Under-correction of preoperative varus alignment does not lead to a difference in in-vivo bone loading in 3D-SPECT/CT compared to neutral alignment.

BACKGROUND: The aim was to investigate the correlation of bone tracer uptake (BTU) in SPECT/CT and changes in coronal knee alignment after total knee arthroplasty (TKA). We questioned if undercorrection of preoperative varus alignment leads to a difference in BTU compared to neutral alignment. METHODS: Consecutive 66 patients who received SPECT/CT before and after TKA were retrospectively included. Adjusted mechanical alignment was the alignment target. The alignment of the knee was measured on 3D-CT by selecting standardized landmarks. Maximum (mean ± SD) and relative BTU (ratio to the reference) were recorded using a previously validated localization scheme (p < 0.05). RESULTS: In the native group, 20 knees were aligned (30.3%) in valgus (HKA > 181.5°), 12 (18.2%) in neutral (178.5°-181.5°) and 34 (51.5%) in varus (HKA < 178°). Overall TKA changed the alignment towards neutral. 48.5% remained in the same groups, whereas 50% of native valgus and 33% of varus knees changed to neutral after TKA. In native varus alignment mean BTU was significantly higher in some medial tibial and femoral regions (fem1ia (p = 0.010), fem1ip (p = 0.002), tib1a.mid (p = 0.005), tib1a.tray (p = 0.000), tib1p.tray (p = 0.000)); in native valgus alignment mean BTU was higher in the corresponding lateral tibial and femoral regions (fem2ip (p = 0.001), tib2a.tray (p = 0.011), tib2p.tray (p = 0.002)). After TKA, a significant decrease in femoral and tibial BTU (femoral preoperative BTU 1.64 +/-0.69; femoral postoperative BTU 0.95 +/-0.42; p = 0.000// tibial preoperative BTU 1.65 +/- 0.93; tibial postoperative BTU 1.16 +/- 0.48; p = 0.000) and an increase in patellar BTU was observed (p = 0.025). Native varus alignment correlated with a higher medial BTU decrease medially. Undercorrection of preoperative varus alignment showed no higher BTU after TKA. CONCLUSION: Preoperative varus alignment correlated with a higher decrease in BTU in specific femoral and tibial medial regions. Preoperative valgus alignment correlated with a higher decrease in the corresponding lateral regions. Undercorrection of preoperative varus alignment did not lead to higher bone loading reflected by BTU after TKA.

Increased patellar bone tracer uptake in preoperative SPECT/CT before medial opening high tibial osteotomy correlates with inferior clinical outcome.

PURPOSE: The purpose of this study was to investigate whether specific bone tracer uptake (BTU) patterns on preoperative SPECT/CT could predict which patients with varus alignment and medial overload would particularly benefit from medial opening-wedge high tibial osteotomy (MOWHTO). It was the hypothesis that an increased preoperative BTU relative to the reference BTU of the femur on SPECT/CT in the lateral and patellar compartments of the knee are predictive factors for inferior clinical outcome and that the clinical outcome correlates with the extent of alignment correction. METHODS: Twenty-three knees from 22 patients who underwent MOWHTO for medial compartment overload were investigated preoperatively using Tc-99m-SPECT/CT. BTU was quantified and localised to specific joint areas according to a previously validated scheme. Pre- and postoperative mechanical alignment was measured. Clinical outcome was assessed at a median of 24 months (range 11-30) after MOWHTO by collecting the WOMAC score. RESULTS: Significant correlations between BTU in the patellar area and the total WOMAC score and its subcategories pain and stiffness were found. Thus, BTU in the 1sPat area (superior lateral patellar compartment) correlated with total WOMAC (rho = 0.43, p = 0.04), pain subcategory (rho = 0.43, p = 0.04), and stiffness subcategory (rho = 0.59, p = 0.003). No significant correlations were found between alignment correction, age, gender and WOMAC. CONCLUSION: This study highlights the role of preoperative SPECT in modern knee surgery to obtain information about the loading pattern on different compartments of the knee. Despite the limited number of participants, the present study shows that a preoperative SPECT/CT scan can help the treating surgeons to identify patients who may be at risk of inferior clinical outcome if an MOWHTO is considered, as an elevated BTU in the patellar region on preoperative SPECT/CT appears to be a potential risk factor for postoperative pain and stiffness. LEVEL OF EVIDENCE: Level III.

["Manubriosternal Synchondrosis": A Rare Problem in Sports Medicine]. / "Synchrondritis manubriosternalis": Ein seltenes Problem in der Sportmedizin.

Non-traumatic, inflammatory and painful lesions of the manubriosternal joint are rare pathologies and, to our knowledge, have not been described in the literature of sports medicine. We report the case of a 30-year-old male strength athlete who developed chronic pain in the manubriosternal joint after exercise. Four-month abstinence from exercise combined with a conservative rehabilitation program performed after clinical and radiological tests did not bring any symptomatic relief. After a local ultrasound-guided single-shot sclerotherapy procedure performed in our clinic, the patient was free of symptoms and quickly regained his ability to exercise.

Symptomatic versus asymptomatic knees after bilateral total knee arthroplasty: what is the difference in SPECT/CT?

PURPOSE: The primary purpose of this retrospective study was to evaluate the differences of bone tracer uptake (BTU) in symptomatic and asymptomatic knees after bilateral total knee arthroplasty (TKA) and identify typical BTU patterns with regards to TKA component position and alignment. METHODS: A consecutive number of 37 patients after bilateral TKA were retrospectively included. The knees were grouped into symptomatic (group A) and asymptomatic (group B) knees. All patients underwent 99m-Tc-HDP-SPECT/CT. Coronal, rotational, and sagittal TKA component position was analysed in 3D reconstructed CT. BTU was anatomically localised and quantified using a validated standardized localization scheme. Maximum BTU values for each area were recorded and normalized values calculated. Signed log-rank test, chi-square test, paired t-tests, and Pearson correlations were used (p <0.05). RESULTS: Symptomatic TKAs were significantly more flexed and had a tendency to be more internally rotated when compared to asymptomatic ones (p < 0.05). In all regions, the mean BTU in asymptomatic knees was lower than in symptomatic knees. In both groups the highest mean BTU was found around the tibial stem (symptomatic 7.30; asymptomatic 6.30, p = 0.061) and at the tip of the tibial stem (symptomatic 5.49; asymptomatic 4.74, p = 0.062). Superior patellar regions showed higher BTU than inferior regions. The highest patellar BTU was found in the superior medial patella (symptomatic 4.99; asymptomatic 3.98, p = 0.048). The lowest BTU was found in the posterior femoral regions (flatsp, flatip, fmedsp, fmedip) (Table 3). Tibial and patellar areas showed twice as high mean BTUs than femoral areas (Fig. 3). A significant correlation of TKA component position and BTU was demonstrated. CONCLUSIONS: Distribution and intensity of BTU in SPECT/CT depends on TKA component position and alignment. In addition, typical BTU patterns in symptomatic and asymptomatic knees were identified. A profound knowledge of BTU pattern, TKA component position, and alignment helps to identify pathologies in patients after TKA. CLINICAL EVIDENCE: Diagnostic study, level II.

[Non-dislocated osteoporotic insufficiency fracture of the medial femoral neck. SPECT/CT makes the diagnostic difference]. / Undislozierte osteoporotische Insuffizienzfraktur des medialen Schenkelhalses. SPECT/CT macht den diagnostischen Unterschied.

Osteoporotic fragility fractures of the femoral neck are the most common type of fractures in the elderly and are associated with a high mortality. Most frequently these fractures are due to falls but spontaneous onset has also been described. In these patients the insufficient quantity and quality of the osteoporotic bone finally leads to the development of a fragility or insufficiency fracture. In some cases of nondisplaced insufficiency fractures the diagnosis cannot be established by conventional radiographs alone and magnetic resonance imaging (MRI), single proton emission computed tomography (SPECT) or SPECT/CT are considered as diagnostic adjuncts. We report the case of an 83-year-old patient who had complained of ongoing weight-bearing pelvic pain for over 6 months. There was no history of trauma. The clinical conventional radiographs as well as CT could not elucidate the cause of the problems. To differentiate between lumbal and hip pain a SPECT/CT was performed and the diagnosis of a medial femoral neck insufficiency fracture was established. In the delayed phase a band-like increased tracer uptake within the medial femoral neck was observed. The SPECT/CT procedure is a promising diagnostic alternative for geriatric patients and can be particularly recommended in cases of persistent unclear pelvic or lumbar spine pain in the elderly.

SPECT-CT imaging in degenerative joint disease of the foot and ankle.

The precise localisation of osteoarthritic changes is crucial for selective surgical treatment. Single photon-emission CT-CT (SPECT-CT) combines both morphological and biological information. We hypothesised that SPECT-CT increased the intra- and interobserver reliability to localise increased uptake compared with traditional evaluation of CT and bone scanning together. We evaluated 20 consecutive patients with pain of uncertain origin in the foot and ankle by radiography and SPECT-CT, available as fused SPECT-CT, and by separate bone scanning and CT. Five observers assessed the presence or absence of arthritis. The images were blinded and randomly ordered. They were evaluated twice at an interval of six weeks. Kappa and multirater kappa values were calculated. The mean intraobserver reliability for SPECT-CT was excellent (kappa = 0.86; 95% CI 0.81 to 0.88) and significantly higher than that for CT and bone scanning together. SPECT-CT had significantly higher interobserver agreement, especially when evaluating the naviculocuneiform and tarsometatarsal joints. SPECT-CT is useful in localising active arthritis especially in areas where the number and configuration of joints are complex.

A randomised, controlled trial of bosentan in severe COPD.

Pulmonary hypertension during exercise is common in severe chronic obstructive pulmonary disease (COPD). It was hypothesised that the use of the endothelin-receptor antagonist bosentan can improve cardiopulmonary haemodynamics during exercise, thus increasing exercise tolerance in patients with severe COPD. In the present double-blind, placebo-controlled study, 30 patients with severe or very severe COPD were randomly assigned in a 2:1 ratio to receive either bosentan or placebo for 12 weeks. The primary end-point was change in the 6-min walking distance. Secondary end-points included changes in health-related quality of life, lung function, cardiac haemodynamics, maximal oxygen uptake and pulmonary perfusion patterns. Compared with placebo, patients treated with bosentan during 12 weeks showed no significant improvement in exercise capacity as measured by the 6-min walking distance (mean+/-SD 331+/-123 versus 329+/-94 m). There was no change in lung function, pulmonary arterial pressure, maximal oxygen uptake or regional pulmonary perfusion pattern. In contrast, arterial oxygen pressure dropped, the alveolar-arterial gradient increased and quality of life deteriorated significantly in patients assigned bosentan. The oral administration of the endothelin receptor antagonist bosentan not only failed to improve exercise capacity but also deteriorated hypoxaemia and functional status in severe chronic obstructive pulmonary disease patients without severe pulmonary hypertension at rest.

Combined transbronchial needle aspiration and positron emission tomography for mediastinal staging of NSCLC.

There are no data available combining transbronchial needle aspiration (TBNA) of mediastinal lymph nodes and positron emission tomography (PET) in the staging of nonsmall cell lung cancer (NSCLC). The aim of the current study was to determine if these two methods can enhance the negative predictive value of the individual modality alone, for a specific lymph node station, and if this integrated approach can reduce the number of mediastinoscopies. A total of 113 patients with enlarged mediastinal lymph nodes (> or = 1 cm), who underwent both TBNA and PET scanning, were included. In 51 patients, histopathology, confirmed by surgical lymph node dissection, was compared with PET results and TBNA. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy to detect malignant lymphadenopathy was 68 (13/19), 89 (119/134), 46 (13/28), 95 (119/125) and 86% (132/152) for PET, respectively; 54% (6/11), 100 (53/53), 100 (6/6), 91 (53/58) and 92% (59/64), respectively for TBNA; and 100 (11/11), 94 (50/53), 79 (11/14), 100 (50/50) and 95 (61/64) for combined TBNA and PET, respectively. Combination of transbronchial needle aspiration and positron emission tomography has the potential to allow adequate mediastinal staging of nonsmall cell lung cancer with enlarged lymph nodes in most patients without the need for mediastinoscopy.

[Report on the capsule dosage and mixing system. 2. Development, design and mode of action of a mixing machine for dental materials measured out in capsules]. / Report zum Kapsel-Dosier- und Mischsystem. 2. Mitt: Entwicklung, Aufbau und Wirkungsweise eines Mischgerätes für in Kapseln dosierte stomatologische Werkstoffe.

The author presents a mixing apparatus for dental materials predosed in capsules. It is characterized by a novel principle of motion and great efficiency, which permits to triturate, in a short time and the best possible manner, all luting and filling materials suited for mechanical mixing, including amalgam alloys. Redrawings of quick-motion pictures illustrate the mixing process in the capsule.