Effects of progressive resistance training prior to total HIP arthroplasty - a secondary analysis of a randomized controlled trial.

OBJECTIVE: To investigate 1-year postoperative effect of preoperative resistance training (RT) in patients undergoing total hip arthroplasty (THA) on patient-reported outcomes on activity and function and objective outcomes on muscle strength and physical performance. DESIGN: A 3-12 months follow-up of a randomized controlled trial. Patients scheduled for THA were randomized into: RT-group, twice a week for 10 weeks prior to THA, or 'care-as-usual' (CG). Primary endpoint of this sequel analysis is HOOS-ADL at 12 months follow-up. Secondary outcome measures are; other HOOS subscales, knee- and hip muscle strength plus function (gait, ascending/descending stairs, and sit-to-stand) at three and/or 12 months. CLINICALTRIALS.GOV: NCT01164111. RESULTS: Eighty patients (70% women, 70.4 ± 7.6 years, BMI of 27.8 ± 4.6) were randomized to RT (n = 40) or CG (n = 40); data from 85% were available at 12 months. No superior effects were observed at 12 months for HOOS ADL (between-group change score [95%CI]) (2.6 [-4.2; 9.8], P = 0.44) or remaining subscales. However, ascending (1.3 s [0.3; 2.3], P = 0.01)) and descending stairs (1.6 s [0.3; 2.9], P = 0.01) demonstrated additional effects. At 3 months clinically relevant change-scores in favour of RT was observed on HOOS-Sport/Rec (10.5 points [1.4; 19.6], P = 0.023), together with higher knee strength of the affected side (14.6 Nm [6.3; 22.9], P < 0.001), and selected outcomes of physical function. CONCLUSIONS: At 12 months after surgery, there was no additional effect of preoperative RT compared with THA alone, but rehabilitation was accelerated at 3 months.

18F FDG-PET/CT has poor diagnostic accuracy in diagnosing shoulder PJI.

PURPOSE: Chronic low-grade periprosthetic joint infection (PJI) of a shoulder replacement can be challenging to diagnose. 18F-FDG PET/CT is suggested as a modality to diagnose lower-limb PJI, but no studies on shoulder replacements exist. The aim of this study was therefore to determine the diagnostic accuracy of 18F-FDG PET/CT in diagnosing chronic PJI of the shoulder. METHODS: Patients evaluated for a failed shoulder replacement during a 3-year period were prospectively included in the study. All patients underwent pre-operative 18F-FDG PET/CT, and were evaluated for signs of infection by three independent reviewers using shoulder-specific criteria. Interrater-agreement was calculated between the reviewers. If the patient had revision surgery, biopsy specimens were obtained and cultured with bacterial growth in the cultures serving as gold standard of infection. RESULTS: A total of 86 patients were included in the study. Nine patients were 18F-FDG PET/CT positive for infection, with only three true positive. Using the gold standard, infection was diagnosed after revision surgery in 22 cases. All infections were chronic and caused by low-virulent microbes. The sensitivity of 18F-FDG PET/CT was 0.14 95% CI (0.03-0.36), specificity 0.91 95% CI (0.81-0.97), positive predictive value was 0.40 95% CI (0.15-0.71) and negative predictive value 0.71 95% CI (0.67-0.75). The inter-observer agreement was 0.56 (Fleiss' kappa), indicating moderate agreement of the visual FDG-PET evaluation using the shoulder-specific criteria. CONCLUSION: 18F-FDG PET/CT has poor diagnostic accuracy in diagnosing low-grade PJI of the shoulder. 18F-FDG PET/CT cannot be recommended as a part of the routine preoperative workup to diagnose low-grade infection of a shoulder replacement.

Three-phase bone scintigraphy for diagnosis of Charcot neuropathic osteoarthropathy in the diabetic foot - does quantitative data improve diagnostic value?

AIM: To investigate whether inclusion of quantitative data on blood flow distribution compared with visual qualitative evaluation improve the reliability and diagnostic performance of 99 m Tc-hydroxymethylene diphosphate three-phase bone scintigraphy (TPBS) in patients suspected for charcot neuropathic osteoarthropathy (CNO) of the foot. METHOD: A retrospective cohort study of TPBS performed on 148 patients with suspected acute CNO referred from a single specialized diabetes care centre. The quantitative blood flow distribution was calculated based on the method described by Deutsch et al. All scintigraphies were re-evaluated by independent, blinded observers twice with and without quantitative data on blood flow distribution at ankle and focus level, respectively. The diagnostic validity of TPBS was determined by subsequent review of clinical data and radiological examinations. RESULTS: A total of 90 patients (61%) had confirmed diagnosis of CNO. The sensitivity, specificity and accuracy of three-phase bone scintigraphy without/with quantitative data were 89%/88%, 58%/62% and 77%/78%, respectively. The intra-observer agreement improved significantly by adding quantitative data in the evaluation (Kappa value 0·79/0·94). The interobserver agreement was not significantly improved. CONCLUSION: Adding quantitative data on blood flow distribution in the interpretation of TBPS improves intra-observer variation, whereas no difference in interobserver variation was observed. The sensitivity of TPBS in the diagnosis of CNO is high, but holds limited specificity. Diagnostic performance does not improve using quantitative data in the evaluation. This may be due to the reference intervals applied in the study or the absence of a proper gold standard diagnostic procedure for comparison.

Preoperative progressive explosive-type resistance training is feasible and effective in patients with hip osteoarthritis scheduled for total hip arthroplasty--a randomized controlled trial.

OBJECTIVE: To investigate the efficacy and feasibility of progressive explosive-type resistance training (RT) in patients with osteoarthritis (OA) of the hip scheduled for total hip arthroplasty (THA). METHOD: Randomized controlled trial (1:1) in patients diagnosed with hip OA and scheduled for THA. The intervention group (IG) performed supervised preoperative progressive explosive-type RT twice a week for 10 weeks; four exercises (hip/thigh) performed in three series each (8-12 repetition maximum). The control group (CG) received 'care as usual'. Efficacy was reported as the between-group difference in the Hip Osteoarthritis Outcome Score (HOOS) (primary endpoint; ADL function), and leg muscle power at post intervention follow-up immediate before surgery. Intention-to-treat analyses were performed in a multilevel regression model adjusting for baseline, sex, age and weight. Feasibility was reported as adherence, exercise related pain and adverse effects. Post-surgical follow up will be reported separately. ClinicalTrials.gov registration: NCT01164111. RESULTS: Eighty patients (age 70.4 ± 7.6 years, BMI 27.8 ± 4.6, 52 females (65%) were included. Adherence was high (93%) with acceptable exercise related pain (VAS score ≤ 5) reported in 83% of sessions and no adverse events. Changes in HOOS 'function' was 10.0 points 95%CI [4.7; 15.3] higher in IG compared to CG (P < 0.001). For all the remaining HOOS subscales IG scored significantly better (P < 0.03) and had higher leg extension muscle power (P < 0.0001) compared to CG. CONCLUSION: Progressive explosive-type RT was feasible in the included group of hip OA patients scheduled for THA and resulted in significant improvement in self-reported outcomes and increased leg muscle power.

Periarticular and generalised bone loss in patients with early rheumatoid arthritis: influence of alendronate and intra-articular glucocorticoid treatment. Post hoc analyses from the CIMESTRA trial.

OBJECTIVES: The aims of this study were to investigate the influence of alendronate and intra-articular betamethasone treatment on bone mineral density (BMD) changes in hand, lumbar spine and femoral neck during 1 year of a treat-to-target study (Cyclosporine, Methotrexate, Steroid in RA (CIMESTRA)). PATIENTS AND METHODS: A hundred and sixty patients with early, active rheumatoid arthritis (RA) received methotrexate, intra-articular betamethasone and ciclosporin /placebo-ciclosporin. Patients with Z-score ≤0 also started alendronate 10 mg/day. BMD of the hand (digital x-ray radiogrammetry (DXR-BMDhand)), BMD of lumbar spine and femoral neck (dual x-ray absorptiometry (DXA-BMDlumbar spine and DXA-BMDfemoral neck)) and x-rays of hands, wrists and forefeet (modified Sharp-van der Heijde score) were measured at baseline and 1 year, with complete data available in 107 patients. RESULTS: The change in BMD in hand, lumbar spine and femoral neck was negatively associated with the dose of intra-articular betamethasone (p<0.01 for all), but the bone loss in hand was modest and in the axial skeleton comparable with that of healthy individuals. Alendronate did not influence changes in DXR-BMDhand, which averaged -2.8%, whereas significant changes were observed in DXA-BMDlumbar spine and DXA-BMDfemoral neck in alendronate-treated patients (1.8% and 0.8%) compared with untreated patients (-1.8% and -2.2%) (p<0.01 and 0.02). Alendronate did not affect the radiographic progression (alendronate-treated patients: 0 (range 0-19), non-alendronate: 0 (0-18)). CONCLUSIONS: In early active RA, intra-articular betamethasone injections added to disease-modifying antirheumatic drug (DMARD) treatment led to minimal loss of hip and lumbar BMD, and the loss could be prevented by treatment with alendronate. Alendronate treatment did not affect radiographic progression.

Slide-based ergometer rowing: effects on force production and neuromuscular activity.

Force production profile and neuromuscular activity during slide-based and stationary ergometer rowing at standardized submaximal power output were compared in 14 male and 8 female National Team rowers. Surface electromyography (EMG) was obtained in selected thoracic and leg muscles along with synchronous measurement of handle force and rate of force development (RFD). Compared to stationary conditions, slide-based peak force decreased by 76 (57-95) N (mean 95% CI) in males (P < 0.001) and 20 (8-31) N (P < 0.05) in females. Stroke rate increased (+10.7%) and late-phase RFD decreased (-20.7%) in males (P < 0.05). Neuromuscular activity in m. vastus lateralis decreased in the initial drive phase from 59% to 51% of EMG max in males and from 57% to 52% in females (P < 0.01-0.05), while also decreasing in the late recovery phase from 20% to 7% in males and 17% to 7% in females (P < 0.01). Peak force and maximal neuromuscular activity in the shoulder retractors always occurred in the second quartile of the drive phase. In conclusion, peak force and late-phase RFD (males) decreased and stroke rate increased (males) during slide-based compared to stationary ergometer rowing, potentially reducing the risk of overuse injury. Neuromuscular activity was more affected in leg muscles than thoracic muscles by slide-based ergometer rowing.

Factors of importance for scintigraphic non-visualisation of sentinel nodes in breast cancer.

PURPOSE: The aim of this study was to analyse different factors of possible significance for non-visualisation of sentinel nodes (SNs) by preoperative lymphoscintigraphy, in order to enable improvement of the success rate of SN visualisation through modification or alteration of some of the factors. METHODS: Between March 1998 and January 2003 we analysed a series of 442 women with unilateral stage T1 and clinical N0 breast cancer. Lymphoscintigraphy was performed after periareolar or peritumoural injection of 99mTc-albumin nanocolloid, with image acquisition after 2-6 h or 18-24 h. Until January 2001, all patients received around 20 MBq tracer, irrespective of time to operation. From January 2001, patients injected on the day before surgery received at least 100 MBq while patients injected on the day of surgery received around 50 MBq. RESULTS: An SN was visualised in 87% of the patients, and at surgery the SN was detected with the hand-held gamma probe in 42% of the remaining patients. By multiple logistic regression analysis, statistically significant independent variables that increased the risk for non-visualisation were increasing age (p=0.0007), increasing body weight (p=0.0189) and peritumoural injection (p<0.0001). Significant interaction was found for imaging time and injected activity (p=0.0017). CONCLUSION: This study conclusively shows that the risk of unsuccessful SN imaging increases with age and body weight. Our findings suggest that the scintigraphic success rate may be improved by periareolar (rather than peritumoural) injection. Early and late imaging procedures are equally efficient, but if a late imaging procedure is used, activity (adjusted for physical decay) in the patient on day 2 should be more than 10 MBq.

Prospective comparison of differences in bone mineral density adjacent to two biomechanically different types of cementless femoral stems.

We compared the differences in bone mineral density (BMD) adjacent to two biomechanically different cementless femoral stems (Spotorno and Evolution-K). Measurements were performed within the first week after surgery and 3, 6, 12, and 24 months postoperatively in a prospective study of 31 patients with 37 total hip arthroplasties. A modified Harris hip score and a visual analogue score for patient satisfaction was used to evaluate the clinical outcome. For both stems, dual X-ray absorptiometry measurements revealed a decrease in BMD in Gruen zone 7. Patients with a Spotorno stem also had a significant decrease in BMD in zones 1 and 2. In patients with an Evolution-K stem, there was a positive correlation between the clinical outcome and BMD in Gruen zones 1 and 4. Our data suggest that periprosthetic bone loss is equal to if not less pronounced adjacent to the Evolution-K stem as compared to the Spotorno stem.

Early periprosthetic femoral bone remodelling using different bearing material combinations in total hip arthroplasties: a prospective randomised study.

The present study was performed to test the hypothesis that different bearing materials have an impact on femoral bone remodelling within the first year after a total hip arthroplasty. A total of 225 patients with osteoarthrosis of the hip or avascular necrosis of the femoral head were included in this randomised prospective study. All patients had an identical hybrid total hip arthroplasty (cemented BiMetric stem and cementless RingLoc acetabular cup) except for the bearing materials: polyethylene-on-zirconia (n = 78), CoCr-on-CoCr (n = 71), or alumina-on-alumina (n = 76). Bone mineral density (BMD) was measured with Dual-energy X-ray absorptiometry (DEXA) in seven Gruen zones adjacent to the femoral implant. The DEXA scan was performed within one week after surgery and was repeated one year postoperatively. There was no significant difference in periprosthetic BMD change between the three groups. After twelve months the relative BMD decrease was highest in the proximal part of the femur, - 6.2% in the greater trochanter region and - 12.7% in the lesser trochanter region. In the distal zones the relative BMD decrease was -5.3, -4.2, -2.1, -2.3, and -5.6%, respectively. The use of different bearing materials had no significant impact on femoral bone remodelling adjacent to the cemented hip stem within one year after surgery.

Increased bone mineral density adjacent to hydroxy-apatite-coated ankle arthroplasty.

We measured bone mineral density (BMD) in patients treated with a unilateral hydroxy-apatite-coated ankle arthroplasty. The study comprised 11 consecutive patients measured preoperatively and postoperatively after 3, 6, and 12 months (group I) and 17 patients measured once at 12 to 82 months follow-up (group II). BMD was measured in the distal tibia adjacent to the prosthesis and in the calcaneus. BMD of the calcaneus was measured bilaterally as an indicator of changes in foot load. In group I BMD was significantly increased in the distal tibia after 6 and 12 months compared to preoperative values. In group II BMD of the distal tibia was significantly higher compared to the non-operated side. No radiolucencies were detected during follow-up in any case. The increase in BMD and the radiographic findings after uncemented ankle arthroplasty indicates that it is being loaded by the prosthesis. This may indicate a well fixed prosthesis.

Increased prognostic value of combined myocardial perfusion imaging and exercise electrocardiography in patients with coronary artery disease.

BACKGROUND: Myocardial perfusion imaging (MPI) with technetium-99m-labeled sestamibi and exercise electrocardiography (EECG) are widely used for risk stratification of patients with known or suspected coronary artery disease (CAD). However, no large-scale studies have addressed the prognostic power of the combined information from these diagnostic tools. METHODS AND RESULTS: We studied 697 consecutive patients who underwent a 2-day Tc-99m sestamibi cardiac perfusion imaging protocol. The EECG was performed on a bicycle ergometer by symptom-limited exercise. Causes of death were obtained from death certificates. Univariate survival analyses were performed with a Kaplan-Meier estimate and a corresponding log-rank test. A multivariate Cox proportional hazards model was applied to test for potential predictor covariates obtained from hospital records. The predominant risk factors of cardiac death were fixed perfusion defects (relative risk, 2.55; range, 1.43 to 4.55) and an impaired circulatory exercise response (relative risk, 3.26; range, 1.74 to 6.08). The major prognostic information of MPI was the ability to detect patients with a definitively low risk. Patients with impaired circulatory response to exercise test and fixed perfusion defects were at a very high risk. CONCLUSION: The combined results of MPI and EECG provide substantial information on the long-term risk of cardiac death in patients with suspected CAD.

The effect of thoracentesis on lung function and transthoracic electrical bioimpedance.

This study aimed to determine the relationship between improvement in lung function and changes in transthoracic electrical bioimpedance (TEB) after thoracentesis in patients with pleural effusions. Fifteen patients with pleural effusions due to either malignant (n = 8) or cardiac (n = 7) diseases were included. Pulmonary function was assessed before and after thoracentesis. During thoracentesis the patients were monitored with TEB. Using linear correlation analysis, the increases for each litre of aspirated thoracic fluid were: forced expiratory volume in 1 s (FEV1) 0.261; forced vital capacity (FVC) 0.331; total lung capacity (TLC) 0.58; and the lung diffusing capacity (DLCO); 2.4 ml min-1 mmHg-1. Baseline impedance increased by 2.3 Ohm l-1 aspirated thoracic fluid. The relative increase in baseline impedance was twice as high for patients with cancer as for patients with heart failure (P < 0.05). We found only minor changes in systolic blood pressure and mean arterial pressure. The improvements in diffusing capacity, airflow, and lung volumes after thoracentesis are correlated to an increase in baseline impedance, but changes are dependent on the primary disease.

Pulmonary damage after modest exposure to zinc chloride smoke.

Thirteen soldiers (11 men and two women) were exposed to zinc chloride smoke (ZCS) during a combat exercise. Even though their initial symptoms were modest, a prolonged follow up with lung function testing and blood samples was undertaken due to previous cases with fatal outcome after exposure to ZCS. Four weeks after exposure there were statistically significant declines from baseline values in lung diffusion capacity and total lung capacity of 16.2% and 4.3%, respectively. At the same time plasma levels of fibrinogen and zinc were significantly elevated, though mainly within the normal range. All variables showed a tendency towards normalization at follow up 8 weeks and 6 months after exposure. These findings indicate an unexpected quantifiable damage to lung parenchyma with a remarkable delay after modest exposure to zinc chloride smoke despite sparse initial symptoms. Exposure to high concentrations of ZCS may induce adult respiratory distress syndrome (ARDS) after a symptom free period of up to 12 days from exposure. Even though none of the soldiers in the present study developed ARDS the assessment of lung diffusion capacity and acute phase reactants is proposed as a supplement when monitoring patients after exposure to ZCS.

Bone loss after hip fracture is correlated to the postoperative degree of mobilisation.

This study quantifies changes in bone mineral density (BMD) in the opposite hip and in both proximal tibiae and the correlation with the use of walking aids for patients with two types of hip fracture during the 1st year after surgery. In all, 26 women and 15 men aged 42-88 years (median 71 years) were included. Twenty-one patients had an intracapsular hip fracture (ICF) and 20 had an intertrochanteric fracture (ITF). All patients were treated with a dynamic hip screw. BMD was measured by dual X-ray absorptiometry (DXA; LUNAR, Wisconsin) within the 1st week after surgery and after 3, 6 and 12 months. Initial BMD of the non-fractured hip was significantly lower for both fracture groups compared with reference material. For both fracture types there was a significant decrease in BMD of the non-fractured hip and proximal tibia of the fractured leg during the first 3 months, which still persisted a year after surgery. Improved mobilisation between two examinations was positively correlated with changes in BMD of the proximal tibia of the fractured leg and the non-fractured hip.

Changes in bone mineral density adjacent to two biomechanically different types of cementless femoral stems in total hip arthroplasty.

We have compared the differences in bone mineral density (BMD) adjacent to two biomechanically different cementless femoral stems used for total hip arthroplasty. Measurements were performed 12 to 38 months after surgery in a cross sectional study of 29 patients. Of these, 15 had arthroplasties using an "off the shelf" type cementless femoral stem (Spotorno), while 14 had a custom made cementless stem (Evolution-K). Dual X-ray absorptiometry (DXA) measurements revealed that the patients who had a Spotorno stem had a significantly lower BMD in the operated leg compared to the non-operated side in both Gruen zones 1 and 7, whereas no significant differences were found in these areas in the Evolution-K group. For both types of prosthesis there was a significant and similar decrease in BMD of the proximal tibia on the operated side.

[Deep wound infection with Salmonella enteritidis following osteosynthesis]. / Dyb sårinfektion med Salmonella enteritidis efter osteosyntese.

A 43-year old man with alcohol abuse had septicaemia with Salmonella enteritidis. After osteosynthesis of an intertrochanteric femoral fracture he developed a deep wound infection with Salmonella enteritidis. The patient was treated with surgical debridement and antibiotics. As a consequence of alcohol abuse the patient may have had a predisposing immunosuppression, and infection with Salmonella enteritidis should be considered in case of postoperative infection in these patients.

[Zinc chloride smoke pollution. Effects of minimal exposure]. / Zinkloridrøgforgiftning. Følger efter beskeden eksposition.

Thirteen patients were exposed to accidental zinc chloride inhalation during an army exercise. Smoke bombs were released in open air. The exposure was modest ranging from "taking a few inhalations" to "5-10 minutes in a house with smoke drifting in through unshuttered windows". Initial symptoms were scanty. All patients received inhalation steroid on admittance followed by i.v. bolus of hydrocortisone. Four patients continued systemic steroid treatment (prednisolone 40 mg with stepwise reduction to zero over four weeks) because exposure was judged significant (> 1 minute of unprotected inhalation). No respiratory symptoms developed within an eight week observation period. However, a gradual decline in pulmonary CO diffusion capacity (to 85% (76-99 of initial capacity) was observed within the first four weeks. It is concluded that a very modest inhalation of zinc chloride smoke may induce prolonged impairment of pulmonary function.

[Traumatic total rupture of the musculus pectoralis major tendon]. / Traumatisk total ruptur af musculus pectoralis major-senen.

Total or partial rupture of the major pectoral muscle is a rare lesion. Early treatment is recommended to regain full strength in the shoulder, but even without surgery 70 to 90% of original strength may be recovered within a year after trauma. We report a case in which a carpenter three months after total rupture of the major pectoral muscle tendon on the dominant side had spontaneously recovered sufficiently to perform his usual job. The diagnosis was visualized by MR imaging. The muscle strength was tested by use of a dynamometer.