, 12, 18 and 26 and year 2. The significance of intergroup differences from the Leppilahti scoring system (LSS), ultrasonography, multislice spiral computerized tomography (MSCT) and electromyography was assessed.

Results

Ultrasonography and MSCT revealed no occurrence of tendon elongation or adhesion. Four patients could perform sustained single-leg heel-raise exercise for 60 s at post-operative day 40. The PCI group also showed increased post-operative LSS score, but recovery was slower. Post-operative complications, such as ankle joint ankylosis and osteoporosis, only occurred in the PCI group.

Conclusions

Compared with cast immobilization, early post-operative rehabilitation results in better clinical outcome and faster overall tendon regeneration of neglected Achilles tendon rupture.

Level of evidence

II.

     

The horizontal Y-shaped graft with respective graft tension angles in anatomical two-bundle medial patellofemoral ligament reconstruction

Purpose

Various techniques for medial patellofemoral ligament (MPFL) reconstruction have been described with two bundles of graft tensioned simultaneously. The present study was to introduce an anatomical reconstruction procedure using a horizontal Y-shaped graft with respective graft tension angles and report the preliminary results.

Methods

A surgical technique for MPFL reconstruction using a horizontal Y-shaped semitendinosus tendon autograft with two bundles tensioned at 0° and 30° of knee flexion was described in detail. The patellar stability was evaluated with the apprehension test and an axial computed tomography (CT) scan at 30° of knee flexion. The knee function was evaluated using the Lysholm and Kujala scores.

Results

No recurrent dislocation or subluxation was reported for 45 patients at a mean of 33.7-month follow-up. On CT images, congruence angle, patellar tilt angle, lateral patellar angle and lateral displacement were restored to the normal range. At the last follow-up, the mean Lysholm score improved from 51.8 ± 6.2 to 91.7 ± 4.1 and mean Kujala score was from 53.4 ± 5.3 to 90.9 ± 6.6 (P < 0.01).

Conclusions

The present anatomical MPFL reconstruction technique with a horizontal Y-shaped two-bundle graft tensioned at respective knee flexion angles could not only recreate the fan-shape of MPFL but also mimic the function bundles of native ligament. Clinical follow-up confirms the good restoration of the patellar stability and significant improvement of knee function without special complications.

Level of evidence

Therapeutic, Level IV.

     

Clinical values of left ventricular mechanical dyssynchrony assessment by gated myocardial perfusion SPECT in patients with acute myocardial infarction and multivessel disease

Purpose

The aim of this study was to evaluate the prognostic value of additional evaluation of left ventricular mechanical dyssynchrony (LVMD) by gated myocardial perfusion single-photon emission computed tomography (GMPS) in patients with acute myocardial infarction (MI) and multivessel disease.

Methods

One hundred and nine acute MI patients with >50 % stenosis in at least one non-culprit artery who underwent GMPS within 2 weeks were enrolled. All patients underwent successful revascularization of the culprit arteries. Those with previous MI, atrial fibrillation, or frequent ventricular premature complexes, cardiac devices, significant patient motion, or procedure-related events were excluded. Phase standard deviation (PSD) and phase histogram bandwidth (PBW) were measured for assessment of LVMD. Patients were followed up for a median of 26 months after index MI, for composite major adverse cardiac events (MACE), which consisted with all-cause death, unplanned hospitalization due to heart failure and severe ventricular arrhythmias (sustained ventricular tachycardia or ventricular fibrillation). Independent predictors of MACE were evaluated.

Results

MACE occurred in 22 patients (20 %). Stress PSD (53.3?±?17.3° vs. 35.3?±?18.9°; p <0.001), stress PBW (147.6?±?54.6° vs. 96.8?±?59.2°; p?=?0.001) and resting PBW (126.8?±?37.5° vs. 96.6?±?48.9°; p?=?0.001) were significantly higher in patients with MACE compared to those without. Multivariate analysis revealed that stress PSD ≥45.5° and stress PBW ≥126.0° were predictive of MACE, as well as suboptimal non-culprit artery revascularization (SNR) and renin-angiotensin system (RAS) blockade medication. Higher stress PSD and stress PBW were associated with poorer prognosis both in patients with and without SNR, and those with RAS blockade medication, but not in those without RAS blockade medication.

Conclusions

LVMD measured by GMPS showed added prognostic value in acute MI with multivessel disease. GMPS could serve as a comprehensive evaluation imaging tool in patients with acute MI and multivessel disease.

     

Palliative radiotherapy for Japanese patients with malignant melanoma: a single-institution experience

Purpose

This study aimed to clarify the significance of palliative radiotherapy for Japanese patients with malignant melanoma based on the experience of our institution.

Materials and methods

Twenty-nine patients with malignant melanoma who underwent palliative radiotherapy at our facility were included in the investigation. Median radiation dose was 30 Gy (4–30).

Results

Median follow-up time was 4.2 months (range 2.7–40.5 months). Twenty-two patient (75.9 %) died during the follow-up. The response rate of overall symptoms to radiotherapy was 63.0 %. The rate of completely resolved hemorrhage was relatively high (81.8 %). The median time of freedom from progression in completely resolved symptoms was 3.1 months (range 0.2–27.8 months). Radiation dose <30 Gy and poor performance status tended to be associated with poor symptomatic relief in treatment site (p = .080 and p = .068, respectively). There were very few severe toxic events.

Conclusion

Two thirds of symptoms were safely alleviated by palliative radiotherapy for Japanese patients with malignant melanoma. The therapeutic effect was retained for a substantial duration. Further domestic studies are warranted.

     

A randomized controlled clinical and radiological trial about outcomes of navigation-assisted TKA compared to conventional TKA: long-term follow-up

Purpose

Well balanced knees with good alignment are essential for a well-functioning TKA with long survival of its implants. This prospective randomized study comparing navigation-assisted TKA and conventional TKA reported the clinical and radiological outcomes at a follow-up of 9 years. The purpose of this study was to compare the clinical and radiological outcomes for patients who underwent navigation-assisted TKA or conventional TKA after long-term follow-up.

Methods

A total of 80 patients (88 knees) were available for physical and radiological examination 9 years after TKA. Clinical outcomes were evaluated using HSS, WOMAC, and KS function and pain scores. And radiological outcomes of the component loosening and its survivorship during 9-year follow-up were also evaluated.

Results

There were no significant differences in the field of clinical outcomes between the two groups. In terms of radiological outcomes, the navigation group had fewer alignment outliers (7.3 vs 20 %, p = 0.006). Although the clinical outcomes showed no differences between the two groups, the survival rate was slightly better in the navigation group than in the conventional group without statistical significance (best-case scenario 100 vs 95.3 %, n.s., worst-case scenario 95.6 vs 88.4 %, n.s.).

Conclusion

Navigation-assisted TKA produced better alignment outcomes and better survival rates than conventional instruments although some of the differences were not statistically significant.

Level of evidence

I.

     

Long-Term Results from the MAJESTIC Trial of the Eluvia Paclitaxel-Eluting Stent for Femoropopliteal Treatment: 3-Year Follow-up

Purpose

To report the 3-year results of the MAJESTIC first-in-human study of the Eluvia Drug-Eluting Vascular Stent System for treating femoropopliteal artery lesions.

Methods

The prospective, single-arm, multicenter clinical trial enrolled 57 patients with symptomatic lower limb ischemia (Rutherford category 2, 3, or 4) and lesions in the superficial femoral artery or proximal popliteal artery. Mean lesion length was 70.8 ± 28.1 mm, and 46% of lesions were occluded. Efficacy measures at 2 years included primary patency, defined as duplex ultrasound peak systolic velocity ratio of ≤2.5 and the absence of target lesion revascularization (TLR) or bypass. Safety monitoring through 3 years included adverse events and TLR.

Results

Primary patency was estimated as 83.5% (Kaplan–Meier analysis) at 24 months, and 90.6% (48/53) of patients maintained an improvement in Rutherford class. At 36 months, the Kaplan–Meier estimate of freedom from TLR was 85.3%. No stent fractures were identified, and no major target limb amputations occurred.

Conclusion

MAJESTIC results demonstrated long-term treatment durability among patients whose femoropopliteal arteries were treated with the paclitaxel-eluting Eluvia stent.

Level of Evidence

Level 2b, cohort study

     

Outcome of hypovascular hepatic nodules with positive uptake of gadoxetic acid in patients with cirrhosis

Objectives

To evaluate the longitudinal risk to patients with cirrhosis of hypervascular hepatocellular carcinoma (HCC) developing from hypovascular hepatic nodules that show positive uptake of gadoxetic acid (hyperintensity) on hepatocyte phase images.

Methods

In 69 patients, we evaluated findings from serial follow-up examinations of 633 hepatic nodules that appeared hypovascular and hyperintense on initial gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) until the nodules demonstrated hypervascularity and were diagnosed as hypervascular HCC. Cox analyses were performed to identify risk factors for the development of hypervascular HCCs from the nodules.

Results

The median follow-up was 663 days (range, 110 to 1215 days). Hypervascular HCCs developed in six of the 633 nodules (0.9 %) in five of the 69 patients. The only independent risk factor, the nodule’s initial maximum diameter of 10 mm or larger, demonstrated a hazard ratio of 1.25. The one-year risk of hypervascular HCC developing from a nodule was 0.44 %. The risk was significantly higher for nodules of larger diameter (1.31 %) than those smaller than 10 mm (0.10 %, p?<?0.01).

Conclusions

Hypervascular HCC rarely develops from hypovascular, hyperintense hepatic nodules. We observed low risk even for nodules of 10 mm and larger diameter at initial examination.

Key Points

? Hypervascularization was rare on follow-up examination of hypovascular, hyperintense nodules ? The risk of hypervascularization in a nodule increased with large size ? Hypovascular, hyperintense nodules require neither treatment nor more intense follow-up

     

Dynamic and static tibial translation in patients with anterior cruciate ligament deficiency initially treated with a structured rehabilitation protocol

Purpose

To compare dynamic and static tibial translation, in patients with anterior cruciate ligament deficiency, at 2- to 5-year follow-up, with the tibial translation after 4 months of rehabilitation initiated early after the injury. Secondarily, to compare tibial translation in the injured knee and non-injured knee and explore correlations between dynamic and static tibial translation.

Methods

Twelve patients with ACL rupture were assessed at 3–8 weeks after ACL injury, after 4 months of structured rehabilitation, and 2–5 years after ACL injury. Sagittal tibial translation was measured during the Lachman test (static translation) and during gait (dynamic translation) using a CA-4000 electrogoniometer.

Results

Static tibial translation was increased bilateral 2–5 years after ACL injury, whereas the dynamic tibial translation was unchanged. Tibial translation was greater in the injured knee compared with the non-injured knee (Lachman test 134 N 9.1 ± 1.0 vs. 7.0 ± 1.7 mm, P = 0.001, gait 5.6 ± 2.1 vs. 4.7 ± 1.8 mm, P = 0.011). There were no correlations between dynamic and static tibial translation.

Conclusion

Dynamic tibial translation was unchanged in spite of increased static tibial translation in the ACL-deficient knee at 2- to 5-year follow-up compared to directly after rehabilitation. Dynamic tibial translation did not correlate with the static tibial translation. A more normal gait kinematics may be maintained from completion of a rehabilitation programme to mid-term follow-up in patients with ACL deficiency treated with rehabilitation only.

Level of evidence

IV.