Tuberculosis (TB) infection of bones and joints accounts for
6.7% of TB cases in England, and is associated with significant
morbidity and disability. Public Health England reports that patients
with TB experience delays in diagnosis and treatment. Our aims were
to determine the demographics, presentation and investigation of
patients with a TB infection of bones and joints, to help doctors
assessing potential cases and to identify avoidable delays. This was a retrospective observational study of all adults with
positive TB cultures on specimens taken at a tertiary orthopaedic
centre between June 2012 and May 2014. A laboratory information
system search identified the patients. The demographics, clinical presentation,
radiology, histopathology and key clinical dates were obtained from
medical records.Aims
Patients and Methods
Management of bone and joint infection can be technically complex and often requires a prolonged course of antibiotics. Traditionally, bone and joint infection management utilises nurse-led outpatient parenteral antibiotic therapy (OPAT) where adherence is unlikely to be an issue. However, with increasing evidence in favour of oral therapy, the question of adherence merits further consideration. We describe the adherence of both oral (PO) and self-administered intravenous (IV) antibiotics in the treatment of bone and joint infection using paper questionnaires (8-item Modified Morisky Adherence Score (MMAS)) and, in a subset of participants, electronic pill containers (Medication Event Monitoring Systems*). All eligible participants enrolled in the OVIVA trial (2010–2015) were randomised to six weeks of either PO or IV antibiotic treatment arms. Self-administering patients were followed up with questionnaires at day 14 and 42. A subset of PO participants was also given the medication event monitoring system* in order to validate the adherence questionnaires. The results were correlated with treatment failures at one-year follow-up.Aim
Method
The objective of this study was to assess the reliability and appropriateness of statistical shape modelling for capturing variation in thoracic vertebral anatomy for future use in assessing scoliotic vertebral morphology. Magnetic resonance (MR) images of the thoracic vertebrae were acquired from 20 healthy adults (12 female, 8 male) using a 1.5 T MR scanner (Intera, Philips). A T1 weighted spin-echo sequence (repetition time = 294 ms, echo time = 8 ms, number of signal averages = 3) was used. A set of slices (number = 27, thickness = 1.9 mm, gap = 1.63 mm, pixel size = 0.5 mm) were acquired for each vertebrae, parallel to the mid-transverse plane of the vertebral body. Repeated imaging, including participant repositioning, was performed for T4, T8 and T12 to assess reliability. Landmark points were placed on the images to define anatomical features consisting of the vertebral body and foramen, pedicles, transverse and spinous processes, inferior and superior facets. A statistical shape model was created using software tools developed in MATLAB (R2013a, The MathWorks Inc.). The model was used to determine the mean vertebral shape and ‘modes of variation’ describing patterns in vertebral shape. Analysis of variance was used to test for differences between vertebral levels and subjects and reliability was assessed by determining the within-subject standard deviation from the repeated measurements. The first three modes of variation, shown below (green = mean, red and blue = ±2 standard deviations about the mean), accounted for 70% of the variation in thoracic vertebral shape (Mode 1 = 44%, Mode 2 = 19%, Mode 3 = 4%). Visual inspection indicated that these modes described variation in anatomical features such as the aspect ratio of the vertebral bodies, width and orientation of the pedicles, and position and orientation of the processes and facet points. Variation in shape along the thoracic spine, characterised by these modes of variation, was consistent with that reported in the literature. Significant differences (p< 0.05) between vertebral levels and between some subjects were found. The reliability of the method was good with low relative error (Mode 1 = 5%, Mode 2 = 8%, Mode 3 = 19%). Statistical shape modelling provides a reliable method for characterizing many anatomical features of the thoracic vertebrae in a compact number of variables. This is useful for robustly assessing morphological differences between scoliotic and non-scoliotic vertebrae and in assessing entry points and trajectories for pedicle screws.
DXA areal-bone-mineral-density (aBMD) is used clinically as a surrogate for true volumetric-BMD to assess bone fragility. Trabecular-Bone-Score (TBS) provides an assessment of bone quality based on the DXA-derived two-dimensional images. Calculated from bone area (BA), aBMD may under- or overestimate true BMD in individuals with relatively low and high BA respectively. This study investigated relationships between BA at the lumbar-spine (L1–L4) and measurements of BMD and TBS. Lumbar spine scans were performed (GE Lunar Prodigy) on 114 women (mean 53 yrs). The study population was divided by L1–L4 BA using the 20th and 80th centiles, and BMD v TBS correlations calculated for the subgroups. BMD and TBS, converted to Z-scores, were correlated with BA.Introduction
Method
Precision error (PE) in Dual Energy X-Ray Absorptiometry (DXA) is important for accurate monitoring of changes in Bone-Mineral-Density (BMD). It has been demonstrated that BMD PE increases with increasing BMI. In vivo PE for the Trabecular-Bone-Score (TBS) has not been reported. This study aimed to evaluate the short-term PE (STPE)) of BMD and TBS and to investigate the effect of obesity on DXA PE. DXA lumbar spine scans (L1–L4) were performed using GE Lunar Prodigy. STPE was measured in 91 women (Group A) at a single visit by duplicating scans with repositioning in-between. PE was calculated as the percentage coefficient of variation (%CV). Group A was sub-divided into four groups based on BMI (A.1. <25kg/m2, A.2. 25–29.9kg/m2, A.3. 30–35kg/m2 and A.4. >35kg/m2) to assess the effect of obesity on STPE. Abnormally different vertebrae were excluded from the analysis in accordance with The International Society for Clinical Densitometry (ISCD) recommendations.Introduction
Method
Weight-bearing is a known stimulus for bone remodelling and a reduction in weight-bearing is associated with reduced bone mineral density (BMD) in affected limbs post lower limb fracture. This study investigated short and long-term precision of a method for measuring relative left/right weight-bearing using two sets of identical calibrated scales. The effect of imbalance on BMD at the hip and on lower limb lean tissue mass (LLTM) was also assessed. 46 postmenopausal women, with no history of leg or ankle fracture, were measured three times whilst standing astride two scales (Seca, Germany). 34 of the participants were re-measured after 6 months by the same method. Bilateral hip and total body dual x-ray absorptiometry measurements were performed using a GE Lunar Prodigy (Bedford, MA). Precision errors in weight-bearing measures were calculated using the root mean square coefficient of variation (RMSCV%). The correlations at the first visit between left/right differences in weight-bearing and differences in BMD and LLTM were calculated. The short-term RMSCV% for left and right weights were 4.20% and 4.25% respectively and the long-term RMSCV% were 6.91% and 6.90%. Differences in left/right weight-bearing ranged from 0 to 24% (SD 8.63%) at visit 1 and 0 to 30% (SD 10.71%) at visit 2. Using data from visit 1, the relationship between hip BMD differences and left/right weight-bearing differences were investigated, with no significant correlations found. However, a weak, but statistically significant correlation of r=0.35 (p=0.02) was found for differences in LLTM and left/right weight-bearing differences. In conclusion, left/right weight-bearing measured using two scales is a precise method for evaluating differences in weight-bearing in the short and long-term. Differences in left/right weight-bearing in this population varied by up to 30%. Participants showed a high degree of consistency in their long-term balance in a natural standing posture. Inequalities in left/right weight-bearing did not correlate significantly with BMD at the hip, but demonstrated a weak but statistically significant correlation with lean tissue mass.
